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“Plans don’t cover”: elderly abandonment exacerbates hospitals’ already weakened finances

Meanwhile, the Administration for Families and Children (ADFAN) acknowledges that some elderly people are dying while waiting to be relocated to long-term care centers

June 19, 2024 - 12:15 PM

Many older adults spend months in hospitals while the government decides which agency should take custody of them and place them in a long-term care facility. (David Villafañe)
Editor's note
Third of four stories in the series "Pliegues en su piel, vacío en su corazón" (Folds in your skin, emptiness in your heart), which analyzes the increasing number of lonely older adults in hospital facilities in Puerto Rico. This work received the support of the Journalists in Aging Fellowship, awarded by the Gerontological Society of America, along with the Journalists Network on Generations and the Silver Century Foundation.

Last year alone, the Sistema de Salud Menonita (Mennonite Health System), a network of hospitals in Puerto Rico, faced $3,099,379 in losses due to 221 cases of abandoned seniors in its seven medical institutions. The million-dollar deficit was the balance of 5,001 days of hospitalizations not paid for by medical plans, since admissions without medical criteria are not billable.


Lee este artículo en español.


The same is true for other hospitals. In the last three years (2021-2023), the Centro Médico de Puerto Rico (Puerto Rico Medical Center) in Río Piedras has referred 322 cases to the Puerto Rico Department of the Family (DF). Abount 54% (174) have been relocated through the foster care service of the government, after the agency assumes physical custody of old people who lack someone to take care for them.

“When there are no longer medical criteria, the plans do not cover,” said María Jorge, supervisor of the Social Work Program of the Administración de Servicios Médicos (Medical Services Administration, ASEM).

She mentioned, for example, that an 84-year-old man, treated at the Trauma Hospital, went 41 days without medical coverage before being discharged. With no one to care for him, the man remained in the hospital while the case was referred to the DF and eventually placed in a long term care facility. This hospitalization generated $78,644 in losses to ASEM.

“Our hospital is a supra tertiary medical facility, so the costs are higher, $1,247 a bed per day at the Trauma Hospital,” said Jorge, detailing that the daily cost in the Emergency Room is $139 and in the Critical Care Unit, $243.

“There has been an increase in the DF referrals. Some are not located because they have improved and family members take them back or they may be alone. Also, they have left for the United States and others have died,” she added.

The losses due to these cases affect all hospitals, but mainly those already financially compromised, warned Ricardo Hernández, executive director of the Mennonite Health System.

He also recalled that the applicability of Medicare and Medicaid in Puerto Rico is limited and does not cover long-term care or home health care services.

Hernández commented that one recent case was hospitalized for more than 160 days without medical criteria, generating over $250,000 in losses for the hospital. He pointed out that, among the elderly abandoned in hospitals, many are mental health patients.

A fatal wait

According to the DF data, from April 2023 to May of this year, 81 elderly and disabled adults died during the referral, care and authorization process of the foster care service that the agency provides to people without family caregivers.

“Not all were going to (be placed in) a Home. Some were in terminal stages or with other comorbidities. They died in that referral and investigation process,” said Glenda Gerena, head of the Administración de Familias y Niños (Family and Children’s Administration), an agency attached to the DF.

Half of these cases (40) were referred to the San Juan Regional Office.

Sometimes, the DF contacts 50 or 100 households presenting a case and, as they are polytraumatized (patients), they do not receive them because they require tracheotomy management and other equipment

At Centro Médico, Jorge explained, after admission to the hospital, a multidisciplinary team evaluates the patient’s needs. But, she warned, there are unidentified people who spend months hooked up to machines or are unable to speak.

“Sometimes, the DF contacts 50 or 100 households presenting a case and, as they are polytraumatized (patients), they don’t receive them because they require tracheotomy management and other equipment. It depends on the patient’s complications,” she said.

The social worker pointed out that ASEM has seven social workers, which she said is “very little” for all the crisis management and coordination of services they manage, including the increase in the number of homeless elderly.

For Hernández, “there are not only economic consequences. An elderly person alone in a hospital is exposed to complications. Not ambulating (walking) makes them disoriented and there is a risk of nosocomial infections. Also, when they are bedridden, they develop ulcers”.

“There are grown ups who release their sick parents to us at Christmas and pick them up after the “octavitas” (aftermath of this festivity),” he said. “Others are admitted under the Ley de Salud Mental 408 (Mental Health Law 408) and, when they leave, their relatives have to take care of those patients,” he added.

Dr. José Ortiz, MMM's corporate medical director, stated that "the two main problems are the lack of communication (with the insurer for case management) and the lack of early referral (to the relevant agency)".
Dr. José Ortiz, MMM's corporate medical director, stated that "the two main problems are the lack of communication (with the insurer for case management) and the lack of early referral (to the relevant agency)". (Josian Bruno/GFR MEDIA)

“Hot potato” among agencies

The hospital should not wait for the patient’s discharge to refer the case to the DF if they first identify worrisome criteria, said, meanwhile, doctor José Ortiz, MMM’s corporate medical director.

“They take patients abandoned in the hospital as hot potatoes. The Administración de Servicios de Salud Mental y Contra la Adicción (Mental Health and Addiction Services Administration) tells the court, ‘It’s not my turn, it’s the DF’. They then cite the DF a month later and that agency says, ‘no, it’s up to Salud’. And the patient is in the hospital for three months (or more) while they decide which agency should take action,” he lamented.

The next problem is the lack of available beds in long-term care facilities that can receive these patients after hospitalization, Ortiz added.

“The two main problems are lack of communication (with the insurer for case management) and no early referral (to the relevant agency),” he said.

He pointed out that MMM’s Intensive Case Management Program follows up on long-stay patients, among other populations that require monitoring. Meanwhile, its Social Work Program helps provide alternatives and resources to the homeless or those living in subhuman conditions, without a caregiver or requiring support.

Sometimes, these cases are not a priority, because for all intents and purposes they are in a safe place (the hospital)

Hilmarie Caraballo, MMM’s social worker, declared that there are “many” patients alone, without family support, of limited resources and over 80 years of age. Several are reluctant to be helped, as they embrace their independence. Other times, when they see them walking or refusing to be helped, the government understands that they do not need assistance. Once they are more deteriorated, the professional lamented, it is difficult to find them a long term care facility that will accept them or they take a long time to relocate them.

“Sometimes these cases are not a priority because for all intents and purposes they are in a safe place (the hospital),” she said.

Without family members or relatives to provide their basic documents, it is difficult to get them, which further delays the hospitalization of these cases, she added.

Amanda Ramos, MMM’s Social Work analyst, indicated that, in the first quarter of 2024, they received 405 Medicare Advantage cases for lack of care and 160 from the Vital Plan (the government medical plan).

“With more resources, we could prevent more. We have to work hard on public policy because there is a growing population of older adults,” she emphasized.


This content was translated from Spanish to English using artificial intelligence and was reviewed by an editor before being published.

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