Patients stuck in Washington hospitals pose quandary for state lawmakers

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Washington needs to do more to keep people from staying at hospitals longer than medically necessary, state health officials told lawmakers this week.

Over the last five years, the Legislature has approved spending and policy changes to help shorten stays for “complex discharge” patients – those who are in hospitals but cannot be discharged to a long-term care or behavioral health facility for a variety of complicated reasons.

In 2020, the average length of stay was 57 days for patients who were referred to the state for long-term support and Medicaid funding, compared to 32 days this year.

But Bea Rector, assistant secretary for aging and long-term support at the Department of Social and Health Services, says 32 days is still too long.

Rector told a state House of Representatives committee on Tuesday that she doesn’t know what the “magic number” is for the average length of hospital stays, but the goal should be to not have patients admitted longer than they need to be for medical care.

Washington hospitals have pushed lawmakers to change state law and invest more in services to help discharge patients who end up stuck in their facilities, furthering strain on already stretched systems. The problem was only exacerbated by the COVID-19 pandemic, which in many ways pushed hospitals to the brink.

The Legislature has responded by increasing investments to expand staff at the Department of Social and Health Services and by creating a pilot program that lets the state assist in assigning guardians for certain Medicaid patients, an issue that can be a roadblock to getting people discharged from hospitals.

Lawmakers also funded payments to hospitals for services like labs and scans that wouldn’t otherwise be covered by a daily rate that Medicaid pays for complex discharge patients.

Additionally, the Legislature set aside more than $20 million over the next two years to establish a task force focused on solving challenges related to complex discharge patients.

The group, which is made up of representatives from the Governor’s Office, the Health Care Authority, the Washington State Hospital Association and others, is initially working with five hospitals, most in western Washington. Its goals include improving access to services, further decreasing patients’ lengths of stay and reducing readmissions.

Despite lawmakers’ efforts, the Health Care Authority estimates about one in five patients in Washington hospitals are stuck because of some kind of barrier complicating their release, said Glory Dole, Medicaid contracts and compliance manager at the Washington State Health Care Authority. Those barriers can include substance use disorders, mental health concerns, homelessness, or medical needs like kidney dialysis.

“When folks are stuck in hospitals, it’s really an access issue,” Dole told the House Appropriations Committee.

In the 2024 legislative session, the Department of Social and Health Services is asking for funding to hire additional home and community services case management workers, which can help speed up the discharge process. They are also asking for funding to support specialized training and rate increases for those working in residential treatment facilities and funding to increase provider rates for those working with assisted living and dementia care clients.

“All of those things are designed to continue to get the right set of services and supports in place to serve the most complex client,” Rector said.

But there are other obstacles. These include workforce shortages in medical and caregiving fields as well as a lack of families planning for long-term care and power of attorney decisions.

Guardian requirement roadblocks

One issue for a small portion of complex discharge patients is how long it can take them to get a state-appointed guardian. For people with dementia or severe mental health disorders, this can be required for them to move to care facilities beyond a hospital.

Hospitals have also criticized the state in recent months for a new interpretation of its guardianship law. In the fall of 2020, the state Department of Social and Health Services clarified that the law says patients’ family members, or others who have designated powers of attorney, could only make choices about health care for people unfit to make decisions on their own. But this does not cover decisions about long-term care.

In those situations, a state-appointed guardian is often the only answer to getting a patient properly discharged from a hospital.

The list of people awaiting a guardian is very short, Rector said, but the number of days they are in a hospital can be very long.

“The guardianship process at its fastest still takes months to complete,” she said.

One solution the state had to the guardianship problem was a pilot program the Legislature funded last year for people in hospitals who are unable to make informed decisions for themselves. It allows the state to assist in assigning a guardian for Medicaid patients who meet certain criteria.

Though the pilot program has led to more referrals to the state Office of Public Guardianship and better communication between the state and hospitals, Rector said there may be more work by advocates in the upcoming legislative session to improve the state guardian law.

by Laurel Demkovich, Washington State Standard

Washington State Standard is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Washington State Standard maintains editorial independence. Contact Editor Bill Lucia for questions: Follow Washington State Standard on Facebook and Twitter.

  1. When the state changed the regulation requiring a registered nurse 24/7 in long term care facilities, many facilities switched their services to an assisted living business model because they could not meet that staffing mandate. Those facilities cannot care for medically complex patients. Patients with mental illness, dementia, etc that may be at risk for self harm and/or harm to others, require a much higher level of care and supervision. Most facilities cannot provide a safe level of care for these patients. Many dementia units have closed. Medicaid reimbursement is low and finding staff to work in such a challenging environment is difficult as the pay is usually much lower. Remember, it’s always about money.

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