One state looks to get kids in crisis out of the ER — and back home

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It was around 2 a.m. when Carmen realized her 12-year-old daughter was in danger and needed help.

Haley wasn't in her room — or anywhere in the house. Carmen tracked Haley's phone to a main street in their central Massachusetts community.

"She don't know the danger that she was taking out there," says Carmen, her voice choked with tears. "Walking in the middle of the night, anything can happen."

Carmen picked up Haley, unharmed. But in those early morning hours, she learned about more potentially dangerous behavior — provocative photos her daughter had sent and plans to meet up with an older boy. She also remembered the time a few years back when Haley was bullied and said she wanted to die. Carmen asked NPR to withhold the family's last name to protect Haley's identity.

She drove her daughter to a local hospital – the only place they knew to look for help in an emergency – where Haley ended up on a gurney, in a hallway, with other young people who'd also come with an urgent mental health problem.

Haley spent the next three days like that. It was painful for her mother who had to go home at times to care for Haley's siblings.

"Leaving [her] in there for days, seeing all those kids, it was terrifying for me," Carmen says.

That week, Haley was one of 115 children and teenagers who came to a Massachusetts hospital ER in a mental health crisis, waiting days or even weeks for an opening in an adolescent psychiatric unit. The problem, known as "boarding," has been on the rise across the country for more than a decade. And some hospitals reported record high numbers during the pandemic.

"We see more and more mental health patients, unfortunately, languishing in emergency departments," says Dr. Chris Kang, president of the American College of Emergency Physicians. "I've heard stories of not just weeks but months."

But now a handful of states and counties are testing ways to provide urgent mental health care outside the ER and reduce this strain on hospitals. Massachusetts has contracted with four agencies to provide intensive counseling at home through a program called emergency department diversion. It's an approach that could be a model for other states grappling with boarding. For Haley, so far, it's a game changer.

A 'nerve-wracking' ER visit becomes an opportunity

To determine what's best for each child, hospitals in Massachusetts start with a psychological evaluation, like the one Haley had on her second day in the ER.

"I didn't know if they were just going to send me home or put me in a really weird place," she says. "It was, like, really nerve-wracking."

DeAnna Pedro, the liaison between pediatrics and psychiatry at UMass Memorial Medical Center, reviewed Haley's report and considered recommending time in a psychiatric unit.

"She was doing a lot of high-risk things," Pedro says. "So there was a lot of thought given to would we need to go to something extreme like a psychiatric admission?"

But both Pedro and Haley's parents worried about this option. It would be a dramatic change for a 12-year-old whose only experience with mental health care was her school counselor. So instead Pedro contacted Youth Villages, one of the youth diversion agencies Massachusetts hired during the pandemic. And Haley's family met with a supervisor right there in the ER.

The first home visit the next day included a safety sweep.

"We look under rugs, we look behind picture frames, we look in the dirt of plants," says Laura Polizoti, the counselor from Youth Villages assigned to Haley's case. Youth Villages also provided window and door alarms that Haley's parents could activate at night.

Counseling for Haley and her parents started right away. A key goal was to understand why Haley was sneaking out at night and taking sexually inappropriate pictures.

During a counseling session one afternoon in December, Polizoti focused on Haley's anger at herself and her mom.

"Have you ever done an emotional thermometer before?" Polizoti asked, laying an oversized picture of a thermometer on the table. It had blank lines for five emotions, from cool to hot.

"It can help you see where your feelings are at," Polizoti explained. "Then we'll come up with coping skills for each level."

In the blank next to the bottom of the thermometer, Haley wrote, "chill." At the top, in the red zone, she spelled out "infuriated."

"Infuriated, that's a good word," Polizoti said. "So when you're infuriated, how do you think you feel physically, what do you notice?"

Haley told Polizoti that her palms get sweaty, she stops talking and she makes "a weird face." Haley scrunched up her nose and frowned to demonstrate. Polizoti laughed.

As the exercise unfolded, Polizoti asked Haley to think of ways to calm herself before irritation turns to anger. Haley suggested spending time alone, watching TV, playing with her siblings or jumping on the family's trampoline.

"That's a good one, the trampoline," said Polizoti. "Can we come up with one more?"

"I could, like, talk with my mom," Haley said, her voice rising in a question.

"Awesome," said Polizoti.

Early signs point to success

Initial numbers suggest this diversion program is working.

Among the 536 children and teens who've opted to try home-based counseling instead of psychiatric hospitalization in Massachusetts, 82% have not returned to an ER with a mental health concern. 92% have met their treatment goals, or were referred for additional treatment services once stabilized by the initial diversion service.

Advocates for parents of children with mental health issues say the main complaint they hear is that hospitals don't present the at-home care programs quickly enough, and that when they do, there is often a wait.

"We would love to have more opportunities to get these diversions with more families," said Meri Viano, associate director at the Parent Professional Advocacy League (in Massachusetts). "We've seen in the data and heard from families that this has been a great program to get children in that next place to heal faster."

And then there's the cost: $8,522, on average, for the typical course of care. At Youth Villages, that's three 45-60 minute counseling sessions a week, in a patient's home or other community setting, for three months. The savings is significant. One study calculated the cost of pediatric boarding at $219 dollars an hour, or $5,256 for just one day. And that's before the expense of a psychiatric hospital stay.

In Massachusetts, the diversion program also seems to be offering some relief for overburdened hospitals and staff.

A report from the Massachusetts Health & Hospital Association (MHA) shows youth ER boarding numbers dropped as more hospitals started referring families to one of the home-based options. Demand for mental health care does vary by season, but the MHA says the numbers are hopeful.

Can other states get past 'inertia' and 'reluctance'?

Dr. Kang with the American College of Emergency Physicians is optimistic about the growing number of mental health organizations like Youth Villages offering urgent care outside of hospitals, but says that starting diversion programs isn't easy.

If state and local governments don't take the lead, hospitals need to vet possible community mental health partners, create new care agreements and figure out how to pay for home-based services. All this while hospitals are already overwhelmed by staffing shortages.

Making these kinds of systemic changes may require "getting past some inertia as well as some reluctance to say 'is this really what we need to do?'" says Kang.

Some families hesitate to try diversion if their child takes psychiatric medications or if they think the child needs to start them. Youth Villages does not have prescribers on staff. Children who need medication see a psychiatrist or primary care doctor outside the program.

It's not clear what percentage of children and teens who go to a hospital ER for mental health care can be treated at home rather than in a psychiatric unit — home isn't always a safe place for a patient. But in other cases, home-based care can be the best option, says Matthew Stone, Youth Villages' executive director in Massachusetts and New Hampshire.

"Many of the mental health challenges that these children are facing are driven by factors in their natural environment: their school, their neighborhood, their peer system," says Stone. "It's our view that you really can't work on addressing those factors with a child in a placement."

Clinicians in psychiatric units do work on family and social issues, sometimes bringing family members into the hospital for sessions. There's no data yet to compare the outcomes, though.

Some mental health advocates argue that the need for diversion will subside as Massachusetts launches a multi-year plan to improve mental health care. But for the time being, Carmen and other parents coping with a new mental health crisis will likely still head for a hospital ER where they may be offered intensive counseling at home.

"A lot of parents don't know what the kids are going through because they don't want to accept that your kids really need help," she said. "Hopefully this can help another family."

This story comes from NPR's health reporting partnership with WBUR and KHN (Kaiser Health News).