ERs in patient 'boarding' crisis

WORCESTER — A crisis is overwhelming some hospital emergency rooms.

It's called "boarding," and it paints a troubling picture — not enough ER staff to handle a wave of behavioral health patients streaming through the front door.

In some cases, patients stay in the ER for weeks — or months — before an inpatient bed is located.

That timeline was provided by Dr. Maxim Lianski, interim chairman of the Psychiatric Department at St. Vincent Hospital.

"Unfortunately, it's our new reality," said Lianski of the boarding dilemma.

Put another way, ER boarding increased 200% to 400% in Massachusetts since June 2020, according to the state Department of Mental Health — a time period that coincides with the coronavirus pandemic.

UMass Memorial Health declined a Telegram & Gazette request for comment on whether boarding is an issue at its emergency rooms.

Why is boarding occurring?

There are many reasons, Lianski said, including a shortage of staff in hospital ERs and behavioral health units.

"A lot of staff left during COVID. It's hard to hire them back," Lianski said.

MetroWest Medical Center experienced a half-dozen resignations in the past two months in its Behavioral Health Unit.

Lianski knows the number, because he is chairman of the Psychiatric Department at MWMC. It includes Framingham Union Hospital and Leonard Morse Hospital in Natick.

Tenet Healthcare Corp., a for-profit company based in Dallas, owns St. Vincent Hospital and MWMC.

Less staff means longer wait times

That is the case at St. Vincent Hospital, where recent boarding accounted for more than a dozen patients waiting in its emergency room for an inpatient bed, Lianski said.

Framingham Union recently had 10 patients boarding in its ER.

"Six months to a year ago, if you had two, three, four patients boarding, it would have been a huge thing," Lianski said.

St. Vincent Hospital has inpatient beds, 20 of them, Lianski said. However, the unit is temporarily closed due to the ongoing nurses strike at the hospital — at eight months, the longest hospital nurses strike in state history.

Framingham Union also has inpatient beds. It added a 14-bed inpatient unit last year, but there's not enough staff to run the operation.

"We're working on that," Lianski said. "We've run into staffing issues. We need nurses, social workers, mental health counselors.

"They need a (competitive) salary. If we don't pay enough, then they will find another opportunity."

Lack of state beds

A contributor to the boarding calamity — a big factor, according to Lianski — is a lack of psychiatric beds run by the state.

It's a case of a clogged system: If the state doesn't have enough beds to discharge ER patients to, there's a lengthy stay for patients in the ER.

"There's a lack of resources at the (state) Department of Mental Health," Lianski said. "For example, before, maybe one, two years ago, for a difficult patient, it would take a month to three months to transfer. Now, several people are waiting more than a year."

The state must supply more group homes, Lianski said. Plus, transitional units for some patients who don't require complex care — a temporary stop where patients receive needed care and services before eventually returning to the community.

"There's a crisis (with transitional units), as well," Lianski said. "A lot have closed. There are no beds."

DMH response

The COVID-19 pandemic is a primary cause of boarding, said the DMH in a prepared statement emailed to the Telegram & Gazette.

"The COVID-19 pandemic has impacted mental health for children, youth and families across Massachusetts and the country," the statement reads in part. "This impact has resulted in workforce shortages and challenges with bed capacity, that need to be addressed.

"...To address the increase in individuals needing hospitalization, the Commonwealth continues efforts to increase inpatient psychiatric treatment capacity and to reduce emergency room waiting times."

The statement mentioned several moves to meet the boarding challenge.

One is $55 million to Massachusetts in the form of federal American Rescue Plan Act funds. The money will boost staffing in several areas, including behavioral health.

Second, 250 inpatient psychiatric beds have been added statewide this year due to financial incentives offered by the state.

Third, the state rolled out "Roadmap for Behavioral Health Reform," a multiyear plan to make outpatient behavioral health and addiction treatment more accessible and equitable for all residents in need.

Hospital closures also contributed to the decline in the number of inpatient beds, the DMH noted.

The department highlighted the closures of inpatient psychiatric services at Providence Behavioral Health Hospital in Springfield, Westwood Lodge psychiatric hospital in Westwood, and flooding that shut down Norwood Hospital.

Crisis for children and adolescents

A particular concern, the state DMH noted, is a lack of psychiatric beds for children and adolescents — a problem exacerbated during the pandemic.

Some of these young patients are getting agitated and difficult to manage in the ER, according to Lianski.

"It's not right for children to spend a day, and sometimes weeks, in the ER," Lianski said. "We don't have the resources to accommodate them."

MassHealth, the state's Medicaid insurance program, starting offering additional funds in October 2020 to increase the number of inpatient psychiatric beds for adults and youth, according to the DMH.

Health care providers who added beds for these patients received one-time funding for each bed and a "substantial" rate increase guaranteed for three years per bed, according to the DMH.

As a result, it's expected the state will have 250 additional psychiatric beds this year.

Some health care providers also made a commitment to add beds that will total more than 300 beds. Nearly half that number will be for children and adolescents.

So far this year, 230 new psychiatric beds have been licensed, the DMH noted, including 80 for children and adolescents, 132 for adults and 18 for geriatric patients.

In total, Massachusetts has 2,969 licensed and 780 DMH-operated psychiatric beds, according to the DMH.

Expedited Psychiatric Inpatient Admissions

This program is in play, the DMH said, to find beds faster for patients who are boarding in ERs.

Since 2018, the online tool matches a boarder with an available bed. If one isn't located, a patient's health insurance provider is contacted to help with the search.

Before the pandemic, a boarding patient was placed into the online system after 96 hours of wait time in an ER. During the pandemic, the wait time was cut to 60 hours, the DMH said.

On average, the online system finds a bed in two days, according to the DMH.

What is the solution?

Simple, Lianski said — more money and resources to help behavioral health patients.

That means hospitals need to hire more social workers, case managers and clinicians.

If that happens, more patients can be treated so they can reenter the community. That will free up what is a limited number of beds in group homes operated by the state for those who need a higher level of psychiatric care.

Ultimately, Linanski said, the state needs to supply more group homes.

"There are quite a few people ready for discharge (from the ER). They're waiting for a bed at a DMH group home. They're sitting here, stable and ready to go, but there is no place to discharge. We need more group homes."

Contact Henry Schwan at [email protected]. Follow him on Twitter @henrytelegram