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Washington chips away at psychiatric boarding

September 24, 2014
by Julie Miller
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In Washington state, patients who have been involuntarily committed to psychiatric treatment wait excessive amounts of time to move from emergency rooms to specialized care. They often stew for days without treatment and become increasingly distressed.

 In fact, such “psychiatric boarding” has spiraled so far out of control in recent years that the state Supreme Court banned the practice, ruling it unconstitutional and a violation of civil rights.

The limitation will go into effect on December 26, which is a few months later than originally mandated because of the backlash from providers. Local leaders stress that there are too few psychiatric beds in Washington as it is and too few community resources to alleviate the bottlenecks. The boarding crisis has become the behavioral healthcare community’s collective challenge.

“You don’t just put up a hospital unit overnight,” says Trish Blanchard, chief clinical officer, Sound Mental Health in Seattle, a not-for-profit, state-certified mental health provider.

Blanchard says the organization recently began a physician support program to help coordinate discharge plans for patients leaving psychiatric hospitals so they will avoid additional admissions. The aim is to take pressure off the inpatient facilities so more beds can be available when needed.

Bed supply

Like much of the country, the root of the issue in Washington is the remarkably low and diminishing supply of psychiatric beds.  Over the years, those beds were whittled away in favor of community-based care.

“On the community side, we appreciate that as a philosophy and movement over time, but the key is, if you close hospital beds, you need to put funding into creating housing, support services, etc., in the community,” says David Stone, CEO of Sound Mental Health. “While the state has done that to some extent, the problem with boarding is that we have not put enough in these community services.”

He says there are a noticeable differences in how states fund and manage community mental health systems, with some allocating more funding for hospital beds.

 “Washington state has among the fewest state hospital beds in the country and is kind of proud of that fact,” he says. “But there are results that come out of that, which aren’t always helpful to patients.”

The boarding issue has become exacerbated for another reason. In King County—the largest county in the state—70% of the patients that arrive in the ER and are involuntarily committed have never had any interaction with the community health system, he says.

“If that hospital doesn’t have psychiatric beds or if the psychiatric beds are full, these days, there are not many good alternatives for what to do with that person,” Stone says. “That’s why the boarding issue has become so difficult in the last few years. Between the reduction in state hospital beds and the influx of these unknown psychiatric patients, it’s gotten kind of out of hand.”

Patient experiences

With fewer available beds, patients have languished for days—or in some cases over a week—in ill-equipped emergency rooms or in randomly “certified” individual beds in the hospital facility. Sometimes they are restrained and medicated to prevent harm to themselves or others as they wait for qualified care. Nurses and emergency room physicians are often at a loss for how to manage violent, disruptive and uncooperative patients to ensure safety.

In the past year or so, involuntary commitments have increased in Washington, and with the treatment facilities at capacity, boarding has become routine.

An October 2013 exposé  by the Seattle Times reported bed capacity in Washington had fallen from 1,759 beds in 2007 to 1,507 in 2012, and in a single year, there were 4,566 cases of psychiatric boarding. Meanwhile, about 70% of its counties don’t have any involuntary-treatment beds at all.

The answer, of course, isn’t just moving more people into psychiatric beds, says Blanchard.

“Another part of it is find ways to improve care coordination within the emergency room and to support care transition and stabilization in the community,” she says.

Although Washington might be among the worst scenarios, boarding is a national problem. According to a poll from the American College of Emergency Physicians, 84 percent of emergency physicians nationwide report that psychiatric patients are being boarded in their emergency departments, with 91 percent saying the detainment has led to violent patient behavior, distracted staff and downstream bed shortages. The organization criticized the Washington court, saying it did nothing to provide guidance or identify resources to solve the boarding problem.

Future solutions

The state is scrambling for solutions. In mid-September, Washington received federal approval of a Medicaid waiver that will allow the program to sidestep the IMD exclusion rule and permit reimbursement for 30-day psychiatric hospital stays for facilities with more than 16 beds—facilities that until now did not qualify for Medicaid payment. The hope is that more facilities will be able to admit involuntary patients and thus reduce the backlog.

The waiver only allows a temporary experiment, which begins Oct. 1, 2014, and ends Sept. 30, 2016. At that point, the policy may or may not be extended.

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Mr. Stone is absolutely correct: the state of Washington is politically proud and "correct" according to one political philosophy of the low number of state paid psychiatric beds but politically silent on the state's elected officials unwillingness to adequately fund the needed community based services to balance the low number of state psychiatric beds despite several studies on community needs, including housing, and number of community based psychiatric beds, over at least the last ten years. The "waiver" the state points to as part of the "solution" is paradoxical at best: the waiver saves money in the state psychiatric hospital (state budget) but does not specifically (by Law) re-direct the money to community based services nor does the current Administration have a comprehensive plan based on the epidemiology of severe and persistent mental illness diagnoses, documented needs by services categories, and population based plans to address housing needs by geographic distribution of need, type, intensity, cost, and timelines. What the state does have is a 1915 (b) waiver for Medicaid state option mental health services that for years has been paid at the low end of the actuarial data while the state continues the argument/"planning on the need for local government involvement. It appears an independent investigation has been in order for some time.

Thank you Richard. We will be quite anxious to see what happens after December 26. No doubt, with the holidays, it will be a critical time for patient care.

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