On one afternoon this week, a typical day for Children’s Hospital Colorado in Aurora, there were 10 children and teens in the emergency department who came because of a mental health crisis.
The child with the shortest length of stay had been there for four hours and 40 minutes at the time Dr. Sandra Fritsch, a child and adolescent psychiatrist at Children’s Hospital Colorado, checked her computer screen. The longest? 963 hours.
That’s 40 days.
The child is stuck in the emergency room because there isn’t an available bed at a step-down residential treatment center in Colorado or even another state. The shortage of treatment options and the massive increase in the number of children showing up in the emergency department for psychiatric help — up 103% in the first few months of 2022 compared with pre-pandemic levels of early 2019 — are why the hospital declared a pediatric mental health emergency in May 2021.
The American Academy of Pediatrics followed a few months later with a national declaration of crisis.
Since then, Colorado has poured $450 million in federal coronavirus aid into the state’s mental health system for children and adults. Now, lawmakers are debating a proposal at the state Capitol that could lead to increased payments for youth treatment centers.
The legislation, House Bill 1269, is an attempt to reverse more than a decade’s worth of closures of residential treatment centers. In the past 15 years, more than 40 residential programs for foster kids and other children with severe behavioral health issues have closed, the result of a nationwide effort to decrease funding for the centers and instead place kids with relatives, in foster families or in group homes.
The bill addresses “extended-stay” and “boarding” patients, which are hospital terms for kids who are staying in hospital beds when they don’t belong there. It’s not safe for them to go home, so they wait until there is space available at adolescent psychiatric hospitals, treatment centers or therapeutic group homes.
Kids stuck in hospital beds are not getting better, Fritsch said. “You’re not going to school,” she said. “You’re not walking around outside. You’re not seeing forward progress in your life.”
Some of them have been kicked out of foster homes or residential treatment centers for being aggressive or other behavioral health problems, which makes it even harder to find an available bed, she said.
“The longer you aren’t accepted someplace, then how do you feel about yourself?” said Fritsch, who calls the new proposal an important “first step.”
“You are developing that inside sense of who you are. That’s a really powerful message. Something needs to be done for these youth.”
The legislation, which passed its first hearing Tuesday, requires the Colorado Department of Health Care Policy and Financing to explore a new payment system that could lead to a larger network of mental health services for kids. Their findings would be due in October. It requires the Colorado Department of Human Services to create a pilot program that would financially incentivize residential treatment centers, encouraging them to expand and to accept young people with high-level problems.
It also would require the state agencies to better keep track of what is happening to children who need mental health care, including how many are sent out of state because there are no available beds in Colorado.
The agencies would have to produce regular reports showing the number of children who are kept in hospitals, hotels or county human services offices because they can’t go home and no appropriate placement was found.
Rep. Dafna Michaelson Jenet, a Democrat from Commerce City and the prime House sponsor of the bill, said that one bill won’t solve the crisis, but it would set Colorado on a path toward a better system. “Some of these kids end up sitting in emergency departments for days on end,” she said.
The measure calls for $100,000 in funding for the state Behavioral Health Administration so the agency can hire a contractor to develop a framework to assess the state’s adolescent mental health system. It’s unclear what a new funding system could cost in future years. But in the meantime, Michaelson Jenet said she wants to target up to $6 million this year in unspent county child welfare funds to support psychiatric beds, extending one-time COVID relief funds used to set up a pilot program for new beds in 2021.
Nearly all pediatric hospitals in the nation, 98.6%, board patients while they wait for a bed in a psychiatric facility, according to a 2021 report in the medical journal JAMA. Hospitals on average are boarding four children per day. The average length of stay in emergency rooms was 48 hours, much longer than the recommended best practice of four hours.
Emergency department visits for children with mental health conditions jumped by 60% from 2007 to 2016, according to the paper.