The Lack of Rehabilitation Beds Is Impacting Patient Safety and Care

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Dr. Peter Papadakos, Professor of Anesthesia and Critical Care, University of Rochester Medical Center, is co-author of this article.

You are an active 30-year-old professional who enjoys bicycling on weekends with family and friends. One Saturday afternoon, you are out riding in a state park near your home to get some fresh air and exercise. Your bike is suddenly hit by a car. You are critically injured, and air lifted to a level one trauma center. Injuries include a traumatic brain injury (TBI) and several major fractures of both of your legs.

After several weeks in the Intensive Care Unit (ICU) and a number of operations, your medical team tells you that your brain and orthopedic injuries will improve with extensive rehabilitation. The main issue preventing you from leaving the hospital is that there are no rehabilitation beds or facilities available to accommodate you.

Your injuries are healed, and you no longer require acute care in a hospital setting, but you cannot be discharged home as a result of physical instability, weakened muscles and need for physical and occupational therapy delivered by specialists. The hospital is forced to keep you in the hospital and thus delay your ability to return to your normal life. This not only affects you but leads to a backlog in the hospital which has no availability of beds to admit new patients who require acute medical and surgical care.

Emergency Departments (EDs) and operating rooms (ORs) grind to a halt. Massive health care costs ensue, reducing hospital operating margins, ultimately affecting the economic health of hospitals that continue to accumulate losses that can amount to millions per month.

This lack of rehabilitation facilities and post-discharge care has evolved into a major issue over the last several years. The public may be unaware of the barriers to accessing proper physical therapy after routine joint replacement or more importantly complex neurological rehabilitation (neuro-rehab) after a stroke or brain injury.

In several areas of the country, trauma hospitals are straining to care for patients with brain and spinal cord injuries who are stable enough to move to rehabilitation facilities but can’t find one that will take them. The significant advances in neurocritical care medicine mean more people are surviving brain injuries and spinal cord trauma that would have been fatal a few short years ago.

For example, there are patients who need inpatient physical and behavioral health services at specialized rehabilitation centers in order to live independently with their injury. Some of these patients may only reach a level of recovery that requires ongoing and lifelong nursing care, but the harsh reality is that these beds are also not available.

Along with a recent uptick in respiratory viruses throughout the U.S. as we enter the holiday season, the lack of post discharge beds in skilled nursing facilities and nursing homes will further complicate and compound an already dire situation.

Overall, the demands for rehabilitation facilities are greatly outstripping their supply. When these patients cannot transition to a rehabilitation program, they remain in the hospital. This, of course, greatly affects the throughput of any given healthcare system. Ultimately, it runs up costly bills and leaves hospitals at full capacity. Emergency departments (EDs), in turn, are overwhelmed and unable to admit patients to hospital wards.

“EDs are canaries in the coal mine for downstream bottlenecks,” according to Jesse Pines MD, MBA, MSCE, Chief of Clinical Innovation at US Acute Care Solutions, the largest physician-owned emergency medicine group in the U.S., and Professor of Emergency Medicine at George Washington University.

‘When rehab beds are constrained, patients stay in the hospital longer. That means less hospital space for new, admitted ED patients, which increases ED boarding. When boarding increases, there’s less space in the ED. The result is all patients wait longer, and ultimately suffer worse outcomes,’ he added.

But it’s also critical to mention that such bottlenecks prevent the operating room from functioning at full capacity due to lack of inpatient bed availability. Importantly, the operating room serves as a major source of revenue to the majority of hospitals regardless of their size.

While the crisis has greatly affected nursing homes that care for the elderly population, it’s also affecting facilities that provide short term rehabilitation services for many orthopedic and surgical procedures.

Simply put, the pandemic devastated U.S. nursing homes by exposing many long-standing weaknesses and logistical issues in the realm of post-discharge care. Such facilities predominately care for two groups of patients: short term patients for post-acute rehab with Medicare coverage and long-term residents with only Medicaid coverage. Medicare is a relatively generous payer, whereas Medicaid often pays below the actual cost of caring for such frail and medically complex patients.

During the pandemic, it wasn’t possible for “short-term” patients to be admitted to rehab, chiefly the result of a decline in elective surgeries which significantly buttressed the economic health of these facilities. Many of these facilities were forced to downsize or even close. Staffing issues were also greatly exposed, including nurses, physical and occupational therapists leaving these facilities to enter other sections of the health industry such as acute care hospitals and outpatient physical therapy practices to just name a few. Many also left healthcare due to retirement or from the widespread burnout that health care workers experienced during the pandemic.

This staffing crisis has led the Biden administration—through the Center for Medicare and Medicaid Services (CMS)—to begin a year-long study and propose new mandatory minimum staffing standards for long-term care facilities to not only enhance patient safety, but reduce burnout and moral injury among healthcare workers. While this is a noble goal, it may actually add to the problem in the short term as a result of a reduced pool of qualified health workers, specifically registered nurses (RNs) as well as certified nursing assistants (CNAs).

The newly proposed rule has met with over 40,000 comments since it was first issued in early September this year. Stakeholders have voiced concern that while the new rules could set the stage for optimal staffing and achieve a safer working environment, there is simply not enough qualified staff to accomplish the aims of implementing such proposed workforce changes.

“Value-based payment, a bipartisan goal supported by both the Obama and Trump administrations, has the potential to improve nursing home care in a dynamic and flexible manner, said Brian Miller, MD, Assistant Professor of Medicine, Johns Hopkins University School of Medicine. “Unfortunately, the new CMS staffing rule encases the current dysfunctional care model in concrete, discouraging innovation in service delivery.”

Innovation to drive such changes may ultimately need to evolve by also considering remote options including the use of Telehealth services or even via the advent of emerging AI applications to aid financially strapped long term care facilities and nursing homes that are unable to find staff to meet the minimum staffing requirements set forth by CMS.

The American Healthcare Association and National Center for Assisted Living, which collectively represents more than 14,000 facilities that provide care for approximately five million patients, released data in April of this year that shows how deeply health care has been affected post pandemic: 579 nursing homes closed from 2020 to 2023, 30 U.S. counties have become nursing home deserts, and only three new nursing homes have opened in 2023, compared to an average of 64 each year between 2020 and 2022. The report also found that 21,000 residents have been displaced by these closures, not only affecting patients, but also the families of these patients.

The report also brought to light how such widespread staffing issues have greatly affected the healthcare industry as a whole. In a nutshell, facilities are unable to admit patients, with over 48 percent of nursing homes having wait lists spanning days to weeks. 21 percent of nursing homes have been forced to downsize beds or units and 24 percent have closed a wing, unit or floor because of labor shortages.

While this bottleneck to secure placement of patients not only poses a patient safety, operational, and economic burden to health systems, it is morally devastating to individual patients and their families.

Medical evidence supports the efficacy and cost-effectiveness of skilled rehabilitation and therapy for all patients following complex medical procedures, but is especially important for neurological rehabilitation for patients after a head injury or stroke.

Although many patients with moderate to severe traumatic brain injuries would benefit from comprehensive interdisciplinary inpatient rehabilitation, most are now being discharged to home or a regular nursing home. The downside is that many of these patients never achieve the degree of recovery they would have typically reached if complex rehabilitation was provided. This will impair patients’ ability to recover and live normal lives and contribute to family life and society as a whole. The downstream effect is that billions of dollars in wages and work productivity will be lost due to inability to provide proper rehabilitation care in licensed facilities.

What’s clear is that leaders in healthcare and government must urgently address this issue. Patients deserve the opportunity to return to their best quality of life. Failure to do so may contribute to the decay of our healthcare system.

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