This story comes to you from Sahan Journal through a partnership with MPR News.
Most of the time, 14-year-old Tyana lives peacefully with her aunt and legal guardian in an apartment on St. Paul’s east side. She likes going to school and dancing in front of the mirror and watching Disney movies and YouTube videos. But her autism causes her to experience occasional outbursts—she may lash out at a caregiver in order to get what she wants.
One day about a year ago, in the company of an adult relative, Tyana felt distraught. Her aunt, Jacqueline Hunter, doesn’t remember exactly what triggered that particular outburst—but she said Tyana often becomes upset if she doesn’t get to go to McDonald’s or Burger King or Dollar Tree.
In order to keep Tyana safe, Hunter sets alarms on her doors and windows to alert her if Tyana tries to leave. But on this day, the alarm wasn’t set, and Tyana jumped from the second-floor apartment window. Tyana wasn’t physically harmed, but Hunter was at a loss for how to keep Tyana safe. Hunter called Tyana’s social worker.
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“They told me to take her to the hospital,” Hunter said.
Hospitals don’t offer the type of care Tyana requires: that is, staff trained in helping kids with autism; and safe spaces for bathing and exercise. But Tyana spent five days in the emergency room, nonetheless. And, with nowhere else to go, she’s been back to the emergency room about five times since that event.
One part of Hunter feels relieved when the ambulance shows up. She knows that Tyana will be physically safe in the emergency room, with someone guarding her to make sure she doesn’t run away. But Hunter also knows that the hospital is not equipped to take care of Tyana’s complex needs.
“You have no other choice,” she said.
Tyana’s experience in the hospital is known as “boarding.” The kids in these situations fall into two categories: those with developmental disorders, such as autism and attention deficit hyperactivity disorder (ADHD); and those with mental-health conditions, such as depression and anxiety. When parents or guardians call 911 in response to a child in crisis, an emergency department will admit the child. (It’s a federal law.) But most hospitals do not have the resources or expertise to care for these patients.
Dr. Mary Beth Lardizabal sees this play out in her role as a child/adolescent psychiatrist at Allina, where she is also vice president of mental health and addiction.
“Boarding is kind of a loose term,” she said, “but in this context, it refers to when patients who don’t require or meet the criteria for acute mental health end up staying in the emergency room because there’s nowhere else to go.”
When kids are boarded, as Tyana was, they’re kept wherever the hospital can find space: in a windowless exam room meant for short-term stays; in a hallway; in a room on the pediatric medical floor; etc. They will receive 24/7 supervision for their physical safety–and perhaps no other treatment.
The number of children and adolescents boarding in Minnesota hospitals has climbed steadily over the past several years and shows no signs of slowing. In 2023, over 1,000 kids in the Twin Cities boarded in emergency rooms operated by the major health systems: Allina, Children’s, Fairview, and Hennepin Healthcare.
Experts say a disproportionate number of these kids are in the foster-care system or county custody, and a disproportionate number are Native American or Black.
Hospitals call it a crisis. The impact goes beyond the kids who are languishing in tiny rooms and hallways, not receiving appropriate care. Hospital staff point out that each bed filled by a boarded patient means fewer resources for patients with the types of other medical needs that often land people in in the ER, including overdoses, heart attacks, or car accidents.
In order to track the problem, Sahan Journal reached out to five health-care systems in the Twin Cities; four responded with data:
The hospitals that shared their boarding data say the situation also leads to poor employee morale and workforce burnout. Doctors and nurses may encounter challenging patients, with complex conditions they haven’t been trained to treat. Sometimes they experience physical altercations. Employee resignations leave the remaining staff with even more demands.
A newly released Minnesota Hospital Association survey of about 100 hospitals estimates the unpaid costs of “unnecessary” patient stays at $487 million–and 195,000 days (or 534 years) for the patients themselves.
These hospitals are asking for relief: A coalition of medical systems testified at the State Legislature in July 2023 and called for help to place these patients outside of hospitals. The hospitals have appealed to the Department of Human Services, and county health authorities. But with the limited options for residential treatment, little progress has been made.
“There’s been lots of condemnation, but not a lot of action,” said Lewis Zeidner, M Health Fairview's system director for clinical triage and transition services. “There have been lots of meetings. Lots of discussion. But we are truly harming these children, and this is not OK.”
How we got here
Even before COVID-19, mental health experts were sounding alarm bells: American youth were in crisis. The pandemic amplified the problem, as demand for treatment accelerated. The number of “beds”— or treatment slots — dropped at psychiatric residential treatment facilities that offer 24/7 care for people with suicidal ideation, severe aggression, and other safety issues. Facilities closed. One industry group has tracked 173 group-home closures since 2021.
As a result, kids with mental health diagnoses such as depression, anxiety, and bipolar disorder sometimes face months-long wait times for placement in residential treatment centers.
When a teen reaches a mental health crisis—say, a suicide attempt or violence toward other family members—parents or guardians call 911 and paramedics bring them to the emergency room.
But the problem also affects a second group of teens: those, like Tyana, who are neurodiverse and may have associated behavioral challenges. These children (primarily kids with autism) face an additional challenge: There are even fewer residential facilities that provide the complex types of care they require. Only a handful of facilities in Minnesota offer beds for kids with autism, where youth can access occupational therapy, medical support, individual and family therapy, and speech support.
“They’re the kids we worry most about,” Lardizabal said. “They’re in this never-never land because there’s a big gap in services.”
Kids who are living at home with limited treatment can become dangerous for the entire family. Desperate parents and guardians show up at the emergency room, sometimes on the advice of county social workers. (The term “guardians” includes foster parents and group-home managers.)
When Brenda Muthoni, a social worker, evaluates patients with mental-health assessments at Children’s Minnesota, they’re often in a crisis, she said. If no in-patient psychiatric beds are available, the children wait. Sometimes group homes drop off kids at the emergency department, then suspend services so the kid can’t return, Lardizabal said.
Under federal law, emergency departments can’t refuse care.
“There are very, very few places to send kids in terms of residential and group homes,” Lardizabal said. “So often kiddos are looking at out-of-state placements, which can take weeks or months. You might present a kid to 100 places and they all say no because the child is behaviorally complex.”
The crisis isn’t due to a broken system, said Sue Abderholden, executive director of the National Alliance on Mental Illness of Minnesota (NAMI). An adequate system was never built.
How boarding harms adolescent patients
Adolescent patients with behavioral needs stay in Fairview’s emergency room for an average of three weeks, Zeidner said. During that time, their living arrangement may consist of a bed in a hallway or a very small room with no windows and no bathroom, he said.
“It’s extremely boring, they don’t get outside, there’s often not an available shower,” he said.
The emergency room is not an environment where many people thrive, but it often proves exceptionally challenging for the kids who end up there. Boarded patients witness everything going on around them in the ER, including patients who are highly intoxicated or in a lot of emotional pain, Zeidner said.
“We can keep them physically safe,” he said, “but we can’t keep them safe from witnessing trauma for weeks and months.”
These kids tend to have developmental delays and behaviors that have become problematic to whoever is caring for them, Zeidner said. In general, kids in this group prefer consistent rules and caretakers. But in the hospital, the nurses and doctors change every eight or so hours.
“Despite the fact that we have a plan for them, there’s human variance in how they’re taken care of,” Zeidner said. “They often begin to act out because that’s what they do. If they don’t have good verbal skills, they might holler, they swing out, they kick out. And then people start to react to that. Then it escalates and those children get worse in terms of behavior and their ability to cope.”
Living conditions for boarding patients are less than ideal, agreed Dr. Aimee Sznewajs, a system medical director at Children's Minnesota. Often, kids who present safety or elopement risks are placed in highly restrictive environments.
“Really, everyone in the hospital gets to know and care for them, but they spend a lot of time essentially living with us,” Sznewajs said. “They’re deprived of normal activities like school, going outside, interacting with peers..”
The doctors and nurses who care for these patients say they are doing the best they can, but often their best isn’t good enough.
Ethically and morally we’re not willing to abandon them, but we don’t have the resources to really care for them.- Lewis Zeidner, M Health Fairview
“Ethically and morally we’re not willing to abandon them, but we don’t have the resources to really care for them,” Zeidner said.
In other words, when you’re boarding in the ER because of a mental health or developmental disorder, “you’re actually not getting treated,” Abderholden said.
All the doctors and advocates Sahan Journal spoke to emphasized that a similar lack of treatment would never be acceptable for patients with other medical needs.
“You wouldn’t say to someone who needs dialysis, ‘Sorry, we just can’t do that,’” Sznewajs said.
Recent research shows that boarded patients often experience a worsening of symptoms in the hospital.
A 2023 study by Brown University researchers, for example, found that boarded patients often fund their basic needs have not been met. As one emergency provider told the researchers, “I’m concerned that kids aren’t getting to shower regularly. Some kids in the ED choose the same food every day. I’ve had parents complain that they aren’t changing undergarments or [receiving] new scrubs.”
Research also chronicles other ways boarding may damage a patient’s health: The chaotic environment frequently heightens psychiatric disorders, and they are also at a higher risk for requiring chemical and physical restraints.”
“I've been doing this work for over 40 years, and few situations have caused as much emotional pain as this,” Zeidner said.
How boarding harms hospitals
In addition to the financial impact, hospitals say boarding impacts their ability to provide quality care to other patients.
Simply put, “we want to match the right resources with the right places,” Sznewajs said.
With staffing tight, boarded patients may limit a hospital’s resources to treat patients with specialized needs in, say, kidney disease or cardiac care. ”We’re not able to always serve the community in the way we need to,” she said.
Some repercussions aren’t as visible, such as the time hospital staff spend trying to find appropriate care for patients, outside the hospital. In one case, Zeidner recalls staff making over 100 attempts at placing a patient in a residential program.
The lack of appropriate resources leaves both patients and staff at a higher risk of being harmed, one study found.
Patients have sometimes hit Fairview staff members, Zeidner said. Employees haven’t left as a result, he said, but research has shown that boarding accelerates staff turnover at other facilities.
Boarding also takes financial resources from hospitals. Often, boarded patients are uninsured or don’t meet the criteria for the hospital to be reimbursed. And when a bed is found at an appropriate treatment center, it may be far from the patient’s home, even out of state.
That increases the care costs exponentially while decreasing the likelihood of followup treatment. The result? Kids show up back in the ER.
Solutions: Alternatives to hospitalization
Everyone who has experience with boarding—doctors, nurses, social workers, advocates—returns to the same core problem: There is nowhere else for patients to go.
“It’s not anyone’s fault, in a sense,” said Abderholden, the president of NAMI-MN.
Solutions will not be simple. A recent policy statement from the American Academy of Pediatrics recommends a multi-pronged 40-step action plan, enlisting hospitals, emergency responders, schools, and crisis-response teams.
The Minnesota coalition of hospitals has called for reforms, too. These range from changing the way counties negotiate with group homes to finding a new way to place kids with complex care in non-hospital settings.
Some changes, experts say, should occur upstream. Increased access to outpatient therapy, for example, could reduce the number of teens who end up in crisis.
Some work has begun on a few of these pieces. For example, Ramsey County is developing an urgent-care model for youth mental health, according to Codie Hillstead, project manager for the expansion.
In addition to expanding mobile crisis teams, the county is dedicating space in its adult mental- health clinic, near Regions Hospital, for families to receive assessments. Intensive therapeutic interventions could help fill in the gaps while waiting for long-term services, Hillstead said. These services could be in place as early as this spring.
But for the kids and families struggling right now, these developments and potential solutions may bring little comfort.
Tyana’s most recent visit to the emergency room lasted 55 days. It finally ended with Tyana getting a placement in a group home in Mendota Heights. But her aunt feels this facility can’t actually deal with some of Tyana’s needs. Hunter recently turned 60 years old, and she said she stays up at night worrying about Tyana and wondering if she should bring her back home.
Unless it’s absolutely necessary, Hunter said, she does not plan on calling 911 again.