If your plan for reducing discharge delays this budget cycle is another case management requisition, the evidence says you will spend the money and keep the delays. Hiring more coordination staff does not fix discharge delays, because the constraint was never the number of people coordinating. The constraint is how much coordination each person can actually drive inside a workflow that is serial, phone-based, and invisible to everyone else on the team. Every new hire inherits that workflow on day one, which is why capacity added at the seat level never becomes capacity at the system level. We know this not from theory but from experience, because the industry just ran the experiment at enormous scale.

The hiring experiment already ran, and throughput lost

The last five years amount to the largest staffing-up experiment in hospital history. According to Kaufman Hall data published by the American Hospital Association, median labor expense per adjusted discharge rose more than one third between 2019 and early 2022, from $4,009 to $5,494. An AHA analysis of Syntellis Performance Solutions data found hospital labor expenses per adjusted discharge up 24.8% by the end of 2022 compared to pre-pandemic 2019 levels. When permanent hiring could not keep up, hospitals rented the capacity instead: contract labor as a share of total labor expenses rose 178.6% over the same period, with median contract nurse wages running roughly three times those of employed nurses.

So what did all that money buy in throughput? Average length of stay increased approximately 19% in 2022 versus 2019, and nearly 24% for patients discharged to post-acute care, according to an AHA issue brief citing Strata Decision Technology data. That figure already accounts for patients arriving sicker and requiring more complex care. Hold those two lines next to each other. Hospitals spent roughly a third more on labor for every discharge, and discharge got slower anyway. If labor supply were the binding constraint on throughput, that much spending should have moved the number. It did not, and the revenue consequences of every avoidable day compound whether or not the labor line grows.

Why the next hire inherits the same broken day

I have spent more than 200 hours shadowing case managers, social workers, and physician leaders on hospital floors, and I want to be precise about what a new coordination hire actually inherits. They arrive well trained and often deeply experienced, and on day one the hospital hands them the same workflow it handed everyone before them. Half of that workflow points outward, and it is serial: one person makes one call at a time, so while they sit on hold with a health plan for forty minutes, the SNF referral for the patient in the next room simply waits its turn. Much of this outward work is governed by dependencies no one in the building controls: the SNF that returns calls after lunch, the insurance authorization sitting in a queue, the family that needs until Thursday to decide. Skill does not rescue time spent waiting on one dependency at a time.

The other half of the workflow points inward, and it is a chase: the discharge order that has not been placed, the PT evaluation that has not happened, the consultant’s final recommendations that exist only in a note nobody has flagged, the physician who will see the secure chat message somewhere between patients. On many floors, discharge information surfaces as a group only at rounds, once or twice a day, so a barrier identified at 2 PM can sit untouched until the next morning.

Both halves run on the same fragile information layer. What has been done, what is pending, and what is blocked live in EMR free-text fields, sticky notes, secure chat threads, and the memory of whoever worked the case yesterday. The case manager does not know what the physician knows, the physician does not know what the case manager has arranged, and handoffs across shifts and days off are hard to document. I have watched two skilled people unknowingly call the same facility about the same patient on the same afternoon. A care management leader at a large health system described the bar this layer cannot meet: you should know the appointment has been scheduled before you finish the plan, even if someone else made the call.

Adding people to a system like this does not dilute the problem, it multiplies it. Every new coordinator adds communication paths that run through the same informal channels of verbal updates, secure chats, sticky notes, and memory, which means more handoffs, more partial pictures of the same patient, and more chances for one fact to exist in two contradictory versions. In a tight labor market, the views you add are often especially partial, because the people available to hire are frequently new to hospital work, as the same leader pointed out: “We have a lot of social workers that are new and have not really been in hospitals and really maybe aren’t able to think about the clinical pieces that might need to come together for that discharge.” Ten people coordinating through fragmented channels are not ten times the capacity of one person. They are ten partial views of the truth, and someone still has to reconcile them.

None of this is a criticism of the people. The case managers I have shadowed are among the most resourceful, mission-driven professionals I have encountered anywhere, and they extract remarkable outcomes from tools that were never designed for this work. Look instead at what hiring actually buys in this environment. Each new coordinator adds call capacity one phone line at a time, and adds reconciliation overhead everywhere at once. It is like adding cooks to a kitchen that runs on one handwritten ticket rail. Every new cook can chop faster, but every dish still depends on everyone reading the same smudged tickets, and the more cooks you add, the more of the shift goes to asking who is doing what. Past a point, the tenth hire makes the kitchen slower.

The centralized throughput office is still people running a manual process

The most sophisticated version of the staffing answer is the centralized throughput office, and I understand its appeal. A physician executive I spent time with recently described one admiringly. A peer health system runs its throughput through a dedicated team of eight full-time employees, and his hope for his own version was that work would reach that team decision-ready, a yes or no, instead of “I’m going to make seven phone calls to figure out whatever.” Notice what that hope concedes. Eight people, at one of the industry’s best-resourced systems, still spend their days on serial phone work. The wish is not for more staff. The wish is for work that arrives ready for a decision, and hiring has never produced that.

The same executive told me about hiring a dedicated interventional radiologist to relieve a genuine procedure bottleneck. He was optimistic it would help, and in the same breath he asked how you progress a patient’s care “without thirty different side conversations.” Here was a hire aimed squarely at a real clinical constraint, endorsed by the leader making it, and even he expected the coordination friction to outlive the hire. The friction is not attached to any seat you can fill. It lives in how the work moves between seats.

The evidence points at process, not headcount

The trade consensus in case management holds that a case manager handling utilization review, discharge planning, and care coordination should carry roughly 15 patients. In the field, I routinely see caseloads of 20 or more. You can read that gap as an understaffing problem, but hospitals just spent five years and billions of dollars testing that reading. The other reading is that each caseload carries far too much manual, transactional work per patient. Case management consultant Brian Pisarsky made this point in Hospital Case Management: throwing more people at the problem is not always the answer, because if the process is broken, adding staff “won’t change the end result.”

The research literature is starting to converge on the same conclusion. A 2025 study of 868,031 Veterans Health Administration hospitalizations, published in BMC Health Services Research, concluded that improving acute care processes may more effectively reduce hospital capacity strain than bolstering post-acute care availability. The increase in length of stay has multiple drivers, from patient acuity to clinical staffing, and coordination is the one hospitals most directly control. The lever, in other words, is inside the building, in how the discharge work itself is executed. That matters even more as mandatory episode-based models like CMS TEAM raise the price of every coordination failure.

The better question: how much coordination can each coordinator drive?

The question worth asking this budget season is not how many coordinators you have. It is how much coordination each one can drive in a day. Headcount is rent, paid again every year through turnover and recruiting, while a better coordination architecture is capacity you keep. That reframe changes the capacity model entirely. The transactional layer of discharge, meaning the calls, faxes, referrals, and status checks across dozens of SNFs, home health agencies, and payers, does not need to happen one call at a time. It can run in parallel. The state of every discharge does not need to live in one person’s memory and a sticky note. It can be visible to the whole team, so no one repeats a call or waits on an answer that already exists. And every judgment call, every clinical assessment, every conversation with a family stays exactly where it belongs, with your staff. When the transactional layer runs in parallel and the work is visible, a 20-patient caseload stops being a crisis, because the patients are no longer competing for one phone line.

This is the premise Caremaze is built on. We do not think hospitals need more people making calls, and we certainly do not think the people making them today are the problem. We think each case manager should be able to drive several times more coordination than the current workflow allows, while spending their license on advocacy and judgment rather than hold music. If you are weighing another requisition against a different approach this cycle, I would welcome the chance to show you how we think about discharge coordination, or you can start with what discharge delays are already costing you.

Pierre-Jean Cobut, CEO & Founder of Caremaze | LinkedIn

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