The ED Boarding Crisis

Boarding: An Ongoing Crisis

As the State Senate begins its budget deliberations this week, MHA is advocating for its 13 priority amendments to the budget, two of which are dedicated to helping alleviate the behavioral health boarding crisis.
Each Monday, emergency departments (ED) report figures that show approximately 300 patients with behavioral health issues “boarding” in emergency departments as they wait for an inpatient psychiatric bed to open. That 300 number does not include reporting from the 22 hospitals in what the state designates as Region 4 (Boston and nearby suburbs of the city), meaning that the weekly boarding number could be closer to 500. In turn, many individuals with behavioral health issues that are in those inpatient beds are stuck in them as they await discharge to a continuing care bed, which have decreased in number due to appropriate COVID-19 related infection control measures and an increase in patients from forensic settings. Hospitals and the state have been expanding the number of behavioral health beds in recent years, but the staff for those beds – from psychiatrists to support staff that don't possess a college degree – is in very short supply.
"The historic behavioral health boarding problem has been made even worse by the pandemic, as behavioral health diagnoses and acuity increases, in-person services have been more difficult to access, and pressures on emergency departments have risen,” said Leigh Simons Youmans, MHA’s senior director of healthcare policy. “Behavioral health has become the epidemic within the pandemic.”
The MassHealth program has taken significant steps to address the issue. MassHealth rate increases and dedicated capital funds for bed expansions have helped. MHA’s budget amendments, one of which passed the House last month, seek to further improve the situation.
Amendment 129 filed by Sen. Brendan Crighton (D-Lynn) would direct the Department of Mental Health (DMH) to collect and publicly report on the availability of adult and pediatric beds at inpatient continuing care facilities operated by or contracted by DMH. It would increase DMH funding for community-based mental health services by $5 million and would increase funding to stand up additional continuing care beds by $6.6 million. The amendment directs DMH and the Trial Courts to assess alternative methods for treating forensic patients that do not rely upon and require placement in continuing care beds, and would also study the feasibility of establishing a forensic treatment setting that does not rely on those beds. The amendment would also direct EOHHS, MassHealth, and relevant providers to establish and implement an enhanced rate to support the provision of psychiatric services for highly acute psychiatric patients and to assess the need to establish additional intensive units to treat highly acute psychiatric patients across the state.
Amendment 545 filed by Sen. Joan Lovely (D-Salem), would continue the FY21 budget’s creation of a new $5 million line item to address emergency department boarding through staffing investments and rate incentives to fully operationalize inpatient mental health acute care beds, intensive inpatient psychiatric beds, community-based acute treatment, and partial-hospitalization programs through a grant program administered by EOHHS. As a result of these and other FY21 funds, more than 250 much-needed inpatient psychiatric beds are anticipated to come online this calendar year. This new line item would allow funds to be expended on additional innovative approaches to fully operationalize new and existing services in the behavioral health continuum of care. Funds would be directed toward staffing investments and rates to ensure both workforce and financial sustainability of these new and existing services.
The FY2023 MassHealth RFA – the main contract between the state and hospitals treating Medicaid patients – is being drafted and it, along with EOHHS’ recently released Roadmap for Behavioral Health Reform, aim at sweeping reform of the behavioral health system. But in the time between that RFA becoming effective and full implementation of the Roadmap and now, help is needed to tackle the boarding problem.
“The boarding problem is widespread with no easy answers to resolve it,” Youmans said. “But Amendments 129 and 545 take the key steps of allowing us to gather the necessary data and make the necessary short-term investments that will ease the burden for behavioral health patients and the people who care for them.” Another MHA Amendment, #111 filed by Senator Brendan Crighton (D-Lynn), aims to address boarding by studying the feasibility of using the federal Hospital at Home program for inpatient psychiatric treatment.
Behavioral health is a major point of emphasis for MHA and member hospitals during the 2021-2022 legislative session. Legislation that Rep. Marjorie Decker (D-Cambridge) filed, An Act to strengthen and expand access to behavioral healthcare, is a priority bill for the association and helps address the boarding crisis by establishing a Behavioral Health Investment Trust Fund, creating a Behavioral Health Rate Task Force, and expanding coverage for medically necessary mental health services across all insurers, among other things.

GAO Report Finds Behavioral Health Cases Rising, Access Diminishing

A recent report from the U.S. Government Accountability Office (GAO) found that the prevalence of behavioral health conditions increased during the pandemic, but access to in-person behavioral health services decreased.
Centers for Disease Control and Prevention (CDC) survey data from April 2020 through February 2021 found that the percentage of adults reporting symptoms of anxiety or depression averaged 38%. A similar survey conducted from January to June 2019 found about 11% of U.S. adults experiencing those symptoms. CDC data also showed that emergency room visits for drug overdoses and suicide attempts were 36 and 26% higher, respectively, for the period of mid-March through mid-October 2020 compared to the same period in 2019.
The GAO report found that providers were forced to cancel or reschedule behavioral health appointments during the pandemic, or decrease their hours or programs altogether.
The GAO found that nationally one of the key contributors to the behavioral health access problem was the shortage of workers in the field. “These workforce shortages are expected to continue,” the report noted. “ For example, before the COVID-19 pandemic, the Health Resources and Services Administration (HRSA) reported that, by 2025, shortages of seven selected types of behavioral health providers were expected, with shortages of some provider types expected to exceed 10,000 full-time equivalents. Additionally, as of September 30, 2020, HRSA designated more than 5,700 mental health provider shortage areas, with more than one-third of Americans (119 million people) living in these shortage areas. In these areas, the number of mental health providers available were adequate to meet about 27 percent of the estimated need.”

Nurse Licensure Compact Receives HPC Endorsement

The Health Policy Commission has voted to recommend that Massachusetts join 35 other states in entering the Nurse Licensure Compact (NLC), which allows registered nurses and licensed practical nurses to hold a multi-state license to practice in their home state and all other compact states.
MHA has been a strong supporter of the NLC, the importance of which become even more evident during the pandemic when Massachusetts, like other states, relied on caregivers crossing borders to meet demand. MHA has advocated for the compact through a coalition with leading nursing and healthcare organizations, including the Organization of Nurse Leaders, American Nurses Association-Massachusetts, and the National Council of State Boards of Nursing.
The HPC study, which was mandated by a provision in the FY2021 budget found that Massachusetts will experience slower growth in the RN labor market in coming years, meaning it may need to find nurses from other states to fill vacancies. The NLC would also help Massachusetts “react more dynamically to unforeseen and sudden changes in nursing needs, during pandemics and other emergencies,” the HPC found.
MHA Vice President of Government Advocacy and Public Policy Emily Dulong agreed with that finding, stating, “Through COVID-19 emergency orders, nurses from across state lines came to Massachusetts and delivered high-quality, lifesaving care to patients. By entering the compact, this talented pool of over two million nurses would be accessible to our healthcare system for future crises – and under all circumstances.”
Because many patients travel to Massachusetts to take advantage of the commonwealth’s renowned healthcare system, the NLC allows Massachusetts nurses to maintain care of their patients after they leave the commonwealth and return home. “The COVID-19 pandemic highlighted the importance of and potential for telehealth and demonstrated the need to remove barriers to cross-state practice in order to strengthen the ability of the health care system to adapt care delivery modes and respond to needs more flexibly in a post-COVID-19 world,” the HPC wrote.
“More than 30 states have joined NLC, including New Hampshire and Maine,” MHA’s Dulong said. “As the most innovative healthcare system in the world, now it’s our turn. We look forward to working with our elected officials as they consider taking the important step of making Massachusetts a part of the Nurse Licensure Compact.”

tMed Coalition Urges Passage of Telehealth “ Glidepath” Amendment


The tMed Coalition (Massachusetts Telemedicine Coalition), which MHA convenes with more than 40 healthcare provider, consumer, technology and telecommunications organizations, is urging passage of an amendment to the Senate FY22 budget that would extend the time by which the state’s telehealth law (Chapter 260 of the Acts of 2020) would be implemented from 90 days to 180 days following the end of the state of emergency in Massachusetts. Chapter 260, which was signed into law on January 1, 2021, codified coverage and reimbursement for telehealth. 
During the state of emergency, the Baker Administration has allowed critical coverage and utilization flexibilities for telehealth. Patients in Massachusetts have had access to the full range of in-network medically necessary healthcare via audio and video technologies, all reimbursed on-par with in-person visits. This has both protected and expanded access to healthcare for innumerable patients across the state, and particularly for populations that have been disproportionately affected by COVID-19. On Monday, May 17, Governor Baker announced that June 15 would be the end of the Massachusetts state of emergency, effectively giving policymakers until September 13 to promulgate regulations to implement the telehealth law. The tMed Coalition is concerned that this timeline is insufficient for not only the regulatory process but also for providers and patients to understand a new telehealth framework. The provision of certain services via telehealth is likely to shift. Many patients are currently on treatment plans that have been reliant upon the telehealth framework established by flexibilities offered during the state of emergency. 
The Coalition’s budget Amendment #565 filed by Sen. Adam Gomez (D-Springfield) would offer the state more time to establish a permanent statewide telehealth system while also preserving existing access to telemedicine for patients who remain primarily reliant upon it. The Coalition has sent a letter in support of the amendment to Senate leadership. Senate budget debate begins Tuesday, May 25.

State to Hospitals: Vaccinate Your ED Patients

If a patient comes into an emergency department and they haven’t been vaccinated yet for the COVID-19 virus, then hospitals should impress upon them the importance of the vaccine and offer them the single-dose Janssen/Johnson & Johnson shot, so says the Department of Public Health (DPH) in new guidance to hospitals.
“While many patients presenting for emergency care will have already received partial or full COVID-19 vaccination, it is likely that some will still be eligible for a single dose of Janssen/J&J vaccine,” DPH wrote in its May 20 guidance. “Among these patients are unvaccinated young adults, individuals experiencing homelessness, persons transferred from correctional and other congregate care settings, persons otherwise disconnected from regular medical care, and others who for any reason have not previously received COVID-19 vaccination.
“DPH urges hospital emergency departments to maintain a supply of Janssen/J&J COVID-19 vaccine, for emergency department staff to routinely inquire about the COVID-19 immunization status of presenting patients, and for staff to offer a single-dose vaccination so as not to miss an opportunity for patients to be fully vaccinated.”
While avoiding waste of vaccines is still important, DPH told hospitals that drawing doses from previously unopened vials of the vaccine – even though there may not be enough patients to use the remaining doses in those vials – is acceptable. “While overall hospital/health system dose wastage rates need to be carefully managed, the emergency department should be considered a special setting in this regard with particular capacity to reach unvaccinated individuals,” DPH said.


Susan Sandberg, R.N., the president and CEO of MelroseWakefield Healthcare and Executive Vice President of Wellforce announced she is resigning the post effective in July. Sandberg is moving to Colorado. She has been in her current role since August 2018.
The combined Tufts Health Plan and Harvard Pilgrim Health Care have appointed Cain Hayes as the organization's next CEO, effective July 5. He will replace Tom Croswell, who announced his retirement in January. Hayes joins the organization from Gateway Health, a managed care organization in Pittsburgh, Pennsylvania, where he currently serves as president and CEO.

Ransomware Threats to Hospitals:
Key Facts and Strategies for Protection

Thursday, June 3, from 12 - 1:15 p.m. ET

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John LoDico, Editor