What’s causing the boarding crisis in hospitals?

Lack of residential services is the root cause of the problem

“THEY’RE COMING in quiet,” the announcement said. They were the emergency medical technicians aboard the ambulance bringing Justice Thompson* from a hospital psychiatric unit to his first day at The Guild School. Though the ambulance siren was muted, there was nothing quiet about Justice’s arrival at The Guild.

Two EMTs wheeled in a gurney holding a long, lanky 15-year-old boy belted down and covered precariously by a damp, white sheet. Justice’s limbs flailed against the restraints, he moaned and thrashed his way into the special education school. The EMTs deposited him onto the classroom floor, naked and afraid. They left moments later without much explanation as to what happened on the 45-minute ride from the hospital.

Justice had spent the better part of a year at the psychiatric hospital’s inpatient unit, which was designed to stabilize youth with developmental disabilities who present danger to themselves or others. Such units are meant for short-term interventions in which patients receive evaluation, medication, and a prompt discharge to home or residential placement.

For Justice and similar patients, there are not enough safe places to discharge. Short-term stays often become prolonged beyond the capacity of the hospitals to serve them. More psychiatric beds are needed desperately to stabilize short-term crises. However, these are inadequate replacements for systems that support lifelong needs. The crisis of psychiatric boarding is actually a crisis of residential services for people with complex developmental and behavioral health needs.

Justice was always a complicated kid. Shortly before his hospital commitment, Justice began pulling pictures off the walls, throwing furniture, and striking himself on the head. He head-butted walls, floors, concrete stairs, and his grandparents. At nearly six feet tall and growing, he could no longer be contained at home. While not true of most people with intellectual disabilities, 10 to 15 percent exhibit self-injury, aggression, and property disruption. Justice’s behaviors were severe.

At the hospital, Justice banged his knee against his head with such force, he required seven staples near his temple. He wore splints on his arms and mitts on his hands while the injury healed. Within weeks, Justice no longer met the standard to stay in the hospital. He was not “in crisis.” The hospital needed Justice’s bed immediately for patients waiting in emergency departments .

Like other families in these circumstances, Justice’s grandparents faced an agonizing situation. Psychiatric hospitals use behavioral controls that cannot be replicated at home, such as 24/7 watch, chemical sedation, mechanical restraints, and locked time-out rooms. They wanted to avoid what frequently happens – a cycle of patients going from home to hospital and back again. Justice needed a residential special education school to keep him safe and teach him coping skills.

For almost a year, Justice’s grandparents worked through a system with long waiting lists and obtained what Justice needed – a residential placement. Meantime, Justice stayed in the hospital far too long, which, according to social workers, caused his behavior to worsen. If there were programs available sooner, this could have been avoided.

Both federal and Massachusetts laws guarantee students with disabilities a free and appropriate education, which can include residential special education programs. Unfortunately, the laws do not ensure that schools receive market rates for workforce, facilities, or program development. Thus, special education schools lack the ability to meet the overwhelming demand for services.

As a result, youth with complex developmental needs are left in precarious situations causing bottlenecks in emergency services and psychiatric units, like the one Justice experienced. Sadly, the problem is even more dire for adults (over 22 years old) with intellectual disabilities.

The Massachusetts Department of Developmental Services (DDS) promises supportive residential programs within 90 days for individuals who have immediate safety needs. Due to capacity issues, the reality of that pledge is often respite care, psychiatric evaluation units, or other temporary holding situations.

Workforce shortages certainly hamper program capacity; but more insidious is the state’s lack of funding for purchasing group homes that are expensive or even making down payments on those properties. Instead, nonprofit agencies have financed the state’s responsibility to provide supportive housing to people with complex developmental disabilities for decades. A pilot program from DDS may help to change that disparity, at least for new group homes.

In December 2022, DDS released temporary funding to incentivize nonprofits to open group homes for high-need adults. These enticements can be used to meet workforce challenges, but also have the potential to support down payments and renovations of new group homes.

Even so, nonprofits will need to leverage limited assets to mortgage homes at a time when both housing costs and interest rates are sky high. Hopefully, Massachusetts nonprofits will take on the challenge and survive. Recently, many have overextended and succumbed to financial pressures, further exacerbating the housing crisis and psychiatric hospital logjams.

As a teen, Justice’s crisis took a positive turn. He was supported by his grandparents’ tenacious advocacy and found a safe home at The Guild School. He learned to communicate more effectively and made new friends. In the coming year, Justice will need that advocacy again, perhaps more than ever. Justice will turn 22, only a few months after the DDS pilot program is set to expire, and his placement at The Guild School will cease.

If extended, DDS funding may offer Justice a safe place to call home. Yet, without such incentives, he may end up in another psychiatric ward like dozens housed at the state’s evaluation unit. Once again, Justice’s fate is uncertain and dependent upon temporary measures — unless the Commonwealth makes financing supportive residential services for people with complex disabilities a permanent priority.

*Last name is a pseudonym to protect privacy.

Amy C. Sousa is chief executive officer of The Guild for Human Services, a Massachusetts’ nonprofit supporting people with complex developmental disabilities. Dr. Sousa is a board delegate of the Massachusetts’ Association of 766 Approved Private Schools.