Overflow and Opportunity: Six Behavioral Health Priorities for Essential Hospitals

Walk into an safety net hospital emergency department (ED) today, and you'll see the behavioral health crisis firsthand. Patients in psychiatric crisis wait days to find inpatient care placement. Beds stay full, ambulances are diverted, staff morale declines, and already-thin financial margins stretch even thinner.

This is not only a logistical challenge but also a test of our health care system's core values: how we care for the most vulnerable, support front-line staff, and ensure the sustainability of hospitals filling a safety net role in their communities.

The statistics are alarming, but the daily reality inside EDs is even more so. In a multi-state survey, 92% of ED directors in Florida, New York, and Texas reported overcrowding as a problem, citing hospital bed shortages and high patient acuity as major drivers. For psychiatric cases in Florida, tens of thousands of patients spent six or more hours in the ED awaiting admission, and almost 40% of those encounters had extended boarding times. And in Florida overall, nearly one in six ED visits results in an admission-well above the national average. All of this points to the same conclusion: our system is stretched beyond mere statistics-it's impacting real people, leading to more waiting, more suffering, and more patients falling through the cracks.

The Challenge for Essential Hospitals

While all hospitals are challenged in caring for an increasing number and acuity of behavioral health patients, essential hospitals, which care for a disproportionate number of Medicaid, Medicare, and uninsured patients, experience these pressures to a greater degree. Every facet of operations is impacted, including:

• ED overcrowding and boarding: Due to limited inpatient and community care resources, patients in psychiatric crisis occupy scarce ED beds for extended periods, sometimes for many days, resulting in less-than-optimal care for the patients, disruptions to care for emergent patients, and stress on staff.
• Inadequate care continuity: Discharge processes often lack coordination, resulting in patients lacking stable follow-up.
• Cycles of recidivism: Inadequate social support, including housing, and a lack of outpatient care providers, can result in repeated ED visits.
• Financial pressure: Hospitals filling a safety net role disproportionately bear high costs of uncompensated behavioral health care with limited resources to offset them.

These patterns are unsustainable, and H.R. 1 will increase the number of uninsured patients and cause even deeper challenges for essential hospital providers.

Strategies That Work

Though the challenges are real, hospitals are not without options. Across the country, hospitals are implementing approaches that help patients receive timely care in the right setting while reducing operational and financial burden. These efforts include:

1. Reducing boarding with early intervention
   Hospitals that integrate psychiatric evaluations early in the ED visit can minimize delays. Collaborations with crisis centers or telepsychiatry providers can support the evaluation process and expedite safe disposition from the ED.
2. Making discharge a true bridge, not a gap
   Peer navigators and care coordinators integrated into ED teams ensure patients leave with scheduled follow-ups, medication support, and warm handoffs to outpatient providers. These steps lower the chances of immediate repeat visits. For example, hospitals can partner with mobile crisis providers and local government to provide services in the ED, ensuring patients are connecting to resources in the community before discharge.
3. Breaking the cycle through community partnerships
   Stable housing, peer support, and outpatient care are essential. Hospitals partnering with community organizations, including community behavioral health providers and federally qualified health centers, tend to see reductions in recidivism and improved patient outcomes.
4. Building operational infrastructure
   Effective staffing models using the spectrum of providers enable effective and efficient care while reducing staff burnout. Coupling effective staffing with technology-enabled workflows further improves performance and outcomes.
5. Addressing substance use disorders
   Administration of medication-assisted treatment (MAT) in emergency department and inpatient settings reduces recidivism and negative outcomes. Integrating substance use disorder treatment into primary care and specialty care further improves outcomes and avoids emergency department visits.
6. Ensuring financial sustainability
   The behavioral health revenue cycle presents unique challenges and requires special billing expertise to reduce denials and improve reimbursement. In addition, developing a service line specific to behavioral health aligns services with community needs while ensuring fiscal sustainability.

Why This Matters Now

Safety net hospitals cannot delay addressing escalating behavioral health needs. Investing in behavioral health is essential. It determines whether EDs function effectively or fail, whether hospitals remain open or close, and whether vulnerable patients are stabilized or abandoned.

The solutions are evident. The question is whether we will give safety net hospitals the support they need to put them into practice.

The Path Forward

Essential hospitals face immense pressures from behavioral health demands, yet they also show what's possible when necessity sparks innovation. By reducing ED boarding, refining discharge planning, and fostering strong community partnerships, they demonstrate that progress is achievable even in the most challenging environments.

These efforts should be regarded as more than isolated victories; they serve as models for broader adoption. Their future depends on our collective commitment to ensuring access and quality in health care.