Making Progress on Hard‑to‑Place Patients
Hospitals across the Nexus Montgomery Regional Partnership, a collaboration among the six hospitals in Montgomery County, continue to face the complex challenge of caring for hard‑to‑place patients—individuals who no longer require acute care but cannot be safely discharged due to medical, behavioral, social, or placement barriers. These additional days in the hospitals are defined as administrative days. This system‑wide issue affects nearly every patient population, including youth, seniors, individuals with developmental disabilities and those with complex medical needs.
“Hard‑to‑place patients are a challenge across the entire continuum of care,” said Marnie Brennan, PCC Senior Program Coordinator, Population Health. “In most cases, people are staying in hospital beds not because they need inpatient care, but because there’s no safe or appropriate place for them to go.” Patients may be waiting for skilled nursing facility (SNF) placement, lack a legal guardian, or have no stable housing options. PCC and the Nexus Montgomery hospital partners now track these patients and identify barriers earlier—supporting care teams in moving patients forward on their journey to wellness.
Encouraging Trends
There is positive momentum. Total administrative day encounters have declined through CY25, reflecting increased focus and coordination across the system. “We’re seeing the impact of paying closer attention to this issue,” Brennan said. “Reducing administrative days takes sustained effort, and the downward trend shows that our work is making a difference.”
While discharge to SNFs remains the largest outcome category for hard‑to‑place patients, an important shift occurred in the second half of FY25. For patients with fewer than five administrative days, discharges to home exceeded discharges to skilled nursing facilities. “That tells us we’re finding better, more appropriate discharge options for some patients earlier in their stay,” Brennan noted
What’s Driving Delays
The top ten diagnosis categories account for 64% of all administrative days among patients discharged to SNFs, with average days per encounter ranging widely—from 2.7 to 74.3 days. These diagnoses include cerebrovascular disease, medical and surgical complications, respiratory illnesses, hip and thigh injuries, diabetes, and hypertensive diseases—highlighting the individualized nature of discharge planning.
Pediatric ED Stays Remain a Concern
Another ongoing challenge is pediatric patients (under age 21) who remain in the emergency department for more than 24 hours. In FY25 alone, prolonged ED stays across the six Nexus Montgomery hospitals totaled the equivalent of nearly nine years of bed day. Eight of the top ten diagnoses associated with these stays involve behavioral health, substance use, or developmental disabilities, with average lengths of stay between 2.3 and 12.3 days.
“Holding children in the ED for extended periods is not appropriate due to the ED's restrictive and chaotic environment, and it places strain on patients, families, and staff,” Brennan said. “This data reinforces the need for stronger pediatric behavioral health pathways.” Nexus Montgomery’s efforts to address these challenges align with the state’s broader initiatives to reduce these barriers, guided by the Pediatric Overstay Workgroup.
Looking Ahead
While hard‑to‑place patients remain a complex challenge, continued collaboration, data‑driven tools, and a system‑wide focus are producing measurable progress. “We still have work ahead,” Brennan said, “but the trends show we’re moving in the right direction—toward better outcomes for patients and a stronger, more efficient healthcare system.”