For some Oregonians, their medical needs are too high to be discharged from a hospital, but they also don’t need the emergency care that hospitals provide. They remain at the hospital while waiting for space at another facility that can provide the appropriate level of care. Oregon lawmakers created the Joint Task Force on Hospital Discharge Challenges to address the issue. The task force recently approved its recommendations, after studying the issue for more than a year, according to reporting by the Oregon Capital Chronicle. We learn more about the proposed solutions from Jimmy Jones, the executive director of the Mid-Willamette Valley Community Action Agency who chairs the task force.
Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. When a patient is no longer sick enough to require a hospital bed but still has medical needs that are too serious for them to go home, they’re supposed to go to a variety of step down facilities. But often in Oregon, that doesn’t happen. There’s just not enough space at these post-acute facilities, leading to jammed up hospital beds and emergency departments.
Oregon lawmakers created the Joint Task Force on Hospital Discharge Challenges to address this issue. The task force met for more than a year and released its recommendations last week. Jimmy Jones is the executive director of the Mid-Willamette Valley Community Action Agency and the chair of the task force. He joins us now. It’s great to have you back on Think Out Loud.
Jimmy Jones: Thank you, Dave. It’s great to be back on the show.
Miller: So, as I noted, the big issue here is that people are stuck in hospital rooms for a variety of reasons, when they should be going into what are known as post-acute care facilities. What’s included in that broad group?
Jones: Well, quite a lot. And I think that the public often believes that we have a single, integrated, unified medical system in the state. But that is far from the truth. Typically, when we have folks who are no longer in need of a hospital level of care but are still in need of some level of care, they are moved on to other facilities. And that sort of enjoins this large post-acute care landscape. So it can be adult foster homes, it can be skilled nursing facilities. And even on the side of homeless services, it can be models like Shelter Care Plus or medical respite models for folks who can essentially get a prescription for shelter, a prescription for housing, and go and recuperate from the medical concerns they have, in a safe warm and dry environment.
During the pandemic, we had an awful lot of people stuck in Oregon’s hospital system. We have about 7,100 hospital beds in Oregon. But during the course of the pandemic, we had compression. We had a lot of people that were waiting to be discharged, but there was no place to send them safely to. The post-acute care side, Dave, has really been, I strongly believe, underinvested in, historically. It has been, in some folks’ minds, heavily overregulated. It has been wildly undercapitalized. We do not have enough folks entering that workforce, we don’t have enough beds available. And there are just a lot of systemic problems that kept this system from working better than it should have.
Miller: There are a couple of big picture ways to look at the effects of this. One is the people who aren’t going to these facilities, sort of moving on from the hospital and getting the appropriate kind of care. The other is looking sort of in the reverse direction. So what are the knock-on effects when people are stuck in hospital beds, when they don’t need to be there, in terms of what happens earlier in the healthcare process?
Jones: Well, the knock-on effects are quite large. A lot of people’s experience with going to emergency rooms over the course of the last five years is frustration around the wait times and the limited access sometimes to needed medical care. If there are no beds available in the hospital, emergency rooms are under tremendous stress. They just don’t have enough space to treat all the clients, all the patients in their system that need access to care.
So we heard stories during the pandemic especially, but even at times right after it, of hospitals putting people out in the hallway, of exiting people from care faster – especially with the homeless population – than they should have been exited. And I got involved in this conversation back in early 2023. As a homeless service provider, we had been frustrated for the last decade of just how many people were passing away outside very needlessly. And in January of 2023, we had in Salem, a really terrible tragedy when Melisa Blake passed away from hypothermia in January. That really motivated me to kind of get more involved in this conversation.
We did push a bill, introduced by Senator Patterson in early 2023, that would have adopted some of the similar protections that they have down in California, with their Senate Bill 1152 that was codified in 2019. There’s a lot of pushback on that in Oregon, but at the same time, the hospitals realized that this question remains unresolved and they need places to send people, desperately. And there was just a lot of frustration, a lot of concern about what the status of our post-acute care landscape looks like in Oregon.
So there was, with House Bill 3396 in 2023, the creation of this task force – a large task force of 21 folks – to take a deep look into this conversation, made up of stakeholders from not only the hospital systems, but the post-acute care landscape, the folks who are responsible for creating, maintaining and training the medical workforce across the state, and certainly social service providers too.
Miller: Let’s turn to some of the task force’s big recommendations. The first two have to do with how state agencies assess if someone is eligible for long-term services and supports through Medicaid. How do you want the system to change? I mean, what’s wrong with the status quo?
Jones: Well, ideally whenever any person entered the hospital system, where they need an inpatient bed or whether they’re going to the emergency room, we would know immediately if they had insurance. We would note immediately, even if they didn’t have state Medicaid or state OHP program, that they were eligible for it so that the hospitals, and then especially the post-acute care landscape that’s supposed to pick those folks up when they no longer need a hospital level of care, were frankly gonna to get paid.
And we saw over the last few years, a large number of the post-acute care providers, skilled nursing facilities, adult foster care, a whole host of that post-acute care landscape accepting patients who were still in the process of being determined whether or not they were eligible for Medicaid. And this process can take 30, 45 days or longer sometimes, depending on how the pipeline gets stuck up in the bureaucratic administrative process. So that post-acute care landscape, those institutions were accepting those patients, not knowing whether or not they were going to be compensated for their services. And sometimes they were not. So you’re talking about losses of quite enormous sums of money, because they’re risking the viability of their business to stay open sometimes by accepting people that we do not yet have a determination of whether or not they’re eligible for Medicaid.
The task force really leaned into this concept of presumptive eligibility, that if someone appeared to be somebody that might be eligible – if they appear to be homeless, if they appear to be low income, if they appear to be qualified – why could we not just go ahead and treat them as such? It turns out that there are a lot of federal complications to that question. And it’s possible we may need another Medicaid waiver down the line in order to be able to adopt that presumptive eligibility model. And if we could presume that those folks were eligible, then everybody else would feel more confident accepting those patients. In terms of the funding on the post-acute care side, it would be a more viable environment.
Miller: Let me make sure I understand the word “presumptive” here. So is the hope that this would simply lead to an expedited process where people who are eligible for this coverage can get it faster, or that it would actually lead to an increase in the number of Oregonians who qualify for that long-term coverage in the first place?
Jones: I think the answer to that is both. Our biggest problem, in terms of decompressing the hospitals and making sure that the system is moving faster, is just the lack of available beds on the post-acute care side. And sometimes it has been because they simply do not have the space, and sometimes it has been because people have made financial decisions about whether or not they can accept a large number of folks, who may not have the ability to pay in a post-acute care environment.
So, on the one hand, I think we want to make sure that both the hospitals and the post-acute care providers are going to be reimbursed for the cost that they’re incurring. On the other hand, we also need to make sure that Medicaid is available to everyone in Oregon that’s eligible for it. And the public has presumed that that has been the case. But frankly, especially for homeless individuals and low income folks, a lot of recent migrants into the region and things of that nature, folks with language barriers, that has not always been the case. There’s actually been a great number of barriers to getting folks signed up for benefits for which they are eligible for.
So part of it I think, Dave, the answer to that question is “yes, and …” We want to make sure that the process is speeded up, so that we can un-gum the system. But also, at the same time, make sure that people are acquiring benefits that they’re eligible for.
Miller: What are the other big ways that you think you can simply increase the number of beds in these various post-acute care facilities?
Jones: Well, you have to look at what the needs are in this particular community that are going into these kinds of facilities. A lot of those folks are older, many of them do not have family supports. A lot of them do not have the financial wherewithal to provide any other kind of private care, in-home care, sometimes. What we really need is a richer post-acute landscape in Oregon that meets the needs of the discharges that are taking place.
And quite frankly, the homeless situation in Oregon has gotten so severe that we do have an aging homeless population that is very ill – the average age of death of a homeless person in my community is 53 years of age. They’re dying of all the same things you and I are dying from, they’re just dying much faster. And they need access to shelter models that have medical respite support, Shelter Care Plus supports, so that there’s a place for them to go when they exit the hospital.
So the homeless crisis, in a lot of ways, has expedited many of these problems. I think we have a behavioral health crisis as well. We have some substance issues as well, that’s impacting all of this. There are a number of very high system users in every community from the homeless population. And that is also impacting the availability of post-acute care beds.
Miller: Is the current funding model for, say, a medical respite version of a homeless shelter viable?
Jones: It is … it’s just not well practiced. So if you look at the history of sheltering across the country, and especially here in Oregon, sheltering was not anything that the state really invested all that much money in until around 2017. But even going back to those years, we’re talking about $10 million a year provided by the state to sheltering across the entire state. So if you look at Oregon Housing and Community Services Agency request budget for the next session in the spring, they are proposing $180 million in sheltering for the biennium. And that’s on top of a lot of the local shelter investments, especially in the city of Portland.
It’s just a different landscape. A lot of that sheltering had been left to sort of charity-based models, and private models, and volunteer systems. And that kind of worked up until around 2010, but it no longer works today with the increasing size of our homeless population. So that’s placing an enormous pressure on a shelter system. We have, in Portland, several examples of really good Shelter Care Plus models. We operate one here in Salem. But there’s no statewide coverage for that model.
So part of the recommendations here is to take a deeper look at ways in which the Oregon Department of Human Services and the Oregon Health Authority can find new investments, whether it’s through the current Medicaid 1115 waiver, or some new general fund commitment, or perhaps even a longer term Medicaid commitment to support medical model shelters in Oregon.
Miller: Jimmy, in just the 30 seconds we have left, how much appetite do you see among lawmakers or state officials to enact their versions of these recommendations?
Jones: I do think that this conversation has a lot of bipartisan support. There’s a lot of concerns on both sides of the aisle about the consequences on hospitals and all the knock-on effects for downstream systems. I don’t necessarily believe that you’ll see all of these recommendations embraced in legislation in the spring. But I do believe that all parts of it, whether it’s not finding its way into a bill, will be directed for OHA and ODHS to study the problem, and come back with future options that will have longer term solutions.
Miller: Jimmy, thanks very much.
Jones: Thank you, Dave.
Miller: Jimmy Jones is the executive director of the Mid-Willamette Valley Community Action Agency and the chair of the Joint Task Force on Hospital Discharge Challenges.
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