Psychiatry
Takes
to the
Initiative
Luis David
Streets:
for the Homeless
R. Marcos, Nardacci,
O
ne of the most frequently and vehemently debated side effects of more than three decades of deinstitutionalization policies is the upsurge in the numbers of chronically mentally ill individuals who are homeless in our city streets (1-8). Although the exact relationship between deinstitutionalization and the increase in homeless mentally ill individuals continues to be a subject of controversy (9-11), it is now apparent that a substantial proportion of the homeless mentally ill are men and women who before deinstitutionalization would have been residents of state mental hospitals (12-14). In recent years, in response to pressure from the media, advocacy groups, and mental health professionals, new reparative programs are emerging to
Received Jan. 5, 1990; revision received May 4, 1990; accepted June 1, 1990. From the New York City Health and Hospitals Corporation, New York University School of Medicine, the Mount Sinai School of Medicine Department of Psychiatry, and Bellevue Hospital, New York. Address reprint requests to Dr. Marcos, NYC Health and Hospitals Corporation, 125 Worth St., Rm. 430, New York, authors thank Khanu Chandnani, Einsohn, Earle Erikson, Denise
Freedberg,
M.S.W.,
Paul Goldstein,
A. Sheola, MPH., and Sam with this project. Copyright © 1990 American
Am
J Psychiatry
Edward
Tsemberis, Psychiatric
I 47: 1 1 , November
M.S.W., Catherine Fran#{231}ois, M.S.W.,
Rohs, Ph.D.,
M.S.W., for
Association.
1990
their
York
Mentally
Ill
City
reach the many deinstitutionalized and nevem-institutionalized seriously mentally ill individuals who memain untreated in our urban communities (15-22). At the same time, public outrage about the inhumane quality of life for the seriously mentally ill who refuse care has brought renewed pressure to relax the laws on involuntary psychiatric treatment (23-25). In the process, the emergency rooms of readily available public general hospitals have become the place of first resort for seriously mentally ill indigent patients, as well as convenient settings for policy makers attempting to provide shelter and treatment for this population (2630). On October 28, 1987, the mayor of New York City instituted an unprecedented program to address the health care needs of homeless individuals living on the street who were severely mentally ill but who consistently resisted support and treatment (31). The new program required the removal from the streets to a public hospital of mentally ill homeless individuals who were neglecting their essential needs for food, clothing, shelter, and medical care and who, by reason of their mental illness, were at risk of physical harm within the reasonably foreseeable future (32). Since its announcement, the New York City program has received extraordinary local and national attention, and many urban centers, similarly affected by the ovenwhelming problems of caring for the homeless mentally ill, have closely monitored the program’s development (33-39). The purpose of this paper is to describe the New York City program, present data on the demographic and dinical characteristics of the patients hospitalized during the first year of the program, and report on the location of these patients 2 years after its implementation. Although the existing literature on the homeless mentally ill is extensive, there have been few studies of specific treatment strategies directed toward this population.
PROGRAM
10013.
The Florence
New
M.D., Neal L. Cohen, M.D., M.D., and Joan Brittain, Ph.D.
The authors describe New York City’s program to remove seriously mentally ill homeless people from the streets to a public hospital. They report on the 298 patients hospitalized during the first year of this program. Most of the patients were male (66%), single (77%), and from outside ofNew York City (79%) and claimed a history of previous psychiatric hospitalization (92 %) and that they had been homeless for more than 1 year (66%). Most of the patients suffered from schizophrenia (80%) and had additional medical diagnoses (73%). Follow-up contact with the patients 2 years after initiation ofthe program revealed that 55% of the patients either were living in a community setting or were under institutional care. (Am J Psychiatry 1990; 147:1557-1561)
NY
The
Codd, Irene
Richard assistance
DESCRIPTION
The evaluation of homeless mentally ill individuals in the streets is the responsibility of the Homeless Emergency Liaison Project (Project HELP). This mobile unit is staffed by psychiatrists, nurses, and social
1557
HOMELESS
MENTALLY
ILL
workers. The psychiatrists are empowered to order the police to transport persons who meet the program’s criteria (i.e., mental illness, need of hospital cane, and risk of physical harm within the reasonably foreseeable future due to neglect of essential needs) involuntarily to Bellevue Hospital’s emergency room for further evaluation and, if indicated, hospitalization. Project HELP responds to referrals from the police, concerned citizens, social agencies, and psychosocial outreach teams through a publicized telephone help line. During the time of this study, Project HELP’s service area included the entire borough of Manhattan, where the great majority of the homeless live. After the patients are evaluated in Bellevue Hospital’s emergency room, if indicated, they are admitted to a specialized 28-bed, short-term intensive came psychiatnic unit. The unit has enhanced psychiatric and medical staff recruited specifically for the program. Once the specialized unit is at capacity, additional Project HELP patients are sent to other psychiatric units of the hospital. Legal representation is available to these patients in accordance with the state’s mental hygiene law. Each patient is examined by a psychiatrist on the street, another psychiatrist in the emergency room, and a third psychiatrist within 48 hours of admission to the inpatient unit. The three psychiatrists have to concur independently as to the need for involuntary hospitalization in order for the patient to remain in the hospital against his or hen will. Another program component is a 70-bed inpatient unit at Creedmoon Psychiatric Center, a long-termcare state facility located in the borough of Queens. This service is for patients who are deemed in need of extended institutional psychiatric care after hospitalization at Bellevue Hospital. Also, the city established a 30-bed rehabilitation transitional living program, staffed by Bellevue Hospital clinicians, at a municipal shelter for men. This setting serves as a temporary discharge alternative for improved patients for whom no other community setting is readily available. In addition to these program-specific aftercare resources, patients also have access to existing community nesidences, adult homes, health-related facilities, and ambulatory aftercare supports. Other elements of the program consist of the various means used to monitor these patients and the services provided to them, such as a computerized tracking systern. In addition, regular interagency meetings are held to share clinical information, to resolve problems, and to monitor services. Finally, a small case management program is in place both at Bellevue Hospital and at Creedmoor Psychiatric Center to facilitate patients’ linkages to aftercare resources.
PATIENT
CHARACTERISTICS
AND
from October 28, 1987, through October 27, 1988, the first year of the implementation of the new program. Demographic data, psychiatric histories, and data on duration of homelessness were obtained from the patients’ clinical records. Psychiatric diagnoses and additional medical diagnoses (ICD-9) were extracted from medical records at Bellevue Hospital. Most of the patients (N=196 [65.8%J) were men, and 143 (48.0%) were white. Most were either single (N=228 [76.5 %J) or separated or divorced (N=S0 [16.8%]). Regardless of their marital status, 54 (18.1%) claimed to have children of their own. Their ages ranged from 16 to 80 years (rnean=43, rnedian=40). For the 178 patients who provided information regarding their education, the average level of schooling completed was the 11th grade. Of those providing such information (N=281), a large number (N=223 [79.4%]) gave a location other than New York City, including foreign countries (N=58 [20.6%]), as their birthplaces. Of the 265 patients who provided such information, 244 (92.1%) had histories of at least one previous psychiatric hospitalization, and 192 (65.8%) of the 292 patients who provided such information had been homeless for more than 1 year; 98 (33.6%) of the 292 patients said that they had been homeless for more than S years. Of the 297 patients for whom diagnoses were available, 238 (80.1%) were given an ICD-9 primary diagnosis of schizophrenia, 23 (7.7%) affective disorders; 16 (5.4%) organic brain disorders, and 20 (6.7%) other psychiatric disorders. Two hundred seventeen (73.1%) of the patients suffered from at least one medical condition in addition to a primary psychiatric diagnosis. The most common physical conditions, suffered by at least 20% of the patients, included peripheral vascular disorders, anemias, infestations, and diseases of the respiratory system, particularly tuberculosis. In addition, 103 (34.7%) of the patients had a secondary diagnosis of substance abuse. The 298 individual patients accounted for 340 emergency room visits at Beilevue Hospital. This is because 37 patients were evaluated more than once in the emergency room, and some of them were nehospitalized during the 1-year study period. In 286 (84.1%) of the 340 cases, the patients were transported to the hospital involuntarily; 328 (96.5%) resulted in hospitalization (315 [96.0%] of these were involuntary). A number of hospitalizations, medical treatments, and transfers to state psychiatric centers for extended cane were challenged subsequently by the patients in 131 count hearings. In the majority of these hearings (N= 1 14 [87.0%]), the court upheld the hospital psychiatrists’ recommendations. The patients’ avenage length of stay at Bellevue Hospital was 61.3 days (range2 to 228 days).
SERVICES DISCHARGE
We examined the records of the 298 mentally ill homeless individuals who, after evaluation by Project HELP in the streets, were brought to Bellevue Hospital
1558
DISPOSITIONS
Discharge dispositions Hospital were obtained
Am
J Psychiatry
AND
FOLLOW-UP
for the 340 from clinical
147:1
visits to Bellevue records. Half of
1, November
1990
MARCOS,
TABLE 1. Follow-Up Contact Location of 298 Homeless Involved in a Program to Help the Homeless Mentally III Location State psychiatric center Community residenceS’ Transitional shelter program Nursing home or health facility Bellevue inpatient ward With relatives or alone On the street1’
Number
Percent
73 62 9 6 1 12 23
24.5 20.8 3.0 2.0 0.3 4.0
Deceased
33
that
by Project confirmation these
1 1.1 25.8
77
alncludes adult homes and bThe subjects were known itored
7.7 0.7
2
Unverified’ Unknown
CNO
Subjects
supervised to be on
HELP. was possible
subjects
were
still
by at their
single-room occupancy hotels. the street and were being montelephone last
(as of Oct. known
31,
1989)
placements.
the patients were transferred to a state psychiatric denten for extended care. This proportion is substantially higher than the 8 % rate of transfer to state facilities for the adult psychiatric inpatient population in New York City public hospitals during the same time period (New York City Health and Hospitals Corporation, Office of Mental Hygiene Services, 1988). Other dispositions include discharge to the care of relatives or self (N=65 [19.1%]), to community residences with different levels of support (N=58 [17.1%]), to the transitional shelter program (N=21 [6.2%]), and to nursing homes and other health care facilities (N= 13 [3.8%]). In 12 (3.5%) of the cases, patients left the hospital without consent. Follow-up information was obtained by means of telephone calls made to patients or their aftercare placement agencies at 3-month intervals. The last follow-up calls were made during October 1989, 2 years after initiation of the program. The locations of the patients at this time are presented in table 1. Sixtythree percent of the 298 patients were contacted in person or their location was confirmed through their aftercane setting. At the time of the follow-up contact, 80 patients were hospitalized in either a psychiatric facility on a health-related facility. Eighty-three patients were living in the community in settings such as residences, adult homes, single-room occupancy hotels, the transitional shelter program, with relatives, or by themselves. Two patients were known to be dead, and 100 patients were either back on the streets or their location was unknown. Most of the 33 remaining patients with unverified locations were living out of New York State.
COMMENTS We can draw data regarding interventions of several reasons
Am
J Psychiatry
only tentative conclusions from these the benefits patients derived from the New York City’s program. There are for this. First, the clinical as well as the
147:1
1, November
1990
COHEN,
NARDACCI,
ET AL.
historical data available for these patients were metnieved from records and were limited in scope. Second, the follow-up contacts with patients or their aftercare agencies were brief and did not include any formal evaluative component. Third, there was no comparison group. Finally, the long-term effects of this program would undoubtedly be affected by the fact that this was a model program that received inordinate public attention and enjoyed an extraordinary investment of enthusiasm and resources. We can hypothesize, however, that had the program not been implemented, many of these seriously mentally ill homeless patients would have remained in the streets and perhaps suffered progressive physical and psychiatric deterioration. That about 28% of the patients were living in the community and 27% were receiving institutional care 2 years after the intervention suggests a limited but positive impact of the program on the target population. Although comparison is difficult because of differences in samples and methods, this outcome appears to approximate the results of other recent pilot studies on posthospital aftercare of the homeless mentally ill (40, 41). Given the known difficulties for the mental health care delivery system in monitoring the seriously and persistently mentally ill, it is noteworthy that some form of contact was made at 3-month intervals with 63% of this group of patients for up to 2 years following their initial inpatient care episode. In this megand, our experience with the program supports the importance of patient tracking systems, case management, and interagency clinical as well as administrative coordination and linkages to enhance continuity of cane through continuity of information for this population (42, 43). Our findings suggest that the provision of needed care to the multiply disabled homeless mentally ill should include aggressive outreach interventions and, if necessary, involuntary hospitalization. Predictably, treatment programs such as New York City’s raise the perennial dilemma between protecting disabled mdividuals and safeguarding their civil liberties, no matter how self-destructive their choices may be. In addition, the cost to the mental health care delivery system is considerable, since due to lengthy legal procedures, time-consuming medical tests and treatments, and the need for intensive psychosocial interventions and dischange planning, the hospital stays of these patients tend to exceed the standard for acute-came hospitalization. The large proportion of patients transferred to a state psychiatric center for extended care, although perhaps reflective of the program’s well-established adcess to a state facility, probably also suggests that many of these patients represent a subset of severely psychiatrically impaired homeless in need of long-term institutional psychiatric care (44). In this regard, preliminary medical record data suggest that our group of homeless patients may be different from the 628 homeless mentally ill persons evaluated at Bellevue Hospital’s emergency room independently of the program
1559
HOMELESS
MENTALLY
ILL
during the same time period. Specifically, fewer homeless patients in this latter group carried a diagnosis of schizophrenia (N=316 [50.3%]), more of them were male (517 [82.3%]), and on average they were youngen (mean age=34.7, median=33) (New York City Health and Hospitals Corporation, Office of Mental Hygiene Services, 1989). The New York City program illustrates how mental health professionals can work with policy makers to develop programs that are responsive to this often neglected, multiply disabled population (45-49). Furthen, apart from its tangible impact on the target population, public reaction to the program, as reflected by the media, suggests that, with the exception of some civil libertarians who expressed concern about the program’s potential for abuse of patients’ civil liberties, it created a positive impression of the actions taken by the city to address the problem. Although the city program targeted a small subgroup of the homeless population and had a limited impact on the large numbers of homeless mentally ill people living in the streets, there was some public recognition that government officials and mental health professionals cared for these people and were willing to do something about the problem (50-52). In this sense, the program can be judged in terms of its good intentions as well as its tangible results (53). Although this study is somewhat limited in its genenalizability due to the particular characteristics of the New York City patients involved in the program, we believe it has contributed still another piece to the large jigsaw puzzle that is our understanding of the homeless mentally ill (54). Certainly, more research is needed to ascertain the impact of specific treatment interventions on particular subgroups of the homeless mentally ill and to explore what patient and service system mdicators may act as predictors of positive on negative outcomes.
from
a statewide
epidemiological
study.
Hosp
Community
Psy-
chiatry 1986; 37:712-719 12.
Arce street
AA, Tadlock M, Vergare MJ, et a!: A psychiatric people admitted to an emergency shelter. Hosp
profile of Commu-
nity Psychiatry 1988; 34:812-817
13.
14. 15.
16.
Dorwart
Med 17.
18.
19.
20.
21.
22. 23.
RA: A ten-year
follow-up
study
of the effects
of dein-
stitutionalization. Hosp Community Psychiatry 1988; 39:287291 Lamb HR: Deinstitutionalization at the crossroads. Hosp Community Psychiatry 1988; 39:941-945 Cohen NL, Putnam J, Sullivan AM: The mentally ill homeless: isolation and adaptation. Hosp Community Psychiatry 1984; 35:922-924 Gudeman JE, Shore MF, Dickey B: Day hospitalization and an inn instead of inpatient care for psychiatric patients. N Engl J
1983; 308:749-753
Hogartv GE, Anderson CM, Reiss DJ, et al: Family psychoeducational, social skills training and maintenance chemotherapy in the aftercare of schizophrenia. Arch Gen Psychiatry 1986; 43:633-642 Lipton FR, Nutt 5, Sabatini A: Housing the homeless mentally ill: a longitudinal study of a treatment approach. Hosp Community Psychiatry 1988; 39:40-45 Schwartz SR, Goldman HH, Churgin 5: Case management for the chronic mentally ill: models and dimensions. Hosp Community Psychiatry 1982; 33:1006-1009 Stein LI, Test MA: Alternatives to mental hospital treatment, I: conceptual model, treatment program, and clinical evaluation. Arch Gen Psychiatry 1980; 37:392-397 Caton CLM, Wyatt RJ, Grunberg J, et al: An evaluation of a mental health program for homeless men. Am J Psychiatry 1990; 147:286-289 Cohen NL (ed): Psychiatry Takes to the Streets. New York, Guilford Press, 1990 Lamb HR. Mills MJ: Needed changes in law and procedure for the chronically mentally ill. Hosp Community Psychiatry 1986; 37:475-480
24.
25.
26. 27.
Recommendations of APA’s Task Force on the Homeless Mentally Ill. Hosp Community Psychiatry 1984; 35:908-909 Treffert DA: The obviously ill patient in need of treatment: a fourth standard for civil commitment. Hosp Community Psychiatry 1985; 36:259-264 Bachrach LL: General hospital psychiatry: overview from a sociological perspective. Am J Psychiatry 198 1 ; 138:879-887 Bachrach LL: The effects of deinstitutionalization on general hospital psychiatry. Hosp Community Psychiatry 1981; 32: 786-790
28. REFERENCES 1. Bachrach LL: Asylum and chronically ill psychiatric patients. AmJ Psychiatry 1984; 141:975-978 2. Bassuk EL, Rubin L, Lauriat A: Is homelessness a mental health problem? Am J Psychiatry 1984; 141:1546-1550 3. Borus JF: Deinstitutionalization of the chronically mentally ill. N
Engl J Med
Eagle PF, Caton CLM: Homelessness and mental illness, in Homeless in America. Edited by Caton CLM. New York, Oxford University Press, New York, 1990 S. Gudeman JE, Shore MF: Beyond deinstitutionalization: a new class of facilities for the mentally ill. N EngI J Med 1 984; 3 1 1: 832-836 6. Jones RE: Street people and psychiatry: an introduction. Hosp Community Psychiatry 1983; 34:807-811 7. Lipton FR, Sabatini A, Katz SE: Down and out in the city: the homeless mentally ill. Hosp Community Psychiatry 1983: 34: 8. 9.
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1981; 305:339-342
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Talbott JA: The shame of the cities. Hosp Community Psychiatry 1983; 34:773 Bassuk EL: The homeless problem. Sci Am 1984; 241:40-45 Lamb HR: Deinstitutionalization and the homeless mentally ill. Hosp Community Psychiatry 1984; 35:899-907 Roth D, Bean GJ: New perspectives on homelessness: findings
Bassuk EL: The impact of deinstitutionalization hospital psychiatric emergency ward. Hosp atry 1980; 31:623-627 Marcos LR, Cohen NL: Taking the suspected streets to public general hospitals. N EngI
36. 37. 38.
on the Community
J
general Psychi-
mentally ill off the Med 1986; 315:
161
Surles RC, McGurrin MC: Increased use of psychiatric emergency services by young chronic mentally ill patients. Hosp Community Psychiatry 1987; 38:401-405 Barbanel J: Mentally ill homeless taken off New York streets. New York Times, Oct 29, 1987, p Al Program for Strengthening Services to the Homeless Mentally Ill in Need of Psychiatric Hospitalization. New York, New York City Health and Hospitals Corporation, Sept 9, 1987 Mayor Koch’s cause (editorial). Washington Post, Sept 5, 1987, p A22 Mayor Koch and the homeless (editorial). Detroit News, Sept 8, 1987, p 18 Stengel R, Svoboda W: At issue: freedom for the irrational. Time, Sept 14, 1987, p 88 Gelman D, Huck j, Wright L, et al: Forcing the mentally ill to get help. Newsweek, Nov 9, 1987, p 47 Getlin J: NY unfazed by critics, takes action on homeless. Los Angeles Times, Dec 20, 1987, p 1 Krauthammer C: How to save the homeless mentally ill. New Republic, Feb 8, 1988, p 26
Am
J Psychiatry
147:1
1, November
1990
MARCOS,
39.
Marcos
LR: Media
power
and public
mental
health
policy.
Am
47.
Marcos
48.
AmJ Psychiatry 1988; 145:331-334 Mollica RF: From asylum to community:
J Psychiatry 1989; 146:1185-1189 40.
Bennett
MI, Gudeman
JE, Jenkins
L, et al: The
treatment
for the homeless
mentally
tal-based
value Am
ill.
of hospiJ Psychi-
tegration
atry 1988; 145:1273-1276 41.
42.
43. 44. 45.
Drake
Sargent M: Update on programs for the homeless mentally ill. Hosp Community Psychiatry 1989; 40:1015-1016 Bachrach LL: Programs and politics: toward new coalitions.
Marcos Community
Am
Wallach
Community
1988; 39:927-928 LR: Who profits from deinstitutionalization? Psychiatry 1989; 40:1221
J Psychiatry
49.
of public
in public
psychiatry.
psychiatric
N Engl
the
J Med
ET AL.
bureaucracies. threatened
1983;
disin-
308:367-
1990
Hosp
Talbott
JA:
The
patient
first
or last?
Hosp
Community
Psychi-
atry 1984; 35:341-344 SO.
Yes street April 14,
51.
Rimer inroads.
52.
Help
the
homeless,
53.
Aug Dye
14, TR:
1989, p A14 Understanding
54.
Prentice-Hall, Bachrach LL:
Psychiatry
1 47: 1 1 , November
Dysfunctions
NARDACCI,
373
MA, Hoffman JS: Housing instability and homelessness among aftercare patients of an urban state hospital. Hosp Community Psychiatry 1989; 40:46-51 Bachrach LL: Continuity of care for chronic mental patients: a conceptual analysis. Am J Psychiatry 1981; 138:1449-1456 Mechanic D, Aiken LH: Improving the care of patients with chronic mental illness. N EngI J Med 1987; 3 17:1634-1638
Hosp
46.
RE,
LR:
COHEN,
some
people 1989,
can be rescued p B32
(editorial).
New
5: Project to hospitalize mentally ill homeless New York Times, July 18, 1989, p B2
caveats.
and
votes
Public
I 972 Interpreting Hosp
win
research
Community
(editorial). Policy. on the Psychiatry
New Englewood homeless 1984;
York
Times,
is making York
Times,
Cliffs,
NJ,
mentally
ill:
35:914-916
1561
Takes
to the
Initiative
Luis David
Streets:
for the Homeless
R. Marcos, Nardacci,
O
ne of the most frequently and vehemently debated side effects of more than three decades of deinstitutionalization policies is the upsurge in the numbers of chronically mentally ill individuals who are homeless in our city streets (1-8). Although the exact relationship between deinstitutionalization and the increase in homeless mentally ill individuals continues to be a subject of controversy (9-11), it is now apparent that a substantial proportion of the homeless mentally ill are men and women who before deinstitutionalization would have been residents of state mental hospitals (12-14). In recent years, in response to pressure from the media, advocacy groups, and mental health professionals, new reparative programs are emerging to
Received Jan. 5, 1990; revision received May 4, 1990; accepted June 1, 1990. From the New York City Health and Hospitals Corporation, New York University School of Medicine, the Mount Sinai School of Medicine Department of Psychiatry, and Bellevue Hospital, New York. Address reprint requests to Dr. Marcos, NYC Health and Hospitals Corporation, 125 Worth St., Rm. 430, New York, authors thank Khanu Chandnani, Einsohn, Earle Erikson, Denise
Freedberg,
M.S.W.,
Paul Goldstein,
A. Sheola, MPH., and Sam with this project. Copyright © 1990 American
Am
J Psychiatry
Edward
Tsemberis, Psychiatric
I 47: 1 1 , November
M.S.W., Catherine Fran#{231}ois, M.S.W.,
Rohs, Ph.D.,
M.S.W., for
Association.
1990
their
York
Mentally
Ill
City
reach the many deinstitutionalized and nevem-institutionalized seriously mentally ill individuals who memain untreated in our urban communities (15-22). At the same time, public outrage about the inhumane quality of life for the seriously mentally ill who refuse care has brought renewed pressure to relax the laws on involuntary psychiatric treatment (23-25). In the process, the emergency rooms of readily available public general hospitals have become the place of first resort for seriously mentally ill indigent patients, as well as convenient settings for policy makers attempting to provide shelter and treatment for this population (2630). On October 28, 1987, the mayor of New York City instituted an unprecedented program to address the health care needs of homeless individuals living on the street who were severely mentally ill but who consistently resisted support and treatment (31). The new program required the removal from the streets to a public hospital of mentally ill homeless individuals who were neglecting their essential needs for food, clothing, shelter, and medical care and who, by reason of their mental illness, were at risk of physical harm within the reasonably foreseeable future (32). Since its announcement, the New York City program has received extraordinary local and national attention, and many urban centers, similarly affected by the ovenwhelming problems of caring for the homeless mentally ill, have closely monitored the program’s development (33-39). The purpose of this paper is to describe the New York City program, present data on the demographic and dinical characteristics of the patients hospitalized during the first year of the program, and report on the location of these patients 2 years after its implementation. Although the existing literature on the homeless mentally ill is extensive, there have been few studies of specific treatment strategies directed toward this population.
PROGRAM
10013.
The Florence
New
M.D., Neal L. Cohen, M.D., M.D., and Joan Brittain, Ph.D.
The authors describe New York City’s program to remove seriously mentally ill homeless people from the streets to a public hospital. They report on the 298 patients hospitalized during the first year of this program. Most of the patients were male (66%), single (77%), and from outside ofNew York City (79%) and claimed a history of previous psychiatric hospitalization (92 %) and that they had been homeless for more than 1 year (66%). Most of the patients suffered from schizophrenia (80%) and had additional medical diagnoses (73%). Follow-up contact with the patients 2 years after initiation ofthe program revealed that 55% of the patients either were living in a community setting or were under institutional care. (Am J Psychiatry 1990; 147:1557-1561)
NY
The
Codd, Irene
Richard assistance
DESCRIPTION
The evaluation of homeless mentally ill individuals in the streets is the responsibility of the Homeless Emergency Liaison Project (Project HELP). This mobile unit is staffed by psychiatrists, nurses, and social
1557
HOMELESS
MENTALLY
ILL
workers. The psychiatrists are empowered to order the police to transport persons who meet the program’s criteria (i.e., mental illness, need of hospital cane, and risk of physical harm within the reasonably foreseeable future due to neglect of essential needs) involuntarily to Bellevue Hospital’s emergency room for further evaluation and, if indicated, hospitalization. Project HELP responds to referrals from the police, concerned citizens, social agencies, and psychosocial outreach teams through a publicized telephone help line. During the time of this study, Project HELP’s service area included the entire borough of Manhattan, where the great majority of the homeless live. After the patients are evaluated in Bellevue Hospital’s emergency room, if indicated, they are admitted to a specialized 28-bed, short-term intensive came psychiatnic unit. The unit has enhanced psychiatric and medical staff recruited specifically for the program. Once the specialized unit is at capacity, additional Project HELP patients are sent to other psychiatric units of the hospital. Legal representation is available to these patients in accordance with the state’s mental hygiene law. Each patient is examined by a psychiatrist on the street, another psychiatrist in the emergency room, and a third psychiatrist within 48 hours of admission to the inpatient unit. The three psychiatrists have to concur independently as to the need for involuntary hospitalization in order for the patient to remain in the hospital against his or hen will. Another program component is a 70-bed inpatient unit at Creedmoon Psychiatric Center, a long-termcare state facility located in the borough of Queens. This service is for patients who are deemed in need of extended institutional psychiatric care after hospitalization at Bellevue Hospital. Also, the city established a 30-bed rehabilitation transitional living program, staffed by Bellevue Hospital clinicians, at a municipal shelter for men. This setting serves as a temporary discharge alternative for improved patients for whom no other community setting is readily available. In addition to these program-specific aftercare resources, patients also have access to existing community nesidences, adult homes, health-related facilities, and ambulatory aftercare supports. Other elements of the program consist of the various means used to monitor these patients and the services provided to them, such as a computerized tracking systern. In addition, regular interagency meetings are held to share clinical information, to resolve problems, and to monitor services. Finally, a small case management program is in place both at Bellevue Hospital and at Creedmoor Psychiatric Center to facilitate patients’ linkages to aftercare resources.
PATIENT
CHARACTERISTICS
AND
from October 28, 1987, through October 27, 1988, the first year of the implementation of the new program. Demographic data, psychiatric histories, and data on duration of homelessness were obtained from the patients’ clinical records. Psychiatric diagnoses and additional medical diagnoses (ICD-9) were extracted from medical records at Bellevue Hospital. Most of the patients (N=196 [65.8%J) were men, and 143 (48.0%) were white. Most were either single (N=228 [76.5 %J) or separated or divorced (N=S0 [16.8%]). Regardless of their marital status, 54 (18.1%) claimed to have children of their own. Their ages ranged from 16 to 80 years (rnean=43, rnedian=40). For the 178 patients who provided information regarding their education, the average level of schooling completed was the 11th grade. Of those providing such information (N=281), a large number (N=223 [79.4%]) gave a location other than New York City, including foreign countries (N=58 [20.6%]), as their birthplaces. Of the 265 patients who provided such information, 244 (92.1%) had histories of at least one previous psychiatric hospitalization, and 192 (65.8%) of the 292 patients who provided such information had been homeless for more than 1 year; 98 (33.6%) of the 292 patients said that they had been homeless for more than S years. Of the 297 patients for whom diagnoses were available, 238 (80.1%) were given an ICD-9 primary diagnosis of schizophrenia, 23 (7.7%) affective disorders; 16 (5.4%) organic brain disorders, and 20 (6.7%) other psychiatric disorders. Two hundred seventeen (73.1%) of the patients suffered from at least one medical condition in addition to a primary psychiatric diagnosis. The most common physical conditions, suffered by at least 20% of the patients, included peripheral vascular disorders, anemias, infestations, and diseases of the respiratory system, particularly tuberculosis. In addition, 103 (34.7%) of the patients had a secondary diagnosis of substance abuse. The 298 individual patients accounted for 340 emergency room visits at Beilevue Hospital. This is because 37 patients were evaluated more than once in the emergency room, and some of them were nehospitalized during the 1-year study period. In 286 (84.1%) of the 340 cases, the patients were transported to the hospital involuntarily; 328 (96.5%) resulted in hospitalization (315 [96.0%] of these were involuntary). A number of hospitalizations, medical treatments, and transfers to state psychiatric centers for extended cane were challenged subsequently by the patients in 131 count hearings. In the majority of these hearings (N= 1 14 [87.0%]), the court upheld the hospital psychiatrists’ recommendations. The patients’ avenage length of stay at Bellevue Hospital was 61.3 days (range2 to 228 days).
SERVICES DISCHARGE
We examined the records of the 298 mentally ill homeless individuals who, after evaluation by Project HELP in the streets, were brought to Bellevue Hospital
1558
DISPOSITIONS
Discharge dispositions Hospital were obtained
Am
J Psychiatry
AND
FOLLOW-UP
for the 340 from clinical
147:1
visits to Bellevue records. Half of
1, November
1990
MARCOS,
TABLE 1. Follow-Up Contact Location of 298 Homeless Involved in a Program to Help the Homeless Mentally III Location State psychiatric center Community residenceS’ Transitional shelter program Nursing home or health facility Bellevue inpatient ward With relatives or alone On the street1’
Number
Percent
73 62 9 6 1 12 23
24.5 20.8 3.0 2.0 0.3 4.0
Deceased
33
that
by Project confirmation these
1 1.1 25.8
77
alncludes adult homes and bThe subjects were known itored
7.7 0.7
2
Unverified’ Unknown
CNO
Subjects
supervised to be on
HELP. was possible
subjects
were
still
by at their
single-room occupancy hotels. the street and were being montelephone last
(as of Oct. known
31,
1989)
placements.
the patients were transferred to a state psychiatric denten for extended care. This proportion is substantially higher than the 8 % rate of transfer to state facilities for the adult psychiatric inpatient population in New York City public hospitals during the same time period (New York City Health and Hospitals Corporation, Office of Mental Hygiene Services, 1988). Other dispositions include discharge to the care of relatives or self (N=65 [19.1%]), to community residences with different levels of support (N=58 [17.1%]), to the transitional shelter program (N=21 [6.2%]), and to nursing homes and other health care facilities (N= 13 [3.8%]). In 12 (3.5%) of the cases, patients left the hospital without consent. Follow-up information was obtained by means of telephone calls made to patients or their aftercare placement agencies at 3-month intervals. The last follow-up calls were made during October 1989, 2 years after initiation of the program. The locations of the patients at this time are presented in table 1. Sixtythree percent of the 298 patients were contacted in person or their location was confirmed through their aftercane setting. At the time of the follow-up contact, 80 patients were hospitalized in either a psychiatric facility on a health-related facility. Eighty-three patients were living in the community in settings such as residences, adult homes, single-room occupancy hotels, the transitional shelter program, with relatives, or by themselves. Two patients were known to be dead, and 100 patients were either back on the streets or their location was unknown. Most of the 33 remaining patients with unverified locations were living out of New York State.
COMMENTS We can draw data regarding interventions of several reasons
Am
J Psychiatry
only tentative conclusions from these the benefits patients derived from the New York City’s program. There are for this. First, the clinical as well as the
147:1
1, November
1990
COHEN,
NARDACCI,
ET AL.
historical data available for these patients were metnieved from records and were limited in scope. Second, the follow-up contacts with patients or their aftercare agencies were brief and did not include any formal evaluative component. Third, there was no comparison group. Finally, the long-term effects of this program would undoubtedly be affected by the fact that this was a model program that received inordinate public attention and enjoyed an extraordinary investment of enthusiasm and resources. We can hypothesize, however, that had the program not been implemented, many of these seriously mentally ill homeless patients would have remained in the streets and perhaps suffered progressive physical and psychiatric deterioration. That about 28% of the patients were living in the community and 27% were receiving institutional care 2 years after the intervention suggests a limited but positive impact of the program on the target population. Although comparison is difficult because of differences in samples and methods, this outcome appears to approximate the results of other recent pilot studies on posthospital aftercare of the homeless mentally ill (40, 41). Given the known difficulties for the mental health care delivery system in monitoring the seriously and persistently mentally ill, it is noteworthy that some form of contact was made at 3-month intervals with 63% of this group of patients for up to 2 years following their initial inpatient care episode. In this megand, our experience with the program supports the importance of patient tracking systems, case management, and interagency clinical as well as administrative coordination and linkages to enhance continuity of cane through continuity of information for this population (42, 43). Our findings suggest that the provision of needed care to the multiply disabled homeless mentally ill should include aggressive outreach interventions and, if necessary, involuntary hospitalization. Predictably, treatment programs such as New York City’s raise the perennial dilemma between protecting disabled mdividuals and safeguarding their civil liberties, no matter how self-destructive their choices may be. In addition, the cost to the mental health care delivery system is considerable, since due to lengthy legal procedures, time-consuming medical tests and treatments, and the need for intensive psychosocial interventions and dischange planning, the hospital stays of these patients tend to exceed the standard for acute-came hospitalization. The large proportion of patients transferred to a state psychiatric center for extended care, although perhaps reflective of the program’s well-established adcess to a state facility, probably also suggests that many of these patients represent a subset of severely psychiatrically impaired homeless in need of long-term institutional psychiatric care (44). In this regard, preliminary medical record data suggest that our group of homeless patients may be different from the 628 homeless mentally ill persons evaluated at Bellevue Hospital’s emergency room independently of the program
1559
HOMELESS
MENTALLY
ILL
during the same time period. Specifically, fewer homeless patients in this latter group carried a diagnosis of schizophrenia (N=316 [50.3%]), more of them were male (517 [82.3%]), and on average they were youngen (mean age=34.7, median=33) (New York City Health and Hospitals Corporation, Office of Mental Hygiene Services, 1989). The New York City program illustrates how mental health professionals can work with policy makers to develop programs that are responsive to this often neglected, multiply disabled population (45-49). Furthen, apart from its tangible impact on the target population, public reaction to the program, as reflected by the media, suggests that, with the exception of some civil libertarians who expressed concern about the program’s potential for abuse of patients’ civil liberties, it created a positive impression of the actions taken by the city to address the problem. Although the city program targeted a small subgroup of the homeless population and had a limited impact on the large numbers of homeless mentally ill people living in the streets, there was some public recognition that government officials and mental health professionals cared for these people and were willing to do something about the problem (50-52). In this sense, the program can be judged in terms of its good intentions as well as its tangible results (53). Although this study is somewhat limited in its genenalizability due to the particular characteristics of the New York City patients involved in the program, we believe it has contributed still another piece to the large jigsaw puzzle that is our understanding of the homeless mentally ill (54). Certainly, more research is needed to ascertain the impact of specific treatment interventions on particular subgroups of the homeless mentally ill and to explore what patient and service system mdicators may act as predictors of positive on negative outcomes.
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