Emergency Department visits for behavioral care on the rise

The number of Massachusetts patients seeking Emergency Department (ED) care for behavioral health conditions increased, as did the proportion of those patients who boarded and the length of boarding, according to data from 2011-2015 that was recently released by the Massachusetts Health Policy Commission (HPC).

The data from HPC – an independent state agency that develops policy to reduce health care cost growth and improve the quality of patient care – indicated that the number of patients seeking ED care for behavioral health conditions increased 13 percent from 2011-2015, and the number of patients who boarded (i.e., patients who spend 12 or more hours in the ED from the time of their arrival to their time of departure), grew from 17.4 percent in 2011 to 22.8 percent in 2015.

Though patients with a behavioral health diagnosis only accounted for 14 percent of ED visits in Massachusetts in 2015, they accounted for 71 percent of all ED visits that boarded. In 2015, the median length of stay for patients with a primary behavioral health diagnosis was twice as long as for a patient without a behavioral health diagnosis (5.4 hours versus 2.6 hours).

“The research suggests that Emergency Department boarding is a symptom of inadequate outpatient behavioral health services,” said HPC Executive Director David Seltz. “These results provide even further evidence that we need to enhance access to behavioral health services across the care continuum.”

Among solutions, Seltz said patients need access to alternative sites for care and stabilization – other than an ED – when they are in crisis.

“And once patients are in the Emergency Department, how are they being diagnosed and treated and managed in an effective way that reduces the potential for the external stimuli of the Emergency Department to further exacerbate a mental health condition?” he said. “Also, out of the Emergency Department – how can we quickly and effectively get that patient into inpatient care or back out in the community?”

One potentially surprising result in the data, Seltz said, was that behavioral health-related ED boarding was a problem across many different health insurance types.

“I think it was previously hypothesized that this is primarily an issue with Medicaid patients and what we found in the data was, in fact, this issue also presents in commercially insured and Medicare insured patients. This is not just a Medicaid problem. This is an all-payer problem.”

The data indicated that while almost half (46 percent) of patients with a behavioral health diagnosis who boarded were MassHealth (the state’s Medicaid program) members, commercially insured members accounted for 20 percent.

The time of day affected the likelihood of boarding – it was highest for patients who arrived in the ED between the hours of 4 p.m. and midnight.

The data suggests a lack of specialized services for children and teens. Of patients who presented to the ED with a behavioral health diagnosis, teens (ages 12-17) were the most likely to board (21 percent of teens boarded in 2015, compared to 14 percent of adults).

“We found teens and children were more likely to board and to board for longer in the Emergency Department,” Seltz said. Almost 13 percent of children ages 6-11 boarded for four or more days. “That is tragic,” Seltz said.

Seltz said there is a lack of specialized outpatient services for subpopulations including children, teens, and patients with developmental disabilities. “And we also heard from providers that finding inpatient care for some of these patients is also difficult, as well, that some of the inpatient facilities are not as well equipped to take care of these different subpopulations; and the data confirmed that,” Seltz said.

Despite the findings, the HPC notes that since 2015 (the end of the data period), there have been new, significant statewide efforts to reduce ED boarding led by the Executive Office of Health and Human Services.

“Over the last couple of years this issue has certainly become a top priority from both the state’s perspective and also increasingly a top focus and priority for quality improvement among hospitals,” Seltz said.

Seltz said the move toward accountable care organizations has resulted in increased coordination between hospitals and physicians and other community resources. “That increased coordination we think will help alleviate this issue,” he said.

Other factors that could spark improvement, the increase in data exchange that allows for hospitals to readily share information and connect with other parts of the health care system, Seltz said, and the state’s new Medicaid 1115 waiver includes new dedicated funding for providers to address ED boarding.

The HPC has been providing grants to community hospitals, and some of those projects have focused on reducing ED boarding. Among them, Beth Israel Deaconess Hospital set a goal of a 40 percent reduction in excess ED boarding for behavioral health patients.

The initiative includes rapid triage and timely crisis evaluation and supportive care of behavioral health patients, expedient linkages to community partners and providers, community care management, peer support, and behavioral health navigation.