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At 10:30 a.m. on Monday, May 13, the healthcare teams at Scripps Mercy Hospital in San Diego started cheering and clapping. Their longest length-of-stay patient ever was finally being discharged.

For more than 3 years -- 1,193 days to be exact -- the patient had been confined to an acute care bed despite the fact that for 948 days, or 80% of that time, he had no medical need to be there. He was what hospitals call "an avoidable bed day" patient, or an ABD, Melody Thomas, RN, Scripps Mercy Hospital's director of patient care and case management, told MedPage Today.

It was a very exciting day to say goodbye to a patient they had taken care of for so long, she said.

His destination: a locked behavioral health facility that was more appropriate for his care.

He had been hospitalized all that time, mostly in the same medical unit room, because no step-down, skilled nursing, or mental health facility had been willing to accept him for a number of disqualifying reasons. But finally, care management teams had found a place that would take him.

For many patients including this one, the hospital must provide a certified nursing assistant to serve as a "sitter," to make sure such patients don't harm themselves or others, or wander off, Thomas said. That's a major reason why step-down facilities won't accept such patients.

So what changed?

Thomas said the team tried to adjust medications and employ creative strategies so the patient would not need a sitter. "One thing we worked on was getting video visits with family he had been estranged from, and which he was not open to earlier," she said. Eventually, that changed the patient's behavior and in time, he no longer required a sitter.

After proving that he could go without a sitter for about 6 months, some facilities were willing to reconsider accepting him.

That's a service these step-down facilities such as the four mental health rehabilitation centers or the two special treatment skilled nursing facilities in the county would not provide, Thomas said.

Whether the patient understood exactly what was happening to him, Thomas couldn't say. Due to the restrictions of the Health Insurance Portability and Accountability Act (HIPAA), she could provide few other details about the saga that kept him in the hospital so long.

Scripps officials requested permission from the patient's conservator to provide more details or allow MedPage Today to speak with the patient's family, but that request was declined.

Not a Unique Case

Except for his exceptionally long stay, Scripps officials said this patient isn't unique. As of May 14, 85 ABD patients had been occupying beds in four Scripps hospitals -- 81 of them for up to 6 months -- and 3 had been there up to a year. All could have been discharged to less acute settings.

One of those ABD patients who had been there more than 27 months was recently discharged; now the longest-stay ABD patient has been there more than 11 months.

The number of ABDs at Scripps hospitals -- just one of several health systems serving San Diego County -- has risen more than three-fold in recent years, from 9,586 in 2019 to 33,417 in 2023. Numbers have recently started to drop in recent months, however, because patients have been easier to place since the height of the pandemic and step-down facility staffing has improved.

Boarding these patients comes with some very high costs. Janice Collins, senior public relations director at Scripps, said that annual ABD costs to Scripps have risen from $17.4 million in 2020 to $59.7 million in 2023. Reimbursement from Medi-Cal, which is the payment source for most of these ABD patients, paid only $704.86 of the hospital's 2023 per-bed day cost of $1,767, or 40%.

In 2024, Scripps' daily ABD cost rose to $1,912.

That hospitals must keep patients with mental illness in rooms adjacent to regular patients can be disturbing. In late 2022, a man being treated for an infection at a Scripps hospital messaged a MedPage Today reporter he knew personally that he was having trouble sleeping because of a persistent voice from a patient a few doors down.

He recorded the voice on his phone.

"He was crying out in Spanish, 'Let me out of here. Let me out of here. Por favor. Por favor,'" the man recalled. When the man asked the staff about the voice, he was told the patient had been there for a year because no post-acute facility would accept him because of his behavioral issues and insurance coverage.

"I'm still haunted by his pleas to get out of there," he said.

Although these ABD patients have extenuating mental health or behavioral issues, most arrived at the hospital because of some medical issue, such as hypertension or needing IV fluids or IV medication, Thomas said. They may have refused care elsewhere, or had thoughts of harming themselves or others.

As the medical issues that brought them in were resolved or stabilized, only the behavioral, competency, or mental health ones remained.

Complicating the issue, Thomas explained, is that many of these patients are unable to perform activities of daily living such that they were placed under state-regulated conservatorships, often under involuntary legal holds.

"Many patients truly don't have the ability to provide their own food, shelter, clothing, and we just don't have a safe discharge disposition for that," Thomas said during the interview, with two Scripps Health public relations staffers present.

"Some have been unsheltered for many years, and now they've had a stroke and can't go back to the same living situation."

Another issue thwarting timely discharge of such patients is that many have been aggressive or behaved violently toward Scripps staff.

"We have had a lot of unfortunate workplace violence incidents where our staff are getting attacked, whether because of (the patient's) paranoia or other thoughts or delusions," Thomas said.

Scripps caregivers try to engage patients with interactive toy , games, , and even supplied an inflated plastic toy for a patient who used to be a boxer.

A few miles away, Sharp HealthCare reported similar problems with 86 patients whose discharges have been delayed, frequently because of managed care insurance companies' delays or denials in granting authorization for placement.

Zachary Lenert, MSN, RN, Sharp's vice president of integrated care management, told MedPage Today in an email that insurance company prior authorization delays and denials have blocked patient discharges, sometimes affecting patient outcomes. Additionally, he said, many post-acute providers just won't accept reimbursement from certain payers.

It's not just San Diego hospitals that struggle. According to a California Hospital Association (CHA) , companies that cover these patients "do not have enough clinicians, psychiatric, skilled-nursing or rehabilitation facilities, home health services, or other types of providers within their network to care for patients after they leave the hospital."

Healthcare worker shortages, especially during and since the pandemic, have limited staffing in some facilities as well.

The CHA estimates that every year, patients in California hospitals occupy acute care beds for one million days a year at a cost of $3.25 billion in avoidable costs. Patients covered by managed care plans, which enroll most of California's Medi-Cal patients, are more likely to experience delays than patients with fee-for-service coverage, the statement said.

Fixing the Problem

Chris Van Gorder, president and CEO of Scripps Health, said payers must increase what they pay for downstream care facilities that now refuse to accept these patients because of low reimbursement. If that's not done, he said, "there will be little motivation for behavioral health and even hospitals to build the beds necessary to care for this population."

Funding for programs to train care providers for this difficult group of patients is an additional challenge, he said.

The problem will only get worse as a new California law, , expands the definition of gravely disabled. The new definition includes patients with severe substance use disorder or inability to provide for one's personal safety or necessary medical care as reasons for placement in an involuntary three-day hold.

Without sufficient psychiatric inpatient facilities or chemical dependency beds, the burden will fall to acute care health systems like Scripps to take care of these patients, he said. "The hospital boarding problem will only get worse."

The problem is being felt coast to coast.

A 2022 by the Healthcare Association of New York State noted how gaps in availability of settings for people with complex healthcare needs has led to long-term boarding in hospital inpatient units and emergency departments.

In just a three-month period, 52 participating New York hospitals reported that 1,115 patients were unnecessarily occupying beds, resulting in 60,000 days of delay in transfer, with an average delay of 2 months. For just those 90 days, these delays cost $169 million, much of which was not reimbursed.

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