Nearly 1 out of 8 children who visit emergency rooms in Oregon while in mental health crisis are stuck there for three days or more, according to new research from Oregon Health & Science University.
The situation of housing people in hospitals that aren’t providing appropriate care for them, known as “boarding,” stems from a fragmented behavioral health system, one that is unable to keep pace with the growing numbers of youths experiencing mental health crisis, according to the report’s author, John McConnell, director of the Center for Health Systems Effectiveness at OHSU.
It’s because there’s no inpatient bed or other placement for the youths, most of whom are suffering from suicide-related behaviors and depression. And while boarding is the polite term, critics use a different one: warehousing.
Part of the problem, McConnell told The Lund Report, is capacity.
“Oregon's numbers reflect a variety of system-level constraints,” McConnell said. Those include a shortage of psychiatric inpatient subacute beds for children, gaps in “step down” or community-based crisis services, workforce shortages, and difficulty in accessing care — challenges that are further stressed by the higher demand in services.
“We know in Oregon that there's been increasing youth mental health needs in recent years, and that probably magnifies those capacity limits and makes it harder to find places for kids who need care,” he added.
The study, published Friday in the journal JAMA Health Forum, examines nationwide Medicaid claims data from 255,000 emergency departments from 2022. It showed Oregon in line with the national average, with about 12 percent of Medicaid-enrolled youths seeking care for mental health conditions being “boarded” for three to seven days in emergency departments, or EDs, because an acute care bed was not available in the hospital.
In Oregon, more than half of all youths age 18 and younger are enrolled in Medicaid, which is the single largest payer for mental health care in the nation.
Boarding children in mental health crises in emergency departments poses numerous problems for patients, their families and staff. Psychotic episodes can create trauma for other ED patients and staff, and even non-psychotic patients can experience delays in care, clinical deterioration, and higher medical bills, which can have a disproportionate impact on children in lower-income families receiving Medicaid, according to McConnell, whose other research has documented the high use of emergency departments for mental health services nationwide.
“ED boarding is not a pleasant experience,” McConnell said, “I think the emergency providers are doing the best that they can, but it's not the ideal, optimal place that we want to have kids who are undergoing a mental health crisis, and that’s especially true for children, and especially true for low income (children).”
That emergency room responsibilities now include housing people experiencing mental illness Is part of a larger shift in recent years, one that providers say has increased demands on them and transformed the nature of their work.
Capacity outstripped by demand
Oregon’s problems meeting the behavioral health care needs of youth have been well documented. Oregon ranks 49th out of 51 on Mental Health America’s 2024 overall state youth ranking, with Oregon reporting higher rates of mental illness and lower rates of access to care than most other states and the District of Columbia.
The same report found 25 percent of Oregon youths reported a major depressive episode in the past year, the highest percentage among all states. With few exceptions Oregon’s youth suicide rate is consistently higher than the national rate.
Earlier this year, the Secretary of State’s Office released an audit of Oregon’s behavioral health services overall, finding not only that the needs outpace the state’s ability to provide services, but often those services don’t align with insurance options, including Medicaid.
The audit noted that initiatives by Oregon’s legislature and governor, including increased funding, have begun to address the problems, but “a higher degree of urgency and prioritization is needed.”
OHSU’s Doernbecher Children’s Hospital provides one example of the growing demand for psychiatric services among youth. The number of kids requiring a psychiatric consultation in the emergency department at Doernbecher has tripled from 150 in 2016 to 453 last year, according to the university.
Providence Oregon, meanwhile, reported that they’ve seen a decrease in the number of pediatric behavioral health cases in their emergency department, but due to decreased overall volumes in the patient population the rate of boarding visits, those held for 24 hours or more, has increased slightly to 16%, and the average length time spent has increased by 9% in 2025 over the previous year.
Youths not suited for Providence’s Child/Adolescent Psychiatric Unit require a lower level of care, which is a huge problem, Robin Henderson, chief executive of Providence Oregon’s behavioral health division said in a statement responding to questions from The Lund Report.
“The regulatory barriers to moving children and youth to lower levels of care …, make it difficult to find a setting that can care for youth who may have challenging behaviors,” Henderson said. “Emergency Departments aren’t designed to hold anyone for extended periods of time. They are noisy, bright environments that can be overly stimulating, which isn’t helpful in a psychiatric crisis.”
Anna Williams is the executive director of the state’s System of Care Advisory Council, an independent advisory group charged with improving the effectiveness of child-serving state agencies and the youth services continuum of care. The council monitors and reports to lawmakers and the governor.
Williams called the boarding issue the “canary in the coal mine.”
“What the ER boarding crisis shows us is that there's a bottleneck from the emergency rooms to that next place,” Williams told The Lund Report. “We are not doing treatment and care in emergency rooms for behavioral health services. We're just warehousing people there, waiting for them to get to the place that is appropriate for them to get the care and service that they need. So when people get stuck there, it's because there's nowhere for them to go next.”
A ‘system’ in which nobody is in charge
McConnell’s research shows that the rates of boarding vary greatly from state to state. Oregon’s is slightly above the national average of 12%, but there are striking state-by-state differences, McConnell said. In Arkansas, it's around 3%; in Iowa, it's about 27%. In five states, more than one in five visits resulted in an ED boarding stay.
McConnell said his research didn’t look into the cause for these variations. But according to his study the substantial differences suggest state-level policies are a factor.
McConnell told The Lund Report that Oregon needs to look at whether it has a cohesive continuum of care for young patients in crisis, with a variety of care options that are supported by Medicaid and other insurance payers.
Echoing the conclusions of outside experts who worked with Gov. Tina Kotek’s office, he and Williams called out Oregon’s disconnected authorities — which are spread over the Department of Human Services, the Oregon Health Authority, the coordinated care organizations that serve Oregon Health Plan members, and other agencies — as contributing to the problem.
Oregon needs a single, statewide entity responsible for all aspects of the mental health care system, they say, to ensure care is available and managed before, after visits to emergency departments — and instead of them.
“One thing that is missing in Oregon … is really a single point of accountability for these kids in need,” McConnell said. “That doesn't exist. Aside from the emergency physicians, there's nobody who's necessarily making sure that they're getting out as soon as possible, they're getting the care that they need, or even they're getting the care that they need before they show up in the emergency department.”
In 2023, the Oregon Health Authority ombuds office recommended Kotek form a new office to cut across agencies and respond to youth mental health needs, including racial disparities in the treatment they receive. No such office has been formed. At the time, one of the investigators who issued the report told The Lund Report the state’s boarding numbers reflect a “broken system.”
Upstream intervention needed
Youth intervention is critical, experts say. Research by the National Institute on Mental Health found that half of all lifetime cases of mental illness or substance use begin by age 14.
The boarding issue indicates problems upstream, before youths reach an emergency department, according to Williams, who said the council’s research has documented that youths are seeking care but are unable to access what they need.
“These are things that are building and building and reaching a point of crisis because they've gone unserved or underserved,” Williams said. “And then they're coming into the emergency room because they haven't been able to get substance use disorder care, or they haven't been able to get depression care, until it finally became a crisis.”
Williams and McConnell both cited the lack of options available for youths to “step down” to lower levels of care appropriate for their needs. In the past 10 years, the state reports Oregon has lost more than 40% of its licensed residential facilities that provide children and youth with behavioral or psychiatric treatment — from 90 facilities in 2014 to 53 facilities in 2024.
In his study, McConnell found that boarding was prevalent among individuals with primary diagnoses of suicide-related behaviors and depressive disorders, conditions that could be treated in subacute facilities if there was space available..
The shortage in care options for youth mental health drove a bill in the Legislature this year, supported by providers and hospitals, that was intended to loosen some regulations and open up select out-of-state care options for youth in the state’s foster care system.
House Bill 3835 drew months of heated debate, with supporters saying overregulation has stifled care options and led to the closures, and critics saying those regulations were essential protections for youths in the state’s welfare system.
The controversy derailed the bill, but the issues it raised are expected to return in upcoming sessions.
