When experiencing a health-related emergency, the hospital emergency department is recognized as the most appropriate place to seek care. While EDs have varying degrees of expertise and services, they are expected to be able to identify and stabilize the emergent condition and secure the next appropriate level of care for the patient. However, mental health emergencies are one of the most complex and least understood conditions presenting in an ED. And, as a byproduct of constrained access to community-based mental health services, the frequency of psychiatric patients presenting in EDs for care is a rapidly growing phenomenon in Missouri.
Since 2006, ED utilization for mental diseases and disorders at Missouri hospitals have increased by 43,000 visits per year — an increase of 42 percent. During the same period, utilization for substance abuse and induced mental disorders rose by 79 percent in Missouri. Combined, these conditions have outpaced hospital utilization for all other reasons by 230 percent in Missouri during the last 10 years.
In the U.S., adults living with serious mental illness die on average 25 years earlier than others, largely due to treatable medical conditions – National Alliance on Mental Illness 
The increasing numbers of patients with mental illness being seen in EDs has captured the special attention of government agencies and hospital administrators. Improving efficiency of care and the quality of care delivered in EDs has become an important focal point for these groups. For example, the Centers for Medicare & Medicaid Services is measuring several indicators of quality of care, including patient length of stay, readmissions and ED boarding times. In Missouri, psychiatric patient boarding times are a significant concern. A recent HIDI analysis of Medicaid mental health patients found an average ED boarding time of nearly eight hours in 2016 (this was up 48 percent over just five years). They also found that the total amount of time spent in an ED for mental health patients with Medicaid had increased by 84 percent since 2012, to more than 100,000 hours — this is the equivalent of 14.4 years (Figure 1).
In the U.S., the movement towards deinstitutionalization has resulted in the closure of psychiatric beds and other available resources making efficiencies in care a challenging issue to tackle. In 1990, Missouri had more than 1,400 additional psychiatric hospital beds as compared to 2012, a decrease in capacity of 32 percent. The net effect of this decline in capacity leaves Missouri with 22.2 psychiatric beds per 100,000 total Missouri population — fewer than half of the recommended minimum of 50 per 100,000.
Movement toward community-based health care and away from inpatient-based mental health care is a goal shared by Missouri hospitals and freestanding inpatient psychiatric hospitals; however, success hinges on resource availability in Missouri’s communities that is adequate to meet the growing need for these services. Today, those resources are scarce and do not meet the need for ongoing care and follow-up within this population. Psychiatric patients are left waiting in EDs for longer periods of time, which compounds an already complex situation.