Mental health crises now represent approximately 5 percent of all emergency department (ED) visits in the United States, a proportion that has remained elevated since the COVID-19 pandemic.¹ However, most EDs lack the on-site psychiatric resources to manage this volume, leaving them reliant on off-site psychiatric consultation workflows with variable and prolonged response times. Only 46 percent of U.S. hospitals report having a psychiatrist available on-site, meaning the majority of U.S. EDs are managing psychiatric patients through systems built around waiting.²

The Gap

This limited access to timely psychiatric care directly affects throughput: ED length of stay for patients presenting with psychiatric emergencies is three times longer than that of other patients. It is driven by delays in evaluation, complex disposition planning, and limited inpatient psychiatric hospital capacity to receive transfers.^3-8 Across millions of visits each year, this inefficiency compounds and contributes to the boarding crisis experienced by EDs nationwide. Addressing this requires rethinking not just how psychiatric patients are managed in the ED but who is there to care for them.

Our Approach

We designed and implemented a novel staffing model, the Psychiatric Model of Care (PMC), to address prolonged ED length of stay for patients seeking mental health care. Our setting was an ED in a tertiary, urban academic medical center. Before the PMC was implemented, emergency psychiatry consultations were staffed by psychiatrists based off-site at a psychiatric hospital across the city. Coverage was intermittent, with reduced availability during nights and weekends. When a patient required psychiatric evaluation, the ED team placed a consult and waited. Reassessments were infrequent—often only once daily. After spending days in the ED, patients who were still waiting for final disposition plans or who could not be transferred quickly to a psychiatric facility were frequently admitted to the medical service simply to restore ED capacity.^3,9,10

We designed the PMC to replace this reactive consultation workflow with a proactive, on-site multidisciplinary team purpose-built for the problem. The core change was embedding psychiatric nurse practitioners (PNPs) in the ED 24 hours a day, seven days a week. PNPs started an initial evaluation within 30 minutes of a consult request from the ED team. Core staffing also included a psychiatric nurse and a psychiatric hospital assistant, along with social workers and substance use navigators already working in our department. The original psychiatry team remained available off-site for complex cases.

We evaluated the model using an interrupted time-series design across 5,222 ED encounters from January 2023 through December 2024, spanning pre-implementation, rollout, and post-implementation periods.

What We Found

Overall, median ED length of stay for patients seeking mental health care decreased by 1.6 hours from pre-implementation to post-implementation. The largest reductions in median ED length of stay occurred among the most severely ill patients—those placed on 72-hour and 14-day involuntary psychiatric holds. Additionally, patients who were transferred to inpatient psychiatric facilities saw reductions ranging from 4 to 18 hours.

Beyond length of stay, admission rates to the medical center decreased, and discharges increased, consistent with improved disposition planning by the new care model. Workplace violence events were also virtually eliminated. Less than 1 percent of patients returned to the ED within 72 hours and required admission or an involuntary psychiatric hold, suggesting that faster dispositions did not come at the cost of premature or unsafe discharges.

What We Learned

Early challenges included staff buy-in, role clarification across disciplines, and care coordination gaps during transitions. We worked through these iteratively to refine workflows and build shared expectations across the team. The rollout period was useful for learning in real time and allowed us to adjust model components before it was fully operational. By the time PNPs reached full coverage, the workflows had already been optimized, which made the PMC more sustainable.

Scaling This Approach

We recognize that not every ED has the resources to replicate this model exactly. Importantly, our PMC’s design built on existing staff and restructured existing workflows. Our findings are most applicable to hospitals without dedicated psychiatric emergency services. Departments with constrained resources can consider scaled versions: a single on-site PNP covering peak volume hours, a designated psychiatric nurse during shifts with the sickest patients, or formalizing the role of social workers who may already be present in the department. The goal is not to build a psychiatric ED inside every emergency department, but to move specialized, accessible expertise closer to the patient, earlier in the encounter, so that care moves faster and patients are better served.

Dr. Hewlett is an assistant professor in the Department of Emergency Medicine at the University of California, San Francisco. Her interests are in social determinants of health, implementation science, and health equity.

Dr. Fahimi is a professor of clinical emergency medicine at UCSF and the Executive Medical Director for Adult Emergency Department at UCSF Health. He is an affiliated faculty in the UCSF Institute for Health Policy Studies. He is a firearm injury prevention researcher and educator. 

Dr. Raven is a professor of clinical emergency medicine, Chief of Emergency Medicine at UCSF Medical Center and a Vice Chair in the Department.  Her research has focused on frequent users of the health system and the intersection of health system use, behavioral health, homelessness and incarceration.​​

Rebekah Manno is a nurse practitioner who holds dual certification in psychiatric mental health and family practice. She has been employed at UCSF in the emergency department and outpatient settings for 8 years. Her interests include managing refractory agitation, decreasing workplace violence and increasing psychiatric literacy in emergency departments.

References

1. Mental health-related emergency department visits. Centers for Disease Control and Prevention. Published February 19, 2026. Accessed March 14, 2026. https://www.cdc.gov/mental-health/about-data/emergency-department-visits.html
2. Ellison AG, Jansen LAW, Nguyen F, et al. Specialty Psychiatric Services in US Emergency Departments and General Hospitals: Results From a Nationwide Survey. Mayo Clin Proc. 2022;97(5):862-870. doi:10.1016/j.mayocp.2021.10.025
3. Nicks BA, Manthey DM. The impact of psychiatric patient boarding in emergency departments. Emerg Med Int. 2012;2012:360308. doi:10.1155/2012/360308
4. Alakeson V, Pande N, Ludwig M. A plan to reduce emergency room “boarding” of psychiatric patients. Health Aff Proj Hope. 2010;29(9):1637-1642. doi:10.1377/hlthaff.2009.0336
5. Major D, Rittenbach K, MacMaster F, Walia H, VandenBerg SD. Exploring the experience of boarded psychiatric patients in adult emergency departments. BMC Psychiatry. 2021;21:473. doi:10.1186/s12888-021-03446-1
6. Wilson MP, Brennan JJ, Modesti L, et al. Lengths of stay for involuntarily held psychiatric patients in the ED are affected by both patient characteristics and medication use. Am J Emerg Med. 2015;33(4):527-530. doi:10.1016/j.ajem.2015.01.017
7. Warren MB, Campbell RL, Nestler DM, et al. Prolonged length of stay in ED psychiatric patients: a multivariable predictive model. Am J Emerg Med. 2016;34(2):133-139. doi:10.1016/j.ajem.2015.09.044
8. Kraft CM, Morea P, Teresi B, et al. Characteristics, clinical care, and disposition barriers for mental health patients boarding in the emergency department. Am J Emerg Med. 2021;46:550-555. doi:10.1016/j.ajem.2020.11.021
9. Zun LS. Pitfalls in the care of the psychiatric patient in the emergency department. J Emerg Med. 2012;43(5):829-835. doi:10.1016/j.jemermed.2012.01.064
10. Bender D, Pande N, Ludwig M. A Literature Review: Psychiatric Boarding. U.S. Department of Health and Human Services; 2008. Accessed June 3, 2025. http://aspe.hhs.gov/reports/literature-review-psychiatric-boarding-0