Continuum of Care

Data indicate hospital operational logjams haven’t ceased after the public health emergency (updated)

Post-acute care facilities are still struggling to bring in enough staff to enable optimal referral processes, and the impact is being felt at hospitals.

August 24, 2023 6:02 pm

Note: The fourth section of this article has been updated with news of proposed mandatory staffing ratios for long-term care facilities.

Some of the problems that strained hospital operations during the peak of the COVID-19 pandemic have eased, but not enough to mark a true industrywide recovery, a recently released report suggests.

Notably, the process of discharging patients to post-acute care facilities continues to be hampered by delays.

“In the face of rising demand for post-acute care, hospitals are finding it harder than ever to place patients in the appropriate post-discharge care setting,” states the report (registration required) issued in July by CarePort, a care coordination vendor.

The findings illustrate providers’ ongoing challenge to adapt to a new reality that in some ways has persisted after the end of the public health emergency (PHE).

A struggling referral system

Between 2022 and 2023, according to the report, referral volumes from hospitals increased by 10% to skilled nursing facilities (SNFs) and 11% to home health agencies (HHAs). Referrals doubled on a per-patient basis, and HHA rejection rates spiked by 40%.

Complicating the referral process is an increase in acuity among hospital patients. Citing a metric used to predict in-hospital mortality, the report puts the acuity increase relative to 2019 at 6%.

That means patients’ post-discharge care needs typically are more complex and present a higher risk of complications and readmissions. Between 2019 and 2022, patients referred to post-acute care had increases in the incidence of neurological disorders (17%), alcohol-use disorders (16%), drug-use disorders (12%) and pulmonary circulation diseases (8%).

Average length of stay is improving but remains approximately a day higher than it was in 2019. Longer stays affect capacity, which “can limit the ability to treat new patients and may result in canceled or delayed procedures,” the report states.

Todd Nelson, FHFMA, MBA, director of professional practice and partner relationships and chief partnership executive with HFMA, said innovative approaches are key to overcoming capacity challenges.

“As patient acuity levels and the corresponding length of stay remain elevated, organizations will need to continue leveraging new tools, technology and techniques to meet the needs of the patients and communities they serve,” Nelson said.

Staffing shortages rear their heads

Hospitals’ staffing issues have been well-documented, although at 5.32 million in July, employment in the sector was about 87,000 higher than it was in February 2020.

SNFs have experienced a more significant crunch. As a result, more than half (54%) of nursing homes are denying patients due to staffing challenges, according to CarePort’s data, while 61% are limiting new admissions.

Signs indicate the shortfall is easing somewhat. Preliminary numbers from the U.S. Bureau of Labor Statistics put employment at nursing and residential care facilities at 3.16 million for July. That’s the highest number since July 2020 and a notable jump from the pandemic-era low of 2.97 million in January 2022.

“Sustained staffing improvements at nursing homes should help improve length of stay/discharge challenges at hospitals,” Richard Park of Fitch Ratings said in a June report issued by the credit-rating agency.

Still, there remains a big deficit compared with the pre-pandemic total of 3.38 million employees in the sector.

Looking at nursing homes specifically, the American Health Care Association and National Center for Assisted Living published a report in January showing that employment fell by 210,000 between February 2020 and December 2022. At the pace of monthly gains seen early this year, nursing homes would not return to pre-pandemic employment levels until July 2027.

Regulations pose constraints

CarePort’s report also notes the impact of the May 11 termination of the COVID-19 PHE on patient throughput. A key regulation that’s back in effect is Medicare’s requirement that patients stay in the hospital for at least three days before being covered for a SNF stay.

Hospitals also must resume informing Medicare beneficiaries of their right to choose where they go for post-acute care, providing a full list of locally available facilities, and sharing quality metrics on post-acute care providers.

A potentially bigger regulatory development is an anticipated rule establishing a mandatory staffing ratio for SNFs. In 2022, CMS announced it would be issuing requirements in Spring 2023, but nothing has been released.

While such requirements could improve operations at SNFs that increase staff to meet the mandate, a February report by CLA (CliftonLarsonAllen LLP) noted access would be impacted if facilities close because they can’t find or afford the requisite staff.

Sept. 5 update: On Sept. 1, CMS published a proposed rule that would establish mandatory staffing ratios for long-term care facilities. Specifically, facilities participating in Medicare and Medicaid would be required to provide a minimum of 0.55 hours of RN care and 2.45 hours of nursing aide care per resident per day.

CMS said the requirement would exceed existing standards in nearly all states, and about three-quarters of nursing homes would have to strengthen staffing in their facilities. Staggered implementation and exemptions would be designed to mitigate any resulting hardships for facilities in rural and underserved communities. For example, the staffing ratios would take effect three years after publication of the final rule for most facilities but five years after publication for facilities in rural areas.

Other facility requirements would include ensuring an RN is on site 24/7 and completing robust facility assessments on staffing needs. The RN requirement would be effective two years after publication of the final year, or three years for facilities in rural areas.

The American Health Care Association said in a statement that the proposal “requires nursing homes to hire tens of thousands of nurses that are simply not there. It then penalizes us and threatens to displace hundreds of thousands of residents when we can’t achieve the impossible.

What hospitals can do

In March, hfm published an Expert Reviewed article by experts with Claro Healthcare, examining how hospitals can enhance patient throughput amid ongoing operational pressures. They wrote that five daily best practices include:

  • Operations huddles
  • Patient progression rounds
  • Afternoon unit huddles
  • Real-time demand capacity huddles
  • Night-shift handoffs

“Although clinicians must take the lead, the ability to effectively address throughput challenges requires a team-based approach involving participation by the care team, operations, finance and transport,” the authors wrote.

Organizations across the care continuum are taking steps to bolster recruitment and retention and to incorporate new processes, Nelson said. At hospitals, these steps include “offering flexible scheduling and compensation, as well as investing in new models of care such as increases in virtual care and hospital at home — which expand staffing and physical bed capacity to treat patients.”


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