In a perfect world, an ill patient would recover in the hospital and return home as soon as possible. When they are medically stable and can leave the inpatient care setting, nothing is holding them back.

Unfortunately, that does not always happen. Even when patients are medically ready to return home, they end up waiting in the hospital longer.

“This happens quite often,” says Whitney Stillwell, BSN, RN, CCM, regional director of case management at McLeod Regional Medical Center, McLeod Health Cheraw, and McLeod Health Clarendon in South Carolina. “Case managers and hospital staff everywhere face these challenges daily.”

A prolonged hospital stay typically is described as a stay that persists for a certain number of days (often 10 days) past the patient’s geometric length of stay. The problem of prolonged hospital stays seems to be getting worse.

“This is happening more frequently than we would like,” says Patricia Wilson, MBA, BSN, RN, director of care transition management at Texas Health Presbyterian Hospital in Dallas. “The avoidable day numbers have significantly increased over the last 18 months. Despite being medically ready, resources and processes are the logjam between acute and post-acute.”

Wilson and Stillwell note this happens for many complex reasons, one of which is the effect of COVID-19.

“Initially, it was a challenge to find post-acute facilities accepting these patients with the first surge,” Wilson says. “There was no way to prepare or predict the needs of COVID patients. Families were not able to see their loved ones, visit post-acute facilities, or see the patients even at these accepting facilities. Early on, working virtually with families was a struggle. It soon became evident, in the older population, that this was not always ideal. We saw more avoidable days attributed to family during the spike of COVID. This was true with the second and third wave as well. The acuity of these patients is also profound.”

Contributing Factors

Even before the pandemic, lack of family support, willingness to bring a sick family member back into the home, decisions on palliative or hospice care, or concern the care needed will be overwhelming can lead to longer stays for the patient.

Demographics and the service lines offered at a hospital also can contribute to prolonged stays. This occurs more frequently when discharge criteria are not met. Social determinants play an instrumental role in successful transitions. Patients who have no safe discharge plan, combined with their challenging social determinants, may face prolonged hospital stays.

In hospitals with a Level II trauma center, such as Texas Health Presbyterian, case managers see these delays more often.

“You can expect a large percentage to be underinsured or uninsured,” Wilson notes. “Discharge planning relies on what benefits and resources the patient has to move through the continuity of care. Often, these patients remain as inpatient to optimize their potential to go home. Community resources are limited due to the increased demands for assistance.”

Likewise, facility location also contributes to prolonged stays. “Smaller cities often don’t have as many resources and shelters, and sometimes no taxi service, so they see this challenge so much,” Stillwell says. “In some situations, the patient may be homeless, so they have a longer stay because of the social aspect.”

Stillwell describes how patients experiencing poverty often do not have funding for rehabilitation when needed. They go through rehab at the hospital while the case manager is seeking other discharge plans for the patient.

One of the longest delays can occur when the patient needs to apply for disability and/or Medicaid. “This process can take three to six months at a time,” Stillwell says. “If the patient truly does not have another plan, and they cannot stay alone, then sometimes the hospital will pay for an alternative residential stay or a hotel. But more likely, these individuals stay for three to six months while waiting for the approval.”

Hospitals might send patients to smaller facilities while they are awaiting their disability approval, which frees up capacity at the larger hospital. “But lately, so many hospitals have all been full, so that process has come to a halt,” Stillwell notes.

Response time for SSA also can contribute to prolonged hospital stays. “COVID has caused an unprecedented delay in process patient applications for SSI/SSDI in our state,” Wilson explains. “[At times], shifting some cases to another state to provide assistance [is possible]. We have patients who have waited greater than six months to hear a decision, [and often there is a] lack of facilities willing to take a Medicaid-pending patient.”

Wilson also notes the effect of location and demographics. “Do you provide care in an underserved area? Are your patients younger and able to afford insurance? Are you working with an aging population?” she asks. “Every case management assessment must identify barriers early on in order to provide the safest discharge plan. Your homeless population will have different challenges for determining medical necessity. The goal is always for a safe discharge. This may mean keeping a patient to complete IV ABX [IV antibiotics] here, where if this were a different patient, with a home or resources, we could have provided post-acute care in multiple care settings.”

Also notable are situations like those of behavioral health patients with medical care needs, as most behavioral health facilities decline accepting patients who need medical attention like wound care.

There also are plenty of issues that can cause prolonged delays that are not quite so patient-centric. Staffing issues can contribute to longer stays and disrupt proactive discharge planning efforts, especially when the hospital is treating many more sick patients. Undocumented immigrants also might experience prolonged hospital stays due to the complexity of arranging care. They could require the attention of a complex care social worker, as these cases can drag out for more than a year and might include the involvement of a legal team.

Payer-related issues also arise when patients are waiting for an authorization for rehab or long-term care facility, which can take up to two weeks or more.

“There’s reluctance to approve IRF [inpatient rehab facility] or LTAC [long-term acute care] without the medical director reviewing the case,” Wilson notes. “Timeliness of approvals for next level of care delays from payers are increasing.”

Effects of Prolonged Stays

The unfortunate implications of these longer hospital stays, which often occur as a domino effect, include:

  • Patient throughput/bed turnover as patients are held in the ED, post-acute anesthesia unit, or other units;
  • Reduced capacity for bringing in patients from other hospitals in need of a higher level of care;
  • Frustration among the care team, including physicians, many of whom are held accountable for shortening length of stay;
  • Case management fatigue that often occurs with long-stay patients;
  • Jeopardized patient safety as the risk of hospital-acquired infections is increased;
  • Inability to steward resources for the hospital, physicians, and patients;
  • Potential for the patient to be held responsible for any days not medically necessary. Since Medicare is not an unlimited plan, this can be especially difficult for patients with chronic illness.

Case managers can mitigate these effects and help manage prolonged-stay situations, bringing compassionate care to the patient and staff. Stillwell and Wilson’s recommendations include:

  • An early and thorough initial assessment. Accurate information will drive the care team’s planning for post-acute level of care.
  • Communication that paints a clear picture of available resources for the care team, patient, and physicians.
  • Huddle often. Trust your team and leadership; do not be afraid to ask for help sooner than later.
  • Work together as a team. One team member can help another to progress the patient.
  • Identify patient goals. Are they realistic or obtainable?
  • Know your resources. Sometimes, calling contacts in the state or an association can help.
  • Identification of the primary caregiver. Work with the caregiver and patient to improve the discharge process.
  • Prepare for the worst and hope for the best. Ask our staff to create at least a plan A and plan B with which all parties agree.

“Case managers need to be prepared to adapt to where the patient is,” Wilson explains. “Understand the care team’s goal and if they are aligned with patient and families. Keep the lines of communication open with patients and their families, [and] notify the care team as soon as possible if something has changed; for example, family dynamics, insurance, or resources. I cannot stress enough how important communication is for long-term patients.”

The patient, most of all, feels the effects of a prolonged hospital stay, and the care team is a close second. Working together rather than against each other, as often as possible, can bring great rewards during a difficult situation.

“When you have long-stay patients — it could be 50, 60, or 100 days — these individuals really become a member of the floor, and you’re like family to them because they’ve been there so long,” Stillwell says. “The cool thing about having a case manager assigned to that floor is that when a patient is not medically needing attention and the physicians need to focus on other patients, the case manager is then the point person for that patient. Often, we see that on holidays. The case manager brings in Christmas trees or celebrates birthdays. They keep the patient connected, especially when they’re depressed because they’ve been there for so long in the same room. We can help keep their spirits up while they’re here and waiting.”

All things considered, case managers should know that, at the end of the day, they have done all that they can to help the patient and prepare for the uncertainties of the following days.

“I often say we make the best of the worst choices,” Wilson says. “As we see trends in payer process/denial, acuity, and fewer resources, working within those restraints often becomes the best of the worst choices. If you put the patient as the priority, then the case manager can leave for the day, knowing she or he has done their best.”