47% of children ultimately admitted to a psychiatric bed in an acute care hospital stayed in the ED more than 24 hours in 2024
BOSTON — Today, HPC staff presented new research on behavioral health boarding in Massachusetts emergency departments. Behavioral health (BH) emergency department (ED) boarding, which occurs when patients remain in the ED awaiting further behavioral health treatment, has been a continuing crisis in Massachusetts.
Behavioral health ED boarding is one symptom of ongoing capacity challenges and may occur for reasons such as: delayed psychiatric evaluations, no available inpatient beds, and delays in finding appropriate care in the community for patients who do not need an inpatient level of care. Despite a decrease in the number of inpatient stays, hospital occupancy rates have increased from 2016 to 2023 due to longer lengths of stay.
“HPC research has found that the percent of patients boarding in the ED has grown across visit types, but especially for BH-related visits,” said HPC Executive Director David Seltz. “This growing trend of behavioral health ED boarding is not only harmful for these patients and their families, but also impacts hospital staff, non-BH patients, and emergency medical services across the Commonwealth.”
HPC Findings on Behavioral Health-Related ED Boarding in Massachusetts:
- The percent of ED patients who boarded has grown both for BH-related visits and other visits as well. For non-BH visits, this grew from 4.5% of visits resulting in boarding in 2020 to 8.1% from January-May 2024, and for BH visits this increased from 31.3% of 2020 visits to 38.8% of visits in this same time period.
- By May 2024, nearly half of patients with mental health-related ED visits boarded (defined by the HPC as visits that were greater than or equal to 12 hours in the ED).
- Patients who boarded during a BH ED visit were more often covered by MassHealth, Asian, Black, or 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 2023: 11% were children aged 0-17; 33% were Asian, Black, Hispanic, or a race other than White; 56% were male; 49% had health insurance coverage through MassHealth; 35% lived in the lowest income communities; and 17% did not have permanent housing.
- Approximately a third of patients that experience BH ED boarding are discharged directly from the ED and not sent to a higher level of care. This has remained consistent over time. Routine departure from the ED (i.e., discharge home) differed by type of BH ED visit. For mental health-related ED visits, 26% were discharged home, while 42% of substance use disorder-related visits were discharged home.
- The proportion of adults ultimately admitted to an inpatient psychiatric bed at an acute care hospital who spend over 24 hours in the ED has declined, from 53% in 2022 to 40% from January-May 2024.
- However, among children who were ultimately admitted to a psychiatric bed in an acute care hospital, the proportion of children staying in the ED more than 24 hours has remained high at 47% in 2024.
- Both commercial payers and MassHealth paid more for ED visits that resulted in boarding and were ultimately discharged from the ED compared to patients who were discharged without boarding (22% and 33% more, respectively). Average spending was $2,014 for commercial patients who boarded compared to $1,653 for commercial patients who did not board, and $984 for MassHealth patients who boarded compared to $742 for MassHealth patients who did not board. Commercial patients that boarded but were ultimately admitted had slightly higher spending compared to those who were admitted but did not board (7% higher).
The full HPC report will also include behavioral-health related boarding in other states, further information on impact on acute-care hospitals, the role of workforce, and related policy recommendations. The presentation is available on the HPC’s website.
