Federal judge rules that boarding of mental health patients in (NH) EDs is an illegal seizure of the hospitals' property that disrupts care of others

[Franzd'Epinay]

I didn't see this posted elsewhere, but I thought this was a very relevant article:

NH illegally ‘commandeers’ hospital resources by boarding psychiatric patients in ERs, federal judge rules

The order does not immediately end the practice, but requires hospitals and the state health department to create a timeline to propose solutions.

www.nhpr.org

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[Dr Mantis Toboggan]

What’s the longest y’all seen someone wait for placement in your ED? We’ve had several over 4 weeks over the last few years.

 

[WilcoWorld]

Wow! What will the consequences of this be?

 

[Brigade4Radiant]

Been boarding an 8 year old foster kid in our ED for 25 days just awful

 

[southerndoc]

We once had a guy for nearly 6 months due to a very unusual circumstance requiring specialized placement.

 

[CoolDoc1729]

What’s the longest y’all seen someone wait for placement in your ED? We’ve had several over 4 weeks over the last few years.

We had a adolescent psych that was at 6 weeks , then she got covid so that tacked on another month 🤦🏻‍♀️

 

[Dred Pirate]

What’s the longest y’all seen someone wait for placement in your ED? We’ve had several over 4 weeks over the last few years.

63 days - stupid long story that everybody (for a reason) wanted to avoid taking this guy

 

[Dred Pirate]

Been boarding an 8 year old foster kid in our ED for 25 days just awful

I might work with you....

 

[CajunMedic]

15 days for a teenage psych.

I can only hope this sets a precedent and spreads like wildfire. I've had up to 5 of them at once, winding each other up and causing additional mayhem...

 

[alphaholic06]

What’s the longest y’all seen someone wait for placement in your ED? We’ve had several over 4 weeks over the last few years.

60+ days for a kid with SI.

 

[alphaholic06]

15 days for a teenage psych.

I can only hope this sets a precedent and spreads like wildfire. I've had up to 5 of them at once, winding each other up and causing additional mayhem...

The last part is a major problem. Usually to everybody getting Vitamin D.

 

[RustedFox]

The last part is a major problem. Usually to everybody getting Vitamin D.

Here's the problem:

We can't keep them in the ER... but where will they go?

Hospital sets up an obs unit for them?

 

[BoardingDoc]

Here's the problem:

We can't keep them in the ER... but where will they go?

Hospital sets up an obs unit for them?

From the article it sounds like the judge is ordering the state to come up with a place for them to go because forcing the hospital to be responsible for boarding them amounts to "an illegal seizure of the hospitals’ property that disrupts care for other patients in need."

If I'm interpreting this correctly, I am 100% for this. It forces the state to provide mental health resources and simultaneously gets these people out of my dept. Everyone wins.

 

[PianoMedic]

If I understand the article’s reporting on the plaintiff argument:

The state of New Hampshire, by not adequately funding mental health resources (in this case staffed psych beds as they have a public psychiatric hospital, while also making it illegal to commit suicide so it’s an unfunded mandate), is denying the hospitals and their patients access to the that specific room the holding patient is occupying. It sounded like the judge was leaving the solution open to be worked on by the hospitals and state. Who knows how/when/if this will be resolved.

Just my interpretation, could be completely wrong, so please correct away if I misinterpreted this.

 

[Janders]

Its a rather brilliant angle of attack on this issue, and was supported by a number of medical organizations. I don't mind seeing psychiatric crisis patients AT ALL (its a core part of our specialty; mental health IS healthcare) but clearly eating 25-65% of our ED beds in a very undersized ED for multiple-day or multiple-week holds causes injury to other people coming in for emergent care. Maybe we take all those record profits from private insurance and see if we can open a few inpatient and crisis stabilization units with them... or at least get the gov't to fund something.

 

[JacobMcCandles]

I love the logic behind this but the actual logistics are impossible. Psychiatric patients being boarded in an ED benefits nobody directly or indirectly involved in the process.

 

[The Knife & Gun Club]

I love the logic here. Basically forces the states hand and says you need to do something about this because you can’t just use EMTALA to strongarm hospitals into holding these people indefinitely because the states can’t come up with the money to fund mental health.

Like providing fire trucks and running water, it’s the governments job to provide a place for these people to go so they don’t jam up the healthcare system.

My system has a separate psych ER so once we medically clear them from the ED they get an ER to ER transfer, and can board in the psych ER until a bed opens. It’s a model Id like to see everywhere - we never board psych for more than 6 hours once a dispo is made. It’s lovely.

 

[The Dayman]

I have a patient currently boarding in our ED psych pod that’s been there >250 days.

 

[Siggy]

I have a patient currently boarding in our ED psych pod that’s been there >250 days.

How is that not a violation of the patient’s 4th amendment (unreasonable seizure)?

Was he homeless prior and perfectly happy with this arrangement?

 

[thegenius]

I have a patient currently boarding in our ED psych pod that’s been there >250 days.

The hospital should just discharge him. What bad thing can happen to this guy. There is not a soul in this universe who would be critical of a hospital after discharging a guy whose been holed up for 250 days.

 

[WorkNoteEmergency]

Interesting how this angle has gained traction while keeping a person handcuffed in a small room for days on end hasn’t.

 

[Sushirolls]

State of WA has been placing fines on their state hospitals there for not getting patients in, who are boarding in the ED. However, the turn over rate for various reasons at those hospitals can't keep up with the influx, in part because of no dispo/discharge plans/places for folks. Funny that one end of the government is putting fines on another.

Options to admit to IM are unlikely, because CMS - government - has rules about where mental health gets admitted and some one some where is keeping tabs that psych isn't getting admitted to IM / gen med floors. If you got a Psych ED, that could be work around?

Insurance companies have long dumped on psychiatry, especially inpatient. I'm psych in PP and my time in the various other practice venues, insurance companies hate us. They will carve out their entire mental health benefits and assign it to another insurance company. For instance, UHC, might assign it to Optum Behavioral Health. Or Aetna might assign it to Compsych. I've seen the oddest combination carve outs. Typically, psych gets lower payment coverage compared to general medical, and gets extra PA paperwork.

The government back out of state psych hospitals notably in the 1960's trying to emphasize Community Mental Health Clinics.
The insurance companies don't really want to pay for it.
Some hospitals are again reversing course and closing down units in some states.
Some docs like me are tired of getting very low rates for insurance XYZ that another doctor with specialty ABC gets almost 2x for reimbursement for same E&M codes(!), so I've simply cut out being in network with some companies.

Things are only going to get worse.

 

[AlmostAnMD]

I think I speak for the rest of this forum when I ask for more details of the 250 day boarder

 

[Pudortu]

I think I speak for the rest of this forum when I ask for more details of the 250 day boarder

Lol there was a hospital boarder for several years at my tertiary care facility where I went to school. The dude was old, had no family, was an undocumented immigrant, had HIV, and was demented. They couldn't find any place to take the guy so he literally got put in a bed for years. In the end the story I hear is that the hospital found it cheaper to rent a private jet and fly the dude back to his country of origin.

 

[DocEspana]

every once in a while CMS comes by and (there is no better term) selects one ED to just grind into dust over this. They have repeatedly, at least 3 times Ive seen, made it clear that long term boarding of psych patients is an issue they have some-but-not-much patience with. They will state that keeping a patient for a week or more is a EMTALA violation because whatever reason your using to not have them evaluated by then is clearly just evidence that you're not looking hard enough/far enough away to find a place and as such are delaying medical stabilization. Now they will let people board for weeks everywhere and then every few years say x hospital system has y number EMTALA violations because they are refusing to send psych patients outside the system/outside the state and has to pay z dollars in fines; where y is a nearly triple digit number and where z is approximating bankruptcy for the hospital.

This is just a more tame version of it. They should be thankful CMS didnt pick them to be the lucky hospital erased from existence that occurs every few years.

 

[The Dayman]

I think I speak for the rest of this forum when I ask for more details of the 250 day boarder

Pretty terrible situation. Kid is autistic, history of frequent behavioral outbursts that we typically see on the severe end of spectrum. After he turned 18, mom said I can’t handle it. Drops him off at psych ED. Social work hold but can’t place him anywhere. Apparently adult disability services are a nightmare in my area.

 

[nexus73]

Putting this on the state is missing the forest for the trees. Insurance has to increase reimbursement, or psych will continue to function with effective price caps which economically we know causes shortages. Low reimbursement-->no psych beds--> ED boarders.

The only reason this is a problem is reimbursement for psychiatry sucks. Do you ever see turf battles between specialties for high paying procedures, like vascular vs IR for different stents, etc? Nobody seems to be battling for psych admits. I'm sure it will never happen but would love to see the ironic day when psych is reimbursed so well neuro and IM are fighting to admit someone with SI.

I don't see this ending in a way that's all sunshine and rainbows for ED docs. Once states have court orders forcing them to find placement for involuntary psych patients, they realize it's insurmountable and will start inappropriately dropping psych holds. This will leave ED docs to discharge patients who are still in crisis. When the bad outcome happens, you can certainly hide behind the fact the state/county dropped the hold, but doesn't mean you won't get sucked into a lawsuit for a year or two. Or be accused of not advocating strongly enough for a patient who was released when they should have been kept.

Nobody wants to pay more for psych services, and without more pay the services will remain anemic.

 

[thegenius]

Putting this on the state is missing the forest for the trees. Insurance has to increase reimbursement, or psych will continue to function with effective price caps which economically we know causes shortages. Low reimbursement-->no psych beds--> ED boarders.

The only reason this is a problem is reimbursement for psychiatry sucks. Do you ever see turf battles between specialties for high paying procedures, like vascular vs IR for different stents, etc? Nobody seems to be battling for psych admits. I'm sure it will never happen but would love to see the ironic day when psych is reimbursed so well neuro and IM are fighting to admit someone with SI.

I don't see this ending in a way that's all sunshine and rainbows for ED docs. Once states have court orders forcing them to find placement for involuntary psych patients, they realize it's insurmountable and will start inappropriately dropping psych holds. This will leave ED docs to discharge patients who are still in crisis. When the bad outcome happens, you can certainly hide behind the fact the state/county dropped the hold, but doesn't mean you won't get sucked into a lawsuit for a year or two. Or be accused of not advocating strongly enough for a patient who was released when they should have been kept.

Nobody wants to pay more for psych services, and without more pay the services will remain anemic.

that's fine, they will pass on the increased costs from premiums onto you and I, the people who pay premiums.

 

[sylvanthus]

What’s the longest y’all seen someone wait for placement in your ED? We’ve had several over 4 weeks over the last few years.

At least 3 months for a psych patient.

 

[nexus73]

that's fine, they will pass on the increased costs from premiums onto you and I, the people who pay premiums.

yeah, I mean they pass on the cost of the GI scopes and the derm biopsies, and hundreds of other high reimbursement services from many specialties

 

[thegenius]

yeah, I mean they pass on the cost of the GI scopes and the derm biopsies, and hundreds of other high reimbursement services from many specialties

They seem to pay for those (perhaps after a fight), but they don't even offer good psychiatric coverage to begin with. Big difference

Remember that the answer to all your questions is money. Insurers won't lose a dime due to new legislation forcing them to increase coverage.

 

[nexus73]

They seem to pay for those (perhaps after a fight), but they don't even offer good psychiatric coverage to begin with. Big difference

Remember that the answer to all your questions is money. Insurers won't lose a dime due to new legislation forcing them to increase coverage.

I think we're on the same page. I have no expectation that insurance will increase reimbursement for inpatient psychiatry. And because they won't this problem may get shifted around a little bit. The state has more skin in the game now. But I doubt it will solve much, and may create more problems. The idea this will be better for EDs is also doubtful.

 

[thegenius]

I think we're on the same page. I have no expectation that insurance will increase reimbursement for inpatient psychiatry. And because they won't this problem may get shifted around a little bit. The state has more skin in the game now. But I doubt it will solve much, and may create more problems. The idea this will be better for EDs is also doubtful.

I agree.