Graphic by Marla Munkh-Achit
Written by: Alicia Duran, Copywriter, Public Health
Edited by: Joseph Nolan, Associate Editor, Public Health
The mental health system in the United States has historically lacked appropriate care for patients experiencing severe mental illness. During the 1960s, mental healthcare shifted from institutional settings to community-based services [1]. Although this shift gave patients with severe mental illness more autonomy over their care, it led to market forces driving a reduction in psychiatric beds without a parallel increase in support for community services [2]. As such, patients seeking preventative care for severe mental illness face long waitlists for community-based services; instead, these patients divert to ill-equipped emergency departments (EDs) for treatment of acute episodes but likewise wait long periods in hallways or other emergency room areas for an inpatient bed, also known as “boarding.”
ED boarding is particularly harmful for psychiatric patients. Indeed, the loud and chaotic nature of the ED environment can worsen conditions of boarded psychiatric patients who have higher rates of psychotic and personality disorders [1]. Yet boarding is more prevalent among psychiatric patients: a 2008 ambulatory care survey revealed that 21.5 percent of psychiatric ED patients boarded, while 11 percent of all ED patients boarded [3].
Psychiatric boarding has remained a prevalent issue in EDs across the United States. The issue has fostered innovative policy solutions, such as the Medicaid Emergency Psychiatric Demonstration (MEPD) under the Patient Protection and Affordable Care Act (ACA) of 2010. The demonstration program attempted to reduce psychiatric boarding by reimbursing emergency psychiatric care for Medicaid-eligible adults [2]. However, policy evaluators found little to no evidence that MEPD affected ED boarding [4]. Thus, psychiatric boarding persists, warranting new policy solutions at the hospital and community level.
A Story of Incentives
Multiple forces contributed to today’s shortage of beds for psychiatric patients. First was the depopulation of state hospitals. The deinstitutionalization of mental health care in the 1960s was driven by a national movement to treat patients diagnosed with mental illness in community-based clinics rather than state facilities [5]. By 1977, 650 community mental health centers were in operation [5]. Secondly, Medicaid and Medicare, introduced in 1965, contributed further incentives to deinstitutionalize mental health care. Written into Medicaid were exclusions that prohibited the public insurer from reimbursing institutions for mental disease (IMDs) (including state hospitals) for services provided to Medicaid enrollees aged 21 to 64. In turn, over 40 state hospitals closed by the 1990s [5].
Changes to reimbursement spurred a decline in acute care beds in private hospitals. In the early 1990s, the increase in health expenditures reached double-digit rates [6]. In response, states contracted with managed care plans to oversee the care of their Medicaid beneficiaries. To contain costs, managed care plans negotiated lower payment rates with providers, and actively managed patients’ access to care. Together, managed care slowed the growth of medical costs [7]. However, it also caused unforeseen market changes: hospitals reduced capacity to remain profitable. Indeed, by 1995 there was a 12 percent reduction in hospital beds [7]. More recently, restrictive managed care plans are less popular, but the situation has not improved. The single largest payer for mental health services in the United States, Medicaid has the lowest reimbursement rate for psychiatric services, disincentivizing hospitals to maintain psychiatric beds [8].
Although there has been growth in community-based services, it is insufficient to offset the decline in acute care beds [9]. Indeed, more and more patients seek psychiatric care in emergency settings: 6-10 percent of ED patients present for psychiatric illness annually, an increasing subset of ED patients [1]. In fact, a 2008 survey of emergency physicians revealed that 29 percent of respondents had no accessible community psychiatric resources [1].
Psychiatric patients who seek care in the ED wait an average of 7 hours for a bed following the decision to admit [10]. For patient transfers, facilities have reported waits longer than 24 hours [10]. Extended ED stays are associated with an increased risk of symptom exacerbation for patients with severe mental illness. ED settings, designed to accommodate crises on a 24-hour basis, feature continuous lighting, loud and unpredictable sounds, and a fast-paced environment; these conditions can increase fear and distress among psychiatric patients, especially suicidal patients who may be more vulnerable to overstimulation [11]. Further, EDs are ill-equipped to provide basic therapeutic needs of psychiatric and suicidal patients. Indeed, in 62% of EDs, no psychiatric treatment is provided to patients with severe mental illness during the boarding period [11]. Finally, boarding has a considerable impact on the entire system of care, including longer wait times for all patients, decreased availability of emergency staff, and lost hospital revenue and consumption of resources [1].
Policy Solutions to Psychiatric Boarding
Under section 2707 of the ACA, the MEPD was established to test whether Medicaid programs could support higher quality care at a lower cost. Medicaid continues to exclude IMDs from reimbursement; however, the demonstration program provided a maximum of $75 million in federal Medicaid matching funds over three years to reimburse private IMDs for treatment of psychiatric emergencies [12]. The goal of MEPD was to directly improve the psychiatric boarding issue by expanding the number of emergency inpatient psychiatric beds available. The demonstration program began in July 2012 in 11 states, and ended in June 2015, in accordance with the legislative requirements.
Policy evaluators found little to no evidence that MEPD affected ED visits and ED boarding times. Although ED visits were not statistically significantly affected, there was a trend toward more ED visits during the period when MEPD was in effect [4]. However, the evaluators note that several demonstration states expanded Medicaid eligibility under the ACA during the evaluation period; thus, the increase in demand in part from Medicaid expansions may have masked MEPD’s effect [4]. Indeed, MEPD was expected to decrease ED visits and boarding times. On the upside, private IMDs appeared to have improved the quality of care received. IMDs had better connections to and documentation of aftercare resources than general hospitals. Likewise, 88 percent of interviewed beneficiaries responded that they felt safe to leave the IMD when they were discharged [4]. Notably, however, discharge planning was made difficult by a lack of available community-based care [4].
Altogether, evaluators concluded that improving access to IMD services may affect inpatient bed searches, but not the other host of factors contributing to psychiatric boarding. Thus, they recommended that future initiatives focus on a more comprehensive approach to mental healthcare that considers the distribution of resources across inpatient, emergency, and outpatient care.
It is becoming increasingly important for community organizations to partner with healthcare providers to manage the care of patients. Given the complexity of psychiatric boarding, solutions will require partnerships between both systems of care. At the hospital level, the management team should allocate resources to improve bed capacity efficiency and the appropriateness of the care provided in the ED. For instance, additional ED staff can manage inpatient capacity, social workers in the ED can assist with facility transfers, and psychiatrists in the ED can provide more appropriate care to psychiatric patients [13]. Further at the community level, the management team should allocate resources to increase access to care management and stabilization services. For example, crisis stabilization units, small inpatient facilities with around 16 beds are effective alternatives to the ED for patients with severe mental illness [14]. Resources should also be allocated to increase outpatient community services in general [13]. Finally, adjunct professionals, such as law enforcement, school workers, and group home staff, should be given training and resources to manage mental health crises before the hospital [13][15].
Looking Ahead
As mental illness becomes more prevalent, psychiatric boarding will continue to be a concern for the health care system. In addition, the COVID-19 pandemic is expected to exacerbate already increasing rates of suicide, anxiety, and depression [16]. Yet, few innovative policy solutions that address a lack of community-based resources and support inpatient and outpatient care have been implemented since the end of the MEPD in 2015. However, mental health is a priority issue. In July 2020, the Federal Communications Commission adopted rules to establish 988 as a nationwide mental health and suicide prevention number [17]. This is an initial first step to addressing the nation’s mental health crisis, but it should be accompanied by an additional policy that supports community-based services to manage mental health more effectively and, in turn, offer a solution to the boarding of psychiatric patients.
References:
[1] Nordstrom, Kimberly, Jon S. Berlin, Sara Siris Nash, Sejal B. Shah, Naomi A. Schmelzer, and Linda L.M. Worley. “Boarding of Mentally Ill Patients in Emergency Departments: American Psychiatric Association Resource Document.” Western Journal of Emergency Medicine 20, no. 5 (September 2019): 690–95. https://doi.org/10.5811/westjem.2019.6.42422.
[2] Alakeson, Vidhya, Nalini Pande, and Michael Ludwig. “A Plan To Reduce Emergency Room ‘Boarding’ Of Psychiatric Patients.” Health Affairs 29, no. 9 (September 1, 2010): 1637–42. https://doi.org/10.1377/hlthaff.2009.0336.
[3] Nolan, Jason M., Christopher Fee, Bruce A. Cooper, Sally H. Rankin, and Mary A. Blegen. “Psychiatric Boarding Incidence, Duration, and Associated Factors in United States Emergency Departments.” Journal of Emergency Nursing 41, no. 1 (January 2015): 57–64. https://doi.org/10.1016/j.jen.2014.05.004.
[4] Mathematica Policy Research. “Medicaid Emergency Psychiatric Services Demonstration Evaluation: Final Report,” August 18, 2016.
[5] Koyanagi, Chris, and David L. Bazelon. “Learning From History: Deinstitutionalization of People with Mental Illness As Precursor to Long-Term Care Reform,” August 2007. https://www.kff.org/wp-content/uploads/2013/01/7684.pdf.
[6] Lesser, Cara S, Paul B Ginsburg, and Kelly J Devers. “The End of an Era: What Became of the ‘Managed Care Revolution’ in 2001?” Health Services Research 38, no. 1 Pt 2 (February 2003): 337–55. https://doi.org/10.1111/1475-6773.00119.
[7] Cutler, David M., and Louise Sheiner. “Managed Care and the Growth of Medical Expenditures.” In Frontiers in Health Policy Research, Volume 1, 77–116. MIT Press, 1998. https://www.nber.org/books-and-chapters/frontiers-health-policy-research-volume-1/managed-care-and-growth-medical-expenditures.
[8] “Behavioral Health in the Medicaid Program—People Use and Expenditures.” Medicaid and CHIP Payment and Access Commission, June 2015.
[9] Sharfstein, Steven S., and Faith B. Dickerson. “Hospital Psychiatry For The Twenty-First Century.” Health Affairs 28, no. 3 (May 1, 2009): 685–88. https://doi.org/10.1377/hlthaff.28.3.685.
[10] Nicks, B. A., and D. M. Manthey. “The Impact of Psychiatric Patient Boarding in Emergency Departments.” Emergency Medicine International, June 12, 2012. https://doi.org/10.1155/2012/360308.
[11] Guzmán, Eleonora M., Katherine M. Tezanos, Bernard P. Chang, and Christine B. Cha. “Examining the Impact of Emergency Care Settings on Suicidal Patients: A Call to Action.” General Hospital Psychiatry, Suicide and Medical Settings, 63 (March 1, 2020): 9–13. https://doi.org/10.1016/j.genhosppsych.2018.07.004.
[12] “Medicaid Emergency Psychiatric Demonstration: Demonstration Design and Solicitation.” Centers for Medicaid and Medicare Services. Accessed October 29, 2021. https://innovation.cms.gov/files/x/medicaidemerpsy_solicitation.pdf.
[13] Abid, Zaynah, Andrew Meltzer, Danielle Lazar, and Jesse Pines. “Psychiatric Boarding in U.S. EDs: A Multifactorial Problem That Requires Multidisciplinary Solutions,” June 2014. https://smhs.gwu.edu/urgentmatters/sites/urgentmatters/files/Psychiatric%20Boarding%20in%20U.S.%20EDs%20A%20Multifactorial%20Problem%20that%20Requires%20Multidisciplinary%20Solutions.pdf.
[14] Saxon, Verletta, Dhrubodhi Mukherjee, and Deborah Thomas. “Behavioral Health Crisis Stabilization Centers: A New Normal.” Journal of Mental Health & Clinical Psychology 2, no. 3 (June 8, 2018). https://www.mentalhealthjournal.org/articles/behavioral-health-crisis-stabilization-centers-a-new-normal.html.
[15] Simon, Jeremy R., Chadd K. Kraus, Jesse B. Basford, Elizabeth P. Clayborne, Nicholas Kluesner, and Kelly Bookman. “The Impact of Boarding Psychiatric Patients on the Emergency Department: Scope, Impact and Proposed Solutions.” American College of Emergency Physicians, October 2019. https://www.acep.org/globalassets/new-pdfs/information-and-resource-papers/the-impact-of-psychiatric-boarders-on-the-emergency-department.pdf.
[16] Panchal, Nirmita, Rabah Kamal, and Cynthia Cox. “The Implications of COVID-19 for Mental Health and Substance Use.” KFF (blog), February 10, 2021. https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/.
[17] Federal Communications Commission. “Suicide Prevention Hotline,” March 5, 2020. https://www.fcc.gov/suicide-prevention-hotline.
