Written by Roneet Lev, MD
Executive Director, IEPC

I had the honor of discharging a 23-year-old patient with autism, let’s call him Austin, who presented to the emergency department on a 5150 psychiatric hold due to violent behavior. There were no locked mental health beds in the area and so Austin remained in our emergency department for two weeks. Austin awoke and went to sleep day after day in the Emergency Department – eating, drinking, and I imagine brushing his teeth. In total he was in the ED more shifts than I was. Some call this psychiatric boarding. I don’t like that term – it’s misleading, it sounds like no medical care was delivered. Stop Calling It Boarding – It’s ED Psychiatric Care During those two weeks Austin had a sitter next to him 24/7. He received regular vital signs, medications, counseling, rounding by the psychiatric team, consultation and orders by different emergency physicians, and daily consultation by a psychiatrist. He received successful medical and psychiatric treatment over those weeks. The treatment, in fact, was so good that Austin was safely discharged home. A mental health bed never opened. Austin was not just boarding in the ED, Austin received Emergency Department based psychiatric treatment. ED psychiatric treatment works, but unfortunately it is not the best place for mental health patients and disastrous for overall ED flow. 2 Now picture yourself as the health insurer who needs to pay for Austin’s care. Austin’s bill would include one hospital ED visit, one ED physician visit, perhaps an observation code, some medications, and a psychiatrist bill. What a bargain! That beats a two week stay in a mental health facility. Health plans must love ED “psychiatric boarding”! What is the incentive to transfer a patient or create new mental health beds if care is provided in the ED for less? What if the health plans were charged a daily ED hospital and ED physician rate for every day that their patient cannot be placed? Now that would align incentives.

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