Can New York's plan for the homeless with mental illness make a difference?

Can New York’s plan for the homeless with mental illness make a difference?

People with serious, untreated mental illnesses on the streets and subways have been a heartbreaking feature of New York City life for decades. But last month, Mayor Eric Adams announced an end to the days of ignoring the problem and revolving doors between hospitals, prisons and the streets.

To help New Yorkers who are a danger to themselves get the help they need, Adams said, they will be taken to hospitals, even if they don’t want to go. He said he wanted hospitals to hold people back until a workable plan was in place for their care outside.

In short, he wants the system to work as it should, but has never done so. It seems like a huge task, and similar efforts by previous mayors have largely failed.

But Mitchell Katz, the city’s director of public hospitals, says it can be done. In an interview this month, he said there were perhaps 1,000 people, out of the tens of thousands of homeless people in New York City, who needed such drastic intervention. “A thousand people is not an insurmountable number,” he said.

Since taking office in January, Mr. Adams has taken aggressive steps to dismantle street encampments and convince homeless people to go to shelters, and the Gotham Gazette news site reported this week that up to by now this year, police had already removed 1,300 mentally ill people from the transit system and transported them to hospital, often against their will. Mayor Adams and Gov. Kathy Hochul have also flooded the transit system with police in recent weeks — something they’ve done several times already this year.

But as of September 30, the number of people in a city database of homeless people who had had contact with outreach workers was 10% higher than a year earlier – 2,163 people, up from 1,974. And although the vast majority of people with serious mental illnesses are not violent, Mr Adams said an increase is “driven by people with mental health problems”.

The laws on involuntary hospitalization have not changed. Mental health workers, paramedics and police have long been able to forcibly take people to hospital if they appear mentally ill and endanger themselves or others, and courts in New York have ​​held since the 1980s that being a danger to oneself involves not being able to meet basic needs such as food, shelter and health care.

What the mayor has mandated is a change in practice, training and discretion. City officials said workers would be made aware of state guidelines that people can be taken to the hospital “even if there has not been a recent unsafe act.”

The plan is being rolled out gradually – police training on how to deal with people with mental illness under the new policy begins this week. To help police determine if a person should be involuntarily taken to hospital, officers will be able to call a hotline staffed by mental health professionals, the mayor said.

The mayor is also pushing for much more extensive use of Kendra’s Law, which allows courts to order people into outpatient treatment if they have a history of hospitalization, violence and non-compliance with recovery plans. treatment. The law does not allow forced medication, but people who stop taking their medication and relapse can be ordered to appear for a status hearing or brought to the hospital for evaluation.

A 2010 study based on data from the law’s first eight years found that people on Kendra’s Law orders were nearly 25% less likely to be hospitalized, spent 20% fewer days hospital and were 47% more likely to receive medication. within the first six months after receiving an order, compared to the previous period.

Homeless people in the throes of a psychotic episode are often transported by ambulance to psychiatric emergencies, where they can be kept under observation. If deemed dangerous to themselves or others, they may be admitted for short-term involuntary hospitalization – up to 15 days.

But there is a shortage of inpatient psychiatric beds in New York City, which means many are languishing in psychiatric emergency rooms longer. Some inpatient psychiatric wards accept few Medicaid patients, which can make it difficult to find beds for the homeless.

For patients ultimately admitted to a psychiatric ward, the median stay in New York City is only about 11 days. Among the homeless, most psychiatric hospitalizations are for schizophrenia and schizoaffective disorder, doctors say.

Finding the right antipsychotic medication for a particular patient can involve trial and error. There are more than a dozen such drugs, but a single hospitalization of 15 days or less may only give time to try one. Patients who show improvement are sent home or to the streets.

Without more supportive housing, many doctors and social workers say that for many homeless patients, the cycle of hospitalizations will continue.

For police officers, training on assessing the need to go to hospital has largely focused on situations where someone threatens to harm themselves or others.

A training manual on how to deal with what police call “emotionally disturbed people” or EDPs, which was in use in the 2010s, included questions such as “Who or what is the EDP angry at, scared or stressed?” and “How long has EDP been acting irrationally?”

For mental health workers, there are detailed guidelines. They involve engaging with the person to determine more than a dozen indicators of psychological health, from affect and thought process to expressions of suicidal or homicidal ideation.

These guidelines can remain largely the same. However, an employee of the Bowery Residents’ Committee, which does outreach in the transit system, said last week that his workers had been ordered by their supervisors to lower the threshold for clinicians who accompany them on the platforms of the metro assess people with a view to possible hospitalization. (The Bowery employee was not authorized to speak to reporters and requested anonymity.)

The old standard required the person to be so mentally ill that they could not care for themselves and also physically ill or injured; the new standard no longer requires physical injury or illness.

Policies have varied over time.

Take the example of the Homeless Awareness Unit, which began as a transit police squad in 1982. Its main purpose was to get homeless people out of the subway system and into placement in shelters and social service programs, though often officers are mostly successful in evicting homeless people from subway tunnels. and forcing them above ground and into parks.

In 2010, the unit’s stated mission was sometimes overshadowed by a different imperative: Arrest homeless people for minor infractions, like being in a park at night or stepping on a subway seat, according to interviews and reports. court records. In some years the unit arrested over 2,000 people, before a change in policy under the previous mayor.

The police themselves often feel ill-placed to help fill gaps in the psychiatric care delivery system.

Experts say bringing homeless people in mental health crisis to hospital will undoubtedly help some of them get desperately needed treatment. But they warn that bringing more people to the emergency room will mostly lead to the same people going through a system that isn’t working for them more often.

Although there is a shortage of inpatient psychiatric beds, the far greater systemic problem, experts say, is that services and support for patients after discharge from hospital are inadequate. A system that sends homeless psychiatric patients back onto the streets or into the shelter system – as often happens now – is unlikely to result in lasting care.

In recent years, the city has increased the number of teams of psychiatrists, nurses and social workers who visit people with serious mental illnesses and histories of hospitalizations, many of whom are homeless.

Mr. Adams said that for his plan to work, the city will not only need more hospital beds, supportive apartments and outpatient treatment options; he will also need Albany to make some changes.

These include, according to a “legislative agenda” recently released by the city:

  • Require hospitals to consider a patient’s history and likelihood of sticking to outpatient treatment when making admission and discharge decisions, and to take steps to ensure coordinated transfers between inpatient and outpatient providers” before releasing someone.

Mr Adams pushed back against critics who have warned the city’s policies could lead to massive, indiscriminate roundups. If someone is walking around without shoes or a jacket in cold weather, “that’s no reason to put you in a hospital,” he said last week. “That’s a reason for us to talk to you and see if you need shoes, if you need shelter.”

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