While managing a 62-bed emergency department (ED) experiencing more than 100,000 visits a year, our most challenging patients were rarely those who had just suffered massive injuries or suffered a massive heart attack or stroke. Certainly, these patients called for an “all-hands-on-deck” response, but it was patients with behavioral and mental health conditions that we most struggled to manage. As a result, many patients spent more time than necessary in our ED waiting to receive care in another facility.
Patients with behavioral and mental health conditions boarding in the ED is far from a new challenge facing the healthcare system. As the U.S. shifted from an inpatient to outpatient strategy for managing mental and behavioral health in the 1980s and many psychiatric hospitals closed, EDs became a care access entry point for many patients, especially those without social support or care resources in their community.
Perpetual access to care challenge
The problem became such a concern for hospitals that in 2021 the Joint Commission reminded its accredited organizations that the “problem of ED boarding stems not – or not only – from a lack of inpatient beds. Psychiatric patients seek care in EDs because they often have nowhere else to go.” I would amend that statement to: “patients seek care in EDs because they do not know where else to go.” These patients often do not have access to acute care settings to manage their chronic behavioral health issues, thus end up in crisis and seek care in the ED. This lack of access can be attributed to numerous factors, including socio-economic circumstances, transportation issues, health system processes connecting the patient to the care setting, and social and acute co-morbidities that complicate the availability of resources to manage complex illnesses.
Certainly, inpatient, outpatient, and community mental health and behavioral resources are largely underfunded, but care is often available, albeit difficult to access. The challenge is that patients have no knowledge of these resources – nor do the ED providers. Clinicians trying to find a bed in a psychiatric hospital, a substance use disorder rehabilitation facility or admission to mental health outpatient program must rely on their memory or a stack of papers in a three-ring binder that may be decades old without knowledge of the actual scope of each potential accepting location. Understanding the clinical capability of each accepting location compared to the patient’s clinical presentation and to include behavioral and acute issues is key to placement for these patients. Lack of this knowledge creates a scenario where the referring providers blindly hit the phones and fax machine trying to find availability. Meanwhile, an unknown provider in the next city or across the state may have the capacity to admit that patient.
Due to the outdated processes and knowledge gaps, the patient waits in an ED, which may add to their psychological stress, further contributing to the ED overcrowding that has been exacerbated by the pandemic and hospital staffing shortages.
Covid-19 contributing to the crisis
Perhaps one of the few silver linings of the pandemic is the acceleration of public awareness and acceptance of mental and behavioral health as conditions deserving of greater resources. For years, research has demonstrated the strong association between mental health and physical health, with a recent study across 17 countries significantly associating mood, anxiety, substance use, and impulse control disorders with the onset of between seven and 10 physical conditions. Studies have also found that treating mental illness tends to improve outcomes in patients with comorbid physical conditions.
The driver of this evolved understanding of mental and behavioral health care is, in part, the social isolation many suffered due to remote working combined with lack of interaction with friends and family due to Covid-19. Americans at home sought behavioral health care through telehealth, but EDs also saw significant increases in patient volume between 2019 and 2020 for reasons such as mental health conditions, suicide attempts, and drug overdoses. This increase is significant because overall ED volume was lower for 2020 due to care avoidance.
A complex process for complex care
Greater attention and resources are now being devoted to connecting patients to the right care at the right time and reducing or eliminating the boarding time in inappropriate care settings. For example, it was announced last year that $3 billion of American Rescue Plan funding was devoted to the Community Mental Health Services Block Grant program and Substance Abuse Prevention and Treatment Block Grant program, which is the largest aggregate amount of funding to date.
Dispersed between states, the funding will be used to help provide “comprehensive community mental health services and address needs and gaps in existing treatment services for those with severe mental health conditions,” according to the U.S. Department of Health and Human Services.
Additional resources and greater coordination on both a state and federal level is overdue considering the largely inefficient manual process that most hospitals use to locate mental and behavioral health services. The lack of progress, however, is not entirely the hospital’s fault. State resources for mental health vary widely, and there is no standardized method for identifying available facilities or programs.
Moreover, not only are hospitals facing a nursing shortage, the lack of available mental and behavioral health professionals is also a nationwide crisis. One estimate shows a 10% increase in demand for mental health professionals by 2026. During that time, 400,000 mental health workers will leave the occupation, leaving employers to fill more than 510,000 total vacancies.
These healthcare professionals are essential for consultations with ED physicians, who may lack the adequate training to care for these patients. Adding to the complexity, patients with mental and behavioral health conditions in the ED often have multiple conditions such as depression and substance use disorder in addition to physical health co-morbidities, making the resource pool even smaller.
Modernizing mental health
Reducing ED boarding of patients with mental and behavioral health conditions requires a similar strategy that helped hospitals and health systems with patient transfers for other conditions: digitization, standardization, and centralization. For decades, ED clinicians relied on paper-based directories of specialty hospitals as well as a list of physician subspecialists to call by phone to arrange a patient transfer. This also resulted in long waits and boarding that could have lasted days while the referring physician waited for an admission approval from an accepting physician.
Transfer centers have become much more than moving patients emergently to the appropriate hospital or specialty center. In many cases, they have evolved into the first line of patient access so health systems can deliver care and services to patients across the continuum quickly and effectively. What used to be inbound and outbound movement in transfer centers has evolved into a more standardized and centralized access center model. An integrated electronic platform that delivers streaming updates of the health system’s facility capacities, physician directories with defined clinical capability, and transportation availability helps providers and patients navigate the increasingly complex care system while load balancing across facilities so hospitals are not overburdened. Recently, health systems have extended this unified process by adding a similar technology capability for post-acute care facilities, such as skilled nursing facilities and rehabilitation centers.
As health systems continue their pursuit of a comprehensive approach to delivering care, integrating behavioral health across the care continuum is the next phase in the evolution and momentum of standardizing patients’ access to care. Like the acute and post-acute settings, expanding this capability into behavioral health settings will further unify the care process by helping ED clinicians discover resources they were previously unaware of as well as expose mental health and substance use rehabilitation organizations to a larger service area. Not only would the streamlined process improve the outcome and experience for patients, but it would also help reduce ED overcrowding and lighten the burden on the limited clinical staff in the department.
While no digital health solution alone can alleviate the shortage of available mental and behavioral health facilities and professionals, it can certainly help load balance across the various organizations. By doing so, hospitals can enable their patients to access much-needed care in less time and improve the mental and behavioral health equity across their state.
Photo: pablohart, Getty Images