Task force report attempts to unpack hospital discharge backlog problem
Photo | Courtesy of Stephen Andrews via Unsplash
A recent task force explored smoothing the hospital discharge process.
A task force focused on ameliorating the logjam of patients waiting to be discharged from hospitals to post-acute care settings has offered a string of legal remedies that overlap with some legislative prescriptions that cleared committee hurdles last session.
Each day, more than 2,000 patients remain stuck in hospitals even after being cleared to leave.
Some patients can end up waiting more than 30 days, with delays exacerbated among patients who have complex needs, including behavioral health problems, dementia, substance use disorders, housing instability, involvement in the criminal justice system, or end-of-life care requirements, according to the task force's recently published report.
The Massachusetts Transitions from Acute Care to Post-Acute Care Task Force partially attributes the bottleneck to patients lacking legally authorized decision-makers, such as a health care proxy or an advanced directive.
Through a health care proxy legal document, Bay Staters can appoint a trusted individual to make care decisions on their behalf should they become unable to do so, according to the Massachusetts Medical Society. That could include when patients are in a coma or temporarily unconscious, or have a condition that prevents them from communicating.
"When no proxy is available or activated, hospitals must often pursue time-consuming guardianship proceedings that vary by county," the task force report says. "Additionally, the lack of a statutory 'next of kin' surrogate decision-making authority and supported decision-making authority compound these delays."
The task force, created by the 2024 long-term care reform law, was chaired by Joanne Marqusee, assistant secretary for operational effectiveness at the Executive Office of Health and Human Services.
After acute care hospital visits, patients can transition to a variety of care settings, including inpatient or outpatient rehab, skilled nursing homes, or home health care. Beyond legal barriers that sometimes force patients to remain in the hospital longer, the task force said other bottlenecks come from capacity constraints and workforce shortages; insurance complexities; fragmentation across the care continuum; and struggles to arrange non-emergency transportation.
Throughput challenges existed before the pandemic, but COVID-19 magnified the problem and "created a large volume of patients who are ready for discharge from hospitals but cannot find an appropriate bed in a post-acute care setting," according to the Massachusetts Health and Hospital Association.
The task force said it supports legislation that would create a "default surrogate hierarchy" for patients who lack the capacity to make their own health care decisions and don't have an appointed health care proxy. Ensuring a "fallback-decision maker" could "prevent discharge delays, reduce emergency guardianship filings, and enable timely care decisions for incapacitated individuals," the report says.
The panel pointed to several health care proxy bills, including a Rep. Carole Fiola bill (H 1692) that the Judiciary Committee redrafted (H 4329) and shipped to the Health Care Financing Committee on July 30. That measure outlines circumstances in which attending physicians can tap surrogate decision-makers to act on behalf of an incapacitated person. The surrogate would incorporate the patient's religious or moral beliefs, or make decisions in the patient's "best interests" if their personal wishes are unknown.
Similar legislation last session stalled in the House Ways and Means Committee.
The task force also supports legislation that would create legal recognition for supported decision-making, saying the model reduces "the need for guardianship" and "preserves autonomy while supporting timely discharge decisions for adults with retained decision-making capacity." The panel pointed to a trio of bills that are awaiting a hearing before the Committee on Children, Families and Persons with Disabilities.
Proposals from Reps. Jay Livingstone and Michael Finn and Sen. Joan Lovely (H 261 / S 155) would allow adults, including those who are older or have disabilities, to enter into voluntary supported decision-making agreements. Adults could receive help from "supporters" as they make choices about where they want to live, and the types of services and medical care they want to receive. Similar legislation died in the House Ways and Means Committee last session.
In another recommendation, the task force said it backs legislation that would fund public awareness campaigns aimed at recruiting retired health care providers and other qualified individuals to serve as volunteer guardians, who also make decisions on behalf of incapacitated individuals. Those proposals from Rep. Thomas Stanley and Sen. Pavel Payano (H 1412 / S 903) had a hearing before the Health Care Financing Committee on July 1.
"Expanding public guardian programs and recruiting volunteers addresses the persistent shortage of available guardians, which contributes to discharge delays and prolonged hospital stays for individuals without decision-makers," the report said.
The Massachusetts Guardianship Policy Institute said the need for guardianship is expected to grow amid the state's aging population. The commonwealth is poised to see an explosion of its 85+ population, which could strain skilled nursing facilities and rest homes that are already struggling to hire enough staff and secure sufficient public funding to keep up with demand for care.
The panel also issued recommendations to standardize hospital discharge paperwork, develop a post-acute system dashboard to show bed and service availability, accelerate discharge to hospice and end-of-life care, monitor prior authorization reforms from the long-term care law, explore the creation of a referral tool to home- and community-based services, expand reimbursement of mobile integrated health programs, support workforce development initiatives, and develop clear discharge and referral processes to Department of Mental Health and Department of Developmental Services group homes, among other policies.
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