No vacancies: How a shortage of mental health beds is keeping kids trapped in emergency rooms (2023)

One evening in late March, a mother calls 911 north of Boston. Her daughter, she says, is threatening to kill herself. Paramedics arrive, help calm the 13-year-old and take her to an emergency room.

Like a growing number of children during the pandemic, Melinda has not been stable for several months. We will only use first names for this teenager and her mother, Pam, to avoid this story haunting the family for years to come. Right now in Massachusetts - andmany parts of the USandthe world- Demand for mental health care is overwhelming supply, creating bottlenecks like the one Melinda will be entering.

Emergency rooms aren't usually places where you check in for the night. If you break your arm, it gets stuck and you leave. When you have a heart attack, you don't have to wait long for a hospital bed. But if your brain isn't feeling well and you end up in an emergency room, there's a good chance the crisis will get stuck there.

Emergency room boarding has increased 200% to 400% in Massachusetts during the pandemic. The Baker administration says the rate of increase has varied each month since last June, but each month's numbers are significantly higher than the same month last year.

"We've been doing this for a long time and it's really unlike anything we've ever seen before," said Lisa Lambert, executive director of the Parent/Professional Advocacy League. "And it shows no signs of slowing down."

Tag 12

I meet Melinda during a phone call on her 12th day in the ER. The state says the average time children wait for psychiatric care in hospitals is six days, but many parents report spending weeks with their children in hospital corridors or overflow rooms in various emergencies because psychiatric wards are full.

This is reported by the state's Health Policy Commission (HPC).39% of childrenwho came to an emergency room with a mental health problem between March and September 2020 ended up in boarding school.

Melinda's first 10 days are spent in a hospital auditorium with about 11 other children on stretchers separated by curtains because the emergency room is full. This is becoming increasingly common throughout Massachusetts. Ainvestigation of emergency roomsEarlier this year, on average, a quarter of all beds were occupied by psychiatric patients of all ages waiting for a psychiatric bed.

At one point, Melinda attempts to escape, is tied up, injected with drugs to calm her down, and taken to a small, windowless room where anything brought in is checked and rejected if it can be used to harm herself. Melinda is disturbed by cameras in her room and security guards in the hallways, partly there for her safety.

"It's a bit like prison," she says. "It feels like I'm desperately looking for help."

Desperate is a word both Melinda and Pam often use to describe the long wait for mental health care in a place that feels alien.

"We occasionally hear screams, screams, monitors beeping," says Pam. "Even as a parent, it's uncomfortable. It's unsettling. It's very scary."

But this experience is not new. Pam says Melinda went into a downward spiral after a fight with a close family member last summer. She has therapists but some of them have changed during the pandemic, the visits have been virtual and she has not made good connections between crises. This is Melinda's fourth trip to a hospital emergency room since late November.

"It's the same routine every time," says Pam, beginning with Melinda being rushed to an emergency room. Then, after a few days there, "she goes to a facility, stays there for seven to 10 days, and comes home."

“We have heard that there are waiting times of up to five weeks or longer for outpatient therapy. If your child says they don't want to live or never want to get out of bed again, you don't want to wait five weeks."

Lisa Lambert, mental health advocate

Pam says each facility suggests a different diagnosis and adjusts Melinda's medication.

"We've never really gotten a good, true diagnosis as to what's going on with her," says Pam. “She's out of control; She feels out of control in her own skin.”

Melinda has been on a waiting list for a neuropsychiatric evaluation since last December. It might help clarify what she needs, although some psychiatrists say observing a patient's behavior is often a better way to make a diagnosis. After all, she has an appointment for the exam later this month. Lambert, the mental health advocate, says there are delays in any type of care.

"We've heard that waiting times of up to five weeks or more are required for outpatient therapies," she says. "If your child says they don't want to live or never want to get out of bed again, you don't want to wait five weeks."

Tag 13

As the wait drags on, Melinda jumps from manic highs to deep emotional lows. The Emergency Department is a reception area for patients who require psychiatric care. It is not designed to offer any treatment or therapy. A psychiatrist comes by once a day to check on her. Pam says it's a 10-15 minute visit.

Today Melinda is excited.

"I just want to get out of here," Melinda says in one of several audio journals she records and sends to WBUR. "I feel kind of helpless. I miss my pets and my bed and real food.”

Pam is concerned to learn that Melinda had a panic attack the night before and needed to be sedated.

"The longer she's here, the more she'll refuse," says Pam. "She's self-injured three times since she's been here."

Emergency rooms can ask the state to expedite a case after a child who needs a psychiatric bed has spent more than two and a half days or 60 hours in boarding. There is now a serious bed shortage due to the need to accommodate more children while COVID precautions have turned double rooms into single rooms or psychiatric units into COVID units. The HPC says Massachusetts270 psychiatric beds lostduring the pandemic due to COVID restrictions and closed units.

Nevertheless, cases like Melinda's should become the top priority.

The longer she's here, the more she'll fall off. Since she has been here, she has injured herself three times.

Pam, Melindas Mutter

The hospital and its parent network, Beth Israel Lahey Health (BILH), declined requests to speak about Melinda's care. But dr Nalan Ward, the behavioral health services network's chief medical officer, says all 11 BILH emergency room directors gather for a daily call to discuss difficult patient placement and other boarding issues.

On any given day, 50-70 patients can board throughout the BIHL. You may have medical or insurance issues that make placement difficult. Many insurers say they must approve a patient transfer before agreeing to pay for the placement, which can cause delays.

"It has to be done on a case-by-case basis," says Ward. "It's really convenient, but we've had very good success with some of the very difficult patients to place."

For Melinda, the problem could be her behavior.

Tag 14

Pam is told that her daughter may be harder to categorize than other misbehaving children. Hospitals say they are looking for patients who are a good fit for their programs and other children to be treated there. Melinda's medical record includes the escape attempt as well as some fights with other patients and staff while she was housed in the lecture room.

Today Pam learns that two girls who came to Melinda and might have behaved better were transferred to the psychiatric ward before their daughter. From Pam's point of view, this is another way Melinda is being punished for her mental health.

"She has behaviors because she has a mental illness that they're supposed to help her with," says Pam, "but they say no to her because she has behaviors."

And Pam says keeping Melinda isolated in the ER only makes things worse.

"Sometimes she's unrecognizable to me," says Pam. "Silence to staff which creates drama for some other patients. She's just so sure she'll never get better."

Melinda describes how she feels increasingly isolated. She checks Instagram, Snapchat, and TikTok every hour of the day when she can use her phone. But she lost touch with friends and most family members in the ER. She stopped doing schoolwork weeks ago. The activity of a24/7 ER reaches Melinda.

"I don't sleep well," she says. "It's tough here. I keep waking up in the middle of the night.”

Tag 15

Boarding is also difficult for parents. Pam, who is separated from Melinda's father, has two jobs. But she comes by every day and brings Melinda a change of clothes, a new book, a fidget toy to help her stay calm, or something special to eat.

No vacancies: How a shortage of mental health beds is keeping kids trapped in emergency rooms (1)

"Some days I'll sit and cry before I get out of the car just to get it out of my system so I don't cry in front of her," says Pam. "Some days I'm just exhausted. Some days I look forward to visiting them. It's different every day.”

When Pam walks in, she says, "I'm kind of taking a deep breath and mentally gathering my strength."

At the nurses' station, she asks for an update. She has said that none of the hospitals that seem to be good for Melinda have opened in two weeks.

Massachusetts has 357 licensed pediatric psychiatric beds. The state says 92 more are coming online. BILH says it will add four beds at Anna Jacques Hospital in Newburyport this fall, bringing that unit to 16. Cambridge Health Alliance says it will more than double its capacity from 27 to 69 beds for children by the end of the year.

Some hospitals say they can't afford to treat patients with acute mental health problems because health insurance doesn't cover them. The Baker administration says it will spend $40 million on incentives this year. That includes $80,000 to $150,000 for new beds opening in the next few months and a more than 30% increase in the rate for children on MassHealth who need inpatient mental health care.

The Baker administration acknowledges that despite these changes, some patients are still not receiving timely care.

Emergency rooms are still flooded with boarders.

Tag 16

"I never thought we'd stay here this long," says Pam.

When she checks into the ER, the news isn't encouraging. "I just don't feel like anybody's going to have a job any time soon," she says.

ER doctors and mental health advocates are urging the state to get more public information on how many children and adults are boarding, where, and for how long. Ainvoicesponsored by MP Marjorie Decker, a Cambridge Democrat, would require more public reporting on children. The latest information on the state boarding schooldashboardis from January.

The Baker administration emphasizes that work is being done to keep children out of emergency rooms and reduce the need for inpatient care by providing more preventative and community-based services. The statesRoadmap to behavioral health reformaims to provide easier access to mental health care, including new community behavioral health centers, emergency care for the mentally ill and out-of-hospital crisis centers to house patients awaiting a hospital bed.

dr Jesse Rideout, former president of the Massachusetts College of Emergency Physicians, says these are solid plans that could keep some people away from emergency rooms. But he worries that patients with serious mental illnesses won't find these programs and will end up in an emergency room anyway.

"These patients will need inpatient psychiatric beds," says Rideout. "Our behavioral health boarding will not improve unless more beds are available."

"Our behavioral health boarding will not improve unless more beds are available."

Dr. Jesse Rideout

Both parents and clinicians are also wondering if Massachusetts can find the counselors and psychiatrists to fill new community clinics, therapy programs and more psychiatric hospital beds. dr Ward, BILH's behavioral health officer, says insurance payments are too low to attract and retain needed staff.

"We're talking about increasing the bed capacity and stuff like that, and the next thing we're talking about is 'how are we going to staff them,'" says Ward. "There's definitely a staffing issue."

On the 16th day, Melinda's voice is listless on the recordings.

"Life is really hard because things that should be easy for everyone are just hard for me," she says. “And when I ask for help, sometimes I imagine going to the hospital. other times,I wish someone would just understand me.”

Late in the evening there is news that Melinda's long wait for foster care will be over.

Limbo ends

Pam's voice trembles as she records the news.

"We finally got the call that she had an internship," says Pam. "Hopefully the help she gets this time stays in place and we're not back in the ER in a couple of weeks doing this again."

On day 17, Melinda is taken to CHA Cambridge Hospital by ambulance. She's lucky to get a seat. There are 50-60 cases of children who have spent more than three days in emergency rooms and are on the waiting list for that one hospital the week of April when Melinda arrives.

"That's dramatically higher," says Dr. Linsey Koruthu, medical director of inpatient child psychiatry services at the Cambridge Health Alliance, said "about double what it was in 2019."

"...when I ask for help, sometimes I imagine going to the hospital. Sometimes I wish someone would just understand me."

Melinda

At Cambridge Hospital, staff adjust Melinda's medication. Her days include meetings with a psychiatrist and social worker, group therapy, time for activities like schoolwork, yoga, and pet therapy. Hospital workers meet up with Melinda and her family. She stays two weeks, a little longer than average.

Cambridge Hospital doctors are recommending that Melinda move from inpatient care to a community-based inpatient treatment program - a kind of bridge between being in hospital and returning home. But she doesn't go. These programs are packed and have week-long delays.

Now Melinda is back home. She has three therapists to help her transition and apply what she has learned. And as COVID restrictions ease, some of these gatherings are taking place in person with Melinda and her family.

dr Koruthu, one of Melinda's doctors at Cambridge Hospital, believes the in-person sessions will make a difference. According to Koruthu, therapists in virtual meetings aren't always able to identify behaviors or family dynamics that may have contributed to some of Melinda's crises, or form strong connections, especially with new clients.

"A lot of mental health work is based on a therapeutic alliance," says Koruthu, adding that virtual meetings haven't worked for many children. "I think that's contributed to the influx of patients into our ER over the past year."

Resources:If you are experiencing a mental health crisis, you can reach the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) (Deaf and hard of hearing: dial 711 then 1-800-273-8255) and Samaritans Statewide Hotline (call or text) at 1-877-870-HOPE (4673). Call2Talk can be accessed by calling Massachusetts 211 or 508-532-2255 (or texting c2t to 741741).

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