'Boarding' Patients for Days, Weeks in Crowded ERs is Common Now

Medical Xpress / By Denise Mann

When Hannah, a California marketing professional, showed up at her local emergency room in March 2023 for a pregnancy-related complication, she wasn't prepared for what happened next.

"I arrived at 2 p.m. and finally saw the obstetrics team at midnight," she recalled.

After an exam, doctors scheduled her for a procedure on the following day, but there wasn't a room available. "I ended up spending the night in a makeshift room in the lobby of the emergency room with a plastic sheet separating me from the rest of the people waiting for attention," Hannah said.

Unfortunately, this is not rare in U.S. emergency departments. Millions of people a day go to emergency rooms to seek care, but many, like Hannah, end up in a holding pattern due to overcrowding.

This is known as boarding, and experts say the problem is only getting worse.

"We are facing a national public health crisis," Dr. Aisha Terry, associate professor of emergency medicine at George Washington University School of Medicine and Health Sciences in Washington, D.C., and ACEP's president-elect, said Tuesday.

Speaking at an ACEP press briefing, Terry said that "emergency departments are overflowing, emergency physicians are overwhelmed, and patient care is at risk."

Research consistently shows that boarding leads to worse outcomes, medical errors, privacy issues and in some cases, death, she said.

Some people spend weeks, even months, waiting to get a room in the hospital or be transferred to an outside facility.

"It's jaw-dropping when you think about the length of time that people are waiting in the emergency department since there is no space to care for them," Terry said.

Boarding has been an issue for decades, but stresses owing to the COVID-19 pandemic such as staffing shortages and an uptick in mental health conditions have made it much worse.

In a new ACEP poll of 2,164 U.S. adults, 44% of respondents said they or a loved one experienced long waits in emergency departments, with 16% waiting 13 or more hours before being admitted or transferred. Almost half of adults surveyed said they would delay emergency care if they knew they could face boarding.

In all, 42% said hospitals should be primarily responsible for improving the situation, while 17% said Congress should pass legislation addressing boarding. Sixteen percent said insurers should ease cumbersome prior-authorization policies that can result in days-long waits for transfer to a skilled nursing facility.

Nine in 10 respondents consider emergency medical services (EMS) essential, roughly the same percentage who said additional or supplemental government funding for essential services should be a priority.

The poll has a margin of error of plus or minus two percentage points.

One health care worker quoted in the ACEP's presentation to journalists said, "Last week our 22-bed emergency department had 35 boarders and an additional 20 patients in the waiting room. Longest boarding time this month was over 200 hours with averages around 70 hours per patient. In addition, we have patients who unfortunately have died in our waiting room while awaiting treatment. These deaths were entirely due to boarding."

Terry told reporters that resource and staff shortages can't be accepted as the new normal.

"We need action now to preserve the safety net for the lives we work every day to save," she said.

ACEP has suggested creating a regional dashboard of available beds that emergency departments can use when needing to place someone. In addition, reimbursement incentives for hospitals that transfer people to avoid extreme boarding could also make a difference, the group suggests.

Terry added that tuition reimbursement, stress relief programs and suicide prevention services need to be available for health care workers to help address the staff shortages. Laura Wooster, senior vice president of advocacy and external affairs at ACEP, agreed.

She added that some groups such as kids in mental health crises are disproportionately affected by staffing shortages and emergency room boarding situations.

Addressing the crisis starts with efforts to increase the number of beds available for these kids in the community, Wooster said. Mental health mobile crisis teams can also help reach these kids where they are, she added.

Report: CMMI has Raised Federal Spending, Not Lowered it

Fierce Healthcare / By Noah Tong
 
The Center for Medicare and Medicaid Innovation (CMMI), once expected to save money and deliver healthcare at a lower cost, is increasing federal spending after all.
 
A report from the Congressional Budget Office (CBO) shows that the office increased direct spending by $5.4 billion between 2011 and 2020. CMMI spent $7.9 billion to operate models, but those models only reduced healthcare benefits spending by $2.6 billion.
 
The new figures reflect a stark contrast from CBO’s projections when the Affordable Care Act (and CMMI) was first enacted. CBO believed at the time that CMMI would reduce spending by $2.8 billion and lower spending on benefits by $10.3 billion, offsetting the $7.5 billion needed to operate CMMI’s models.
 
CBO now anticipates spending will increase an additional $1.3 billion from 2021 to 2030, though the office notes that the “budgetary effects of CMMI’s activities over the first decade and its updated projects are subject to considerable uncertainty.” For example, the report did not capture savings that were gained by accountable care organizations (ACOs) through the Medicare Shared Savings Program.
 
The agency believes that its incorrect projections can be attributed to several factors.
One, CBO thought that CMMI would continue to find models that reduced spending, but after the first two models were certified, the rate of certification declined over time. Second, CMMI models are largely voluntary, meaning providers can choose models that have positive financial outcomes and drop models that have the opposite effect. CMMI has discussed implementing mandatory participation for this reason. Third, CBO said it did not realize CMMI models would contradict within health systems, creating conflicts for providers, as well as payment policy changes.
 
Several days before the CBO report was released, Senate Budget Committee members briefly praised the CMMI for working to lower spending, prematurely praising CMMI during a hearing on Medicare solvency when it did not actually lower spending.
 
Blair Childs, president and CEO of healthcare communications company Childs and Associates and a senior executive advisor for Premier Inc., said the CBO report is “missing the forest for the trees.”
 
“We are undergoing a tectonic shift in the incentives in healthcare payment,” he said in a LinkedIn post. “This is due to a bipartisan movement to shift payment from fee-for-service to accountable, value-based care. CMMI is a key player in making that change a reality under traditional Medicare and Medicaid. While Washington skeptics don’t want to stick their heads out and attribute this spending decline to the movement to value-based care, I submit that, based on strong evidence, it is the dominant cause of this change.”

Diabetes Multiplies Hospital Admission Risk for Home Health Patients, Study Finds

McKnight’s / By Adam Healy
 
Home health patients with diabetes are three times more likely to be hospitalized than those without, according to a new study published in Nursing Outlook. 
 
Almost half of home health patients suffer from diabetes. According to the study, it is one of the most common chronic conditions among people in this population. Among 5,300 community-dwelling home health patients with diabetes, the study recorded a hospital admission rate of 29.5%, affected by risk factors such as past hospitalizations, decreased performance in activities 
of daily living, depression or unhealed acute injuries.
 
The researchers compared this to people with diabetes in assisted living. These people may struggle more with activities of daily living or have greater cognitive impairments, the study noted, but they had a lower rate of hospital readmission due to access to round-the-clock assistance, meaning they were able to receive more timely preventive care 
 
For home health patients, one of the best predictors of hospital readmission was whether a person had been hospitalized in the past six months. Home health patients who had been recently hospitalized were more than twice as likely to be readmitted. Another strong predictor was someone’s function completing activities of daily living. The participants who struggled to manage their daily activities were more likely to be hospitalized. 
 
Conditions such as depression, decreased cognitive function and unhealed acute injuries like ulcers were all found to impact people’s ability to manage activities of daily living. While assisted living patients had greater access to support for these conditions, home health patients who lack access faced a higher risk of hospitalization, according to the study. Therapy services and other health interventions can help manage these conditions and help prevent rehospitalization, the researchers noted. 
 
Other research has found that staffing problems in the home care industry may lead to discontinuity of care, which can increase a patient’s risk of hospital readmission.

President's Message

Posted: October 4, 2023

Last week, APTA released a ground-breaking report titled, “The Economic Value of Physical Therapy in the United States”. This report analyzed the savings per episode of care that physical therapy services yield for eight common conditions. Sophisticated economic modeling was used to determine the true value that physical therapy provides for conditions such as osteoarthritis of the knee, vascular claudication, fall prevention, low back pain, and cancer rehabilitation. Savings per episode of care for these conditions ranges from a few thousand dollars to upwards of ten thousand dollars.

The take home message from this important study is: “Choosing physical therapy helps Americans live better lives and could save the health care system millions of dollars annually, ultimately providing more resources for better services to individuals and communities nationwide. Physical therapy helps Americans avoid complications from surgeries, long recoveries, and the risks of overuse of prescribed opioids and other medications.” In other words, this scientific work proves what we have been saying for years.

This study was funded by APTA (your dues at work!) and led by a group of physical therapists, including APTA Home Health member Jason Falvey, PT, DPT, PhD. Included in the report is a list of several more common health conditions that have been identified for inclusion in later versions of this report pending staffing, funding, and improved evidence around each condition.

You can find more information and download your own copy of this study at http://valueofpt.com.

Sincerely, 

Phil Goldsmith
President
APTA Home Health