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Mental Health “Boarding” and a Federal Judge’s Surprise Ruling

Mental Health “Boarding” or “psychiatric boarding” occurs when children are kept in a hospital emergency department (“ED”) because the intensive mental health treatment services they require are not available.

Boarding, hoteling, and dwelling are related but differ. Hoteling occurs when a state has more children in foster care than can be cared for in the state’s supply of foster homes. The shortage of foster homes forces the state to place children in hotels. Dwelling occurs when a child completes treatment in a psychiatric hospital but must remain in the hospital (or “dwell”) while awaiting their next placement into the proper level of care. Some states use the acronym CWOP to describe “children without placement.”

All three – boarding, hoteling, and dwelling – are evidence of broken child well-being infrastructure.

I have often said that every child in foster care needs a judge on their side. A recent news story from New Hampshire explains the power of a judge to resolve problems for children.

On May 26, 2023, New Hampshire had 15 children waiting in hospital emergency rooms for mental health placement. With only 15 children being boarded in New Hampshire, a judge moved to end the practice. On May 18, a federal judge ruled that New Hampshire has one year to stop holding psychiatric patients in emergency rooms after determining earlier that the practice is an “illegal seizure of hospital property.”

As a result, New Hampshire’s Department of Health and Human Services announced “mission zero,” a plan to eliminate hospital emergency room boarding of psychiatric patients by 2025. New Hampshire bought a former private psychiatric hospital and is renovating it for children.

The News from New Hampshire: Ribbon Cutting at State’s East Acres at Hampstead Psychiatric Facility –

Additional Information on Mental Health Boarding

Boarding of Mentally Ill Patients in Emergency Departments: American Psychiatric Association Resource Document National Library of Medicine. Pub Med Central.

This lack of treatment provided to patients psychiatrically boarding is a major concern. As noted previously, 62% of ED medical directors responding to the ACEP survey reported that there are no psychiatric services involved with the patient’s care while he or she is being boarded prior to admission or transfer. Boarded patients tend to have higher rates of psychotic and personality disorders, and are more likely to require physical restraints/seclusions. Due to its loud and chaotic nature, the ED environment can exacerbate underlying conditions.

A Literature Review: Psychiatric Boarding. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation.

It is important to understand psychiatric boarding within the larger context of the mental health system. First, the mental health system suffers from significant capacity constraints for psychiatric inpatient services. Beginning in the 1960s, “deinstitutionalization,” defined as placing psychiatric patients in outpatient and community-based treatment facilities, has resulted in significant psychiatric bed shortages. Second, demand for psychiatric services is increasing.

The Impact of Boarding Psychiatric Patients on the Emergency Department: Scope, Impact and Proposed Solutions: An Information Paper. American College of Emergency Physicians.

… being a pediatric patient with a decompensated psychiatric problem (has) been shown to be (a) risk factor for prolonged ED length of stay. Within the pediatric population independent risk factors include suicidal ideation, a diagnosis of autism, developmental delay, medical illness requiring close monitoring, and presenting on nights, weekends, or during months without school vacations.

‘The boarding has gotten much, much worse’ Mental Health taskforce issues new report on patients stuck in ERs by Kent Erdahl, (2023/06/01).

Patients with a psychiatric diagnosis are nearly five times more likely to be stuck waiting for treatment in emergency departments, and resources keep disappearing.

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