At the same time, behavioral health resources have been systematically reduced in the health care system. In North Carolina for example, nearly 70 percent of public inpatient psychiatric beds closed due to policy and reimbursement shifts from 1992 to 2012.3 And although there are signs of progress — such as requiring coverage of behavioral health services as an “essential health benefit” in the Affordable Care Act, the recent inclusion of significant behavioral health support in the 21st Century Cures Act and many private efforts in communities nationwide — our journey to an effective and just behavioral health system undoubtedly will be long and complicated.

But within this broad landscape, there are two extremely important and often hidden problems that directly affect the care of patients and the safety of behavioral health patients and caregivers in our nation’s hospitals and health systems: emergency department behavioral health patient boarding and the associated risks to health care workers’ safety from an expanded behavioral health patient population. 

Patient boarding

A 2010 Health Affairs paper presented an American College of Emergency Physicians survey of 328 ED medical directors finding that “roughly 80 percent believed that their hospitals “boarded” psychiatric patients.”4 The problem is so acute today that the Joint Commission issued a Quick Safety advisory in late 2015 noting, “The dramatic rise in emergency patients with chronic psychiatric conditions is a national crisis, with millions of people across the U.S. seeking care in our nation’s overcrowded and often overwhelmed EDs.”5  

The Joint Commission documented in a series of 2014 interviews that ED directors “reported acting as a safety net for psychiatric treatment due to severe gaps in access to both inpatient and outpatient psychiatric care.” The problem is even more challenging for rural hospitals due to the profound lack of behavioral health services and qualified professionals in those areas. One 2014 example from the Oregon Office of Rural Health reported significant difficulty in finding inpatient beds for behavioral health patients in rural hospitals, with stays in EDs lasting up to 18 days.6

Mission Health understands this challenge well. Our organization is a patient-centered, regional safety-net health system serving the nearly 1 million residents of the 18 westernmost counties in North Carolina and areas in neighboring states. This population is disproportionately older, poorer, sicker and less likely to be insured than state and national averages. Mission Health, based in Asheville, is North Carolina's sixth largest health system and its only nonprofit system that is regionally owned and governed. More than 70 percent of its patients are covered by Medicare and/or Medicaid or have no insurance at all. Despite these challenges, Mission Health was recognized as one of the nation’s 15 Top Health Systems from 2012 to 2015 by Truven Health Analytics, formerly Thomson Reuters, becoming the only health system in the nation to earn this designation in four consecutive years.

Mission Health has achieved these quality outcomes despite an ongoing struggle with the onslaught of patients suffering deeply from behavioral health conditions. Since January 2014, the number of new behavioral health patients presenting monthly to a Mission Health ED has increased from 419 to a peak of 547 in July 2016 (a 31 percent increase). Not surprisingly, given the lack of available inpatient psychiatric beds in the state, the number of behavioral health patients boarded in Mission Health EDs has increased even more rapidly — nearly fourfold, from 15 to nearly 60 — during the same time period, nearly all without financial support. 

Tragically, Mission Health has had behavioral health patients board in the ED as long as three months. Currently, one patient has been “living” continuously in a Mission Health hospital for almost two years — with no end in sight — despite repeated, heroic efforts to find appropriate placement for this individual. All of this has occurred despite the fact that Mission Health is the region’s largest inpatient psychiatric provider, operating 33 adult, eight geriatric, nine adolescent and eight pediatric behavioral health beds.

Worker safety

The impact of behavioral health patients is felt far beyond the confines of the ED or inpatient psychiatric unit. Patients suffering from mental illness also regularly receive care for medical problems. Infrequently, these patients are more prone to outbursts because of their mental illness, and to risky interactions that may place staff at risk — particularly when these patients are housed in inappropriate, crowded settings due to lack of available beds.  Given this situation, Mission Health has worked relentlessly to reduce and eliminate risk to staff. 

Training on awareness, education and de-escalation is a cornerstone of avoidance. But even so, assaults on staff members have fallen only to an average of approximately 15 per quarter. So Mission Health went beyond training and created its Behavioral Emergency Response Team to reduce further risk. The BERT, modeled on rapid response teams for medical patients, can be activated by any staff member at any time. Calls have averaged 30 per month since the program was initiated.

Data deficit

This situation is far from unique to Mission Health. There are, however, no central reporting databases or registries that enable practitioners or policymakers to gain an understanding of the true depth and breadth of these problems. Mission Health believes that organiztions in the hospital and health system sector should work together to report, on a deidentified basis, key statistics including (each by diagnosis):

  • Number of behavioral health patients presenting to the ED per month.
  • Median number of behavioral health patients boarding in the ED per month.
  • Median and maximum wait times for behavioral health patients to access an inpatient bed per month.
  • Number of staff calls for immediate behavioral health patient intervention per month.
  • Number of incidents of violence on staff and incidents with injury per month related to behavioral health patients.

Such a sectorwide, de-identified database would allow leaders, practitioners, policymakers and others to develop a true understanding of the size and scope of the issues our nation faces in behavioral health and inform potential solutions. This problem is too important, affects too many people who are suffering severely, and cannot be resolved without more complete information about its true extent. 

Mission Health is ready to join this effort. Are you?

Ronald A. Paulus, M.D., is president and CEO of Mission Health in Asheville, N.C.

The opinions expressed by the author do not necessarily reflect the policy of the American Hospital Association.


1. "The State of Mental Health in America 2017," Mental Health America, 2017.

2. Ibid.

3. See and Mebane Rash and John Quinterno, "Serving Mental Health Patients in Crisis: A Review of the State’s Program to Buy Beds and Build Capacity in Local Hospitals," North Carolina Center for Public Policy Research, December 2012.

4. Vidhya Alakeson, Nalini Pande and Michael Ludwig, "A Plan to Reduce Emergency Room ‘Boarding’ of Psychiatric Patients," Health Affairs 29, No. 9 (2010): 1637-42, doi:10.1377/hlthaff.2009.0336. 

5. "ACEP Psychiatric and Substance Abuse Survey 2008," American College of Emergency Physicians, 2008, cited March 22, 2009, available at

The Joint Commission, "Alleviating ED Boarding of Psychiatric Patients," Quick Safety, 19 (December 2015).

6. Ibid.