Oregon’s hospitals have too many patients with nowhere to go.
Patients who are ready to leave the hospital who still need care to recover from a surgery or illness. Older patients who need skilled nursing. Patients experiencing mental illness or a substance use disorder who may be unhoused and need a place other than the streets to receive help.
The use of hospitals for “boarding” people — rather than patient care — is having ripple effects across the Oregon health care system, prompting lawmakers to assemble a task force that is finalizing recommendations for next year’s legislative session.
“The entire system is just gummed up,” Jimmy Jones, executive director of the Mid-Willamette Valley Community Action Agency and task force chair, told The Lund Report. “The hospitals are not shelters. They’re not skilled nursing facilities. They're not post-acute care providers. They’re there to solve acute health needs and then get people moving on to other destinations.”
Oregon hospitals no longer make public the number of beds filled with non-patient boarders, which once totaled as much as 500 or more. But it remains high — and that affects patients’ access to care and providers’ ability to focus on care. The average Oregon hospital stay increased by 27% to nearly four days between 2017 and 2022, according to a consultant’s report produced for the task force.
The average stay has grown to nearly five days in 2024, and patients have spent more than 57,000 days in Oregon hospitals since January waiting to be transferred to the appropriate level of care, according to the Hospital Association of Oregon.
“This means that beds aren’t available for community members in need, and, in many cases, hospitals aren’t being paid for additional days ‘boarding’ patients,” Sean Kolmer, the hospital association’s executive vice president of external affairs, told The Lund Report in a statement. “The longer this continues, the greater the impact will be on patient care and hospitals’ financial stability.”
Even if people boarded at hospitals are not receiving hospital medical care, they still must have a nurse or other caregivers handy as hospitals try to comply with a new state law requiring higher levels of staffing.
Looming over the issue? A federal law that requires hospital discharges and transfers be “appropriate.” That means hospitals must ensure patients are stabilized, are set up to receive needed care and that psychiatric patients will be protected from harming themselves.
The problem particularly affects large urban hospitals where patients in need of emergency care may find themselves waiting hours more than necessary due to lack of beds.
Instead, those beds are filled with patients for whom the hospitals can’t receive revenue because they are not providing covered health care. That affects other parts of the state, too. Urban hospitals are the ones that typically generate profits for larger health systems, that in turn staff and fund care at rural hospitals.
Patients stuck boarding in hospitals, meanwhile, may not be receiving appropriate care. More vulnerable Oregonians face longer stays, according to the consultant’s report. Those experiencing frailty, housing insecurity as well as Alzheimer’s Disease or dementia experienced average stays of over five days.
Multifaceted problem
A primary driver of the situation is a lack of staffing at Oregon’s skilled nursing or long-term care facilities, which have fewer beds for discharged patients who still need care in less-intensive settings.
Meanwhile, nursing and care facilities are reluctant to accept patients without a guarantee of compensation.
Sarah Ray, a long-term care facility owner in Ontario and member of the task force, said during a recent meeting that a facility might admit someone thinking they would qualify for Medicaid. After taking the patient in, they may not qualify and end up being disruptive while the owner has a hard time removing them because of Oregon’s housing protections, she said.
“And then removing this person is just a complete fiasco,” she said.
Another challenge spotlighted by the task force: delays in the eligibility checks needed to sign up patients for the low-income Medicaid health plan, which would pay for care they might need after being discharged.
Dr. Raymond Moreno, an emergency physician at Providence St. Vincent Medical Center, said at the hearing that Providence patients wait 30 to 60 days while waiting for their eligibility check.
“I don’t think this problem is going to be solved by just throwing millions more dollars at it. We’ve got to make the current system work better.”
Task force has ideas
The problem caught the attention of lawmakers last year, who created a 19-member task force— which includes representatives for hospitals, nursing homes, state agencies, lawmakers and others — to look into the problem and produce a final report by November in time for next year’s legislative long session.
After meeting for about a year, the task force has released a draft of 10 recommendations that seek to create more options for patients ready for discharge but who still need some level of care. The overlapping recommendations include:
- Streamline Medicaid eligibility checks.
- Ramp up workforce development programs.
- Increase reimbursement rates for adult foster homes.
- Funding more guardians, court-appointed positions charged with making decisions for adults found incapable of caring for themselves.
- Require coordinated care organizations, Oregon’s regional Medicaid insurers, to arrange services for complicated patients discharged from hospitals, including case management, home care and discharge and transition services
- Expand medical respite programs, which provide short-term housing to a homeless patient along with health services.
“We appreciate that the (task force) has made funding and policy recommendations aimed at tackling discharge issues in a systematic and patient-centered way,” the hospital association’s Kolmer said. “We’re supportive of the task force’s proposed solutions.”
However, the recommendations will not take effect immediately. Multiple recommendations require federal approval or changes to state programs that state lawmakers need to sign off on. Implementing the recommendations will take at least two legislative sessions and will not be fully implemented until 2028 at the soonest.
“And then removing this person is just a complete fiasco,."
Prospects for change
During its meeting last week, state Sen. Deb Patterson, a Salem Democrat who chairs the Senate Health Care Committee, and outgoing state Rep. Christine Goodwin, a Canyonville Republican, both expressed support for the recommendations.
Currently, the recommendations do not have a price tag. Jones said the task force’s most costly recommendation will likely be funding to cover facilities expenses in cases where they agree to take a patient from a hospital but later find out they are not eligible for Medicaid.
Jones said the task force will limit how much funding it requests for the recommendations and is more focused on making regulatory changes.
“I don’t think this problem is going to be solved by just throwing millions more dollars at it,” he said. “We’ve got to make the current system work better.”
““If you are building a system that is based on the idea that anyone can and eventually will recognize that they need treatment … it means the population of people who literally can’t because they have anosognosia are just invisible to the system,” said Lisa Dailey, the executive director of the national organization Treatment Advocacy Center.” Anosognosia is the main symptom that keeps almost half of people who have schizophrenia or bipolar from getting the treatment they need. They simply lack the ability to recognize that they are ill. In other words, they’re too ill to know they’re ill, due to the way their brain malfunctions.
Hello, I read over the members of the OHA Behavioral Health Committee and would like to suggest that those who are on the front lines of dealing with untreated severe mental illness are not represented on your committee. Specifically, police departments, families of those who have loved ones with severe mental illness, those who in addition to their brain disorder also suffer from anosognosia, the lack of insight into their illness, those with lived experience who are unable to attend due to languishing in Oregon's jails and prisons, the homeless, CAHOOTS, and other crisis response teams. Please see the two comments below, one from CAHOOTS and one from the Springfield Police Department retired police chief Richard Lewis "Theresa Boudreau, a crisis worker for CAHOOTS, thanked Wyden for his visit but reminded the gathering that improvements to public safety need more than expanded crisis response. "My perspective, being on the street, is that we could have 800 Cahoots vans and 1,000 workers, and that's great, except for not having a place to take them, not having the services that they need," Boudreau said. "And that's critical." Chief Richard Lewis - his comment to the KVAL article regarding the mentally ill person in crisis the department responded to - The reality is until the nation and Oregon wakes up and starts properly funding mental health, you're going to continue to see tragedies, and you're going to continue to see high profile police interactions when there should have been many interventions before that person gets there." I am respectfully submitting the five-part plan below that outlines real changes and request it be presented to the committee. It would be so appreciated.
More outreach without more services is like cutting more doors into an empty building.
Police are needlessly overburdened by the mentally ill abandoned by the mental health system A FIVE-PART PLAN TO ADDRESS SERIOUS MENTAL ILLNESS (SMI)
1. RECLASSIFY SERIOUS MENTAL ILLNESS (SMI)) FROM A BEHAVIORAL CONDITION TO WHAT IT IS, A NEUROLOGICAL MEDICAL CONDITION WHY RECLASSIFICATION IS IMPORTANT Reclassification will unlock more research funding and help eliminate discrimination in treatment, insurance reimbursement, and the perception of SMI as a “behavioral” condition. SMI is a human rights issue. NIMH ranks SMI among the top 15 causes of disability worldwide with an average lifespan reduction of 28 years. PRESIDENTIAL ACTION * Create a cabinet position exclusively focused on SMI. * Push for Congressional appropriations to include schizophrenia in a CDC program that collects data on the prevalence and risk factors of neurological conditions in the US population.
2. REFORM THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPPA) WHY HIPAA REFORM IS IMPORTANT Overly strict HIPAA laws make it extremely difficult for families and caregivers to partner in the treatment of their loved ones, resulting in important life-saving medical information gaps. By eliminating this barrier, family support will be strengthened, reducing the chance of relapse, homelessness, imprisonment, and death. PRESIDENTIAL ACTION * Work with legislators to change HIPAA law to ensure mental health professionals are legally permitted to share and receive critical diagnostic criteria and treatment information with/from parents or caregivers of SMI.
3. REPEAL MEDICAID’S INSTITUTES FOR MENTAL DISEASE EXCLUSION (IMD) WHY IMD REPEAL IS IMPORTANT IMD repeal will increase the availability of psychiatric inpatient beds. The IMD exclusion is not only discriminatory of those suffering from neurological brain disorders; it is a leading cause of our national psychiatric hospital bed shortage. It prohibits Medicaid payments to states for those receiving psychiatric care in a facility with more than 16 beds who are 21-65, the age group with the most SMI. PRESIDENTIAL ACTION * Work with legislators to repeal the IMD exclusion.
4. PROVIDE A FULL CONTINUUM OF CARE WHY A FULL CONTINUUM OF CARE IS IMPORTANT A continuum of care ensures that SMI patients receive early intervention at all stages of their illnesses, long-term care when needed, and follow-up treatment (medications and therapies) when they’re released. It reduces visits to jails, ER’s and hospitals, homelessness, and morgues. A continuum of care provides lifetime management. Fully fund and institute mental health courts and Assisted Outpatient Treatment programs. PRESIDENTIAL ACTION * Create federal incentives to states which are addressing a full array of inpatient, outpatient, and supportive housing care.
5. DECRIMINALIZE SERIOUS MENTAL ILLNESS (SMI) WHY DECRIMINALIZATION OF SMI IS IMPORTANT People suffering with other neurological conditions like Alzheimer’s and dementia can get treatment promptly without being kicked out of their homes to wander the streets until they are arrested and put in jail or prison rather than a hospital. Setting the bar so impossibly high for getting help ensures that a very large percentage will "disappear", making tragedy before treatment the status quo. These souls will disappear to the streets, jails and prisons, and the morgue. Serious mental illness is the only disease where the doors to treatment are shut unless a crime is committed. This is pure and simple discrimination with the disastrous results we see in our country today — homelessness, incarceration, the disintegration of families, and death. PRESIDENTIAL ACTION * Work with legislators to change “must be a danger to self or others” criteria. * Work with legislators to change involuntary commitment criteria, alleviating the subjective nature of “gravely disabled” and redefining it in objective terms based on scientific medical need for treatment. Psychosis, like a stroke, is a traumatic brain injury and needs immediate treatment for the best outcome.
The system is incredibly overloaded and disjointed. I have been told twice by two different sources at Lane County Behavioral Health that they release people into homelessness, but can "try to provide them with some supplies such as a tent and clothing." The fact that they're openly admitting to releasing the mentally ill to the streets is astonishing - it seems like that should be a criminal act.