‘A supreme form of advocacy’: When finding a psychiatric bed seems impossible, one state’s patients have a partner

Hallie-Beth Hollister is a master at cold calling. She has to be.

She and a small team of psychiatric bed searchers are responsible for calling hospitals across Massachusetts any time a patient is in need of an inpatient psychiatric bed. At any given moment, 20 to 60 mental health patients are temporarily being cared for in one of the five hospital emergency departments covered by Behavioral Health Network, the Western Massachusetts-based emergency service provider where Hollister works. In complex cases, these searches have taken up to six weeks.

But unlike most health systems across the country, her team has a special tool to speed up that search: a dedicated, state-funded system to back them up. Massachusetts is home to a novel effort known as the Expedited Psychiatric Inpatient Admissions, or EPIA. Created in 2018 by the state’s mental health department, it is designed to cut the red tape to get psychiatric patients placed in appropriate care far faster.

Patients and family advocates, health providers, insurers, and hospital leaders tell STAT the program — coupled with new state incentives to bolster mental health care and bed availability — is already making a difference. And many of the program’s proponents believe it could become a national model of how to improve inpatient care for people in urgent need.

“We have a partner in the state who is holding this part of the system accountable to doing its job. It feels like everyone is rowing in the same direction,” said Lisa Lambert, a children’s mental health advocate with the nonprofit Parent/Professional Advocacy League.

Among other changes, EPIA requires hospitals to expedite placement for patients after they’ve boarded in an ER for 60 hours — but it also provides critical logistical support to help make that possible. Once the clock starts ticking, BHN and the state’s other regional emergency service providers can immediately call on the state’s mental health department, insurance companies, and hospital administrators to escalate the admissions process and clear any barriers standing in the way of placing a patient.

In some difficult cases, top officials at the state’s mental health department will personally make calls to expedite the process.

“It’s a supreme form of advocacy,” said Hollister. “It’s a whole lot different when a hospital administrator gets a call from a [state] official asking if the ‘no’ one of my BHN bed searchers just received from hospital admissions was a ‘soft no’ or a ‘hard no.’”

Research has shown that patients experiencing mental health emergencies that require hospitalization wait nearly four times longer for an inpatient bed than people with other acute issues, and more than five times as long for transfer to another facility. In large part, that’s due to a shortage of inpatient psychiatric beds or staff to care for those patients. While health workers like Hollister hunt for a bed, patients are left to wait, often in the emergency room or, occasionally, another wing of the hospital.

The problem is especially dire for the growing number of young people with mental health conditions. In Massachusetts, only 340 of the state’s 2,717 psychiatric beds are now available to patients under 18. There are none available for those younger patients in Western Massachusetts, where Hollister’s team is based.

“Before the protocol went in place, families called hospitals directly and found that the admissions person had never heard of their child. Some places didn’t keep lists, sometimes mobile crisis teams described kids but didn’t give names, etc.,” said Lambert. “The new protocol has pushed each hospital to have a common process so those things are less likely to happen.”

For some parents, like Northampton’s Jamie Guerin, the program’s work, while not a panacea, is a hopeful step. A year ago, her teenage daughter was rushed to a local hospital after a suicide attempt. Guerin said the hospital tried sending her home while she was still physically ill.

“Then she was locked in the ED,” Guerin said, adding that during the time her daughter had to board in the ER, an adult patient experiencing a psychotic episode barged into her daughter’s room. Her daughter had to board in the ER for four days before EPIA’s requirements kicked in, and she was able to be moved to an appropriate facility.

In May, as the pandemic took hold, the state mental health department temporarily changed its policy, allowing hospitals to use EPIA for help placing patients after boarding for 24 hours. That has helped patients like Guerin’s daughter — who was hospitalized again in June 2020 — get transferred out of the ER far faster.

“If the state had not intervened I don’t know how long she might have boarded in that ED,“ said Guerin.

For health systems, one of EPIA’s biggest benefits is that it helps to strategically prioritize the order that patients need to be placed in inpatient beds, which are often in short supply.

“What makes EPIA invaluable to our decentralized mental health system is that the state [mental health department] can now set a priority with a hospital for a member who is difficult to place in an inpatient bed,” said Greg Harris, associate medical director at Blue Cross Blue Shield of Massachusetts. “When a bed opens up, they are first in line. This is the way the system should work.”

Experts said that other state efforts will be crucial to expanding access to inpatient mental health care alongside EPIA. That includes a move last October to incentivize hospital acceptance of more patients from the state’s public MassHealth program. For at least a year, each designated hospital receives up to a daily $330 bonus for each psychiatric patient exceeding the number cared for the previous year.

The state also recently approved $10 million in funding for the creation of new inpatient mental health acute care beds, with priority given to beds for children and adolescents in underserved areas of the state. Payments could be up to $150,000 per new bed.

In the region of western Massachusetts where Hollister works, two hospitals are already considering plans to open new psychiatric units.

Even with state intervention now beginning after 60 patient hours in the ER, Behavioral Health Network is also looking to fill the treatment gap with an enhanced short-term community crisis stabilization program. It serves patients waiting for psychiatric hospitalization — and in theory, helps reserve inpatient psychiatric beds for the highest-priority patients.

“It’s a higher level of residential treatment care than previously existed in the community,” said CEO Steve Winn. “We created it for people whose needs are a little bit below inpatient care.”