Emergency Rooms Becoming ‘Dumping Ground’ for Psychiatric Patients

With fewer inpatient beds and inadequate outpatient services, patients often have no other choice but the ER

Waiting room
Individuals facing a mental health crisis are more likely to seek help through the hospital emergency room than in the past and often languish there for hours or days longer than patients with a physical malady, new studies show. And the problem is growing worse.

Researchers agree that, whether looking at New Jersey or at national trends, the problem reflects the longtime need for far greater investment in behavioral health services. The current situation results in suboptimal treatment for patients dealing with a psychotic break and eats away at resources that could be used to treat others, they said.

The findings are based in part on a detailed report by the New Jersey Hospital Association, scheduled to be released today. It shows emergency room visits are rising — and nearly half of the increase between 2014 and 2015 involved patients with mental health or substance use disorder diagnoses. While the total number of emergency room visits in the Garden State increased less than 4 percent in that year, ER use by patients with serious behavioral health issues jumped more than 10 percent.

The NJHA’s data echoed the results of a national poll released Monday by the American College of Emergency Physicians, which revealed that more than half of those surveyed agreed mental healthcare systems are growing weaker and emergency rooms are absorbing the fallout. Three out of four doctors said at least one patient in a mental health crisis would request help during each ER shift; one in five said these patients often languish for up to five days in the emergency unit.

“We know that treating people in a mental health crisis in the emergency department can place stress on the patient; it’s simply not the right setting to handle their complex needs,” said Betsy Ryan, president and CEO of the hospital association. “At the same time, it places increased strain within the emergency department, adding to overcrowding, long waits and increased healthcare costs.”

[related]Dr. Rebecca Parker, an emergency room physician in Chicago and president of the ACEP, which conducted the poll of 1,700 members earlier this fall, agreed: “The emergency department has become the dumping ground for these vulnerable patients who have been abandoned by every other part of the health care system.”

The healthcare system for those with serious mental illnesses has evolved over the past four decades from one focused on large, residential facilities — often criticized for locking individuals away like inmates — into a complex network of community based non-profit organizations that provide outpatient programs and medical care; smaller, residential group homes; and a handful of state-run institutions. While many have praised the goal of better integrating individuals with family members and the community, experts agree there has never been enough funding available to create the comprehensive system required to support those in need.

The dwindling availability of inpatient beds, together with a lack of access to appropriate outpatient services, combine to leave patients with few options other than the ER, doctors said. Investing in a system of integrated and preventative care will improve the health of those suffering from mental illness and save money over time, Carolyn Beauchamp, president and CEO of the Mental Health Association in New Jersey said during the NJ Spotlight on Cities conference in Newark last Friday.

“Right now, we wait until it gets so bad that people are in crisis,” Beauchamp said during a panel on integrated healthcare. If better outpatient care was available, “we can identify issues much earlier and help people before they reach the stage where they have to rush to an emergency room. And that’s a huge benefit to everyone.”

Nationwide, psychiatric visits to the emergency room increased 55 percent between 2002 and 2011, according to research by Dr. Renee Hsai, who presented her findings along with the ACEP survey. And while all patients spent roughly the same length of time in the ER in 2002, she found that nine years later visitors with mental health diagnoses could linger as much as 14 hours longer before they were discharged or admitted for further care.

“All these findings suggest deficiencies in our healthcare system’s capacity to care for patients with mental health needs,” Hsai said Monday.

In the Garden State, nearly 217,000 more patients used the emergency room between 2011 and 2015 — more than half in the last year alone — based on the NJHA’s analysis of hospital billing codes. Nearly two-thirds of these individuals showed up as a result of a behavioral health crisis, or were diagnosed with a mental health or substance use disorder condition while in the ER. Overall, behavioral health diagnoses made 18 percent of the total emergency visits in 2015, the association found, up from 15 percent four years earlier.

The good news, said Ryan said, is that a growing number of the ER’s behavioral health visitors have health insurance; nearly 30 percent had Medicaid coverage in 2015, almost twice the rate in 2011. New Jersey added almost 500,000 residents to the Medicaid rolls since 2014, when the program was expanded under the federal Affordable Care Act.

“It’s great that these New Jerseyans are covered by insurance, but we also need to make sure they have access to appropriate behavioral health services, in the right setting — and that setting should not be the emergency department,” Ryan noted.

Despite these gains in insurance coverage, studies by Dr. Susan Catherine Lippert, an emergency physician with Stanford University, showed that nationwide, emergency room patients with mental illness are less likely to have insurance than those with physical ailments. They are also more likely to be admitted to the hospital, transferred to other in-patient facilities, or to have been seen by another emergency department within the previous 72-hours, she said.

“We don’t have the outpatient resources to help them manage this crisis and we don’t have the inpatient beds,” Lippert said. “This is like a perfect storm brewing, this growing crisis of unmet psychiatric needs.”