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Worcester Hospital Discharges Patient Without Caregiver in Storm

Thursday, February 20, 2014


At the height of Tuesday's snowstorm, a local Worcester woman received a call at work that her 80-year-old mother was being discharged from Saint Vincent Hospital.

“Obviously there was a snowstorm,” said Susan Mathews, who as a result told the hospital that she wasn't able to pick her mother up. “They called me back and said they were sending her home in a wheelchair van.”

“I asked, 'Can you wait, can you wait until the morning?' And they said 'Nope, she's already on her way.'”

Mathews' mother, identified last spring as exhibiting the beginning stages of dementia, had signed her own release form.

Patient and discharge planning rights

The decision to release Mathews' mother would appear to revolve around a thorny issue of inpatient versus outpatient observation care, and Saint Vincent's above-average readmissions rate .

Dating to 1893, Saint Vincent was purchased by Vanguard Health Systems in 2005, which was then acquired by Dallas-based Tenet Healthcare last year.

Beth Donnelly, the hospital's public relations director, did not respond to requests for comment by press time.

Patient rights policy followed by Saint Vincent and hospitals across the state come from Massachusetts' Patient Bill of Rights and standards set by The Joint Commission. Discharge policy and procedure is heavily regulated at the state and federal level, but there are holes in the system particularly for individuals ostensibly seen on an outpatient basis for “observation.”

“In general, hospitals are supposed to make a safe discharge, and that has various meanings,” according to Alfred J. Chiplin, a senior policy attorney with the Center for Medicare Advocacy. “First of all, they have to make sure the patient is in a stable position.”

“Over the last several years patients are in hospitals for a number of days under 'observation',” on an outpatient basis, Chiplin continued. “They are not protected under discharge planning rights because they are not admitted patients.”

Mathews' mother was checked into the emergency room Sunday, but Mathews said she wasn't aware whether it was on an inpatient or observation basis. On Monday, a doctor said she might be able to be released the next day.

On Tuesday, Mathews rushed from work, delayed a half-hour by a traffic accident, and arrived home in time to meet her mother, in a hospital gown and snow-encrusted slippers. “It just happened to be that I was there and the snow plow was there.”

“I just feel like it was just bad timing, and I can't believe someone couldn't use a little common sense.”

With her 83-year-old father scheduled to move to a post-surgery rehabilitation center from UMass Memorial Medical Center the same day — his move was delayed — “Everything is just crazily overwhelming,” Mathews said Wednesday.

More patients in hospital beds on an outpatient basis

Discharge planning rights for Medicare beneficiaries are prescriptive in requiring hospitals to provide written notice in advance of release. The discharge plan includes where and how a patient receives care after discharge, identifies problems to watch out for and medications, and generally prepares the patient and/or caregiver following a hospital stay.

“The long and the short of it is, discharge planning really only applies to patients admitted,” Chiplin said. “That's the rub and the existing gap in the law.”

“The norm is not to keep you in observation status for more than 72 hours.”

A 2012 study by researchers at Brown University confirmed that increasing numbers of Medicare patients were being admitted on an observation basis, replacing inpatient stays in acute care hospitals nationwide.

Reviewing Medicare claims from 2007 to 2009, researchers found a 34 percent increase in observation stays during that three-year period, while inpatient admissions dropped, suggesting “a substitution of outpatient observation services for inpatient admissions,” the authors said.

They also reported a 7 percent increase in the average length of an observation stay, and 10 percent of beneficiaries were kept on an outpatient basis for more than 48 hours. The Brown researchers found an 88 percent increase in the number of individuals kept under observation for 72 or more hours: from 23,841 in 2007 to 44,843 in 2009.

In a more recent report, the Office of the Inspector General of the Department of Health and Human Services found 26 percent of the 1.5 million observation stays in 2012 lasted two night, and 11 percent lasted at least three nights.

Inpatient or outpatient status determines whether Medicare Part A or B picks up the tab and, by extension, follow-up nursing care that is only covered if a patient is admitted.

Last August, the Centers for Medicare and Medicaid Services issued a new “two-midnight” rule that limits observation stays, requiring individuals to be admitted on an inpatient basis for longer periods of time.

Despite new limit, pressures keep observations going

But two factors continue to drive observation stays: The first is potential liability to pay back Medicare should a future audit determine that hospital officials gave inpatient status to someone who could have just as easily been cared for under observation.

The second influence is pressure on hospitals to reduce their rates of readmission, an indicator of medical care quality. Under the Affordable Care Act, hospitals with unusually high rates of preventable readmissions are now penalized.

Because observation patients are never officially admitted, they don't count as a readmission if they return.

Saint Vincent was one of 364 hospitals cited by Medicare earlier this year for its higher rate of unplanned readmissions .

Since Medicare began penalizing hospitals for readmissions in the fall of 2012, Saint Vincent has lost 0.32 percent and 0.3 percent of its Medicare reimbursement revenue in the past two years .

(Similarly, UMass Medical has lost 0.96 percent and 0.73 percent of its Medicare revenue because of readmissions.)


Related Slideshow: Massachusetts Emergency Care Report Card

The American College of Emergency Physicians released America's Emergency Care Environment report for 2014 in January, issuing report cards for each state in the U.S. Massachusetts ranked second overall - see the Bay State's report card grades and highlights in the slides below.

Prev Next

Access to Emergency Care Grades

2014 Grade: B

2014 National Rank: 4

2009 Grade: B

2009 National Rank: 3

Prev Next

Access to Emergency Care Highlights

* Board-certified emergency physicians per 100,000 population: 14.2

* Emergency physicians per 100,000 population: 19.7

* Neurosurgeons per 100,000 population: 2.6

* Orthopedists and hand surgeon specialists per 100,000 population: 12.7

* Plastic surgeons per 100,000 population: 3.3

Prev Next

Quality + Patient Safety Environment Grades

2014 Grade: B+

2014 National Rank: 5

2009 Grade: A

2009 National Rank: 6

Prev Next

Quality + Safety Environment Highlights

* Funding for quality improvement within the EMS system: No

* Funded state EMS medical director: Yes

* Emergency medicine residents per 1 million population: 33.1

* Adverse event reporting required: Yes

* Percent of counties with E-911 capability: 100%

Prev Next

Medical Liability Grades

2014 Grade: D-

2014 National Rank: 40

2009 Grade: D

2009 National Rank: 33

Prev Next

Medical Liability Highlights

* Lawyers per 100,000 population: 24.5

* Lawyers per physician: 0.5

* Lawyers per emergency physician: 12.4

* Malpractice award payments per 100,000 population: 1.4

* Average malpractice award payments: $519,991

Prev Next

Public Health + Injury Prevention Grades

2014 Grade: A

2014 National Rank: 1

2009 Grade: A

2009 National Rank: 1

Prev Next

Public Health + Injury Prevention Highlights

* Traffic fatalities per 100,000 population: 3.8

* Bicyclist fatalities per 100,000 population: 1.9

* Pedestrian fatalities per 100,000 population: 2.1

* Percent of traffic fatalities alcohol related: 39%

* Front occupant restraint use: 73.2%

Prev Next

Disaster Preparedness Grades

2014 Grade: C

2014 National Rank: 20

2009 Grade: B

2009 National Rank: 19

Prev Next

Disaster Preparedness Highlights

* Per capita federal disaster preparedness funds: $6.54

* ESF-8 plan shared with all EMS and essential hospital personnel: Yes

* Emergency physician input into the state planning process: Yes

* Drills, exercises conducted with hospital personnel, equipment, facilities per hospital: 0.2

* Public health and emergency physician input during ESF-8 response: Yes


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