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Psychiatric Boarding
One State’s Story about a National Problem
Laura Collins, LICSW Psychiatry Administrator
Harborview Medical Center, Seattle WA
Topics to Highlight
• Psychiatric Boarding: The National
Problem
• Psychiatric Boarding in Washington
State – Single Bed Certification Ruling
• Washington’s response
• King County’s Response
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• The number of psychiatric patients treated in U.S. EDs has been
steadily rising
• In 2000 5.4% of adult ED visits were
mental health related. By 2007 it had
increased to 12.5 percent Owens, Mutter, Stocks: Agency for Healthcare Research &
Quality 2010
• In a 2008 survey, more than 90 percent of
• ED directors reported boarding psychiatric
• patients every week with more than
• 55 percent stating that patients board daily
• or on multiple days during the week Urgent Matters Policy Brief June 2014
A national Public health Problem:
Psychiatric Boarding
The National Problem
Approximately 41 percent of psychiatric visits lead to hospital admission—over 2.5 times the rate of ED visits for other conditions. Owens, Mutter, Stocks: Agency for Healthcare Research and Quality 2010
Between 2001 and 2006, the average duration of ED visits for psychiatric complaints was 42% longer than for non-psychiatric complaints. Slade, Dixon, Semmel: Psychiatric Services 2010
Nationally: The number of inpatient psychiatric beds fell from 524,878 in 1970 to 211,199 in 2002 Center for MH Services, US, 2004. Substance Abuse & MH Admin, US DHHS, 2006
Between 1990 and 2000, inpatient psychiatric beds per capita declined 27 percent. New Freedom Commission on MH Subcommittee on Acute Care: US DHHS, 2004
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Psych Boarding: The National Problem
Psychiatric Boarding Definition: “The practice of holding patients in the emergency department or a temporary location after the decision to admit or transfer has been made.” Standards Revisions to Address Patient Flow Through the Emergency Department, Standard LD.04.03.11, The Joint Commission
Prolonged boarding in the ED for psychiatric patients is associated with lower quality care for psychiatric patients and further contributes to overall ED crowding. Urgent Matters Policy Brief 2014
Psych Boarding: The National Problem
Six in ten ED directors report that psychiatric services are not provided during the boarding period. Alakeson, Pande, Ludwig, Health Aff 2010 Bender, Pande, Ludwig. Lit Review: Psych Boarding. US DHHS 2008
The ED environment can increase psychological stress on patients who are already often in psychotic or depressed states, further exacerbating their condition. American College of Emergency Physicians. ACEP Psychiatric & SA Survey, 2008
Psychiatric patients who are boarded will typically be placed in any available ED bed; others may board in hallways, in separate areas for psychiatric patients, or in locked units for patients who are potentially violent. Urgent Matters Policy Brief June 2014
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Washington State: Quick Overview of our
Involuntary Treatment System
• The WA State civil commitment system allows us to evaluate whether or not a person can care for themselves and safely live in the community, and if not, get them the inpatient or outpatient treatment that will allow them to do so.
• The preference throughout the system is for persons to receive treatment in the community and in the least-restrictive manner possible.
Washington State Involuntary Treatment:
Who May be Civilly Committed?
• The decision is based on whether an individual has a mental disorder and whether, as a result of the mental disorder,
– the individual is ‘gravely disabled’ or
– presents a ‘likelihood of serious harm’ to themselves or to others, and is in need of involuntary treatment.
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Washington State: Who Makes
Detention Decisions?
• In many states physicians have the ability to carry out
the initial detention of an individual.
• In Washington, physicians and other providers can only
refer a patient for evaluation for detention.
• The final decision of whether to detain an individual
belongs to the Designated Mental Health Professional
(DMHP).
Washington State Picture
Source: Washington State Institute Public Policy: Inpatient Psychiatric Capacity in WA State Assessing Future Needs and Impacts (part one)
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Psychiatric Beds in WA State
Psychiatric Beds per 100,000 Population – (2009)
Rank Facility Psychiatric Beds
Psychiatric Hospital
Total Pop Bed Per 100,000 Pop
47 Washington 2013
707 726
22 6,664,195 6,971,406
10.52 10.41
2 Massachusetts 2323 44 6,593,587 35.23
AHA annual survey database for fiscal year 2009. Copyright: Health Forum, LLC, an affiliate of the American Hospital Association, 2010. Annual population estimates from US Census, Washington State Hospital Association
Fairfax Hospital 45
Harborview Medical Center
(UW Medicine)
61
Lourdes Counseling Center3 20
PeaceHealth St. John Medical
Center
22
PeaceHealth St. Joseph
Medical Center
20
Providence Sacred Heart
Medical Center/Children's
Hospital
72
Seattle Children's 20
Skagit Valley Hospital 15
Swedish Edmonds 18
Yakima Valley Memorial Hospital
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Population has increased by over 300K since 2009
Washington State Inpatient Psychiatry Capacity
0
100
200
300
400
500
600
700
800
900
1,000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Freestanding E&T Beds
Beds Not Certified for Involuntary Patients
Beds Certified for Involuntary Patients
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Psychiatric Boarding of Mentally Ill Needs to End
The epidemic of boarding of people with severe mental illnesses in hospital emergency rooms needs to end, writes guest columnist Eleanor Owens Special to The Times
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Single Bed Certification and In re DW
– By administrative rule (WAC), a facility
not certified as an Evaluation
&Treatment facility (E&T) may receive
authorization to care for detained
patients in certain situations:
• To provide medical care not
available at the E&T/State Hospital,
and for Continuity of Care reasons
• This is called a “single bed
certification”
• On August 7, the State Supreme Court
issued a decision in the case of D.W. et
al vs DSHS and Pierce County
Supreme Court Strikes Down ‘Psychiatric Boarding’ of
Mentally Ill Sean Robinson Tacoma News Tribune August 7, 2014
• The Court held that issuance of an
SBC is not statutorily authorized when
issued solely to lack of room at
certified facilities
– The court noted in a footnote that allowing
SBC’s on the basis of overcrowding may
violate both the ITA law and the
Constitution
• The Court’s ruling put at risk the
ability of the involuntary treatment
system to safely hold people with
serious mental illness who have been
found to be a danger to themselves or
others.
•
“While we respect the state court’s decision, federal law (Emergency Medicine Treatment and Labor Act) still prevents hospital emergency departments from discharging unstable patients — for example suicidal or homicidal patients — back into environments where they could cause harm to themselves or to others.”
Dr. Alex Rosenau, President of the American College of Emergency Physicians
Given these risks two critical steps
were taken:
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• Gov. Jay Inslee approved $30 million to fund treatment
for psychiatric patients being warehoused in hospital
emergency rooms or other non-mental-health facilities
across the state while they wait for long-term beds to
open up. – By Andy Mannix Seattle Times staff reporter, August 22, 2014
– A motion was filed to stay the Supreme Court mandate
for 120 days to allow time for an orderly and effective
response.
• The stay was granted until December 26, 2014
Gov. Inslee Approves $30M to Ease
Psychiatric Boarding
DSHS’ Initial Plan – Two Phase
Approach – Aug 7-Oct 31 2014 • Identify and support additional bed expansion in larger
E&T’s (IMD’s)
– Federal Medicaid funds can now pay for short term stays when
those services are provided in lieu of more costly hospital
services
• Start up funds for E&T expansion incl. beds on the State
Hospital campus’
• Residential Treatment Facilities with capacity now
authorized to accept detained patients
• Funding for Enhanced Care facility beds
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Phase 1 - Continued
• Emergency Rule expanding SBC criteria:
Facilities that can provide “timely and
appropriate” mental health treatment can be a
site of an SBC.
– This revision to the WAC does not create additional
beds.
• They allow facilities that already have, or are willing to
develop, capacity to provide appropriate mental health
treatment
• and may thereby reduce the need to fund new beds in the
mental health system
Phase 2 – November 1, 2014 – June 30,
2015
• Multiple options, including working with
Regional Support Networks to add
community-based evaluation and treatment
capacity in their service areas
• Identifying means to maximize the use of
Medicaid funding to support evaluation and
treatment services.
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King County Executive Boarding Task Force
• Charter: Prevention, Support Bed Expansion,
Less Restrictive Options and Efficient
Placement of Patients
– Patient Placement Guidelines
• Triaging patients to the right level of care
– Patient Placement Coordinator (PPC)
• supports 24/7 placement
– WATrac:
• utilizing disaster preparedness site
– Leader Expeditors
