Mission Zero: A DHHS plan to eliminate boarding of psychiatric patients in emergency rooms by 2025

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People in acute behavioral health crisis at times end up in medical emergency departments, waiting for care in another setting—an occurrence known as “ED Boarding.”

CONCORD, NH– During Mental Health Awareness Month in May, the New Hampshire Department of Health and Human Services (DHHS) announces “Mission Zero,” a plan to eliminate hospital emergency department (ED) psychiatric boarding by 2025. The work to address ED boarding reduction is already a top focus for NH and DHHS, as outlined in NH’s 10-Year Mental Health Plan. Mission Zero will add additional resources and attention to overcome this urgent, complex challenge in collaboration with community stakeholders.

“Rebuilding our mental health system has been a priority since day one,” said Governor Chris Sununu. “Emergency department boarding lists exist in every state, but here in New Hampshire we have brought that number down to zero in the past and feel confident with broader community partnerships and engagement we can do it again.”

People in acute behavioral health crisis at times end up in medical emergency departments, waiting for care in another setting—an occurrence known as “ED Boarding.” ED boarding of individuals seeking inpatient psychiatric treatment is a national problem stemming from an array of economic and structural challenges in healthcare, compounded by severe workforce shortages and COVID-era increases in the prevalence and acuity of mental health issues.

“Building on years of progress, we are hitting the gas to fully eliminate ED boarding and build a mental health system that serves people at the right place at the right time,” said DHHS Interim Commissioner Lori Weaver. “The strategies employed as part of ‘Mission Zero’ are bold and proactive, designed to accelerate New Hampshire’s efforts to increase community-based services and reduce the need for, and length of, inpatient psychiatric admissions.”

DHHS has been planning Mission Zero for several months and knows it cannot be achieved overnight. The Mission Zero plan will address the key drivers of New Hampshire’s ED boarding challenge:

  • Front Door Issues – in which people in crisis go to the ED because they have been unable to receive timely services in the community to address their psychosocial needs and/or immediate psychological crisis;
  • In-patient Supply & Coordination Issues – in which people with acute psychiatric needs are unable to be transferred to an appropriate inpatient bed due to a shortage or system fragmentation of such beds; and
  • Back Door Issues – in which people are exceeding medically necessary stays in inpatient psychiatric facilities due to a lack of the right levels of support they need to discharge safely.

DHHS analyzed over 30 priority interventions and—integrating system data, longstanding community concerns, and national best practices—determined a subset of the most efficacious, shovel-ready efforts that align with ongoing implementation of and investments in the 10-Year Mental Health Plan. Among the strategies DHHS will pursue to address these drivers is a focus on expanding funding for community mental health centers (CMHCs) in the next State budget, which will allow for better workforce recruitment and greater financial security for CMHCs to make upstream investments in areas such as housing.

The Department will also launch the Certified Community Behavioral Health Clinic model pilot project to increase access to integrated and financially sustainable behavioral healthcare, laying the groundwork to potentially building a network of such centers in the state to operate as an alternative to hospital EDs and provide connections to mental health and substance use services. Additionally, DHHS will expand transitional housing and step-down care and develop landlord incentives to increase supportive housing for individuals awaiting discharge from New Hampshire Hospital. Providing they receive legislative approval, all of these components will be implemented by the fall of 2023.

Other strategies include the implementation of expanded designated receiving facility (DRF) capacity: Dartmouth Health will establish five new DRF beds that will open by fall 2024, and SolutionHealth will open a 120-bed behavioral health facility in early 2025. DHHS is also designing a Care Coordination function to oversee all adult referrals submitted for inpatient mental health treatment across all DRFs to ensure patients are admitted into the most appropriate bed in a timely manner. With legislative approval, it is expected to begin operating by the winter of 2023-2024.

This transformational work will not be achieved by one entity. In order for New Hampshire to reach Mission Zero, all stakeholders will work closely together to achieve its goal. The Department looks forward to ongoing collaboration with our partners throughout the State’s mental health system.


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NH Department of Health and Human Services