Patients want to give up their hospital beds – politicians need to help them do it
A/Prof Steven Faux (St Vincent’s Hospital Sydey’s Director of Rehabilitation) - SMH 16 Jan 2022
Mr Mendez is 79 years old. He has a hot and cold relationship with his neighbours. In the hospital, we know him well. He falls, he neglects himself to the point of collapse and, apart from an unwavering belief that his neighbour has him under surveillance, he is sharp as a tack. Usually, at this stage in his recovery, a community nurse could treat him at home; until Omicron.
Next to him is Colin, a paraplegic for more than 15 years, who keeps getting urinary tract infections and occasionally ends up in our intensive care unit. He was managing, until Omicron.
But it’s Sandy in the next room, who lost her leg from a fall, who is in big trouble. She is just learning to walk with an artificial leg, which she needs to do to see her methadone prescriber weekly. She is in real trouble because of Omicron.
None of them have Omicron – it is the other 100,000-odd people in NSW who have it that are their problem. We need the beds occupied by Mr Mendez, Colin and Sandy, right now, yet this trio simply cannot get out of hospital because no rehabilitation alternatives are available for them. This situation means the 400 people who turn up each day to our emergency department can’t get in. That is the bigger problem and it is happening across the state.
Rehabilitation physicians and subacute clinicians like me hold the keys to the exit doors of the system. Our job is to ensure that those who can manage in the community after an illness or injury will receive care at home while they continue to recover. We play a critical role in moving recovering patients through the hospital system and back into their homes, so they continue their care there and release their hospital beds for others waiting in the emergency department. But right now our hands are tied.
Mr Mendez, Colin and Sandy all understood why we needed to move them. They were reassured they would be cared for, and they were willing to co-operate. “Anything to help, doctor.” It was humbling.
The nursing home that would take Mr Mendez is run by a private consortium that has decided he must have a negative PCR swab even to be considered for transfer, but it might take five days to get the result. Other nursing homes are closed as they battle infections in their own staff and residents. So he stays in hospital.
As for Colin, he has support through the National Disability Insurance Scheme but by the time it takes to get the NDIS to increase his level of funding for care at home, at least two-to-four weeks will pass. (They have to decide whether our recommendations are appropriate and hire staff.) So he stays.
Sandy has private health insurance so we can transfer her to a private hospital to complete her rehabilitation, but one has closed due to staff issues, another has active COVID-19 cases and cannot take her and a third has staffing problems and will not have a bed for three weeks. By then she will be walking. So she stays.
Meanwhile, our emergency department director is begging us to free up beds for those still in ambulances waiting to get through the hospital’s front door.
Our rehabilitation services are not in crisis, but we are definitely not in a “strong position”. Other states of Australia will face similar problems including Victoria where bed block in rehab was an issue in the previous waves, but their lockdown meant numbers were more predictable.
Our state-run hospital’s rehabilitation department relies on community and aged care services to discharge people safely back home. These services are all run by the federal government, not the state, and the federal government has devolved the responsibility of managing the aged care sector to private providers.
The NDIS is yet to put in place plans to expedite access for new patients or those with changed circumstances due to Omicron. The federally funded Transitional Aged Care Program, which supplies care into people’s homes, has been devolved to state-run local health districts that are struggling with staff shortages and the private health insurers are extremely limited in funding medically led rehabilitation in the home.
What we need is some state and federal co-operation and leadership that recognises the fact that if you cannot safely get patients out of hospital, you will never get new ones in. Our federally funded community programs and private insurers need to explore what they can do to help the state hospitals and the tens of thousands of patients in them. We need to find more subacute beds now, so we can keep accepting and admitting patients.
The need for better rehabilitation planning is not a new problem. The Council of Australian Governments initiative of 2009-2014 showed that investment in enhanced rehabilitation services saved money ($4.80 for every $1 spent) and created capacity in our hospitals (16 virtual beds in a 300-bed hospital), but there was no federal follow-up.
COVID-19 has made the problem worse. We will be living with COVID-19 for a long time and long COVID will fill the rehabilitation and respiratory clinics for years. The need to safely discharge patients to alleviate pressure on emergency departments will be unyielding.
We have never had a national rehabilitation strategy, nor an integration plan for federal and state subacute health services, not even a debate. Mr Mendez, Colin and Sandy would do anything to help. Let’s hope they inspire those in power to do the same.