Curbside Consult with Dr. Jayne 2/12/24

Several of good friends from medical school hold significant physician leadership roles. I always enjoy catching up with them and hearing what is going on at their hospitals, as well as trading ideas for solving the different kinds of challenges our organizations are facing. Sometimes one of us has already been through an issue and there’s no sense in reinventing the proverbial wheel when you don’t have to.

Although my colleagues are knowledgeable about their own departments as well as those that they have to work with closely, they don’t always have the broad view of hospital operations that I have as an informatics leader. I think that when working with large enterprise EHR implementations, clinical informatics leaders are just conditioned to make sure that we are thinking about every part of the hospital as well as systems that aren’t even under our roofs, such as emergency medical services, transfer infrastructure, and more.

Regardless of region or state, everyone is facing hospital overcrowding. When there aren’t enough inpatient beds available, patients start backing up into the emergency department. The root cause of the inpatient bed shortage is multifactorial. Sometimes physical beds are lacking, and sometimes there are actual beds open but the shortage is one of staffed beds. There just aren’t enough personnel to keep a unit open.

Although many disciplines are in short supply, including respiratory therapy, the major issue I see in my region is still a nursing shortage. Hospitals in our area are still playing games with nurse compensation and have instituted staffing policies that negatively impact nurses and their families. Of my friends who are nurses, all have left hospital care except one, and I guarantee if she worked on a medical/surgical unit, she would leave, too.

Unless people are actually impacted by these shortages, they don’t tend to get engaged around the policy work that is needed to solve the problems. I was excited to see NBC News bring some of these issues to light this week, as it reported on the potential end of funding for Hospital at Home programs at the end of this year and how that end might worsen already tragic emergency department (ED) overcrowding.

CMS created the program, which is officially called Acute Hospital Care at Home, in 2020. The program allows hospitals to deliver high-acuity care to patients in their homes, where they receive visits from community paramedics and are connected via technologies such as video visits and home-based monitoring systems. The programs can help boost ED throughput by admitting patients back to their homes rather than potentially having to board them in the ED while they wait for a physical hospital bed.

Although more than 130 health systems have been approved to participate, it’s difficult to understand how many are truly bought in or what level of resources are being dedicated to program initiatives. Even if they are participating, hospitals may be left dangling at the end of the year unless Congress votes to extend funding for the program. Although some private payers are participating, CMS still provides the majority of funding for programs.

Even for those organizations that have embraced Hospital at Home programs, their impact is incremental. Atrium Health, for example, is treating 60 patients per day in its program in North Carolina and hopes to ramp that up to 100 patients per day by the end of 2024, which is a fraction of its total count of inpatients. If Hospital at Home programs are sunset, patients who might have been referred to them are instead going to need regular inpatient beds, which will further worsen the situation in systems where those programs had been successfully making a difference.

Policymakers need to look at other causes of ED overcrowding. In addition to the shortage of staffed beds on medical/surgical units, there are fewer beds available in nursing homes, psychiatric units, and rehabilitation facilities. Mental health services are in short supply everywhere, with families sometimes bringing loved ones to the emergency department because they feel they have nowhere else to turn. Telehealth solutions can help mitigate this to some degree, identifying patients who might qualify for outpatient management or who need help navigating the system, such as obtaining medication refills or finding a new provider for ongoing care. Progressive states are looking at the upstream causes of the mental health crisis and are allocating money to community programs, but other states seem to be just looking the other way.

The report also mentioned other pitfalls of our state-by-state patchwork of healthcare solutions. It looked at data from Massachusetts hospitals, including data on patients who are boarded in the emergency department while they wait for beds in the hospital. It profiled the venerable Massachusetts General Hospital, which has been boarding at least 45 patients at a time for more than a year, and in January of this year hit a count of 103 boarders with 220 people across the state in the same situation. The hospital considers this to be a “capacity disaster” and has asked the state to approve additional beds to help the situation.

They have also instituted a Hospital at Home program and have created a Discharge Lounge to help speed patient departures from the hospital building. Patients can wait there for their caregivers to pick them up, rather than remaining in a standard hospital room. That intervention helps 125 patients per month leave more than 60 minutes earlier, which will add up over time and as the program is expanded. The hospital is also providing transportation services to help patients leave when they don’t have reliable transportation.

Other solutions that can help make beds more available include virtual nursing care, where offsite nurses can work with patients and families to deliver patient education and discharge teaching, freeing up bedside nurses to deliver care that must be rendered by an in-person nurse. Virtual nursing programs in my community are keeping nurses that have been placed on light-duty restrictions active in patient care, rather than sidelining them. The technologies can also be used as a “phone-a-friend” solution for early career nurses to bring in a second set of nursing eyes to evaluate a particular patient. Having been a newly minted intern, I appreciate the idea of using technology to consult dedicated virtual resources rather than having to interrupt colleagues who are already knee-deep in patient care of their own.

The NBC News report goes on to note that Massachusetts is “unique” in the way that it keeps statistics on emergency department boarding, and that many states are lacking high-quality data on the problem. I know my own state doesn’t do a good job of tracking it, let alone communicating it, which means that citizens in our communities have no idea there’s as big of a problem as there actually is. The majority of my neighbors and friends in the community think that because COVID is “over” and there aren’t daily stories on the news about how bad things are at the hospitals, that everything is fine. That is, until a loved one sits for 17 hours in the waiting room before they see a physician. But it’s unclear if those experiences translate to actions, such as lobbying one’s legislators.

Demographics are shifting in the US, with increasing numbers of elderly patients and more of us who are living with chronic conditions. We are not spending enough money on preventive care, health promotion, or disease prevention, so the problem is likely to get worse before it gets better. Let’s hope that stories like this help to raise awareness and generate change so that we don’t continue in the downward spiral in which many of us feel trapped.

Does your organization support Hospital at Home activities, and how are they going? Leave a comment or email me.

Email Dr. Jayne.