The behavioral health needs of children and youth have been rising for over a decade, and roughly 1 in 5 have a diagnosed behavioral health disorder. An estimated 50 percent of these children and youth do not receive necessary treatment or services. Without access to appropriate programs, services, and supports, unaddressed behavioral health needs of children and youth may become more significant and require more intensive care. Pediatric behavioral health-related emergency department (ED) visits have risen in recent years, and ED staff report these settings are often ill-equipped to respond. States and hospitals also have reported increased “boarding,” in which children and youth stay in the ED beyond when medically necessary while waiting to be connected to appropriate treatment.
Emergency department boarding is a complex issue driven by numerous factors and affecting many populations, including both children and adults with behavioral health needs and/or medical conditions. To address these challenges, many states are prioritizing efforts to improve the continuum of care for children and youth and address pediatric behavioral health-related ED boarding. Often, this requires a multi-pronged strategy developed in partnership with families, providers, and other partners. Given the breadth of this issue, this brief is not exclusive of all strategies, but highlights several key approaches states are taking.
Key State Strategies
- Tracking Data and Implementing Information Systems: States are tracking ED boarding data and developing information systems to better understand the need and to inform strategies to address this issue.
- Developing Cross-Sector Responses: States are developing cross-sector collaborations that include Medicaid, behavioral health, child welfare, juvenile justice, and other systems to identify systemic barriers and coordinate resources to reduce pediatric behavioral health-related ED boarding.
- Implementing Emergency Department Diversion and Transition Supports: States are implementing policies and initiatives to strengthen transition services for children and their families and divert them from the ED when appropriate.
- Expanding Intensive Behavioral Health Service Capacity and Quality: To better address the needs of those who currently are or are at risk of ED boarding, states are focusing efforts on developing and enhancing intensive home- and community-based services — such as crisis and stabilization services and supports, intensive in-home services, and intensive care coordination — and residential and inpatient care, such as psychiatric residential treatment facilities.
Tracking Data and Implementing Information Systems
States are tracking ED boarding data to better understand the scope of the issue in their state. These data may include the number of people with behavioral health needs boarding in EDs by location and/or region; the population’s demographics; and psychiatric provider capacity, including for inpatient psychiatric beds. Information technology systems and different methods of data tracking can help to identify needs and opportunities both at the individual and system level. For example, bed registries can support providers in real time to identify available inpatient psychiatric beds within the state and/or region. Data tracking, including through data dashboards, can support the identification of system-level drivers as well as inform policies and practice improvement.
- In 2021, Maine enacted a law requiring the state Department of Health and Human Services to coordinate with hospitals to develop a system that consistently tracks data on children in EDs for behavioral health needs. Officials in Maine are required to report these data to the legislature annually. The agency’s Office of Child and Family Services also maintains a Children’s Behavioral Health Data Dashboard that provides information on the number of children on a waitlist for behavioral health services and the number of children receiving residential treatment services, among other data points.
- Massachusetts established an Expedited Psychiatric Inpatient Admissions protocol to better address ED boarding for behavioral health needs and escalate cases to relevant state and clinical provider leadership. The protocol is supported by the statewide Behavioral Health Treatment and Referral Platform, which allows emergency department providers to make referrals electronically to providers with inpatient beds, including those specifically serving children and youth. The child’s health plan is automatically notified within 24 hours of referring through the platform, and the case is escalated to the Department of Mental Health when a child has been in an ED for 48 hours or more beyond when medically necessary and has an indicated need for inpatient admission. The initiative has published monthly dashboards with data on referrals, demographics, and the amount of time it takes to connect the individual to psychiatric care.
Developing Cross-Sector Responses
Children and youth with behavioral health needs are often served by multiple child- and family-serving systems, including Medicaid, behavioral health, child welfare, juvenile justice, and special education programs in schools or communities. Regardless of prior connection, the child welfare or juvenile justice system may become involved when a child is boarded in an ED. For example, a hospital may engage child welfare if it is attempting to discharge a child from the ED but the family does not feel equipped to bring the child home. Relatedly, some states have also reported increases in children staying in child welfare and juvenile justice offices due to limited treatment capacity. Recognizing the complexity of this issue, many states are developing cross-sector collaborations to identify systemic barriers and coordinate resources to reduce pediatric behavioral health-related ED boarding. Examples include:
- In 2023, Missouri enacted a law requiring the state Department of Mental Health and Department of Social Services to collaborate to assess and develop recommendations for improving responses to pediatric behavioral health-related ED and hospital boarding in the state. The law requires the state to partner with hospitals, health insurers, providers, schools, children and families, and other community partners to inform the recommendations by January 2025. These efforts have been supported by a cross-sector group, the Children’s Mental Health Collaborative, that has regularly met since 2022 to address this and other issues related to children’s behavioral health.
- North Carolina’s Department of Health and Human Services facilitates the cross-departmental Rapid Response Team to coordinate support for children and youth with behavioral health needs who are involved with the child welfare system and are boarding in EDs or county child welfare offices. When a child is admitted to a hospital for behavioral health needs, the county social services agency and the child’s Medicaid managed care plan are notified to support assessment and connection to appropriate treatment. If barriers to this process arise or are anticipated, the Rapid Response Team is notified to identify needed action. This team, which is defined in state law, is led by the state’s Child Behavioral Health Unit within the Division of Child and Family Well-Being of the state’s Department of Health and Human Services and includes representatives from the state’s child welfare, Medicaid, and behavioral health divisions and the division that oversees state-operated health care facilities. The Rapid Response Team coordinates closely with county child welfare agencies, local management entity-managed care organizations, and other partners. Additionally, the state created an Executive Response Team that includes leadership from across the department to support the Rapid Response Team.
Implementing ED Diversion and Transition Supports
States are implementing policies and initiatives to strengthen transition services for children and their families and divert them from the ED when appropriate. While some children and youth may require an inpatient level of care, many can transition to a less intensive level of care when connected to appropriate services and supports. Timely access to assessment, crisis intervention, stabilization, care coordination, and other behavioral health services can help to address the needs of children and their families and support the transition to an appropriate level of care.
- In 2024, New York invested funding to support critical time transition programs for children, youth, and families for six providers. These programs are co-designed by a number of child-serving agencies and implementation support is led by mental health, child welfare, and developmental disability agencies. These programs are designed to serve children and youth ages 11 to 17 who are boarding in EDs through a critical time intervention team and transitional residential settings. The critical time intervention team facilitates transitions from hospitals to the community or transitional settings through stabilization supports, intensive care management, and family engagement. These services are provided by case managers, an educational/vocational specialist, and a program director. Transitional residential settings are available for youth, as needed, for up to 120-day stays, where services are provided by a team that includes clinicians, registered nurses, family and youth peers, therapists, and behavior support specialists.
- In 2023, Oregon’s statewide stabilization services for youth launched as part of the crisis system and the state’s mobile crisis intervention services. The state’s stabilization services built on a decade-long pilot program, Crisis and Transition Services (CATS), that began in 2015 to support children and youth with behavioral health needs to transition out of EDs. The CATS pilot was established as a partnership between Oregon Health Authority, Oregon Health & Science University, and county and community-based organizations. Local CATS teams services included clinical (e.g., assessment, therapy) and peer support services (e.g., psychoeducation, skills development) for children and their families. Findings from a program evaluation indicate the program had positive effects, including reduced recidivism to EDs and suicide attempts, and increased youth and family skills and connection to resources. Oregon’s stabilization services are complemented by the state’s Intensive In-Home Behavioral Health Treatment program, launched in 2021. This service, an intensive community-based alternative to residential treatment and inpatient hospitalization, also aims to address ED utilization and boarding and support youth in transitioning to a lower level of care.
Hospital Models and Approaches to Addressing Pediatric Behavioral Health-Related ED Boarding
In addition to state efforts described in this brief, hospitals are advancing efforts to address pediatric behavioral health-related ED boarding by enhancing their services and transition supports. Example models and approaches include:
- From 2021 to 2022, Boston Children’s Hospital reduced pediatric behavioral health-related ED boarding by 53 percent by hiring additional staff to provide enhanced services, stabilization, and care coordination for children boarded in the ED and opening a new inpatient psychiatry unit.
- Children’s Hospital of Philadelphia designed and implemented a protocol to provide stabilization and education supports to families of children boarded in EDs, resulting in a higher rate of children safely discharged and a decrease in transfers to inpatient hospitalization.
- As of March 2025, the Medical University of South Carolina Shawn Jenkins Children’s Hospital is designing and implementing a pediatric Emergency Psychiatric Assessment, Treatment, and Healing unit — called EmPATH — to improve access to child- and family-centered psychiatric care for children in the ED.
Expanding Intensive Behavioral Health Service Capacity and Quality
Preventing and addressing ED boarding requires sufficient service capacity across the continuum of care to meet the needs of children and youth. This continuum includes a variety of services and supports ranging from preventive approaches such as mental health screening to identify needs early on, to residential care for those who need it. To address the needs of those who currently are or are at risk of ED boarding, states are focusing efforts on developing and enhancing intensive home- and community-based services — such as crisis and stabilization services and supports, intensive in-home services, and intensive care coordination — and residential and inpatient care, such as psychiatric residential treatment facilities (PRTF). These efforts include developing and enhancing:
- A range of home- and community-based services to prevent the use of EDs when possible and increase service capacity for children to transition out of EDs to the community
- In 2022, Ohio implemented the state’s specialized Medicaid managed care program for children and youth with complex behavioral health needs, OhioRISE (Resilience through Integrated Systems and Excellence). The program is designed to better serve this population in their communities by expanding coverage of several key services and supports, including intensive home-based treatment, mobile response and stabilization services, intensive and moderate care coordination, peer support services, behavioral health respite, and flex funds. The program also covers PRTFs to meet the needs of children and youth who require a residential level of care.
- States are building a comprehensive crisis care continuum (e.g., crisis call centers, mobile crisis teams, crisis receiving and stabilization facilities, and post-crisis supports) to better respond to children, youth, and families experiencing crisis. For example, New York and Wisconsin have developed crisis receiving and stabilization facilities to address the needs of youth and families in less restrictive settings.
- Alternatives to residential care, such as therapeutic foster care, for temporary community-based treatment or out-of-home respite
- Michigan operates a 1915(c) waiver program for children with serious emotional disturbances who meet a hospital level of care need. This program provides a range of home and community-based services for children who would otherwise require care in an inpatient psychiatric unit. This service array includes Children’s Therapeutic Family Care (formerly Therapeutic Foster Care). Following the evidence-based Treatment Foster Care Oregon model, children and youth engaged in this service in Michigan voluntarily reside in a therapeutic home temporarily (often six to nine months) without transfer of guardianship, while the family also engages in services. Therapeutic homes are licensed and overseen by community mental health agencies, as opposed to foster care homes overseen by the child welfare system. Therapeutic parents, as part of a treatment team from the community mental health agency, provide individualized and family-based treatment.
- Access to and quality of residential treatment for those requiring higher levels of care
- Often, children and youth with more complex needs (e.g., intellectual/developmental disabilities, significant externalizing behaviors, etc.) face additional barriers to accessing needed residential care due to limited staffing, resources, and clinical expertise. Several states, such as Oklahoma, offer “complexity add-on” payments to support PRTFs in serving children and youth with more complex needs who may require additional staffing and resources. In Oklahoma, this add-on payment is offered to PRTFs serving children who require more intensive treatment services and for those who are non-verbal. Oklahoma has also developed a provider designation for specialty PRTFs, which provide more acute care than standard PRTFs and serve children and youth with co-occurring mental disorders and intellectual/developmental disabilities. Through Medicaid, providers meeting the criteria for this designation receive additional payment per child per day to account for additional care costs.
Pediatric behavioral health-related ED boarding is a complex issue that requires a comprehensive strategy to improving children’s behavioral health systems. States are advancing a variety of approaches to address this issue, from developing near-term mitigation responses to enhancing services and supports across the children’s continuum of care to prevent and address the issue long term. NASHP will continue to track state approaches in this area as part of our work on children’s behavioral health.
Acknowledgments
Several NASHP staff contributed to this brief through input, guidance, and draft review, including Karen VanLandeghem and Heather Smith. NASHP wishes to thank the state officials who reviewed information NASHP gathered, as well as officials at the Health Resources and Services Administration for their review.
This resource is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under the National Organizations of State and Local Officials as part of a three-year award. The information, content, and conclusions are those of the author(s) and do not necessarily represent the official views of, nor are an endorsement, by HRSA, HHS, or the U.S. government. For more information, please visit HRSA.gov.
