Staffing shortages in skilled nursing facilities and other long-term care centers are causing bottlenecks that are bad for patients and companies
Throughout the pandemic, hundreds of people at any one time have languished for weeks and even months in hospital beds they didn’t need.
They should have been in a lower level of care.
But nursing homes, rehabilitation facilities, long-term care and other treatment centers in Oregon have been overloaded, with beds for patients in short supply due to severe workforce shortages.
That’s created a bottleneck that has persisted even as daily hospitalization numbers slowed in the wake of the Covid-19 surge in September.
Having people stuck in the hospital, waiting to be discharged to another setting, is bad for the those hospitalized and those needing admission. It’s also bad for hospitals, costing them hundreds of millions of dollars.
That, in turn, drives up health care costs, which inevitably fall back on consumers, said Becky Hultberg, president and CEO of the Oregon Association of Hospitals and Health Systems.
“In an acute care setting, they are in the highest-cost care setting possible,” Hultberg said. “That is going to have an impact on our overall health care system and on the insurance rates that we pay. Sometimes insurance will cover the cost of boarding to a point, but very often it is essentially uncompensated care.”
State officials have been working on the issue for weeks.
“This is absolutely a priority,” Dr. Margaret Cary, a senior advisor for the Oregon Health Authority’s Covid response and recovery unit, told the Capital Chronicle earlier this month. “Everything’s on the table.”
One small piece of the puzzle was put into place last week, with the health authority announcing an extension of a contract for health care professionals to work in hospitals, long-term care and behavioral health centers. Originally worth $100 million and due to expire this month, the contract with Jogan Health in Colorado will now cost $250 million and last until mid-January.
It pays for nearly 600 registered nurses, respiratory therapists, certified nursing assistants, medical assistants, lab technicians and others to work in hospitals. The other part of the contract covers “long-term care crisis response teams” made up of three registered nurses and five certified nursing assistants each. Originally limited to 10 teams, the health authority is now paying for 95.
Most of those teams will serve residential facilities specialized in treating behavioral health problems.
“We see children and adolescents in need of behavioral health treatment, frequently boarding in the ED for unacceptably long periods of time,” Hultberg said.
As the Capital Chronicle reported in the series, Children in Crisis, Oregon’s behavioral health system has come close to imploding. Several facilities mentioned in the series – Trillium Family Services’ Children’s Farm Home, Albertina Kerr’s sub acute facility, Jasper Mountain’s facilities – will get extra help under the extended contract. So will adult mental health facilities.
Other contract staff are reserved for long-term care and rehabilitation services to service beds so that patients can be discharged from hospitals.
Hultberg welcomed the extension.
“It’s good news,” she said in a statement. “For several months hospitals have been collaborating with the state to address the staffing crisis, which unfortunately is not over. This is the right thing to do for patients.”
Hospitals remain full
The number of patients awaiting to be discharged has edged up in recent weeks, according to the hospital association. Last week, more than 320 people were in the hospital who were ready to shift to a lower-cost skilled nursing or other facility. About 180 other patients were “boarding” in emergency departments, awaiting transfer to a skilled nursing facility, long-term care center or behavioral health care home.
Though hospital capacity eased somewhat after the Covid-19 surge in September, many Oregon hospitals remain fairly full, depending on the region.
In southern Oregon (region 5), 12% of intensive care beds were available on Monday. Southwest Oregon (region 3) had 13% availability and central Oregon (region 7) had 11%. The availability in north-central (region 6) and eastern Oregon (region 9) hovered around 30%. In northeast Oregon (regions 1 and 2), 7% to 8% of ICU beds were free.
The availability of beds changes daily, as does the number of people stuck, but the number of patients awaiting discharge remains stubbornly high.
“One of the reasons that the discharge numbers are staying stable is that our hospitals are at or near capacity,” Cary said. “Also, people are coming to the hospital sicker.”
Hospitals have devised strategies to cope.
Oregon Health & Science University set up a special transitional unit at its medical center in Hillsboro for patients awaiting discharge to a setting where they can continue healing.
“Finding the right location where the patient can really thrive and get better and recover and have a chance, that is really what we’re striving for,” said Dr. Matthias Merkel, senior associate chief medical officer for capacity management and patient flow at OHSU.
Some cases are complicated, however. Severely ill patients who end up on a ventilator or on dialysis often face long recoveries after they’re discharged.
“These patients rarely can just go home,” Merkel said. “They need a lot of time in the hospital for their treatments, and then they need care afterwards.”
Staying in the hospital when they’re ready to be discharged after weeks of treatment hinders their recovery, Merkel said. Hospitals are noisy, there’s not much privacy and disruptions are frequent, with staff regularly checking on patients.
“The ICU is a safe environment,” Merkel said, “but ideally you want to be in a room where you have your own bathroom and a little bit more independence because it also tests your readiness to then actually go home.”
OHSU currently has more than 50 patients awaiting transfer to another facility. Though the discharge delay is usually days or weeks, OHSU has had some patients for more than 100 days.
That’s difficult to see, Merkel said.
“It’s hard to see your patient being sort of stuck,” he said. “Who wants to be in the hospital unless you really need it?”
Some patients don’t have relatives or someone with a power of attorney to advocate for them. Others can’t go home because they don’t have anyone there to continue their care.
“Some people could be discharged home if they had a home or if they had a caregiver to help them in their home,” Hultberg said. “So it’s not just an issue of skilled nursing facilities or assisted living facilities.”
Hospitals also have patients with memory or behavioral health issues along with complex medical needs that can make it difficult to find a suitable setting for them outside the hospital.
But once they’re ready to be discharged, insurance companies often stop reimbursing hospitals for their stay.
Merkel wouldn’t say how much it costs OHSU to board patients, but every hospital in the state is paying a price. According to the hospital association, Salem Health had 40 patients awaiting discharge and nearly 20 other patients boarding in the ER, awaiting transfer elsewhere as of late last week. Lisa Wood, the health system’s spokeswoman, said they cost the hospital an average of $80,000 a day.
Asante, with three hospitals in southern Oregon, consistently has 40 patients awaiting discharge, said Lauren Van Sickle, Asante’s spokeswoman.
“For every day over the expected length of stay for these patients, Asante is 100% covering the cost,” Van Sickle wrote in an email. “Additionally, a patient who we’re unable to place uses a bed for a patient who could have had an elective surgery. The average net revenue of a surgery patient (both inpatient and outpatient) is roughly $9,000 per patient.”
The cost adds up to tens of millions of dollars, Van Sickle said.
State directs resources to ease discharge
The state Department of Human Services established a team to help hospitals find a place for patients in a long-term care facility or an adult care home, which are limited to five residents. The team also works to arrange care in the home. Hospitals decide whether to solicit the agency’s help. So far the team has worked with 20 of the 65 licensed hospitals in Oregon, assisting with about 700 cases, according to Elisa Williams, an agency spokeswoman. They’ve only accounted for a fraction of patients needing discharge in recent months.
The agency also supports the crisis teams working to help long-term care facilities accept discharged patients, and it has set up eight Covid recovery units for patients from hospitals and long-term care facilities who become infected. The units free up staff in the facilities so that they can take discharged patients.
“Without them, a long-term care facility would have to maintain a separate set of staff to care for Covid-19 positive residents,” Williams wrote.
In southern Oregon, the state has been paying for months for a unit in a skilled nursing facility to help Asante discharge patients. Operated separately from the hospital, it can take up to 60 patients.
“We still meet with representatives from the state twice a week to find solutions, and they’ve been very helpful,” Van Sickle wrote.
Williams told the Capital Chronicle on Monday that the department plans to pay for five more units, each for 20 to 12 patients, in Portland, Oregon City, Salem, Eugene and Bend. They will open soon, she said.
Every effort helps, experts say, but none has been a panacea.
Marquis Companies, which owns 14 skilled nursing facilities, five assisted living facilities, three memory care centers and one independent living facility, continues to admit residents when someone dies or leaves, but it stopped taking hospital discharges. Even though it benefited from state-paid contracted workers, that help has not been enough, Marquis said in a statement.
“The state-provided staff are very limited and are primarily provided to facilities that are in a Covid outbreak,” the statement said. “Outbreaks require dedicated staff, so this state staff doesn’t increase the ability to take more admissions. As soon as a building is out of an executive order, those staff immediately leave. While the state staff has helped us in crisis situations, they are not given to buildings purely for increasing admission capacity.”
Most long-term care facilities have been hard hit by the pandemic, according to the Oregon Health Care Association, the industry’s trade group. They’ve had widespread Covid outbreaks, which have slowed thanks to vaccination campaigns. Like other health care facilities, they have seen surging costs for protective gear, medical supplies and staff. Unable to fill positions, they’ve turned to temporary agencies, as have hospitals.
Those companies have exploited the demand, said Rosie Ward, the association’s spokesperson.
“Temporary staffing agencies are taking advantage of the situation by price gouging health care providers, including long-term care, by charging high rates that are causing financial turmoil and reducing the quality of care that a more stable caregiver workforce provides to residents and patients,” Ward said in a statement. “Something must be done to stop staffing agency rates from soaring in the midst of a global pandemic.”
Though pay rates have gone up in long-term care, which traditionally has paid minimum wage for entry level positions and low wages to others compared with hospital wages, those increases are still not enough to make a big difference, Ward said.
“Despite substantial increases in compensation for CNAs and nurses being paid by nursing facilities, they still simply cannot compete with the wages that hospitals are willing and able to pay,” Ward said.
The problem with staffing is not new, and patients ended up boarding in hospitals before the pandemic. The prolonged epidemic has exacerbated existing problems. “I think one of the challenges is that hospitals are under OHA’s regulatory authority and post-acute care is under DHS,” Hultberg said. “So, we have some silos within state government.”
But for perhaps the first time, the two agencies have been working together, she said.
“During the pandemic, there was significant cooperation in trying to free up hospital beds,” Hultberg said.
Having a coordinated response would be helpful, industry experts said.
“We need a very centralized organization in how we manage that so that we can use these resources the most effectively across all health systems,” Merkel said.
The state is continuing to work on the problem, but it it’s not likely to be solved overnight.
“I don’t think anyone has discovered the magic bullet,” Merkel said.
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