When Care Isn’t the Problem: What Social Holds, Homelessness, and Policy Shifts Mean for Hospital Capacity

You’ve seen it. We’ve seen it. And the hospital thirty miles down the road has seen it too —

Patients in limbo, with nowhere to go.

The team had already ruled out infection. No meds needed. Vitals stable.

But he couldn’t be discharged — not to the street, not to a shelter, not safely.

So he stayed.

The patient in the next bed?

Diabetic foot ulcer. Wagner Grade III. HBOT consult pending.

But the bed was full. The nurse was tied up. The chart hadn’t moved.

This isn’t a staffing issue.

It’s a systems issue.

And it’s spreading.

What Are Social Holds, Really?

A social hold happens when a patient is medically cleared but can’t be discharged — not because of a clinical reason, but because there’s nowhere safe for them to go.

That might mean a child whose caregiver is unavailable.

A patient with dementia and no one to receive them at home.

Or — increasingly — an adult with chronic wounds, substance use history, and no stable housing.

At LifeBridge Health in Baltimore, social holds have become so common they began tracking them separately. These aren’t just long-stay cases — they’re discharge delays rooted in social instability, not medical need. One of their hospitals recently recorded two patients who remained in the emergency department for over 30 days simply because no discharge option existed¹.

In pediatric settings, the conversation often centers around child protective services¹. But in adult medicine — especially wound care — social holds look like:

• Patients missing follow-ups because they were discharged to the street

• HBOT consults that stall out because there's no place to safely recover

• A full bed, tied up by someone who doesn't need it — while another patient is waiting to be seen

At SHS, we don’t control housing. We don’t run the ED.

But we do support wound care teams caught in the crossfire — when stable discharges break down, when consults stall out, and when capacity disappears one hold at a time.

Because this isn’t just a care issue.

It’s an access issue.

And for medically complex patients, access is everything.

The New Twist: Executive Order on Homelessness and Hospitalization

On July 24, 2025, a new federal executive order signaled a major shift in how the U.S. addresses homelessness and mental illness. The order directs federal agencies to end “housing first” policies in favor of involuntary commitments for individuals experiencing homelessness who also struggle with addiction or serious mental illness².

In theory, the goal is treatment.

In reality, many hospitals may be pulled even further into the gap — absorbing patients who don’t meet traditional inpatient criteria but can’t be safely discharged. The result?

• Longer emergency department stays

• Psychiatric holds in medical beds

• Soft admissions for patients in behavioral or social crisis

Hospitals already overwhelmed with social holds could soon face a policy-fueled surge in volume — without any new capacity.

This isn’t about politics. It’s about preparation.

And for wound care and HBOT teams already working at the margins, any disruption to patient flow is a disruption to healing.

Why This Matters for Wound Care and HBOT Access

It’s easy to think this is someone else’s problem — the ED’s, the psych unit’s, social work.

But when patient flow stalls, so does access to wound care.

Emergency department and inpatient bottlenecks delay more than just discharges — they delay transfers, referrals, authorizations, and follow-up. Patients who would benefit from advanced wound care or hyperbaric oxygen therapy (HBOT) can fall through the cracks entirely.

Many of these patients rely on:

• Home health orders

• Skilled nursing facility (SNF) placement

• Durable medical equipment (DME) coordination

But those systems depend on stable housing, reachable contacts, and clean handoffs. Without them?

• Missed wound care and HBOT windows.

• Denied coverage.

• Delayed documentation.

And wounds that should have improved — don’t.

At SHS, we help our hospital partners spot and fix those gaps early. Whether it’s screening for HBOT eligibility, flagging discharge risks, or coordinating with case management, our goal is simple:

"Don’t let patients disappear just because the system lost track of them."

The Hidden Risks for Hospitals

Hospitals that admit or hold patients without a clear clinical justification risk drawing the attention of payers and auditors. Improper use of inpatient or observation codes — even with good intent — can raise red flags, trigger medical necessity reviews, and lead to clawbacks or recoupments.

And the risk isn’t just financial. It’s operational. It’s burnout. And it’s a reimbursement red flag CMS auditors are trained to spot from day one.

Care teams weren’t trained to manage housing crises, behavioral instability, or custody disputes — especially while also managing the treatment of chronic, non-healing wounds, coordinating HBOT referrals, and keeping up with documentation and regulatory compliance.

At LifeBridge Health, 30% of workplace violence incidents in the ED over the last year involved pediatric patients on extended social holds¹. Most of those incidents stemmed from just five long-stay patients — all medically cleared, all stable, but stuck with no discharge plan and nowhere safe to go.

What Social Holds Mean for Acute Care Hospitals

There’s no hard cap on average length of stay (ALOS), but high ALOS metrics can quietly damage reimbursement and public rankings:

• Case mix index (CMI) may be distorted⁴

• Star ratings and quality scores can drop⁵

• CMS and commercial payers compare your LOS to national expectations — and repeated outliers can trigger audits⁶

• A backlog of social holds may look like poor discharge coordination or unnecessary admissions

No medical institution wants to end up in an auditor’s crosshairs because a medically stable patient lingered for seven days or longer.

How Social Holds Threaten Critical Access Hospital Status

For Critical Access Hospitals (CAHs) the risk is even sharper.

By law, CAHs must maintain an average annual length of stay of 96 hours or less per patient³. If they exceed that?

They risk losing their CAH designation — and with it:

• Cost-based reimbursement⁷

• 101% of reasonable costs⁷

• Eligibility for federal rural support programs⁷

One extended social hold may not seem like much. But enough of them, left unmanaged?That can jeopardize the financial survival of a CAH.

Unmanaged social holds — no matter the setting — quietly erode stability and elevate risk for patients, care teams, and the hospital itself.

SHS helps our hospital partners build workflows that support patients without slipping into liability — giving clinical teams the tools to stay focused, safe, and compliant.

What SHS Partners Do Differently

At SHS, we help our hospital partners avoid exactly this kind of mission drift.

We don’t manage housing crises.

We don’t run emergency departments.

But we do equip wound care teams with the tools they need to stay focused on treatment — even when the system around them is stretched thin.

Our support focuses on what we can control:

• Building smart referral workflows that minimize bounce-backs and delays

• Equipping teams with discharge templates that include social risk flags, like unstable housing

• Providing care coordination tools that reduce “limbo” patient cases and missed follow-ups

• And strengthening documentation and compliance — so your team stays protected, even when the system isn’t

We stay focused on care. You stay focused on your patients. And together, we avoid the kind of mission creep that leads to burnout, audit exposure — or worse.

“Our role is to support your team with proven strategies and clinical expertise —

the success is yours to own.”

Because in the eyes of a CMS auditor, the difference between compliance and chaos…might be as simple as knowing who’s supposed to go home — and when. 

Final Takeaway: Clarity in Chaos

• Your ED wasn’t built to solve homelessness.

• But your wound care team can’t wait for the system to catch up.

• SHS helps you stay focused on healing — while we equip you to navigate the rest.

References:

1. Twenter P. Social holds: An emerging capacity issue. Becker’s Hospital Review. Accessed July 31, 2025.  https://www.beckershospitalreview.com/care-coordination/social-holds-an-emerging-capacity-issue/

   
   

2. Twenter P. Executive order on homelessness could increase hospitalizations. Becker’s Hospital Review. Accessed July 31, 2025. https://www.beckershospitalreview.com/care-coordination/executive-order-on-homelessness-could-increase-hospitalizations.html

   
   

3. Centers for Medicare & Medicaid Services. Conditions of participation: Critical access hospitals – 42 CFR §485.620. U.S. Government Publishing Office. Accessed July 31, 2025. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-485/subpart-F/section-485.620

   
   

4. Gernert-Dott P. Four ways to improve care delivery across the continuum: Reduce hospital readmissions and provide quality of care while lowering costs. Huron Consulting Group. Accessed July 31, 2025. https://www.huronconsultinggroup.com/-/media/Resource-Media-Content/Healthcare/Four-Ways-To-Improve-Care-Delivery-Across-The-Continuum-Huron-Healthcare.pdf

   
   

5. Curry K. The silent driver behind 4+ star CMS ratings. UASI. Published May 12, 2025. Accessed July 31, 2025. https://www.uasisolutions.com/the-silent-driver-behind-4star-cms-ratings

   
   

6. Hughes AH, Horrocks D, Leung C, Richardson MB, Sheehy AM, Locke CFS. The increasing impact of length of stay “outliers” on length of stay at an urban academic hospital. BMC Health Services Research. 2021;21(1). doi: https://doi.org/10.1186/s12913-021-06972-6

   
   

7. Centers for Medicare & Medicaid Services. Information for critical access hospitals. Medicare Learning Network (MLN) Booklet. Accessed July 31, 2025. https://www.cms.gov/files/document/mln006400-information-critical-access-hospitals.pdf