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.
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its sad for the elderly no to be discharged untill the nhs are ready …
Why pay for nursing home care if you can stay for free in a hospital?
No you can’t. The fee in hospital for ALC patients is the same.
Co-pay is $1707.59 a month. There aren’t many nursing homes out there for that price with any quality of care. “The co-payment applies once their doctor designates them as requiring complex continuing care. In some cases a patient who has been so designated may pay a lesser amount; in some cases the co-payment may not apply.”If you check the MOHTLC website the cutoffs for no co-pay or reduced co-pay are extremely generous. The bottom-line is that in most cases it is economically and qualitatively advantageous for ALC patients and their families to choose continued hospital care and therefore you will continue to have bed blockers until you remove that incentive to remain in hospital.
This is a timely and well analyzed synopsis of ‘need’ versus too many ‘misguided’ assumptions that drives so much of health care planning these days. Specialized (rented or borrowed) home care assistive and communication equipment is needed that offers capacity bridging to better help families and patients manage at home until a long-term spot is available. Incentives need to be made to innovators to find ways to lower costs with better technology.
Your emphasis on patient flow throughout their care experience is right on the mark. I look forward to the Kingston group providing further insights they generate through this in depth analysis of actual patient experiences. I suspect that including a time series analysis of specific patient groups experiences will provide valuable lessons for others as well.
At one of the hospitals in Windsor, there is a designation “PLC,” which is just like ALC, except the most responsible diagnosis for the patient’s admission is a psychiatric one. This must lead to discrimination at nursing homes and elsewhere.
Jeremy, well presented. The only question that I ask is who is going to be responsible for bearing the heightened costs associated with these groups. If adequate payment was available for their care, they would already be looked after. But because they require specialized/more intensive care, thye languish because the current payment model can’t address the costs. The relationship between the disease states and socioeconomic status is at the same time overwhelming and nebulous. Overwhelming because they are often in a position where they themselves cannot afford the cost of premium/specialized care and nebulous because once they are in the health care system a hospital bed is blind to socioeconomic status.
One of my biggest complaints is that the government itself has made this problem worse by allowing patients and families the right to refuse a nursing home bed by choice. In a system with public funding I think that is a non-starter. Allowing someone to say no and as a result stay months longer in an acute care hospital bed disadvantaging countless other patients is neither fair nor is it affordable.
It’s interesting because this same discussion can be had about individual’s abilities to access primary care where complicated and chronic disease management is not adequately compensated. It feels like the same old story.
Hi Mark – thanks for your comment. Cost is always a challenge in trying to improve quality or create efficiency. On one hand, moving these patients out of acute care will almost certainly result in more efficient care for those patients (we’ll save money on their care). However, other patients will immediately flow into those acute care beds, so the system won’t save money in absolute terms, since there will be more patients overall in the system. More efficiency could also be created by providing more comprehensive home care services (more affordable than nursing homes), but there are real limits as to how many nursing home patients can be cared for at home. So you are right that providing these patients with a more appropriate level of care is going to cost money. Given the potential effect on wait times throughout the system and the opportunity to address inequity, I think this is an appropriate target for public investment (ie. I think we should look at creating special per diems for nursing homes to facilitate the introduction and maintenance of specialized beds for targeted high needs populations, and accompany these payments with monitoring to ensure nursing homes receiving these boosted per diems are providing this specialized care)
This is important analysis, thanks for sharing. I am going to ask our team to do a profile of this group of patients using the characteristics in this study. Far too often we are chasing a solution that is not matched to the problem at hand, and taking time to drill down like this is essential. One additional thing we need to do in talking about this issue is to stop labeling these patients as “bed blockers”, which implies it is their fault they are in the wrong place. It’s a very common, but negative way to describe people who are experiencing the consequences of a system that is failing them. Interesting that when we put a patient experience advisor at the table at our patient flow task force at the hospital, this language stopped in its tracks because staff because there is a face and a name to the “problem” they are addressing.
Thank you for your comment Leslee, and I’m glad the analysis is helpful. I appreciate your point about the term “bed blockers” – I debated for some time about using it, for exactly the reason you very rightly raise. I ultimately decided to, only because the term is familiar to so many, more so than “delayed discharge, alternative level of care, etc.” I’d very much like to drop “bed blocker” from my vocabulary, but I haven’t found a great replacement yet. Has your team been able to find a more thoughtful, less pejorative term to use that isn’t too jargony?