No one wants to go to the emergency room.
Often, however, it’s not a choice.
Motor vehicle crashes, household accidents or the sudden onset of a medical condition mean the flashing lights and wailing siren of an ambulance and a swift trip to the hands of skilled experts trained and equipped to handle whatever comes through the doors.
But what if the emergency isn’t a physical one?
Patients with behavioral health issues — whether brought on by conditions such as clinical depression, extreme anxiety or made worse by substance abuse — can find themselves in hospital emergency rooms, too. And sometimes that’s where they stay because there is nowhere else for them to go.
Hospitals large and small around Massachusetts have faced a continuing issue with a phenomenon sometimes known as psychiatric boarding, where patients in need of mental health care wind up in emergency departments or in hospital medical units waiting — sometimes for days or even longer — for space in a facility that can treat them.
“There is insufficient funding for lower levels of care from basic community clinics, intensive outpatient programs, community crisis stabilization units, and respite services,” according to a report released in July by The Joint Commission, a national nonprofit organization that accredits more than 22,000 U.S. health care organizations and programs.
Last month, Gov. Charlie Baker signed a law intended to make it easier for patients in crisis to access mental health services.
The law, known as the “Mental Health ABC Act: Addressing Barriers to Care” creates online portals that provide access to data on youth and adults seeking mental health and substance use services and includes a search function that allows health care providers to easily search and find open beds. It requires the state Health Policy Commission to prepare and publish a report every three years on the status of pediatric behavioral health as the youth boarding crisis is particularly acute; requires the Center for Health Information and Analysis to report on behavioral health needs; updates the expedited psychiatric inpatient admissions protocol and creates an expedited evaluation and stabilization process for patients under 18.
“This legislation is a sea-change, greatly improving access to mental and behavioral health services and addressing some of the most challenging aspects of delivering this critical health care to all,” state Rep. Hannah Kane, R-Shrewsbury, said at the August bill signing ceremony. “Far too many families have seen loved ones suffering and unable to access the short and long term care they need to get well and be well, my family included. I am grateful for the work of the conferees and the leadership of the Legislature.”
The Massachusetts Hospital & Health Association, which represents 70 health care facilities around the state, backed the legislation.
Leigh Simons Youmans, senior director for healthcare policy at the association said in a statement: “MHA and our members are deeply grateful for the action state officials are taking to address the behavioral health boarding crisis in our hospitals. From investments to boost the healthcare workforce to reimbursement for extended boarding stays, these are measures that will make a difference to patients, families, and caregivers.”
She added, “We know there is still work to be done. Hospitals are working around the clock with state leaders to build a behavioral health system that is even more accessible, equitable, and sustainable.”
While the new legislation addresses several of the issues outlined in a story that appeared in The Sun Chronicle in January, it’s very early in the game to see what kind of impact it might have locally.
“From the administrative vantage point, our outlook is hopeful,” Dr. Ron Van Ness-Otunnu, chief of emergency medicine at Sturdy Memorial Hospital in Attleboro said in an email to The Sun Chronicle. “It has not been long since the ABC Act was passed, so we are not seeing the full complement of benefits this legislation will bring just yet. That said, we feel positively about the forward movement the new reforms will bring in addressing the behavioral health crisis once they are fully off the ground.”
And while the intent of the law is laudable, it hasn’t necessarily boosted the supply of psychiatric beds in the area, although the state is holding a series of information sessions through December to craft regulations to implement the new law.
But, while the number of beds has increased, nearly 20% of those statewide are not being used, because there are not enough workers to staff them, according to a new survey from MHA and the Massachusetts Association of Behavioral Health Systems (MABHS).
According to the August survey of 56 facilities that represent 2,858 licensed inpatient psychiatric beds, 568 of those beds (19.9%) are offline due to staffing need, the report says. “That figure has been steadily increasing from 9% and 14% in February and October 2021, respectively,” according to the report.
The greatest number of vacancies are among bachelor’s level mental health workers (504), registered nurses (472), and social workers.
“Between February 2021 and now, the number of full-time equivalent workers needed to staff offline beds in the commonwealth has doubled or more in nearly every category of worker, from R.N.s, to social workers, to sitters and personal care attendants,” the MHA’s Youmans said of the report.
Last year, the Baker administration allocated $31 million from American Rescue Plan Act funding to the behavioral health workforce crisis. Hospitals used the temporary funds to increase wages and signing bonuses to incentivize and retain workers at the bedside, and for hiring temporary staff to keep current beds online.
A COVID-19 recovery bill that the legislature passed in late 2021, and Baker signed, contained $111 million for behavioral health workforce loan forgiveness. That forgiveness program is now being designed. The legislation also contained $198.6 million for a behavioral health trust fund that has yet to be allocated.
The problem, hospitals say, is getting insurers to reimburse more fairly for behavioral health services, to expand loan repayment programs and other workforce development programs, and to create employee well-being support to minimize the great strains of working in the behavioral health sector, the report says.
Meanwhile, the number of people needing those beds “is pretty consistent“ Van Ness-Otunnu said in a phone interview last week.
“Today, we have seven boarding, one has been with us for 10 days. It sounds like a good day,” he said, adding that they can have up to two dozen people awaiting behavioral health care when the ER at Sturdy, a nonprofit community hospital, has 32 regular emergency room beds.
“It goes up and down,” he said and is not always predictable.
MHA’s weekly Behavioral Health Boarding report for Sept. 19 found there were 597 total patients waiting in emergency departments statewide. That was down from 679 patients in the Sept. 12 report. The organization reported that it’s Region 5, which includes Southeastern Massachusetts, Cape Cod and the Islands, had 147 boarders across 13 hospitals, one being Sturdy.
By its very nature, it’s hard to see a surge in emergency patients coming. Van Ness-Otunnu said he’s seen as many as 186 patients with health needs of all kinds go through his department in a day, but, “that was a bit of a crazy day.” But even at the average of around 130 a day, to have an added 30 people, for example, with behavioral health issues he said, “makes it a challenge.”
Justine Zilliken, chief strategy officer at Sturdy, said this year the emergency department is trending to deliver care to approximately 49,000 patients with health needs of all kinds.
A quick snapshot earlier this month, provided by the Massachusetts Behavioral Health Access website which tracks the availability of inpatient care in the state, showed only about 9 psychiatric care beds with in a 30-mile radius of Attleboro, with the closest at Brockton Hospital with five beds. The next nearest site is at the Corrigan Mental Health Center in Fall River with two. Expanding the search to 50 miles, that number available was still under 20 beds.
Sturdy does not have an on-site psychiatric department, but it does have mental health professionals on call, Van Ness-Otunnu said, and behavioral health nurses on staff.
“They’re great at interacting with patients,” he said, particularly those who can be come agitated and frustrated while awaiting treatment. “They are well-trained in verbal deescalation.”
The hospital also can consult with psychiatrists who can make recommendations on medication.
Older patients can present their own challenges.
As an accredited geriatric level 2 emergency department, Sturdy has a particular focus on older patients who, Van Ness-Otunnu noted, “may have dementia issues and psychiatric issues secondary to their state.” They may stay in the ER for a prolonged period but, he says, “we can get them to a better state.”
The shortage of psychiatric care beds, while still an issue, could be easing soon, the Massachusetts Hospital & Health Association says.
It notes that through an incentive program launched by the Baker Administration last year, approximately 300 new inpatient behavioral health beds are in the process of coming online.
The American Rescue Plan Act bill passed by the state Legislature recently commits $400 million to expand access to mental and behavioral healthcare services, including behavioral health workforce needs.
As part of that bill, the Legislature established a $198 million Behavioral Health Trust Fund to address behavioral health access services across the continuum of care.
The HCA says that hospitals and health systems are championing the creation of a Behavioral Health Rate Task Force to evaluate ways to ensure the financial stability of behavioral health units and facilities, and to allow behavioral health providers to pay their workforce adequate salaries, prohibiting clinical denials due to an administrative or technical defect in a claim, and require coverage of all medically necessary mental health services and addressing administrative barriers for providers that wish to expand behavioral health services.
That can help community hospitals like Sturdy, Van Ness-Otunnu said. “We’ve taken the initiative to provide services.”