Gotham Gazette https://www.gothamgazette.com/component/tags/tag/632 Thu, 01 Oct 2020 07:53:04 +0000 Joomla! - Open Source Content Management en-gb webmaster@gothamgazette.com (Webmaster) New York City Public Hospitals Were Unprepared for Major Crisis, Costing Lives During Covid Outbreak, Review Finds https://www.gothamgazette.com/city/9605-new-york-city-public-hospitals-were-unprepared-for-major-crisis-costing-lives-covid-outbreak https://www.gothamgazette.com/city/9605-new-york-city-public-hospitals-were-unprepared-for-major-crisis-costing-lives-covid-outbreak 5 health hos elmhurst

Mayor de Blasio visits Elmhurst Hospital (photo: Ed Reed/Mayor's Office)


New York City and State governments’ lack of support for the city’s public hospitals left them underprepared in almost every way for the COVID-19 pandemic, even when the disease seemed likely to come to the city and despite warnings dating back to 2006 about the very conditions that would lead to an overwhelmed hospital system that became a real-life nightmare for New Yorkers, according to a preliminary report by New York City Comptroller Scott Stringer

And when COVID-19 inevitably did come to the city, miscommunication and poor management of the city’s public hospital system worsened the outcomes for many New Yorkers, even “at a cost in human lives,” Stringer wrote in a letter to New York Governor Andrew Cuomo about the report, which was launched at Cuomo’s request amid some of the worst days of the crisis in New York, where more than 30,000 people have died of COVID-19.

"[T]he reported conditions in our public hospitals during this unprecedented public health crisis are alarming, and my office is committed to working with the Governor and the Mayor to find answers,” Stringer said in a statement. “Our public health system serves families and residents that already face significant barriers to quality health care, and our frontline workers can't take care of us if we fail to protect them. We must ensure that our public hospitals have the funding, protections, resources and support they need, properly managed and coordinated, to protect New Yorkers during these uncertain times."

In his preliminary report released July 17, Stringer outlined in detail the factors that contributed to New York City Health + Hospitals being overwhelmed by the pandemic that left New York as the worst-affected state (thus far) in the worst-affected country, with more than 23,000 of the 30,000-plus deaths among New York City residents, and over 400,000 cases across the state. 

And although H+H is a public benefit corporation, it is in significant ways run and funded by city government as a quasi-city agency, receives federal funds distributed through a formula in state law and, like all hospitals in New York, receives guidance from state entities, including in regards to preparing for and addressing a pandemic. For these reasons, Stringer’s report has implications as to how city and state government, including Governor Cuomo and Mayor Bill de Blasio, could have put H+H in a better position to respond to the crisis.

Cuomo had asked Stringer to perform the review that was launched on May 14 during a time when public hospitals like Elmhurst Hospital in Queens and Jacobi Medical Center in the Bronx were inundated with coronavirus patients. At one point, the two hospitals had patient-to-worker ratios of 23:1 and 15:1 in their emergency rooms, a ratio that normally should be kept at 4:1, according to The New York Times.

At Elmhurst Hospital and others, trucks with built-in freezers had to be sent to be able to preserve the increasing number of dead bodies. With variations among the facilities, Health + Hospitals’ 11-hospital system appeared completely overwhelmed, with new accounts every day of staff working without PPE, huge surges in patients and deaths, and other harrowing stories. Questions quickly became evident as to why a small number of the 11 hospitals were exceedingly overwhelmed and not able to rely more on other facilities within the system. This led to Cuomo to ask for Stringer’s review.

But one answer quickly provided by elected officials and experts was the leadership of Cuomo and de Blasio, which has come under scrutiny due to their slow responses during the early stages of the coronavirus outbreak in New York, around decisions like closing schools and businesses or issuing a stay-at-home order, delays experts have said cost lives. Stringer’s initial findings in an ongoing investigation into Health + Hospitals further highlight issues with city and state leadership, and within H+H itself, in preparing New York’s public hospitals for a major public health crisis and addressing issues that arose during the COVID-19 pandemic’s peak.

Stringer’s finding that problems at the city’s public hospitals cost lives appears to contradict a claim Cuomo has repeatedly made during the crisis, that no one died in New York because they did not get the care they needed.

In his letter to Cuomo, Stringer noted that, partially due to a lack of funding, public hospitals already served more people, and particularly more underinsured and minority populations disproportionately impacted by COVID-19, than private hospitals. And H+H hospitals were short on personal protective equipment (PPE) and ventilators vital to safely treating infected patients and keeping those with the worst cases alive. The lack of equipment mirrored a lack of planning on how to deal with such a situation, leading to “on the fly” solutions, as Stringer’s report puts it, to problems New York officials had been aware of since as early as 2006.

The most prominent issue highlighted in the report was hospitals seemingly complete lack of a plan for transferring patients from overwhelmed hospitals to those that still had open beds, despite past warnings from experts who testified to or developed plans for elected officials regarding pandemic preparedness. At first, individual staff at overwhelmed H+H hospitals would make calls to another hospital to try and arrange a transfer. But this inefficient system is partially what led to the accounts at hospitals like Elmhurst, which was completely overwhelmed and where staff worked inordinate and dangerous shifts.

While Elmhurst was overwhelmed, other hospitals were not, leading to inequitable conditions across H+H that were eventually addressed through a daily conference call and then an email portal to manage patient transfers, according to Stringer’s report.

Stringer made multiple recommendations, such as codifying ad hoc solutions like the email portal that was developed, as well as increasing training — especially critical care training — for H+H doctors and nurses and creating a set protocol for dealing with the types of situations that arose during the pandemic.

“The lack of preparedness forced all players to improvise responses, sometimes successfully, sometimes not — but inevitably at a cost in human lives,” Stringer said in the letter to Cuomo. “Several deficiencies were noted, including inadequate access to needed supplies and equipment, a lack of systems and procedures for managing patient loads across hospitals, and insufficient protocols for deploying staff.”

Cuomo’s office did not specifically address multiple requests for comment regarding the apparent fact that Stringer’s findings contradicted the governor’s comments about lives lost or regarding the state’s role in H+H challenges outlined in the report that the governor had requested.

“We commend the comptroller for undertaking this effort, we will review these preliminary findings, and look forward to his final conclusions,” Cuomo senior advisor Rich Azzopardi said in a statement.

In a statement, Health + Hospitals press secretary Stephanie Guzmán largely ignored criticisms brought up by Stringer and focused on the efforts H+H has made to save lives.

"NYC Health + Hospitals has been on the frontlines of the COVID-19 crisis, providing the highest quality care to all New Yorkers in the face of an unprecedented global pandemic,” Guzmán said. “Throughout this crisis, we acted as a system, coordinating across facilities and with our central office. Lives were saved across our city at the virus's peak thanks to the heroic efforts of our staff, who tripled and quadrupled, ICU capacity, surged resources and personnel, and even came to the aid of our city's private hospitals in their times of dire needs. We remain focused on providing the highest possible care for New Yorkers across our 11 hospitals for the duration of this crisis and beyond."

Some of the findings in Stringer’s review provide significant insight into Health + Hospitals’ struggles during the pandemic. Despite repeated warnings, the city and state did not seek to increase its stockpiles of ventilators or PPE before it was too late, the review showed, leading to dangerous conditions for patients and health-care workers.

For example, the New York City Department of Health and Mental Hygiene published its Pandemic Influenza Preparedness and Response Plan more than a decade ago in 2006, which suggested the city maintain a six- to eight-week stockpile of masks and gloves. However, hospitals did not maintain stockpiles of PPE, which Stringer attributed in part to a recurring problem for H+H — not having enough money to both address current needs and prepare for future ones. 

And when H+H sought to get its hands on more PPE in January, they had already become a global commodity that was near-impossible to obtain. With many hospitals across the world facing similar shortages, though, the Centers for Disease Control changed its guidelines regarding how often a protective facemask could be used, which Stringer’s report alleges was “driven by lack of available supplies, rather than by science and medical standards.”

“The State Department of Health disseminated the CDC guidelines, despite their obvious deficiencies, and H+H and other hospitals followed them: the lack of sufficient supplies precluded them from following more medically sound standards,” the letter reads. “The changing guidance and ensuing confusion rendered H+H health care workers even more vulnerable to COVID-19, with many becoming sick and dying.”

According to the letter, at least 35 members of the New York State Nurses Association had died of COVID-19 as of early June. In an attempt to address unsafe conditions related to a scarcity of PPE,  Cuomo announced on May 3 that New York would be working with neighboring states to buy PPE and that he would mandate all hospitals to have a 90-day stockpile of PPE. But, Stringer’s letter says, “the State has yet to issue such order promised on that date. In addition, fulfilling the order would be nearly impossible in the current supply-constrained circumstances.” 

The same 2006 New York City response plan also predicted a shortage of ventilators, and said the city could be short as many as 9,500 in the case of a pandemic. Stringer’s review also showed that additional concerns about ventilators, PPE, and other issues (like a shortage of hospital beds) the city ended up experiencing were expressed in a presentation on Medical Emergency Preparedness in 2007, a hearing on the city’s response to H1N1 held by the City Council’s Committees on Governmental Operations, Health, and Public Safety in 2009, and New York State’s November 2015 Ventilator Allocation Guidelines.

The only time the city had acted on these concerns was when, in 2006, it acquired a few hundred ventilators that were soon auctioned off due to the cost of maintaining them, something mentioned in Stringer’s letter and reported by ProPublica in April.

Another issue past public health experts had the foresight to see, but the city was unprepared for, was that of hospitals being unable to transfer potentially contagious patients, especially in the face of some facilities reaching max capacity.

“The surge of patients requiring medical treatment at an H+H hospital was uneven across the H+H system,” Stringer said in the letter. “In an effort to address the disparities between the demand at each facility and its available resources, individual H+H staff would telephone another facility to attempt a transfer.”

The lack of a centralized system resulted in inefficiencies as public hospitals already struggling to deal with unprecedented numbers of patients with a highly contagious virus needed more space. “The surge of patients requiring medical treatment at an H+H hospital was uneven across the H+H system, as press accounts about issues confronted by Elmhurst Hospital revealed,” the letter says, referring to the Queens hospital that on March 24 had 13 deaths in one day and faced severe shortages of PPE, ventilators and staff.

H+H eventually developed an email portal to streamline transfer requests, and a process using a 1-800 number for the distribution of PPE to hospitals that needed it most, according to Stringer’s review. The city Department of Health and Mental Hygiene began a weekly distribution of PPE from its warehouses to all hospitals, public and private, in late March, according to Stringer’s report.

But patients weren’t the only ones whose transfers were mismanaged, according to Stringer, as some staff were deployed to areas they should not have been due to a lack of recent — or any — training required to complete the tasks they were assigned. Struggling under great strains and running out of qualified staff, H+H assigned existing staff to areas where the need was greatest.

“[S]uch action resulted in doctors and nurses being redeployed to assignments that required specific skills they either did not have or had not used in many years, often without adequate or needed training,” Stringer said in his letter. “This included, for example, assignment of neonatal nurses to the intensive care unit, or of a physical therapist who had not worked as a respiratory therapist for decades to treat COVID patients in respiratory distress.”

And when H+H used paid volunteers, some of whom were recruited through city and state efforts, it exacerbated these issues.

“[I]ntegrating those volunteers magnified redeployment issues. The volunteers needed to be credentialed and did not have access to or knowledge of H+H computer systems,” Stringer’s letter says.

As experts had dating back to at least 2006, City Council Member Carlina Rivera, chair of the Council’s Committee on Hospitals, also said she had been calling for H+H preparation and management issues to be addressed for some time.

“Many advocates and I have been calling for New York hospitals to work together in this sort of fashion since before the COVID-19 pandemic, and long before the capacity situations at Elmhurst Hospital and elsewhere reached crisis levels,” Rivera said in a March 30 statement, after Cuomo announced plans for intersystem hospital coordination across the state. “There are specific reasons that certain hospitals are facing more challenges in responding to this pandemic, and they often go back to issues of further contraction of our inpatient hospital systems as well as inequitable funding and distribution of under or uninsured patients. Some of these issues would also be easily solved in the long-term through a universal healthcare system.”

Rivera had also called for the city to increase preparedness efforts for coronavirus as early as January, per a statement she released at the time. The mayor and top city health officials said in late January and into March that the city was well-prepared and ready, including at a March 5 City Council hearing on that preparedness, which was chaired by Rivera and City Council Member Mark Levine, chair of the Council’s health committee. 

In a statement responding to Stringer’s report, she reiterated another aspect of its findings: that many of the issues highlighted within it — from a lack of supplies and staff to no centralized management — stem from insufficient funding. In his report, Stringer notes that because H+H patients are disproportionately either uninsured or on Medicaid (70% of H+H patients fall under these categories, compared to 40% in private hospitals), H+H hospitals rely on public subsidies to fill their budget gaps. 

The report also notes that those gaps may be widening, as after falling in recent years, the number of uninsured H+H patients rose by 8% in the first four months of the 2020 fiscal year (July-October 2019). With many New Yorkers losing their employment, and so their insurance, due to COVID, it is likely the situation has worsened. Yet, the recent state budget adopted at the start of April cut Medicaid funds by $2.2 billion, which the report says, “could affect H+H’s bottom line.”

In a recent statement, Rivera said H+H funding shortfalls likely made worse issues of insufficient stockpiles of key medical supplies, not enough beds or staff, and more.

“H+H worked to alleviate some of these challenges, and while there are certainly numerous issues that H+H must reckon with and improve, the ultimate failure lies with the State for never pursuing real health care equity and reform,” Rivera said. “The same crises that every hospital system faced were magnified at H+H by a State budget that unfairly allocates more Medicaid and Medicare funds to private hospitals over our public system, by a State health insurance system that forces uninsured and under-insured New Yorkers to use H+H emergency departments as their only source for medical care, and by State health leaders who never sought to explore a universal healthcare model where patient loads and supplies could be more easily shared and planned between hospital systems. We’re not going to permanently solve the failures of any one hospital system unless we first consider the radical reforms we need to the way health care is delivered in this State and our nation.”

In his report, Stringer first put forward short-term solutions to the problems raised in preparation for a future health crisis, including a potential second wave of COVID-19 this fall. He recommended that the state and city departments of health, the city’s Department of Emergency Management, and other state and city government offices, and major public and private hospitals, should come together to form a plan that “provides clear chains of command and responsibility for different aspects of crisis management,” in the event of an emergency. Stringer recommends H+H create the same plan for within its own system, too.

He also advises that a centralized inventory and procurement system for things like PPE and ventilators be created. This would help identify and obtain critical supplies in advance of the next health crisis and ensure supplies are available when needed. Stringer also recommended that innovations such as “mechanisms developed for the transfer of patients between and among H+H facilities” be formalized; that H+H doctors and nurses be cross-trained to support ICU and critical care staff; that transferred or volunteer personnel be provided with training in skills they have not had to use for some time; and that state and city departments of health, H+H and other hospitals develop health and safety protocols and guidance to avoid confusion and miscommunications.

Stringer also included in his letter to Cuomo a similar sentiment as expressed by Rivera — that larger issues played a role in creating and worsening problems for H+H and should be addressed.

According to Stringer, H+H hospitals were already at a disadvantage due to chronic underfunding, as well as hospital closures and downsizings that have resulted in about 20,000 fewer hospital beds in New York State since 2000. In his letter, Stringer mentions that Elmhurst Hospital serves over 372,000 New Yorkers, while private hospitals such as NYU Langone serve 127,000 and the citywide average is 174,000. This translates into public hospitals’ abilities to serve their patients, as it can take as long as 12 hours to be admitted to some of them, compared to a citywide average that is half that long.

And public hospitals serve populations disproportionately impacted by COVID-19, such as Black and Hispanic New Yorkers who, as of mid-May, had an age-adjusted death rate that was twice as high as their white and Asian counterparts, according to Stringer. This added to the strain that was put on H+H hospitals during the pandemic.

“The City and State must address the underlying inequities in access to health care that both directly resulted in a disproportionately high death toll among the City’s most vulnerable populations and threatened to overwhelm existing capacity and systems,” Stringer wrote.

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by Victor Porcelli, Gotham Gazette

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New York City Public Hospitals Were Unprepared for Major Crisis, Costing Lives During Covid Outbreak, Review Finds Sat, 25 Jul 2020 04:00:00 +0000
Coronavirus Death Toll at State Psychiatric Facilities Climbs Quickly https://www.gothamgazette.com/state/9336-coronavirus-death-toll-at-state-psychiatric-facilities-climbs-quickly https://www.gothamgazette.com/state/9336-coronavirus-death-toll-at-state-psychiatric-facilities-climbs-quickly kingsboro

Kingsboro Psychiatric Center (photo: New York State Office of Mental Health)


The death toll from the novel coronavirus at state psychiatric facilities is rising, according to what scant official figures are available, hinting at a nightmare unfolding inside some of New York's least visible institutions. In just over a week, the number of residents confirmed to have died from the virus has tripled, according to data provided by the state Office of Mental Health (OMH), which runs the 23 centers.

Thirty residents are dead and another seven are suspected to have died from COVID-19, out of roughly 3,500 patients living in state-run inpatient psychiatric facilities. Another 259 current residents, many of whom are there involuntarily after being diagnosed with a severe mental illness, have tested positive for the coronavirus as of Wednesday, April 22. An OMH spokesperson said the agency is in the process of updating the number of employees who have tested positive. On April 17, officials reported 283 out of about 14,400 staff members had contracted the virus.

Citing privacy laws, OMH would not report on staff deaths or even comment on a tip that an employee at Manhattan Psychiatric Center had died of the virus. The agency has also denied requests for a breakdown of positive cases and deaths by facility, county, or region.

This snapshot of the virus' wreckage, now common in other contexts, has only begun to surface 55 days after Governor Andrew Cuomo declared a state of emergency in New York, and only after inquiries. Asked by Gotham Gazette, OMH acknowledged 10 resident deaths at its facilities on April 14. For more than a week after, OMH did not provide updated numbers on its facilities until Thursday, April 23, when the 37 confirmed and suspected coronavirus-related deaths were reported.

People with knowledge of the facilities say the pace at which officials are releasing information and the amount left undisclosed is part of a pattern of obscurity that is able to flourish around a population with few people advocating for it on the outside. It may also suggest an agency without a firm grasp on conditions in its facilities, where the virus is claiming many lives.

Gotham Gazette had identified close to 20 resident deaths in just two psychiatric facilities in downstate counties, when OMH was still reporting just ten. An OMH spokesperson wrote in an email Thursday that the initial ten referred only to confirmed cases.

Meanwhile, the number of confirmed COVID-19 cases and deaths statewide, and in other congregate living sites like nursing homes, ticks up by hundreds each day.

"OMH said that there were ten deaths in all 24 facilities?" asked an employee with direct patient contact at Rockland Psychiatric Center in an interview Wednesday. "No. It's more like ten deaths per facility."

"They are officially acknowledging at least 9 deaths at my facility. I think we are currently up to ten or eleven," the employee told Gotham Gazette.

Members from the Public Employees Federation, a union representing thousands of employees working in the state-run psychiatric centers, have reported to union leadership that at least seven residents at Pilgrim Psychiatric Center on Long Island have died from COVID-19. A patient advocate who works with residents at Pilgrim said they were aware of nine patients who have died there since the outbreak began. (The New York Times reported Friday that the state had confirmed that 10 patients at Rockland and nine patients at Pilgrim have died.)

Everyone who spoke with Gotham Gazette for this story spoke on the condition of anonymity out of fear of reprisal from OMH or for the protection of their clients.

"I think Manhattan Psychiatric also [has] about nine or ten" residents who have died, said the Rockland employee. That information came to them through an informal grapevine of doctors, nurses, and other direct care workers who have become increasingly concerned about the conditions in facilities and the silence surrounding them.

"We talk to each other," the Rockland employee said. "The administration does not communicate that information."

OMH inpatient facilities have been among the hardest hit but most under-discussed congregate living settings in New York. Throughout the months of March and April, patients have continued to gather in close quarters and employees have struggled to get sufficient personal protective equipment (PPE), as Gotham Gazette first reported, creating a fertile environment for spreading the virus. Reports from various service-providers say patients, also lacking PPE, do not have the resources to maintain sanitary conditions and many do not apprehend social distancing and hygiene guidelines.

Patients in New York's psychiatric institutions suffer from severe mental illness like bipolar disorder and schizophrenia. Most residents are admitted through the criminal justice system and are held involuntarily. Many have underlying medical issues that exacerbate the risk of dying from COVID-19.

According to union officials, in the last week of March OMH leadership told labor unions they were still in the process of assessing how much PPE was available at each facility. The Rockland Psychiatric Center employee told Gotham Gazette it wasn't until the second week of April that staff with direct patient contact began receiving one N95 mask per week. Multiple accounts from union leaders and psychiatric staff suggest employees were not allowed to wear certain PPE, even if it was available, until April. Only last Friday, April 17, did employees at Rockland Psychiatric who worked with patients start getting one N95 mask, one surgical mask, and one gown per day.

With the supply of PPE low statewide, the new arrangement is as much as workers feel they can hope for. "This is the first week where we feel we are adequately staffed and have adequate PPE," said the Rockland employee. "But we've had many, many patients get sick, many, many staff get sick in that time."

As in the general population, the distribution of coronavirus cases and deaths at psychiatric centers is not even across New York. While downstate institutions like Rockland, Pilgrim, and Manhattan have many positive cases and deaths, upstate centers have not been hit as hard. Some upstate facilities have had few if any positive cases -- Rochester Psychiatric Center, for example, has not had any positive cases as of Sunday, according to an employee there.

Other facilities have been ravaged. Mid Hudson Psychiatric Center, in Marcy, New York, is one of the biggest and most notorious psychiatric institutions in the state. With a high number of so-called forensic patients -- residents who have come in involuntarily through the criminal legal system -- the facility is already prone to violence and chaos. Since the outbreak began, at least 89 employees there have called out sick, according to a Public Employee Federation leader.

At Rockland Psychiatric, only three units out of 14 are without COVID-19 positive patients, according to an internal report from union leadership that was reviewed by Gotham Gazette. Forty union members have tested positive there and at least one staff member, a mental health therapy aide, has died, the report says. At Kingsboro Psychiatric Center in Brooklyn, staff members exhibiting COVID-19 symptoms could not take paid sick leave unless they tested positive, even if they had a note from a doctor, per emails among employees shared with Gotham Gazette.

OMH has not released information on how many facility-based workers have died of the novel coronavirus, despite numerous requests for that information from Gotham Gazette. In the most recent response, on Friday April 24, OMH Director of Public Information, James Plastiras, wrote: "Suspected COVID-19 related employee death totals at the facilities do not meet the data privacy reporting threshold." In response to a tip that an employee at Manhattan Psychiatric Center had died after contracting the coronavirus, Plastiras last week wrote, “OMH is prohibited by State and Federal privacy laws from providing protected health information.”

But an OMH employee newsletter sent in the beginning of April and obtained by Gotham Gazette includes the names and biographies of four "heroes," workers at OMH psychiatric facilities "who were lost to us during the epidemic." The employees -- a secure care treatment aide at Rockland Psychiatric; a security officer at Kirby Forensic Psychiatric Center; and two mental health therapy aides, one at Kingsboro Psychiatric Center and one at Manhattan Psychiatric -- had a collective 86 years of service, according to the newsletter.

Plastiras said OMH had gotten permission from the employees' families to publish the information, and that the newsletter was only meant to be seen by OMH staff, not the general public.

Cuomo has faced intense pressure from members of the media to provide detailed information on testing, positive cases, and deaths in nursing homes, where residents live closely to one another and are already highly susceptible to the virus because of their age and underlying conditions. In response to scrutiny about incomplete information on where nursing home deaths have taken place and other details, Cuomo has repeatedly said the state can only report to the public what nursing homes, most of which are privately run, report to the state Department of Health. But the Office of Mental Health runs the state's 23 public psychiatric institutions directly and is not dependent on outside entities for information about its facilities.

OMH is not the only government agency restricting information about inpatient mental health facilities, and their patients and staff. Gotham Gazette has been seeking data from New York City Health + Hospitals, the city's public hospital system, about the number of patients transferred since the start of the coronavirus outbreak from city hospitals to OMH inpatient centers.

A Health + Hospitals spokesperson did confirm to Gotham Gazette that psychiatric patients that could not be discharged from hospitals were transferred to state institutions as part of the city's effort to free up hospital beds for COVID-19 patients.

"We have not disclosed the number of inpatients psychiatric transfers to State facilities," the spokesperson wrote in an email. The spokesperson did not directly respond to questions about why they are not publishing the figures, writing, "We haven't shared this data publicly. We'll let you know when it's available."

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by Ethan Geringer-Sameth, reporter, Gotham Gazette
     

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Coronavirus Death Toll at State Psychiatric Facilities Climbs Quickly Fri, 24 Apr 2020 04:00:00 +0000
10 Dead, Hundreds Infected as State Psychiatric Facilities Become Another Crisis Point in Coronavirus Outbreak https://www.gothamgazette.com/state/9321-ten-dead-hundreds-infected-new-york-state-psychiatric-facilities-crisis-coronavirus-outbreak https://www.gothamgazette.com/state/9321-ten-dead-hundreds-infected-new-york-state-psychiatric-facilities-crisis-coronavirus-outbreak hospital pano

Manhattan Psychiatric Center, Wards Island (photo: @nicknormal via Flickr)


Ten people have died of coronavirus and another 193 have tested positive among the nearly 3,500 residents living in state-run inpatient psychiatric facilities, according to officials, making them one of the hardest hit institutional settings per capita in New York State. Another 283 staff that work at the state's 23 centers have tested positive for COVID-19, which has killed well over 13,000 people across the state.

After inquiries, the information was provided to Gotham Gazette on April 14 by the state Office of Mental Health (OMH), which runs the 23 sites. On April 17, just before publication of this story, OMH said it did not have any new numbers to share.

The centers are home to people with the most severe mental illnesses, who cannot manage their symptoms alone, and are proving to be particularly fertile settings for the virus' spread. They are experiencing exacerbated risks, similar to other congregate settings like jails and nursing homes, which have thus far received virtually all the attention.

Testimony from psychiatric center staff, labor union leaders, and an elected official with oversight of the centers paints a picture of sites where patients continue to gather in groups and staff lack the personal protective supplies needed to limit exposure to the coronavirus, where even basic hygiene and space to quarantine positive cases is lacking. Experts are concerned that the potential for violence among residents, already high, is heightened as they respond to life under the austere conditions of a societal lockdown.

Officials at OMH say the agency has taken precautions to protect residents and staff from the virus, but frontline workers say they have seen few changes on the ground. Union officials representing the workers said they are considering legal action to protect their members.

"There is a degree of fear and uncertainty amongst our workforce as well as, I think, amongst the patients," said Randi DiAntonio, vice president of the Public Employees Federation (PEF), a union representing thousands of healthcare workers in inpatient facilities. "We want to provide the services but we want to be safe and we want the right equipment. We don't want to be going into places when it's not absolutely necessary and critical and we want to be heard."

OMH did not provide information on coronavirus deaths among its staff. In response to an inquiry about a tip that an employee at Manhattan Psychiatric Center had died of COVID-19, spokesperson James Plastiras did not deny the fatality, but wrote: “OMH is prohibited by State and Federal privacy laws from providing protected health information.”

When asked, OMH also did not provide a breakdown of the patient deaths and positive cases by facility or county.

Based on confirmed cases, the psychiatric center coronavirus figures represent an infection rate twice that of nursing homes, and a death rate four times greater than in New York City jails, two settings that have been the focus of significant public attention, as their populations live in crowded spaces, sometimes against their will, and are often more likely to be killed by the virus.

Governor Andrew Cuomo and Mayor Bill de Blasio have each, in the face of public pressure, supported to varying degrees reducing the populations in other congregate living sites and taking stricter precautions to protect the people living in them. Cuomo has faced intense pressure to release more prisoners using his powers of clemency.

But staff and union leaders have reported "business as usual" in psychiatric centers with group therapy sessions of up to 20 people and residents gathering at mealtime in a single large dining room. Health-care workers often see patients with no protective face coverings as they continue to provide support for dozens of residents in shifts of eight to twelve hours.

"In most of the facilities patients were sitting right on top of each other," said Darlene Williams, an occupational therapist at New York State Psychiatric Institute in Washington Heights, of the group sessions that continue to meet during the pandemic. She is a 40-year veteran of the state's inpatient centers and a regional coordinator for PEF members in downstate facilities, including some of the largest in the state, like Manhattan, Bronx, and Kingsboro Psychiatric Centers.

"Somebody is going to have to die and then maybe a change will happen," she said. "I had one co-worker just tell me three days ago, 'Darlene, I don't want to die because I had to come into work.'"

In response to the outbreak, Plastiras said OMH has taken steps to ensure the safety of residents and staff, including restricting visitors except in certain cases for children, and during discharge. The agency is no longer congregating people in groups and that clinicians and staff are providing services via video and phone whenever possible, he wrote in an email to Gotham Gazette.

"OMH is taking every precaution to protect our staff and the people we serve while we continue to provide essential behavioral health services,” he wrote.

But Williams says at the Psychiatric Institute, which is attached to Columbia Presyterian, group sessions have only been reduced to no more than five patients, and that at other larger institutions in the city the sessions continue without distancing of at least six feet between individuals, as recommended by public health officials. OMH may issue directives, she said, "but that information doesn't trickle down all the way into facilities."

Protective Precautions
Workers in OMH facilities are expressing concern that they have not been given the proper protective equipment to keep themselves and the residents safe. In emails among employees at several psychiatric centers reviewed by Gotham Gazette, workers shared with one another heartbreak and extreme duress at having to work with patients who are ill and dying without personal protection.

"We were begging, begging OMH to make sure that we could wear surgical masks because we were still so close working together, employees along with patients," Williams said. She added, if it was not for Wednesday's executive order requiring masks in public at all times, "we still wouldn't be wearing masks."

In an April 7 letter to OMH Commissioner Ann Marie Sullivan, State Senator David Carlucci, a Rockland County Democrat and chair of the Senate’s mental health committee, raised alarms about conditions at an inpatient facility in Sing Sing Prison jointly operated by OMH and the state Department of Corrections and Community Supervision.

"[T]he deteriorated mental health of many of the patients in the program have prevented them from abiding with recommended hygiene practices…,” he wrote. “Despite these concerns, the Sing Sing ICP has not been provided with any hand sanitizers, cleaners, nor protective supplies."

Plastiras said OMH is working to procure and distribute personal protective equipment from available sources in accordance with CDC and state Department of Health guidance.

Staff aren't the only people in need of protective supplies, according to Williams. "The patients are also frightened because a lot of them this is their home and we're coming in and bringing in the virus. A lot of the patients are afraid, 'what will happen to me if I do get the virus?...where am I going, who is going to look after me?'" she said.

The residents of state psychiatric centers have substantial mental health factors that make it difficult for them to live on their own and meet their own daily needs. Many suffer from severe depression, delusions, bipolar disorder, and schizophrenia.

Patients may check into an inpatient facility voluntarily, but often people wind up admitted against their will after being seen in a general population hospital or other clinical setting and deemed by psychiatric doctors to be a danger to themselves or others.

Like other congregate living situations, state psychiatric centers are susceptible to unique consequences of the current coronavirus crisis. In addition to needing round-the-clock staffing, treatment for residents typically requires regular therapy, medication, and evaluation, as well as the structure and routine of life in an institution. Patients frequently have additional medical complexities that may make them more susceptible to the virus and patients may not be inclined to adhere to public safety guidelines.

"Our members, they care about this work and they want to do what's right for the patients,” said DiAntonio, the vice president of PEF. “And we recognize that there is a delicate balance between taking care of people that have high needs and that are going through real disruption, but also keeping people safe."

"One of the biggest issues we had with OMH is they made everybody ‘essential’ and refused to allow any remote working," DiAntonio told Gotham Gazette. "I've worked in facilities, I get that there are things that are hard to do from a distance. But again we are talking about a temporary situation that really may make a difference between life and death."

Plastiras said OMH is no longer holding non-essential trainings, though PEF leaders say they are still taking place. Workers are also afraid of what they have described as substandard quarantining procedures for patients who have tested positive for COVID-19.

Psychiatric wards in the past had isolation rooms for patients with infectious diseases but over the years facility budgets have been reduced and the quarantine rooms have disappeared, according to Williams, the occupational therapist at the Psychiatric Institute in Washington Heights. When a patient -- typically two to a room -- tests positive, their roommate is removed, she said, but the air is still circulated throughout the entire unit.

The union has struggled to get information on positive cases and deaths of patients and its members. "They are not openly sharing that. We finally were able to get them to make sure quarantine notices were being sent to employees if a home or location was under quarantine or there was a suspected case but for the longest time we were not getting that notice. They just started this week," DiAntonio said.

As the Times Union first reported, the New York State Correctional Officers & Police Benevolent Association has filed a complaint with the state and plans to go to court over conditions for its members working in the Central New York Psychiatric Center.

"The health and safety of our members is our number one priority. We are considering any and all actions, including legal action if necessary, to ensure their safety," wrote a PEF spokesperson, in an email to Gotham Gazette.

More Like a Hospital Than a Nursing Home
Reports from several sources indicate public health officials have treated OMH facilities, themselves hotbeds of coronavirus infection, more like overflow for overburdened city hospitals than like the homes of vulnerable populations.

According to DiAntonio, they have become overcrowded in recent weeks as hospital psychiatric units seeking to free up precious bed space for COVID-19 cases transfer to the facilities patients who cannot be discharged on their own or to a caregiver.

The Office of Mental Health did not respond to inquiries about how much the inpatient population has grown since the coronavirus outbreak began, but Plastiras said that 65 new employees had been hired in the last three weeks. The screening process for patient admissions has been "enhanced," according to Plastiras, but he did not elaborate on what the new protocol consists of.

The state Department of Health, which is coordinating the state's hospital system, did not directly respond to questions about patient transfers to OMH facilities, but a spokesperson for New York City Health + Hospitals, the city's public hospital system, confirmed that psychiatric patients that were not ready to be discharged were transferred to state psychiatric centers.

In a March 30 letter, PEF President Wayne Spence wrote to OMH Commissioner Sullivan imploring the agency to adopt a quarantine plan for patients transferred from coronavirus "hotspots" in hospitals to psychiatric centers, including isolation for the 14 days estimated to be the virus' incubation period. PEF representatives say quarantining protocols still do not include a full 14-day isolation.

On April 2, Dr. Brian Belfi, executive director of Kirby Forensic Psychiatric Center on Ward's Island, sent an email to staff saying the center would soon be taking admissions from female units on Rikers Island. "These are inmates that would have historically gone to Elmhurst which is overburdened with COVID," read the email, which was reviewed by Gotham Gazette.

Williams said there was a push by OMH to discharge patients from psychiatric centers but it was largely unsuccessful. "The movement of patients was a lot easier before the pandemic," she added. "Admissions are still happening but patients aren't going anywhere."

Meanwhile, a five-story addition to South Beach Psychiatric Center on Long Island, which was set to open this month to replace an old building damaged by Superstorm Sandy, is now being used to treat coronavirus patients and will no longer house psychiatric residents, according to Plastiras.

Element of Violence
It isn't all business as usual in the pandemic. Major disruptions in residents' routines are taking place as family visitations are cut off, favorite staff members fall ill, and off-campus movement is restricted. "It's sadder on our unit than it used to be. For a person who has been there for so many years and has seen so many things -- I've never seen anything this depressing," Williams said.

The limitations mean some required therapy sessions or family visits cannot take place, which for some is a barrier to being discharged. "We have some places where people are pissed because ‘I'm not getting out as quick’," she said.

OMH has one of the highest rates of workplace violence of any government agency. According to a state Department of Civil Service report, "patient restraint" is a leading cause of workers' compensation incidents, accounting for roughly 9 percent of the total in fiscal year 2019. The report says the job titles with the three highest workplace incident rates were Correction Officer, Direct Support Assistant, and Mental Health Therapy Aide. The two facilities with over 500 employees that had the highest rates were Mid-Hudson Psychiatric Institute and Bedford Hills Correctional Facility.

Williams says physical altercations are not uncommon in inpatient psychiatric settings, but the current strain on daily life may push it to extremes. "It puts staff and our patients at risk because now violent outbursts can happen" more easily, she said.

"I think that's also probably one of the reasons that OMH is so resistant to changing things that might keep employees and patients safer because they do worry that too many changes will create more problems," said DiAntonio, the union vice president. "However...I think there are a lot of things that are in between having no services and having services provided in an alternative way."

"Radio Silence"
Inpatient psychiatric centers have gone entirely unmentioned in the daily briefings held by Governor Cuomo and Mayor de Blasio, where they’ve fielded many questions about other vulnerable populations, including those in nursing homes and correctional facilities.

"In the realm of this specific branch of healthcare delivery it just feels like there's radio silence from providers, from the press, and just I think the general public awareness," said Dr. Julia Eilenberg, a psychiatrist who runs a private practice in Rhinebeck, New York.

"I have a patient who I just spoke to today who is profoundly depressed," she said. "And I'm trying so hard to keep her from needing to be admitted somewhere because I just don't know enough about where it would be safe from an infectious disease standpoint for her to go."

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by Ethan Geringer-Sameth, reporter, Gotham Gazette
     

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10 Dead, Hundreds Infected as State Psychiatric Facilities Become Another Crisis Point in Coronavirus Outbreak Fri, 17 Apr 2020 04:00:00 +0000
Max & Murphy Podcast: City Council Member Carlina Rivera on Hospital Oversight Amid Coronavirus https://www.gothamgazette.com/city/9293-max-murphy-podcast-city-council-member-carlina-rivera-on-hospital-oversight-amid-coronavirus-oubreak https://www.gothamgazette.com/city/9293-max-murphy-podcast-city-council-member-carlina-rivera-on-hospital-oversight-amid-coronavirus-oubreak 2 city council ant carwbai

Council Member Rivera visits a hospital (photo: John McCarten/City Council)


April 08, 2020 - Max & Murphy Podcast: City Council Member Carlina Rivera on Hospital Oversight Amid Coronavirus

carlina rivera 150wbaiCity Council Member Carlina Rivera, chair of the Council's hospitals committee, joined the show to discuss her oversight of the city's response to the coronavirus outbreak and what needs improvement.

Listen to the conversation and let us know what you think -- we're on Twitter @TweetBenMax and @JarrettMurphy. You can listen to the show through the embedded audio below or download the episode wherever you get your podcasts, under "Max & Murphy," and listen to Max & Murphy live on Wednesdays at 5 p.m. on WBAI radio, 99.5FM or wbai.org.

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by Ben Max, Gotham Gazette
     

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Max & Murphy Podcast: City Council Member Carlina Rivera on Hospital Oversight Amid Coronavirus Wed, 08 Apr 2020 04:00:00 +0000
As They Issue Dire Shortage Warnings, Neither State Nor City Has Plan for Ventilator Triage https://www.gothamgazette.com/state/9235-as-they-issue-dire-shortage-warnings-neither-state-nor-city-has-plan-for-ventilator-triage https://www.gothamgazette.com/state/9235-as-they-issue-dire-shortage-warnings-neither-state-nor-city-has-plan-for-ventilator-triage gov cuomoo 3way

Gov. Cuomo gives dire warnings about hospital capacity (photo: Darren McGee/Governor's Office)


City and state officials have been saying for over a week that as the spread of coronavirus continues New York's hospitals will not be able to provide life-saving treatment for everyone who needs it. One of the most immediate needs is ventilators, which are required to save the most critical COVID-19 patients and are already in short supply in New York City hospitals. With the note of alarm reaching a fever pitch in recent days, public health officials have not made available an official policy regarding ventilator triage, and have not said that any exist.

The pace of urgent developments and the overwhelming set of challenges posed by the unprecedented coronavirus crisis have left the state's highest officials themselves triaging the most pressing life-or-death matters. Governor Andrew Cuomo and Mayor Bill de Blasio have been calling on the federal government to provide more medical supplies -- most importantly ventilators -- while also pursuing them themselves.

Saying on Sunday that he had actually been able to secure an additional 6,000 ventilators, Cuomo said, "Ventilators are the most important piece of equipment and the piece of equipment that is most scarce.”

De Blasio is now saying New York City will need more ventilators very soon to avoid additional loss of life. The mayor said on CNN Monday morning that on Sunday evening he told President Trump and Vice President Pence, “if we don't get a supply of ventilators quickly, our public hospital system, literally after about a week or so, we will not have enough ventilators to keep people alive who could live through this crisis and could be saved.”

As of Monday afternoon, 1,500 of the city's 3,500 ventilators were in use, according to the mayor's office, and the administration is seeking 15,000 from the federal government by April. In the afternoon, the mayor announced the federal government was sending the city an initial 400 ventilators to help.

Calling ventilators “the number one precious commodity” during a Monday briefing from Albany, Cuomo said that there are 3,000 ICU beds across the state, but that “we may need between 18,000 to 37,000. That's my greatest concern because that's where we need ventilators to turn those ICU beds into beds for people suffering from the virus."

But as they predict dire situations and scramble to secure more ventilators, New York government and public health officials do not yet appear to be creating any ventilator allocation policies. 

And the likely shortfall and short timeline are worrisome for medical ethicists who say any government policy that may ultimately dictate who lives and who dies should be thoroughly communicated and publicly vetted.

Asked about ventilator triage guidelines and policy-making, a spokesperson for the city's Department of Health and Mental Hygiene told Gotham Gazette that such guidelines fall into the state Department of Health’s jurisdiction.

In response to a Gotham Gazette inquiry about how difficult decisions will be made by doctors when there are not enough ventilators to save every patient, a spokesperson for the state Department of Health (DOH) wrote: "Under Governor Cuomo’s direction, hospitals in New York State continue to rapidly modify their current operating function to accommodate increasing support for patients with COVID-19 as well as the rest of the hospital population. Specific tactics include stopping elective procedures, reducing current inpatient population and expanding bed capacity. Commissioner of Health Dr. Howard Zucker has discussed this with senior hospital leadership from throughout New York State, and this is being enacted throughout the state."

A council led by Ken Raske, president of the Greater New York Hospital Association, and Michael Dowling, president of Northwell Health, has been tasked by the governor with developing hospital surge capacity. That body would be responsible for making decisions about ventilator allocation, according to another DOH spokesperson.

At this point in the state's response, the council is discussing every aspect of managing hospital surge, that spokesperson said, with the focus now on ensuring that the required equipment and processes are in place. Cuomo has already made several announcements about how the state is increasing hospital capacity, including with federal help.

In 2015, the DOH's New York State Task Force on Life and the Law developed guidelines for ventilators in a influenza pandemic, which Zucker described as "a foreseeable threat" in the report's introduction. While the task force's guidelines were designed with a "severe pandemic" in mind, the DOH spokesperson said that it is not a binding policy document steering the state's response, though it has been well circulated and read recently within the Department.

Notably, an FAQ accompanying the report specifically mentioned that the state would not be able to stockpile enough ventilators for such a scenario. The stated question was, "Can the State stockpile as many ventilators as would be needed in a severe pandemic?" The answer reads, "Even if New York State purchases additional ventilators, the demand would quickly outpace supply in a severe pandemic. No matter how many ventilators are available, in a severe pandemic there will be shortages because so many people will be sick at the same time. In addition, even with enough ventilators, a sufficient number of trained staff may not be available to operate them, particularly because health care workers will be among the ill."      

The guidelines are broken into three different categories for triaging ventilators (adult, pediatric, and neonatal guidelines) and consider a set of exclusion criteria and mortality risk with treatment. Exclusion criteria include medical conditions connected with "immediate or near-immediate mortality even with aggressive therapy," according to a fact sheet accompanying the document.

Advanced age, disability, “social worth,” are not exclusion criteria under the guidelines. Healthcare providers assessing adult mortality risk use a scoring system called SOFA (Sequential Organ Failure Assessment). For pediatric and neonatal, determinations should be made through "physician clinical judgment, a structured decision-making process that carefully considers only specific clinical factors based on available medical evidence," the sheet said.

Ethicists have been thinking about this at least since the SARS outbreak in 2003, according to Dr. Alison Bateman-House, assistant professor in the Division of Medical Ethics at NYU School of Medicine attached to NYU Langone Health. "When we saw the SARS epidemic and there were more people critically ill than we had the machines to provide for, people actually did the hard work of sitting down and saying, 'Well, if we're going to have to make difficult choices, how do we make them?'"

"Obviously no one was planning per se for COVID-19, because it is new and novel, but the basic principles were there of, there is some sort of respiratory disease that is widely infectious and we don't have enough equipment, how do we prioritize?" she said of the 2015 task force guidelines.

The task force estimated that in a severe pandemic the state could see a shortfall of as many as 15,783 ventilators. President Trump, citing claims made in an op-ed published by former New York State Lieutenant Governor Betsy McCaughey, said Tuesday that New York's current projected shortfall is Cuomo's failure for not purchasing more ventilators in 2015.

The report briefly addresses the idea of stockpiling ventilators and illuminates the state's thinking in 2015. "The State’s current approach to stockpiling a limited number of ventilators balances the need to prepare for a potential pandemic against the need to maintain adequate funding for current and ongoing health care expenses," the report reads. At the time, the state had 1,750 ventilators in reserve.

A footnote later states: "There are significant financial burdens associated with obtaining, storing, and maintaining equipment and supplies. In addition, stockpiling results in significant opportunity costs when choosing stockpiling over another priority."

In terms of hospital capacity, Governor Cuomo has been focused on three things: reducing the rate of the outbreak's spread to help distribute the burden on hospitals over a longer period of time; building new hospital space with the help of the U.S. Army Corp of Engineers, the Federal Emergency Management Agency (FEMA), and local stakeholders; and securing necessary medical equipment, from masks to gowns to ventilators. The state DOH says there are also plans to redistribute resources from hospitals in areas that have not been hit hardest.

With more than 60% of the confirmed coronavirus cases statewide, New York City's hospitals may experience the most imminent shortages. As of 6 p.m. Sunday, the Mayor’s Office reported 10,764 positive cases of COVID-19 and 99 related fatalities, with at least 1,800 people hospitalized due to the virus, and of those individuals, at least 450 in the ICU, where ventilators are typically used.

“I made clear to them what I need right now is action, not words, and every day counts because we're literally in that very tight window now that if we don't get the ventilators in particular we will actually start to lose lives who could have been saved,” de Blasio said on CNN Monday of his conversation with Trump and Pence.

The mayor is imploring the federal government to deliver ventilators, surgical masks, gloves and gowns using its emergency production powers, which have in previous times of crisis been used to mandate factories produce necessary supplies. Even as he also asks Trump to produce more ventilators and other essential supplies and deliver them to New York, Cuomo has been purchasing and otherwise securing such equipment. The governor made the Sunday announcement that the state has purchased an additional 6,000 ventilators and is redistributing existing ones to the areas with the highest needs throughout the state, he said.

As with the state, the city's public health officials have not formalized a plan for ventilator allocation and in some ways appear to be ignoring the issue.

A spokesperson for New York City Health + Hospitals, the city's system of 16 public hospitals and other health care facilities, told Gotham Gazette by email Friday that there were no plans to implement ventilator triage and that every patient who needs a ventilator would receive one. The spokesperson noted that Health + Hospitals is a single health system that could shift resources from one facility to another as needed, and that it is coordinating closely with city, state, and federal agencies to ensure the most clinically appropriate care is provided.

In response to an inquiry Friday seeking clarity on the apparently contradictory information coming from the Mayor and Health + Hospitals, a spokesperson wrote, "We expect to meet our patient’s [sic] needs."

In terms of the city's private hospitals and coordination with City Hall and the public system, mayoral spokesperson Freddi Goldstein said that "There is a daily call” among Deputy Mayor for Health and Human Services Dr. Raul Perea-Henze, Health + Hospitals CEO Dr. Mitchell Katz, and Ken Raske, the president and CEO of the Greater New York Hospital Association, which represents 250 not-for-profit hospitals in New York, New Jersey, Connecticut, and Rhode Island.

During an appearance this past week on the New York Times podcast The Daily, host Michael Barbaro asked Governor Cuomo about how the apparently imminent choices of which critical patients get ventilators and which do not will be made. "Well, I pray we don’t get there,” Cuomo said. “But if we get there, it should be a medical decision. Unless God intervenes and God makes the determination first."

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by Ethan Geringer-Sameth, reporter, Gotham Gazette
     

Read more by this writer.

Note: This article has been updated with the latest ventilator information from the mayor's office on Monday afternoon and Cuomo's Monday comments about ventilators and ICU beds, as well as additional information on ventilator stockpiles from the 2015 DOH Task Force report. 

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As They Issue Dire Shortage Warnings, Neither State Nor City Has Plan for Ventilator Triage Mon, 23 Mar 2020 04:00:00 +0000
How the City's New Jails Plan Accounts for Those with Serious Mental Illness https://www.gothamgazette.com/city/8910-how-city-close-rikers-jails-plan-serious-mental-illness https://www.gothamgazette.com/city/8910-how-city-close-rikers-jails-plan-serious-mental-illness Rikers Island inmate detainee

(photo: Michael Appleton/Mayor's Office)


In an historic vote last month, the New York City Council approved the plan to close the Rikers Island jail complex and replace it with four borough-based jails by 2026. When the Council voted through the plan, estimated at $8.7 billion in new construction costs, it also announced, with Mayor Bill de Blasio, a $391-million package of citywide and community investments in criminal justice reforms and initiatives to responsibly accelerate the reduction of the city’s jail population.

For city officials, one of the most complex issues they face is ensuring that the new system is less punitive and more rehabilitative, particularly for the 43% of incarcerated individuals who suffer from some form of mental illness. Experts and advocates say the plan is taking an appropriate approach to that issue but also insist that it provides a novel opportunity to rethink how the criminal justice system deals with the mentally ill, especially those suffering from more acute problems.

Given that one of de Blasio’s signature programs as mayor is the ThriveNYC mental health “roadmap” spearheaded by his wife, Chirlane McCray, the mayor’s approach to services for those with severe mental illness, particularly those who wind up involved in the criminal justice system, has been the source of intense scrutiny, again heightened as the new jails plan was crafted.

With most major crimes at or near record lows in the city and recent shifts in law enforcement and prosecutorial policies, particularly around non-violent offenses, the number of people incarcerated in city jails has been consistently declining. That drop has been so sharp that the de Blasio administration projects the average daily jail population to fall to 3,300 by 2026, when Rikers is set to close, down from about 7,000 this year and aided by state bail reform that will go into effect in January.

The Rikers closure plan will involve building four new facilities in every borough except Staten Island, with roughly 885 beds each. The facilities are meant to be fairer and safer than the dilapidated jails on Rikers. Another 250 new beds will be created in existing public hospital facilities for those individuals who require continuing access to specialized medical services.

Mayor Bill de Blasio himself has acknowledged that the city has its work cut out for it when it comes to individuals with mental illness who are locked up in jails. The day after the Council’s vote, the mayor made his weekly appearance on WNYC’s The Brian Lehrer Show and a caller named Winston who was formerly incarcerated on Rikers prodded him on improving access to mental health services. De Blasio emphasized the decarceral aspects of the plan, which include greater investments in alternatives to incarceration, supervised release programs, and mental health initiatives.

“This thing is not in isolation. Six years of changing the approach to criminal justice and it’s all been consistent with reducing crime at the same time and I’m very convinced that this is the right approach,” said the second-term Democrat. “But you’re right, it will take some important adjustments and investments and getting people more access to mental health services, which is the whole concept behind the Thrive[NYC] initiative, is absolutely necessary going forward, and providing better and more consistent mental health for those who do happen to be incarcerated, which is also in this plan.”

One of the key elements of how things unfold will be the dichotomy of mental health services for those with serious mental illness who need treatment while serving jail time versus those who can be removed from or kept out of jail given appropriate treatment options and enrollment in such programming.

City Council Speaker Corey Johnson, in a statement to Gotham Gazette, said, “The time of locking people up because they're mentally ill has to come to an end. This is why we are creating new Intensive Mobile Treatment (IMT) teams to provide intensive treatment to adults with recent and frequent contact with the mental health, substance use, criminal justice, and homeless services systems. It is time to eliminate an unjust system that has criminalized mental illness and destroyed so many of our communities.” 

In a background briefing, an official from the Mayor’s Office of Criminal Justice, which took point on the jails plan, laid out the various pillars of the city’s approach. The official reemphasized what de Blasio said on the radio: that the administration’s focus is to minimize the number of people in jail with behavioral health, mental health, and substance misuse problems, and to prevent reincarceration by providing services that address their needs.

Correctional Health Services, an arm of NYC Health+Hospitals, is charged with providing medical services to the city’s jail system, from pre-arraignment through reentry. According to a H+H spokesperson, roughly one-third of the 43% of detainees who receive a mental illness diagnosis have severe mental illness – schizophrenia, bipolar or depressive disorders, and post-traumatic stress disorder – making up about 16% of the total jail population. For a population of about 7,000 detainees, that means just over 1,100 people with serious mental illnesses at any given time.

Currently, each jail has what H+H says is the equivalent of an outpatient clinic. For detainees with serious mental illness, intellectual disabilities, or who might be more vulnerable in the general jail population, there are 18 so-called mental observation (MO) units across the 10 jails and Horizon Juvenile Center. There are also inpatient psychiatric beds at Bellevue Hospital for men and at Elmhurst Hospital for women, all of whom are considered part of the city’s jail population while being treated.

The community investments package that the City Council and mayor agreed to includes an expansion by Correctional Health Services of two programs that provide discharge and reentry services to the formerly incarcerated, the Community Reentry Assistance Network (CRAN) and Point of Reentry and Transition (PORT) programs.

Though the city is hoping for the best, it is planning for the worst. About 40% of the beds in the new borough jails will be therapeutic housing units to account for the percentage of the jail population that suffers at least some kind of mental illness.

The city plans to reduce the population through various efforts, including implementing recommendations from the city’s Crisis Prevention and Response Task Force announced last month, which will change how police respond to people experiencing mental health crises. The city is putting $23 million in total towards those recommendations by 2023, which includes adding four Health Engagement and Assessment (HEAT) teams of clinicians and peers who have experienced mental illness to handle non-emergency responses, and six more mobile crisis teams (mental health professionals who respond to calls to the NYC-WELL hotline) to conduct home visits and respond to urgent situations.

These programs aim to ensure that people suffering from mental illness do not wind up in jail, or back in jail as the case may be.

Additionally, the city is investing $11.2 million to add 380 beds of “justice-involved supporting housing,” for a total of 500 across the city, and is increasing the number of post-release transitional beds for those with mental health needs and a history of homelessness to 500 with a $25 million investment.

About $27 million in new funding will go to mental health services (for a total of $37 million) through various programs. And the Council also passed the Get Well And Get Out Act, which will allow those with serious mental illness to push for their release from custody if they improve with treatment.

But the official from MOCJ conceded that there will inevitably be individuals with serious mental illnesses in jails, despite the city’s best efforts to reduce that population, which has stubbornly hovered in the 10-15% range even as the overall numbers of detainees have fallen. Almost all of the people held in city jails are either awaiting trial, locked up due to a parole violation, or serving sentences of under one year.

The new borough facilities and the Rikers plan account for the fact that some detainees will suffer from serious mental illnesses by expanding two key programs that address this population: Clinical Alternative to Punitive Segregation (CAPS) and Program to Accelerate Clinical Effectiveness (PACE).

The Council’s agreement with the mayor includes $12.8 million to double the number of existing PACE units by the end of the current fiscal year. The city has yet to decide the breakdown of those units in the borough facilities, the MOCJ official said.

The 250 new Outposted Therapeutic Units outside the jail system, however, will be dedicated to those individuals who have some form of substance abuse disorder, mental health or behavioral health issue as well as a complex need for medical care. The MOCJ official said they had identified a gap in the current continuum of care for these detainees, who don’t necessarily require inpatient hospitalization but benefit from proximity to specialized care. They can spend hours going to and from hospitals for even the shortest of check ups with specialists. 

The city is currently in the process of identifying vacant sites for those units and has contracted Lothrop Associates to conduct a feasibility study that is expected to be concluded by the end of the year, the MOCJ official said. The study will help determine the costs and needs of the new facilities and the city will then put out solicitations for redesigning the new spaces to accommodate incarcerated individuals. The project is separate from the borough-based jails plan and the official said it would likely move much faster since it would not require approval through the city’s land use process.

Insha Rahman, director of Strategy and New Initiatives at the Vera Institute, said a larger goal of the Rikers closure plan should be to minimize the harm that jails do to inmates, not just those with mental illness.

“If we're going to say, ‘We are still going to have incarceration in this city,’ which we are, for the foreseeable future, 5, 10, maybe even 20, 30 years from now, we should be constructing these new facilities as buildings first, and then outfitting them to be places of incarceration so that they're not built with just incarceration and jail design front and center,” she said in a phone interview. 

She cited the example of jails in countries like Germany and Norway. “To the extent that we're thinking about how do we address people's underlying needs and how do we provide therapeutic care and counseling for those who are in custody, anything that looks fundamentally like a jail is going to inflict some amount of harm and trauma,” she added, insisting that the city should look not to prison architects but to behavioral and mental health experts for ideas for the new jails.

Rahman also urged the administration and Council to invest further at the community level in permanent affordable housing, community-based treatment and counselling that can preempt interactions with the criminal justice system.

A stark reality that the city faces is dealing with those individuals with serious mental illness who pose a threat to themselves and others, a concern that was brought to the fore last month when a mentally ill homeless man killed four men sleeping on the street in Chinatown. It prompted the city to review how it implements Kendra’s Law, which allows courts to mandate involuntary “assisted outpatient treatment” for such individuals. That review is meant to be completed by next week. The number of individuals ordered into treatment under the law was 2,476 in fiscal year 2018, down from 2,517 in fiscal year 2017 but up from 2,368 in fiscal year 2016 and 2,176 in fiscal year 2015, according to data provided by the de Blasio administration.

Rahman warned against harsher enforcement of the law. “I think enforcing Kendra's Law more strongly is not necessarily going to get us fewer people in our jails that have serious mental health needs,” she said. “I think the most important initial response is more community-based treatments and figuring out how can we actually resource families and neighbors.”

There is some disagreement on that front, however. D.J. Jaffe, executive director of Mental Illness Policy Org, criticized the city’s ThriveNYC mental health initiative and called for an expansion of Kendra’s Law in an op-ed in the New York Daily News following the Chinatown murders.

Jaffe argues the City Council should require “the city’s Department of Health and Mental Hygiene to start evaluating all seriously mentally ill people being discharged from Rikers; all seriously mentally ill leaving shelters; and all mentally ill patients being discharged from city hospitals after an involuntary commitment. Those are the three highest risk groups; evaluate them all to see if they are eligible for Kendra’s Law and get them into it if they are.”

Minister, Dr. Victoria A. Phillips of the Urban Justice Center Mental Health Project echoed Rahman’s view, but also stressed that the new jails should prioritize interactions between detainees and health care workers, rather than with corrections officers.

“Behind correctional walls, it’s never the health staff that takes the lead, and I think the Department of Corrections has shown itself to be unable to change its culture of violence,” she said, pointing to the most recent report by a federal monitor with oversight of the city’s Department of Correction, which showed that use of force by corrections officers has risen dramatically while the jail population has dropped.

Former New York Chief Judge Jonathan Lippman, who led the independent commission that proposed the leading Rikers closure plan, praised the approach the city is taking, while acknowledging that the overarching objective is to keep people with mental illness out of jails. “If you have people who the system decides to incarcerate, then you have to deal with that,” he said in a phone interview. “In an ideal world...people who have serious problems with mental health should get help and not be incarcerated. But, you know, we don't live in the ideal world.”

[READ: 'No One Should Enter the Criminal Justice System for Something Related to Mental Illness']

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by Samar Khurshid, senior reporter, Gotham Gazette
     

Read more by this writer.

Note - This article has been updated. 

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How the City's New Jails Plan Accounts for Those with Serious Mental Illness Thu, 07 Nov 2019 05:00:00 +0000
‘Nobody Should Enter the Criminal Justice System for Something Related to Mental Illness’ https://www.gothamgazette.com/state/8705-new-york-criminal-justice-system-mental-illness-thrive-nyc https://www.gothamgazette.com/state/8705-new-york-criminal-justice-system-mental-illness-thrive-nyc first lady chirl mcc first

Chirlane McCray on Rikers Island (photo: Michael Appleton/Mayor's Office)


A rising number of 911 calls to report emotionally disturbed persons, several fatal encounters between police officers and people with serious mental illness, and an increasing percentage of seriously mentally ill people among those detained in city jails have all raised questions about how New York City and State provide care for those suffering from the most serious mental illnesses.

These questions and concerns don’t have easy answers. The city’s public hospital system, NYC Health + Hospitals; the mayor’s mental health care roadmap, ThriveNYC; services from the city’s Department of Health and Mental Hygiene; treatment within the city Department of Correction; private clinics; mental health shelters; and more combine to create a complex and stratified framework for treating those with a serious mental illness (SMI).

For some, much of what is at times called a crisis of treatment for those with serious mental illnesses like schizophrenia can be traced to the trend whereby the state closed down psychiatric hospitals with many thousands of inpatient beds while requisite treatment systems were not put into place to help people who would no longer be institutionalized, many of them cycling through the criminal justice system and inappropriately receiving their best mental health care while in jail.

There is insufficient use of mandatory outpatient treatment, some critics of the city and state say, with significant recent criticism also aimed at Mayor Bill de Blasio and First Lady Chirlane McCray over how resources have been allocated in their signature ThriveNYC program. Meanwhile, others have focused on questioning that police officers with guns are often first responders to people experiencing a serious mental health crisis, and those critics have been successful to some extent in getting protocols changed, though they say there is clearly more to do.

Dr. Mitchell Katz, president and CEO of NYC Health + Hospitals, says he’s troubled by the gaps in treatment and looking for new answers that would require the city and state to work together.

“The problem with the current mental health system, from my point of view, is for people with serious mental illness, the people we most worry about, the people we sometimes see on the subway or sitting on the bench, that right now there is nothing in between acute hospitalization and traditional outpatient care,” he said in April during an appearance hosted by the Citizens Budget Commission (CBC), a nonprofit think tank.

During an interview after the CBC event on the What’s The [Data] Point? podcast from CBC and Gotham Gazette, Katz was asked for more on his view about how to fill that gap.

He said H+H is working with the state on fixing a system that “drops off too precipitously.” Katz said he was in discussions to create programming to increase services for those who don’t qualify or don’t want to be admitted for inpatient care at a hospital but don’t receive enough treatment or care in the current outpatient system.

“We know in New York City there is a group of people with very serious mental health and addiction problems who rotate between the acute hospital, the shelter, and the jail,” he said on the podcast. “They don’t need to be locked up but let’s provide them a positive residential program that they want to stay at because it’s better than shelter and it’s better than the jail when we know that there are people who get arrested in order to be taken care of in jail.”

Over the course of months since Katz’s April comments, Gotham Gazette reached out multiple times to New York City Health + Hospitals and the Mayor’s Office but didn’t receive any further details on Katz’s vision for the program or whether there are ongoing discussions to make it a reality. State law and the state Office of Mental Health (OMH) have near full authority over the types of mental health treatment options allowed throughout the state, and are essential to the discussion, as Katz indicated.

In a statement to Gotham Gazette, a spokesperson for the New York State Office of Mental Health said, “as New York State continues to transform its mental health system to serve more individuals in the least-restrictive setting possible, we are expanding our reach through community-based services. These treatment models allow people to stay in the communities where they are best supported.”

Serious mental illnesses are not the types of mental illnesses and mental health issues that plague a little under 50 million Americans; according to the National Institute of Mental Health, about 4.5% of American adults have a serious mental illness -- meaning roughly 239,000 New Yorkers based on population statistics.

The three most common SMIs are schizophrenia, bipolar disorder, and major depression – less severe depression and anxiety are not categorized as serious mental illnesses although both the National Institute of Mental Health and the Substance Abuse and Mental Health Services Administration (SAMHSA) agree there is some ambiguity in the cut-off line for what’s considered a “serious” mental illness. It’s also important to note that there are complications with the term “serious mental illness”; it is not a diagnosis itself, but a level of disability or a threshold for having a particularly significant and debilitating mental illness.

In asking how New York treats those estimated 239,000 New Yorkers, there are the unavoidable questions of where they can and should be treated, as Katz indicated. Back in the early 20th century, many people with SMIs were admitted into state psychiatric centers, more commonly known as “insane asylums”; however, over the past 80 years there has been a major shift in placing those with serious mentally illness into inpatient treatment.

In the 1950s, New York began deinstitutionalization – a shift from inpatient care (a patient admitted into a hospital full-time) to community-based outpatient care. According to a 2018 report by Manhattan Institute senior fellow Stephen Eide, the process of deinstitutionalization continues to this day but may have gone too far. According to the report, the city’s public hospital and health care system, NYC Health + Hospitals, is the leading provider of inpatient psychiatric care in the city with only 1,218 beds dedicated to adult inpatient psychiatric care, representing 48% of adult inpatient beds in the city. State psychiatric centers in the city account for 1,058 adult inpatient beds.

ThriveNYC, led by McCray, has come under fire on multiple fronts, including general money mismanagement and lack of clear outcome-tracking, but also for how it helps -- or doesn’t help -- those with serious mental illnesses. During a City Council budget and oversight hearing on March 26, McCray was pressed on the issue several times, including pointed questions about how much of the ThriveNYC budget is dedicated toward treatment for those with SMIs.

At one point she said, “All of Thrive is really focused on the seriously mentally ill,” but she and others who testified about the program eventually offered more clarity.

Thrive, which is called a “roadmap” and spends around $200 million per year on programming and coordination, does include services solely focused on those with serious mental illness, but its main objective is to plug gaps of already existing services run by H+H and the city Department of Health and Mental Hygiene (DOHMH), while reorienting health care to always include mental health care and extend awareness and treatment into all of the city’s communities.

“Thrive is dedicated to prevention when possible, early prevention, treating people in crisis, and making sure people are stabilized when they do reach a crisis point,” McCray said. In arguing that all of Thrive is aimed at serious mental illness, she argued that untreated lower-level mental health issues can spiral.

Thrive, in the context of treating those with SMIs, is criticized for focusing more on mental health rather than mental illness; most of its 54 initiatives are focused on combating stigma, the negative factors that can lead to mental illness, and encouraging people to spot mental health issues in others and themselves, and to seek help.

In a May op-ed in the New York Post, DJ Jaffe, the executive director of Mental Illness Policy Org, and Eide of the Manhattan Institute called for the reallocation of ThriveNYC’s entire budget to focus on those with serious mental illness. They offered specific ways in which to redirect funding into different programs, such as enhancing existing crisis intervention teams, creating an office to exclusively manage the use of Kendra’s Law in New York CIty, and promoting supportive housing for homeless people with serious mental illnesses.

“The most serious cases are the ones most likely to become homeless, arrested, incarcerated, hospitalized and violent if they go untreated,” they wrote. “Yet Thrive virtually ignores this group in favor of people with less severe illnesses.”

Susan Herman, the recently-appointed executive director of ThriveNYC, said during the March testimony, “we are filling strategic gaps and piloting innovative programs for the seriously mentally ill to be able to work with people so they can stay in community by connecting them to services, by helping them connect or reconnect to treatment. We’re helping people both before crisis and after crisis.”

For example, McCray said in an op-ed in New York Daily News that Thrive adds $30 million of funding (about 15% of its budget) to the $300 million the Department of Health and Mental Hygiene already spends directly to help people with SMIs.

“Thrive-supported programs are designed to enhance and complement these existing services, not compete with or replace them,” she wrote.

For someone who voluntarily requests care, they can go to a public hospital for informal short-term hospital care as well as traditional outpatient care. The average stay for someone hospitalized for mental illness is 11 days, according to the New York City Department of Health and Mental Hygiene.

Outpatient care -- preferred by many for its community-based nature -- consists of things like meeting with a therapist or a psychiatrist and getting medication prescribed. Influential 1999 Supreme Court case Olmstead v. L.C. ruled public entities must provide community-based services to those with mental illness whenever possible.

“Lots of people have schizophrenia,” says Dr. Gary Belkin, Executive Deputy Commissioner for Health and Mental Hygiene in the city's Health Department and Chief of Policy and Strategy of ThriveNYC, in a phone interview. “The vast majority don’t end up on the street untreated and that’s because there are things that happen earlier, things that Thrive is working on – getting better care connections, having many points of contact, opportunities for family/friends to bring them mobile help."

Thrive has Assertive Community Treatment (ACT) teams dispatched around the city, often in mental health shelters, to treat people with serious mental illness. There are at least 50 ACT teams in New York with the capacity to serve 3,500 people at any time, according to Herman’s March 26 testimony. Thrive also created intensive mobile treatment teams that mostly go to shelters and provide treatment for homeless people. These outreach efforts mostly help people with outpatient care, but can lead to more intensive intervention, though it is very rare for judges to order people into inpatient hospitalization in New York.

Some of these efforts will now be part of ThriveNYC’s recently-announced outcome-tracking procedures, announced in late June.

The key questions, it seems, are whether Thrive’s efforts and the increased emphasis on outpatient programs on the state level -- perhaps including what Katz of H+H said he’d like to see -- can successfully fill gaps left by deinstitutionalization, while creating a more humane care system, and reduce threats posed by those with serious mental illness to themselves and others.

Deinstitutionalization in New York has been drastic. According to Eide’s report, as of November 2018, the average daily number of people in New York state adult psychiatric centers was 2,267. In 1955, there were over 93,000. Even in just the last four years, the number of state inpatient psychiatric beds -- in other words, the capacity for inpatient care -- has dropped by 19% statewide, from 2,866 in 2014 to 2,335 in 2018.

The drop in average daily patients and inpatient beds has coincided with an increase in the number of seriously mentally ill homeless people in New York and the proportion of inmates with a serious mental illness diagnosis in city jails.

According to Eide’s findings, there are more psychiatric beds in New York City mental health shelters than the number of psychiatric beds in state psychiatric centers and Health + Hospitals facilities combined.

Supportive housing, which provides housing and social services for those with serious mental illness, is also seen as a key tool. There are currently 52,000 units of supportive housing statewide, half of which are funded by the state Office of Mental Health (the other half don’t necessarily serve those with mental illness). Supportive housing, which is built and funded by both the city and state, sometimes in conjunction, is typically run by nonprofit providers who provide onsite mental health care, medication delivery systems, and more.

According to testimony given in a May City Council hearing by the Supportive Housing Network of New York, there are around 33,000 units of supportive housing in New York City. Amid calls for more units, both Mayor de Blasio and Governor Andrew Cuomo have made pledges to develop more supportive housing.

In his NYC 15/15 Supportive Housing Initiative announced in November 2015, de Blasio said the city would develop 15,000 additional units of supportive housing over 15 years. Two months later, Governor Cuomo announced his plan to build 20,000 units over the same 15-year timespan. These announcements came after the two were unable to come to an agreement on what have been known for decades as “New York-New York” supportive housing deals whereby the city and state work together to develop thousands of units.

The New York State Senate and Assembly Democratic majorities see a need for more programming aimed at mental health care and housing, too. Earlier this year, the two bodies unanimously passed a bill creating a temporary commission to study what is seen as chronic underfunding for these housing programs. The commission would “provide policy guidance and recommendations relating to the adequacy of funding levels and need for sufficient staffing in all supportive housing under the auspices of the Office of Mental Health.”

According to a June 25 press release from supportive housing provider Bring It Home, “[t]he bill would prompt a study of current funding and staffing levels across the state and investigate ways the state can begin to remedy its years-long failure to adequately fund mental health housing programs.” Advocates are urging Cuomo to sign the bill so the commission can issue its report in time for the next state budget season.

Another discussion that has played out over many years, at the state level especially, is over how to treat individuals who are too sick to seek help.

Per New York State Law, the criteria to involuntarily admit someone due to mental health is fairly strict – the person can’t understand the need for care or presents a substantial harm to self and/or others, among other standards.

According to a 2015 New York City Department of Health and Mental Hygiene report, 40% of adult New Yorkers with serious mental illness didn’t receive medical treatment in the prior year.

Courts can and do order people to outpatient care: assisted outpatient treatment (AOT) is also known in New York as Kendra’s Law. Originally passed in 1999 in New York State (the first law of its kind and emulated in many other states since), Kendra’s Law allows select people close to a mentally ill person to petition the court to mandate a treatment plan for that person. According to OMH’s website, as of Monday (July 29) there were 3,109 people under active court order via Kendra’s Law, 1,377 of them in New York City.

Jaffe of Mental Health Policy Org, a staunch supporter of Kendra’s Law, estimates around 4,000 people should be in mandated treatment under the law. Critics of Kendra’s Law typically accept the principle but say it’s overly strict, such as the need to show an instance of seriously violent behavior in the last four years. Once a petition to mandate care is successfully filed, the chances of the courts granting the petition are extremely high: 90% of Kendra’s Law petitions were granted statewide from July 29, 2018 through Sunday (July 28, 2019), according to OMH’s website.

Kendra’s Law affects a very small population but has shown signs of working: the state Office of Mental Health says for someone who went through an assisted outpatient treatment program, psychiatric hospitalization was reduced by 64% after AOT, incarceration by 72%, and homelessness was reduced by 61%. Jaffe and Eide in their op-ed call for the creation (and funding) of a Kendra’s Law Office to deal solely with helping the city expand its efforts to get more people into Kendra’s Law.

Meanwhile, ThriveNYC offers NYC Well, a mental health helpline that has the ability to dispatch mobile crisis intervention teams to someone experiencing a mental health crisis. The phone line is something that de Blasio and McCray often cite in their public remarks about Thrive and the city’s efforts to improve mental health care.

Another big piece of the current picture of care for those with serious mental illnesses is correctional health services, which have been needed more and more. Although the daily inmate and detainee population in city jails is decreasing, the percentage of those diagnosed with a serious mental illness has gone from 10.2% in city fiscal year 2014 to 14.3% in fiscal year 2018, according to the Mayor’s Management Report.

Dr. Katz  said on What’s the [DATA] Point? that “In the case of correctional health…we know in New York City there is a group of people with very serious mental health and addiction problems who rotate between the acute hospital, the shelter, and the jail.”

One goal of ThriveNYC is to limit the number of people going to jail due to serious mental illness. The city will open two health diversion centers later this year. Announced in late 2018, the diversion centers will provide somewhere for police officers to take someone who has committed a low-level, non-violent crime but they believe is exhibiting behavioral problems due to mental health. The centers will offer mental health treatment and have overnight beds but stays will be capped at five days.

Skeptics of the idea point out that there will only be two diversion centers, one in the Bronx and one in East Harlem, and each center will only serve its specific community. Plus, the centers will have a “no-refusal” policy that could edge out those with serious mental illness if the centers are at capacity. According to Herman at the March City Council hearing, Thrive plans to evaluate the success of the two programs and possibly create more centers next year.

“We want to catch [people] before entry into the criminal justice system,” said Dr. Belkin. “Nobody should enter the criminal justice system for something related to mental illness. We should be able to reach those people so that doesn’t happen, where they can be treated and managed in a health context before they get ensnared in the criminal justice system. I think everyone wants to avoid that path."

Critics argue, as alluded to by Katz and recently brought up during a Council hearing on recidivism of those with mental illness, that mental health services outside of the criminal justice system are less robust than those offered in city jails. According to Katz, “the fact that we make it necessary for some people to commit shoplifting in order to ensure they’re in a safe place, get their meds, get their food, get their house, when we could do that so much less expensively elsewhere is really a condemnation on us.”

Another option, proposed by Jaffe and Eide, is the expansion of mental health courts, which allows judges to divert those with serious mental illness and charged with crimes to treatment instead of jail. They say current mental health courts cannot offer housing to these people, which weakens its effectiveness.

City Council Speaker Corey Johnson is attempting to prevent those with mental illness from going to jail and to ensure they get better treatment instead. In a speech on criminal justice reform on May 16 at John Jay College, he announced the Council will create a program to house 100 people with SMI caught in the criminal justice system and emphasized the 100 beds are a start, but the program will need further investment and focus to add more beds.

Johnson also pointed out how targeting the legal system can keep people with SMI out of jail; he announced the Council will fund a program to connect social workers with defense attorneys to find alternatives to prison. He also previewed the Get Well & Get Out Act, which would require correctional services staff to keep attorneys informed of their clients’ mental health.

The bill was introduced on June 13 by Council Member Margaret Chin of Manhattan and six other Council sponsors, including Speaker Johnson. The Council quickly held a hearing on the bill that was combined with an oversight hearing on recidivism rates for those with mental illness. The bill has not yet received a committee vote.

How the city handles crisis situations including people with serious mental illness has come under increased scrutiny over the last few years. According to the NYPD and an investigation from THE CITY, calls to 911 involving EDP’s, or emotionally disturbed persons, have risen from around 97,000 in 2009 to 180,000 last year. Fourteen people who appeared to be suffering from acute mental illness have been killed by police officers in the past three years.

The extent to which the city’s roughly 37,000-member police force has been trained in crisis prevention is an ongoing issue. THE CITY estimated that only about 11,970 uniformed officers had undergone crisis prevention training at the time of its March reporting.

In April 2018, de Blasio and McCray launched the NYC Crisis Prevention and Response Task Force to create a strategy to better deal with mental health crises in the city. That report was due in January and has not been publicly released. The Task Force consists of leaders from the Department of Health and Mental Hygiene, ThriveNYC, and the NYPD, among others.

McCray in her Daily News op-ed said serious mental illness and EDP calls aren’t as related as they appear.

“Unfortunately, too many people think of serious mental illness as ‘crazy people in the subway,’ or 911 calls involving emotionally disturbed persons. But not everyone sleeping in the subway or on the streets has an illness,” she wrote. “And emotional disturbance describes erratic behavior at a given time — not a chronic disease.”

In an attempt to treat EDPs, Thrive created what it calls co-response teams that proactively send a police officer with a clinician to people who have shown violent tendencies or behavioral problems in the past. The forensic ACT teams, the mobile intervention teams, and the co-response teams are all a part of Thrive’s NYC Safe program.

It’s possible that the program Dr. Katz spoke about in April -- creating a residential program for the seriously mentally ill to fill in the gaps of treatment between outpatient care, inpatient care, and prison -- is what’s called “Intensive Outpatient Treatment,” or IOT, which offers a much higher intensity of services but still in the patient’s community. Patients under IOT would visit a psychiatrist more often and for longer than traditional outpatient programs.

Already existing outpatient programs must apply for a waiver to the state Office of Mental Health for permission to offer an intensive outpatient treatment program. OMH has approved waivers for 35 clinics beginning in August 2017, according to OMH’s website (they are required by state law to publicly release waiver requests and decisions).

Otherwise, the most intensive treatment with the most consistent care can be found in hospitals, prisons, or homeless shelters.

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by Truman Stephens, Gotham Gazette

Read more by this writer.

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‘Nobody Should Enter the Criminal Justice System for Something Related to Mental Illness’ Mon, 29 Jul 2019 04:00:00 +0000
City Council Looks at Reducing Recidivism for People with Mental Illness https://www.gothamgazette.com/city/8608-city-council-examines-how-to-reduce-recidivism-for-people-with-mental-illness https://www.gothamgazette.com/city/8608-city-council-examines-how-to-reduce-recidivism-for-people-with-mental-illness council comm cj

Elizabeth Ford of Health + Hospitals, left, & Becky Scott of DOC (photo: John McCarten/City Council)


City Council members on Monday held an oversight hearing to examine how New York prevents formerly incarcerated mentally ill persons from returning to jail. The hearing made clear that the de Blasio administration, Health + Hospitals public hospital system, and City Council members all want to reduce the number of mentally ill persons who rely on the jail system for their mental health care and keep those with serious mental illness out of jail altogether.

But, it was evident at the hearing that there is much more emphasis on services for the imprisoned mentally ill than on keeping those with serious mental illness out of jail, whether for the first time or in all-too-common recidivism.

The psychiatric services offered in city jails -- like nurse and doctor staff, therapeutic groups, and medicine -- are robust but someone with a serious mental illness often loses the best care upon leaving jail. This then contributes to high recidivism rates.

The hearing centered several key data points: roughly 43% of those held in city jails are suffering from mental illness (14% have serious mental illness); the recidivism rate in New York City is 20%, but for those with mental illness it’s 47%.

Held by the Council’s Committee on Justice System, Committee on Criminal Justice, and Committee on Mental Health, Disabilities and Addiction, the hearing looked at the different ways the city Department of Correction and Correctional Health Services, a part of New York’s public health care system, New York City Health + Hospitals, provide care for the mentally ill in prison and once they leave. Two pieces of legislation dealing with notifying defense attorneys of their detained clients’ mental health and returning unused commissary money to recently released inmates were also discussed with various stakeholders who testified.

As the overall jail population has declined significantly, the proportion of New Yorkers with mental illness in city jails has risen in recent years: the overall average daily population of city jails decreased from around 11,500 in 2014 to around 8,900 in 2018, and the percentage of people with mental illness increased from 38% to 43%.

The percentage of those with a serious mental illness, defined by Correctional Health Services as anyone with schizophrenia, bipolar disorder, major depressive disorder, or post-traumatic stress disorder, has increased from 10.2% to 14.3% in that same time frame.

Council Member Keith Powers, a Manhattan Democrat and chair of the Committee on Criminal Justice, asserted that the City Council and the different city agencies in attendance all agree that jail is not the place to help seriously mentally ill people. However, jail is often where people with serious mental illness wind up, and jails often offer medical services – city jails have many psychiatric services located in one place (in fact, Rikers Island is the third-biggest provider of psychiatric care in the United States behind jails in Los Angeles and Chicago).

Currently, city jails put inmates diagnosed with mental illness in “mental observation houses” (MOs), where there are advanced levels of service and psychiatric nurses available, or the more intensive option, PACE (Program to Accelerate Clinical Effectiveness) units where there’s 24/7 embedded staff and more therapeutic groups, according to Dr. Elizabeth Ford, who testified for Correctional Health Services.

However, through questioning from Powers, Ford admitted right now there are people who qualify for PACE but due to spacing issues are only in MOs. THE CITY reported in April that the de Blasio administration is well behind on its planned 12 PACE units by 2020 (currently there are six).

Council member questions made clear that there are many mental health services available in prison, but the key organizing question of the hearing was: what happens when an inmate/patient is released? Ford said CHS gives inmates seven days of their medicine so they don’t drop off too preciptiously after leaving jail, a 30-day prescription which can be fulfilled at a pharmacy of their convenience, and many referrals to outpatient treatment programs.

Outpatient treatment is the primary way people with mental illness are treated in New York, most of which are run by New York City Health + Hospitals. Outpatient care requires patients to appear at appointments, as opposed to inpatient care or state institutionalization – mental health care nationwide over the past 60 years has transitioned away from state-run facilities once known as “insane asylums” or “psychiatric hospitals” and towards outpatient care.

When asked how CHS can make sure recently-released inmates follow through on getting care, Ford mentioned they are hiring more social workers and focusing on making sure existing services, like existing mobile care teams, work well rather than accepting “new mandates.”

In terms of keeping mentally ill people out of prison in the first place, Ford brought up the new plan from the administration of Mayor Bill de Blasio of helping mentally ill people go to the Health + Hospitals system, instead of prison.

Furthermore, two diversion centers -- in East Harlem and South Bronx -- will offer police officers a place to bring emotionally disturbed people who exhibit signs of mental illness instead of arresting them. They’re not open yet, but are supposed to open later this year.

Ford hopes the community-based aspect of the diversion centers will be especially useful as the centers will be located to existing outpatient care.

Supportive housing is another way to prevent recidivism, according to Ford. Supportive housing offers mental health services to people struggling to find housing. The de Blasio administration plans to build 15,000 supportive housing units over 15 years.

If the roughly 1,200 city jail detainees diagnosed with serious mental illness were to be released tomorrow, the relatively minor supportive housing options and short-term diversion centers combined with New York’s disinclination towards inpatient care throw doubt on how the seriously mentally ill would be treated without jail-based services.

The city has created what they call Community Re-Entry Assistance Network (CRAN) teams, which are six-month transitional teams to help those with serious mental illness re-enter the community after release.

On the two pieces of proposed legislation being considered at the hearing, the lead sponsor of the defense attorney notification bill is Manhattan Council Member Margaret Chin, while Queens Council Member Donavan Richards is the lead sponsor of the commissary bill.

Chin’s bill, Intro. 1590, would require the Department of Health and Mental Hygiene to notify the defense attorney of a person who is in the custody of the Department of Correction and who has been diagnosed with a serious mental illness.

The bill, co-sponsored by City Council Speaker Corey Johnson and six other Council members, is not supported by Correctional Health Services in its current language. Although Dr. Ford chose to keep some reservations of Correctional Health Services private, she did mention that the agency has a newly-created court liaison program intended to act as a go-between for defense attorneys and medical officers.

The current process for notifying the defense attorney of a seriously mentally ill person who is accused of a crime is the patient must give consent to Correctional Health Services and CHS gives information relevant to the mental illness diagnosis to the defense attorney.

The bill “attempts to break the cycle of imprisonment,” said Chin, as ideally more cases could take mental illness into account.

The most intense exchanges of the hearing occurred in regard to the other piece of legislation discussed Monday. Intro. 0903, Council Member Richards’ bill, would require the Department of Correction to notify all recently-released former inmates if there is money in their individual jail commissary account as well as return that money within 60 days of release.  

A commissary account, which can be deposited into by an inmate’s family, is essentially a bank account that the inmate can use to purchase snacks or personal products while in jail. Currently, the Department of Correction is holding $3.7 million from as far back as 2012 in unclaimed commissary money for the over 140,000 individuals who have not claimed it.

Richards, indignant, heavily implied DOC wasn’t making any effort to return the money, while DOC testifiers stated multiple times they don’t use the unclaimed money for their own purposes.

According to those who testified for the Department of Correction, the only outreach done by the DOC has been to put posters -- only in English -- in the jails. DOC representatives said the often unpredictable nature of inmates’ release schedules as well as the general difficulty in remaining in contact with released inmates makes returning the money difficult. DOC does not support the bill, citing difficult logistics.

In a fitting summary of the hearing, Council Member Diana Ayala of Harlem and the Bronx said if the Department of Correction cannot find people leaving prison to give them their money back, how can they ensure the mentally ill leaving prison get the mental services they need?

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by Truman Stephens, Gotham Gazette

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City Council Looks at Reducing Recidivism for People with Mental Illness Tue, 18 Jun 2019 04:00:00 +0000
Ending Health Disparities That Disproportionately Impact New Yorkers of Color https://www.gothamgazette.com/130-opinion/8548-ending-health-disparities-that-disproportionately-impact-new-yorkers-of-color https://www.gothamgazette.com/130-opinion/8548-ending-health-disparities-that-disproportionately-impact-new-yorkers-of-color woodhull cm cr ar mt jm

Council Member Carlina Rivera, left, one of the co-authors (photo: John McCarten/City Council)


New York City is one of the largest, most diverse, and advanced cities in the country – in fact, New Yorkers are living one-and-a-half years longer than a decade ago and nearly nine years longer than 25 years ago. Yet behind that positive sheen lies a shameful truth – our city persistently falls short in health outcomes for people of color.

As a New York City lawmaker chairing the committee that oversees our city’s largest public health system and as the founder and leader of the city’s largest physician-led nonprofit health care network, we are troubled that despite economic and technological leadership, our city continues to fall short on health basics.

Persistent health disparities are spread across all five of New York City’s boroughs, most noticeably in communities of color. So, with another Minority Health Month in the rear-view mirror, we are hoping to spur solutions and bring much needed attention to these crises beyond just one month. Whether it is tackling the epidemic of diabetes, maternal mortality rates, or depression and suicides, we can no longer take on these issues without highlighting the disparate rates at which these medical issues affect New Yorkers of color.

And the solutions to these challenges can’t just come from one sector. We need policymakers, community doctors on the front lines, and healthcare experts to all fight together for essential access to preventive care, increasing basic health education and literacy, and addressing the social determinants of health.

Our urban reality is stark: compared to their white neighbors, Latinx women are 60% more likely to be diagnosed with cervical cancer and are 70% more likely to receive late or no prenatal care; Asian-Americans are 30% more likely to be diagnosed with tuberculosis and 10% more likely to be diagnosed with diabetes; and African-Americans are 60% more likely to experience a stroke that could end in them becoming permanently disabled.

In addition, key survey findings in SOMOS’s State of Latino Health report highlighted a series of health disparities Latino New Yorkers struggle with every day. For example, 33 percent of Latinos don’t think people in their community get the health care they need, and 61 percent of providers think that Latinos face unique barriers that keep them from accessing health services.

Many of these conditions are exacerbated by what are known as social determinants of health, or more simply, the conditions in which New Yorkers live. These social determinants are attached to economic stability, education level, social and community context, health and health care; and neighborhood and built environment. And, every single one of these factors can determine a wide range of health risk outcomes.

Overall, New Yorkers who live in poverty and cultural isolation, including immigrant and first-generation New Yorkers, live underserved and in a political climate hostile to the historically disenfranchised. Put simply, this crisis is decades in the making, which is why the City Council Committee on Hospitals has been dedicated to examining these issues at our hearings and advocating for solutions from our city’s biggest medical providers.

We must improve health literacy through building awareness – and use cutting edge technology to meet diverse New Yorkers where they live and how they receive information. New York City has more languages and dialects than the United Nations, and we are stronger and more unique for it – yet in many communities our access to internet services is far too low. We need to translate simple, effective health literacy messages from nutrition and exercise to smoking cessation in order to better reach more families and employ digital and handheld technology to carry the message.

We must make sure nutrition and healthy eating are no longer the purview of elites. It’s worth repeating that farmers markets and supermarkets that specialize in natural, low-calorie, low-sugar, low-fat foods are economically far out of reach for far too many neighborhoods. Lowering food costs and making healthy food far more accessible and culturally relatable can make a huge difference in basic health for hundreds of thousands of New Yorkers who want to eat healthily but simply can’t afford it or aren’t exposed to it. And we know that local vendors who partake in farmers’ markets and sell to health food markets would like to reach more consumers.

Together, we are pursuing a collaborative agenda defined by our partnership, expertise and unique lived realities.

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City Council Member Carlina Rivera represents the 2nd district, which includes portions of the Lower East Side in Manhattan, is Chair of the Council’s Committee on Hospitals and Co-Chair of the Council's Women’s Caucus. Dr. Ramon Tallaj is Chairman of SOMOS, a non-profit, physician-led network of more than 2,000 health care providers serving over 700,000 Medicaid beneficiaries in New York City, with providers delivering culturally competent care to patients in some of New York City’s most vulnerable populations.

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Have an op-ed idea or submission for Gotham Gazette? Email opinion@gothamgazette.com

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Ending Health Disparities That Disproportionately Impact New Yorkers of Color Mon, 03 Jun 2019 04:00:00 +0000
What's The [Data] Point? 1,112,975, with Dr. Mitchell Katz, President of NYC Health + Hospitals https://www.gothamgazette.com/city/8430-what-s-the-data-point-1-112-975-with-dr-mitchell-katz https://www.gothamgazette.com/city/8430-what-s-the-data-point-1-112-975-with-dr-mitchell-katz whats the data point


What's The [Data] Point? Episode 71 -- 1,112,975, with Dr. Mitchell Katz, president of NYC Health + Hospitals [You can download What's The [Data] Point? wherever you get your podcasts, including on iTunes]

artworks 000515225592 2py301 t500x500Dr. Mitchell Katz is in charge of the city's public hospital system, which includes 11 hospitals and dozens of other facilities and clinics. Katz came to New York City Health + Hospitals to help turn around the struggling system, especially in terms of its finances, but also in its delivery of care. He recently spoke at Citizens Budget Commission breakfast, after which he joined the podcast to take a few questions -- this episode consists of that Q&A followed by Katz's remarks at the breakfast about what he's doing to change H+H, what progress has been made and what challenges persist.

Listen to the conversation and let us know what you think: Ben Max of GG (@TweetBenMax), Maria Doulis of CBC (@MariaDoulis). Listen below or download wherever you get your podcasts!

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by Ben Max, Gotham Gazette
     

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What's The [Data] Point? 1,112,975, with Dr. Mitchell Katz, President of NYC Health + Hospitals Thu, 04 Apr 2019 04:00:00 +0000