The Boston Globe – January 4, 2025
By ELI CAHAN, Globe correspondent
Workers say at times many beds in these urgent-care clinics still sit empty.
Late on a Sunday night a few summers ago, Charlie Wainwright and his son drove up to a nondescript building in Salem. Wainwright had just rescued his son — also named Charlie— from the side of a road near Springfield after a manic episode. The younger Charlie had been shuttling vegetables from Western to Central Massachusetts as part of what he had convinced himself would be a profitable scheme. The delusion ended with an empty gas tank and a set of car keys lost in a tangle of forest.
In Salem, the two rang the doorbell and were welcomed inside a clinic that catered to people experiencing mental health crises. What ensued, Wainwright said, was “kind of all [we] wanted.” Muted light, open seating, private rooms, trained behavioral health staff on hand. The younger Charlie was evaluated, cared for, and eventually transferred to a private in-patient hospital on the North Shore for longer-term treatment. It was a dramatic shift from the typical chaos of emergency rooms, where patients like Charlie often end up, Wainwright said. “It didn’t have to be Disneyland,” Wainwright said. “It just had to be there and open when you needed it.”
In recent years, as America’s mental health crisis has hit historic proportions, national and state authorities have scrambled to find new treatment options for those in need of emergency care.
A cornerstone of the Biden administration’s plan: Community behavioral health centers like the one the Wainwrights turned to. Massachusetts, where the number of people reporting poor mental health tripled between 2019 and 2021, has embraced the centers, investing around $375 million into 31 locations since 2023. As of Aug. 1 this year, the federal government had invested nearly $41 million into the state’s CBHC rollout.
For people like the Wainwrights, who saw immense benefits from the center they visited, the initiative has been a boon. In her State of the State address last January, Governor Maura Healey touted CBHCs for “cutting in half emergency room stays for youths.” All residents of the Commonwealth, regardless of insurance, have access to CBHC crisis services. Yet many may still not have full access to the wider range of center services, including around 13 percent of MassHealth members, though they will gain full access later this year. Meanwhile, the centers— especially those few serving young people — are treading water financially as bills designed to increase reimbursement rates languish in the State House. One has already been closed, threatening the gains made in the first year of the program.
If the centers start closing in Massachusetts or elsewhere across the country, said Joshua Breslau, a senior behavioral scientist at RAND, a nonpartisan health care research organization, “a lot of the promise” of the program may be lost. CBHCs are mandated to provide urgent-care services 24 hours a day, seven days a week, for people suffering mental health crises. They offer focused care including de-escalation, counseling, and treatment soon after patients arrive. The centers also help relieve overcrowded emergency rooms where patients in need of mental health care can wait for days without getting treatment. Such waits, which averaged 49 hours in Massachusetts last January, according to the most recent data available, are not just inconvenient but also dangerous. Patients often get little or no psychiatric care in ERs — a setting that can actually worsen mental health crises, according to a report by The Joint Commission, the country’s leading accrediting body for hospitals.
As of Dec. 16, 329 behavioral health patients, including 47 children, were boarding in Massachusetts emergency rooms, down from 522 adults and 60 children last year. Behavioral health boarders and behavioral health patients awaiting evaluation now occupy 12 percent of ER beds across the state, down from 16 percent a year ago, according to data from the Massachusetts Health & Hospital Association. According to Breslau, the national consensus on CBHCs has been similar. “The reception has been positive,” Breslau said. “The program has been expanded and extended continuously.”
Pam Bolarinho, who leads Child & Family Services, a community behavioral health center in New Bedford, said her staff has helped hundreds of patients since it opened in January 2023.
Sean McCarthy of New Bedford, who suffers from episodes of psychosis, said he has taken to spending a few days at Child & Family Services after his hospital stays as a form of “step-down” care. “The goal of the crisis center is to return you to a functioning life,” said McCarthy, 55. “You feel like less of a number.” Among the patients who arrive at Bolarinho’s center in crisis, some 90 percent have successfully been discharged to the community after a few days without ever needing to go to the hospital, she said.
For all the good they’ve done, Bolarinho said her center’s crisis-services arm has struggled to stay afloat. On a given night, only about two-thirds of adult beds are full, she said. But given the reimbursement rate paid by MassHealth, the centers need to fill more of their beds to avoid losing money. Vicker DiGravio, president of Riverside Community Care, a community behavioral health center based in Dedham, said he needs to fill 90 percent of his center’s beds; anything below that, and they’re in the red. Bolarinho said the trends were more dire still when it came to their youth crisis units — services which, as of January, only 5 of 31 CBHCs were providing. At the Center for Human Development, a CBHC based in Springfield, only 40 percent to 50 percent of the facility’s 10 youth beds have been full on a typical night, according to data obtained by The Boston Globe. Part of the challenge, Bolarinho said, has been persuading emergency medical services and police departments to bring people to the centers rather than ERs. “Getting [EMS] and police to be open minded to this — that’s where this all starts.”
Often that decision may be driven by inertia or convenience rather than medical decision-making, said Derek Belong, assistant deputy police chief in New Bedford, where the department has the opportunity to divert patients in crisis to Bolarinho’s center. “From a police perspective, sometimes it is easier to bring people to the emergency room,” Belong said. “Officers can always take people there, drop them off, and leave.” There’s also the question of liability, Belong said. In Massachusetts, public agencies like EMS or police departments, and individual employees like officers, can be held liable for medical negligence. Given that negligence is defined by the Massachusetts Supreme Judicial Court as “a breach of the standard of care,” it’s not clear how bringing patients in crisis to CBHCs — a new, untested model — would be interpreted if things went south. So, the decision can come down to officers’ “comfort level,” Belong said.
The state’s Executive Office of Health and Human Services said that community behavioral health centers are still relatively new and that it was typical to see a period of ramp-up, but they were confident the services would become more financially sustainable as occupancy increased.
The reimbursement rate for crisis services has been another a major obstacle to expanding the program, said DiGravio of Dedham’s Riverside Community Care. Last year, DiGravio testified at the State House in support of two bills designed to increase reimbursement rates paid by MassHealth. But those bills stalled in the Legislature; in September, they were killed.
Another obstacle: For many Massachusetts residents, their insurance may not cover the broader range of CBHC-based care at all. Around 4.1 million citizens of the Commonwealth are privately or self-insured, according to data from the Kaiser Family Foundation. Under these plans, the services are still not necessarily covered. These barriers are forcing some centers to rethink what services they provide. One senior executive at a behavioral health center in a Boston suburb said their organization has considered opening beds for youths in crisis, but so far they’ve been hesitant to do so.
Others are already fleeing the business. Italian Home for Children, a CBHC based in Jamaica Plain, closed its youth crisis services arm in December, 2023. The organization did not respond to requests for comment. Since then, two new youth crisis stabilization units have opened — The Home for Little Wanderers in Walpole and Vinfen in Lowell. Still, despite the financial challenges, people like Bolarinho remain optimistic about the long-term prospects of the CBHC model. “I think it will be successful. . . . I really, really do,” she said. “But we need help.”
This story has been updated to reflect that all Massachusetts residents have access to crisis services provided by Community Behavioral Health Centers, regardless of insurance.