Since she fell and injured her arm in May, 77-year-old Park Chevalier hasn’t been able to live on her own as she once did in downtown Kona.

She needs to move into a long-term care facility due to complications from the fall, according to her family, but no beds are available.

Like so many other patients in the state, Chevalier is stuck in a kind of limbo. She’s been in the hospital for months, not because she needs treatment, but because there’s nowhere else she can go.

One in 10 hospital beds in Hawaii is occupied by a patient who can’t be discharged because there isn’t space for them at a post-acute care facility, such as an assisted living center or nursing home. That’s according to the Healthcare Association of Hawaii, a trade group that represents hospitals and other health care facilities in the islands.

These “waitlisted” patients can languish for days, weeks and sometimes years in hospitals — and the average time they spend there is getting longer.

The issue has wide-ranging implications for hospitals, communities and the patients themselves. Most notably, it strains hospital capacity, already limited in the wake of the coronavirus pandemic.

It also hurts the bottom line as hospitals often must absorb the cost of holding patients — which can be about $1,200 or more per day — after their insurance runs out.

Longer Stays

In November, 219 patients in Hawaii were waitlisted, according to a survey conducted by the Healthcare Association of Hawaii. There were also 219 waitlisted patients in May, but their average length of stay went up.

In November, people waiting for long-term care stayed an average of 78 days in hospitals before they were discharged. In May, it was 123 days.

The longest stay was 720 days. 

“That means they were ready to be discharged two years ago, but we can’t find a placement,” said Hilton Raethel, president and CEO of the Healthcare Association of Hawaii. “They’re living in a hospital room for two years. That’s not a good environment for anyone.” 

There are a variety of reasons a patient may be waitlisted. They might not have insurance that covers their long-term care. A facility might not be available that can assist them with their specific behavioral or medical condition. 

Patients on Medicaid have more difficulty finding placements because some facilities are reluctant to take them in, Raethel said. Assisted living facilities, for example, don’t get reimbursed by Medicaid, although his group is working on addressing that.

Also, long-term care facilities don’t have enough staff to meet the need, experts say. The state has 4,323 nursing home beds and 2,593 assisted living beds, according to the state long-term care ombudsman, but that doesn’t mean they can all be filled with patients.

Ohana Pacific Health, the largest provider of long-term care in the state, could increase its capacity by 175 beds or more if it had more nurses, according to CEO Wes Lo.

The longstanding problem of staff shortages worsened during the pandemic when many nurses, licensed practical nurses and certified nursing assistants moved from care facilities to work in hospitals for higher pay, Raethel said. Many others burned out or switched fields.

Federal funding that helped bring travel nurses to Hawaii from the mainland also dried up in the spring, said John McDermott, the state’s long-term care ombudsman.

The problem is worse on smaller islands that have fewer resources. 

Molokai, for example, has no nursing homes or assisted living facilities. 

Arsenia Masiglat runs the island’s only licensed community care foster home where she cares for two elderly patients in her house. 

Masiglat said she takes calls almost every week from hospitals on other islands asking if she has space for new patients. 

A few months ago, she got a call from a woman whose husband was ready to be discharged from a hospital in Honolulu. The woman wanted to bring him home to Molokai but couldn’t care for him by herself because he had Alzheimer’s disease. 

Masiglat didn’t have a bed for him and didn’t have any other resource on the island to suggest.

“I can’t recommend nobody here because there is nobody,” she said. 

‘There’s A Lot Of Waiting’ 

Chevalier’s family has been told no beds are available in long-term care facilities on Hawaii island, her daughter, Malia Lloyd said, speaking by phone from New Jersey. On top of that, the family must wait to get approval from Chevalier’s Medicare for coverage of long-term care treatment.

“It’s been stressful, sometimes frustrating, not getting the answers that you want,” Lloyd said. “And there’s been a lot of waiting.” 

Chevalier was first admitted to Kona Community Hospital in early May after she fell and broke a bone near her wrist. After treatment, the hospital released her to Lloyd’s brother, who lives on the island, but both siblings were concerned about her living without professional care. 

Over the next 48 hours, her arm began to worsen, and she ended up back in the hospital, Lloyd said.

Once she recovered from multiple surgeries, her children planned to move her to a long-term care facility where she could have more independence, social interaction and stimulation. But Chevalier has been waiting nearly four months in the hospital.

Meanwhile, Lloyd said her mother’s mental state is deteriorating. Plus, she can’t see her grandchildren, who are 7 and 5, because the hospital only allows visitors who are 14 and older to certain wards.

“My mom that I knew six months, nine months ago doesn’t even exist anymore,” Lloyd said.

Kona Community Hospital currently has 28 patients on the waitlist for long-term care, many of whom are elderly or have a history of stroke, mental illness or other health issues that make it unsafe for them to return home, said Lynn Reinert, a hospital management officer. 

They’re well taken care of at the hospital but would benefit from the active, social setting a long-term care home could offer.

“We’re a critical care facility, and we’re just not set up to provide the mental stimulation some of these folks would thrive with,” she said. 

‘The Whole System Backs Up’ 

Longer hospital stays mean fewer beds available for new patients. 

“We’ve had cases where we’ve had 10, 12 ambulances backed up waiting to admit patients,” Raethel said. “We’ve had ambulances sitting in the bays treating patients in the back of the ambulance because we can’t even get them into the emergency room.” 

Hospital capacity in Hawaii is already stretched thin. 

The state’s major hospitals have about 3,000 licensed beds, but there isn’t enough staff to tend to all of them, Raethel said. According to the American Hospital Directory, the state has staff for 2,538 beds.

On average, around 2,400 of those beds are occupied by patients each day, Raethel said. 

That number has increased since the wildfires in Maui. On Aug. 23, more than two weeks after a fire destroyed Lahaina and claimed at least 115 lives, there were 2,532 patients in the state’s hospitals, Raethel said. While most of the new patients were not directly injured in the fires, Raethel said the stressful situation created by the disaster exacerbated many people’s health issues.

And while hospitals can flex their staffing levels based on need, they can’t do it on a long-term basis.

“We have probably four or five of our hospitals right now that are above their licensed bed capacity, meaning they’ve got every single bed full,” he said.

Additionally, holding patients in hospital beds is expensive, Raethel said. 

For example, the minimum cost to stay in a hospital is around $1,200 a day, but that number can more than triple, especially if a patient needs intensive care, he said. A stay in a long-term care facility, meanwhile, costs about $300-$500 per day.

While insurance companies reimburse hospitals, they do so at a flat rate, he said. If a patient is diagnosed with a condition that usually requires three days to treat, the insurance company will only cover a three-day hospital stay.

“This becomes a real challenge when you’ve got an average length of stay for these waitlisted patients of over 120 days,” Raethel said. “The hospitals are not getting paid for all of those additional days. They only get paid that fixed amount based on the reason the patient was in the hospital in the first place.”

The hospital can’t then bill the patient and often can’t go back to the insurer to ask for additional money because they have a contract dictating how much they can be paid for each particular diagnosis. In the end, the hospital must absorb the extra cost.

“The margins in hospitals are really, really low, so that’s why it’s a big issue,“ he said. “It inhibits their ability to buy new equipment, to invest in their building renovations, to pay their staff more.” 

Until long-term care facilities can increase their capacity, many patients are left with no option but to wait.

“(My mom) keeps asking when she’s going to go home, and we keep saying, ‘Not today, mom. Not today, mom,’” Lloyd said. “We just can’t wait until she gets to a place where maybe she can have a little of her own space and start the next chapter of her life.”

Civil Beat’s community health coverage is supported by the Atherton Family Foundation, Swayne Family Fund of Hawaii Community Foundation, the Cooke Foundation and Papa Ola Lokahi.