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Online ISSN: 1099-176X    Print ISSN: 1091-4358
The Journal of Mental Health Policy and Economics
Volume 23, Issue 2, 2020. Pages: 61-75
Published Online: 1 June 2020

Copyright © 2020 ICMPE.


 

Determinants of Boarding of Patients with Severe Mental Illness in Hospital Emergency Departments

Jangho Yoon,1* Linh N. Bui,2 Diana J. Govier,3 Megan A. Cahn,4 Jeff Luck5

1MSPH, PhD, Health Management and Policy Program, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA
2MIPH, PhD, University of California, Berkeley, and Sutter Health Center for Health Systems Research, Berkeley, CA, USA
3MPH, Health Management and Policy Program, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA
4MPH, PhD, Legacy Research Institute, Legacy Health, Portland, OR, USA
5MBA, PhD, Health Management and Policy Program, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA

* Correspondence to: Jangho Yoon, Associate Professor, Health Management and Policy, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Oregon State University, 464 Waldo Hall, Corvallis, OR 97331, USA.
Tel.: +1-541-737 3839
Fax: +1-541-737 4001
E-mail: jangho.yoon@oregonstate.edu

Source of Funding: This research was funded by Oregon Health Authority (Agreement Number 139058). The funding was indirect via Oregon State University.

Abstract
We examined extent and determinants of “boarding” of patients with severe mental illness (SMI) in hospital emergency departments (ED) and tested whether greater mental health system capacity may mitigate the degree of ED boarding. We linked Oregon’s ED Information Exchange, hospital discharge, and Medicaid data to analyze 34,207 ED claims by 7,103 persons aged 15 to 64 with SMI from October 2014 through September 2015. Boarding was defined as an ED stay over six hours. We estimated a simultaneous-equation model to test the pathway that mental health system capacity affects ED boarding via psychiatric visits. Psychiatric visits were more likely to be boarded than non-psychiatric visits (30.2% vs. 7.4%). Severity of psychiatric diagnosis, substance abuse, and discharge destinations are also among important predictors of psychiatric ED boarding. Greater supply of inpatient and community mental health resources corresponded with a reduced risk of ED boarding via fewer psychiatric ED visits.


Background: Boarding of patients in hospital emergency departments (EDs) occurs routinely across the U.S. ED patients with behavioral health conditions are more likely to be boarded than other patients. However, the existing literature on ED boarding of psychiatric patients remains largely descriptive and has not empirically related mental health system capacity to psychiatric boarding. Nor does it show how the mental health system could better address the needs of populations at the highest risk of ED boarding.

Aims of the Study: We examined extent and determinants of ``boarding'' of patients with severe mental illness (SMI) in hospital emergency departments (ED) and tested whether greater mental health system capacity may mitigate the degree of ED boarding.

Methods: We linked Oregon's ED Information Exchange, hospital discharge, and Medicaid data to analyze encounters in Oregon hospital EDs from October 2014 through September 2015 by 7,103 persons aged 15 to 64 with SMI (N = 34,207). We additionally utilized Medicaid claims for years 2010-2015 to identify Medicaid beneficiaries with SMI. Boarding was defined as an ED stay over six hours. We estimated a recursive simultaneous-equation model to test the pathway that mental health system capacity affects ED boarding via psychiatric visits.

Results: Psychiatric visits were more likely to be boarded than non-psychiatric visits (30.2% vs. 7.4%). Severe psychiatric visits were 1.4 times more likely to be boarded than non-severe psychiatric visits. Thirty-four percent of psychiatric visits by children were boarded compared to 29.6% for adults. Statistical analysis found that psychiatric visit, substance abuse, younger age, black race and urban residence corresponded with an elevated risk of boarding. Discharge destinations such as psychiatric facility and acute care hospitals also corresponded with a higher probability of ED boarding. Greater supply of mental health resources in a county, both inpatient and intensive community-based, corresponded with a reduced risk of ED boarding via fewer psychiatric ED visits.

Discussion: Psychiatric visit, severity of psychiatric diagnosis, substance abuse, and discharge destinations are among important predictors of psychiatric ED boarding by persons with SMI. A greater capacity of inpatient and intensive community mental health systems may lead to a reduction in psychiatric ED visits by persons with SMI and thereby decrease the extent of psychiatric ED boarding.

Implications for Health Policies: Continued investment in mental health system resources may reduce psychiatric ED visits and mitigate the psychiatric ED boarding problem.

Received 29 November 2019; accepted 19 February 2020

Copyright 2020 ICMPE