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(April 16, 2019) Every day, communities across the country grapple with the shortage of psychiatric treatment beds.

Gaps in treatment options differ place to place, and all psychiatric beds are not created equal. State statutes, local policies, procedures, and financing all dictate who can access what type of bed, when, and for how long. Bed types include public psychiatric beds in state hospitals, psychiatric units in general hospitals, as well as acute care, sub-acute, crisis, and residential beds. Any community could have an adequate supply of one type, but a shortage of another, limiting treatment access for people with severe mental illness who will need multiple forms of care at various stages of their illness.

A research paper by colleagues Richard O’Reilly, Tarun Bastiampiallai and Stephen Allison published earlier this year attempts to address these questions by proposing a novel approach to calculating an appropriate number of psychiatric beds for a given community.

The authors begin by stating that the de-institutionalization movement and the discovery of psychotropic medications have shifted attitudes about the need for inpatient psychiatric treatment and led to a dwindling supply of psychiatric beds throughout the world. And, “in the absence of established targets, funders and administrators generally reduced the numbers of psychiatric beds using a “how low can you go?” approach,” they write.

But this “how low can you go?” approach has negatively affected patient care and safety. No matter the level of services in the community, evidence shows that bed numbers have been reduced below a minimal threshold, according to the authors. Indeed, there are now fewer state hospital beds per capita in the United States than there were in 1850, and every state falls short of having enough last-resort psychiatric hospital beds for patients whose treatment is not being adequately addressed in a community setting.

Here are a few ways the authors suggest calculating the number of beds that are needed:

• Expert consensus: agreement on defined principles between experts after careful review and discussion. This approach was used by the Treatment Advocacy Center as well as the Canada Psychiatric Institute which both led to an agreement that public psychiatric bed targets should be 50 per 100,000 population.
• Normative approach: based on the assumption that jurisdictions with similar health care systems and demographics will require the same number of beds. A community that is delivering good service can then act as a model on which a similar jurisdiction can base its estimate of the required number of beds.
• Population health: utilizing prevalence of serious mental illness in the population and applying standards for the components of psychiatric care needed. This requires certain assumptions about care delivery and length of stay that may limit its ability to accurately predict the number of needed psychiatric beds.
• Observed-outcome approach: proposes that varying access to psychiatric beds can be measured using observable outcomes on systems and populations. By examining the relationship between bed numbers and indicators, researchers can calculate the minimum and optimum bed requirements for a particular area to avoid negative outcomes. For example, measuring psychiatric boarding of patients with severe mental illness in emergency departments could be used as an indicator of adequate inpatient treatment supply.

The indicators the authors propose for the observed-outcome approach include hospital indicators such as occupancy rates and hospital readmissions, as well as population outcomes such as rates of homelessness among people with serious mental illness and suicide rates. The authors suggest that hospital indicators, in particular, will be most sensitive to bed changes within a community.

The authors conclude that the observed-outcome approach will allow policy makers to be more confident in setting target numbers of psychiatric beds. “When indicators such as bed occupancy, out of area admissions and length of stay in emergency rooms increase despite the provision of additional community resources, adjusting bed numbers upwards would seem to be the most appropriate action,” the authors write. “If our hypothesis, that there are thresholds for the number of psychiatric beds below which adverse outcomes begin to appear, is correct, the development of bed targets may avoid turmoil within hospital systems and ultimately improve the outcomes for patients and their families.”

This research lays the foundation for utilizing an observed-outcome approach to determine psychiatric bed targets in the United States. With regulatory changes last November, states may now apply for waivers to receive Medicaid reimbursement for inpatient stays at psychiatric hospitals with more than 16 beds. Previously, states were not reimbursed for this type of care, disincentivizing treatment within such facilities. As a result, determining the appropriate number of beds for a given state is especially pertinent. The observed-outcome approach represents an innovative avenue for states to use when applying for these waivers and looking to better address the treatment needs of their communities.

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