No Way Out: How to Manage Declined Discharges 

Among the many nightmares we face as Physician Advisors, managing patients who refuse to discharge from the hospital is one of the most draining.  We all want the best for our patients.  At the same time, hearing “no” is more than frustrating; it’s a patient safety issue.  Chances are you have acutely ill Emergency Department boarders, urgent day of surgery cases, and pending outside transfers in desperate need of your beds.   Delaying the care of those patients because your patient won’t leave can have dire consequences.    

Judging from the traffic this topic generated on RAC Relief, this is a common scenario.  At the University of Vermont Medical Center, it happens often enough that we needed a clear plan to help us balance patient centered care with the wise allocation of inpatient beds.  Unfortunately, there was little in the literature or the Utilization Management community to guide us in making a policy.  So we made our own. 

We convened a multidisciplinary team that included nurses, physicians, advanced practice providers, residents, case management, utilization management, quality, compliance, legal, risk management, ethics, finance, medical psychology, palliative care, spiritual care, diversity, equity, and inclusion, and patient-family advisors.  We spent months developing a policy that was approved by senior leaders. 

Several key principals frame the policy: 

• A clear discharge plan that is consistently communicated to patients and families goes a long way to prevent declined discharges.   
• We offer all patients a reasonable discharge plan. We define reasonable as any location that meets the patient’s medical needs at the time of discharge.   
• We are committed to the precepts of Patient and Family Centered Care.  This does not equate to honoring all patient/family requests, particularly if granting a request for one individual could harm others. 
• Declined discharges should never be accepted without further inquiry.  Prior to the policy, refusal was often accepted with few questions asked. 
• Time is of the essence, as discharge options can disappear quickly.  Each step in the policy has a clear timeline. 

Using this framework, we created a three-step management protocol (see Figure 1 below). 

• Step 1: Explore and Respond.   
• Reflect on your own response: hearing “no” can trigger negative reactions.  Before engaging with the patient, take a moment to reflect on your response and put yourself in a calm frame of mind. 
• Explore the reasons for refusal, identify and address barriers: approach the discussion with curiosity and compassion, consider the principles of trauma-informed care, and work with others in your system to resolve barriers where possible. 
• Defer payment issues to Case Management:  while Physician Advisors have the expertise to have these discussions, many front-line clinicians do not. 
• Respond based on discharge location:  details vary depending on the discharge location.  If the discharge is to a non- hospital setting, this is the time to discuss the risks of remaining hospitalized, such as hospital acquired conditions.   It’s also when we emphasize the safety risk their refusal poses to other patients.   
• Explain that remaining hospitalized will not be the default option and that further discussion will follow. 
• Re-evaluate if the discharge plan is still reasonable: after inquiry we sometimes agree that the proposal is no longer appropriate. 
• If still appropriate, then re-attempt discharge. 
• Step 2: Escalation 
• If the patient continues to decline discharge, we escalate the review to Case Management Leadership.  If they agree that the discharge plan is reasonable, then the patient is given the option of accepting the discharge plan or discharging to self-care. 
• Throughout Steps 1 and 2, we move forward with discharge planning.  We set a date, arrange transportation, and complete all discharge tasks. 
• The timeline for Steps 1 and 2 combined is 24 hours. 
• Step 3: Adjudication 
• If the patient declines both options, the primary team disagrees with the escalation decision, or an administrative discharge to self-care appears unrealistic then the case is sent to the Adjudication team (see Figure 1), who make the final decision. 
• The timeline for Step 3 is one business day 

Concurrent with these steps we follow payer-specific processes of important messages, notices of non-coverage, and beneficiary appeals.  These exist in a separate policy but aside from traditional Medicare cases don’t typically influence outcomes and if applied too bluntly can stifle collaboration. 

The policy has been active for a year.  At first it represented a real culture change but has gradually become part of our daily practice.  Clinicians particularly appreciate the backing of a policy, something they could point to as “the rules” when the going gets tough. 

To date, most declined discharges resolve in Step 1, demonstrating yet again the power of good communication. As best as well can tell, Step 1 discussions occur several times a month, but it’s hard to distinguish between refusal and strong preference.   Six cases have gone to escalation and two to adjudication, with all but one resulting in discharge. To be mindful of potential bias, we track age, race, gender, and payer for cases that go to escalation. 

Bringing this policy to life was a difficult endeavor, but one perfectly suited to Physician Advisors, melding administrative and clinical expertise with strong communication skills, teamwork, and innovation.  For years we have relied on guidance from the ACPA community and we hope, in turn, you find this helpful. 

Dr Grant is ACMO for Care Coordination and Patient Transitions at University of Vermont Medical Center, Burlington, Vermont