Behavioral Health Boarding

Capturing a Crisis: MHA’s Weekly Behavioral Health Boarding Reports

Psychiatric boarding occurs when a patient must wait in an emergency department (ED) or medical-surgical floor until a psychiatric inpatient bed is available. While boarding was a major issue for Massachusetts patients and hospitals before the pandemic, the effects of COVID-19 have worsened the situation and created a behavioral health crisis

For years, the behavioral health system in Massachusetts, and nationally, has struggled with serious challenges relating to patient access, inadequate reimbursement, and workforce shortages. The COVID-19 pandemic has exacerbated these issues by increasing the need for behavioral health services, intensifying the acuity of patients’ behavioral health presentations, and making the challenges facing the behavioral health system – including a paucity of clinical and support staff – more complex. EDs and medical-surgical units were not designed to handle the needs of these behavioral health patients, yet these settings now serve as the last available refuge for patients as they await appropriate placement. 

This report examines both weekly and trending data from Massachusetts acute care hospitals on the number of behavioral health patients who are waiting for a psychiatric evaluation or who have had an evaluation and are awaiting a bed. The information is further broken down by patient age and geographic region within the state.

Addressing the behavioral health boarding challenge will require a coordinated effort to:

1. increase physical capacity;
2. bolster and expand the entire behavioral healthcare workforce, including entry level mental health worker positions, as well as nurses, social workers, psychiatrists, and more; and
3. ensure the financial stability of behavioral health units and facilities.

Through partnership with the Baker administration and the legislature, the inpatient psychiatric system added nearly 300 new inpatient psychiatric beds in 2021, including beds both in psychiatric units at acute care hospitals and in freestanding psychiatric facilities with more to come in 2022. But staffing for existing beds continues to be insufficient, and fully staffing these new beds is already proving to be a considerable barrier to opening new or expanded services. Much more needs to be done to ensure behavioral health patients have access to needed care, in particular by increasing the pipeline of staff and ensuring the sustainability of services. 
Identified solutions to address the remaining behavioral health challenges include:
Ensuring hospitals are reimbursed for the care they provide to patients while they board so facilities have the staffing and programmatic resources needed to care for those patients.
Continued development of the behavioral health workforce pipeline across all positions, including the use of American Rescue Plan Act funds in the newly established Behavioral Health Trust Fund for this purpose.
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 requiring coverage of all medically necessary mental health services.
Reducing continuum of care challenges that create bottlenecks in the behavioral health system and limit patient access to needed services.
Addressing administrative barriers – such as Determination of Need requirements – for providers that wish to expand behavioral health services.
MHA will continue to work collaboratively with its members, our partners in the behavioral health space, and the state to improve behavioral healthcare in these areas.