Long-term limbo: Beds at care facilities are scarce; hospitals can't discharge patients without placement

Many of Kootenai Health’s hospital beds are filled, and often staying full, with patients waiting for transfers to post-acute care facilities that are also at capacity and unable to take new patients.

Post-acute care is prescribed for patients who no longer need hospital-level care, but do require continued treatment, often long-term, for things like mobility issues and dementia.

“I think it’s a crisis in the making and we’re inching closer to it,” said Heidi Peterson, owner of Peterson Place Assisted Living in Hayden. “You’re seeing homes close down all over the United States. If you can’t find people to work the homes, you can’t fill it. And if you can’t fill it, they can’t be profitable. People are going to need a place to stay and there isn’t going to be a bed.”

Long-term care facilities and hospital staff are already seeing that strain firsthand.

“What we’re seeing is about half of the (post-acute facility) beds are staffed,” said Dr. Karen Cabell, chief physician executive at Kootenai Health.

Hospitals are unable to discharge patients who need long-term care to facilities that can’t provide the care that is needed. With no vacancies in facilities that provide post-acute care, the responsibility falls on the hospital to keep these patients in a bed where they receive the attention they need.

“What ends up happening is patients back up into the hospital,” Cabell said. “At any given time we have about 30 people medically ready for discharge with no place to go. They will sit for days, to weeks, to months.”

One patient has been in the hospital for a year without a long-term care facility to take them, Cabell said. Most will spend about a month waiting for a transfer, depending on their medical needs.

“It got a lot worse with COVID-19,” said Dr. Maggie Greene, hospital medical director. “It really got backed up for the past few years. At one time, it reached 70 people waiting to transfer to a care facility.”

Long-term care facilities have been short-staffed, though some are starting to see improvements in hiring and retaining care providers. Each staff member has a legal maximum number of patients they can have in their care at one time, so when these limits are met, facilities must place hospital patients seeking transfers on waitlists.

Cabell said facilities reduced their post-acute beds during the pandemic.

“We just don’t have enough beds, in particular with people who need memory care,” she said.

As a result, the responsibility of in-patient care is shifting to the hospital.

“Now the patients with more needs are the ones staying here for longer periods of time,” Cabell said. “Which really impacts their care.”

Kootenai Health has had to turn away patients from transfers or referrals while hospital beds are full. While the hospital is always available for emergency care, wait times for beds are longer and hospital staff and finances are strained by the backlog.

Pandemic relief grants and funding helped the hospital reduce its backlog of filled beds, but those expired in June.

“We had some momentum prior to those incentives going away,” Cabell said.

And that movement toward freeing up beds has slowed.

“It absolutely puts additional strain on the hospital, and that makes it more difficult to care for the additional patients,” she said. “It strains the people because there’s more patients to care for, and it also strains the hospital finances. If someone is in a hospital bed for four days or 50 days, insurance providers pay the same amount.”

The lack of supply in nursing homes or care facilities puts pressure on discharge staff to find creative solutions to discharge patients, which can put families on the front line to provide much needed care.

In-home caregivers have seen an increase in hospital referrals and they have to turn people away every day.

“If we don’t have a nurse available within 48 hours we can’t take a patient on,” said Malia Sampfel, patient care manager for North Idaho Home Health, an in-home care agency.

Sampfel has seen increases in the aging population and decreases in skilled nursing staff, impact the availability of at-home care.

Even if a family finds support staff for in-home care, the cost can be prohibitive, and the process for physician-mandated in-home care can take a month to get approval through insurance.

“Non-medical or personal care services put a financial burden on the family or patient,” Cabell said. “And there are limited resources with Medicare or Medicaid.”

Demand is too high for assisted living or post-acute care facilities, and supply is down, especially with memory care facilities.

Carol Harder’s mother, Mary Thompson, has dementia and was staying in an assisted living facility that offered tiered care (including dementia) in Kootenai County. Thompson would try to get out of her bed sometimes when she got confused.

“Her care was fragmented,” Harder said. “She wasn’t that difficult to manage, she was just confused. These places, they’re short staffed, people running up and down the hall.”

Before Harder decided to remove her mother from the facility, Thompson fell and had an incident at the dinner table when she passed out because she was having some issues with her medications. The facility brought Thompson to the hospital emergency room.

Before the incidents, “they were going to put her in the locked area, and I knew she wouldn’t respond well,” Harder said.

Thompson stayed in the hospital emergency room for nine days.

Because Thompson didn’t have major injuries, like a broken hip or major damage from her fall, she wasn’t formally admitted, though she did get a quiet room in the ER.

“Nurses were kind and compassionate, and she ate well and everything, but she regressed a lot,” Harder said.

Luckily, because Thompson was on a waiting list at Peterson place, on the ninth day of staying in the hospital Harder received a call saying there was a bed available there.

“I’m glad,” Harder said. “I didn’t understand why she was in the ER. I feel like God opened the door for Peterson Place, which was where she needed to be.”

Peterson Place is a 16-bed facility, though it has plans to expand.

“We are definitely seeing a surge,” Peterson said. “Demand is higher than it’s ever been.”

Assisted living and skilled nursing facilities have long waitlists, and receive new referrals daily and many long-term care facility staff members only see demand increasing as the aging population grows.

“We can take in maybe two or three people a year from the hospital,” said Anne Johnson, executive director of Orchard Ridge Senior Living. “We had to turn away over 200 people last year on Medicaid.”

And it's not just Kootenai Health that's seeing this surge.

"Hospitals everywhere are seeing the same thing," said Caiti Bobbitt, public affairs strategist for Kootenai Health.