‘Rays of Sunshine’: Nursing Home Staffing Shortages Loom Large in Hospital Discharge Crisis, but Solutions Exist

The crisis involving patients languishing at hospitals awaiting discharge into appropriate post-acute care settings has shown little signs of abating.

The root causes of these discharge delays are manifold, but chief among them are workforce shortages at nursing homes.

According to experts at a webinar hosted by ATI, the discharge crisis is amplified by a perfect storm of factors post-pandemic. Long fraught with difficulties, the process of release into nursing homes has, in recent years, been also plagued by changing patient acuity levels and systemic payment issues.


And, the delays are the greatest when it concerns discharges to SNFs compared to other settings.

“We see an increase in the length of stay across all of these discharge destinations, but the average length of stay on the whole is the highest for the skilled nursing facilities,” said Anne Tumlinson, CEO and founder of ATI Advisory.

Tumlinson noted a survey of skilled nursing facility executives by the American Health Care Association (AHCA) that revealed the staggering ongoing staff deficits compared to pre-pandemic levels. These shortages hinder SNFs’ capacity to accept patients with complex medical needs.


“The vast majority of skilled nursing facilities are still at workforce levels that are lower than what they were able to staff at pre-pandemic, and [SNFs] have absolutely responded by limiting new admissions,” she said.

SNFs limiting admissions

Moreover, about 20% of operators have closed at least a wing or a unit due to challenges, Tumlinson said.

“So we’re definitely seeing that the labor that the skilled nursing facilities rely on to operate to be able to admit patients has become a real challenge, and a big part of the reason why we’re seeing people boarding inside hospitals,” she said.

The data on hospital stays from across the U.S. bears out the extent of the crisis, said Fred Bentley, managing director of ATI’s post acute and long-term care practice group.

In Minnesota alone, an estimated 66,000 unnecessary hospital days were recorded over a six-month period due to delayed discharges. Meanwhile, similar trends were observed in New York, where 500 patients exceeded their expected hospital stays by more than 30 days within a three-month span in 2022, for example.

Such prolonged hospitalizations not only strain hospital resources but also compromise patient outcomes and inflate health care costs, he noted.

To top that, there is a lack of housing for clinically complex patients with behavioral health needs. And the increasing acuity of hospitalized patients, driven by demographic shifts towards an aging population with more complex health care needs, has increased the demand for SNFs.

And yet, inadequate post-acute care capacity along with payment issues exacerbate the discharge crisis, leaving hospitals grappling with prolonged patient stays.

“From a policy and payer perspective, programmatic problems and challenges are also contributing to this,” said Tumlinson. “We’re also waiting on state Medicaid agencies and their fiduciaries to make the long-term care determinations that can help tap a financing stream or payment for the services.”

Delayed pre-authorizations in Medicare Advantage and other managed care plans are also significantly contributing to the discharge issue related to SNFs.

‘Rays of sunshine’

That said, all is not lost, and there are solutions to be sure, the ATI analysts said.

Collaboration between hospitals and post-acute care providers is pivotal, with efforts focusing on enhancing care transitions and supporting staffing in SNFs. Also, innovative models in development can also alleviate pressure on traditional post-acute care settings.

Moreover, advocates are pushing for policy interventions, including Medicaid reimbursement reforms and a streamlined prior authorization processes, which can facilitate smoother transitions and optimize resource allocation.

“There are rays of sunshine here,” said Bentley. Despite all the different root causes for the discharge crisis and the fact that not any single provider can solve this on their own, Bentley said that there are steps that hospitals and health systems, post-acute providers and other healthcare providers can take to at least mitigate the challenges.

For starters, overcoming some of the barriers to timely placement of patients in post-acute settings must involve better collaboration across the various health care settings, Bentley said.

“We are heartened by the level of engagement between hospitals and health systems and post acute providers. Now, there’s always been partnership there, and there’s always been engagement around care transitions. But honestly, that needs to intensify, and there needs to be a lot more collaboration and coordination,” he said.

One of the ways hospitals – which have fared better than SNFs on the staffing front in attracting workers – can collaborate better with post-acute care settings is by supplying workers to SNFs.

“It’s not as if hospitals have lots of staff, but there are certainly hospitals out there that have provided some staffing and support and some training as well to help post-acute providers manage more complex patients,” said Bentley.

Moreover, hospitals can discharge to new types of settings besides long-term care, such as rehab-at-home models and medical respite centers for homeless patients, for example.

“We also see hospitals and health systems developing more or alternative settings,” he said. “[These] can include developing specialized capabilities that maybe a skilled nursing facility had not contemplated developing in the past; getting more training in mental health and behavioral health to support the many patients and the increasing proportion of their patients who are struggling with severe mental illness or substance use disorder.”

A clarion call

And last but not least, one big solution to bottlenecks should focus on reducing hospital admissions.

“This is now a kind of clarion call for the health system to really focus on preventing hospitalizations to begin with. So in order to think about this holistically, we’ll also be thinking about what it is that primary care providers can be doing around care management, care coordination, assisting with care transitions, if and when necessary, to either prevent hospitalizations or at least make that transition as smooth as possible,” Bentley said.

And while there is a role for all providers in addressing this challenge across the care continuum, there’s also clearly a big role for states.

States could play an important part in creating incentives in the Medicaid long-term care reimbursement structure for nursing facilities so as to allow them to take on more complex patients, Bentley said. They could focus on creating incentives for post-acute care organizations to take on more complex patients, especially when it concerns partnering with managed care organizations.

“There are opportunities for innovation here to build capacity, to increase staff capabilities and find alternative settings for patients who are ready to be discharged [from hospitals],” he said.

The ATI analysts said that the hospital discharge crisis poses formidable challenges, and stakeholders across the continuum need to collaborate better, innovate, and implement systemic reforms.

“I’ve been working on skilled nurse facility issues for my whole career. This is by far the most severe and most challenging workforce shortage that I have ever seen in my career,” Tumlinson said.

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