What happens in your country if someone can't be discharged from hospital?

[Laura Corin]

This is if someone has no medical need to be in hospital any more. Typical reasons in the UK might be because

- their house has been discovered to be unsafe and it takes a while to sort out

- they need at-home/residential continuing care but the services are overloaded and family cannot provide care.

In the UK it often leads to someone just staying in hospital too long - not the healthiest place to be and taking up a bed that could be used for others. It's an intractable problem, particularly post-Brexit when there are many openings for carers that can't be filled. 

This is not a personal question  - I'm just interested in how other countries manage this 'bed blocking'.

[alysee]

Here in Canada, or at least the few cases I have heard is the exact same thing in the UK, They stay in hospital until a bed can be found in a nursing home. 

[Pam in CT]

It depends on the hospital and its business model.  In Catholic or other non-profit/ teaching hospitals, patients get enrolled (by on-staff social workers) into Medicaid if they aren't already, and stay on until a Medicaid-supported nursing home bed can be found.  The quality of fully-Medicaid-supported facilities varies widely. 

The fully for-profit hospitals/ networks will discharge. Back to a demonstrably unsafe house or living on the streets if that's the patient's life.  (Our system generally isn't checking the safety or appropriateness of housing for adults anyway, even very elderly/ very impaired adults; so I don't know how a hospital would even know that issue.)

[Drama Llama]

Just now, Pam in CT said:

It depends on the hospital and its business model.  In Catholic or other non-profit/ teaching hospitals, patients get enrolled (by on-staff social workers) into Medicaid if they aren't already, and stay on until a Medicaid-supported nursing home bed can be found.  The quality of fully-Medicaid-supported facilities varies widely. 

The fully for-profit hospitals/ networks will discharge. Back to a demonstrably unsafe house or living on the streets if that's the patient's life.  (Our system generally isn't checking the safety or appropriateness of housing for adults anyway, even very elderly/ very impaired adults; so I don't know how a hospital would even know that issue.)

And if the person doesn't leave, either because they actually can't, or they are too scared, they can be arrested.  Substituting police for medical care is a huge problem in the US.  

[Janeway]

In the US, they throw them to the streets. If they refuse to leave, security will physically pick the person up and take them off property and dump them.  And by this, I mean if they are physically unable to leave due to illness or disability, the hospital will do this to them- dump them, on the streets.

Edited July 6, 2023 by Janeway

[Laura Corin]

4 minutes ago, Pam in CT said:

  (Our system generally isn't checking the safety or appropriateness of housing for adults anyway, even very elderly/ very impaired adults; so I don't know how a hospital would even know that issue.)

In one case I know of, the ambulance staff smelled gas when they picked up the patient. The patient no longer had a good sense of smell.

[Drama Llama]

1 minute ago, Laura Corin said:

In one case I know of, the ambulance staff smelled gas when they picked up the patient. The patient no longer had a good sense of smell.

Did the ambulance staff call the gas company?

In my experience in the US, the gas company is one of the most responsive public agencies.  EMT's would make a call, and a gas leak would actually get addressed.  If the issue is that someone has dementia that has progressed to the point that they're turning on the stove wrong and causing danger, that would be less likely to be addressed appropriately.

[wintermom]

44 minutes ago, alysee said:

Here in Canada, or at least the few cases I have heard is the exact same thing in the UK, They stay in hospital until a bed can be found in a nursing home. 

It's also dependent on the province and the specific region within the province. The individual may be moved to a bed in a facilitaty far away from the original hospital (primarily because there simply aren't spaces in nearby facilities in smaller towns and cities).

ETA: I should also add that we were informed that if my mom needed to stay in the hospital past a certain date if there were no other facilitaties available, and didn't medically 'need' to be in the hospital, we'd be charged for her food and room. It was a pretty cheap daily rate - certainly MUCH cheaper than a hotel - but it would have added up if she had to be in for months.

Edited July 6, 2023 by wintermom

[Laura Corin]

Just now, BandH said:

Did the ambulance staff call the gas company?

In my experience in the US, the gas company is one of the most responsive public agencies.  EMT's would make a call, and a gas leak would actually get addressed.  If the issue is that someone has dementia that has progressed to the point that they're turning on the stove wrong and causing danger, that would be less likely to be addressed appropriately.

Yes they did. But the gas leak lead to a further investigation into dangerous wiring, broken stairs, etc. I'm not sure of the procedure for that.

[Mrs Tiggywinkle Again]

I remember one patient who was in the hospital 11 months before they could find a nursing home that would take him.  He was well over six hundred pounds and could not care for himself and family could not either.  Very few nursing homes can manage someone in that weight range.

DH, as a paramedic supervisor, has refused to transport a patient home from the hospital via ambulance if we know they’re unsafe at home.  The hospital then usually grudgingly admits the person under a social admit while the social worker tries to find a placement for rehab or long term.  They hate it when we do that. 

[Mrs Tiggywinkle Again]

7 minutes ago, Laura Corin said:

Yes they did. But the gas leak lead to a further investigation into dangerous wiring, broken stairs, etc. I'm not sure of the procedure for that.

I’ve been in this situation and we transported the patient back to the hospital after notifying the fire department. FD came in, called the gas company and then code enforcement condemned the home.  I assume the patient probably would up in a nursing home or a relative’s house.

[denarii]

38 minutes ago, wintermom said:

ETA: I should also add that we were informed that if my mom needed to stay in the hospital past a certain date if there were no other facilitaties available, and didn't medically 'need' to be in the hospital, we'd be charged for her food and room. It was a pretty cheap daily rate - certainly MUCH cheaper than a hotel - but it would have added up if she had to be in for months.

I had the same experience with my late MIL. She was not stable enough to be home, stable enough to be discharged from the hospital, no room in LTC, so she stayed in the hospital until she passed and we were charged for every day for 2 months. 

[wintermom]

4 minutes ago, denarii said:

I had the same experience with my late MIL. She was not stable enough to be home, stable enough to be discharged from the hospital, no room in LTC, so she stayed in the hospital until she passed and we were charged for every day for 2 months. 

I'm so sorry you and she had to go through this. It's so hard to be in limbo for this long and have no control over where one's loved ones live. 

[Katy]

55 minutes ago, Janeway said:

In the US, they throw them to the streets. If they refuse to leave, security will physically pick the person up and take them off property and dump them.  And by this, I mean if they are physically unable to leave due to illness or disability, the hospital will do this to them- dump them, on the streets.

Not Catholics hospitals. It’s one reason I liked working in them. 

[Faith-manor]

In my area, often the patient is sent to an inpatient rehab facility because long hospital stays often end with someone being quite weak. Usually rehab can make excuses to keep them at least 30 days, but sometimes longer, and during that time a social worker looks for a nursing home bed or if there are enough assets to pay for assisted living, they look at that too. I have also heard of police being sent to transport someone to a homeless shelter. 

Never ever sign for any adult at the hospital that you will pay their bills or anything like that. Even if you have POA. There will be a lot of pressure on you to then house the person because they are going to bankrupt you for the medical bills. Also, if they can get a family member to take them, it often ends any help from the hospital social worker for getting in home PT/OT or CNA, or assistance finding a nursing home bed. I have seen that so many times. They figure the problem is yours now, so no skin off their nose what happens. It isn't because the hospital workers are cold hearted. It is a survival mechanism because the system is so damn broken, and they are overwhelmed as such a huge generation has reached its elder years.

[SHP]

1 hour ago, Laura Corin said:

Yes they did. But the gas leak lead to a further investigation into dangerous wiring, broken stairs, etc. I'm not sure of the procedure for that.

Well, here the person could refuse access to the house and limit what the gas company could do inside. It takes the house visibly falling in to get the city to have it condemned and only then can the person be forced to vacate. It's a huge problem. We looked at buying a house for an adultling to fix up. It was occupied and dangerous. The basement was flooded up to the electrical panel, the bathroom didn't have a floor of any kind, not even joists. Just a giant hole. Did I mention someone was living there? Our realtor went back and forth with their realtor because we didn't think it would be that dangerous if someone was living it in. 

[BusyMom5]

It would depend on the situation,  but a rehabilitation facility or long-term care.  Hoping to get my aunt into a nursing home on Medicaid!  It is possible, but it can be hard to find a bed.  I firmly believe we need to bring back more institutionalized housing for mental health and for those that are in the place between nursing home Level needs, but unable to live alone all the time.  My family has dealt with several aging parents and aunts, uncles.  What we currently have doesn't address this middle stage.  It gives too much agency to those who are unable to properly care for themselves, but too stubborn to take the help offered.  Dementia is a cruel disease and from my experience it takes sooooo much to get the person into a care facility. 

[wathe]

In Ontario they stay.  They are designated "ALC" (alternate level of care) and are charged a co-pay  - equivalent to the cost of basic LTC (long term care) accommodation fees.  Co-pay may be reduced  based on financial circumstances.

These patients really aren't dischargeable. We have oodles workers whose only job is facilitating discharge - all alternative options are explored.  Patients don't stay a moment longer than necessary.  Keeping them in an acute care hospital when there is nowhere else to go really is the only humane and ethical choice, but also has serious consequences, especially for the ED:  Hospital overcrowding is a main (IME the main)  contributor to ED overcrowding.  It is a serious issue.

More than 1/3 of beds at my acute care hospital are occupied by ALC patients.  This is similar to other hospitals across the province (and definitely there are GTA hospitals that are even worse off).  Which means that admissions from the ED have nowhere to go, and pile up in the ED.  Which means new ED patients have nowhere to be assessed  and pile up in the hallways and waiting room.  It's not unusual  to have 100+ patients registered in a 40-something bed ED.  We have patients in chairs in every hallway, and stretchers in every conceivable nook and cranny, as well as lining the halls.  Admitted patients can be in ED hallway stretchers for days, ie frail pt with dementia with hallway noise, traffic, no privacy, and lights that never go off.   Storage closets and waiting rooms and offices and anterooms have been "converted" to patient-care space.  The stuff that used to go in the storage spaces now clutters up the halls. Stuff and patient chairs/stretchers line every inch of hallway wall. --- every inch).   We have improvised  workstations (some of them in hallways, of course!)  for nurses to look after the hallway and chair patients.  It makes provision of excellent care impossible.  It makes work conditions for staff terrible.  I'm also convinced that it increases ED violence:  Everyone on top of each other, and staff having to pick their way past frustrated/angry patients in the halls in order to do their work, all shift long.  Definitely a top cause of burnout.

We really, really, really need more nursing home beds!

 

 

 

 

[Pam in CT]

re gas company responsiveness

3 hours ago, Laura Corin said:

In one case I know of, the ambulance staff smelled gas when they picked up the patient. The patient no longer had a good sense of smell.

 

3 hours ago, BandH said:

Did the ambulance staff call the gas company?

In my experience in the US, the gas company is one of the most responsive public agencies.  EMT's would make a call, and a gas leak would actually get addressed.  If the issue is that someone has dementia that has progressed to the point that they're turning on the stove wrong and causing danger, that would be less likely to be addressed appropriately.

In my very very limited experience (two adult ESL students over 10 years, who enlisted me to help communicate with the gas company when they thought they might have a leak) this has been true here as well.

 

 

The issue with discharging patients who don't have a safe place to go is not (fundamentally) a matter of greedy cold hearted hospitals. It's a multi-pronged structural matter, with

• very limited in-home services in most states for adults, either to check basics, or to install grab bars and carbon detectors and emergency call systems; or nursing / OT / PT / meal prep / daily living tasks
• Insufficient *beds* in rehab centers, coupled with
• insurance limits on how long patients can stay in rehab centers, particularly if they aren't showing measurable improvement at the pace demanded by the insurers, and
• ..... most fundamentally and structurally of all, a yuge portion of our health care sector is on a for-profit business model.  Hospitals, testing centers, rehab centers, nursing homes, physical medical devices, pharmaceutical companies, insurers, the drug pricing intermediary companies, the patient navigator services -- throughout the entire system there are private sector companies who necessarily are beholden to the same profit imperatives and quarterly earnings pressures as any other private sector company in construction or hotel management or etc.  (Like any other private sector company) they need to ensure revenues and limit costs.  Within the health sector, that can create some very lousy incentives.

[TechWife]

I’m the US several scenarios are possible.

If the person is capable of caring for themselves, the hospital case manager would try to find a friend or family member that can provide temp housing or try to find them a bed in a shelter. Hospitals can put a discharged patient on “boarding” status if they don’t require assistance while housing is located, but that’s entirely their choice and many hospitals don’t have beds available for that purpose. Oftentimes, however, the hospitals discharge them with a list of shelters in hand. It really varies by location and the services available.

If the person needs to be placed in a long term care facility (commonly called nursing homes) then the hospital social workers will find an LTC bed for them and they will stay in the hospital while a bed is located. Usually a patient has limited choices as, again depending on location, many facilities have wait lists. 

[Hannah]

Here they put you out on the street. 

My mil was not able to go home and we needed to take leave from our jobs for a few weeks to care for her 24/7 while frantically finding her a place in a nursing home. Thankfully we were able to find a place and were able to afford it. 

Edited July 6, 2023 by Hannah

[gardenmom5]

A step down care facility.   Not a hospital,  but still offers care.

[bookbard]

I find that it depends. With old people, they stay there for ages until they find them a nursing home spot. But I do know one younger person who had a brain injury who was let out before he was ready and started running through the streets throwing stuff at people. Fortunately (he had no family), local people called the ambulance and hospital and managed to get him a spot in a rehab hospital and now he's 100% fine. I wouldn't say that sort of thing happens a lot, but I wonder if it happens more than it should. This is Australia - medical systems under extreme strain since Covid, where there are several thousand extra people taking up beds due to illness than there were before the pandemic.

[Resilient]

12 hours ago, Janeway said:

In the US, they throw them to the streets. If they refuse to leave, security will physically pick the person up and take them off property and dump them.  And by this, I mean if they are physically unable to leave due to illness or disability, the hospital will do this to them- dump them, on the streets.

This has absolutely NOT been my experience with elderly who can’t pay a single dime. The hospital staff find a nursing care bed for the patient. BTDT multiple times. 
 

People who have to leave a hospital are in better shape than the poor soul who lives at home but needs a nursing bed now.  “Sorry dearie, we’re 8 weeks out.”  BTDT, too.  

[Harriet Vane]

15 minutes ago, Resilient said:

This has absolutely NOT been my experience with elderly who can’t pay a single dime. The hospital staff find a nursing care bed for the patient. BTDT multiple times. 
 

People who have to leave a hospital are in better shape than the poor soul who lives at home but needs a nursing bed now.  “Sorry dearie, we’re 8 weeks out.”  BTDT, too.  

This did unfortunately happen to a friend of mine. She has a long history of mental illness and she also has a low IQ. She has always worked low-wage jobs and has very basic insurance that she obtained through Obama Care. She had what was later diagnosed as a migraseizure--she had an epileptic seizure that brought on a severe migraine. She was unable to talk properly or walk a straight line. While she does have epilepsy and is prone to migraines, she had never had a severe event like this or anything even remotely like this. Her epilepsy had been controlled for decades. She seriously, really, looked and sounded like she had had a stroke. The ER determined there was no drug abuse, stroke, or heart attack, and they kicked her out. When they escorted her to a pay phone, she was unable to speak clearly or walk a straight line. Someone took pity on her (this was some years ago before the pandemic and I honestly don't remember if it was another patient or a nurse or a police officer) and helped her call a cab. The cab driver took pity on her and helped her to her door. For several days she had a terrible time getting any response from ANY medical professional. Finally a mutual friend took her back to the ER (I would have participated but I live two states away) and that friend pitched a FIT when the hospital attempted to discharge her without further care or a diagnosis for her condition (virtually unchanged from her original ER visit--seriously garbled speech and unable to walk a straight line). That's when she was finally admitted to the hospital and proper attention was given to her. 

[Gil]

The very title of this thread is confusing to me because in my country, someone can always be discharged from the hospital. Hospitals will put you out on the street if you don't have transportation or someone to take out.

I personally know 2 people who went to the ER for help, and insisted that they were sick and begged for help but were turned away/sent home. They went home and died--one within hours, the other the next day at work.

 

[Gil]

You can google "Patient Dumping" and watch dozens of videos on YouTube of Patient Dumping.

[sbgrace]

Around here you would be discharged. Options:

Send them to rehabilitation if that type of care is needed and insurance will pay.

Send them home until they deteriorate and cycle back to the hospital.

Send them to a nursing home to spend down their household resources until they qualify for medicaid. 

 

[Laura Corin]

12 hours ago, gardenmom5 said:

A step down care facility.   Not a hospital,  but still offers care.

My local hospital functions in this way. People in need of a bit more medical supervision, but not acute services,  are sometimes transferred here from the big city hospitals. I imagine that the stage after this can still be tricky. 

Edited July 7, 2023 by Laura Corin

[EKS]

I only have personal knowledge of one instance and that was with a quadriplegic.  He was kept in the hospital until he could be discharged into an appropriate living situation.

[gardenmom5]

6 hours ago, Laura Corin said:

My local hospital functions in this way. People in need of a bit more medical supervision, but not acute services,  are sometimes transferred here from the big city hospitals. I imagine that the stage after this can still be tricky. 

It's less than a hospital, some medical care, but not much.   we went through several of these events with my mom.  she wasn't ready to be released from medical supervision, but she didn't need a hospital either.

[annandatje]

On 7/6/2023 at 8:55 AM, Janeway said:

In the US, they throw them to the streets. If they refuse to leave, security will physically pick the person up and take them off property and dump them.  And by this, I mean if they are physically unable to leave due to illness or disability, the hospital will do this to them- dump them, on the streets.

Hard to believe isn’t it?  I’ve known someone to whom that happened.  He died at home two days later from his hernia.