Massachusetts Hospitals Are Stuck With Patients Who Can’t Leave. Here Is Why Nursing Homes Won’t Take Them.

Boston, Massachusetts — A severe shortage of medical guardians is creating a logjam at Massachusetts hospitals, leaving hundreds of patients stuck in acute care beds long after they are medically stable enough to move to skilled nursing facilities.

The bottleneck is costing the state’s Medicaid program millions and preventing other sick residents from accessing hospital beds, according to a new report from the Department of Public Health.

The problem centers on “unrepresented individuals” — patients who cannot make medical decisions for themselves and lack a surrogate decision maker, guardian, or advance directive. These patients typically include people experiencing homelessness or serious mental illness, those who have outlived family and friends, or individuals without a willing or appropriate healthcare surrogate.

Without someone legally empowered to consent to a transfer, these patients cannot be discharged from hospitals until a court appoints a guardian. That process is taking longer than ever because Massachusetts is running out of qualified professionals willing to take on the role.

“Massachusetts relies on a limited and shrinking pool of professional or pro bono guardians, usually attorneys or retired attorneys, to fill this gap,” the report found.

The core issue is money. Compensation for guardians serving indigent patients is “inadequate or nonexistent,” according to the report. The cases are often complex and time-consuming, requiring considerable investment from guardians to execute appropriately and ethically.

For MassHealth members in nursing facilities, guardians can earn $50 per hour, with annual payments capped at $1,200. Those rates were set in 1999 and would need to rise to $94 per hour and $2,256 annually just to keep pace with inflation.

The financial reality is so bleak that attorneys searching for pro bono guardians on behalf of hospitals end up contacting four to 13 guardians before finding someone willing to take a case.

The consequences ripple through the entire healthcare system. Hospital discharge processes slow to a crawl, delaying transitions to long-term care settings and preventing other patients from accessing scarce acute care beds.

Services for guardians can cost $10,000 to $11,000 per client annually — creating a potential fiscal impact of $31 million to $54.5 million on MassHealth, according to the report.

Governor Maura Healey’s administration has acknowledged the problem. The Health Care Affordability Work Group released recommendations this month targeting “transitions of care,” with the goal of easing the more than 2,000 patients stuck in acute care hospitals on any given day.

Healey said the administration will “explore action to modernize surrogate decision-making and health care proxy laws.” One potential solution is adopting a default surrogate statute, which would allow close family members and friends to make healthcare decisions for incapacitated patients without requiring a court-appointed guardian.

Massachusetts is one of just four states without such a statute. Bills to establish one have been introduced in the legislature but remain stalled in committee.

The report was supposed to be filed by July 31, 2025, but arrived a year late — meaning its recommendations for boosting guardian pay, ensuring training and monitoring, and enacting surrogate consent laws will likely wait until next session for potential action.

Meanwhile, hospitals continue to board patients who could be discharged, nursing homes wait for consent paperwork that may never come, and the state pays millions for care that could be delivered more efficiently elsewhere.