It is normally a good thing to be ready for discharge from the hospital. The idea brings to mind images of patients returning home to a large crowd of family members, friends delivering meals to support everyone, and patients taking a long-earned exhale as they sit down in their favorite chairs. But the reality of being ready to “go home from the hospital” is not always so warm-hearted. The continuum of care in the United States healthcare system is long and stretched. More often, the patient will need to go to a rehab facility, a skilled nursing facility, or another secondary care setting.

All of this depends on the next facility “accepting” the patient, which means they agree they are able to meet the patient’s medical needs and admit them. These facilities do not have to accept patients and often refuse the most complicated and challenging ones—whether the complications are medical, social, or contextual. This means that many patients are dependent on a facility choosing and agreeing to accept them. This is additionally challenging for patients with mental health conditions, as many locations do not believe these patients are the best fit or that they can meet both the mental health and medical needs. When these patients are refused admission to all facilities, they become residents of the hospital.

The Case of Ms. Topol

Take Ms. Topol. Ms. Topol was a 62-year-old woman who was found down and brought to the hospital. She had several complicated medical conditions, including COPD and diabetes, but she also had long-term mental health conditions that likely directly impacted her ability to access care. She refused to take any medications and became very combative. She had always refused to participate in treatment for her diabetes, and now several of her organs were impacted.

To gain access to a facility that could meet her mental health needs, she required a Level 2 authorization and a surrogate decision maker to agree. Without both of these, every facility would decline to accept her. So the hospital was left with the situation of keeping her until the Level 2 assessment could be completed and then petitioning the court for a guardian for the patient (a cost the hospital would likely have to absorb). After all of that, the patient would then be reviewed by facilities and discharge planning could begin.

Vicious Cycle

These are a lot of hoops that need to be jumped through in order to help Ms. Topol get the resources she needs. Without them, she would likely return to her previous life, fail to maintain her health conditions, and further decline—and then, likely, readmit to the hospital.

Modern health care is incredible and keeps patients alive with conditions that used to be a death sentence only a short time ago. We are able to keep more patients alive than before, but that has also impacted the rest of the system, as we now have more patients needing more and more resources. Without a conscious, deliberate effort to provide for these patients, they will continue to remain abandoned by society and left to places of last resort—which, more often than not, is the hospital.