Understanding the First Steps in Addressing Custodial Hospitalizations

Custodial or social hospitalizations have been a long-standing issue within acute care hospitals. 

These patients generally arrive to the Emergency Department (ED) with vague or even no acute complaints. 

Following initial work-up, it’s clear they don’t medically require hospitalization but deficits in their day-to-day needs or the ability to care for themselves remain unsolved.  As such, there is significant concern by the medical team and often, the patient themselves, that there is no safe path forward to ensure the patient’s well-being.

Some hospitals have Herculean initiatives and well-staffed teams focused on finding alternative modalities of care or placement out of the ED; but even they are unable to avoid hospitalization in every case.  Every day, scores of patients across the country enter inpatient hospital beds for what amounts to custodial care. 

Assistance with ambulation, transfers, and activities of daily living (ADLs), administration of medications, and delivery of meals are all available in the hospital setting but don’t require the hospital to take place.  Absent a perfect world with strong and all-encompassing support systems for these individuals who need assistance to safely live their lives, hospitals are the social safety net. 

Much has been written and discussed about this topic, including how to address or mitigate the problem.  In fact, I and fellow MedLearn Media Talk Ten Tuesday panelist, Tiffany Ferguson, presented at the American College of Physician Advisors’ National Physician Advisor Conference recently about this very topic.  But what often gets overlooked are the very first steps hospitals need to take when considering solutions. 

These initial steps seem incredibly simple but can be astonishingly complex involving multiple teams to participate and ensure success – case identification and data collection.

In theoretical discussion, custodial cases seem easily identifiable.  In reality, clarity wanes when medical staff are faced with providing care to dozens of patients over the course of a shift and are intimately aware of these patients’ profound limitations. 

Does that extremely debilitated, practically cachectic, 90-year-old man who hasn’t yet been able to take his medications without dropping a pill or two, really not need hospital care?  What about the 42-year-old woman with severe developmental delays who was brought to the ED because her elderly parents simply can’t manage her transfers, toileting, and bathing any longer? 

What were the parents supposed to do?

Targeted discussion and education delivered to nurses, physicians, social workers, and case managers should focus on identifying the difference between no other available option to provide patient care, and care which can only be provided in the hospital.  Emphasizing robust identification of these patients will allow the health system to effectively investigate augmentation of or collaboration with outpatient services and community support. 

Point out that when these patients are effectively cared for outside of the hospital setting, more hospital beds will be available for those who truly require them for their acute medical needs. 

Identification is one aspect, but collection of the data is another.  Do you have modalities to capture different scenarios or discharge barriers in your electronic medical record?  Who can enter this information, and is it simple for them to do so? 

If only case managers have this tracking tool access, how does the message get passed along when a nurse, social worker, or physician suspects a patient’s hospitalization is custodial in nature?  Ultimately, who is reviewing the data and making sense of it all, providing recommendations of action? 

Patients who are hospitalized solely for custodial or social reasons should be classified as Outpatient or Outpatient in a Bed.  They do not have need for Observation services, and their lack of need for care which can only take place in the hospital setting creates ineligibility for Inpatient status (regardless of how many days they are in a hospital bed before an outpatient care plan is established and the patient is discharged). 

However, what if a patient who is hospitalized for custodial reasons, then develops a condition which requires hospital care or investigation?  In this instance, adding Observation services, at least, would be appropriate.  But if your hospital’s method of identifying and tracking custodial cases involves designation of Outpatient status at discharge, these patients would be lost due to the addition of Observation services to the claim. 

This could be remedied by adding a different designator in your electronic health record which is independent of patient status and even allows tracking of days associated with cases which become custodial following a justified medical or surgical hospitalization.  Since this is a situation to which case managers would be most attuned, application of this type of identifier by this team might make the most sense. 

However, they should not carry this mantle alone, which brings us back to education for physicians, bedside nurses, and others to participate in prompt identification.

Routine review of collected cases by a physician advisor should involve sorting into categorization types, payors, and length of time custodial care was provided.  Categorization types might include the following:

1. Assistance with ADLs
2. Assistance with transfers/ambulation
3. Family no longer willing/able to care for patient
4. Facility no longer able to care for patient
5. Guardianship/other legal challenge
6. Unhoused

Collaboration with members of the hospital’s revenue cycle team can then assign a financial impact to these cases based on the cost of services provided without reimbursement.  Additionally, retrospective review of the hospital’s ED boarding numbers and potentially lengthened throughput during days when there were high levels of custodial patients occupying hospital beds can provide more clarity to the overall impact of these cases to the hospital’s ability to function at its highest level for the surrounding community.

Support for development of comprehensive and effective processes will be realized only when the scope and impact of custodial hospitalizations is made clear to your hospital’s leadership. 

Before expending effort into how to address this issue, focus first on synthesizing a clear picture of the challenges and impacts.

Programming note:

Listen live this morning when Dr. Ugarte B. Hopkins reports this story during Talk Ten Tuesday with Chuck Buck at 10 Eastern.