How to solve the Emergency Department boarding crisis? Systemwide change

BlogEmergency Department (ED) “boarding” – when patients get stuck in the ED for hours, sometimes days, because there is no placement option readily available – is an issue across the country and has received much attention in Massachusetts recently. Earlier this month, The Boston Globe published an article highlighting the fact that many of these individuals have behavioral health conditions.

We at Beacon Health Options took a look at our own data in Massachusetts to better understand the issue. We found that among individuals entering the ED with behavioral health conditions, the patients remaining there the longest were disproportionately children and adolescents with behavioral health issues, ranging from “aggressive” behavior to intellectual and developmental disabilities. The average length of stay for a boarder (we defined as those in the ED for longer than 12 hours) was approximately three days. There were even some patients who remained in the ED for longer than a week.

We found that among individuals entering the ED with behavioral health conditions, the patients remaining there the longest were disproportionately children and adolescents with behavioral health issues.

Solving the ED boarding crisis requires the entire system to change

It’s easy to blame the EDs for not getting these patients out faster, or the inpatient hospitals for not having enough beds. However, the reasons (and therefore solutions) behind ED boarding are manifold and across the system.

  • Emergency rooms: Patients exhibiting behavioral health needs should be given a mental health assessment as soon as possible to assess their needs. In Massachusetts, one solution is to embed Emergency Service Providers (ESPs) in the ED to do onsite assessments and more quickly assess a broad range of community-based services.
  • “High-intensity” inpatient beds: The lack of inpatient bed availability is often cited as a reason for keeping patients in the ED. At least half of the ED boarders in our data required “high-intensity” beds, such as 1:1 staffing, 24/7 surveillance, single occupancy rooms, or specialized staff who have experience with the complex needs of this population. Unfortunately, there are few inpatient providers equipped with the resources to address this group.
  • Timely discharge from inpatient care: There are some instances when children are unable to leave inpatient care because of funding delays for residential placement. This delay impacts inpatient bed availability, compounding the ED-boarding issue. Addressing this problem requires better coordination both within and outside of the health care system.
  • Shared infrastructure: Matching available supply-and-demand across the state is not easy. We need to continue investing in statewide infrastructure, such as the Massachusetts Behavioral Health Access (MABHA) website that helps providers locate an available bed.
  • Community providers: Ideally, individuals with urgent behavioral health needs should be seen in the community rather than the ED, whenever possible. We should explore expanding urgent care access to psychiatry as well as creating alternatives in the community. For example, the “Living Room” is a community crisis respite center in Western Massachusetts where “guests” can go instead of to the ED.
  • Payers: Payers play a critical role in building the financial supports required to create an improved system. For example, the economics of building and maintaining high-intensity inpatient units is not favorable for providers today. Payers will need to develop better reimbursement strategies that encourage the right interventions and resources for both hospitals and community providers.

As challenging as the solution may be, the alternative of leaving the most complex individuals in the ED room is unacceptable. A systemwide problem requires a systemwide solution: payers, providers, and community stakeholders must coordinate efforts to work towards that solution.

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