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Pediatric Mental Health Boarding Crisis in Emergency Departments

July 19, 2021
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Med Student's Research Can Facilitate Design of Better Care Models

The increased demand on emergency departments to provide behavioral health care to children—believed to be related to the stress of the COVID-19 pandemic on children and families—has escalated into a national crisis.

The challenge of providing a more appropriate care model for these patients would benefit from knowing the true cost of providing this type of care in ED settings.

Marcella Jewell, rising second-year medical student in the Population-based Urban and Rural Community Health track, is conducting research to understand the financial implications and resource utilization of caring for behavioral health patients in Baystate's pediatric emergency department. (Photo: Marcella Jewell holds  an illustration created for her by a patient boarding in Baystate's Pediatric ED)

Her Work Has Garnered National Attention

Assessing costs is challenging because traditional costing strategies may neglect to consider non-medical unreimbursed costs. 

Jewell's study used time-driven activity-based costing to calculate the true cost of care provided to a patient—from arrival to discharge—and that allows for accurate comparison of ED and non-ED care options.

Her important work has been widely recognized—she has given oral presentations at three national or regional conferences in the past year: Pediatric Academic Society, Society of Academic Emergency Medicine (SAEM)—her abstract is under consideration for an award, and the SAEM New England Regional Meeting where she was a plenary speaker.

Findings Have Already Had an Impact at Baystate

Jewell says this project was a true Baystate-wide collaboration. It was completed in the Baystate Medical Center's Pediatric ED under the guidance of Dr. Joeli Hettler, Chief of Pediatric Emergency Medicine, and in partnership with Dr. Jack Fanton, Division of Child Psychiatry, and Ashley Donovan and Andrea DiRico from the finance team.

Findings revealed a cost of $219 for every hour a child spends waiting in the Emergency Department for proper treatment. Wait time, boarding, and mandated safety companions constituted the majority of that. The total yearly cost at Baystate Medical Center was $3,900,000, of which $3,100,000 was non-value added.

Her results have already played a key role in operational initiatives to improve care for pediatric behavioral health patients.

"These figures can now be compared against other care options that are more cost effective, and likely safer," she said.

Culmination of Years of Work and Mentorship

Jewell began working with Dr. Hettler about four years ago as a pre-med student and a scribe in the ED. She soon became Hettler's research associate as well as a Trainee in the Institute for Healthcare Delivery and Population Science.

She and Hettler have worked on numerous quality improvement, data science, and advocacy projects together on this issue. Winning the AEXI Quality Improvement Grant in 2019 and other funding is supporting her current summer research project—helping Hettler design a health system-wide dashboard to track all the pediatric behavioral health patients in the system at once.

Jewell is grateful to Dr. Hettler for her trust and for the autonomy to take ownership of the project—she lead the project during her pre-med years and is first author on publications.

More About the Project

Abstract Title: “Assessment of Behavioral Health Care Costs for Pediatric Emergency Department Patients using Time -Driven Activity-Based Costing.”

The objective of this study was to identify the cost of boarding behavioral health patients in Baystate Medical Center's pediatric emergency department, an academic pediatric ED with a yearly behavioral health census of ~1000.  

To overcome weaknesses of cost strategy methods that ignore non-reimbursable efforts, time-driven activity-based costing was used to calculate the true cost. The study was supervised by Robert Kaplan, PhD, one of the co-creaters of the methodology at the Institute of Strategy and Competitiveness at Harvard Business School, to ensure the methodology was used rigorously.

Process maps were designed to detail each activity required to take care of these patients. Ten trained research associates rotated around the clock to track the time required to complete these tasks. The activities were categorized into stages: medical clearance, wait time, evaluation, and boarding—the first and third being the only value-added stages.