With no place to go, some patients in Maine spend months in hospitals
Mar. 5—Susan Cameron spent 164 days this winter in the same small hospital room at Southern Maine Health Care in Biddeford — a gray room with a view of the parking lot.
Cameron was ready to be discharged weeks after being admitted for a series of breathing problems. But, like hundreds of other patients around the state, the 76-year-old remained hospitalized longer than necessary — in Cameron's case months longer — because she could not find a bed in a nearby assisted living facility and was not well enough to go home.
Hospital officials say there's a glut of patients stuck in the same limbo, although there is no statewide data to measure the scope of the problem. The backup is creating a domino effect, hampering patient care and jeopardizing the finances of health services, both at hospitals and long-term care facilities.
It's a bottleneck that is straining hospitals and frustrating patients nationwide. Staffing shortages at long-term care facilities, such as nursing homes, rehabilitation centers and assisted living centers, are the primary driving force behind the problem.
"I got here Sept. 4 and I'm still here," said Cameron on Feb. 16 from her hospital bed, hours before she was finally discharged. But Cameron said she understands her predicament was not the fault of the hospital, but rather a lack of supply at nursing homes and assisted living facilities.
"What were they going to do?" she said. "They couldn't put me out in the street. So here I am."
Cameron was discharged on Feb. 16 to St. Andre Health Care rehabilitation center in Biddeford. Cameron suffers from COPD and other breathing issues, and she needs a BiPaP — bilevel positive airway pressure — machine to breathe.
While hospital officials say Cameron's situation is far too common in Maine, it's difficult to quantify as statewide data on how many patients are languishing in hospitals is lacking.
But there are signs the problem is acute.
As of Friday, Maine Medical Center in Portland alone had 50 patients who were ready to be discharged but remained stuck at the hospital while waiting for a bed in a long-term care facility.
At Eastern Maine Medical Center in Bangor, the hospital created a "discharge unit" for patients who are ready to be released but don't have a place to go, said Christopher Laird, associate vice president for nursing operations at Northern Light Health. Laird said the 27-bed discharge unit is filled up, and there's a waiting list.
"The system is stretched right now, in every aspect," Laird said.
Hospital officials and those representing the long-term care industry paint a grim picture.
A severe workforce shortage at nursing homes, skilled care and assisted living facilities means the supply of beds for patients to be discharged to is low, while the demand for beds is high.
Despite being licensed for more than 6,300 beds, Maine nursing homes were only able to house and care for about 5,100 residents, according to a November 2022 report. Overall nursing home utilization has declined by about 10% since 2018, according to state statistics.
"Hospitals are not designed for people to live in," said Katie Fullam Harris, chief government affairs officer for MaineHealth, the parent company of Maine Medical Center and seven other Maine hospitals, including Southern Maine Health Care. "They are meant for acute care for people who need that level of care."
Angela Westhoff, executive director of the Maine Health Care Association, which represents long-term care facilities, including nursing homes, said 84% of the facilities reported in a December survey that they had staffing shortages. About 10% of the workforce has left the industry, and so far people are not coming back, she said.
"We've had more people exiting the profession than ever before," Westhoff said. "It's difficult work emotionally, and hard on the body. If you can make $20 an hour flipping burgers, or working at a convenience store, well, that's a tough choice."
Laird said the pandemic exacerbated health industry workforce shortages, and that many people across all professions have stopped working in health care. He said health system recruitment and retention should be a top priority.
But recruiting and retaining employees in a tight labor market takes money.
Westhoff said with low reimbursement rates by MaineCare for services, it's difficult to pay competitive wages. And long-term care facilities have been forced to pay traveling employees, sinking millions into temporary workers. Fifteen long-term care facilities have closed since the pandemic, Westhoff said. Wages vary, and nursing homes have been forced to pay more despite not having the funding to do so, but are often paying less than $20 per hour for unskilled labor.
"It's creating this perfect storm," Westhoff said. "The path we are on is unsustainable."
Westhoff said there's at a minimum $60 million that needs to be infused into the system with state or federal dollars, which would allow long-term care facilities to pay competitive wages. The Mills administration agreed to spend $25 million in one-time federal money to help nursing homes. Westhoff said while that's helpful, it's only putting a Band-Aid on the problem.
"It's very helpful, but it doesn't close the gap," Westhoff said. The Maine Department of Health and Human Services is conducting a comprehensive rate review to reform how nursing homes and other recipients of MaineCare funding are reimbursed. But the rate review is expected to take years, and Westhoff said the problem is immediate.
"How many more facilities are we going to lose in the next two years before we get to the next reimbursement rate?" Westhoff said.
Jackie Farwell, spokeswoman for Maine DHHS, said in response to severe workforce problems at nursing homes that the agency "continues to explore opportunities to address nursing facilities' concerns in the near term."
Maine already has a short supply of licensed nursing home beds despite being one of the oldest states in the nation. According to the Kaiser Family Foundation, Maine's licensed-bed supply was the sixth-lowest in the nation.
Farwell said that in addition to examining what to do in the short term, the state has recently increased funding for long-term care facilities, and is working on longer-range solutions.
"As of December 2022, occupancy at nursing facilities across the state is higher than it's been over the last two years," Farwell said. "Enrollment is up in several home care programs, and wait lists have declined. Although the improvement is slight in some cases, the positive year-over-year data across a number of services suggest that providers have been able to reduce staff vacancies in the past year and the direct-support workforce is stabilizing."
Farwell said the budget includes $47 million in cost-of-living adjustments for long-term care facilities, and the federal government sent $50 million directly to nursing homes as part of COVID-19 relief efforts.
"Maine is making progress in restoring access to a range of long-term support services in the wake of the pandemic," Farwell said.
Westhoff said aside from increasing reimbursement rates, another idea to alleviate the workforce shortage is to offer free community college to workers such as CNAs — certified nurse assistants — and nutrition and housekeeping jobs at assisted living facilities. That would give workers an incentive to take these jobs, she said. A bill before the Legislature would make community college free for such workers.
Harris, the MaineHealth chief government affairs officer, said a similar dynamic is playing out with patients hospitalized for psychiatric reasons who need to be discharged to residential treatment, but can't get into programs because of a lack of supply.
DELAYED DISCHARGES, DELAYED CARE
Harris said hospitals are not set up for comprehensive therapy that helps patients recover, such as physical therapy or mental health counseling. As a result, plans for after-care healing are upended, delaying patient recoveries.
Another ripple effect, Harris said, is that people needing preventive screenings and elective surgeries, such as knee and hip replacements, are having their procedures delayed.
"A delayed cancer screening can result in failing to detect cancer before it has spread. Or a delayed cardiac test can result in a heart attack that could have been prevented," Harris said. "Health care is like an ecosystem, and when one part fails, there are serious consequences on the other elements of the system."
Patients languishing in hospitals also cause myriad financial problems for hospital systems, Harris said. One example is that Medicare will only reimburse what is supposed to be the average length of stay for a procedure. So if a patient ends up at the hospital for two months when they were supposed to be discharged in seven days, Medicare is reimbursing hospitals for the seven-day stay, and the rest of the time the hospital has to pay for patient care.
"It's an untenable situation," Harris said. "These are patients who don't belong in a hospital at all."
MaineHealth operated with a $45 million deficit in fiscal 2021-22, and while Harris said it's not possible to break out how much of the deficit was caused by patients languishing in hospital rooms, it was part of the reason for the deficit. Labor costs, especially the cost of traveling nurses and doctors, are also straining budgets. The deficit would have been much higher if not for a $102 million infusion in one-time COVID-19 relief funds from the federal government, Harris said.
But Harris said despite the financial woes, the most important reason to fix the problem is that patient care is suffering.
Tom and Sandy Verge of Buxton both had to cope with delayed discharges from hospitals.
Tom Verge, 77, suffered a brain injury after falling from a ladder in November 2021. He should have been discharged within two months but stayed at Maine Medical Center until April 2022. Verge, who cannot speak because of the brain injury, is now at St. Joseph's Rehabilitation and Residence in Portland.
Daughter Terry Davenport said her father had to wait on crucial therapy services while being stuck at Maine Med.
"He needed all kinds of therapy. There was all kinds of stuff that he needed that they couldn't do at the hospital," Davenport said. "They kept saying there was no place for him."
In March 2022, Sandy Verge, Tom's wife, fell in the bathroom and punctured a lung and fractured her ribs. She was taken to Mid Coast Hospital before being transferred to Maine Medical Center.
She spent about three weeks longer at Maine Med than was necessary, which she said was frustrating. She was discharged to rehab in the same room as Tom at St. Joseph's, recovered and was back living at home in Buxton. Davenport said on Friday that her mother recently suffered another fall and is back at St. Joseph's rehab.
"I wanted to go home," Sandy Verge said of her extra, unnecessary weeks at Maine Med. "I didn't want to be stuck in the hospital."