Emergency Department “Boarding” and the Need to Enhance Community Treatment Capacity

January 11, 2021

Every day, hospital departments are on the front lines of helping Americans overcome their mental health crises:

• A teenager engages in self-harm and the parents, not knowing where else to turn, take their child to the emergency department for treatment
• A nursing home resident with dementia becomes violent and can’t be managed by staff
• An ambulance is called, and the resident is taken to the local emergency department
• A person experiences extreme stress as a result of a conflict with loved ones or exposure to trauma or violence, and experiences suicidal thoughts. Having nowhere else to turn, they drive to the nearest hospital

These scenarios play out across Pennsylvania and the rest of the nation day and night, 365 days a year. When there are failures in the health care delivery system, emergency departments are the providers of last resort.

While emergency departments effectively triage patients, all patients—including those requiring behavioral health services—often face long delays in finding post-acute services. For patients in need of behavioral health services, these delays are often due to inpatient and outpatient treatment capacity issues.

Delayed discharges impact patients as well as health care delivery system outcomes:

• Increasing psychological stress upon patients and their families, delaying treatment that could mitigate the need for inpatient stays
• Consuming scarce emergency department resources
• Worsening emergency department crowding
• Delaying treatment for other emergency department patients

The potential consequences are even more severe today, as every single hospital bed may be necessary to address the COVID-19 pandemic.

In a survey of HAP members, more than 97 percent of respondents indicated that patients have been brought to their emergency department who do not have a medical issue but are exhibiting behavioral problems (dementia or cognitive deficits) and have been identified as being aggressive. Nearly 93 percent of these same hospitals indicated that they have identified needed long-term care services for these patients, but they have not been able to place them in a long-term care setting following treatment.

What can be done to address this crisis?

As a first step, HAP advocated for House Resolution 268 of 2019, which directed the Joint State Government Commission (JSGC) to appoint an advisory committee to conduct an assessment of the commonwealth’s current behavioral health needs and the impact that the behavioral health care system’s capacity has on hospital emergency departments and patient health. Based on this resolution, the JSGC report titled, “Behavioral Health Care System Capacity in Pennsylvania and its Impact on Hospital Emergency Departments and Patient Health,” included a series of recommendations.

HAP recently engaged in discussions with one of Pennsylvania’s leading behavioral health associations, the Rehabilitation and Community Providers Association (RCPA), to identify common advocacy priorities. These priorities were communicated in a letter to Governor Wolf’s newly created Interagency Health Reform Council (IHRC). The council was created as part of Governor Wolf’s “Whole-Person Health Reform Initiative.” This council is composed of agencies involved in health—i.e. the Departments of Health, Human Services, Insurance, Corrections, and Drug and Alcohol Programs—and the Governor’s Office. The IHRC is tasked with developing recommendations to find efficiencies in the health care system. 

In a joint letter, HAP and RCPA urged the commonwealth to:

• Continue telehealth policies following the COVID-19 crisis to address patient concerns and maintain access to care for both physical and behavioral health care services
• Work to provide adequate funding to support adequate behavioral health crisis service capacity to alleviate pressure on hospital emergency departments
• Set forth an active process to systematically address the issue of “true parity” between behavioral and physical health services
• Implement an escalation policy that would enable hospitals to engage counties, managed care organizations, and the department when a difficult placement situation is occurring in programs administered by the Office of Mental Health and Substance Abuse Services, the Office of Long-term Living, and the Office of Developmental Programs

This joint advocacy effort is just a small step to a much broader effort to address this crisis and shape the delivery system necessary to meet the needs of all Pennsylvanians.

For additional information, contact Jeff Bechtel, HAP’s senior vice president, health economics and policy, or Jennifer Jordan, HAP’s vice president, regulatory advocacy.