Overcrowded hospitals gain financial relief from state

Minnesota hospitals have reported nearly 14,000 instances this year in which patients were stuck in their emergency rooms or inpatient units because nursing homes or other step-down facilities couldn't or wouldn't take them.

Hospitals tallied these boarding cases in the first five months of 2023 to apply for $18 million in state compensation and in doing so offered the first detailed evidence of a problem that is causing overcrowding and delaying patient care.

About 580 patients were boarding in Minnesota hospitals at any point in time, according to a Star Tribune review of the hospitals' requests.

"That is an egregious number of patients who are sitting in hospitals waiting for appropriate transfers," said Mike Phelps, chief executive of Ridgeview Medical Center in Waconia, which reported 343 incidents and is slated to receive $310,000 in state support.

Patient boarding has long been recognized as a lose-lose-lose problem, because hospitals don't get paid by insurers for extended stays, patients languish in their recoveries, and emergency rooms get backlogged. But the number of boarding incidents this year even caught hospital executives like Phelps by surprise.

The majority of patients stuck in hospital ER bays or inpatient rooms had mental health, behavioral or substance abuse issues and needed transfer to residential or outpatient treatment programs that had no openings.

Hospitals boarded 1,022 children in their emergency rooms because of behavior problems, including foster children that county child protection workers struggled to place anywhere else. One child boarded for months at Ridgeview over the past year, and some of his outbursts resulted in injuries and prompted one worker to file a police report.

Some boarding is inevitable at times of peak demand, such as the winter flu season, because hospitals are required by federal law to treat all patients who walk in their ERs. Closures and worker shortages at nursing homes have exacerbated the problem.

Hospitals reported thousands of incidents in the first half of 2023 in which they couldn't transfer older adults because nursing homes had no space or declined to take them. The boarding cases involved patients with obesity or disabilities, or required complex wound care or intravenous medications.

Worker burnout from the COVID-19 pandemic made matters worse, and nursing homes haven't regained the expertise they lost to handle such patients, said Dr. Will Nicholson, vice president of medical affairs for M Health Fairview's St. John's and Woodwinds hospitals in the East Metro.

"The mental health crisis established sooner and has grown faster ... but we're seeing the same type of gaps in care now for elderly folks and people with complex medical needs," said Nicholson, who reconfigured his ERs in response to the backlog so they can treat and triage patients in waiting rooms when needed.

Lawmakers earlier this year proposed spending more than $200 million to compensate hospitals and provide incentive payments to nursing homes to accept high-need patients they might otherwise refuse.

The idea was shelved until the last week of the legislative session, when budget negotiations freed up $300 million to support nursing homes. The funding came without incentives to accept complex patients, but should help by allowing nursing homes to increase staffing and open beds, said Joe Schindler, vice president of finance policy and analytics for the Minnesota Hospital Association.

That left $18 million to compensate hospitals this year for all boarding cases in their emergency departments, and any cases in inpatient units beyond seven days in length. The state had been willing to pay up to $1,400 per day, but at that rate it would have needed $63 million. Instead, each request was funded partially at $395 per day.

"That amount is appreciated and it is a drop in the bucket compared to the cost of managing the crisis," Nicholson said.

Large hospitals predictably gained the most compensation — with more than $2 million earmarked for Mayo Clinic in Rochester and M Health Fairview University of Minnesota Medical Center in Minneapolis.

The average ER boarding delay lasted a day and a half, but some were longer. Mayo's Mankato hospital is scheduled to receive $379,000, because the average delay was 20 days for the 33 patients who got stuck in its ER.

The 6,771 inpatient boarding cases lasted 11 days on average until patients were discharged, but hospitals only included them in state funding requests if they were a week or longer. Shorter boarding incidents went unreported.