Patients staying past their stays

[Iamnew2]

WAnted to get some feedback on this issue.
We have some patients that just love our facility and they are not necessarily safe to go home but their medicare/insurance days are over or we can't find placement as the SNFs are full. Currently they are essentially allowed to stay in house until a SNF eventually takes them - sometimes they go over their stay by 2 weeks or more. I am horrified by this. Until I became med director this year, the hospital has essentially lost money, not until this year when I essentially doubled their census did they start making a very healthy profit. However I find this insane. How do you all deal with this?

Thank you all

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[Momentum70]

WAnted to get some feedback on this issue.
We have some patients that just love our facility and they are not necessarily safe to go home but their medicare/insurance days are over or we can't find placement as the SNFs are full. Currently they are essentially allowed to stay in house until a SNF eventually takes them - sometimes they go over their stay by 2 weeks or more. I am horrified by this. Until I became med director this year, the hospital has essentially lost money, not until this year when I essentially doubled their census did they start making a very healthy profit. However I find this insane. How do you all deal with this?

Thank you all

Im assuming that you mean IPR patients that are not well enough and it is past the CMG days so trying to move to SNF. I've gotten better at looking through a prescreen and estimating the amount of time I will get and what level I think the patient will get to by the time they are done. If they dont have a support system that can take them in that condition then I dont admit as the dc plan will most likely be to SNF if they have certain insurances. For instance United medicare replacement policies loves to blanket deny transition to SNF. They say we approved IPR so they would not go to snf now its your mess to deal with.

 

[RangerBob]

We rarely have issues with ins auth to SNFs where I practice, so I don't worry as much about that as the above poster.

The reason we get stuck with patients for more than a few extra days is because family support drops off and no SNF will accept them. So they stay on our unit until they get independent or an out of area SNF finally accepts them. Our longest stay was about 6 months for a patient who became homeless when admitted and was declined by all SNFs. Eventually an out of area one accepted him. Usually it's more like a week or two over that patients go.

If it becomes known that the pt is going to require a SNF (family backs out, just can't provide the needed support based on how they're doing, etc.) then we start referrals right away, so usually SNF discharges don't go much over their estimated days. Unfortunately most gains made on IPR are lost at a SNF, but we can't fix that.

 

[Iamnew2]

We rarely have issues with ins auth to SNFs where I practice, so I don't worry as much about that as the above poster.

The reason we get stuck with patients for more than a few extra days is because family support drops off and no SNF will accept them. So they stay on our unit until they get independent or an out of area SNF finally accepts them. Our longest stay was about 6 months for a patient who became homeless when admitted and was declined by all SNFs. Eventually an out of area one accepted him. Usually it's more like a week or two over that patients go.

If it becomes known that the pt is going to require a SNF (family backs out, just can't provide the needed support based on how they're doing, etc.) then we start referrals right away, so usually SNF discharges don't go much over their estimated days. Unfortunately most gains made on IPR are lost at a SNF, but we can't fix that.

I guess I find it crazy though that a patient would just stay in an IP unit being taken care of while essentially not paying. When did hospitals become hotels? So frustrating

 

[sloh]

I guess I find it crazy though that a patient would just stay in an IP unit being taken care of while essentially not paying. When did hospitals become hotels? So frustrating

But what's the alternative? Surely, you can't just kick them to the curb haha

 

[Iamnew2]

But what's the alternative? Surely, you can't just kick them to the curb haha

Well no, but patients were living somewhere before. If I don't pay my rent or mortgage, I get kicked out, lose my home, etc. We've had some families essentially use the hospital as their vacation time - literally! We had a family that went on vacation - not once but twice! and then coudln't take the patient home because they were on vacation! We've had other families who simply don't want to help. Or want patients to be at a super high level that's not realistic.

 

[RangerBob]

Well no, but patients were living somewhere before. If I don't pay my rent or mortgage, I get kicked out, lose my home, etc. We've had some families essentially use the hospital as their vacation time - literally! We had a family that went on vacation - not once but twice! and then coudln't take the patient home because they were on vacation! We've had other families who simply don't want to help. Or want patients to be at a super high level that's not realistic.

That's when you have the program director show pt/family a Medicare letter saying their LOS is up and they'll be responsible for the ~5k or whatever per day it costs to be on rehab. I think ultimately the hospital would just eat the cost, but technically the pt/family are responsible for payment once we've certified they no longer meet acute rehab criteria. Same would go for private insurance--if their auth is up, technically they're responsible.

We've had to pull the above a handful of times when the patient had met all their rehab goals and was safe for dc, but was either unwilling to leave or family unwilling to take them. Family being unwilling vs unable can be a fine line, but when it's clear the resources/availability is there we push harder. We always err on the side of the patient/family, so it's rare for us to have to resort to above tactics.

I like to set expectations from the get-go and tell patients if I think they'll be here about one week, two weeks, or occasionally 3/3+ weeks, etc. Then CM/SW's job is to get family prepared and ready. We always do caregiver training a few days ahead of dc to help out patients and family feel ready, so like I said it's really not too often we actually run into the above situation. More common is they legitimately have no safe dispo option and we're just waiting for a SNF bed.