That number has improved slightly in recent years — 12-hour wait times for mental health patients accounted for 37.5 percent of emergency department visits in 2024, down from nearly 40 percent in 2022. Still, barriers at every step of a patient’s journey through the mental health system slow their access to care, the report says.
The reasons for boarding “are both from patients coming to the emergency department in the first place, as well as the challenge of discharging patients when they are ready, either to community-based care or to inpatient care,” said Laura Nasuti, director of the Commission for Research and Analysis. “And those who are inpatients, it’s trying to get the right community support before they’re discharged.”
For the final analysis, the commission looked at wait times for patients seeking care for mental health concerns, substance use disorders, and certain neurodevelopmental disorders such as ADHD. The commission defined boarding as waiting time greater than 12 hours after evaluation in the emergency department, although the definition of boarding varies among professional groups. The Massachusetts College of Emergency Physicians, for example, defines boarding as any visit that lasts four hours.
Mental health boarding has been a major focus for Massachusetts policymakers in recent years as wait times have soared for patients who suffer from extra hours in the loud, bright chaos of emergency rooms. A 2017 study of 10 Massachusetts hospitals found that psychiatric patients regularly waited 16 to 21 hours in the emergency department.
The state has implemented a series of policy changes in recent years that have shown promise, said Lee Simmons, vice president of policy and regulatory affairs at the Massachusetts Health and Hospital Association. These include increased mental health funding, requiring emergency departments to provide their own mental health assessments, and new protocols to expedite psychiatric admissions for patients waiting more than 24 hours.
The proportion of adult patients admitted to psychiatric beds for more than 24 hours decreased from 53 percent in 2022 to 40 percent in 2024. For children, the proportion fell from 46 percent to 30 percent over the same period. Still, waiting even less than 24 hours can increase symptoms and emotional dysregulation for patients experiencing a mental health crisis, the report says.
Placements for medically complex patients, such as those with diabetes or autism or those who exhibit aggression, are especially hard to come by, Simmons said.
“Children who are insulin-dependent, they are often stuck in group homes because they lack the capacity to administer insulin,” Simon said.
One of the most surprising findings, Nsuti said, was the large proportion of patients who were admitted to the emergency department only to be discharged home. About 26 percent of people who waited more than 12 hours were discharged, while another 23 percent were admitted for observation, but ultimately went home to their regular mental health providers.
“People spend a lot of time in the emergency department but don’t need inpatient care,” Nasuti said. “This suggests that perhaps these patients would be better served in a community-based setting, even something like a behavioral urgent care or a community-based behavioral health center.”
Community behavioral health centers, which provide around-the-clock mental health emergency care services, are thought to relieve many emergency rooms. But the centers have struggled financially in recent years, a fact exacerbated by federal spending cuts under the Trump administration.
Inpatient beds available for cases that cannot be treated in the community are in short supply, and not all licensed beds are available. A 2022 report by the Massachusetts Health and Hospital Association and the Massachusetts Association of Behavioral Health Systems found that 20 percent of inpatient psychiatric beds were offline due to staffing problems.
Alan Seger, a health policy expert at Boston University’s School of Public Health, said the Health Policy Commission’s latest report is helpful in clarifying the problem, but why Massachusetts fares so poorly in mental health boarding compared to other states requires further analysis.
“It’s hard to fix a problem without understanding the root causes as much as possible,” Seeger said. “If there is a shortage of inpatient psychiatric beds, why? One obvious answer is that inpatient psychiatry can be a money-losing service.”
Another reason the problem may be more significant in Massachusetts is that hospitals are admitting emergency room people at a higher rate than in other states, Nasotti said.
The boarding problem is very important for some people. People with low incomes and those who are homeless are more likely to seek mental health care in the emergency department and are more likely to wait longer than people with higher incomes. Black residents also disproportionately seek emergency mental health care and experience longer wait times.
Marin Wolf can be reached at marin.wolf@globe.com.
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