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doi: 10.1377/hlthaff.2009.0336
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A N A LYS I S C O M M E N TARY
HEALTH AFFAIRS 29,
& NO. 9 (2010): 1637–1642
©2010 Project HOPE—
The People-to-People Health
I
n a 2008 survey of 328 emergency room greater collaboration among hospital emergency
(ER) medical directors, the American rooms, community mental health providers, and
College of Emergency Physicians found law enforcement agencies, and and it proposes
that roughly 80 percent believed that investments in the development of community
their hospitals “boarded” psychiatric pa- infrastructure. The paper highlights opportuni-
tients.1 The term boarding is generally under- ties in the new health reform law that support the
stood to mean the time spent waiting in an implementation of this action plan.
emergency room for a hospital bed or for transfer
to another inpatient facility. Boarding times in
Georgia, for example, average thirty-four hours, Background
and many patients wait several days for an inpa- Psychiatric patients’ overuse of and boarding in
tient bed in one of the state’s seven psychiatric emergency rooms are symptoms of a lack of ap-
hospitals.2 In Maryland, many emergency rooms propriate care stemming from a severe crisis in
treat more than a dozen psychiatric patients a the mental health system. Beginning in the
day and can board up to a dozen for days at 1960s, the deinstitutionalization movement re-
a time.3 sulted in a decrease in the number of inpatient
Because emergency rooms are poorly equip- and residential psychiatric beds in state and
ped to deal with mental health needs, boarded county mental hospitals. The number of beds
patients do not receive high-quality care there. nationwide dropped from approximately
Their presence affects the care received by other 400,000 in 1970 to 50,000 in 2006.2
patients because boarded patients reduce ER The Community Mental Health Centers Act of
capacity and increase pressure on staff. In addi- 1963 was intended to create a mental health
tion, boarding has a negative financial impact on center in every community to serve those who
hospitals because reimbursement rates do not had been moved out of institutions. But this
account for boarding. vision was never adequately funded or fully
This paper presents a seven-point action plan realized.4
to reduce the boarding of, and ER use by, psy- This initial failure to create a robust commu-
chiatric patients. The plan aims to develop nity mental health system has been compounded
Part of the work for this paper was the views of the authors and not those
completed under U.S. Department of of the U.S. Department of Health and
Health and Human Services Contract no. Human Services.
HHS-100-03-0027. This work reflects
S e p t em b e r 2 0 1 0 29 :9 H ea lt h A f fai r s 1641
Downloaded from content.healthaffairs.org by Health Affairs on April 11, 2015
at NYU MED CTR LIB PERIODICALS DEPT
Emergency Department Use
NOTES
1 American College of Emergency 8 Appelbaum P. Starving in the midst 15 Katz A. Patients wait for hours in
Physicians. ACEP psychiatric and of plenty: the mental health care hallways; strain felt throughout
substance abuse survey 2008 [In- crisis in America. Psychiatr Serv. state. New Haven Register. 2006
ternet]. Irving (TX): ACEP; 2008 2002;53:1248 (source of quote). Apr 16.
[cited 2009 Mar 22]. Available from: 9 Bender D, Pande N, Ludwig M. A 16 National Council for Community
http://www.acep.org/uploaded literature review: psychiatric board- Behavioral Healthcare. Access and
Files/ACEP/Advocacy/federal_ ing. Washington (DC): U.S. Depart- retention project: first year summary
issues/PsychiatricBoarding ment of Health and Human Services, report [Internet]. Washington (DC):
Summary.pdf Office of the Assistant Secretary for The Council; 2008 [cited 2009
2 Tuttle GA. Report of the Council on Planning and Evaluation; 2008. Aug 17]. Available from: http://www
Medical Service, American Medical 10 Bender D, Pande N, Ludwig M. .thenationalcouncil.org/galleries/
Association: access to psychiatric Psychiatric boarding interview sum- business-practice%20files/Access%
beds and impact on emergency mary. Washington (DC): U.S. De- 20&%20Retention%20Summary%
medicine [Internet]. Chicago (IL): partment of Health and Human 20Report.pdf
AMA; 2008 [cited 2009 Mar 22]. Services, Office of the Assistant 17 Hnatow D. Providing care for the
Available from: http://www Secretary for Planning and Evalu- acute mentally ill: a community re-
.ama-assn.org/ama1/pub/upload/ ation; 2009. sponse. Urgent Matters Patient Flow
mm/372/a-08cms2.pdf 11 Stefan S. Emergency department Enewsletter [serial on the Internet].
3 Maryland Patient Safety Center. assessment of psychiatric patients: 2005;2(6) [cited 2010 Aug 4]. Avail-
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Elkridge (MD): The Center; 2006 Jul Internet; login required]. 2006 Aug 1 318777
[cited 2009 Mar 22]. Available from: [cited 2010 Jul 21]. Available from: 18 Maples M. Texas mental health and
http://www.marylandpatientsafety http://cme.medscape.com/ substance abuse crisis services
.org/html/collaboratives/ed/ viewarticle/541478 redesign. Paper presented at:
documents/StrategiesForHandling 12 Institute for Behavioral Healthcare National Olmstead Conference.
PsychPatientPopulation.pdf Improvement. Summary of the pio- Washington, DC; 2008 Sep 29–Oct 1.
4 Grob G, Goldman H. The dilemma of neering collaborative on improving 19 Mental Health and Mental Retarda-
federal mental health policy: radical care for behavioral health clients in tion Authority of Harris County.
reform or incremental change? New emergency departments [Internet]. Local plan review FY2006–2007:
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Press; 2007. [cited 2009 Mar 22]. Available from: overview [Internet]. Houston (TX):
5 The Interim Final Rule implement- http://www.ibhci.org/summary- The Authority; [cited 2010 Aug 6].
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Addiction Equity Act of 2008 elimi- 13 International Society of Psychiatric– .mhmraharris.org/LocalPlan/
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