Let’s get kids in mental health crisis out of hospital emergency departments

Not where kids in crisis belong. Photo by Getty Images.

Children suffering from behavioral health crisis are collectively spending hundreds to thousands of hours boarding in hospital emergency departments.

A bill (HR4779) sponsored by Rep. Kim Hicks, DFL-Rochester, would allow Medical Assistance — the Minnesota version of Medicaid, a public health insurance program for people with disabilities and the indigent — to be used for children to get treatment at a psychiatric residential treatment facility, or PRTF. There is a concurrent Senate bill (SF 2485) by Sen. Heather Gustafson, DFL-Vadnais Heights. Both bills expand state Medical Assistance programs to include treatment at a PRTF. One of the goals of the bills is to encourage expansion of PRTF services statewide.

Although it’s a step in the right direction, a problem is not being addressed: a lack of capacity. Psychiatric residential treatment facilities provide treatment to children and youth under 21 with complex mental health conditions. PRTFs are supervised by a physician seven days a week and provide residents and their families with individual, family and group therapy, as well as specialty services including occupational, physical and speech therapies.

Children with private insurance are currently able to be directly referred by their primary mental health care provider to a PRTF and are admitted upon first availability.

For children on state medical insurance or financial assistance, however, the process is long and tedious to get approval for treatment at a PRTF. Once approval has been given, children on Medical Assistance go on a wait list until a bed is available. The average stay at a PRTF is six to nine months, so waits for beds are long and often do not open in time, so the child ends up having a behavioral health crisis requiring treatment at an hospital emergency department.

As of April, Minnesota has four licensed PRTFs totaling 158 beds across the entire state. Legislation in 2015 directed the Department of Human Services to certify 150 PRTF beds, and subsequent legislation in 2019 authorized an additional 150 beds by July 2023. Three of the four original PRTFs are still operational, with a new facility that opened in December 2023. Even with legislation directing DHS to certify 300 beds by July 2023, the state lacks 142 of the authorized beds. Those 142 beds would reduce hospital emergency department boarding time of children who need residential treatment.  

Improving access for patients on Medical Assistance is one necessary part of the fix, but won’t be effective if the few treatment facilities are always at capacity.

With some legislative help, the Minnesota Department of Health instituted an exception to the public hearing process for licensing of mental health beds in hospitals, which has increased the amount of licensed short term care beds in the state. 

The exception does not apply to PRTFs, however, which means they still have to go through an extensive licensing process. To get a bed licensed for use as a PRTF, the MDH, the Joint Commission, and DHS all need to approve the license. The process is long and cost prohibitive for facilities just getting started. Even after fully constructed and ready to accept patients, any one of the licensing departments may decide not to license the facility, leaving it empty.

Legislators may see their proposed legislation as a fix to the bed problem because the program will allow for more revenue to the facilities treating children on Medical Assistance. While more revenue may go to the existing facilities, the increased revenue only goes to benefit the existing PRTFs and does not go to help open more facilities, which means the capacity problem will persist.

The Legislature needs to increase the number of beds and facilities the Minnesota Department of Health is allowed to license. Lawmakers should create a grant program to encourage new facilities to open and to lessen the burden on facilities during the licensure process. 

More PRTFs will benefit Minnesota families in crisis and reduce the strain on our hospital system. When we can get children out of hospital emergency departments and into PRTFs, beds in the hospital become available to people who need medical treatment.

Indeed, helping these children is not just a moral obligation — doing so will benefit all of us.

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