From Boarding to Breakthrough: Tailored Interventions for Vulnerable Patients

Abstract

Emergency Department (ED) boarding–prolonged stays in the ED while awaiting inpatient placement–is a crisis exacerbating crowding, increasing costs, and negatively impacting health outcomes. Vulnerable populations, including individuals with low socioeconomic status (SES), medically-complex older adults, and psychiatric patients are disproportionately affected. Yet, solutions tailored to their needs remain underexplored. This discussion examines root causes of boarding and proposes innovative, scalable interventions to mitigate its harms, specifically for marginalized groups. We highlight three strategies: (1) Patient Navigators, who assist low-SES patients navigating healthcare systems, (2) Community Paramedicine, which delivers in-home care to complex patients, and (3) Emergency Psychiatric Assessment, Treatment and Healing (EmPATH) Units, which provide targeted care for psychiatric patients. All three are associated with reduced ED visits. Traditional approaches to boarding have fallen short, particularly for vulnerable populations. Patient navigation, Community Paramedicine, and EmPATH units represent feasible, evidence-based solutions that health systems can implement. Broader adoption of these models can alleviate crowding, enhance care quality, and promote health equity. Future efforts must align these innovations with policy and funding mechanisms to ensure sustainable, system-wide improvements.

ED Boarding: Trends, Causes, and Harms

Boarding in Emergency Departments (EDs) remains a pressing challenge in modern healthcare. Characterized by holding patients in the ED for prolonged periods while awaiting inpatient beds or appropriate care coordination, this inefficiency strains resources and results in increased morbidity, mortality, and dissatisfaction.[1]ED Boarding Overview. Accessed December 27, 2024. https://www.acep.org/administration/ed-boarding-stories/ed-boarding-stories-overview,[2]Pearce S, Marchand T, Shannon T, Ganshorn H, Lang E. Emergency department crowding: an overview of reviews describing measures causes, and harms. Intern Emerg Med. Published online March 1, 2023:1-22. doi:10.1007/s11739-023-03239-2 It is also costly, resulting in millions in lost hospital revenue annually.[3]Foley M, Kifaieh N, Mallon WK. Financial impact of emergency department crowding. West J Emerg Med. 2011;12(2):192-197. Boarding contributes to overcrowding, longer wait times, and reduced access to emergency services, underscoring an urgent need for systemic solutions.[1]ED Boarding Overview. Accessed December 27, 2024. https://www.acep.org/administration/ed-boarding-stories/ed-boarding-stories-overview Despite decades of mitigation efforts, ED boarding continues to impact care delivery and hospital efficiency.

Strategies to mitigate boarding’s harmful effects rarely focus on marginalized groups. This discussion proposes solutions to mitigate the harm of boarding on vulnerable populations. Three interventions–Patient Navigators, Community Paramedicine programs, Emergency Psychiatric Assessment, Treatment and Healing (EmPATH) units–offer scalable solutions to address immediate challenges in EDs, as well as broader systemic inefficiencies in healthcare.

Crowding: Causes and Consequences

ED crowding is a result of patient-, system-, and staff-level factors. Input factors (aging populations, increased burden of chronic disease with episodic worsening, inadequate outpatient services) have led to increasing demand for emergency care, while throughput inefficiencies (extended wait times for diagnostics and treatment) contribute to crowding by keeping patients in the ED longer. Output challenges (shortages of beds at long-term care and rehabilitation facilities, insurance barriers to disposition) prevent patients from leaving the hospital and have been exacerbated since the COVID-19 pandemic.[2]Pearce S, Marchand T, Shannon T, Ganshorn H, Lang E. Emergency department crowding: an overview of reviews describing measures causes, and harms. Intern Emerg Med. Published online March 1, 2023:1-22. doi:10.1007/s11739-023-03239-2 Together, these forces have led to overtaxed ED environments where the demands of new and ongoing care come into conflict amidst inadequate space and staffing resources.

Traditional Solutions and Their Limitations

Existing financial incentives and penalties to ameliorate the boarding crisis have not been effectively enforced, or they have been removed. More generous reimbursements, and more substantial punishments for underperforming hospitals were thought to better motivate investment in previously unexplored solutions.[4]Weiner SG, Venkatesh AK. Despite CMS Reporting Policies, Emergency Department Boarding Is Still A Big Problem—The Right Quality Measures Can Help Fix It. doi:10.1377/forefront.20220325.151088 However, their effectiveness and sustainability have not yet been proven.

Additional strategies such as expanding observation units, ambulance diversion, and alternative admissions have been explored to address boarding. The success of observation units depends on accurate triage of patients who are appropriate for observation and on the nature of their chief concern.[5]Berger D, King S, Caldwell C, et al. Returns After Discharge From the Emergency Department Observation Unit: Who, What, When, and Why? West J Emerg Med. 2023;24(3):390-395. doi:10.5811/westjem.59023 Ambulance diversion can be a helpful short-term solution to overcrowded EDs. However, it does not address underlying causes of boarding and has been shown to increase mortality for certain conditions.[6]Yankovic N, Glied S, Green LV, Grams M. The Impact of Ambulance Diversion on Heart Attack Deaths. Inq J Health Care Organ Provis Financ. 2010;47(1):81-91. doi:10.5034/inquiryjrnl_47.01.81 Meanwhile, alternative admissions such as fast-track admissions can reduce stress on EDs, yet their feasibility is limited by available beds and physicians.[7]Oredsson S, Jonsson H, Rognes J, et al. A systematic review of triage-related interventions to improve patient flow in emergency departments. Scand J Trauma Resusc Emerg Med. 2011;19(1):43. doi:10.1186/1757-7241-19-43 Here, we focus on tangible solutions that merit further attention.

ED Boarding and Vulnerable Populations

Current strategies overlook unique barriers faced by vulnerable populations, such as individuals with socioeconomic risk factors, older adults with complex medical conditions, and patients with psychiatric needs. These individuals are disproportionately affected by boarding and face compounded difficulties in accessing care, highlighting the need for targeted solutions.

Low-SES populations and impact of boarding

Patients with lower socioeconomic status (SES), including Medicaid enrollees, have higher ED utilization rates compared to privately insured individuals in part due to challenges accessing primary care. In a nationally representative study, individuals with Medicaid visited the ED at nearly double the rate of those with private insurance.[8]Gindi RM, Black LI, Cohen RA. Reasons for Emergency Room Use Among U.S. Adults Aged 18-64: National Health Interview Survey, 2013 and 2014. Natl Health Stat Rep. 2016;(90):1-16. Increased ED visits for non-emergent conditions exacerbate overcrowding and can prolong length of stay for all patients in the ED. Moreover, patients with Medicaid or without health insurance are more likely to experience longer boarding times compared to those with private insurance.[9]Olson RM, Fleurant A, Beauparlant SG, et al. Prolonged Boarding and Racial Discrimination and Dissatisfaction Among Emergency Department Patients. JAMA Netw Open. 2024;7(9):e2433429. doi:10.1001/jamanetworkopen.2024.33429 This disparity is often due to difficulty finding inpatient beds in facilities that accept Medicaid or uninsured individuals. Delayed inpatient care for Medicaid patients can worsen health outcomes, particularly for chronic conditions such as diabetes or heart disease, which are more prevalent at baseline in low-SES populations due to social risk factors. Medicaid expansion itself has also been associated with increased wait times in the emergency department.[10]Allen L, Gian CT, Simon K. The impact of Medicaid expansion on emergency department wait times. Health Serv Res. 2022;57(2):294-299. doi:10.1111/1475-6773.13892 It is therefore imperative to investigate new routes to improve timely care for this growing population.

Primary care of older populations and impact of boarding

Developing robust outpatient care coordination via innovative community programs is an avenue to better serve older individuals, who are often medically-complex due to comorbid chronic conditions. Adults aged 60 and over account for an estimated 20% of emergency visits, and patients over 65 years old make up roughly 30% to 50% of patients boarded in EDs.[11]Ashman JJ. Emergency Department Visits Among Adults Aged 60 and Over: United States, 2014–2017. 2020;(367).,[12]Taylor M. The patient population most at risk of ED boarding. May 6, 2024. Accessed January 6, 2025. https://www.beckershospitalreview.com/care-coordination/the-patient-population-most-at-risk-of-ed-boarding This group faces higher risk in overcrowded EDs due to their vulnerability to adverse outcomes, including from immunocompromise, higher number of medical comorbidities, and increased likelihood of developing delirium. A French study, for instance, found that among 1598 patients (median age of 86) from 97 EDs, patients who spent the night in the ED had higher in-hospital mortality compared to those admitted before midnight (15.7% versus 11.1%; adjusted risk ratio 1.39; 95% CI, 1.07-1.81).[13]Roussel M, Teissandier D, Yordanov Y, et al. Overnight Stay in the Emergency Department and Mortality in Older Patients. JAMA Intern Med. 2023;183(12):1378-1385. doi:10.1001/jamainternmed.2023.5961 Studies have examined ED revisits among older adults, finding that among Medicare beneficiaries aged 65 years and older, one in five ED observation stays is followed by a hospital revisit within 30 days.[14]Dharmarajan K, Qin L, Bierlein M, et al. Outcomes after observation stays among older adult Medicare beneficiaries in the USA: retrospective cohort study. The BMJ. 2017;357:j2616. doi:10.1136/bmj.j2616

Furthermore, patients who experience delirium or agitation are generally older, more likely to have dementia, and have longer mean ED boarding duration, which leads to increased risk of physical deconditioning and further cognitive decline.[15]Joseph JW, Elhadad N, Mattison MLP, et al. Boarding Duration in the Emergency Department and Inpatient Delirium and Severe Agitation. JAMA Netw Open. 2024;7(6):e2416343. doi:10.1001/jamanetworkopen.2024.16343,[16]Ehrlich A, Erickson M, Oh E, James T, Saxena S. Prioritizing Care of Older Adults in Times of Emergency Department Overcrowding. J Geriatr Emerg Med. 2023;4(4). doi:10.17294/2694-4715.1067 Interventions outside the hospital that cater to this population are critical in order to address boarding.

Psychiatric patients and impact of boarding

Psychiatric patients face prolonged ED stays due to limited inpatient beds and mental health resources[17]Yoon J, Bui LN, Govier DJ, Cahn MA, Luck J. Determinants of Boarding of Patients with Severe Mental Illness in Hospital Emergency Departments. J Ment Health Policy Econ. 2020;23(2):61-75., while individuals with compounding social needs encounter systemic barriers that delay discharge or appropriate referrals.[18]Nicks BA, Manthey DM. The Impact of Psychiatric Patient Boarding in Emergency Departments. Emerg Med Int. 2012;2012:360308. doi:10.1155/2012/360308 Psychiatric patients often require 1:1 monitoring and security, which are limited resources. In addition, prolonged stays in loud and chaotic EDs can exacerbate psychiatric symptoms, further prolonging stays.[19]Nordstrom K, Berlin JS, Nash SS, Shah SB, Schmelzer NA, Worley LLM. Boarding of Mentally Ill Patients in Emergency Departments: American Psychiatric Association Resource Document. West J Emerg Med. 2019;20(5):690-695. doi:10.5811/westjem.2019.6.42422 A study in Annals of Emergency Medicine found psychiatric patients had a mean ED length of stay of 194 minutes, significantly longer than 138 minutes for medical-only patients. Additionally, 7% of psychiatric patients in that study experienced stays exceeding 12 hours, compared to only 2.3% of medical patients.[20]Lippert SC, Jain N, Nesper A, Fahimi J, Pirrotta E, Wang NE. 249 Waiting for Care: Differences in Emergency Department Length of Stay and Disposition Between Medical and Psychiatric Patients. Ann Emerg Med. 2016;68(4):S97. doi:10.1016/j.annemergmed.2016.08.263 Interventions should aim to mitigate the harmful effects of boarding for this population.

Innovative interventions to mitigate boarding harms for vulnerable populations

In addition to other strategies such as enacting new Centers for Medicare & Medicaid Services (CMS) payment requirements or building new hospital capacity, we suggest alternative interventions to reduce hospitalizations and mitigate ED boarding for vulnerable patients in ways that do not involve governmental regulatory reform or erecting buildings. Patient Navigators for low-SES patients, Community Paramedicine programs for elderly patients with complex conditions, and EmPATH units for patients with psychiatric conditions all demonstrate promising results for improving care pathways and reducing harms of ED boarding. These three programs are effective, feasible, and within the power of local systems to enact.

Patient Navigators

Patient navigation programs involve care coordinators who guide patients through health systems, ensuring timely access to services. These programs are successful with under- or uninsured patients. At one hospital, seven full-time, bilingual navigators were trained to connect patients with insurance and financial resources, as well as to schedule primary and specialty care visits. An impressive 81% of patients who enrolled later attended follow-up appointments scheduled by the navigator.[21]Peretz PJ, Vargas H, D’urso M, et al. Emergency department patient navigators successfully connect patients to care within a rapidly evolving healthcare system. Prev Med Rep. 2023;35:102292. doi:10.1016/j.pmedr.2023.102292 Additionally, a randomized controlled trial found an 18.7% cumulative decrease in hospital-based utilization (p=0.038) and fewer ED visits at 180 days among older patients receiving navigator support (p=0.09). Navigators in this study supported patients after discharge with a variety of needs ranging from medication adherence to insurance and transportation.[22]Balaban RB, Zhang F, Vialle-Valentin CE, et al. Impact of a Patient Navigator Program on Hospital-Based and Outpatient Utilization Over 180 Days in a Safety-Net Health System. J Gen Intern Med. 2017;32(9):981-989. doi:10.1007/s11606-017-4074-2 An ED navigation program in Massachusetts achieved a 52% greater likelihood of completed follow-up appointments within its intervention arm (odds ratio [OR], 1.52; 95% CI, 1.29-1.77) and a 32% decreased odds of repeat ED visits within 30 days (OR, 0.68; 95% CI, 0.52-0.90).[23]Bakshi S, Carlson LC, Gulla J, et al. Improving care coordination and reducing ED utilization through patient navigation. Am J Manag Care. 2022;28(5):201-206. doi:10.37765/ajmc.2022.89140 These studies demonstrate that by decreasing ED stays and increasing outpatient follow-up visits, patient navigators could reduce hospitalizations.

In another study, “super-utilizers” of the ED (5 or more visits per year) were randomized to receive support from a patient navigator who reviewed their care plan to identify follow-up services and arrange appointments and transportation within 12 months of the ED visit. The study found that ED visits decreased, and the authors estimated that health system costs decreased roughly $800,000 (20.2% decrease; 95% CI, 19.5%-20.9%) in the year after the study against a program cost of $34,808.[24]Seaberg D, Elseroad S, Dumas M, et al. Patient Navigation for Patients Frequently Visiting the Emergency Department: A Randomized, Controlled Trial. Acad Emerg Med. 2017;24(11):1327-1333. doi:10.1111/acem.13280

A 2020 trial investigated whether an ED-initiated patient navigation program could decrease ED visits, hospitalizations, and costs among 100 Medicaid-enrolled frequent (4-18 visits in the prior year) ED users. At twelve months, patients receiving support averaged 1.4 fewer ED visits (p=0.01), 1.0 fewer hospitalizations (p=0.001), and reduced per-patient hospital costs. If social needs were identified via screening, navigators provided information to connect individuals with housing, food, and other resources.[25]Kelley L, Capp R, Carmona JF, et al. Patient Navigation to Reduce Emergency Department (ED) Utilization Among Medicaid Insured, Frequent ED Users: A Randomized Controlled Trial. J Emerg Med. 2020;58(6):967-977. doi:10.1016/j.jemermed.2019.12.001

Community Paramedicine

Community paramedicine leverages mobile healthcare teams to provide in-home care, reducing reliance on EDs for non-urgent or preventable conditions. These programs address gaps in care for high-risk populations, including older adults and those unable to access primary care.

Queen Anne’s County Mobile Integrated Community Health (MICH) Program provided care coordination and home-based services for 233 high-risk patients with an average of 9.55 medications and 5.37 comorbidities per patient and accomplished a reduction in ED visits.[26]Queen Anne’s County Mobile Integrated Community Health (MICH) Program | Playbook. February 1, 2024. Accessed December 27, 2024. https://bettercareplaybook.org/resources/queen-annes-county-mobile-integrated-community-health-mich-program The authors found reductions in hospital readmissions at 30 days and 90 days after enrollment into the program. Their teams offered education about conditions, fall-risk assessment, home safety checks, and additional social support, contributing to a total cost savings of $3.39 million over three years.[26]Queen Anne’s County Mobile Integrated Community Health (MICH) Program | Playbook. February 1, 2024. Accessed December 27, 2024. https://bettercareplaybook.org/resources/queen-annes-county-mobile-integrated-community-health-mich-program

A 2023 study evaluated whether paramedic intervention could reduce hospital and ED readmission for patients discharged with myocardial infarction, congestive heart failure, or chronic obstructive pulmonary disease, and found significantly reduced readmissions at 120 days (34.6% vs 64.1%, p<0.001) and 210 days (43.6% vs 75.6%, p<0.001) compared to controls.[27]Burnett A, Wewerka S, Miller P, et al. Community Paramedicine Intervention Reduces Hospital Readmission and Emergency Department Utilization for Patients with Cardiopulmonary Conditions. West J Emerg Med. 2023;24(4):786-792. doi:10.5811/westjem.57862 This study’s intervention involved a visit from the paramedic within 48 hours of discharge and 1-2 times weekly for 30 days following the visit.[27]Burnett A, Wewerka S, Miller P, et al. Community Paramedicine Intervention Reduces Hospital Readmission and Emergency Department Utilization for Patients with Cardiopulmonary Conditions. West J Emerg Med. 2023;24(4):786-792. doi:10.5811/westjem.57862

By managing care in community settings, paramedicine programs decrease the influx of preventable ED visits, hospital readmissions, and free up resources for cases requiring immediate attention.

EmPATH Units

A newer concept called EmPATH units, or spaces designed for patients experiencing psychological distress, expand on opportunities to care for patients with psychiatric illness.[28]EmPATH Units: Better Care for Patients in Psychiatric Emergencies. Accessed December 30, 2024. https://www.vituity.com/healthcare-insights/empath-units-better-care-for-patients-in-psychiatric-emergencies/ In well-lit, comfortable settings, EmPATH units offer a calming environment and support connecting patients to the appropriate level of care. These units address unique needs of psychiatric patients, a group disproportionately affected by boarding. At M Health Fairview Southdale Hospital, use of an EmPATH unit led to a 10% decrease in ED returns within 30 days.[29]Diversion unit easing Minnesota’s psychiatric bed crisis. Accessed January 7, 2025. https://www.startribune.com/diversion-unit-easing-minnesotas-psychiatric-bed-crisis/600287451

The EmPATH unit is designed to operate in conjunction with the ED. The patient is typically seen in the ED, where the physician conducts medical and safety screenings to ensure the EmPATH unit is appropriate for the patient. Patients triaged to the EmPATH unit are then independently evaluated by a psychiatrist or advanced practice provider and either admitted, discharged, or sent to a care facility, depending on the trajectory of their symptoms. If the patient is unsafe, the ED is available to stabilize the patient.[30]Stamy, C., Shane, D. M., Kannedy, L., Van Heukelom, P., Mohr, N. M., Tate, J., Montross, K., & Lee, S. (2021). Economic Evaluation of the Emergency Department After Implementation of an Emergency Psychiatric Assessment, Treatment, and Healing Unit. Academic Emergency Medicine, 28(1), 82–91. https://doi.org/10.1111/acem.14118

By diverting psychiatric patients from EDs to specialized care, EmPATH units alleviate overcrowding and ensure patients receive appropriate, evidence-based treatment tailored to their needs. EmPATH units reduce the need for inpatient psychiatric admissions and free up ED resources for other patients, while connecting patients with psychiatric conditions to psychiatrists, nurses, and social workers.[31]Kim AK, Vakkalanka JP, Van Heukelom P, Tate J, Lee S. Emergency psychiatric assessment, treatment, and healing (EmPATH) unit decreases hospital admission for patients presenting with suicidal ideation in rural America. Acad Emerg Med Off J Soc Acad Emerg Med. 2022;29(2):142-149. doi:10.1111/acem.14374

Conclusion

Addressing ED boarding is a logistical challenge requiring multifaceted solutions that ensure equitable access to healthcare. The failures of traditional approaches, particularly for vulnerable populations, highlight the need for tailored solutions that address both the immediate crisis in EDs and the systemic inefficiencies across healthcare networks.

Innovative models such as patient navigation programs, community paramedicine, and EmPATH units offer promising pathways to reduce harms of ED boarding on lower-SES patients, those with complex medical conditions like the elderly, and those with psychiatric needs. By adopting and scaling these strategies, health systems can alleviate the boarding crisis and provide more efficient, compassionate, and equitable care.

It is important to highlight barriers and limitations to these interventions. For all three proposed solutions, the financial, logistical, and human resources available define what is possible for implementation. For instance, patient navigation programs may be challenging to develop without volunteer staffing or funding for new employees. The navigators might need to be equipped with the phones, space, and computers to contact patients if the support were provided following the visits. Alternatively, if navigators are to work with patients in the hospital setting before discharge, they would require training in working in this environment, orientation to hospital and patient safety regulations, and to meet compliance requirements. This could be a large lift for underresourced hospitals.

Community Paramedicine programs could be daunting to initiate. Emergency medical services would need to integrate with the local health system to identify participants and to prepare to meet their specific needs. Paramedics would need to be trained to provide preventative care required by complex patients, and staffing levels might need to be increased to maintain both an intact emergency response system and a community care program. Flight nurses that can staff mobile intensive care units might even need to be hired to deliver the appropriate level of care to chronically ill patients.

EmPATH units require physical space and qualified psychiatric staffing. The upfront investment to erect a new hospital unit and appropriately staff it will not be feasible for many hospitals, particularly in underinvested communities. These models will require clear buy-in from health system leadership teams in order to integrate vertically across interdisciplinary specialties within a single hospital and horizontally across hospital systems.

Future efforts must implement these solutions into a cohesive, data-driven framework that aligns with policy incentives and funding mechanisms. By fostering collaboration among policymakers, providers, and community stakeholders, we can develop sustainable models that enhance care coordination and reduce healthcare disparities.

Contributions

AM conceptualized the paper. TS and AP wrote the original draft. AM, TS, AP, and JB reviewed and edited the original draft. All authors contributed equally to literature searches, analysis and review of the writing.

References

1. ED Boarding Overview. Accessed December 27, 2024. https://www.acep.org/administration/ed-boarding-stories/ed-boarding-stories-overview
2. Pearce S, Marchand T, Shannon T, Ganshorn H, Lang E. Emergency department crowding: an overview of reviews describing measures causes, and harms. Intern Emerg Med. Published online March 1, 2023:1-22. doi:10.1007/s11739-023-03239-2
3. Foley M, Kifaieh N, Mallon WK. Financial impact of emergency department crowding. West J Emerg Med. 2011;12(2):192-197.
4. Weiner SG, Venkatesh AK. Despite CMS Reporting Policies, Emergency Department Boarding Is Still A Big Problem—The Right Quality Measures Can Help Fix It. doi:10.1377/forefront.20220325.151088
5. Berger D, King S, Caldwell C, et al. Returns After Discharge From the Emergency Department Observation Unit: Who, What, When, and Why? West J Emerg Med. 2023;24(3):390-395. doi:10.5811/westjem.59023
6. Yankovic N, Glied S, Green LV, Grams M. The Impact of Ambulance Diversion on Heart Attack Deaths. Inq J Health Care Organ Provis Financ. 2010;47(1):81-91. doi:10.5034/inquiryjrnl_47.01.81
7. Oredsson S, Jonsson H, Rognes J, et al. A systematic review of triage-related interventions to improve patient flow in emergency departments. Scand J Trauma Resusc Emerg Med. 2011;19(1):43. doi:10.1186/1757-7241-19-43
8. Gindi RM, Black LI, Cohen RA. Reasons for Emergency Room Use Among U.S. Adults Aged 18-64: National Health Interview Survey, 2013 and 2014. Natl Health Stat Rep. 2016;(90):1-16.
9. Olson RM, Fleurant A, Beauparlant SG, et al. Prolonged Boarding and Racial Discrimination and Dissatisfaction Among Emergency Department Patients. JAMA Netw Open. 2024;7(9):e2433429. doi:10.1001/jamanetworkopen.2024.33429
10. Allen L, Gian CT, Simon K. The impact of Medicaid expansion on emergency department wait times. Health Serv Res. 2022;57(2):294-299. doi:10.1111/1475-6773.13892
11. Ashman JJ. Emergency Department Visits Among Adults Aged 60 and Over: United States, 2014–2017. 2020;(367).
12. Taylor M. The patient population most at risk of ED boarding. May 6, 2024. Accessed January 6, 2025. https://www.beckershospitalreview.com/care-coordination/the-patient-population-most-at-risk-of-ed-boarding
13. Roussel M, Teissandier D, Yordanov Y, et al. Overnight Stay in the Emergency Department and Mortality in Older Patients. JAMA Intern Med. 2023;183(12):1378-1385. doi:10.1001/jamainternmed.2023.5961
14. Dharmarajan K, Qin L, Bierlein M, et al. Outcomes after observation stays among older adult Medicare beneficiaries in the USA: retrospective cohort study. The BMJ. 2017;357:j2616. doi:10.1136/bmj.j2616
15. Joseph JW, Elhadad N, Mattison MLP, et al. Boarding Duration in the Emergency Department and Inpatient Delirium and Severe Agitation. JAMA Netw Open. 2024;7(6):e2416343. doi:10.1001/jamanetworkopen.2024.16343
16. Ehrlich A, Erickson M, Oh E, James T, Saxena S. Prioritizing Care of Older Adults in Times of Emergency Department Overcrowding. J Geriatr Emerg Med. 2023;4(4). doi:10.17294/2694-4715.1067
17. Yoon J, Bui LN, Govier DJ, Cahn MA, Luck J. Determinants of Boarding of Patients with Severe Mental Illness in Hospital Emergency Departments. J Ment Health Policy Econ. 2020;23(2):61-75.
18. Nicks BA, Manthey DM. The Impact of Psychiatric Patient Boarding in Emergency Departments. Emerg Med Int. 2012;2012:360308. doi:10.1155/2012/360308
19. Nordstrom K, Berlin JS, Nash SS, Shah SB, Schmelzer NA, Worley LLM. Boarding of Mentally Ill Patients in Emergency Departments: American Psychiatric Association Resource Document. West J Emerg Med. 2019;20(5):690-695. doi:10.5811/westjem.2019.6.42422
20. Lippert SC, Jain N, Nesper A, Fahimi J, Pirrotta E, Wang NE. 249 Waiting for Care: Differences in Emergency Department Length of Stay and Disposition Between Medical and Psychiatric Patients. Ann Emerg Med. 2016;68(4):S97. doi:10.1016/j.annemergmed.2016.08.263
21. Peretz PJ, Vargas H, D’urso M, et al. Emergency department patient navigators successfully connect patients to care within a rapidly evolving healthcare system. Prev Med Rep. 2023;35:102292. doi:10.1016/j.pmedr.2023.102292
22. Balaban RB, Zhang F, Vialle-Valentin CE, et al. Impact of a Patient Navigator Program on Hospital-Based and Outpatient Utilization Over 180 Days in a Safety-Net Health System. J Gen Intern Med. 2017;32(9):981-989. doi:10.1007/s11606-017-4074-2
23. Bakshi S, Carlson LC, Gulla J, et al. Improving care coordination and reducing ED utilization through patient navigation. Am J Manag Care. 2022;28(5):201-206. doi:10.37765/ajmc.2022.89140
24. Seaberg D, Elseroad S, Dumas M, et al. Patient Navigation for Patients Frequently Visiting the Emergency Department: A Randomized, Controlled Trial. Acad Emerg Med. 2017;24(11):1327-1333. doi:10.1111/acem.13280
25. Kelley L, Capp R, Carmona JF, et al. Patient Navigation to Reduce Emergency Department (ED) Utilization Among Medicaid Insured, Frequent ED Users: A Randomized Controlled Trial. J Emerg Med. 2020;58(6):967-977. doi:10.1016/j.jemermed.2019.12.001
26. Queen Anne’s County Mobile Integrated Community Health (MICH) Program | Playbook. February 1, 2024. Accessed December 27, 2024. https://bettercareplaybook.org/resources/queen-annes-county-mobile-integrated-community-health-mich-program
27. Burnett A, Wewerka S, Miller P, et al. Community Paramedicine Intervention Reduces Hospital Readmission and Emergency Department Utilization for Patients with Cardiopulmonary Conditions. West J Emerg Med. 2023;24(4):786-792. doi:10.5811/westjem.57862
28. EmPATH Units: Better Care for Patients in Psychiatric Emergencies. Accessed December 30, 2024. https://www.vituity.com/healthcare-insights/empath-units-better-care-for-patients-in-psychiatric-emergencies/
29. Diversion unit easing Minnesota’s psychiatric bed crisis. Accessed January 7, 2025. https://www.startribune.com/diversion-unit-easing-minnesotas-psychiatric-bed-crisis/600287451
30. Stamy, C., Shane, D. M., Kannedy, L., Van Heukelom, P., Mohr, N. M., Tate, J., Montross, K., & Lee, S. (2021). Economic Evaluation of the Emergency Department After Implementation of an Emergency Psychiatric Assessment, Treatment, and Healing Unit. Academic Emergency Medicine, 28(1), 82–91. https://doi.org/10.1111/acem.14118
31. Kim AK, Vakkalanka JP, Van Heukelom P, Tate J, Lee S. Emergency psychiatric assessment, treatment, and healing (EmPATH) unit decreases hospital admission for patients presenting with suicidal ideation in rural America. Acad Emerg Med Off J Soc Acad Emerg Med. 2022;29(2):142-149. doi:10.1111/acem.14374