Dr. Ray Moreno, chief medical officer at Providence St. Vincent Medical Center in Portland, Oregon, was part of a state task force charged with coming up with ideas to address hospital discharge delays.
In November, the Joint Task Force on Hospital Discharge Challenges released a 105-page report with its nine recommendations on how to address challenges the report says persist "as hospitals serve an aging population with growing needs for mental health, addiction, and housing supports that the traditional
post-acute care model was not designed to address."
Moreno
Moreno spoke with Catholic Health World about the work of the task force. His answers have been edited for length and clarity. Providence St. Vincent is part of the Providence St. Joseph Health system.
How did you come to be part of the task force?
I was nominated, and I was happy to be. I think the reason they tapped me on the shoulder was in September 2022 I had the opportunity to talk about the impact of discharge delays on hospital capacity at an Oregon Senate hearing. I had been looking at
the data on length of stay, collaborating with many Providence colleagues. As we were looking at the data, there was this staggering realization that the impact of patients stuck in the hospital was very, very large.
How long did the task force work on its report?
One year. We had meetings almost every month, for about four hours. It was a cross section of Oregonians: a senator, a representative, representatives from the legislative office, from the governor's office, from nursing homes, long-term care, hospitals
and others. It was a very broadly representative group.
How significant a concern has hospital discharge been for Providence facilities in Oregon?
We looked at a year's worth of data spanning September 2022 through August 2023. We were looking at how long patients are staying in the hospital that is longer than is expected. There's a certain amount of expected time based on their conditions, ages,
the complaints that they come in for. When you add the extra time across our eight Providence hospitals, it was 5,700 extra days per month.
If the expected average length of stay for a patient is about five days, you take that 5,700 days and divide that by five, that gives you over 1,100 extra patients that you could care for a month, if you could solve this global problem of people being
in the hospital longer than expected.
When you saw the stats, were you surprised?
When you're working in the hospital, you see them a little bit at a time, so you're zoomed in too far. I think when you're zoomed in, you don't appreciate how those weeks and days add up.
Oregon has one of the lowest numbers of beds per capita in the United States, so we're always a little full. As we worked through the data, we wondered where can we make more capacity. We can't build any more beds quickly enough. Where are the opportunities?
It isn't just Providence that's experiencing this kind of discharge delay, right?
We were not unique. Oregon Health & Science University, for example, also shared data that seemed equally impressive. So we were not alone at all.
What do you see as the major factors that are driving discharge delays?
Some patients are truly very complex, medically, and sick, for sure. That's part of it. But the eligibility assessment and approval for long-term services and support take a long time, so that accounts for some of the delay. Sometimes there are simply
no places that have space. Sometimes patients don't have their own decisional capacity, and there's not an identified person who has that capacity. It can take months for someone to get an Oregon-appointed state public guardian.
Are there any particular situations related to discharge delays that stand out in your memory?
One example is someone with very little income who needs long-term services and support. They have an old car that's worth $4,000 but the asset limit is $2,000 before that person can qualify for assistance. We need to figure out a disposition for that
car. This is amazing that a hair over $2,000 in assets makes it that much more difficult.
Another example: Let's say you need time in a skilled nursing facility. You have an orthopedic injury. You're expected to be able to recover, but you need time to get your strength and your balance and the muscles to work again. Private insurance pays
for a certain number of nursing home days. Medicare pays 100% of the first 20 days, and then 80% from 20 to 100 days. Medicaid pays 20 days, full stop.
Every other week or so, we'd encounter a patient that needs a skilled nursing facility next, but they have Medicaid. We know we're going to have a hard time finding anybody to take them, because it's only 20 days of coverage. Understandably, those facilities
that are providing this care are worried that those 20 days don't match the average length of stay in a skilled nurse facility, which is longer.
What do you see as the task force's key recommendations?
I think it is tempting to try to boil the ocean for a big problem like this. It's really complex. But I think, because this was a legislative task force, we tried to be really practical and focused on the things that government can do.
One that I think is important is updating the eligibility process and the workflows for obtaining long-term services and support. The eligibility assessment has two parts — a medical/functional assessment of what the patient needs to help them with their
daily living and a financial assessment. By statute, there are 45 days that that assessment can take if you're in a hospital. That's 45 days that patient could be waiting in the hospital. So there was a lot of support on the task force for streamlining
that process.
Another recommendation that I think will be impactful is having Oregon Health Plan (the state's version of Medicaid) increase skilled nursing coverage from 20 days to 100. That would capture many patients who are kind of stuck.
Any other recommendations that stand out?
I think there are a couple of things that you could broadly lump together, under the heading of fixing the economics. For example, during the pandemic, when we were particularly constrained, there was a hospital decompression initiative. For a period
of time, the state said to our adult foster homes, we know that it's difficult to take care of sick people with multiple things going on in a system that was designed a couple of decades ago for folks that weren't as sick. So the state had a one-time
incentive of, in addition to the regular payment, an extra $10,000 — $5,000 up front, and $5,000 in the future, if that patient was still living with them. It was amazing. At that price point, these places were able to pull extra resources and staff
into their facilities. And we saw a moment of rapid decompression of the hospital.
It's very clear that we have to figure out how to have a contemporary model of reimbursement for the various places that take care of people after the hospital in a way that is affordable and reflects the cost of taking care of folks who are too complex
to be at home, but not complex enough to be in the hospital.
Are the poor and people who are unable to make their own health care decisions more likely than others to have to stay in acute care hospitals longer than necessary?
Yes, on both counts. Being poor gives you fewer resources and these things require lots of complicated, complex decisions. If you can't make those for yourself, it's harder to involve other folks in that decision-making process. If you're lucky, you've
got trusted loved ones who can help you with this. And if you don't have that, then it becomes really, really hard.
How confident are you that the task force's recommendations will be enacted?
I'm hopeful, because I think we had all the right people on the task force. Twenty-two stakeholders spent a year looking at this problem from different angles. It was a nice example, it was a hopeful example, of how you can bring people together to work
on a hard problem.