By Shira Schoenberg
December 24, 2017
"Boarding is the canary in the coal mine of a broken system."
|Providence Behavioral Health Hospital in Holyoke has a 24-bed unit for children|
and adolescents. It is the only inpatient psychiatric unit for children in
all of Western Massachusetts. (File photo / The Republican)
Christine was pregnant when her 6-year-old son was taken to the emergency room at Berkshire Medical Center.
It was not unusual. Her son, now 9, has been diagnosed with multiple behavioral disorders. He can be aggressive and violent, threatening to harm himself.
But the hospital was unable to find an inpatient bed for him -- for three days.
"I had to stay in the hospital with him and sleep on a gurney for three days, because they didn't want to provide him with a sitter," Christine said. "I had a combative security guard ready to take him down, instead of dealing with him as a child."
Christine, who lives in Pittsfield, asked that her last name be withheld because of safety concerns.
The practice of "boarding" -- keeping mental health patients in a hospital emergency department for more than 12 hours because of a lack of a treatment placement -- is a known problem in Massachusetts. Teenagers are the most at risk, and younger children also face difficulties.
One state health expert said boarding is a symptom of other problems throughout the mental health system.
"Boarding is the canary in the coal mine of a broken system," said Kate Ginnis, director of behavioral health advocacy and policy at Boston Children's Hospital and part of the leadership team of the Children's Mental Health Campaign, a statewide advocacy coalition for children's mental health.
According to 2015 data from the Massachusetts Health Policy Commission, 21% of teenagers who showed up at an emergency room with a behavioral health diagnosis spent more than 12 hours there, compared to 14% of adults and 12% of children.
Among those who boarded, approximately 20 percent of children and teenagers under 17 were kept for two days or longer, compared to just 9 percent of adults.
Research by the Parent/Professional Advocacy League, which helps children and their families who are dealing with mental health problems, found that only 30 percent of children whose families they surveyed waited for treatment for less than 12 hours. And 13 percent reported waiting at least a week.
Not all remained in the emergency room that entire time -- 31 percent of families were told their child needed inpatient care but could wait at home.
"There are a large number of kids who are in need of acute psychiatric care, and for a host of reasons, can't access care in a timely manner," Ginnis said.
The children and their families end up waiting for days in environments that are not always conducive to treatment. Christine recalled a time when her son was stuck in a loud psychiatric ward with adults. "People are screaming at night," she said.
He was fed pizza and French fries and sat watching TV most of the day.
Ginnis said one problem is it is less profitable for a treatment facility to have an adolescent bed than an adult bed. Fewer children are admitted to treatment during the summer and school vacation, since school often causes stress in children.
Advocates say reimbursements rates from insurers are not high enough to cover the costs if beds are unfilled for one-fifth of the year because children do not need them at those times.
A child who cannot get outpatient care is more likely to end up in the emergency room. A study by the Blue Cross Blue Shield Foundation looking at outpatient mental health treatment found especially long waits for appointments for children and adolescents, due to the difficulty in finding a clinician who treats children, who takes a child's insurance, who is a good match for that child and who can see a child when they are not in school.
"You get down to a narrow window of finding someone who has the right kind of expertise, who will see a child when I can get them in," said Audrey Shelto, president of the Blue Cross Blue Shield of Massachusetts Foundation. "That's most likely going to take a while to find someone."
Ginnis said children on MassHealth can access a range of community-based services to help them with mental health problems, but private insurers do not offer those extra services.
"Kids can't get outpatient services, they can't get access to community-based services, so they end up in the ER," Ginnis said.
Once a child lands in an emergency room, the hospital must find an appropriate placement. Only specific facilities are equipped to take children or adolescents. According to 2014 figures, there were around 230 psychiatric beds for children and adolescents in Massachusetts -- around 10 percent of all of the state's psychiatric inpatient beds.
Providence Behavioral Health Hospital in Holyoke, which has a 24-bed unit for children and adolescents, is the only inpatient psychiatric unit for children in all of Western Massachusetts.
"A young child could wait for awhile if all those beds are full," said David Matteodo, executive director of the Massachusetts Association of Behavioral Health Systems.
Ginnis said for some children -- such as children who have both autism and a severe mental health problem -- there are no facilities in the state with specialized enough care.
Breanna Santiago, of Pittsfield, has a 7-year-old daughter with severe mood disorder, ADHD and other behavioral health problems. She gets physically aggressive and has tried to hurt herself and others.
Santiago said her daughter was once kept in an emergency room for nearly a week waiting for a placement. She said hospital clinicians have been rude to her and her daughter and have watched her daughter attack her without intervening.
There is different staff each time. Once, she said they kept her daughter in bed all day with a heated blanket watching television, then sent her home because she was no longer in crisis, without offering further treatment.
Santiago said hospital clinicians have tried to send her daughter home when she is in crisis -- even after an incident in which she stabbed her sister -- because there is nowhere else for her to go.
"Nine out of ten times, it's bed availability," Santiago said.