Wait times still long in EDs

Patients having mental health emergencies who require hospital admission wait nearly four times longer for an inpatient bed than their medical counterparts, according to a study published in Annals of Emergency Medicine.

Additionally, mental health patients waited more than five times as long for transfer to another facility, according to the study, “Analysis of Emergency Department Length of Stay for Mental Health Patients at Ten Massachusetts Emergency Departments.”

“Boarding, the practice of prolonged waiting in the emergency department for an inpatient hospital bed or transfer to another facility, is a pervasive public health problem that disproportionately affects mental health patients,” said lead study author Mark Pearlmutter, M.D., FACEP, chairman of Academic Department of Emergency Medicine at Tufts University School of Medicine in Boston, in a statement.

Uninsured patients and those with Medicaid had significantly longer waits in the emergency department (ED), Pearlmutter said.

The study included 871 patients who had a mental health evaluation in one of 10 unaffiliated Massachusetts hospitals during a two-week period in 2012.

For patients admitted to the hospital from the ED, the average length of stay was 4.2 hours for medical/surgical patients; 16.5 hours for mental health patients.

For patients who required transfer to another facility, the average length of ED stays for medical/surgical patients was 3.9 hours; 21.5 hours for mental health patients.

Uninsured patients were 2.8 times more likely to have an ED stay greater than 24 hours and Medicaid (called MassHealth) patients were twice as likely to have an ED stay longer than 24 hours than privately insured patients.

“I think the primary factor is inpatient bed availability,” said Shoshana Fagen, Psy.D., Massachusetts Psychological Association’s advocacy committee co-chair. “There are some new units that have opened up, so it’s a little better. But in my experience, almost without fail, the primary reason is availability of beds.”

In recent years, some improvements have taken place. Laurie Martinelli, J.D., MPH, executive director of NAMI Massachusetts, noted that some insurers, including Blue Cross Blue Shield and Tufts, have done away with the prior authorization requirement for psychiatric hospital stays. Additionally, state data shows an increase in the number of licensed psychiatric beds.

But Martinelli said even in cases where there are licensed beds, facilities may not have appropriate staffing available, so beds remain empty. She also said the problem can be seasonal and affected by other issues such as homelessness.

“This is a very complicated and longstanding issue that has been going on for decades,” she said “There’s no easy solution.”

Martinelli, part of a task force last year under state Secretary of Health & Human Services Marylou Sudders, said, “I do feel confident that this administration is going to release something that is going to address this problem in a meaningful way.”

Martinelli said one issue is the high number of people who present to an ED who don’t need to be there. “If there were more mental health services in the community and outpatient services, that probably wouldn’t happen.”

She said part of the solution may be found in expanding current programs such as the mobile clinical services offered under the state’s Emergency Services Programs (ESP). “If you have MassHealth, you can call your ESP providers and they will come to your home,” diverting people away from the ED, Martinelli said.

“We think the role of peers may be part of the solution, as well,” she added, referring to the recovery learning communities funded in the state and peer-run respite programs.

Fagen cited low reimbursement rates as another barrier to placement. “When you are dealing with a medical case, you don’t just bill inpatient stay, you bill based on the diagnoses and complexity, so there are multiple billing codes you can submit to cover the different kinds of services patients need,” Fagen said.

“There’s no equivalent in mental health. It’s a flat fee per day; it doesn’t matter how complex this patient is.”

More acute patients can cost units more for increased supervision and care, Fagen said. The unit can also become unsafe if there isn’t appropriate staffing to handle acute patients, which could lead to those patients waiting longer in EDs, she said.

Another factor that can slow down the process for MassHealth patients is that MassHealth requires that their contracted providers be the one to do the mental health evaluation, rather than the ED mental health workers. “They don’t do that on the medical side,” Fagen said.

Treatment is delayed while patients wait in an ED. “You don’t get treated in the emergency room for a mental health condition,” Fagen said. “You’re in an environment that is not set up for mental health.”

Patients can become bored and agitated while waiting. “A large portion of the people who have mental health issues also have trauma histories,” Fagen said. “To be in that kind of closed environment with security staff outside your door can be triggering.”

Also, Fagen said patients released too soon from inpatient care often wind up back in the ED. “They are not well enough to go back into the world and get the help they need,” Fagen said. “The system for integrating people back into the community after hospitalization is practically non-existent for adults.”