This may sound familiar: A patient with dementia is ready for discharge and a bed is available in a dementia unit, but the patient declines to leave because the unit is two hours away from family. With no medically necessary reason for the patient to stay in the hospital and its beds desperately needed by other patients—emergency department boarders, urgent day-of-surgery patients and pending outside transfers—the hospital must usher the patient out the door. Sometimes that’s easier said than done.

“It’s not a comfortable conversation for physicians or nurses to have with patients,” said Steven Grant, M.D., associate chief medical officer of care coordination and patient transitions at University of Vermont Medical Center (UVMC) in Burlington. Facilitating discharges and transfers of patients who have declined them requires a thoughtful, multidisciplinary approach.

There are different reasons why patients refuse discharge. The No. 1 reason is their destination—an available bed in a skilled nursing facility (SNF), for example—is too far from home and they’re holding out for a bed in a closer SNF. There are other explanations, such as unflattering remarks they’ve heard about a SNF or other post-acute care facility. Whatever the reason, the patient isn’t budging, even though they’ve been informed about shouldering the costs of the continued stay.