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���������� Note: The following article takes a deeper look at strategies to engage and assist ���������� City residents who experience recurring mental health crises. We cannot medicate, mandate, incarcerate, shelter or hospitalize our way out of the community and system wide mental health crises that we have responded to in piecemeal fashion for decades.
Our answers to the crisis of homelessness will not substantially be found in increasing the number of inpatient beds, especially via steps to lower the threshold for involuntary psychiatric hospital admissions on what will be questionable grounds in too many instances.
Our answers to homelessness will begin with an even greater expansion of safe and stable housing with supports, in particular low threshold Housing First or Safe Haven housing that accepts people regardless of whether they’re in states of stability and/or sobriety. The Coalition for the Homeless has called for another 1,000 beds at a cost of $50 million.
Voluntary admissions in NYC are often far too brief (2 days vs 2 weeks) and the discharge plans are far too often wholly inadequate. Responsible discharge plans must include an appropriate level of housing, a peer bridger transitional supporter who can develop and maintain a supportive relationship for 6 months or so thereafter to support individuals to make successful adjustments and find alternatives to avoidable relapses and crises and some form of care coordination or case management that connects people to an array of necessary social, mental health and health and financial resources.  Employment is all too often disregarded although the path to stabilization is often aided not complicated by helping people into meaningful roles that add to or make up their resources.
The Governor’s proposals to increase housing, hospital beds and supports, crisis hotline and stabilization services and pay increases to attract and retain the workforce are strong starters and the Mayor has proposed a number of differing outreach teams, safe haven housing expansion and drop in services in the subways that will be essential. We can’t get these up fast enough.
The legislature can take action to solidify the workforce with a proposed 11% COLA and by funding alternatives to an expansion of Kendra’s Law, including an array of peer outreach and transitional support services (see INSET and Peer Bridger Project brochure for examples).

Psych Beds are No More Than a ‘Band-Aid’ for Mentally Ill Homeless, Experts Say
Gov. Kathy Hochul and Mayor Eric Adams are the Latest Politicians to Try and Fix the Broken Cycle.
By Amanda Eisenberg, Shannon Young and Deanna Garcia  Politico  March 17, 2022

NEW YORK — Felix Guzman was living in a homeless shelter with a violent roommate he knew he had to escape. So he sought help at Bellevue, America’s oldest hospital and one of ���������� City’s behavioral health treatment centers.

It was one of numerous times Guzman stayed at the Manhattan facility, which has been serving the city’s neediest residents since 1736. At 40, he’s come to consider it a “safety net.” But that doesn’t mean he’s gotten the help he needs — or felt much safer.

“The help that I received was inconsequential,” Guzman said in an interview. “I don’t think that the mental health system has to come a long way to the point where it can actually address my concerns and issues as opposed to just medicating me out of the problem. It helped to get me out of the environment I was in but didn’t address my problems.”

Bellevue, part of the city’s public hospital system, has more than 300 psych beds. It remains the largest mental health treatment facility in the five boroughs at a time when units are shrinking across the state. The crunch has coincided with what Gov. Kathy Hochul has described as a “humanitarian crisis” of homeless people — many with untreated mental illness and living in the subway system — and high-profile crimes committed by a small sliver of that population. Hochul, Mayor Eric Adams and other local elected officials have seized on the mantra of “more psych beds” as a central solution to the problem. But experts say only expanding the wards is like covering up a chronic disease with a Band-Aid.

“We don’t have appropriate next steps for people,” Mitch Katz, head of NYC Health + Hospitals who oversees Bellevue, said in an interview. “If the answer is, ‘Discharge them to a shelter or a street,’ that’s not going to bring long-term stability to their life. They need housing, and they need supportive housing.”

Hochul has called for “major investments to improve psychiatric support for those in crisis,”  statewide; more than $12 million for 500 supportive housing beds; and nearly $10 million for recruitment and retention of psychiatrist and psychiatric nurses — with up to $150,000 in loan forgiveness for those individuals.

The new funding aims to address homelessness among people with serious mental illnesses such as schizophrenia and bipolar disorder, which often triggers paranoia and makes living in a group shelter nearly impossible during a severe episode. It’s an issue city and state officials have long tried to manage, but the systematic defunding and closures of psych beds, as well as the greater issues around accessing mental health care, make it harder to connect people to treatment.

���������� state had 5,419 psych beds in 2018, with 2,781 beds located in ���������� City, down from 6,055 beds in 2000, according to  from the ���������� State Nurses Association. The decline is attributed to hospital closures and private hospitals reducing their bed counts over a state Medicaid reimbursement change, which disincentivized the systems from taking care of those patients, according to the NYSNA report.

As a result, NYC Health + Hospitals became the primary place, other than jail, for police to bring people in mental distress. The average length of stay varies, though , where individuals can be evaluated and put on medication or have their dosages tweaked, as well as get care for any physical ailments.

Staff at the hospital system work to discharge a patient to a family member or find a place for that individual to stay, whether at a shelter or in supportive housing, said public hospital spokesperson Chris Miller.

Though advocates have long decried the dearth of affordable housing, the options are still severely lacking for individuals who need to be discharged from a psych bed to stable housing. And when those needs aren’t met, people are more likely to wind up back on the street.

Another government fix
Hochul and Adams are the latest politicians to try and fix the broken cycle. Hochul, who is up for her first election since taking over for disgraced former Gov. Andrew Cuomo last summer, is likely courting downstate voters by addressing quality-of-life issues. She’s also in charge of managing the finances of the cash-strapped Metropolitan Transportation Authority, as people are avoiding the subway following a spate of unsettling attacks on commuters.

Michelle Go, a Deloitte consultant, was fatally pushed in front of a train at the Times Square subway station in January. Other subway riders have been slashed with a collection of motley weapons from pipes to hatchets, often during unprovoked incidents.

“People … tell me their fears. They tell me their worry. They have a baby stroller, couple of toddlers and an infant. And they say, ‘We want the old ���������� back. We don’t feel safe anymore,’” Hochul recounted when she and Adams rolled out their subway safety plan last month. Adams, at the press briefing in Fulton Street station in lower Manhattan, touted the plan as a way to get dangerous people off the streets and into care.

“We’re not going to wait until someone shoves a person onto the tracks,” he said. “We’re being proactive, and we’re going to engage ����������ers who are unhoused or dealing with mental health crises.”

While Adams noted that most people with mental illness who are living on the streets are more likely to be victims of violence than perpetrators of it, many of the high-profile attacks have come from people who failed to receive mental health treatment after multiple incidents. Gerald Brevard III, a 30-year-old man with a history of mental health issues and police interactions, was arrested in Washington, D.C., Tuesday in connection with five shootings of men sleeping on the streets of D.C. and ���������� City this month, .

And with much of the proposed funding for those new initiatives still tied up in state budget negotiations, it’s unclear how soon the programs could be up and running.

In addition to the nearly $50 million for improving mental health crisis care, Hochul is also seeking a 20 percent increase (half of which would be state share) in how hospitals are reimbursed through Medicaid for psychiatric beds; new regulations that give law enforcement and others more authority to intervene when someone exhibits “extreme” and potentially dangerous mental health symptoms; and an extension of “Kendra’s Law” — which created a framework for court-ordered assisted outpatient treatment — through June 30, 2027. Adams has long been a proponent of expanding Kendra’s Law, passed over 20 years ago after 32-year-old Kendra Webdale was pushed in front of a moving subway train by a man with schizophrenia.

Hochul’s proposed funding would greatly boost the reimbursement rate for mental health care, which has not received parity for physical health ailments that keep people in the hospital overnight. Because psych beds are expensive to service, fewer private hospitals offer them — causing NYC Health + Hospitals to pick up the slack.

“NYC Health + Hospitals does the disproportionate share of mental health care for hospitalized patients in ���������� City,” Katz said at the system’s board of directors meeting on Feb. 24. “While we represent 20 percent of inpatient medicine volume, we represent about 55 percent of mental health inpatient volume, and that’s because the rates for mental health don’t cover the cost, so the private hospitals have gotten out of the business of doing psychiatric care.”

State Division of the Budget spokesperson Shams Tarek said the programs announced in February would be funded through the fiscal year 2023 budget, which is due at the end of March and still being negotiated with Albany lawmakers.

He noted that the $12.5 million in increased supported housing for homeless individuals will be funded by the Empire State Supportive Housing Initiative, while the $9 million for recruitment and retention of psychiatrists and $27.5 million for inpatient psychiatric bed rates “will be added to the enacted budget.” All three investments, Tarek added, “are recurring annually and in addition to” the $577 million year-to-year spending increase for the state’s mental health budget — with $60 million in new capital funding to be spent over five years for existing community beds.

Getting people off the streets
Typically, the city and its shelter providers deploy teams to engage with homeless individuals living in the subway stations and on the streets, many of whom are known to frequent or sleep in those areas. Unless those individuals are a risk to themselves or others, or if temperatures drop below 32 degrees, prompting , workers cannot mandate that people without housing enter into a shelter.

New guidance, , will give those authorities stronger grounds to forcibly place someone in a psych bed for treatment.

The guidance clarifies the rules for when cops or other city workers can bring someone in for a psych evaluation. It offers examples for when an evaluation is warranted, including if someone exhibits erratic behavior or simply cannot care for themselves.

“Patients can meet criteria for involuntary admission even when there is no recent dangerous act. Courts have found that evaluating psychiatrists may consider an individual’s whole history when determining if an individual needs involuntary admission,” according to the guidance.

The guidance also offers examples for people who may qualify for an emergency psychiatric admission.

One scenario is a 19-year-old who yelled and shook his fists at several customers in a supermarket, and “pushed over a shopping cart, damaged products, and tried to break a display case.”

Harvey Rosenthal, CEO of the ���������� Association of Psychiatric Rehabilitation Services, has raised concerns that the new guidance around involuntary inpatient commitments could result in inappropriate admissions. He’s urged lawmakers not to expand Kendra’s Law, arguing it’s “very controversial” and “unproven.”

“Unfortunately, it’s all being done through the lens of violence and danger. This idea that we’re going to sweep the subways can sound like we’re going to sweep away people’s rights,” he said in an interview. “A lot of these folks need housing, not a hospital bed.”

Shelly Nortz, deputy executive director for policy at the nonprofit Coalition for the Homeless, said assisted outpatient treatment is controversial not because it mandates mental health care, but because it’s applied in “a racially disparate way,” with about 3 in 4 people court ordered for treatment identifying as Black or Hispanic.

“The tragedy that created Kendra’s Law was a mentally ill man trying to get mental health care,” she said. “He had been trying to get mental health care and had been turned away. His psychiatric records had showed how the mental health system had failed him.”

The problem isn’t getting people out of the subways, she continued, it’s getting them into a psych bed.

About 4.5 adults per 100,000 were hospitalized in a state Office of Mental Health-run inpatient bed in ���������� City in 2019, down from 5.1 adults per 100,000 in 2012,  collected by the state. The city statistics reflect the downward statewide trend, which reported 3.8 hospitalizations per 100,000 people in 2019, compared to 5.1 hospitalizations per 100,000 people in 2012. The volume surpasses NYSNA’s estimated psych bed count, indicating that an open bed is hard to come by.

When ���������� City went into lockdown and upwards of 700 people were dying a day, every hospital bed was flipped into a Covid-19 bed. Nearly two years later, about 600 psych beds have yet to be converted back, leaving little space for people in need of mental health treatment, Nortz said.

“Do you know what the cops say? ‘What’s the point?’” Nortz said. “‘We’re going to take people to the hospital and they’re not going to get admitted.’”

In response, the NYPD highlighted the number of times it takes people into a hospital for medical care.

“The NYPD continues to bring people in a mental health crisis to the hospital for medical professionals to determine an appropriate level of care,” said police department spokesperson Lt. Jessica McRorie. “In 2021, more than 54,800 mental health calls handled by the NYPD resulted in a transport to the hospital.”

What’s next
For the people who do get a psych evaluation and a hospital stay, the ideal next step is to get housed in a supportive place.

NYC Health + Hospitals’ Katz estimates that about 1,000 people living on the streets are experiencing mental health issues that would make them candidates for supportive housing, which allows them to live independently but under professional supervision to ensure they’re taking their medication and getting other needs met.

Supportive housing, which NYC Health + Hospitals is building on or near its campuses, offers a 24-hour staff member — like a desk clerk — to monitor the residents while case managers and a nurse check in on the residents. The system has committed to building at least 1,325 units of affordable and supportive housing,  that opened in 2018.

The resource-heavy housing option is preferable to the current system of using Rikers Island, the city’s jail, and homeless shelters to house people with mental health issues after they’ve been discharged, Katz said.

Guzman, who now lives in private housing and has become an advocate for shelter residents, agreed.

“If you go into a psych ward for a few weeks you’ll get stabilized but once you return back to the same situation you’ve been in there’s no solution other than being in a supportive housing,” said Guzman, who serves on the City Council Commission on Community Reinvestment and the Closure of Rikers Island.

Albany lawmakers have until the end of the month to finalize the budget for fiscal year 2023, which officially begins on April 1. Those talks are ongoing as Senate and Assembly leaders complete votes on one-house budget proposals and negotiate with the governor’s office on a final spending plan.

“Each of these one-houses and even the executive proposal are far cries from a lot of the previous budgets that many of us are so used to seeing. Certainly we’re in a much stronger position than we were last year at this time,” said Sen. Samra Brouk (D-Rochester), who chairs the Senate’s mental health committee and co-chairs the Legislature’s joint mental hygiene budget subcommittee, in a meeting Tuesday.

“We’ve got some substantial investments. Because really what we’re doing is reversing the course of past austerity measures that we’ve seen with previous administrations — and really disinvestment from many of the agencies that we all represent. That said, I do think we’ve got some work to do … to get to a final agreement,” Brouk said.

Healthcare Association of ���������� State President Bea Grause told POLITICO that her organization, which represents hospitals and other health care facilities across the state, is “extremely supportive” of the proposals. “That’s really long overdue,” she said in an interview, noting that they would benefit some HANYS members.

Julia Marsh contributed to this report.