Reduce Boarding in the Emergency Department With In-Home Care

Reduce Boarding in the Emergency Department With In-Home Care

An emergency department program collaborates to get mental health patients quickly connected to at-home care.

With the ongoing mental health crisis and a shortage of psychiatric staff across the country, more and more children experiencing a mental health crisis are staying in emergency department facilities until they can be admitted into a psychiatric treatment program or transferred to another facility. While boarding keeps vulnerable patients physically safe from injury, waiting in an ED does not provide the appropriate level of specialized mental health treatment kids need to help them recover.

To reduce the number of patients boarding in the ED, the Massachusetts Department of Mental Health (DMH) launched an ED diversion program in partnership with their contracted community-based partners and Boston Children’s Hospital.

The program is four to eight weeks in the patient’s home with a community-based team. The program starts between 24 or 48 hours after discharging from the hospital.

The program has several benefits for the hospital and their patients:

  • Reduces the length of boarding.
  • Frees up limited hospital capacity.
  • Results in low rates of return.
  • Expedites patient access to community supports.

How it works

Patients in this program receive in-home support from three professionals:

  • Clinician support. Services include safety planning, family support, regulation skills, coordination of care and referral to long‐term support.
  • Therapeutic support specialist. Specialists work with the clinician to support youth around community integration/connections, managing mental health, and improving communication and social skills.
  • Parent or caregiver support. A peer with lived experience provides support around parenting, community connections and managing mental health needs.

The DMH program also connects patients to long-term support. Of the patients in the program, about half were connected with long-term in-home services, 30% were referred to an outpatient therapist, and about 18% continued with intensive care coordination, which included case management but not intensive therapeutic services.

Who is eligible

The program is for patients ages 3 to 22 and do not require acute inpatient level of care. Because this service is specifically for patients who don't have other means of care, they are not eligible for the program if they are already connected to another service or community agency.

The hospital’s psychiatric clinicians and resource specialists review patients boarding in the ED and on the inpatient medical floors to determine candidates for the program. The specialist and the patient fill out a form for the program lead in the community, who responds with a plan within 48 hours. Depending on the situation, the hospital keeps the patient until they receive the safety plan or discharges them knowing the family is going to receive an answer quickly about eligibility and intake.

The funding for the program came from the Substance Abuse and Mental Health Services Administration (SAMSHA) grant via federal COVID-19 relief dollars. Additional funding also came from the Massachusetts’ state budget. For a program like this to be sustainable, continued funding from multiple sources, including from insurers, is necessary.

An example case

Jamie, a 14-year-old nonbinary white adolescent, presented to the ED for a psych evaluation from school. Jamie made suicidal statements to their guidance counselor and revealed superficial scratch marks on their arm. After an evaluation, Jamie spent five days in the ED boarding for a CBAT (community based acute treatment) bed, and was then transferred to a medical floor to continue boarding.

While boarding, Jamie was seen by psychiatry clinicians daily and continued to endorse passive thoughts of suicide but never a plan or intent. Jamie talked with the psych social worker about wishing that they had someone to talk to in the community, and was able to identify future goals and hopes. Jamie also repeatedly said that boarding was “making my mental health worse.”

The psych social worker met with Jamie and their parent to discuss the ED diversion program as an option to implement immediate community supports and end the extensive boarding process. A referral was made and Jamie was assigned a clinician two days later. Jamie discharged in the morning with a plan to have an intake with their new clinician that afternoon.

Written By:
Miranda Collura, LICSW
Lead Psychiatric Social Worker, Psychiatry Consultation Service, Boston Children’s Hospital
Written By:
Amara Anosike, JD
Director, Behavioral Health Policy and Advocacy, Boston Children’s Hospital

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