Dishonorably discharged?

At age 56, Roberto can barely move or talk. He suffers from Alzheimer’s, and has just been temporarily admitted into a long-term care facility in Gran Canaria. Before that, he spent seven months in a hospital even though he had been discharged much earlier than that. His daughter Carla, 34, refused to take him home: because of the advanced state of his condition, she could neither care for him personally nor afford a private nursing home.

Roberto and Carla are assumed names, but their case is real. So are those of the other 390 patients who remain in general hospitals throughout the Canary Islands well beyond their discharge date. The situation was recently disclosed by regional premier Paulino Rivero, but it is by no means exclusive to this part of Spain.

“Spain has not properly resolved the transition between the healthcare system and the social care system,” says David Casado of the Catalan Institute for Public Policy Evaluation, who has 15 years’ experience assessing social care services for the elderly, the poor and people with illnesses and disabilities.

“This is the healthcare system’s great challenge today,” adds Laura Pellisé, director of the Economy and Health Research Center at Pompeu Fabra University. “The challenge involves adapting to the needs of multiple pathologies and chronic patients, and moving on from the current system to one with greater continuity between the health aspects and the social aspects. It is a slow process and a global challenge.”

Hospitals are becoming increasingly more technical places focusing on fast patient turnaround. But on occasion, when patients get discharged, continuity of care is not guaranteed because there are no mid-term care facilities or residences available for them. “They are people whose social conditions make it impossible to take them out of hospital,” says Eduardo Zafra, author of several studies on the subject.

And so the patients remain in hospital, surrounded by technology they don’t need and failing to receive the low-to-middle intensity health or social care they require. Given the lack of alternatives, hospital stays are unnecessarily extended, and this has an impact on more than the patients themselves. Spending goes up: an acute care hospital bed costs six times as much as a bed in an intermediate care facility. And the more hospital beds are taken up, the longer the waiting lists for other patients requiring hospitalization.

It is not easy to gauge the extent of the problem in Spain. Besides the information offered by Rivero, there is little else to go on as no official data exists, the Health Ministry admits. It is a very different story in countries with a great tradition of transparency, such as Britain, where the National Health Service provides data on bed blocking on its website. Records show that current figures are the highest in the last three years: in November of last year there were 4,190 patients in England who were well enough to be discharged yet continued to take up hospital beds. The delayed transfers were basically due to late patient assessments and a lack of vacancies in care homes.

In Spain, the Edad & Vida Foundation, which comprises health insurers and elderly care home companies, estimates that 5,238 acute patient beds are being occupied by people who need social care, “at a cost of 1.5 billion euros for the National Health System.”

Experts consulted by EL PAÍS underscored two key elements to bed blocking in Spain. One is a shortage of beds for mid-to-long-term care patients. The latest Health Ministry data, available for 2011, shows that for every 10 beds for acute patients in public hospitals there is just one bed in mid-to-long-term care facilities, which are the best place for long convalescences or physical rehabilitation.

“There are very few, and in the end the acute hospitals play this role,” says Agustina Hervás, head of the social care unit at Virgen del Rocío Hospital in Seville.

The other major bottleneck lies in the dependents system, built to assist people who cannot take care of themselves. The waiting list for social services covered by the law (residential care, day centers, home care and so on) affects 190,000 people who are eligible for aid but have yet to receive it.

The needs of chronic and dependent patients are a result of the medical success in handling disease. The rise in life expectancy has also increased incidences of chronic illness: the prevalence of diabetes rose from seven to 17 percent in 10 years in people 75 years and over. Over 25 percent of people 45 and older also suffer from more than one chronic illness. And there are growing numbers of elderly people with serious conditions that make them dependent on others for care.

The transition between the healthcare and social care systems is poor”

Faced with this scenario, hospitals are developing several strategies to prevent bed blocking, says Bernardo Valdivieso, head of planning at La Fe Hospital in Valencia. One is to follow up on chronic patients at risk of destabilizing, in order to reduce the risk of them being admitted into hospital because of an emergency. The management of the discharge process is also being improved. At large medical centers there are teams who start planning the discharge of patients from the moment they are admitted, so that if any kind of social care is expected to become necessary, it will be available when it is needed. Another strategy is home hospitalization.

But adapting to the needs of chronic patients with several conditions is not something that hospitals can do by themselves. Not even the health services can, not without some extra help.

“There must be greater continuity of care, and that requires reorganizing health and social care, and reassigning the roles in primary and specialized care and in the social services, all of which must lead to an integration of health and social care," says Laura Pellisé.

To date, the greatest efforts in that direction have been made “in Catalonia and the Basque Country,” she adds.

Estimates say over 5,000 acute patient beds are being blocked in Spain

But experiences have varied widely, not only in the different regions but also in health departments, hospitals and local institutions within the same region.

When Paulino Rivero disclosed the Canary Islands’ data on bed blocking, the Health Ministry issued a statement noting that it was working on a plan to integrate health and social care with the aim of offering integral care assistance.

This kind of work is being closely followed by the association of elderly care homes, which has over 50,000 vacancies and has already volunteered to help free up acute beds at hospitals.

“Between 50 and 60 percent of our facilities are adaptable to the needs of these patients,” says Alberto Echevarría, head of the Federation of Dependence Entrepreneurs.

Meanwhile, Roberto continues to wait for a definitive solution. “If all goes well, in 12 months my father will have a definitive spot in a public social care center,” says his daughter — who began doing the paperwork three years ago.

With reporting by María Sosa Troya, Patricia Tubella, Reyes Rincón and Sonia Vizoso.