Custodial Admissions from the ED: Major Issue Nationally

Health systems are grappling with custodial/social admissions from the ED.

A specific quandary is playing out in emergency departments (EDs) all over the country, and no one seems to have a clear answer on how to address it. The situation? Patients presenting to EDs because they are unable to care for themselves, or others are unable to care for them. 

There are significant, concrete reasons why this happens – patients are elderly, frail, deconditioned, no longer able to ambulate independently (or even with assistance), and they or their caregivers simply cannot manage the situation any longer. 

Many times, these individuals appear in the ED with complaints of extreme fatigue, weakness, generalized pain, or poor oral intake. Sometimes, IV fluids are administered to address suspected mild dehydration, a topical pain patch or medication by mouth is provided, but work-up for etiologies of a condition significant enough to warrant hospitalization returns negative. This leaves everyone involved, from the patient to those accompanying them to the entire ED care team, to ask – what do we do now?

These patients cannot safely remain in their living situation, but their needs do not require the hospital setting. But what about assistance with ambulation and activities of daily living (ADLs)? All can be provided in a variety of ways, from live-in professionals to intermittent drop-in services, to residence in a loved one’s home, an assisted-living facility (ALF), skilled nursing facility (SNF), or inpatient rehabilitation facility (IRF). How about monitoring to ensure day-to-day safety, compliance with medications, assurance of appropriate oral intake, and hygiene? Again, this kind of supervision does not require hospital professionals nor services.

There is usually a myriad of reasons why the patient’s needs can’t be addressed in the ED, allowing for discharge. These range from the practical – it is 2 a.m., and there are no home health agencies or SNFs accepting calls to arrange new patient services – to the simplistic: the patient has no ability or desire to pay out-of-pocket costs for assistance. And therein lies the rub. ED physicians, case managers, and social workers are not bartenders. They cannot announce to the patient and those in the room with them, “sorry folks…you don’t have to go home, but you can’t stay here.” So, what happens?

Unfortunately, many of these patients are hospitalized. At first blush, it might seem a no-brainer to resort to this tactic. The patient is happy, their family is happy, the ED bed opens up, and…isn’t this precisely the type of situation case managers and social workers are in place to address, on the units? But there are many reasons why this “solution” is problematic:

  • Despite a multitude of safety mechanisms, every patient in the hospital is inherently at risk for nosocomial infections, falls, and medication errors. This risk is particularly egregious when you consider that these patients never needed to be hospitalized in the first place.
  • Every patient occupying a hospital bed without medical necessity keeps another patient who does need a bed in the ED. Especially during times of high census – like now, when influenza rates are booming – this creates havoc, as hospitals are forced to board ill patients within their EDs. In turn, there are fewer available beds for assessment and treatment of patients arriving with emergent conditions.
  • Patients hospitalized for reasons outside the scope of medical necessity belong in outpatient status, and as such, will result in little or no reimbursement to the hospital for care provided – even if that care spans multiple days. At a generalized cost of $1,000 per day for simple custodial care, this means health systems are losing tens of thousands of dollars on a yearly basis.

In the scenarios reviewed so far, the patient, caregivers, and medical team are all on the same page: that the patient is no longer safe in their current living situation. But hospitals are also encountering more and more situations in which the medical team believes that the patient not only doesn’t require hospital care, but also has no contraindication to returning back to from where they came. Despite reassurances, the patient and/or their family may disagree, and refuse to leave the ED or accept any outcome other than hospitalization. Or, the facility from which the patient originated may refuse to accept the patient back. 

In light of disturbing exposés like this report from Baltimore or this case involving a service dog, both in 2018, hospitals are extremely wary of creating their own PR nightmares. But appetite is high for putting processes in place and developing a culture of understanding to address risks to the patient and the hospital alike.

The following are a few ways in which health systems are trying to manage these situations involving custodial or social admissions:

  • Present the patient a financial liability form, such as an Advance Beneficiary Notice (ABN), Hospital-Issued Notice of Non-Coverage (HINN), or internally created document that informs the patient they will be responsible for hospital charges, if hospitalized.
  • Form close alliances with home health services, SNFs, ALFs, and IRFs to allow near round-the-clock availability for assessment and placement of patients straight from the ED. This also often includes agreements with such facilities to accept patients without pre-authorization from insurance plans, given pre-established financial support from the hospital itself.
  • Fund a “hospital hotel,” wherein patients have access to short-term, monitored, but non-specialized care, until a long-term plan is established.

Out of all of these options, the most common by far appears to be the first. Requiring no financial risk from the hospital, but potentially leading to significant PR risk, it continues to remain a loaded topic of debate in board rooms, and within medical executive committees nationwide.

Coming up in a future article, I will delve into the pros and cons of these considerations, and how you might help your health system decide which path to choose.

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Juliet Ugarte Hopkins, MD

Juliet B. Ugarte Hopkins, MD is Immediate Past President of the American College of Physician Advisors, Physician Advisor for Payor Peer-to-Peer Services for R1 RCM, Inc, and a member of the consulting teams for Phoenix Medical Management, Inc., Enjoin, CSI Companies, and Pediatric Resource Group via Velvet Hammer Physician Advising LLC. Dr. Ugarte Hopkins practiced as a pediatric hospitalist for a decade and then developed the physician advisor role for case management, utilization, and clinical documentation at a three-hospital health system where she worked for nearly another decade. She is a member of the RACmonitor editorial board, author, and national speaker.

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