Letters to the Editor

Alternatives to the Emergency Department

TO THE EDITOR: The November Taking Issue column by Marvin S. Swartz (1) tackles the complex problem of emergency department (ED) boarding and its relationship to inpatient psychiatric bed capacity. As an organization specializing in facility-based crisis services, we are glad to see this issue receive attention and have the following comments:

Although the Smith et al. study (2) demonstrated that the poorest and sickest languish in EDs the longest, we disagree that there are “vanishingly few realistic alternatives.” Alternatives exist and increasingly are being adopted with positive results. Dedicated crisis centers with the capability to provide on-demand psychiatric assessment, intervention, and discharge planning are associated with reduced ED boarding and inpatient utilization, whether serving a specific ED (3) or a regional catchment area (4). Here in Arizona, a state with a long history of managed Medicaid and organized regional planning, such facilities can be found in every metropolitan area. We operate two of the largest, and in our experience the 23-hour observation model allows 60%270% of patients who would otherwise board in an ED (or jail) to instead transition to less restrictive and less costly community-based care...

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