Emergency Department Boarding and Behavioral Health

Emergency department (ED) boarding for patients with mental and behavioral health needs is a growing access-to-care challenge for academic health systems and the communities they serve.

When patients remain in the ED while waiting for appropriate mental and behavioral health care, the issue often reflects gaps across the broader care continuum — including crisis response, inpatient capacity, community-based services, workforce, financing, and care transitions.

The AAMC is exploring system-level approaches that can help academic hospitals and health systems leaders, policymakers, payers, and community partners reduce avoidable boarding, improve timely access to care, and strengthen care pathways before, during, and after an ED visit.

Explore strategies for strengthening mental and behavioral health access, improving patient flow, and creating shared accountability across the care continuum.

Strengthening Access Across the Mental and Behavioral Health Continuum

Mental and behavioral health ED boarding is not simply an emergency department operations issue. Boarding is the downstream result of fragmented systems, limited psychiatric bed availability, insufficient crisis capacity, weak transitions to community care, regulatory complexity, and misaligned incentives.

Promising approaches focus on shared responsibility within and across hospitals, community mental health providers, state agencies, Medicaid and managed care organizations, emergency medical services, law enforcement, crisis providers, and specialty behavioral health partners.

Insights and Tools for System-Level Solutions

Dedicated stabilization and observation models

Mental and behavioral health stabilization environments — such as EmPATH units, psychiatric observation areas, and crisis stabilization centers — can provide therapeutic space, psychiatric leadership, active treatment, de-escalation support, short-stay observation, and rapid linkage to outpatient or community-based services.

Examples from academic health systems and community partners suggest that these models can reduce ED strain by helping patients receive timely mental and behavioral health assessment and treatment rather than waiting passively in ED beds:

Workforce models that expand mental and behavioral health capacity

Persistent shortages of psychiatrists, psychiatric nurses, social workers, mental health clinicians, behavioral health technicians, peer specialists, crisis workers, and staff trained to support patients with high-acuity mental and behavioral health needs contribute to challenges throughout the care continuum.

Promising workforce strategies include psychiatric ownership of ED behavioral health patients, advanced practice provider-led models, behavioral emergency response teams, certified crisis workers, peer recovery navigators, mobile crisis clinicians, psychiatric residents, and staff with lived experience.

ED leaders, clinicians, and staff have important roles to advance improvement by engaging in interprofessional collaboration and delivering safe, empathetic, trauma-informed care that reflects front-line realities.

Sustainable improvement will require not only recruitment, but also role design, training, deployment, retention, and reimbursement for multidisciplinary behavioral health care teams:

Financing and policy levers for sustainability

Many clinically valuable behavioral health models reduce ED strain and improve patient experience but remain financially fragile. Crisis stabilization, bridge clinics, behavioral health urgent care, observation units, peer navigation, mobile crisis services, and transition-of-care outreach often depend on grants, philanthropy, temporary state support, or uncompensated hospital investment.

Stakeholders have identified potential national and state levers — quality measurement, clinical standards, payment incentives, access requirements, and improved communication — but also emphasized statutory constraints, state variation, behavioral health carve-outs, network adequacy challenges, and limited incentives for longitudinal coordination. These financing barriers make many promising models difficult to sustain even when local results are strong.

Payment redesign, Medicaid and managed care alignment, quality measurement, clinical standards, access requirements, and policy advocacy are critical to helping effective models scale and endure:

Community alternatives and care transitions

Boarding cannot be solved downstream without strengthening upstream and post-discharge care. Mobile crisis teams, 988 and EMS integration, behavioral health urgent care centers, bridge clinics, peer recovery navigation, crisis hotlines, school-based coordination, intensive outpatient and partial hospitalization programs, home-based crisis supports, and care transition outreach can help connect patients to care outside the ED.

The most credible strategies combine ED-based improvements with front-door diversion and back-door transition supports, while ensuring community partners, crisis providers, payers, and health systems share accountability for follow-up care.

These approaches reflect a whole-person, team-based strategy for helping patients receive the right care in the right setting at the right time:

Opportunities for Action

Hospital and health system leaders, policymakers, and community partners can take the following actions to advance system-level solutions:

Adopt a system-level strategy. Frame behavioral health boarding as a cross-continuum access and accountability problem, not only an ED operations problem.
Invest in stabilization capacity. Assess the feasibility of EmPATH-like units, psychiatric observation, crisis stabilization, behavioral health urgent care, and other active-treatment alternatives to ED boarding.
Align incentives with desired outcomes. Engage payers, Medicaid agencies, and policy partners to support models that reduce boarding, improve transitions, divert avoidable ED use, and strengthen crisis response.
Build multidisciplinary workforce capacity. Integrate crisis workers, peers, advanced practice providers, psychiatric residents, behavioral emergency response teams, and targeted training for ED and behavioral health staff.
Create shared metrics and governance. Establish measures, dashboards, escalation pathways, and joint accountability structures across hospitals, behavioral health providers, payers, and state or community partners.

Questions? Email mentalhealth@aamc.org to learn more about AAMC resources to improve mental and behavioral health care access and reduce avoidable ED boarding.

Resources

AAMCNews:

Walk-in Clinics Tackle Urgent Mental Health Needs

AAMC Advocacy and Policy:

General ED boarding:

Clinical care: