Health systems recognize that they need to address the psychiatric boarding problem because EDs bring in a lot of paying patients. Delays in serving them because of the boarding of psychiatric patients can hurt revenue.
Hospitals also are hoping that more mentally ill patients will gain insurance coverage for behavioral care through the federal healthcare reform law and the new federal mental health parity rule. In addition, many states are more closely integrating behavioral healthcare and substance-abuse treatment with physical healthcare in their revamped Medicaid managed-care programs, recognizing that better and more coordinated care for these expensive patients is key to reducing Medicaid costs.
Experts say the boarding problem arises in part from the political powerlessness of this patient population. “The mentally ill have the most limited self-advocacy because of the nature of the illness,” said Dr. Martin Buxton, a psychiatrist at Chippenham Hospital in Richmond, Va. “It's been a perfect storm that's been brewing for the last 30 years.”
In Ohio, which has one of the most critical bed shortages in the country, six hospitals have collaborated to create a Web-based “bed board,” an online database that allows clinicians to find available psychiatric inpatient beds and transfer patients to those facilities on a first-come, first-served basis.
Hospitals also are investing in crisis-oriented outpatient care as another way to steer patients away from the emergency room. “A lot of the folks that are being seen may not need a hospital bed,” said Dr. Larry Miller, a University of Arkansas psychiatrist who serves on the American Psychiatric Association's council on healthcare financing.
The deinstitutionalization of mentally ill patients starting in the 1960s and inadequate financing for community-based care has left many Americans without access to quality mental healthcare. In addition, hospitals across the country have sharply cut back on money-losing psychiatric beds. All of this has created a strain on hospital EDs, which are the last resort for patients, their families and public-safety officials dealing with people suffering from acute mental illness and substance-abuse problems.
Hospitals often resort to holding admitted psychiatric patients in hallways or other ED areas—sometimes in locked rooms—until inpatient beds are available. Patients may be admitted because of liability concerns related to the potential for suicide, but may not receive prompt and adequate assessment and treatment. Experts say the loud, hectic environment of the ED is bad for patients who are struggling with suicidal ideation, hallucinations or drug withdrawal. Staff and other patients may feel threatened by their behavior, requiring the presence of security officers and possibly the use of restraints. It's particularly hard to find psychiatric beds for patients with disabilities or special needs.