Families, advocates sound alarm over patients stuck in the hospital without a medical need Sep 03, 2019 at 10:02 am

Christopher Davis was lying on the floor watching cartoons one night last December while his mother, Beverly, decorated her Spokane home for Christmas. From time to time, she showed him a decoration. But Christopher, a 46-year-old developmentally disabled man, just pushed them away.

“It’s going to be OK, Chris,” his mother recalled telling him that night. With that, she says, Christopher stood up, picked her up and tossed her across the living room. Beverly, who is 74 and 5-foot-2, said she sustained a hairline fracture to her pelvis and a bruise down the length of her right leg. Although Christopher -- who is autistic and nonverbal -- is often agitated, Beverly says the act of physical violence was surprising and unusual; she attributed it to a change in medication. The next day she called his doctor and then took Christopher to the emergency room. More than eight months later, Christopher is still at Providence Sacred Heart Medical Center in Spokane. He is one of hundreds of patients -- most on Medicaid, Medicare or both -- who are stuck in Washington hospitals because of a lack of community-based options. It's a growing problem that's drawn the attention of the Washington State Hospital Association, the state's developmental disabilities ombudsman, a handful of state lawmakers and even a rural emergency room physician.

In April, KING 5 television profiled Shawn Murinko, a disability rights expert and attorney at the Washington Department of Health, who was stuck in Harborview Medical Center in Seattle for more than six months following an accident. The crisis prompted Murinko and Disability Rights Washington to file a lawsuit against the state alleging that developmentally disabled clients in Washington are “being stranded” in hospitals because community-based services are not available. Christopher Davis was admitted to Sacred Heart not because he had a medical condition that required hospitalization. Rather, he was admitted because he was too unstable to be released back into the community, or what the hospital calls a “social admit.” “It's just a mess,” said Beverly, who visits her son at the hospital most days. She says Christopher is confined to his hospital room, outfitted with a special restraint vest designed to keep him in bed, and sometimes placed in wrist restraints. Recently, Beverly said, it took four security guards and four nurses to get her son back into bed. In this photo, Christopher Davis, who is autistic and nonverbal, is shown restrained to his hospital bed in Spokane. He has been hospitalized for more than eight months without a medical need to be there.



Sacred Heart hospital officials couldn't speak to specific cases, but said restraints are used as a last resort to keep patients safe. While lawmakers have started responding to the crisis that leaves people like Christopher in this position, there are no immediate fixes and a long-term solution could be years off.

Credit: Courtesy of Deborah Davis



'A tipping point' Besides the toll on individuals and their families, these patients are putting a strain on hospitals, which have a limited number of patient beds and are often not reimbursed for the cost of caring for people who don't have a medical need for hospital-level care.

“It kind of has hit a tipping point,” said Peg Currie, the chief executive of Sacred Heart Medical Center and Holy Family Hospital in Spokane. On any given day, Currie said, as many as 110 of her hospitals' 700 patients are individuals who are medically stable, but can't be safely released from the hospital. These “long-length-of-stay” patients, as they're known, typically remain in the hospital for six to eight months until an appropriate long-term placement can be found. In one case, a patient stayed two years. “It's the highest cost environment to get health care, and hospitals aren't really the place to be when you want to breathe fresh air and you want recreational therapy and to try to live a little bit more of a normal life,” Currie said. In 2018, long-length-of-stay patients accounted for 11,000 patient days at Sacred Heart and Holy Family hospitals, Currie said, as well as roughly $12 million in uncompensated care. Last summer, the Washington State Hospital Association surveyed 11 hospitals in the greater Puget Sound region and found that 1,441 patients stayed an average of 67 days beyond what was medically necessary.

In some cases, the patients arrive at the hospital with an acute care need and are admitted, but remain at the hospital after they are ready to be discharged. In other cases, like with Christopher Davis, there was never a medical need for hospitalization. In either scenario, the cycle begins when a caregiver brings the person to the emergency room -- for medical treatment or because their behaviors have become unmanageable -- and then can't or won't take the person back. “And they can't be discharged to the streets, so it really presents a social conundrum to everyone involved,” Currie said. Workforce crisis The state of Washington, hospitals and advocates say the crisis of people stuck in the hospital has been building in recent years as the state's population swells, the needs of clients become more complex and as community-based providers struggle with a gaping workforce shortage, particularly among direct care staff. “I hear every day from providers who say I would … be able to serve this client, but I don't have enough staff and I'm struggling to recruit and retain staff,” said Bea Rector, director of Home and Community Services, a division of Washington's Department of Social and Health Services.

As of Aug. 20, 356 Home and Community Services (HCS) clients were hospitalized, including one who had been waiting to leave the hospital for 289 days. A quarter of the clients had a diagnosis of dementia, making them particularly hard to place in the community, because the number of beds available for Medicaid-paid dementia care is limited. Earlier this year, the hospital association asked state lawmakers for a $10 million increase in Medicaid long-term care payment rates for patients living with dementia, but that was not included in the 2019-21 state budget. Rector said her division is working to develop more specialty contracts with providers to care for the most difficult-to-place clients, such as those with dementia who exhibit assaultive behaviors. Currently, HCS has 74 contracts serving 855 clients with dementia. “That's part of the solution,” Rector said, adding that her agency may also ask lawmakers for an increase in specialty provider rates next year. Christopher Davis represents a second, smaller, but more vexing group of patients who are stuck in the hospital. They are clients of Washington's Developmental Disabilities Administration (DDA), which provides residential services to about 4,500 clients. As of Aug. 27, 17 DDA clients, including three younger than 18, were waiting to transition from the hospital to a community-based setting. That was down from 24 clients in February. Of the 17, two clients had been offered placements, but either the client or their family declined, according to DDA. “Our numbers are small, but I have to tell you even one individual that's in the hospital longer than they need to be is one too many,” said Evelyn Perez, the assistant secretary who oversees DDA. The average length of stay in the hospital for DDA clients is 107 days, according to the agency; the longest stay to date is 255 days. Perez said a growing demand for DDA services combined with a shortage of community providers has put a strain on the system in recent years. Providers of in-home care for DDA clients, known as supported living, report that front-line staff turnover is 50 percent, according to the state. This year, Washington lawmakers funded a 13.5 percent increase in reimbursement rates for supported living providers. That one-time increase, which takes effect in January, falls short of the 20 percent increase that was requested. The budget also funds seven additional state-operated residential beds for DDA clients and a handful of crisis diversion beds beginning in 2021. But Perez cautioned it's not enough to solve the problem. “We are doing all the things we can within our resources,” Perez said. “[But] until the bigger systems are fixed … this is a challenge.”

Credit: Courtesy of Deborah Davis