Oregon task force finds ways to prevent patients from boarding in hospitals

By Ben Botkin, Oregon Capital Chronicle

SALEM, Ore. (KTVZ) -- Across a sprawling system of nearly 60 acute-care hospitals, Oregonians take up beds they do not need while other patients board in emergency rooms for days on end with nowhere to go.

Those patients don’t require a hospital anymore but are not well enough to simply walk out. They still need care, like a long-term care facility. 

Some are waiting for Medicaid coverage approval to move into a long-term care facility. Others are looking for a homeless shelter to take them in as they continue a recovery from drug addiction. 

The clogged system in Oregon affects thousands of people who are not getting the care they need when they need it, including many low-income residents and homeless people, who die by the hundreds every year on the streets.

For the last year, a 21-member state task force met to map out strategies to aid the flow of patients through hospitals and into appropriate settings, with an eye on vulnerable Oregonians who lack housing or a stable living environment. 

On Tuesday, the Joint Task Force on Hospital Discharge Challenges unanimously approved its recommendations in an 83-page report that outlines where the problems lie – and what Oregon could do to improve the flow of patients through the state’s state’s 7,135-bed hospital system.

Broadly, the recommendations outline ways to speed up the ability of patients to access Medicaid and move more quickly into other care facilities like group homes and skilled nursing facilities for long-term care. They also look for ways to provide care to homeless people who no longer need a hospital but remain vulnerable when they return to the streets.

“I do think this is a jumping off point in the conversation,” Jimmy Jones, co-chair of the task force, said in an interview with the Capital Chronicle. “It’s not the end of the conversation. This is one of the first steps that we’re taking toward building a better model.”

With no singular culprit to blame, the task force wrestled with the issue for the past year. A combination of circumstances drives the clogged pipeline, which impacts patients waiting to exit and new patients needing emergency care.

Oregon has a lack of residential care facilities for people with behavioral health needs. Oregonians also face red tape and long waits to get approved for Medicaid – which provides health care coverage for low-income people. Group homes and other facilities that rely upon Medicaid are reluctant to take on new clients without an approval in hand. 

Meanwhile, hospital beds are taken, forcing longer waits for others. Patients who enter the hospital – including the emergency room –  can board there for days, waiting for a bed to open up outside the emergency department. 

Fewer resources as stays stretch out

For everyone, the problem is straining fewer resources. In 2023, Providence Health & Services, Oregon’s largest hospital provider, had patients across its eight hospitals who stayed 5,700 extra days per month when they could have been discharged but weren’t simply because they were stuck there.

For an average five-day stay in a hospital, that translates into an extra 1,140 patients a month. It’s also the equivalent of admitting 37 patients a day and keeping them for five days. 

“It’s a mind-blowing number,” Dr. Ray Moreno, chief medical officer at Providence St. Vincent Medical Center in Portland and a task force member, said in an interview. “This is like building another hospital that could admit 37 patients a day and keep them for five days.”

Recommendations outlined

To combat the problem, Oregon lawmakers passed House Bill 3396 in 2023, which set up the task force. 

The sweeping recommendations would require action from the Legislature, state agencies or the federal government. They also reflect the complex bureaucracy people face as they navigate through different systems – like hospitals and long-term care – and seek health care coverage as providers coordinate their care plans. 

The task force calls for the state to do more to support Oregon’s Public Guardian program, which helps provide legal guardians to people who need support making decisions about their care. They can include people who are homeless or have endured abuse or neglect.

Guardians can be friends, family members or others. 

The recommendation says Oregon’s Public Guardian program should seek funding from the Legislature to increase services and provide grants for legal services and training to family members and friends preparing to serve as guardians. 

Sarah Ray, a task force member who operates three adult foster homes in Malheur County, said the recommendation to support guardians is important, especially for people with complex medical needs.

Without guardians, sometimes facilities are reluctant to accept an individual without someone to help guide the decision-making process, Ray said.

“They really need someone to see them through that whole stream from hospital to discharge to long-term care,” Ray said in an interview.

The recommendations also give state agencies work.

For example, one recommendation calls upon lawmakers to direct the Oregon Health Authority and Oregon Department of Human Services to study regulations and look for ways to improve flow of patients with complex needs through the state’s system of long-term care facilities.

Outside hospitals, space is limited. The report noted Oregon lacks adult foster homes, which have up to five residents and serve people with a variety of needs, such as older adults and people with physical disabilities and behavioral health needs. Oregon has nearly 1,400, but the state’s target is 1,441, the report said.

The report also calls for the state to increase base rates for adult foster homes, which receive a monthly rate of $2,029 to $3,136 per person, on average. Under the recommendation, the state would pay a higher rate while the Oregon Department of Human Services researches what a new permanent rate structure should look like. 

Sen. Deb Patterson, D-Salem, a task force member and chair of the Senate Health Care Committee, praised the group’s work. She said she anticipates legislation to come out of the recommendations.

“This is all about getting people into the right place at the right time,” Patterson said in an interview.

One unknown is how much funding will be available, Patterson said.

Smoother transitions

The recommendations also look for ways to ease the transitions of people on Medicaid when they move from a hospital stay to a long-term care facility. 

For example, the report suggests ways to get people Medicaid coverage sooner for long-term services outside hospitals, such as residential care facilities. Specifically, it recommends that administrators and state agencies presume low-income people are likely eligible for Medicaid coverage for long-term care so they can exit the hospital sooner. That’s called “presumptive eligibility” and could happen through different ways, such as someone attesting to their eligibility and income levels.

That would speed up a key bottleneck, the report said. 

When people enrolled in the Oregon Health Plan enter the hospital, they need to complete a different application process if they later need long-term care. As a result, hospital discharges are often delayed while patients wait to qualify for long-term care. For example, Providence St. Vincent Medical Center in Portland told the task force that patients waited nearly 23 days on average to get a decision on long-term coverage, which kept them in the hospital longer than clinically necessary. 

“During that period of time, they are ready for another setting of care, and they don’t need hospital-based level of care,” said Moreno, the hospital’s chief medical officer. “And they’re in a bed, and we’re in a state which has one of the fewest hospital beds per capita in the United States. And when that happens, there are always people who need to be in a hospital, and there are folks who don’t need to be in a hospital that are kind of stuck while they’re waiting for that evaluation.”

Oregon has about 1.6 hospital beds per 1,000 people, the second lowest per capita rate nationwide, the task force report said. The pandemic exacerbated Oregon’s low number of hospital beds, but problems have persisted in the years since as hospitals are overwhelmed and staff turnover remains high, the report found.

Another recommendation would expand Medicaid coverage for long-term care. Under the group’s proposal, Oregonians on Medicaid would be covered for up to 100 days in a skilled nursing facility after a hospital stay of three days or longer. That’s an increase from just 20 days. 

After that 20-day period, people need to either leave the nursing facility or get long-term care covered through the Oregon Department of Human Services’ Medicaid-paid program, which requires a separate application to qualify. 

But the current 20-day period is shorter than the time people need to qualify for the program, meaning that Oregon Health Plan enrollees face a gap in coverage. The report also noted that 20 days isn’t long enough to cover a standard regimen of intravenous antibiotics, which often drives the need for nursing care after a hospital stay. 

Sean Kolmer, executive vice president of external affairs for the Hospital Association of Oregon, said the trade group will focus in the next legislative session on streamlining the eligibility of patients to access long-term care services and expanding the 20 days of post-hospital care to 100 days.

“These changes will improve access to care, particularly for our most vulnerable patients,” Kolmer said in a statement.

Homelessness recommendations

The report also calls for the Legislature and Oregon Health Authority to look for ways to increase medical respite programs that serve people who are homeless. The goal is for these programs to help homeless people who are too weak to recover on their own from an injury or infirmity, but not sick enough to be in the hospital.

Examples of respite care include short-term housing for people who exit a hospital and need a place to stay as they continue their recovery or short-term residential care with ongoing medical services like wound care, medication and meals. 

Essentially, medical respite care can close a gap between hospital-level care and a homeless shelter that doesn’t have any medical services.

Jones, the task force co-chair, is also executive director of Mid-Willamette Valley Community Action Agency, which shelters homeless people and other vulnerable populations in the Salem area through its ARCHES Project.

In an interview, he said his shelter can connect people to community health programs and work with people, but more integration and coordination would help.

“People who are homeless and have been in a hospital still need some level of care, but no longer need a hospital level of care, and that’s where things have gotten stuck,” he said. “There’s no intermediate system out there to address that.”