Bed blocking a problem of equity, not just efficiency
One of the big challenges facing modern health care systems is how to reduce delayed discharge from acute hospitals by patients for whom acute care is not longer medically necessary – better known as the problem of bed blockers. Bed blocking occurs when a patient is ready for discharge, but has to stay in hospital until a space becomes available in a facility providing a more appropriate level of care (most often a nursing home). Bed blocking generates problems throughout the health care system, from longer wait times in emergency departments to poorer health outcomes for patients from accelerated functional decline, social isolation, and loss of independence.
A recent study from Ontario offers a very interesting perspective on bed blocking, one which could help us address the problem more effectively. Researchers at the University of Waterloo and the Hamilton and Niagara Haldimand Brant Community Care Access Centre profiled patients whose discharges were delayed. They found that while patients with delayed discharge who were waiting for nursing home admission accounted for only 9% of patients with delayed discharge, these patients accounted for over 40% of delayed discharge bed days. In other words, patients waiting for nursing home admission are a fairly small portion of bed blockers, but block beds for much longer than average.
These findings are important, because they suggest that a great deal of the pressure on acute care hospitals caused by bed blockers could be alleviated by concentrating on a relatively small subset of patients (those waiting for nursing home admission), through an expansion of home care, complex continuing care and nursing homes. But this study revealed some other very important characteristics of patients with delayed discharges, characteristics that suggest a simple expansion of the current long term care model may not be enough to fully address the problem.
The researchers found that patients with the longest discharge delays tended to have one of four characteristics: morbid obesity, a psychiatric diagnosis, abusive behaviours, or stroke. This is important, because it means that a significant portion (23%) of delayed discharge bed days involve patients who cannot easily be cared for in many of Ontario’s existing nursing homes.[i] Lifting and transferring patients is already one of the leading causes of injury for health care workers, and these risks are magnified the heavier patients are. At the same time, while many nursing homes are experienced in caring for patients with dementia, not all have the capacity to address a broad spectrum of psychiatric disorders or abusive patients. Similarly, many patients who have suffered from stroke can regain some function with appropriate rehabilitation, but not all nursing home can provides such therapy.
The fact that many bed blockers share certain characteristics is not just a problem of efficiency – it is also a problem of equity. Patients with specific medical conditions are facing very real barriers in accessing the level of care they need, and their health is suffering for it. That at least one of these conditions is correlated with low socioeconomic status only amplifies the inequity. Addressing discharge delays for this population will not just improve the efficiency of our system, at a more fundamental level it is simply the right thing to do.
Given the challenges in caring for these patients in existing nursing homes, it is unlikely that a simple expansion of the current long term care system will be sufficient to reduce discharge delays among these populations. Instead, we must focus on how new and existing facilities can be (re)designed to accommodate the needs of these patients. Facilities will need to invest in specialized bariatric patient lifts, rehabilitation staff, and nurses and personal support workers with experience and specialized training in caring for patients with psychiatric disorders and abusive behaviors. These will come with a price tag, which means that funding mechanisms will need to be developed to ensure nursing homes can make the necessary investments to provide this specialized care. Thankfully this is clearly on the Ministry of Health's radar, as the Long Term Care Act proclaimed in 2010 enables different funding formulas for different types of beds (prior to 2010 most nursing home funding was done on a flat per diem). The ministry and the CCACs have also introduced specialized beds before, when they introduced about 300 convalescent care beds in 2005. However, since demand on the long term care sector is so high, it may ultimately be necessary to introduce financial incentives for nursing homes to take on these specific populations in order to facilitate the reduction of discharge delays in acute care.
There is growing awareness of the need for increased specialization in long term care. The Ontario Long Term Care Association’s Long Term Care Innovation Expert Panel has recently called for increased specialization throughout Ontario’s long term care sector as a way to improve quality. This new research suggests specialized beds could simultaneously improve equity and relieve pressure on acute care hospitals. Together, these suggest that we don't just need more beds in long term care, we need more beds for complex patients – we need beds for bed blockers.
[i] It should be noted that not all patients with these characteristics were waiting for nursing home beds – in each case a modest proportion were bound for home (with home care services), but in all cases the overwhelming majority were waiting for placement in either residential or complex continuing care.