As all of us know, it has been increasingly difficult for us to place our neurocritical care patients in post-acute facilities after discharge from the ICU. Hospitals across the country are filled with patients ready to be placed in rehabilitation or skilled nursing facilities, but despite the outstanding work of our social workers throughout the hospital, there is nowhere for our patients to go. As a result, the flow of acute care beds is stalled, which has been a growing crisis in our hospitals. It has led to emergency room crowding, delayed admissions, and cancellation of elective surgery in extreme cases. This of course not only affects patient care but can also affect the bottom line in an already financially strapped health delivery system. Hospitals are dependent on the high reimbursement of elective surgery—a lesson all of us understand from the pandemic. 

Our system of both rehab and skilled nursing facilities was also impacted by the pandemic, and the crisis only appears to be getting worse. Nursing homes predominantly care for two groups of patients: short-term rehab patients with private insurance or Medicare, and long-term resident patients with Medicaid coverage. Medicare and private insurance are more generous payers, whereas Medicaid often pays below the actual cost of caring for these medically complex and frail patients. The several year-long slowdown of elective patients that needed post-discharge rehab was a major blow to this industry.

Sobering data from the American Health Care Association and National Center of Assisted Living (AHCA/NCAL), which represent over 14,000 nursing homes and long-term facilities that provide care for approximately five million people each year, clearly summarize the growing crisis we are facing. Their report released in August 2023 shows that there was a fourfold overall decline in the number of nursing home beds during the pandemic. Between 2020 and today, 579 nursing homes were closed and 21,000 residents were displaced; 30 or more counties now have no beds whatsoever and are considered care deserts, while two out of five closures were among four- and five-star facilities. Another devastating fact is that only three nursing homes opened in 2023, compared to a yearly average of 64 each year between 2020 and 2022. To make matters worse, these rehab and nursing facilities are also affected by the acute shortage of bedside staff that has affected all aspects of health care.

Certified Nursing Assistants (CNAs) do the bulk of the hands-on care in these facilities. Over the last three years, the number of residents they care for has often swelled from 15 to 20, and even up to 50 in some areas, with subsequent ripple effects felt by both patients and caregivers. This has been a significant contributor to burnout, and coupled with low wages and a lack of support has resulted in a 100 percent median turnover rate among CNAs in the industry, which has worsened an already dire crisis. Not only has this staffing issue contributed to facility closures, but it has also led facilities that are still standing to block off beds and close entire wings.

The staffing crisis has also greatly affected acute rehab facilities, which we rely on for our brain and spine patients. We all can attest to the immense value that neuro-rehab centers impart to our patients and their families. They provide multiple types of interventions to assist in recovering from the physical, cognitive, emotional, and behavioral consequences of a patient’s injury or illness, and evidence clearly supports their efficacy and cost-effectiveness. As a result, the placement crisis has greatly impacted our patients and limited their recovery.

We as a profession need to address this crisis, and we must work with our colleagues in rehabilitation medicine to help find answers. In conjunction, we must raise awareness of the issue to mobilize our local and national leaders, or else it will continue to impact our society as a whole.