NY Times Article about taking people to hospitals

[Sushirolls]

---

Members don't see this ad.

Any folks see the NY times article on taking people to the hospital by EMS and/or Police if deemed mentally disturbed, even if not threat to self or others as means to clean up the streets?

Any NYC people here want to chime in?

Sounds good in principle, but oh, that's right, we have existing case law and civil rights that permit people to be psychotic on the street. [insert popcorn eating emoji here] Can't wait to see how this back fires on the mayor and NYC with these round ups. At best this just wastes the hospital ED staff time with evaluating and discharging. At worst this leads to a whole bunch of lawsuits and wastes even more tax dollars.

 

[mistafab]

This appears to me as another poorly veiled means of dispensing undesirables from the city in the name of humanism. With enough harassment, they hope the number of these folks in the city will decrease.

 

[comp1]

Pointless. How does a brief acute psych stay fix any of this? Just makes the revolving door turn faster. It's the same issue as with CA's new mental health court. What good does it do to conserve people if there are no long term locked facilities for them to go to? All of NY's state mental health facilities are completely full, same with CA.

 

[Ironspy]

I worked in NYC and the police already did this. They pick up a bunch of homeless people who are intoxicated. Patients sober up, are evaluated by psych and discharged same or following day. Don’t see any way in which doing this more would be helpful.

 

[G Sheb]

This is a housing and social support issue for people who are definitely mentally ill and unable to care for themselves.
Treating them for a couple of weeks with antipsychotics on an inpatient unit is not going to solve the "problem" before they go back to the streets again.

 

[WisNeuro]

Not a comment on the policy, but rather a clarification. The language used was that hospitalization would be used on individuals who were deemed unable to care for, and were thus a danger to themselves. And, from the OMH memo, it just looks like they have clarified existing policy and procedure, and are asking the named agencies to enforce the already existing policy under sections 9.41 and 9.58 of OMH policy for involuntary psych admission.

 

[calvnandhobbs68]

These always end up being discharge disasters too if they are actually admitted. Most of these patients end up being either chronically mildly psychotic or engaging in frequent drug use, where you're basically just letting them sober up in the hospital for a few days (as noted above). If we felt that "can't take care of themselves" was a reason for eval and admission, then what's the discharge criteria? Where do you discharge them to? Back to the street? A homeless shelter (that's what we'd usually end up trying to do)?

More unfunded crap to try frame as a "mental healthcare access problem" instead of a resource problem, just like California:
"Starting July 1, 2022, a new law, California Senate Bill 221, went into effect requiring HMOs and health insurers to provide individual follow-up mental health and substance use disorder therapy appointments within 10 business days of the prior appointment unless the treating therapist determines that a longer wait will not have a detrimental impact on the patient’s health."

 

[Sushirolls]

If EMS and police are using that criteria, they better have quite the lengthy report when they drop people to support that criteria for hospitalization.

 

[comp1]

Police very rarely need much of a report at all to drop a person off at an ED. Chronically homeless/psychotic individuals tend not to be very well connected or litigious.

 

[FlowRate]

These always end up being discharge disasters too if they are actually admitted. Most of these patients end up being either chronically mildly psychotic or engaging in frequent drug use, where you're basically just letting them sober up in the hospital for a few days (as noted above). If we felt that "can't take care of themselves" was a reason for eval and admission, then what's the discharge criteria? Where do you discharge them to? Back to the street? A homeless shelter (that's what we'd usually end up trying to do)?

"Mr. Adams said the city would direct hospitals to keep those patients until they are stable and discharge them only when there is a workable plan in place to connect them to ongoing care."

It'll be interesting to see how that gets interpreted. The issue with chronic psychosis, as we all know, is often patient nonadherence/disinterest in ongoing care, not availability of care.

 

[tr]

It's because the mayor is an ex police officer who has no clue about mental health care and is just trying to dump the visible problem of the undomiciled into someone else's lap. I'm certain he has no clue what involuntary hospitalization costs or what sorts of problems it is useful for. Spoiler: Solving homelessness is not one of them.

 

[SmallBird]

These always end up being discharge disasters too if they are actually admitted. Most of these patients end up being either chronically mildly psychotic or engaging in frequent drug use, where you're basically just letting them sober up in the hospital for a few days (as noted above). If we felt that "can't take care of themselves" was a reason for eval and admission, then what's the discharge criteria? Where do you discharge them to? Back to the street? A homeless shelter (that's what we'd usually end up trying to do)?

More unfunded crap to try frame as a "mental healthcare access problem" instead of a resource problem, just like California:
"Starting July 1, 2022, a new law, California Senate Bill 221, went into effect requiring HMOs and health insurers to provide individual follow-up mental health and substance use disorder therapy appointments within 10 business days of the prior appointment unless the treating therapist determines that a longer wait will not have a detrimental impact on the patient’s health."

As you said, you discharge them with information for a homeless shelter. You can set them up for 'follow-up' appointments but if Mr Adams means that you should only discharge once there is a strategy to ensure their psychosocial recovery then I would discharge them to city hall with plan to request those services from his office directly.

 

[psychmd03]

This leads me to ponder everyone’s thought on what would be steps that would help the chronically psychotic and let’s say they aren’t using drugs. I’m talking the people that can be chronically UDS negative but yet come in wildly psychotic and with two antipsychotics or clozapine even, still end up decently psychotic. What are your dispo options current in your states? And what would like to see? I have this talk often with families about the massive hole in our system but have little hope of that void being filled

 

[SmallBird]

This leads me to ponder everyone’s thought on what would be steps that would help the chronically psychotic and let’s say they aren’t using drugs. I’m talking the people that can be chronically UDS negative but yet come in wildly psychotic and with two antipsychotics or clozapine even, still end up decently psychotic. What are your dispo options current in your states? And what would like to see? I have this talk often with families about the massive hole in our system but have little hope of that void being filled

I find it helpful to break down into treatment needs and containment needs.

From a treatment perspective, if the patient has active psychosis at baseline then an ACT team or some type of wrap around could be helpful. For containment, supportive housing programs can be helpful, and if patients have DDS entitlements they may qualify for group homes. If patients have baseline major neurocognitive issues rather than positive symptoms of psychosis, nursing homes are possible options for containment. State hospitals may provide a combination of treatment and containment but I try not refer patients there who are at a presumed baseline, but rather those for whom a longer and more aggressive treatment course is anticipated.

 

[dl2dp2]

It's because the mayor is an ex police officer who has no clue about mental health care and is just trying to dump the visible problem of the undomiciled into someone else's lap. I'm certain he has no clue what involuntary hospitalization costs or what sorts of problems it is useful for. Spoiler: Solving homelessness is not one of them.

Not sure if this is true.

I have some connections to the inside, and they have a pretty qualified advisory board. Some you can reasonably claim as world experts in this area.

The legal issues are also well planned ahead. This is based on a "broader read" of a law. There is highly qualified legal counsel on this. This is all Bloomberg's old team. Several are solicitor general level people working pro bono.

They are also opening a new unit at Manhattan Psychiatric which is being staffed by a position that pays $580k a year.

I think most people don't know what they are talking about. They started planning this when he got elected and delayed it by 2 years because they want to be credible. That being said, perhaps things will still get f-ed up, but this is as good an attempt as you could imagine given the hostile environment.

 

[psychmd03]

I find it helpful to break down into treatment needs and containment needs.

From a treatment perspective, if the patient has active psychosis at baseline then an ACT team or some type of wrap around could be helpful. For containment, supportive housing programs can be helpful, and if patients have DDS entitlements they may qualify for group homes. If patients have baseline major neurocognitive issues rather than positive symptoms of psychosis, nursing homes are possible options for containment. State hospitals may provide a combination of treatment and containment but I try not refer patients there who are at a presumed baseline, but rather those for whom a longer and more aggressive treatment course is anticipated.

Solid thoughts. We certainly in most states could use a lot more funding for these programs. In my state ACT teams are hard to come by. NH and GH are mostly, putting it lightly, horrendous places and the larger problem is any and all patients can walk out even if they are court ordered there.

 

[tr]

Not sure if this is true.

I have some connections to the inside, and they have a pretty qualified advisory board. Some you can reasonably claim as world experts in this area.

The legal issues are also well planned ahead. This is based on a "broader read" of a law. There is highly qualified legal counsel on this. This is all Bloomberg's old team. Several are solicitor general level people working pro bono.

They are also opening a new unit at Manhattan Psychiatric which is being staffed by a position that pays $580k a year.

I think most people don't know what they are talking about. They started planning this when he got elected and delayed it by 2 years because they want to be credible. That being said, perhaps things will still get f-ed up, but this is as good an attempt as you could imagine given the hostile environment.

Interesting. I'm sure the legal issues have been well covered. Not so sure the practical implementation is going to work out well.

 

[MacDonaldTriad]

It would be hard to imagine a more expensive and less effective way to handle the homeless crisis than bring them to psychiatry ERs. Despite the layperson's belief that all homeless are mentally ill, this is not true. We have learned the hard way to accept police drop offs graciously and give the officers enough time to towel off the urine from their back seats before letting these people go. It irritates them to see patients walk by before they have even left the parking lot. Ultimately, the show has to get on the road and waiting a minute, 10 minutes, an hour, a day, or a week will not make a difference in outcome when measured a month down the road for most of these cases.

I will disclaim, the mentally ill do need our help and do benefit from our treatment, but just collecting the homeless and taking them to the hospital only drains needed resources from those that need help.

 

[SmallBird]

It would be hard to imagine a more expensive and less effective way to handle the homeless crisis than bring them to psychiatry ERs. Despite the layperson's belief that all homeless are mentally ill, this is not true. We have learned the hard way to accept police drop offs graciously and give the officers enough time to towel off the urine from their back seats before letting these people go. It irritates them to see patients walk by before they have even left the parking lot. Ultimately, the show has to get on the road and waiting a minute, 10 minutes, an hour, a day, or a week will not make a difference in outcome when measured a month down the road for most of these cases.

I will disclaim, the mentally ill do need our help and do benefit from our treatment, but just collecting the homeless and taking them to the hospital only drains needed resources from those that need help.

The only thing worse is creating a mandate that they remain in the hospital until they are connected to services which must not exist because if they did that would be where the individuals should have gone to begin with. They will probably then hire case managers thereby competing for social workers from programs that are actually trying to offer some source of services and the problem will exacerbate itself.

 

[PsyDr]

It's 50 beds.

 

[allantois]

It seems like the goal of politicians in this country is to bring down the health care system as fast as they can. We all know ED staff hate dealing/are clueless around psych patients. I wonder if anyone in the behavioral or even legal field was consulted on this??

I can also see a slew of families of these homeless coming out of nowhere to sue anyone and everyone

 

[Stagg737]

This leads me to ponder everyone’s thought on what would be steps that would help the chronically psychotic and let’s say they aren’t using drugs. I’m talking the people that can be chronically UDS negative but yet come in wildly psychotic and with two antipsychotics or clozapine even, still end up decently psychotic. What are your dispo options current in your states? And what would like to see? I have this talk often with families about the massive hole in our system but have little hope of that void being filled

In my area of the state there's several CMHCs with ACT teams though they are always in need of more staff. Group homes are there, though they never seem to have availability since COVID. Placement at level 2 facilities is more common than it likely should be. I'd like to a see an increase in facilities like there were before the deinstitutionalization of the 70's which could be accomplished by having more availability of level 2 facilities dedicated to MH patients.

 

[comp1]

I would like patients who revolve in and out of acute settings to be conserved and in state mental hospitals. There is excellent literature that patients are permanently harmed by each psychotic episode and that it takes at least six months of continual antipsychotic adherence to see maximal benefit and where the patient's actual functional baseline is.

 

[Merovinge]

It's 50 beds.

That's definitely going to cover the largest metropolis in the country... nothing to see her boys, wrap it up.

 

[dl2dp2]

That's definitely going to cover the largest metropolis in the country... nothing to see her boys, wrap it up.

Well, this is a start. They designed a proof of concept with fairly prominent academic and clinical players and put REAL money to it. It might still fail, but it is what it is.

We can ask you to design this system, and do you think you can do a better job? There's actually no data on the number of people who would be eligible for state hospitalization triage who are currently street homeless. The analytics system doesn't exist. This is being built as part of the system. So you don't really even know if 50 is enough or not. It's really interesting. You should call the recruiter for that job that pays 580k. Fascinating conversation.

 

[dl2dp2]

It would be hard to imagine a more expensive and less effective way to handle the homeless crisis than bring them to psychiatry ERs. Despite the layperson's belief that all homeless are mentally ill, this is not true. We have learned the hard way to accept police drop offs graciously and give the officers enough time to towel off the urine from their back seats before letting these people go. It irritates them to see patients walk by before they have even left the parking lot. Ultimately, the show has to get on the road and waiting a minute, 10 minutes, an hour, a day, or a week will not make a difference in outcome when measured a month down the road for most of these cases.

I will disclaim, the mentally ill do need our help and do benefit from our treatment, but just collecting the homeless and taking them to the hospital only drains needed resources from those that need help.

Actually, I sat through one of the presentations, this is a half-truth. While MOST of the sheltered homeless are not SMI (~90%), most of the street homeless ("persistent unhoused") are SMI + SUD (~60-70%). This is a fairly recent survey but consistent with historical data.

Most "persistent unhoused" would be eligible for the NYS ACT criteria. This aspect was thought through way ahead of time.

This current plan as is designed is also not just an ER drop-off. That's step #1. They designed a wraparound service around this. These are not amateurs. That being said, I read a version of the protocol and there are definitely still issues. A lot of issues. Especially relating to SUD. But, it's not because they didn't get enough smart people to work on it. I'm almost certain that people here who are blowing hot air can't really come up with a better plan. This is not a trivial thing--they have a large budget and stipulated specific metrics. It's all Bloomberg-style work.

 

[TheRightMedication]

I'm sure the technocrats have made many plans with many data sets, metrics, and rational recommendations.

I will still dare to give my humble opinion that those 50 beds will fill the first night this goes live, and this will not provide a meaningful benefit for the city residents.

Who number in the millions.

 

[Stagg737]

most of the street homeless ("persistent unhoused") are SMI + SUD (~60-70%). This is a fairly recent survey but consistent with historical data.

Let's be real for a second. How many of the individuals in this category are truly SMI/SPMI with SUD vs individuals who come in with substance-induced psychosis and get a primary psychotic diagnosis because they're still psychotic a couple days later? How was this diagnosis of primary SMI obtained? Because unless we're counting all the cluster B malingerers and calling any patient with a trauma history severe PTSD, I don't believe for a second that 60-70% of homeless individuals have SPMI/SMI unless we're using some weirdly specific definition of "persistent unhoused".

 

[G Sheb]

Actually, I sat through one of the presentations, this is a half-truth. While MOST of the sheltered homeless are not SMI (~90%), most of the street homeless ("persistent unhoused") are SMI + SUD (~60-70%). This is a fairly recent survey but consistent with historical data.

Most "persistent unhoused" would be eligible for the NYS ACT criteria. This aspect was thought through way ahead of time.

This current plan as is designed is also not just an ER drop-off. That's step #1. They designed a wraparound service around this. These are not amateurs. That being said, I read a version of the protocol and there are definitely still issues. A lot of issues. Especially relating to SUD. But, it's not because they didn't get enough smart people to work on it. I'm almost certain that people here who are blowing hot air can't really come up with a better plan. This is not a trivial thing--they have a large budget and stipulated specific metrics. It's all Bloomberg-style work.

I agree, this is an improvement, in the sense these individuals who most likely comprise a lot of chronically psychotic individuals will at least be in the system.
But the real problem here imo is not that they are not getting inpatient treatment; it's the lack of resources once they go out. Only way to solve this is to invest in housing and long term placement for chronically psychotic individuals. Certainly seen my share of schizophrenia pts +/- SUD who come in/out hospitals and who remain homeless and unable to take care of their basic needs.

 

[dl2dp2]

Let's be real for a second. How many of the individuals in this category are truly SMI/SPMI with SUD vs individuals who come in with substance-induced psychosis and get a primary psychotic diagnosis because they're still psychotic a couple days later? How was this diagnosis of primary SMI obtained? Because unless we're counting all the cluster B malingerers and calling any patient with a trauma history severe PTSD, I don't believe for a second that 60-70% of homeless individuals have SPMI/SMI unless we're using some weirdly specific definition of "persistent unhoused".

This is semantics. They get re-diagnosed at intake. I agree some are cluster B malingerers, but state hospital is a reasonable place (vs. jail). I don't actually see a lot of difference since jails are now housing "genuine" SMIs, and "genuine" SMIs commit crimes. Anyone who's worked at a state hospital knows that these are overlapping. The point of the program is to have a board-certified psychiatrist lay eye on these people and make a triage, with one possible end outcome being this MPC site, IF meeting specific eligibility criteria, as opposed to leaving them in the streets fending on their own or circulating in the shelter and causing havoc.

I think some persistently homeless individuals who are malingerers might end up better at a specialized long-term state hospital, don't you? Where would you send them? Nobody wants them! Not even state hospitals!!

I agree, this is an improvement, in the sense these individuals who most likely comprise a lot of chronically psychotic individuals will at least be in the system.
But the real problem here imo is not that they are not getting inpatient treatment; it's the lack of resources once they go out. Only way to solve this is to invest in housing and long term placement for chronically psychotic individuals. Certainly seen my share of schizophrenia pts +/- SUD who come in/out hospitals and who remain homeless and unable to take care of their basic needs.

This is part of the protocol. One branch of the state hospital service is repurposed as an intensive wraparound with supportive housing and long-term placement. There ARE beds, but the theory is that the beds booked at central booking are not correctly managed to contain this group. LOL believe me you are not the first person to think about this. People at Kirby have experience managing some of these people on an outpatient basis. The problem I see is that I don't know if people at Manhattan Psychiatric will be able to meaningfully "stabilize" at discharge as mandated.

Say this works and dramatically reduces street homeless with SMI re-entry for a group, it's still unclear if this is a scalable solution. As of current, SUDs without SMI are not eligible participant for the trial. I frankly don't think ER psychiatrists can differentiate well between the two groups. And as an SMI with SUD, if you don't treat the SUD, the SMI might not get better. There's no sufficient wraparound on the SUD. People on the advisory board raised this issue, but there are major regulatory issues on integrative SUD treatment. In fact, two different state agencies deal separately with SUD vs. SMI. The city itself has no SUD agency at all--prior administration had ONE MD in charge of the entire SUD program in the city. There are certain regulatory restrictions of HUD funding going to SUD treatment. LOL.

As I said, trial and error, trial and error. Everyone can critique every program. Maybe you want to try and write a program and I will give you 10 million.

 

[G Sheb]

This is semantics. They get re-diagnosed at intake. I agree some are cluster B malingerers, but state hospital is a reasonable place (vs. jail).



This is part of the protocol. One branch of the state hospital service is repurposed as an intensive wraparound with supportive housing and long-term placement. There ARE beds, but the theory is that the beds booked at central booking are not correctly managed to contain this group. LOL believe me you are not the first person to think about this.

Oh, I am sure I am not the first person to think about this, but experience counts.
It's almost impossible to find long term placement for pts who are inpt hospitalized. Usually the response from the SW is that there is x years wait list or something.
So I'll be skeptical that this will workout without considerably more resources for long term placement but pleasantly surprised if it does.

Also the legal ramifications are going to be very interesting. I imagine they are arguing here for more extensive application for 9.29 (2PC) which does allow pts to be hospitalized if they are unable to take care of themselves in the community. But how will this be implemented case by case is going to be tricky. This is certainly not the way doctors like to justify hospitalizations. Risk to self or others is a lot easier to justify. And there will be legal reverberations and significant opposition from pt support groups (there already is). And will the city come to the aid of the ER psychiatrist who signed the 9.29?

Overall, I agree that since someone is trying to do something, that's actually a good thing.
It's also not as complicated as you make it sound. You need to pump resources into supportive housing and long term hospitalization. If there is political will, there is a way. But you need the $$$ and the political priorities for that.

 

[Stagg737]

This is semantics. They get re-diagnosed at intake. I agree some are cluster B malingerers, but state hospital is a reasonable place (vs. jail). I don't actually see a lot of difference since jails are now housing "genuine" SMIs, and "genuine" SMIs commit crimes. Anyone who's worked at a state hospital knows that these are overlapping. The point of the program is to have a board-certified psychiatrist lay eye on these people and make a triage, with one possible end outcome being this MPC site, IF meeting specific eligibility criteria, as opposed to leaving them in the streets fending on their own or circulating in the shelter and causing havoc.

I think some persistently homeless individuals who are malingerers might end up better at a specialized long-term state hospital, don't you? Where would you send them? Nobody wants them! Not even state hospitals!!

You said yourself we don't differentiate well between the groups and SUD without SMI are ineligible, so it's not really semantics at all. Even if it's semantics, if they're being diagnosed at intake at the ER you're not necessarily going to be getting an accurate diagnosis. Substance-induced psychosis can last weeks or more after the substance is cleared, and depression can last months. Again I'd want to see actual methods before I believe that 60-70% of the persistently homeless have SMI that's a non-substance-induced psych disorder.

And the MPC site will do what exactly? Is this a long-term treatment program? What is the dispo from there? House them and treat them forever? If it's the 50-bed site noted above, how is that going to be remotely adequate for this population? I can't find the article, so idk. The way it's outlined here doesn't seem like things will go well though. I do not think that the persistently homeless malingerers without SMI/SPMI would be appropriate for a long-term state hospital, as there are too many people who are actually sick with a treatable diagnosis that can be helped and the malingerers aren't actually getting better at these programs. Idk what it's like in NY, but where I'm at it's not uncommon for patients to stay in our ER for days waiting for a bed at a state hospital to become available. No one needs true malingerers or non SMI patients sapping those resources from people who actually NEED them.

I'll also add some politically controversial common sense, there's a sub-group of people who just cannot be reasonably helped and some who just don't want to be helped. It sounds like per this plan those people would be taken to an ER to be assessed because....someone says their current existence isn't acceptable? This seems like an ethical time bomb just waiting to be ignited.

 

[psychmd03]

I would like patients who revolve in and out of acute settings to be conserved and in state mental hospitals. There is excellent literature that patients are permanently harmed by each psychotic episode and that it takes at least six months of continual antipsychotic adherence to see maximal benefit and where the patient's actual functional baseline is.

I wish we had better state hospitals. A few states do and their referrals move quickly and efficiently. Most states though have a large deficit in availability. And, at least in the hospital in my area, the workers seem to almost do more work to try and deflect cases than it would be for them to accept them. And the worsening of episodes and the need for a consistent therapeutic level of medication is something I have seen in some research that nicely fits the confirmation bias of my anecdotal experience. I have had a few very psychotic people that I had basically given up on swapping meds in and out and left them on good doses of medication and left them decently psychotic only to have them magically improve after a few weeks without any changes to medication.

 

[allantois]

The place sounds like it would be an absolute hell hole to work in for every staff level - I don’t even know how they plan on staffing it. Psych facilities are closing beds all around due to staff shortages as is

 

[SmallBird]

I wish we had better state hospitals. A few states do and their referrals move quickly and efficiently. Most states though have a large deficit in availability. And, at least in the hospital in my area, the workers seem to almost do more work to try and deflect cases than it would be for them to accept them. And the worsening of episodes and the need for a consistent therapeutic level of medication is something I have seen in some research that nicely fits the confirmation bias of my anecdotal experience. I have had a few very psychotic people that I had basically given up on swapping meds in and out and left them on good doses of medication and left them decently psychotic only to have them magically improve after a few weeks without any changes to medication.

Don't you think that state hospitals are maybe unnecessarily intensive for many of these patients? A state hospital still has physicians, full time nursing etc. And I definitely think they should exist. But I also think much less expensive programs that provide supportive housing (e.g, somewhere someone can live and be given food, not have to file taxes, not need a bank card) combined with ACT treatment (3 x week visits from their local CMHC to check on them, monthly med checks and on LAI, but no need for vital signs at breakfast and midnight). There is not enough of this type of option I think.

 

[dl2dp2]

I'll also add some politically controversial common sense, there's a sub-group of people who just cannot be reasonably helped and some who just don't want to be helped. It sounds like per this plan those people would be taken to an ER to be assessed because....someone says their current existence isn't acceptable? This seems like an ethical time bomb just waiting to be ignited.

Correct. This is exactly the intention of the programming. LOL. I think maybe you should read that sentence again. I'm not sure being homeless and sleeping on a curb at 30 degrees outside if you "cannot be reasonably helped and don't want to be helped" is "acceptable"...especially when this implies you have a high chance of death while given fentanyl.

The involuntary hospitalization law says one could be involuntarily hospitalized if they cannot reasonably care for themselves. While this might seem like a legal gray zone, there's an existing infrastructure for adjudicating this, mental health court, ACT, blah blah. The problem is actually a lot more basic when you look at the data: people who are CLEAR candidates of these programs aren't in them. Patients are not being tracked, and they are lost to follow-up and become persistently homeless, endangering themselves and the public. Are there people who have no SMI and still decide on their free and clear mind to stay persistently homeless? YES, but that's a minority, and USUALLY, this is the case of people with "pure" SUD without SMI. That's a question I'm more interested in, but at the moment they don't even want to touch that.

 

[Merovinge]

Correct. This is exactly the intention of the programming. LOL. I think maybe you should read that sentence again. I'm not sure being homeless and sleeping on a curb at 30 degrees outside if you "cannot be reasonably helped and don't want to be helped" is "acceptable"...especially when this implies you have a high chance of death while given fentanyl.

The involuntary hospitalization law says one could be involuntarily hospitalized if they cannot reasonably care for themselves. While this might seem like a legal gray zone, there's an existing infrastructure for adjudicating this, mental health court, ACT, blah blah. The problem is actually a lot more basic when you look at the data: people who are CLEAR candidates of these programs aren't in them. Patients are not being tracked, and they are lost to follow-up and become persistently homeless, endangering themselves and the public. Are there people who have no SMI and still decide on their free and clear mind to stay persistently homeless? YES, but that's a minority, and USUALLY, this is the case of people with "pure" SUD without SMI. That's a question I'm more interested in, but at the moment they don't even want to touch that.

I appreciate your perspective on this and I look forward to reading about the data in 5-7 years. That said, the article hardly makes this sound like a small pilot project and it seems to be touted more as a real attempt to solve this incredibly complex problem. I understand politicians need to grandstand, but I can still laugh at 50 beds and some additional wrap around services being touted as the solution. I sure hope it proves to be cost effective and human effective and scales further or provides some new insights into how to help those society has tried to forget in our biggest metropolis.

 

[comp1]

In general, no, I don't think anything less than long term (six months+) of state hospitalization will be sufficient for patients who have multiple repeated involuntary hospitalizations. ACT type engagement can be a step down following this if appropriate. Very few of these patients are able or willing to go straight from an acute 5-10 day hospital stay to ACT engagement, nor are they able or willing to utilize provided housing appropriately. I say this as someone who has a unique population of patients who are both severely mentally ill and also relatively wealthy. This is NOT just a housing or resource access problem. Our medications and other interventions are simply not effective in the rapid turnaround time we sometimes like to believe.

 

[FlowRate]

people who are CLEAR candidates of these programs aren't in them. Patients are not being tracked, and they are lost to follow-up and become persistently homeless, endangering themselves and the public. Are there people who have no SMI and still decide on their free and clear mind to stay persistently homeless? YES, but that's a minority, and USUALLY, this is the case of people with "pure" SUD without SMI. That's a question I'm more interested in, but at the moment they don't even want to touch that.

The most frustrating thing to me when I was in residency in Boston was that the area CMHC system requires that the patients voluntarily engage to a somewhat high degree. Otherwise they just drop them from their programs. Like the whole point of that level of CMHC is having ACT/outreach, but it's viewed as a patient failure, not a program failure. I get that you have to prioritize resources, but there didn't seem to be any discussion of how to capture those patients who are often lost to follow-up for short periods of time (1-2 months) who then end up back in intensive care settings and back on the wait list for the CMHC.

I'm not sure about your assertion that the vast majority of homeless are due to undertreated SMI. Maybe you're referring to a particular "type" of homeless? The modern explosion of homelessness seems to have a wide spectrum from SMI to severe SUD to frank criminality and exploitation. There's a lot of very organized and resourceful behavior by the homeless/semi-homeless around here that wouldn't be consistent with untreated psychosis.

 

[Stagg737]

Correct. This is exactly the intention of the programming. LOL. I think maybe you should read that sentence again. I'm not sure being homeless and sleeping on a curb at 30 degrees outside if you "cannot be reasonably helped and don't want to be helped" is "acceptable"...especially when this implies you have a high chance of death while given fentanyl.

If someone doesn't have SMI and they just want to be there, what right do you have to say they can't do it or that it's not acceptable? Does autonomy not matter if behavior is risky? Maybe I'm missing your point, but those with severe SMI often end up finding their ways to ERs or behaving in ways that get them brought in anyway. Do we really need a team rounding these people up? Also, I'm not sure how an expensive program like this is more effective for those individuals than expanding shelters and stable housing options. Call me crazy, but seems like the best way to house the homeless is to improve the available housing system...

The involuntary hospitalization law says one could be involuntarily hospitalized if they cannot reasonably care for themselves. While this might seem like a legal gray zone, there's an existing infrastructure for adjudicating this, mental health court, ACT, blah blah. The problem is actually a lot more basic when you look at the data: people who are CLEAR candidates of these programs aren't in them. Patients are not being tracked, and they are lost to follow-up and become persistently homeless, endangering themselves and the public. Are there people who have no SMI and still decide on their free and clear mind to stay persistently homeless? YES, but that's a minority, and USUALLY, this is the case of people with "pure" SUD without SMI. That's a question I'm more interested in, but at the moment they don't even want to touch that.

I'm aware of the reasons for involuntary hospitalization as it's a large part of my job as an ER psychiatrist and I think the gray zone is much smaller than people think if one takes the time to actually evaluate the patient. And if the issue is that patients aren't being tracked, this seems like more of an issue with available resources to sustain treatment, not with actually getting them plugged in. Unless the program is aimed at that and the SMI homeless round-up is meant to be an initial phase of the plan meant to eventually be scaled down it seems like a misguided direction. Maybe I'm just not understanding the program as I can't access the NYT article, I still don't get how bringing in an SMI person against their will when they're not actively endangering people is going to improve their care.

 

[nexus73]

Another unfunded mandate? From government?

Is there info missing where all this care is paid by the city/county/state?

Personally I'm in support of an expansion of the gravely disabled arm of the commitment laws IF there are resources in place and funding to pay for it. I say this because it's what I would want for myself, and what I think most people would want if they were living under an overpass, hearing voices, neglecting myself, using drugs. I would want to be treated and brought back closer to reality.

 

[dl2dp2]

I'm aware of the reasons for involuntary hospitalization as it's a large part of my job as an ER psychiatrist and I think the gray zone is much smaller than people think if one takes the time to actually evaluate the patient. And if the issue is that patients aren't being tracked, this seems like more of an issue with available resources to sustain treatment, not with actually getting them plugged in. Unless the program is aimed at that and the SMI homeless round-up is meant to be an initial phase of the plan meant to eventually be scaled down it seems like a misguided direction. Maybe I'm just not understanding the program as I can't access the NYT article, I still don't get how bringing in an SMI person against their will when they're not actively endangering people is going to improve their care.

This is actually EXACTLY what the program is aimed to be.

As I said, there are world experts in public psychiatry on this advisory panel that wrote up this program to trial. As per usual, NYTimes doesn't cover the details in their coverage.

 

[Candidate2017]

As I said, trial and error, trial and error. Everyone can critique every program. Maybe you want to try and write a program and I will give you 10 million.

Society (politicians, voters, taxpayers) long ago gave up on accepting the fact a percentage of the population can only function within an institutional asylum that requires trillions of dollars in funding. Other than that, I bet it's quite easy and cheap to stabilize a lot of severe mental illness with blow darts loaded with LAIs and governmental immunity.

Politicians have also found it easier to blame mental illness: Too much crime, homelessness, school shootings, fentanyl ODs, etc.? Mental illness.

 

[psychmd03]

Don't you think that state hospitals are maybe unnecessarily intensive for many of these patients? A state hospital still has physicians, full time nursing etc. And I definitely think they should exist. But I also think much less expensive programs that provide supportive housing (e.g, somewhere someone can live and be given food, not have to file taxes, not need a bank card) combined with ACT treatment (3 x week visits from their local CMHC to check on them, monthly med checks and on LAI, but no need for vital signs at breakfast and midnight). There is not enough of this type of option I think.

Depends on what patients we are talking about. I am thinking of my sickest meaning two antipsychotics and a mood stabilizer barely keep them from getting PRNs. Clozapine and augmentation (although I wont use clozapine unless I know they are going to a nursing home) and still psychotic and disorganized. I have an abundance of these types of patients. They walk out of the nursing home. ACT teams lose them and they stop their meds they need the structure of a NH that they cant walk out of basically. But Yes a step below that we need more housing and ACT/Community teams and I think that would greatly help. We basically seem to need help at all levels. But there is a gap at least for me at that need for highly structured but locked place

 

[dl2dp2]

Society (politicians, voters, taxpayers) long ago gave up on accepting the fact a percentage of the population can only function within an institutional asylum that requires trillions of dollars in funding. Other than that, I bet it's quite easy and cheap to stabilize a lot of severe mental illness with blow darts loaded with LAIs and governmental immunity.

Politicians have also found it easier to blame mental illness: Too much crime, homelessness, school shootings, fentanyl ODs, etc.? Mental illness.

Isn't this a bit nihilistic? What's the point of doing implementation science then? I think there's a conflation of. politics and policy. Policy can be tested, and one could imagine that new solutions can be better than old ones, with cost as a constraint. Politics are ideological and generally appeal to emotion, and aren't solution-oriented at all. Here's a present problem and one might try to solve it (and this is the whole Bloomberg-style governance), or you might appeal to demons. I just find the latter not very appealing.

 

[SmallBird]

The idea that we should try and do more to find long term containment and treatment options for a large proportion of individuals who are homeless makes a ton of sense, but for all the reference to 'public psychiatry experts' I just don't understand how the hospital has anything to do with that. It seems an expensive way to facilitate care coordination; it is often a traumatizing experience and we know from extensive patient-focused research that when people are brought to the hospital by police they often don't even consider it to be medical treatment but more like a punishment. For decades we have been saying we need to help people 'in the community'. Bringing everyone to the hospital is not the first step in a process of creating a broad set of containment and treatment resources that more accurately reflect the needs of the actual population but it is a way to increase costs without actually achieving anything which does sound like a typical political solution.

 

[When is graduation again?]

The most frustrating thing to me when I was in residency in Boston was that the area CMHC system requires that the patients voluntarily engage to a somewhat high degree. Otherwise they just drop them from their programs. Like the whole point of that level of CMHC is having ACT/outreach, but it's viewed as a patient failure, not a program failure. I get that you have to prioritize resources, but there didn't seem to be any discussion of how to capture those patients who are often lost to follow-up for short periods of time (1-2 months) who then end up back in intensive care settings and back on the wait list for the CMHC.

I'm not sure about your assertion that the vast majority of homeless are due to undertreated SMI. Maybe you're referring to a particular "type" of homeless? The modern explosion of homelessness seems to have a wide spectrum from SMI to severe SUD to frank criminality and exploitation. There's a lot of very organized and resourceful behavior by the homeless/semi-homeless around here that wouldn't be consistent with untreated psychosis.

I'm an ACT Psychiatrist. I'm not sure how liberal the Boston teams were with dropping patients, but I'll say that mine typically try to hold on to patients for at least 3 months after last contact. We try hard to keep our patients.

The real problem is that we often get patients that want nothing to do with us, despite signing up voluntarily. Or the worst are the one's with guardians who sign them up, despite the patient aggressively not wanting treatment. It's not safe for anyone involved to repeatedly ignore psychotic patients who make it very clear that they want nothing to do with you. Especially, when they are actively using substances. Safety aside, it is also a huge waste of man-power for no pay, since we get paid based on monthly contacts. That is time better spent reaching people who need and want our help.

Teams are also more cohesive with less turnover when they feel they are actually reaching people who want and need our help and when safety isn't as much of an issue. When teams are stable, all the patients on the panel benefit. My team stabilized, after years of upheaval, just before I joined and with the stability of a permanent psychiatrist, the difference in care is night and day.

 

[FlowRate]

I'm an ACT Psychiatrist. I'm not sure how liberal the Boston teams were with dropping patients, but I'll say that mine typically try to hold on to patients for at least 3 months after last contact. We try hard to keep our patients.

The real problem is that we often get patients that want nothing to do with us, despite signing up voluntarily. Or the worst are the one's with guardians who sign them up, despite the patient aggressively not wanting treatment. It's not safe for anyone involved to repeatedly ignore psychotic patients who make it very clear that they want nothing to do with you. Especially, when they are actively using substances. Safety aside, it is also a huge waste of man-power for no pay, since we get paid based on monthly contacts. That is time better spent reaching people who need and want our help.

Teams are also more cohesive with less turnover when they feel they are actually reaching people who want and need our help and when safety isn't as much of an issue. When teams are stable, all the patients on the panel benefit. My team stabilized, after years of upheaval, just before I joined and with the stability of a permanent psychiatrist, the difference in care is night and day.

I definitely get it with refusal of care. I had a few patients who would engage for a while, make good use of services, then go out of state or otherwise just be out of contact for just long enough that they got dropped (around 3 mo) but then ended up back inpatient on month 4 and now facing working through the waitlist and screening process for CMHC services rather than at least having some sort of fast-track to getting reconnected.

 

[SmallBird]

I'm an ACT Psychiatrist. I'm not sure how liberal the Boston teams were with dropping patients, but I'll say that mine typically try to hold on to patients for at least 3 months after last contact. We try hard to keep our patients.

The real problem is that we often get patients that want nothing to do with us, despite signing up voluntarily. Or the worst are the one's with guardians who sign them up, despite the patient aggressively not wanting treatment. It's not safe for anyone involved to repeatedly ignore psychotic patients who make it very clear that they want nothing to do with you. Especially, when they are actively using substances. Safety aside, it is also a huge waste of man-power for no pay, since we get paid based on monthly contacts. That is time better spent reaching people who need and want our help.

Teams are also more cohesive with less turnover when they feel they are actually reaching people who want and need our help and when safety isn't as much of an issue. When teams are stable, all the patients on the panel benefit. My team stabilized, after years of upheaval, just before I joined and with the stability of a permanent psychiatrist, the difference in care is night and day.

I support this 100% - a team needs to do what they can do and feel good about and as long as you stay busy helping the patients you are well set up to help, you are doing a great job. The idea that clinics should do more than they are set up to do because of some public health reason is misguided and a problem to be solved by higher ups.