Discussion
In this study, we found that patients experiencing delays in discharge were more likely to be older, unhoused and discharged to a postacute care or home health facility. Patients with private insurance or Medicare were less likely to experience a delay in discharge.
Our findings are consistent with those from other studies that found systems issues—such as affordable housing, insurance coverage or bottlenecks in discharge destinations—are the main driver of excessive length of stay, rather than severity of illness.7 14 15 Although several studies found that severity of trauma is associated with delays in discharge,7 8 16 this relationship is likely correlative rather than causal, because increased illness severity is associated with disposition to SNF or a rehabilitation facility.14
Discharge destinations for unhoused patients are sparse and often unsafe. According to one study in an academic medical center, 27% of unhoused patients were discharged after dark and 11% reported sleeping on the street on the first night of discharge.17 In general, unhoused individuals experience much higher rates of assault and violence and emergency shelters offer little privacy, stability or resources for physical rehabilitation.18 Medical respite programs, designed to provide care to unhoused individuals too sick for shelter but too healthy for the hospital, have been shown to reduce hospital readmissions and improve housing outcomes.19 Yet, San Francisco has only 75 medical respite beds for a homeless population over 8000,20 21 leading to wait times that can exceed several weeks. Rehabilitation facilities also have long wait times. Nationally, private payments for nursing homes have risen more quickly than inflation, suggesting a growing shortage.22
Insurance coverage can contribute to delays in discharge as well.9 23 California has one of the lowest Medicaid reimbursement rates in the USA, which disincentivizes postacute care facilities, such as SNFs, from accepting patients on Medicaid.24 Unlike other patients at our safety net institution, who are predominantly on public insurance, trauma patients have diverse insurance plans since they have little control over where they are admitted. We found patient with private insurance had a lower chance of experiencing delays in discharge, reflecting higher reimbursement rates.
Zip code of residence had no significant effect on likelihood of experiencing a delay, suggesting that coordinating with geographically distant discharge destinations did not increase the chance of experiencing a delay. We were surprised by this finding because discharge criteria can vary by postacute care facility and county, and the San Francisco Health Plan only provides coverage within the boundaries of San Francisco. One possible explanation is social work and case manager staff at our institution may be sufficiently familiar with the requirements of geographically distant discharge destinations.
Our findings point out the need for increased investment in postacute care centers and affordable housing. Such investments are particularly critical in light of the COVID-19 pandemic, which is projected to increase strain on discharge destinations and hospital beds.25 In anticipation of growing COVID-19 cases, many hospitals have attempted to increase their bed capacity by safely discharging patients and canceling non-emergent procedures.26 Reducing delays in discharge allows hospital beds, an increasingly precious resource,27 to be used more efficiently. By decreasing delays in discharge, investments in postacute care centers and affordable housing are also likely to reduce recovery times, risk of hospital acquired infections and overall patient morbidity.2
Our study has several important limitations. Although our findings are consistent with research conducted in other settings,7 15 we only studied delays in discharge at a single institution, which may limit the generalizability of our results. In addition, the number of unhoused patients is likely under-represented because patients with ‘unknown’ housing status were considered housed. Furthermore, we did not collect information on the prevalence of marginally housed patients. Although prior research has suggested that injury severity does not contribute to delays in discharge,8 we did not consider medical diagnosis in our analysis. Transfer from the inpatient trauma service to the ‘lower level of care’ service was a decision made by a multidisciplinary care team, and although there were predetermined criteria for transfer, team members rotate on the service, introducing personal variability on how criteria were applied. This may also underestimate delays in discharge, given staff had to make a decision to transfer a patient from the inpatient census to the lower level of care census. Finally, we did not analyze the financial impact of delays in discharge. However, the average reimbursement rate for a hospital day at ZSFGH is $2700, and days spent on the lower level of care service reimburse at only a fraction of that rate (as low as $0/day for patients remaining in the hospital for only behavioral observation). With 1147 total patient days delayed in 2018, the total opportunity cost of discharge delays is likely on the order of millions of dollars.
In conclusion, our results suggest that older patients, unhoused patients, patients with MediCaid or San Francisco Health Plan and patients discharged to a postacute care facility were more likely to experience a delay in discharge. Policymakers should seek to address the root causes of delays in discharge. Efforts to reduce delays in discharge should be directed to addressing homelessness, lack of adequate insurance and investing in increased availability of postacute care rehabilitation beds.