ABOUT THE PROJECT:
Since its inception, CMHC has been concerned about issues of access to children's mental health services and committed to comprehensive system reform. The C.F. Adams Charitable Trust, aligned in this goal, has awarded CHMC a grant for a 3-year project aimed at developing a better understanding of the factors contributing to pediatric psychiatric "boarding" and advocating for solutions.
Boarding occurs when a person in the Emergency Department (ED) requires inpatient care, but there are no appropriate psychiatric placements available. This leads to longer stays in hospital EDs or non-psychiatric medical units. These children may also experience "boarding at home"- where the child in crisis is sent home with in-home crisis stabilization services as support.
Many children with behavioral health challenges do not access treatment until there is a crisis, at which point the ED becomes the point of entry into the mental health system. Despite many improvements to the children's mental health system, children in psychiatric crisis are still awaiting care in EDs across the Commonwealth. While children await placements, they do not receive the treatment they were assessed to require. Boarding creates a multitude of stressors for children, families, health care providers, and hospitals across the Commonwealth.
The Campaign's boarding project has two interrelated key elements: data gathering and analysis, and policy development and advocacy.
DATA GATHERING AND ANALYSIS:
During the course of a year, we collected data from ten Emergency Departments from across the state in addition to inpatient and intensive service providers across the state. Data collection, which began in January 2016 and continued through December 2016, occurred every weekday from one week each month.
Two types of date were gathered:
Individual Level Data
- The "Demographics Background Form" was filled out by the hospitals once for each patient that is boarding during the week of data collection. This captured information about the child or adolescent who is boarding, when s/he arrived, and extensive information about clinical and other characteristics.
- The "Daily Bed Finding Form" was filled out daily by the hospitals during collection week for each child or adolescent boarding.
System Level Data
Project staff collected data from the inpatient and other intensive services across the state in order to evaluate the interaction between boarding and other "stuck" places in the system.
- Child adolescent inpatient and partial hospital programs data collected daily, to understand bed availability, movement of patients in and out of units, and reasons units may not be at full census.
- The Community Based Acute Treatment (CBAT) and Children's Behavioral Health Initiative (CBHI) services date was collected once per week to get a snapshot of waitlists for community-based stabilization and diversionary services.
In 2016, PPAL developed and distributed a survey to gather information from caregivers about their experiences with boarding. The survey is comprised of 49 multiple choice questions and concludes with one open ended request for additional narrative comments. During the spring of 2016, PPAL completed the preliminary assessment of the survey data and conducted targeted focus groups with parents and other stakeholders to more deeply assess specific issues which have emerged with the survey.
THE CAMPAIGN'S REQUEST FOR INFORMATION (RFI) REGARDING SPECIALTY INPATIENT BEDS
The project team advocated for EOHHS/DMH to release a Request for Information (RFI) to current and prospective pediatric psychiatric inpatient providers to get feedback on models for developing specialty inpatient units. These units would include beds for children with co-occurring conditions including autism and other intellectual and developmental disabilities, substance use disorders, chronic medical conditions, and those who are seriously assaultive or dangerous. The RFI sought information about the staffing, models of care, site requirements, and reimbursement levels that would be necessary to develop and sustain these services.
POLICY DEVELOPMENT AND ADVOCACY
Working with members of the project advisory committee, Health Law Advocates assessed avenues for potential legal action to address boarding in the following areas:
- Reasonable promptness under Medicaid law;
- Early Periodic Screening Diagnosis and Treatment;
- The MA Mental Health Parity Law, in particularly the provision that requires coverage of mental disorders to include a range of services that permit medically necessary and active and non-custodial treatment to take place in the least restrictive clinically appropriate setting;
- The non-quantitative treatment limitation (NQTL) provisions of the Mental Health Parity and Addiction Equity Act (MHPAEA), in particular, provider reimbursement rates and methodologies and standards for provider admission to participate in a network.
CMHC hosted a stakeholder summit on December 6th 2016. Over 130 healthcare providers, insurance companies, parents, advocates, legislative office staff, and senior level state agencies staff attended the event and shared their expertise and ideas for solving the problem of pediatric ED boarding.
The work of the summit formed the foundation of a set of recommendations which was advanced by the CMHC and its partners. Read the report here.