By Granite State Report
On a recent winter night in New Hampshire, an adult in acute psychosis arrived at a community hospital emergency department in handcuffs.
He’d been picked up by police after wandering into traffic, shouting at cars that weren’t there. In the ER, staff removed the cuffs, took his shoelaces, locked away his belongings, and placed him in a small, windowless room. A physician signed an Involuntary Emergency Admission certificate, declaring him too unsafe to leave.
Under state law, that moment is supposed to trigger immediate access to psychiatric care and a probable-cause hearing within three days. In practice, it often triggers something else: a wait that can stretch into days—sometimes a week or more—on a hallway stretcher or in a repurposed storage room, under fluorescent lights, watched not by psychiatric nurses but by overworked ED staff and sometimes a security guard. (Naminh)
This is psychiatric boarding—keeping people who need inpatient mental-health treatment in emergency departments because there’s nowhere else to send them.
Emergency boarding happens all over the country. But for more than a decade, New Hampshire has been something of a grim case study and legal test bed—drawing scrutiny from the U.S. Department of Justice, the ACLU, the state Supreme Court, and a federal judge who ruled that the practice “commandeers” hospital resources and violates patients’ rights. (InDepthNH.org)
The state now says it is on the cusp of ending adult psychiatric boarding through an ambitious initiative called Mission Zero. In December 2024, officials announced—for the first time since they began tracking the numbers nearly four years earlier—there were zero adults in New Hampshire ERs waiting for inpatient psychiatric treatment. (NH DHHS)
That milestone matters. But the crisis is not over, especially for children and families. And the long path to get here exposes deep structural failures that go far beyond any courtroom deadline.
This is the story behind the numbers.
What “boarding” actually looks like
In emergency-medicine jargon, boarding means a patient is stuck in the ER after the decision to admit them has been made, because no inpatient bed is available. For psychiatric patients, boarding is routine rather than exceptional.
Nationally, studies have found:
- Psychiatric patients are roughly twice as likely to be boarded as medical patients, and their boarding times are close to five times longer. (ACEP Now)
- Nearly three in five youth seeking mental-health care at emergency departments are boarded. (ACEP Now)
- About one in three pediatric mental-health ED visits that result in admission or transfer involve boarding beyond 12 hours, with significant disparities by race and insurance type. (ScienceDirect)
For the patient, that can mean days in a loud, bright, chaotic environment designed for heart attacks and car crashes—not for someone in suicidal despair, psychosis, or a manic spiral.
In New Hampshire, advocates have long described scenes of people in crisis spending days:
- On stretchers parked in hallways
- In windowless “safe rooms” stripped of cords, sharps, and personal items
- Under constant observation, with no therapy, outdoor time, or meaningful activity
NAMI New Hampshire has been blunt: “Emergency department boarding is wrong medically, legally, ethically, morally and economically.” (Naminh)
How New Hampshire became a symbol of the crisis
The roots of New Hampshire’s boarding crisis go back years.
A fragile system, then budget cuts
Like other states, New Hampshire followed the national trend of deinstitutionalization—moving people out of large psychiatric institutions with the promise of robust community supports. The first part happened. The second never fully materialized.
By the early 2010s, federal officials were sounding alarms: a 2011 letter from the U.S. Department of Justice warned the state about its inadequate community mental-health system. That was followed by an Olmstead lawsuit over institutionalization and access to services. (Crisis Now)
Then the state cut funding again. Around 2013, closures and downsizing of psychiatric units, combined with shortages at the state psychiatric hospital, collided with rising demand. NAMI NH declared an “ED boarding crisis” at a 2013 press conference. (Crisis Now)
By 2021, on “many recent days more than 80 mental health patients had been involuntarily detained in emergency rooms,” including record numbers of children. (Naminh)
From quiet suffering to lawsuit
Advocates initially focused on the human and clinical harms. Hospitals added their own grievance: boarding was clogging EDs and tying up staff needed for other emergencies.
In 2018, the ACLU of New Hampshire filed a federal class-action lawsuit on behalf of “John Doe” and other patients, arguing that holding people for days in EDs without a timely court hearing violated due-process rights.(ACLU of New Hampshire)
Hospitals soon intervened. The New Hampshire Hospital Association and nearly 20 hospitals argued that the state’s practice of using their emergency departments as holding pens amounted to an unconstitutional seizure of their property—commandeering beds and staff. (KFF Health News)
The result was a rare alliance: patients’ civil-rights lawyers and hospital executives, standing on the same side of the courtroom, both saying the system was broken.
The legal turning point: Jane Doe and John Doe
Two court cases fundamentally reshaped the debate.
The Jane Doe decision: rights start at the ED door
In Jane Doe v. NH Department of Health & Human Services, a woman was held involuntarily at New Hampshire Hospital for 17 days before getting a probable-cause hearing—far beyond the three-day limit envisioned in state law. The state argued the clock didn’t start until she arrived at the psychiatric facility.
The New Hampshire Supreme Court disagreed. In a 2021 decision, it ruled that an Involuntary Emergency Admission (IEA) begins when the certificate is signed—typically in the ED—and that the state has a “duty mandated by statute” to provide a hearing within three days of that moment. (Justia Law)
In plain English: you can’t hide days of ER limbo outside the legal timeline.
The John Doe case and federal court
Meanwhile, the John Doe federal case zeroed in on boarding itself. In 2022, U.S. District Judge Landya McCafferty ruled that New Hampshire’s practice of keeping psychiatric patients in emergency departments for days violated both patients’ rights and hospitals’ property rights, calling it an illegal “commandeering” of hospital resources. (KFF Health News)
Her injunction required the state to eliminate psychiatric waitlists and ensure that once someone is held involuntarily, they get actual mental-health treatment—not days of waiting in an ED—within six hours. The original compliance deadline: May 2024. (New Hampshire Public Radio)
The state did not appeal. Instead, it negotiated.
In July 2023, DHHS and the New Hampshire Hospital Association announced a settlement ending the long-running “ER boarding” lawsuit. The agreement codified the May 2024 deadline and locked in the six-hour standard. (New Hampshire Public Radio)
New Hampshire, a small state with a big problem, suddenly became the national example in a major Mayo Clinic review of psychiatric boarding—held up as a sign that courts might force systems to change. (mayoclinicproceedings.org)
The human stories behind the statistics
Legal language can make this crisis sound abstract. The reality is brutally concrete.
“It felt like a cell”
In a 2023 profile, the New Hampshire Business Review told the story of a 29-year-old man, Dowling, diagnosed with schizoaffective disorder. After seeking help in crisis, he found himself stuck in an emergency department for days. “I wanted to get help, but no one was helping me and I was just stuck,” he recalled. “It felt like a cell almost, because I couldn’t leave or do anything.” (NH Business Review)
His experience isn’t unusual. On peak days earlier in the crisis, NAMI NH tracked dozens of people waiting at once—sometimes over 70 individuals, including more than 20 children, scattered across emergency rooms and correctional facilities while they waited for beds. (Facebook)
Children in limbo
For children, the stakes may be even higher.
National data show a “national emergency in child and adolescent mental health,” with rising rates of depression, anxiety, and suicidal behavior, and a growing fraction of youth presenting to EDs for psychiatric emergencies. (JAMA Network)
Emergency departments, designed around adult trauma and medical emergencies, are rarely equipped for a 14-year-old who just attempted suicide, or a 10-year-old in violent rage, or a nonverbal autistic child in meltdown. Boarding means they may spend days:
- Sleeping under bright lights that never fully dim
- Hearing trauma resuscitations and overhead codes
- With little access to family therapy, schoolwork, or structured activities
Clinicians interviewed in national reporting have described children waiting five days or more in EDs for psychiatric beds, deteriorating in the process. (ScienceDirect)
New Hampshire’s own numbers reflect that pressure: while adult waitlists have recently hit zero on some days, children still regularly wait for beds, according to the state’s daily psychiatric bed report. (NH DHHS)
Families and staff
Behind each boarded patient is a family waiting for a phone call, and a staff trying to hold the line.
Emergency clinicians say boarding warps the ED itself. A bed filled for days by a psychiatric boarder is a bed that can’t be used for new chest-pain patients or trauma victims. ACEP, the national emergency physicians’ group, now calls boarding a national public-health crisis linked to higher mortality, medical errors, staff burnout, and ED violence. (ACEP)
Boarding is not just a mental-health problem; it’s a whole-system failure.
Why boarding happens: the system behind the crisis
If you pull back from the individual patient, the causes come into focus.
1. Not enough beds, not enough staff
New Hampshire’s psychiatric system has a fixed number of Designated Receiving Facility (DRF) beds—the hospitals officially allowed to accept involuntary patients. The state’s own dashboard shows that demand for IEA beds frequently outstripped supply, especially before recent expansions. (NH DHHS)
It’s not just a bed count. Psychiatric units need psychiatrists, psychiatric nurses, mental-health clinicians, and mental-health workers. Workforce shortages have been acute nationwide; recruitment is especially tough in rural parts of northern and western New Hampshire. (Psychiatric Times)
2. Community services were hollowed out
When community mental-health centers can’t keep people stable—because caseloads are high, therapy slots are scarce, crisis teams are thin, or housing is precarious—people fall into crisis and end up in EDs.
New Hampshire’s 10-Year Mental Health Plan, released in 2019, acknowledged these gaps and set out a roadmap: strengthen community support, improve crisis services, and reduce ED boarding. (NH DHHS)
But plans don’t immediately rewind a decade of underinvestment. For years, the ED boarding list functioned as a visible pressure gauge on all the unseen upstream failures.
3. Discharge bottlenecks: nowhere to go after the hospital
Even when a psychiatric bed opens and a patient gets admitted, discharge can be slow—especially for people with serious mental illness who also need supportive housing or long-term residential care.
State reports on Mission Zero highlight this “back door” problem: patients are clinically ready to leave but remain at New Hampshire Hospital for weeks or months because there’s no appropriate housing or community placement. That backs up beds and keeps ED waitlists high. (NH DHHS)
The solution isn’t just more hospital beds. It’s more apartments with rental support, more residential programs, more step-down units, and more supportive services.
4. Kids and Medicaid patients face extra barriers
National research using Medicaid data shows wide variation between states in how often youth with mental-health ED visits end up boarded. In 2022, more than 1 in 10 such visits involved three to seven days of boarding, with suicide-related visits and depressive disorders particularly likely to be stuck. (JAMA Network)
New Hampshire’s own ranking on overall mental-health outcomes and access is mixed: the state has relatively high prevalence of mental-health needs and ongoing gaps in access to child psychiatry and intensive services, especially in rural areas. (New Hampshire Employment Security)
When you combine youth, Medicaid, and complex social needs, the probability of boarding spikes.
Mission Zero: New Hampshire’s high-stakes experiment
By 2023, the court orders, public outrage, and daily boarding lists had backed the state into a corner. It responded with a plan that is as ambitious as its name.
What Mission Zero promises
In May 2023, DHHS formally announced Mission Zero—a collaborative effort with NAMI NH and the New Hampshire Hospital Association to eliminate emergency department psychiatric boarding. (InDepthNH.org)
The goals:
- Add more inpatient capacity.
- Reopen beds at New Hampshire Hospital.
- Support a new 144-bed private psychiatric hospital in southeastern New Hampshire (a SolutionHealth project backed with $15 million in state funds). (New Hampshire Bulletin)
- Build a real crisis system.
- 24/7 mobile crisis response.
- Walk-in crisis centers and stabilization units (for example, a new crisis center and transitional housing in Derry). (InDepthNH.org)
- Fix the back door with housing.
- Transitional and supportive housing to move long-stay patients out of New Hampshire Hospital.
- Landlord incentive programs to rent to people leaving psychiatric facilities. (NH DHHS)
- Track the data in public.
- A new DHHS dashboard now shows ED psychiatric wait times, inpatient capacity, and Mission Zero metrics. Since early 2024, average wait times for inpatient beds have been under five days, down from longer waits in previous years. (Concord Monitor)
What’s actually changed so far
Progress is real, if uneven.
- In September 2024, New Hampshire reported average ED waits for involuntarily held patients had fallen to about 2.4 days, down from 4.8 days in January—still far from the six-hour legal goal, but moving in the right direction. (New Hampshire Public Radio)
- On December 6, 2024, the state hit a symbolic milestone: no adults in any emergency department awaiting psychiatric placement. It was the first zero day since data collection began in 2021. (NH DHHS)
A federal judge has twice extended the state’s deadline to comply with the court order—most recently into 2025—citing meaningful progress but recognizing that deeply entrenched system problems can’t be solved overnight. (NHCBHA)
There’s a tension here: legally, six hours is the standard. Clinically and politically, shaving waits from a week to two days to less than a day is still a big deal. Both things can be true.
How New Hampshire compares to the rest of the country
It’s tempting to frame this as a uniquely Granite State fiasco. The reality is uglier: New Hampshire is just one of the few places where the crisis has been dragged fully into daylight.
Nationally:
- A 2015 study found that psychiatric patients are twice as likely to be boarded and wait five times longer than medical patients. (ACEP Now)
- A 2020 Pediatrics study found nearly 60% of youth seeking mental-health treatment in EDs were boarded. (ACEP Now)
- The Joint Commission calls ED boarding of psychiatric patients a “continuing problem,” citing increased suicide risk, use of restraints, and staff burnout. (Joint Commission Digital Assets)
- AHRQ—essentially the federal research arm on healthcare quality—recently convened a national summit on ED boarding and is now soliciting targeted research to reduce it, explicitly describing boarding as harmful and linked to higher mortality and costs. (AHRQ)
New Hampshire’s legal rulings and Mission Zero are now showing up in national medical literature as a rare, concrete attempt to force systemic change. (mayoclinicproceedings.org)
The uncomfortable takeaway: ER mental-health boarding is not an aberration. It’s how a stressed, fragmented U.S. mental-health system naturally behaves unless someone intervenes.
Where the system is still failing
Mission Zero and the lawsuit settlement are necessary. They are not sufficient.
Children and teens
The clearest gap is pediatric care.
New Hampshire still has limited child and adolescent psychiatric bed capacity. On many days, DHHS’s own data show youth waiting for placements even when the adult list is at or near zero. (NH DHHS)
Nationally, children and teens with mental-health emergencies are more likely to be Black, Latino, or covered by Medicaid, and more likely to experience longer boarding. (ScienceDirect) That pattern won’t magically skip New Hampshire.
A serious fix would require:
- Dedicated pediatric crisis stabilization units
- More child psychiatrists and advanced-practice clinicians
- Embedded mental-health teams in pediatric practices and schools
- Better step-down and residential options for youth with complex needs
Rural residents
Most of New Hampshire’s psychiatric infrastructure sits in or near Concord, Manchester, Nashua, and the Seacoast. Patients from the North Country and Monadnock region may wait in small rural hospitals that have fewer staff, fewer security options, and fewer on-site psychiatric resources.
Telepsychiatry has expanded, but it doesn’t replace a missing bed or a missing safe discharge plan. (Psychiatric Times)
The invisible queue: outpatient waiting lists
Even as the ED boarding numbers improve, outpatient and community waiting lists remain long. A WMUR report from 2021 described dozens of children and adults in emergency departments waiting for beds, while statewide there were only a handful of open psychiatric beds. That scarcity was driven partly by crowded community services and limited step-down options. (WMUR)
Mission Zero could, perversely, succeed in its narrow goal—zero ED waitlist—while people wait months for therapy, case management, or housing. It’s the old balloon problem: squeeze one end, the bulge moves somewhere else.
What patients and families can do right now
For someone currently sitting in an ER with a loved one, long-range policy fixes are cold comfort. A few practical realities in New Hampshire:
- You have rights.
Once an IEA certificate is signed, the clock starts toward a probable-cause hearing within three days (excluding Sundays and holidays), as the Jane Doe decision clarified. Patients and families can ask hospital staff and appointed counsel about the hearing timeline. (Justia Law) - NAMI New Hampshire offers specific “ED wait” resources for both adults and children, including what to expect, questions to ask, and ways to advocate during boarding. (Naminh)
- Mission Zero’s public dashboard lets advocates and journalists track wait times and bed availability statewide, making it harder for officials to downplay the problem. (Concord Monitor)
That doesn’t fix the suffering in the room. But information and visibility are leverage.
What still needs to happen
If New Hampshire genuinely wants to end psychiatric boarding—not just meet a court deadline on paper—several things have to be non-negotiable.
1. Treat the six-hour standard as real, not aspirational
The federal court order didn’t pick six hours at random. Emergency medicine literature shows that the risks of medical error, violence, and clinical deterioration rise significantly as ED stays lengthen. (ACEP)
Even if the state hits “zero people on the list,” the question should be: How long did they wait? A patient who spends 47 hours in a seclusion room before a bed opens has still been failed—just in a way that doesn’t show up neatly on a dashboard.
2. Make children the priority, not the afterthought
Every major national body—from the American Academy of Pediatrics to the CDC—has warned about a youth mental-health emergency. Boarding a suicidal teenager for days in an adult ED is the opposite of trauma-informed care. (JAMA Network)
New Hampshire’s next big investments should be in:
- Child and adolescent psychiatric beds
- Crisis stabilization and partial-hospital programs for youth
- School-based and telehealth models that keep kids out of the ED in the first place
If Mission Zero solves adults first and then stalls, the state will have simply moved the crisis onto a younger population.
3. Build and fund the “invisible” services: housing and community supports
The people who stay longest in New Hampshire Hospital are often not the ones with the “hardest” psychiatric symptoms; they’re the ones with nowhere safe to go.
Mission Zero’s early housing pilots—transitional homes, landlord incentives, supportive apartments—are exactly the right direction. But they’re small compared to the need and vulnerable to budget cycles. (NH DHHS)
Ending boarding for good means committing to:
- Long-term rental subsidies tied to mental-health treatment
- Expanded supportive housing for people with serious mental illness
- Stronger guardrails so discharge planning can’t be “figure it out later”
4. Stop pretending this is “just” a mental-health problem
Boarding is what happens when multiple systems fail at once: health care, housing, child welfare, education, criminal justice.
- Jails and prisons become de facto psychiatric facilities.
- Schools become triage points for crises they weren’t designed to manage.
- EDs become the last open door for every problem upstream systems couldn’t or wouldn’t solve. (ACEP)
New Hampshire’s 10-Year Mental Health Plan and Mission Zero both gesture at cross-system work. The question is whether that collaboration survives past the current court orders and media attention. (NH DHHS)
Watch: Videos that bring the crisis into focus
For readers who want to see and hear these issues directly, these videos are a good starting point:
- “Health officials working to eliminate hospital emergency department psychiatric boarding” – WMUR-TV
Short segment on Mission Zero, featuring state officials, NAMI NH, and hospital leaders describing the human impact of ED boarding and the plan to end it.
https://www.youtube.com/watch?v=udhQy5h8JoQ (YouTube)
- “Federal judge orders phase-out of mental health boarding in NH emergency rooms” – WMUR-TV
News coverage of Judge McCafferty’s ruling and how it reshaped the state’s obligations.
https://www.youtube.com/watch?v=Fktl-xk9qd0 (YouTube)
- “NH ER boarding agreement reached” – WMUR-TV
Explains the settlement between DHHS and hospitals to end psychiatric boarding and what compliance is supposed to look like.
https://www.youtube.com/watch?v=QS5byzjQNso (YouTube)
- “Emergency Department Boarding is Wrong” – 988 Crisis Jam featuring NAMI NH’s Ken Norton
A deeper dive into why NAMI NH has been calling boarding “wrong medically, legally, ethically, morally and economically” for more than a decade.
https://www.youtube.com/watch?v=kHZyd2n8rhQ (YouTube)
- “The state of mental health care amid an effort to end ER boarding” – Granite State News Collaborative
A recent explainer on Mission Zero, with on-the-ground perspectives from patients, providers, and advocates.
Article and video embedded: https://www.collaborativenh.org/granite-solutions-coronavirus-1/2025/7/28/the-state-of-mental-health-care-amid-an-effort-to-end-er-boarding (Granite State News Collaborative)
References & further reading
- NH Department of Health and Human Services – Mission Zero overview and updates. (NH DHHS)
- NH DHHS – State Run and Designated Acute Psychiatric Bed Data (daily adult/child waitlist and bed availability). (NH DHHS)
- NAMI New Hampshire – ED Boarding resources for adults and children. (Naminh)
- Jane Doe v. NH DHHS – NH Supreme Court opinion on involuntary emergency admissions and due-process timelines. (Justia Law)
- NHPR, NH Business Review, and Concord Monitor coverage of the ER boarding lawsuit, Mission Zero, and the evolving wait-time data. (New Hampshire Public Radio)
- ACEP, Joint Commission, AHRQ, and JAMA articles on the national boarding crisis and pediatric mental-health boarding. (ACEP)
If you or someone you know is in crisis
- 988 Suicide & Crisis Lifeline – call or text 988 anywhere in the U.S.
- NAMI NH Information & Resource Line – 1-800-242-6264 (business hours). (Naminh)
- NH Rapid Response Access Point – 1-833-710-6477 or chat at NH988.com for 24/7 mental-health crisis support. (Naminh)
The ER mental-health boarding crisis isn’t inevitable. It’s what happens when a society quietly decides that psychiatric care can wait. New Hampshire has been forced to say, in court and in policy, that it can’t. Whether that promise holds—especially for the kids still sleeping under ED fluorescents—will be one of the quiet, defining tests of the state’s health system in the years ahead.
