The price of behavioral health patients boarding in rural EDs
Rural hospitals know the behavioral health shortage through lived experience. A patient arrives at the emergency department during a psychiatric crisis. The team stabilizes the immediate risk, but the next step is unclear. The patient may wait for hours or days under bright lights with little privacy while nurses, physicians, social workers, security staff, and family members try to hold the situation together.
That waiting period is often described as psychiatric boarding. The phrase sounds administrative, but the experience is clinical, operational, financial, and human. For rural health care leaders, boarding is not only a behavioral health issue. It affects ED flow, nursing workload, patient safety, ambulance availability, transfer patterns, staff morale, and community trust.
Rural emergency teams are highly skilled at triage, stabilization, and urgent decision-making, yet psychiatric cases often require questions that need specialty input. Does this patient need inpatient psychiatric hospitalization? Can discharge be safe with a clear safety plan and rapid follow-up? Is the presentation driven by psychiatric illness, substance use, delirium, trauma, a medical condition, or several factors at once? Does the patient have capacity to make decisions? Is involuntary commitment still warranted?
Without timely psychiatric consultation, the safest option may appear to be holding the patient. That choice can be understandable, especially when beds are scarce and liability concerns are real. Still, holding is not harmless.
The ED is not built for prolonged psychiatric care. Noise, light, interruptions, shift changes, limited privacy, and long waits can worsen agitation, paranoia, anxiety, trauma responses, and despair. Staff must maintain suicide precautions, manage escalation, explain delays to families, coordinate placement, and protect other patients, often while also caring for stroke symptoms, chest pain, sepsis, falls, respiratory distress, and other emergencies.
Boarding also consumes scarce capacity, as that bed cannot be used for the next ambulance arrival, procedure, admission, or patient seeking care close to home. For a small hospital, even one or two boarded patients can change the rhythm of an entire day.
Helping rural patients access timely psychiatric care
Telepsychiatry will not solve every rural behavioral health challenge. It does not create inpatient beds, replace local crisis services, or remove the need for strong community partnerships. Its value is more practical: it brings psychiatric decision-making into the emergency care workflow when the bedside team needs it.
That distinction matters. The goal is not to place a psychiatrist on a screen and call the gap closed. The goal is to create a usable clinical plan, such as discharge with safety planning and rapid follow-up. The plan may also include medication changes, de-escalation strategies, observation, medical admission with psychiatric consultation, transfer to inpatient psychiatry, or continued involuntary commitment when risk truly warrants it.
Peer-reviewed data from the North Carolina Statewide Telepsychiatry Program (NC-STeP) give rural leaders a useful benchmark. One study reviewed 86,931 adult behavioral health ED visits across 30 North Carolina hospitals. Among patients with stays longer than two days, 62 percent were discharged when NC-STeP was available compared with 43 percent when it was not. Transfers to psychiatric facilities fell from 46 percent when the program was inactive to 29 percent when it was active.
Those findings do not mean discharge is always the right outcome. Some patients need inpatient psychiatric care, and rural hospitals need reliable transfer pathways for those cases. The point is to reduce transfers driven by uncertainty rather than clinical need.
The same program also reported a financial impact. Over 6.5 years, NC-STeP supported 19,383 ED telepsychiatry encounters. Among 13,537 encounters involving involuntary commitment, 4,627 commitments were overturned, or 34 percent. Of those patients, 85.9 percent were discharged home. Using a $4,500 avoided hospitalization estimate, the authors reported more than $20.8 million in savings.
How telepsychiatry offers a broader return
For rural hospitals, the return is broader than avoided hospitalization alone. Boarding consumes nursing hours, physician reassessments, sitter coverage, security response, environmental safety precautions, case management time, placement calls, documentation, and avoidable observation or inpatient days. It also carries opportunity cost when ED beds are unavailable and throughput slows.
The human cost matters, too. Rural clinicians often know the patient, the family, the employer, the school, or the broader story. That connection is a strength, but it can make prolonged boarding especially painful. Staff feel the gap between the care they want to give and the options available to them. Over time, that gap contributes to moral injury.
A strong telepsychiatry program can share clinical responsibility. A psychiatrist can help clarify risk, distinguish psychiatric illness from delirium or substance-related symptoms, advise on medication, support capacity determinations, assess whether an involuntary hold remains appropriate, and document a plan the care team can use.
For rural hospitals, the best programs are not one-off video consults. They are integrated services with simple ordering, dependable response times, documentation that fits the clinical workflow, local pathway development, and feedback from emergency medicine, nursing, hospital medicine, social work, security, and administration.
Leaders should judge telepsychiatry by practical measures: time from consult request to psychiatric evaluation, ED length of stay for behavioral health patients, decision-to-disposition time, transfer and discharge patterns, involuntary commitment rates, restraint and emergency medication use, safety events, 7- and 30-day return visits, staff confidence, avoided hospitalization, and recovered capacity.
Access is not a slogan. It is whether the patient is seen, whether the team has a plan, whether the ED bed turns over, whether the transfer was necessary, whether the nurse feels supported, and whether the patient leaves with dignity and a next step that can actually happen.
For rural hospitals, telepsychiatry is most valuable when it helps care move again. Movement matters for a patient in crisis. Time matters. Dignity matters. So does protecting the local hospital’s ability to care for the next patient who comes through the door.
NRHA adapted the above piece from Equum Medical, a trusted NRHA partner, for publication within the Association’s Rural Health Voices blog.
 | Richard Catanzaro, MD, serves as assistant chief medical officer and director of psychiatry at Equum Medical, where he provides clinical leadership for virtual care services and leads the development of telepsychiatry programs designed to expand access to mental health care. He previously served for more than 11 years as chairman of psychiatry at Northern Westchester Hospital. |
References
The Impact of the North Carolina Statewide Telepsychiatry Program (NC-STeP) on Patients' Dispositions From Emergency Departments
DOI: 10.1176/appi.ps.201900431
The Impact of NC Statewide Telepsychiatry Program (NC-STeP) on Cost Savings by Reducing Unnecessary Psychiatric Hospitalizations During a 6½ Year Period