At any given time, the emergency department at the Johns Hopkins Howard County Medical Center is treating an average of 11 patients with mental health or substance use crises — in a unit equipped for just six of them. Behavioral health patients at the emergency room often wait 24 hours to be transferred to a facility with an open bed, said Dr. Shafeeq Ahmed, the hospital’s president.

But next fall, Howard County’s hospital is set to quadruple the number of beds in its behavioral health unit. Construction is about to start on a more modern and therapeutic 7,000-square-foot “transitional space” for 24 patients while they wait for placement in an inpatient facility or stabilize enough to be discharged safely.

It’s also likely to shorten ER wait times for everyone else.

“It’s a really great move for the behavioral health population that comes to emergency rooms,” Ahmed said. “But also it does help if you’re using the emergency room in general because this opens up the space for people that don’t have psychiatric issues.”

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Patients who require psychiatric hospitalization to recover from a mental health crisis — usually because they are suicidal, homicidal or experiencing symptoms of a serious mental illness that make them unsafe — must board in the emergency department until an inpatient bed is found.

Delays in discharging behavioral health patients are one reason Maryland’s emergency room wait times are the longest in the nation. In a 2019 study, the Maryland Hospital Association found 42% of behavioral health patients experienced a delay in discharge or transfer, and these waits accounted for nearly half of the time they spent in emergency departments — an average of 20 hours total per patient.

Children and teens were delayed twice as long as adults, the same study found.

The number of visits to the emergency department for behavioral health went up by 12% between 2016 and 2020 while visits for all other reasons decreased by 11% over the same time period, according to the hospital association.

Extended time in an already crowded emergency department not meant for dedicated psychiatric care can also cause mental health symptoms to worsen.

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Howard County Medical Center has 20 inpatient psychiatric beds available for adults and Sheppard Pratt, a psychiatric hospital in Elkridge, offers another 85 beds for adults and adolescents. Otherwise, patients who visit the ER and need more intensive care transfer to other psychiatric facilities throughout the state, Ahmed said, depending on available space and their individual needs.

The pediatric emergency department at the Howard County Medical Center has a behavioral health unit that can accommodate four children, Ahmed said, but the hospital does not have an inpatient psychiatric unit for kids, and no others exist in Howard County.

ERs bear a disproportionate burden of behavioral health care because they’re so accessible to patients. Most outpatient psychiatrists or psychotherapists don’t accept public insurance, and many accept cash only.

Psychiatrists are by far the least likely of all physician specialists to accept any type of insurance, but the high demand for mental health care means they can run busy practices without it.

When patients with mental health challenges can’t access outpatient care, “their conditions deteriorate, and they really need acute mental health help,” Ahmed said. The ER is often their only option.

Then, once patients are discharged — whether it’s from the ER or inpatient care — connecting them with consistent outpatient care that can help prevent mental health crises and repeated trips to the emergency room is “one of our ongoing challenges; not just for this hospital, for all hospitals,” Ahmed said.

Sarah True is a public health reporter for the Baltimore Banner. She previously worked as a freelance journalist covering healthcare and health policy, and has been both a medical social worker and a health policy analyst in a past life. She holds dual Master’s degrees in public health and social work. 

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