Investigative Report | Hospital Capacity Series | October 2026
The Discharge Gridlock
Why patients cannot leave the hospital, what it costs, and the EXIT Model for restoring flow
- 35% medically ready on one day
- 781,000 unnecessary days in Florida
- 88 sources
- Interactive EXIT calculator
The back door of access
A bed that cannot be emptied cannot be filled
Every hospital leader knows the front door story: crowded emergency departments, hallway boarding, ambulances on diversion. This infographic is about the other end of the stay, the moment a patient is medically ready to leave and simply cannot. No federal system counts these days, which is why the problem has been so easy to underestimate.
The delays that begin at the back door eventually reach the front door as boarding, diversion, refused transfers, and cancelled surgery. Use the tabs above to follow the evidence from scale to cause, cost, solutions, and a model leaders can put to work.
Six numbers that define the gridlock
Select any number to open the evidence behind it.
The bottom line
Avoidable days are not a length-of-stay variance to be explained. They are beds held hostage.
A hospital at 85% occupancy with an avoidable day rate of 12% is holding roughly one bed in ten for patients who no longer need it. Cutting those days by one quarter in a 300-bed hospital recovers about 7.65 staffed beds without hiring or construction. Try it in the EXIT Model tab.
How large is the gridlock?
There is no national meter, but every measurement points the same way
Medicare claims carry no code that flags a delay day, and the American Hospital Association asked MedPAC in October 2026 to begin measuring the time from discharge readiness to transfer. Until that happens, the best evidence comes from clinical studies, the VA, and state hospital associations.
One weekday, 15 academic hospitals
Attending physicians assessed every general medicine inpatient on a single weekday in fall 2022.
Source: Bann et al., J Hosp Med 2023;18(9):795-802. The month-or-longer count is 44.4% of the 189 patients with a major barrier.
What the numbers mean
- More than four in five stuck patients needed skilled therapy or help with daily activities to leave.
- Delayed patients held between 20.7% and 35.3% of all patient days in participating hospitals.
- Admission to a safety-net hospital tripled the odds of a prolonged delay (odds ratio 3.21).
- A Vizient survey of 168 hospitals found 2% of admissions drive 15% of prolonged days, at more than $2 billion a year.
An honest counterpoint
Across 109 VA hospitals, avoidable days per stay rose from 0.64 to 1.05 (2019 to 2023), yet only about 16% of the rise in length of stay came from avoidable days. Length of stay alone overstates delay, so measure readiness directly.
Source: Lucas et al., BMC Health Serv Res 2025;25:1595.
State hospital association snapshots
Sources: California Hospital Association (via Becker’s; a second estimate of $2.9 billion also circulates); Florida Hospital Association (July 2026); Minnesota Hospital Association (2024); HANYS (2023, 52 hospitals, one quarter). Methods, periods, and cost per day differ, so these figures are not additive.
Length of stay is easing, but not for every patient
Source: McGarry et al., JAMA Intern Med, September 2025; 89.3 million admissions, 4,075 hospitals. Observational, not proof of causation.
- Average stays rose 19.2% from 2019 to 2022, and 28.9% (case-mix adjusted) for patients discharged to psychiatric hospitals.
- Kaufman Hall data show stays down 8% from 2022 by October 2025, except in the smallest hospitals, where stays rose 2.5% year over year in April 2026.
- By 2023, Medicare Advantage admissions were 19.5% more likely to last 14 days or longer, about 1.8 million extra bed days in 2022.
Who gets stuck
Sources: Bann et al. (SHM 2023 abstract); Minnesota Department of Health (2024); Silver et al., JAMA Netw Open 2024; New Hampshire Hospital Association (2024).
Why patients cannot leave
Five root causes: three outside the hospital, two inside
Discharge delay is usually blamed on the hospital, and some of it belongs there. Most of it does not. Filter the causes by who controls them, then open any card for the evidence.
Medicare-participating skilled nursing facilities fell from 15,297 to 14,518 between 2019 and 2024. Long-term care hospitals fell from 371 to 329, and their Medicare stays nearly halved. Freestanding nursing care occupancy reached 86.7% in early 2026, the highest since 2016. Home health referral non-acceptance reached 76% in late 2022, and state psychiatric beds sit at a record low of 10.8 per 100,000.
Primary owner: post-acute providers and state policy; hospitals act through partnerships.
Medicare Advantage plans denied long-term care hospital requests at initial rates of 65% and inpatient rehabilitation at 54%, against under 8% for all requests. Each initial denial delays post-acute care by about five to six days. In Florida, prior authorization was tied to 41% of all discharge delays and 52% of Medicare Advantage delays. Traditional Medicare requires no prior authorization for these settings.
Primary owner: health plans and CMS; hospitals act through payer management.
Patients without a legal decision maker often cannot be admitted to a nursing facility, and even an efficient guardianship takes months. Medicaid long-term care processing is named as a primary driver in New Hampshire, New York, Washington, and Maryland. Beginning January 1, 2027, Medicaid retroactive coverage shrinks to two months for aged, blind, and disabled applicants and one month for expansion adults.
Primary owner: courts and state Medicaid; hospitals act through legal partnerships.
The federal nursing home staffing rule was repealed effective February 2, 2026, but the shortage remains: 46% of nursing homes limited admissions and 20% closed units or wings for staffing in 2024. Home health faces a 1.3% Medicare cut for 2026 and a national enrollment moratorium on new agencies announced in May 2026.
Primary owner: post-acute providers; regional workforce strategy.
Only 13.2% of Florida weekday discharges occurred by noon in 2022. Radiology services drove more than half of procedure delay days in a classic academic study, and one 700-bed center found inpatient MRI order-to-result times of about 35 hours. A discharge-pending imaging flag shortened stays by about a day per targeted patient, and weekend hospitalist staffing raised weekend discharges without harming outcomes.
Primary owner: hospital leadership. This is the cause the hospital controls fully.
The downstream system is shrinking where it matters most
Source: MedPAC, July 2026 Data Book, Section 8. FFS means fee-for-service Medicare.
Medicare Advantage denies post-acute care far more often
Source: KFF, July 6, 2026, using HHS OIG data on 2024 requests.
Source: HHS OIG OEI-09-24-00330 (June 2026), June 2024 requests from 19 Medicare Advantage organizations.
What the gridlock costs
An avoidable day is never a neutral day
The cost lands in four places at once: on patients, on capacity, on the operating statement, and on the people who work the floor.
Patients
of older inpatients develop hospital-associated disability
Giacomino et al., PeerJ 2023
of hospitalized older adults can be affected by delirium (up to)
Inouye et al., Lancet 2014
These studies measure hospitalization broadly rather than delay days specifically. No rigorous U.S. study has yet estimated harm per avoidable day, but the direction of the evidence is consistent.
Capacity: the back door controls the front door
National adult occupancy
Source: Leuchter et al., JAMA Netw Open 2025. The projection holds length of stay at 2009 to 2019 levels, so rising avoidable days would bring 85% sooner.
Median ED boarding by hospital occupancy
Source: Janke et al., JAMA Netw Open 2022; 1,289 to 1,769 hospitals, 2020 to 2021.
- More than a quarter of admitted patients boarded 4 hours or longer in ordinary months from 2017 to 2024, and about 35% in winter.
- A rise in inpatient volume drove ambulance diversion seven times more than an equal rise in emergency volume.
- One academic system declined 1,836 transfer requests for lack of capacity in a single fiscal year.
- Outside the U.S., high occupancy has been linked to 9% higher mortality (Denmark) and overnight ED stays to higher mortality in older patients (France).
Finance: the unpaid day and the lost admission
What a day costs versus what is paid for it
Sources: KFF 2023 adjusted expense per inpatient day (nonprofit); Florida and Minnesota hospital associations; California DHCS (CY 2026, Level 1); Maryland Medicaid (FY 2026, general rate).
Under Medicare’s inpatient payment system, a hospital receives a fixed payment per diagnosis group, so days beyond medical need are generally unpaid. That loss lands on a Medicare hospital margin MedPAC estimated at negative 12.1% for 2024.
Read the dollar figures carefully
Association estimates use average, fully loaded cost per day. The variable cost of a final day is far lower; one surgical study put it at 2.4% of total stay cost. The real loss is the admission, transfer, or surgery that could not happen because the bed was full.
The workforce
Hospital case managers work inside a system that generated nearly 50 million Medicare Advantage prior authorization requests in 2023.
Sources: Loke et al., Joint Commission 2023; Norton et al., Health Aff Sch 2025; AHA Cost of Caring 2025.
A necessary caution
Eliminate non-clinical days. Protect clinically necessary ones.
Across 129 VA hospitals, shorter stays came with fewer readmissions, but hospitals below the average stay saw 6% higher readmissions for each day below it. The extra days created by restoring Medicare’s three-day SNF rule improved neither mortality nor readmissions.
Grading the evidence
What works, what might, and what does not
The strongest evidence supports the least glamorous work: planning discharge from admission, setting an expected date, and reviewing it every day with the whole team. Filter the thirteen interventions by strength of evidence.
Showing 13 of 13 interventions
Structured, individualized discharge planning
Cochrane review of 33 trials: stays 0.73 days shorter for medical patients and fewer readmissions (relative risk 0.89).
Expected discharge date in multidisciplinary rounds
Safety-net hospital: average stay fell from 6.09 to 5.51 days. A 406-bed hospital removed 3,813 excess days in 10 months and saved $6.7 million. Mayo Clinic cut opportunity days per patient by about 45%.
Hospital at home
Matched Medicare cohort: in-hospital mortality 0.4% versus 3.6% and ICU escalation 3.5% versus 7.9%, with similar readmissions. The CMS waiver now runs through September 30, 2030.
Early supported discharge
Cochrane review: about 7 fewer hospital days for stroke patients.
Guardianship acceleration
Boston Medical Center: stays for patients awaiting a guardian fell from 150 to 39 days, freeing 5 to 10 beds every day.
Predictive discharge tools
Hartford HealthCare: 0.63 days shorter per patient across 7 hospitals. Johns Hopkins: gains on two units, none on two others.
Weekend discharge capability
NYU Langone: medical stays fell and weekend discharges rose from 19% to 22%, with no change in readmissions or mortality.
Imaging and test prioritization
A discharge-pending imaging flag shortened stays by about one day per targeted patient.
Discharge lounge
AdventHealth Daytona Beach: discharges before 2 p.m. rose from 19% to 43%, and ED admit door-to-departure fell from 843 to 519 minutes.
Post-acute partnerships and leased beds
UCLA leased skilled nursing beds and saved 2,516 acute days in one year; a hospital transitional care unit discharged 86% of patients home.
Medical respite for people experiencing homelessness
Durham pilot: inpatient days fell 70%, without a comparison group.
Capacity command centers
Strong self-reported U.S. results, but the only independent controlled evaluation (England) found no consistent effect. Technology helps only when attached to a redesigned process.
Discharge before noon targets
Linked to longer stays at one academic center and to no effect across 189,781 Ontario admissions. Track it as a balancing measure, not a goal.
The pattern
A command center that watches a broken discharge process in real time is still watching a broken process.
Interventions that change the destination (hospital at home, early supported discharge, guardianship acceleration) produce the largest effects for the longest-staying patients. The better target is time from readiness to departure, the core measure of the EXIT Model.
The EXIT Model
Four levers, one outflow measure, and beds you can count
The EXIT Model turns the evidence into an operating framework built on three principles: measure readiness rather than length of stay, assign every barrier to an owner, and convert days into beds. It is designed as the outflow module of the Timely Care Access Model.
Score your Discharge Flow Index
Enter your hospital’s value for each lever’s primary metric. Each lever scores 0 to 25 points. Starting values are illustrative: 6.6 referrals is the national average and 35 hours is a published inpatient MRI baseline.
Expected date discipline
Percent of inpatients with an expected discharge date documented within 24 hours of admission
25 pts at 90% or more | 19 at 75% to 89% | 13 at 60% to 74% | 6 at 40% to 59% | 0 under 40%
eXternal capacity
Referrals sent per patient placed in a post-acute facility
25 pts at 2.0 or fewer | 19 at 2.1 to 3.5 | 13 at 3.6 to 5.0 | 6 at 5.1 to 7.0 | 0 over 7.0
Insurer velocity
Median hours from post-acute authorization submission to decision
25 pts at 24 h or fewer | 19 at 25 to 48 | 13 at 49 to 72 | 6 at 73 to 168 | 0 over 168
Throughput of services
Median order-to-result hours for discharge-dependent diagnostics
25 pts at 6 h or fewer | 19 at 6.1 to 12 | 13 at 12.1 to 24 | 6 at 24.1 to 36 | 0 over 36
Critical
The constraint is severe across several levers. Start with the lever the hospital controls fully: expected date discipline.
Lowest-scoring lever: E, X, and T (6 pts each)
The scoring bands are proposed starting points for calibration, not validated standards. Each organization should validate them against its own baseline and case mix.
Recovered Bed Equivalents calculator
Starting values reproduce the report’s worked example (Table 5) for an illustrative 300-bed hospital. Replace every assumption with local data.
Occupancy before and after
Margin from new admissions assumes unmet demand exists. Contribution margin follows a Kaufman Hall scenario; variable cost per avoided day is an illustrative input. Formulas: inpatient days = beds x 365 x occupancy; Recovered Bed Equivalents = avoidable days eliminated / 365; occupancy relief = Recovered Bed Equivalents / beds x 100; added admissions = Recovered Bed Equivalents x 365 x occupancy / average length of stay.
The three outcome measures
- Avoidable Day Rate
- Days flagged medically ready but still hospitalized, divided by total inpatient days.
- Discharge-Ready-to-Departure Interval
- Median hours from the first medically ready flag to physical departure, by destination and payer. The single best measure of discharge flow.
- Recovered Bed Equivalents
- Avoidable days eliminated in a year, divided by 365. Converts improvement into staffed beds.
How EXIT connects to the Timely Care Access Model
The Timely Care Access Model measures how quickly patients can enter care. EXIT measures how quickly the hospital can release capacity to receive them. Recovered Bed Equivalents and occupancy relief feed the hospital care component of the access model, where they become emergency boarding time, transfer acceptance, and elective surgical access.
Read together, the two models show the full path of a patient through the hospital and make it possible to see when an access problem is really a discharge problem.
Policy outlook and leadership agenda
What changes in 2027, and what leaders can do in 90 days
Several federal and state developments will shape discharge flow over the next 18 months. Some will help; others will make placement harder. Select any milestone for detail.
CMS-0057-F decision timelines, in effect since January 1, 2026
Medicare Advantage and Medicaid plans must decide expedited requests within 72 hours and standard requests within 7 calendar days, give specific denial reasons, and publish annual metrics. The first public metrics show a 13% Medicare Advantage denial rate, but they are not broken out by service type, so post-acute denials remain hidden in the averages. A week is still far too long for a patient who is ready to leave today.
National enrollment moratorium on new home health and hospice agencies
Announced by CMS on May 13, 2026 for six months as an anti-fraud measure. The American Hospital Association warned it could worsen discharge problems in rural and underserved areas by limiting new home-based capacity.
Prior authorization and payer-to-payer electronic interfaces, January 1, 2027
Required under CMS-0057-F. Hospitals that connect early should see faster, more transparent post-acute requests and can benchmark plans against the public metrics.
Medicaid changes under Public Law 119-21, January 1, 2027
Retroactive coverage shrinks from three months to two for aged, blind, and disabled applicants and to one month for expansion adults, making it harder to bridge from Medicare skilled nursing coverage to Medicaid long-term care. Nursing facilities are likely to grow more reluctant to accept Medicaid-pending patients. Work requirements for expansion adults begin the same day, adding uninsured patients with no post-acute payer.
Pending federal legislation
The Medicare Advantage Improvement Act (S. 4384) would require 72-hour standard and 24-hour expedited decisions, limit automated denials, and require long-term care hospital and inpatient rehab networks. The STAR Act (H.R. 9468) addresses long-term care hospital payment, and the ABC-ED Act (S. 1974) would strengthen boarding data. Separately, the AHA has asked MedPAC to measure time from discharge readiness to transfer, a first step toward a national meter.
Acute Hospital Care at Home waiver extended through September 30, 2030
Extended in the Consolidated Appropriations Act, 2026, signed February 3, 2026. The five-year runway makes hospital at home a credible capital investment for the first time.
A 90-day leadership agenda
Days 1 to 30
Measure
- Create a daily medically ready flag in the record.
- Establish baseline Avoidable Day Rate and Discharge-Ready-to-Departure Interval by unit, destination, and payer.
- Name an executive owner (often the COO) and a clinical co-owner.
Deliverable: baseline Discharge Flow Index and outcome dashboard
Days 31 to 60
Fix what the hospital owns
- Require an expected discharge date within 24 hours.
- Standardize multidisciplinary rounds.
- Flag discharge-dependent imaging and tests.
- Extend weekend case management and discharge capability.
Deliverable: improved E and T lever scores
Days 61 to 90
Engage the outside
- Publish a payer authorization scorecard; escalate plans missing the 72-hour standard.
- Select committed post-acute partners with shared metrics.
- Fund guardianship acceleration through legal partnerships.
- Evaluate hospital at home.
Deliverable: improved X and I lever scores and a first Recovered Bed Equivalents report to the board
The governance principle
The board should see Recovered Bed Equivalents as often as it sees operating margin.
Reported as a length-of-stay variance, avoidable days look like a documentation issue. Reported as beds, they become a strategic asset.
Sources
The evidence behind every number
All 88 references from the report, numbered exactly as they appear in The Discharge Gridlock. Filter by source type. Figures are reported as published; state association estimates are directional and should not be added together.
Showing 88 of 88 references
- 1Bann M, et al. Medically ready for discharge: a multisite "point-in-time" assessment of hospitalized patients. J Hosp Med. 2023;18(9):795-802. doi:10.1002/jhm.13184Peer-reviewed
- 2American Hospital Association. Letter to MedPAC on Medicare Advantage and post-acute transitions. October 2, 2026; reported in Becker’s Hospital Review, October 5, 2026. LinkHospital associations
- 3Florida Hospital Association. FHA survey finds delays in post-hospital care slow patient recovery, increase healthcare costs (data July 1, 2024 to June 30, 2025). July 15, 2026. LinkHospital associations
- 4Minnesota Hospital Association discharge delays survey (2023 data), reported by the Post Bulletin, January 31, 2024. LinkHospital associations
- 5California Hospital Association estimates, as reported by Chief Healthcare Executive (October 25, 2023) and Becker’s Hospital Review (May 14, 2024). LinkHospital associations
- 6Healthcare Association of New York State pilot survey (52 hospitals, April to June 2022), reported by Fierce Healthcare, February 2023. LinkHospital associations
- 7Medicare Payment Advisory Commission. July 2026 Data Book, Section 8: Post-acute care. LinkFederal and state government
- 8Skilled Nursing News. Hospital to skilled nursing facility referral rate stable, admission rate rises (WellSky data). December 2025. LinkNews and case reports
- 9Biniek JF, Freed M, Cubanski J. Medicare Advantage insurers deny prior authorization requests for post-acute care at substantially higher rates than the overall denial rate. KFF. July 6, 2026. LinkPolicy research
- 10HHS Office of Inspector General. Medicare Advantage organizations overturned nearly all appealed prior authorization denials for skilled nursing facility admission (OEI-09-24-00331). June 2026.Federal and state government
- 11Giacomino K, et al. Assessment tools and incidence of hospital-associated disability in older adults: a rapid systematic review. PeerJ. 2023;11:e16036.Peer-reviewed
- 12Inouye SK, Westendorp RGJ, Saczynski JS. Delirium in elderly people. Lancet. 2014;383:911-922.Peer-reviewed
- 13Leuchter RK, Delarmente BA, Vangala S, Tsugawa Y, Sarkisian CA. Health care staffing shortages and potential national hospital bed shortage. JAMA Netw Open. 2025;8(2):e2460645.Peer-reviewed
- 14Janke AT, Melnick ER, Venkatesh AK. Hospital occupancy and emergency department boarding during the COVID-19 pandemic. JAMA Netw Open. 2022;5(9):e2233964.Peer-reviewed
- 15Gonçalves-Bradley DC, et al. Discharge planning from hospital. Cochrane Database Syst Rev. 2022;CD000313.Peer-reviewed
- 16Prasad R, et al. Impact of expected discharge date discussion on length of stay. Society of Hospital Medicine Converge 2024 abstract. LinkAbstracts and posters
- 17HealthCity, Boston Medical Center. Guardianship process change better for patients and hospitals. May 10, 2019. LinkNews and case reports
- 18Vakkalanka JP, et al. JAMA Netw Open. 2026;9(5):e2610810 (hospital at home compared with matched inpatient care, Medicare beneficiaries 65 and older); summarized by AJMC, May 5, 2026. LinkPeer-reviewed
- 19Rajkomar A, et al. The association between discharge before noon and length of stay in medical and surgical patients. J Hosp Med. 2016;11(12):859-861.Peer-reviewed
- 20Mebrahtu TF, et al. The impact of hospital command centre on patient flow and data quality: findings from the UK NHS. Int J Qual Health Care. 2023;35(4):mzad072.Peer-reviewed
- 21Micallef A, et al. Defining delayed discharges of inpatients and their impact in acute hospital care: a scoping review. Int J Health Policy Manag. 2022;11(2):103-111.Peer-reviewed
- 22American Hospital Association. Patients and providers faced with increasing delays in timely discharges (issue brief). December 2022. LinkHospital associations
- 23Bann M, et al. Prolonged discharge delays across US hospitals: prevalence, cause, and impact. Society of Hospital Medicine Converge 2023 abstract. LinkAbstracts and posters
- 24Lucas BP, et al. Do discharge delays explain longer stays at Veterans Health Administration hospitals? BMC Health Serv Res. 2025;25:1595. doi:10.1186/s12913-025-13682-wPeer-reviewed
- 25Becker’s Hospital Review. 2% of admissions drive 15% of longer stays, $2B in costs: Vizient. June 2, 2026. LinkNews and case reports
- 26Kaufman Hall National Hospital Flash Report (October 2025 data), reported by Becker’s Hospital Review, December 31, 2025. LinkNews and case reports
- 27Kaufman Hall. National Hospital Flash Report, March and April 2026 metrics; Fierce Healthcare, May 19, 2026. LinkNews and case reports
- 28McGarry BE, Wilcock AD, Gandhi AD, Grabowski DC, Barnett ML. Extended hospital stays in Medicare Advantage and traditional Medicare. JAMA Intern Med. September 8, 2025. doi:10.1001/jamainternmed.2025.4411Peer-reviewed
- 29American Hospital Association. The cost of caring: challenges facing America’s hospitals in 2025. LinkHospital associations
- 30Minnesota Department of Health. Behavioral health discharge delay study. July 22, 2024. LinkFederal and state government
- 31Silver CM, et al. Morbidity and length of stay after injury among people experiencing homelessness. JAMA Netw Open. 2024;7(2):e240795.Peer-reviewed
- 32New Hampshire Hospital Association data on medically cleared patients, reported by Concord Monitor (August 29, 2024) and Manchester Ink Link (March 2024). LinkHospital associations
- 33American Health Care Association and National Center for Assisted Living. 2024 Access to Care report (reported by Skilled Nursing News and Becker’s Hospital Review, August 2024). LinkHospital associations
- 34Generations (American Society on Aging). When full nursing homes mean fewer choices (citing NIC MAP occupancy data). 2026. LinkPolicy research
- 35Medicare Payment Advisory Commission. March 2026 Report to the Congress, Chapter 7: Skilled nursing facility services. LinkFederal and state government
- 36CarePort (WellSky). Referral rejection rates, patient complexity in home health care reaching all-time highs (2023 Evolution of Care report). LinkNews and case reports
- 37Treatment Advocacy Center. Prevention over punishment: state psychiatric bed data, 2023. 2024. LinkPolicy research
- 38HHS Office of Inspector General. The three largest Medicare Advantage organizations denied requests for long-term acute care and inpatient rehabilitation at some of the highest rates (OEI-09-24-00330). June 2026.Federal and state government
- 39Centers for Medicare & Medicaid Services. Fact sheet: CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F). January 17, 2024. LinkFederal and state government
- 40HME News. Prior authorization metrics provide new insight, KFF says. August 2026. LinkPolicy research
- 41DistilINFO. Court orders UnitedHealth to disclose AI denial algorithm. March 12, 2026. LinkNews and case reports
- 42Maryland Hospital Association. Comment letter to the Maryland Health Care Commission on post-acute care. May 15, 2026. LinkHospital associations
- 43National Health Law Program. Retroactive coverage and home equity. February 12, 2026. LinkPolicy research
- 44KFF. A look at waiting lists for Medicaid home and community-based services from 2016 to 2024. October 31, 2024.Policy research
- 45Federal Register. Medicare and Medicaid programs; repeal of minimum staffing standards for long-term care facilities (CMS-3442-IFC). December 3, 2025. LinkFederal and state government
- 46Centers for Medicare & Medicaid Services. Fact sheet: CY 2026 Home Health Prospective Payment System final rule (CMS-1828-F). November 28, 2025. LinkFederal and state government
- 47AHA News. CMS announces 6-month enrollment moratorium for home health and hospice providers. May 13, 2026. LinkHospital associations
- 48Epstein RH, Dexter F, Fahy BG. Most weekday discharge times at acute care hospitals in the state of Florida occurred after 3 PM in 2022. J Med Syst. 2025;49(1):31.Peer-reviewed
- 49Kim CS, et al. Excess hospitalization days in an academic medical center. Am J Manag Care. 2011;17(2):e34-e42.Peer-reviewed
- 50Kottewar S, Segon A, Sandles CR. A process improvement project to reduce MRI turnaround time. Society of Hospital Medicine Converge 2024, Abstract 410.Abstracts and posters
- 51Main Line Health. Reducing turnaround time for routine inpatient MRIs to improve length of stay. Vizient Connections 2023, poster P413.Abstracts and posters
- 52NYU Langone weekend hospitalist staffing study, J Gen Intern Med, May 2015; summarized by Today’s Hospitalist. LinkPeer-reviewed
- 53Kortebein P, et al. Effect of 10 days of bed rest on skeletal muscle in healthy older adults. JAMA. 2007;297(16):1769-1774.Peer-reviewed
- 54Lim Fat GJ, et al. Healthcare-associated adverse events in alternate level of care patients awaiting long-term care in hospital. Geriatrics. 2022;7(4):81.Peer-reviewed
- 55Janke AT, Burke LG, Haimovich A, et al. Hospital "boarding" of patients in the emergency department increasingly common, 2017-24. Health Aff. 2025. doi:10.1377/hlthaff.2024.01513Peer-reviewed
- 56Hsia RY, Sarkar N, Shen YC. Is inpatient volume or emergency department crowding a greater driver of ambulance diversion? Health Aff. 2018;37(7):1115-1122.Peer-reviewed
- 57Mass General Brigham. MGB hospitals face constant capacity disaster. 2025. LinkNews and case reports
- 58Madsen F, Ladelund S, Linneberg A. High levels of bed occupancy associated with increased inpatient and thirty-day hospital mortality in Denmark. Health Aff. 2014;33(7):1236-1244.Peer-reviewed
- 59Roussel M, et al. Overnight stay in the emergency department and mortality in older patients. JAMA Intern Med. 2023;183(12):1378-1385.Peer-reviewed
- 60Medicare Payment Advisory Commission, March 2026 report to the Congress, as reported by HFMA, March 20, 2026. LinkFederal and state government
- 61California Department of Health Care Services. Administrative day rate, Level 1 (CY 2026); Maryland Medicaid PT 16-26, FY26 rates for administrative days (September 5, 2025). LinkFederal and state government
- 62Florida Hospital Association. 2025 Patients Awaiting Discharge (data July 2023 to June 2024). LinkHospital associations
- 63KFF hospital adjusted expenses per inpatient day, 2023, reported by Becker’s Hospital Review, May 14, 2025. LinkPolicy research
- 64Taheri PA, et al. Length of stay has minimal impact on the cost of hospital admission. J Am Coll Surg. 2000;191(2):123-130.Peer-reviewed
- 65Becker’s Hospital Review. The cost of unnecessary hospital days in 8 numbers (Kaufman Hall scenario). May 14, 2024. LinkNews and case reports
- 66Loke DE, et al. Emergency department boarding’s impact on patient care and clinician well-being. Jt Comm J Qual Patient Saf. 2023.Peer-reviewed
- 67Norton V, Schreyer KE, Kuhn D. Workforce impact of emergency department boarding. Health Aff Sch. 2025;3(8):qxaf134.Peer-reviewed
- 68Kaboli PJ, et al. Associations between reduced hospital length of stay and 30-day readmission rate and mortality. Ann Intern Med. 2012;157(12):837-845.Peer-reviewed
- 69Abir M, et al. The association between hospital occupancy and mortality among Medicare patients. Jt Comm J Qual Patient Saf. 2020;46(9):506-515.Peer-reviewed
- 70Chen, Kosar, Trivedi. JAMA Intern Med. 2026 (effects of reinstating the Medicare three-day SNF rule); summarized by Brown University, February 9, 2026. LinkPeer-reviewed
- 71The Joint Commission Journal on Quality and Patient Safety. Virtual multidisciplinary rounds and excess days at a 406-bed community hospital. September 2023. LinkPeer-reviewed
- 72Buechler TE, et al. Overcoming the long Minnesota goodbye. American College of Healthcare Executives 2025 poster, Mayo Clinic.Abstracts and posters
- 73American Medical Association. Lawmakers extend CMS hospital-at-home waiver for five years. March 2, 2026. LinkNews and case reports
- 74Gonçalves-Bradley DC, et al. Early discharge hospital at home (services for patients discharged home early). Cochrane Database Syst Rev. 2017;CD000356.Peer-reviewed
- 75Patient outcome predictions improve operations at Hartford HealthCare. INFORMS Journal on Applied Analytics (Interfaces). doi:10.1287/inte.2024.0170Peer-reviewed
- 76Levin S, et al. Machine-learning-based hospital discharge predictions can support multidisciplinary rounds and decrease hospital length-of-stay. BMJ Innovations. 2020.Peer-reviewed
- 77Gromlovits K. Implementation of a discharge lounge. American Nurse Journal. September 8, 2025. LinkPeer-reviewed
- 78Bed leasing program helps hospitals discharge hard-to-place patients. Hosp Case Manag. 2015;23(12).News and case reports
- 79Becker’s Hospital Review. A hospital unit that helps complex patients discharge home in 13 days. September 10, 2026.News and case reports
- 80Biederman DJ, et al. Health care utilization following a homeless medical respite pilot program. Public Health Nurs. 2019.Peer-reviewed
- 81Johns Hopkins Medicine. Capacity Command Center celebrates 5 years of improving patient safety, access. 2021. LinkNews and case reports
- 82Kirubarajan A, et al. Morning discharges and patient length of stay in inpatient general internal medicine. J Hosp Med. 2021;16:333-338.Peer-reviewed
- 83Dwyer-Matzky K, et al. Earlier medically ready for discharge date entry associated with lower unnecessary bed days. Society of Hospital Medicine Converge 2025 abstract.Abstracts and posters
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About the author
Kelly Emrick, DHSc, PhD, MBA, BSRT(ARRT)R, is a healthcare executive, author, and registered radiologic technologist. Her work spans population health, fiscal management, radiology outcomes, adaptive leadership, predictive analytics, value-based care, and healthcare leadership. She maintains a free resource ecosystem of interactive tools and dashboards for healthcare leaders at kellyemrick.com, kellyemrick.org, and kellyemrick.blog.
Suggested citation: Emrick K. The Discharge Gridlock: Why Patients Cannot Leave the Hospital, What It Costs, and the EXIT Model for Restoring Flow. Investigative report. October 2026.