Updated HPC research recommends action to decrease ED boarding
BOSTON — Today, the Massachusetts Health Policy Commission (HPC) published updated research and policy recommendations, “Emergency Department Boarding in the Commonwealth of Massachusetts.” Emergency department (ED) boarding, which the HPC defines as patients remaining in the ED for 12 or more hours awaiting further treatment, has been a continuing crisis in Massachusetts, particularly for patients awaiting further behavioral health (BH) treatment.
ED boarding is one symptom of ongoing hospital capacity challenges, and may occur when a hospital has no available inpatient beds or when there are delays in finding appropriate care in the community for patients who do not need an inpatient level of care.
The HPC, updating previous ED boarding research through 2024, found that while the number of ED patients who boarded has grown since 2020, there has been a slight decrease in BH ED boarding from 2022 to 2024, perhaps as a result of multifaceted policy interventions. Overall, the percentage of ED visits that resulted in boarding rose from almost 7% in 2020 to 11% in 2024. The percentage of BH-related visits that boarded increased from 31% in 2020 to 37.5% in 2024, a decrease from the high of 40% in 2022.
In addition to representing challenges for patients and hospital capacity, boarding can also result in increased spending. Both commercial payers and MassHealth, the Commonwealth’s Medicaid program, paid more for ED visits that boarded and were ultimately discharged from the ED compared to patients who were discharged without boarding (22% and 33% more, respectively).
“We have convened stakeholders across the health care system, and they all echo what the data is highlighting – ED boarding is a significant issue in Massachusetts, occurring in over 37% of all BH-related ED visits in 2024,” said HPC Executive Director David Seltz. “The Commonwealth has invested in tackling this challenge, and now is the time to take that commitment even further by executing the recommendations put forth by the HPC. This action is critical for the health and well-being of patients and their families, hospital staff, and emergency medical services across the Commonwealth.”
Key HPC Findings on Emergency Department Boarding in Massachusetts:
- While the percent of ED patients who boarded has grown since 2020, there has been a slight decrease in BH ED boarding from 2022 to 2024. Overall, the percentage of visits to the ED that resulted in boarding rose from 2020 to 2024 (7% to 11%). The percentage of BH-related visits that boarded increased from 2020 to 2024 (31% to 37.5%), a decrease from the high of 40% in 2022. 4,500 fewer patients experienced BH ED boarding in 2024 compared to 2023.
- National data on ED wait times show that Massachusetts has the second longest wait time for any ED visit nationwide and sixth highest for patients experiencing behavioral health conditions nationwide in 2024.
- Patients who boarded during a BH ED visit were more often unstably housed, covered by MassHealth, were Black, non-Hispanic, and living in the lowest income communities, though these characteristics do reflect the population experiencing BH ED visits. Of BH visits that resulted in boarding in 2024: 18% did not have permanent housing; 58% were male; 48% had health insurance coverage through MassHealth; and 34% lived in the lowest income communities.
- While ED boarding overall has increased, the percentage of patients who needed an inpatient level of care and took over 24 hours to place started to decrease from 2022 to 2024. By 2024, 61% of adults and 70% of children who came to the ED for a BH problem were placed in an inpatient setting of care within 24 hours.
- Both commercial payers and MassHealth paid more for ED visits that boarded and were ultimately discharged from the ED compared to patients who were discharged without boarding (22% and 33% more, respectively).
- Overall, mental health patients with commercial insurance who had an ED visit and were ultimately admitted to an inpatient stay had an average length of stay of fourteen days, regardless of boarding status. However, patients with MassHealth who experienced boarding spent an average of four days longer when they were admitted to an inpatient setting compared to those who did not board (17 versus 13 days).
Policy Recommendations to Decrease ED boarding in Massachusetts:
- Continued and expanded research monitoring ED boarding, outcomes for these patients, and quality of care for these patients.
- Instituting practices and policies supporting the admission and transition of BH patients into more clinically appropriate care that should reduce ED boarding in acute care hospitals while improving outcomes and quality of care for patients, including: identifying best practices for patients facing placement challenges; promoting access to community-based behavioral health care; supporting direct admissions from the community; developing ED diversion regulations for patients experiencing BH crises; and expanding discharge support.
- Ensuring adequate reimbursement for services provided to patients experiencing BH boarding, including: clarifying payment rules; examining rates paid to BH providers; and encouraging adequate payment to community-based care.
- Investing in the BH workforce to improve access for patients needing BH care.
Explore the full report and policy recommendations on the HPC’s website.
