Around one in 10 youth enrolled in Medicaid spent days stuck in the emergency room after being admitted for a mental health crisis. That’s according to a new study from Oregon Health and Science University. John McConnell is a professor in emergency medicine and the director of the center for health systems at OHSU. Rebecca Marshall is a professor in child and adult psychiatry with OHSU. She is also a practicing psychiatrist at Doernbecher Children’s Hospital and Doernbecher emergency department. They both join us to share more on the study and what it means for the kids waiting to be admitted.
Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. Imagine being a 15-year-old in the middle of a mental health crisis, bad enough that you ended up in the emergency room. Now imagine spending at least three days in that ER before an inpatient bed or other treatment option opens up. That is not a rare occurrence. Nationwide, according to Medicaid data, that happened to about 1 in 8 young people in 2022 and Oregon was right around that national average.
John McConnell crunched these numbers for a recent study that was published in JAMA Health Forum. McConnell is a professor in emergency medicine and the director of the center for health systems at OHSU. He joins us now, along with Rebecca Marshall. She is an associate professor at OHSU and a child and adolescent psychiatrist at Doernbecher Children’s Hospital. Welcome to you both.
Rebecca Marshall: Thank you.
John McConnell: Yeah, thanks. It’s great to be here.
Miller: Rebecca Marshall, first – what are the most common reasons that an adolescent or a teen might show up at an emergency room in the middle of a mental health crisis?
Marshall: Well, I think often a young person is struggling and their parent or caregiver may not realize it. And then at some point they do realize it, whether it’s because the child discloses that they’re having suicidal thoughts or they’ve actually had a suicide attempt. Sometimes it’s a child who’s had a lot of difficult experiences and trauma, and begins acting out in ways that are unsafe. So, if parents or the child are not able to get the services and support they need in the community, then they come to the emergency department, which is a place where they think they’re going to be able to get help.
Miller: Is it common for families to try to get help in other places first, in some kind of community setting before they would go to an ER?
Marshall: Yeah, it’s very common. I think, unfortunately, our behavioral health system is very complicated and difficult to navigate. So parents might call a number of different agencies or therapists, or try to get developmental disability services. And it’s often not only hard to get those services, but hard to know who to call to help you figure out how to get services.
Miller: John, why did you decide to study this particular question, so-called boarding in ERs of children in psychiatric crises?
McConnell: I’d been hearing about this issue from some emergency physicians at OHSU and they encouraged me to talk to Dr. Marshall. This has been going on for a while, I heard about it pre-COVID. We are really interested in the Medicaid program and this is a natural place to look at this study. Medicaid covers about half of all children nationally and about three-fourths of low-income children. It’s also the largest payer of mental health services in the country, so this is a good opportunity to take a look at a population-wide basis and understand how often this is happening.
I’m not quite sure what the right number is, but this is not something we want to happen. Maybe we were hoping this would be in the 1 in 1,000 event or 1 in 100 event, but as you mentioned up front, this is 1 in 8. So it really suggests this is not something as rare as we would like it to be.
Miller: Rebecca, what is an emergency room, an emergency department like for a young person who’s in the middle of a psychiatric crisis?
Marshall: Well, I think, first of all, for any young person to want to go to an emergency department usually suggests that they’re really having a hard time because behavioral health problems are often hard to talk about. They involve feeling really low, feeling really vulnerable, often feeling like you’ve done something wrong. So to go to a place where there are going to be a bunch of strangers you don’t know, and talk about these really vulnerable thoughts and feelings is, in itself, difficult.
And then emergency departments are busy. They’re designed to manage medical emergencies. They’re bright, they’re loud. There are often ambulances coming in, staff moving fast and sometimes very scary medical issues that everyone is witnessing, so it’s a pretty overwhelming place, by nature. They’re not designed to be long-term therapeutic spaces.
Miller: Well, John, to that end, I was really surprised by the day cut-off that you and your team chose. It’s three days, meaning 1 in 8 young people who are on Medicaid in various states spent at least three days in an emergency room. I would have thought that even 48 hours, two days, could be an immense amount of time for somebody in crisis in the setting that Rebecca Marshall just mentioned. How did you choose three days?
McConnell: I think on one hand we wanted to be conservative and make sure that these were real boarding issues. We’re looking at some claims data and so we’re looking for stays that last two midnights. There are some cases where somebody might come in at 11 p.m. and get discharged at 1 a.m., and that would be one midnight, so a short stay. But by doing two midnights, you capture at least a full 24 hours, probably more like 48 or 72 hours there.
The other thing that we did is, we cut off the end of this, so this is between three days and seven days, because we didn’t want to confuse any transfers or things like that that might be hard to detect in the data. So it’s conservative really on two sides, but I think Dr. Marshall can describe that there are lots of children and adolescents who end up staying for … Maybe not lots, but there are cases where people are staying for more than a week in the emergency department.
Miller: And I want to hear more about that in just a second, but John, sticking with you, how much higher do you think the numbers would be if we were looking at, say, including people who were there for a full 24 hours as opposed to a full 48?
McConnell: I don’t have that number and maybe that’s something that Dr. Marshall could speak to. But I think there’s probably a lot who have long stays but maybe don’t make it the full three days, but it’s still something that’s longer than we would like it to be.
Miller: Well, Dr. Marshall, what does it mean in practice for someone to spend, say, three days in an emergency room? I mean, are they sleeping in a gurney in a hallway or waiting area? Are they in one of those little exam rooms just where the curtains are pulled around you? I’ve spent some number of unhappy hours here and there in ERs, and I’m not sure where people would be for days on end.
Marshall: Well, it varies by emergency department. At OHSU, if we have a child who’s having a behavioral health crisis and we’re worried about safety, then we try to put them in a room. And that’s because it makes it easier for the staff and the emergency department to keep track of them, make sure they’re doing OK. What that means is that the child and often the family are stuck in a room for however long they’re in the emergency department.
There’s no fresh air, they can’t walk around the ED, they can’t go outside. You know, while we do the best we can, we don’t have a lot of therapeutic activities that we can offer in an emergency department setting. And most importantly, they’re not able to do the developmentally normal things that a child or teenager should be doing, like interacting with other children and engaging in activities that will be meaningful and will help them cope with the stressful environment they’re in.
Miller: But as bad as that is, what you’ve just described, it seems like … it’s very easy to imagine much worse scenarios in hundreds of emergency rooms across the country. Worse than what you’ve just described, where ideally someone would at least have their own small room.
Marshall: Yeah, I think we do that really well at OHSU. What it does mean is that sometimes other patients don’t get a room. I’ve seen medically ill children who are on gurneys in the hallway. I think there’s a moving around puzzle pieces that has to happen when we have three or four kids in our small emergency department who are boarding and using that space that then is not available for children who come in with medical emergencies.
Miller: What do you tell your patients and their families about their having to stay in those rooms for days on end?
Marshall: That’s a hard one. We try to be honest that the scarcity of beds in Oregon means that for one child to get a bed in an inpatient psychiatric unit, another child has to leave. We don’t always know how long the stay is going to be. So what I tell them is, “We’ll check in with you every day, we’ll update you about whether a bed is available. We’ll be checking in on you, making sure you’re doing OK and trying to give you some things to work on while you’re here, but it’s gonna be a waiting game.”
Miller: Do families ever say after 12 hours, or 24 or 48, “We’re going home?”
Marshall: Yes, they do. And I think that’s a really agonizing decision for parents to make. But when you’re sitting in a room with your child who you brought in for help and you see them getting worse – because they’re stuck in this room and they can’t use kind of the normal things they use to help themselves cope and feel better – sometimes it feels like the better of two bad options is to go home, try to do what you can to keep them safe and get help in the community.
Miller: John, as we mentioned, you were looking at Medicaid populations. In Oregon, more than half of the kids qualify for the Oregon Health Plan. How much can we extrapolate from this population to kids as a whole?
McConnell: I think it’s pretty easy to extrapolate. I think this is happening across different types of insurance coverage. I think Dr. Marshall could probably confirm that she’s seeing children coming from families that have commercial insurance, employer-sponsored insurance, insurance purchased on the exchange. So I think it’s quite common across insurance types.
Miller: Rebecca, does that ring true to you?
Marshall: Yeah, we keep data on the children that we see on the child psychiatry side of things in the hospital, and it’s pretty evenly split between private or commercial insurance and public insurance.
Miller: John, we’ve heard for years about Oregon’s high prevalence of youth mental health challenges, and conversely, just the abysmal state of treatment options, the lack of treatment options. So I would have thought that, given that, in a national study about ER boarding that we would be near the bottom of the pack. Instead, we’re about average. How do you explain that?
McConnell: I was a little surprised. I think that it’s not as low as we want it to be. It’s still 1 in 8. We’re slightly above the national average. Some states are worse off. I’m not quite sure why that is. Florida and Iowa were at the top. Something like 1 [in] 5 kids with a mental health condition who show up in the emergency department experience a boarding event. But we still have a lot of work to do in Oregon and we really do have a shortage of inpatient beds on the child psych side.
Miller: Dr. Marshall, can you help us understand the deeper reasons for this? We’ve been talking about, as John just mentioned, the shortage of inpatient beds on the child side. Where are the other shortages in this patchwork? I almost called it a system, but it doesn’t really feel like a cohesive system. Where are the shortages as a whole?
Marshall: Well, I think there are shortages, really, across the board. That includes preventative services or early-intervention services, so when a child first starts to struggle and the parents are trying to get help for them, we need to have more accessible ways for them to get the help they need.
What I hear from parents again and again is that they started to see their child was struggling, they tried to reach out for help and they weren’t able to get the help they needed. And then the child got worse and ended up in the emergency room. So I think preventive services, early-intervention services are really key ...
Miller: If I could stop you there, before we even move down the line … So ideally, what would it look like in a better system with a prevention-oriented society? What would happen when parents realize that their kids are in trouble? Ideally, what would it look like?
Marshall: Ideally, I think we would have a more navigable system, where parents could call a community health agency, or go to the school, or call their insurance company and say, “I need a really good therapist for my child,” and there would be an easy to access array of providers. I think our system is so fragmented right now that what services you can access depends on where you live, what insurance you have and what your child is struggling with. And that is very difficult to navigate, especially for a family that’s already potentially struggling with a child who’s not doing well.
Miller: So let’s move down the line here, because I think it’s worth saying that, even with much better preventative care, some kids and adults are still going to end up in crisis and might still end up in an emergency room. What should happen in emergency departments when a young person shows up?
Marshall: I think that, first of all, we need to have better systems in place so that a child who’s not doing well doesn’t necessarily have to go to an emergency department. And Oregon has been working really hard to scale up some mobile-crisis programs throughout the state so that families, youth, teachers or therapists can call and say, “things aren’t going well, we’re getting towards a crisis, we need some help.” And a mobile crisis team can go to that site, help the family and potentially get them into more supportive care. That is in place in Oregon, but the scaling up of the program has been a challenge because of a number of issues, including workforce issues. I think Oregon is really doing a good job at trying to get community-based crisis services in place.
I think, ideally, if a child ends up in the emergency department because whatever is happening in the community isn’t enough, we need to have enough inpatient beds that I can see a child in the emergency department and I can say, “OK, you’ve tried this, it’s not working. You really need to be in an inpatient psychiatric program so you can get what you need in a safe setting.” And then we need to put the referrals in and get them over to that program within a matter of hours – not days.
Miller: The data from this study was from 2022, a time when the dislocation and the chaos of the pandemic was a lot fresher in our lives. Is there any reason to believe that the numbers would be any better now?
Marshall: That’s a difficult question. There was just some research that showed that suicide rates have decreased slightly on a national basis. That is, of course, wonderful news. I would say Oregon, for children 5 to 24, suicide is still the second-leading cause of death in the state. So I don’t think we can make any really great conclusions from that. But in terms of our hospital data, the numbers of youth coming in for behavioral health reasons has not decreased. It has continued to increase since 2014.
Miller: John, are any states providing a model worth emulating?
McConnell: There’s none that come to mind. I think that some states have done more to invest in what we call a continuum of care. As Dr. Marshall noted, navigating the mental health world is quite challenging and there are a number of types of beds that are important here. There’s inpatient’s, there’s step-down, there’s sub-acute, there’s residential beds. There’s some nice modeling that’s happening at OHSU to try to understand the dynamics of these. For example, just increasing one type of bed probably doesn’t get us what we need because there are bottlenecks elsewhere. So we really do need to have a robust continuum of care. And I think there’s some other states that have done that.
I think one thing that would be really helpful – and I’m not sure if we can point to another state, but it’s missing here – is that there’s not really a single point of accountability, and this is the flip side of a complicated and fragmented system to navigate. There isn’t anybody who is accountable for the mental health of kids in Oregon, so there’s nobody who’s really incentivized to make sure that these boarding rates go from 1 in 8 to 1 in 80 or 1 in 800.
So everybody is doing their best. We’re spending a lot of money to try to build out certain parts of the mental health system or increase workforce, but there’s not something that really ties that together and there’s not a system that is looking at outcome-based metrics to try to really move the system in the right direction. So that’s one piece that I would look for, that I think we could do better on.
Miller: John McConnell and Rebecca Marshall, thanks very much.
Marshall: Thank you.
McConnell: Yeah, thanks so much.
Miller: John McConnell is the director of the center for health systems effectiveness at OHSU. Rebecca Marshall is an associate professor there and a child and adolescent psychiatrist at Doernbecher Children’s Hospital.
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