Mental Health Update

Two weeks ago, the New York Times did an investigative report on a number of serious violent incidents involving people with mental health issues.  The details of the report are sadly not shocking.  There were failures of the system along the way—lack of coordination, collaboration or accountability.

How do we stop this crisis?

We have proposed an 8 point plan that if implemented will help to dramatically reduce and diminish the mental health crisis in New York City and across the State.

Responding to the November 20^th 2023 New York Times Article

On Monday, November 20^th, there was an article in the New York Times, ‘Behind 94 Acts of Shocking Violence, Years of Glaring Mistakes’

This article was critical of the care of people with mental health issues who are violent and homeless.   While mentioned in the article, it is important to note that most people with mental health issues are not violent and are much more likely to be the victim of violence.

That said, this expose identifies people who have fallen through the ‘social safety net’ of care in our communities.

In these cases, the commitment to ‘warm hands off’ between hospitals and shelters, hospital and housing program and other community programs, and prison to the community settings effectively become ‘cold handshakes’ that don’t result in the optimal clinical outcomes.

To be fair, there are numerous examples of discharges being incredibly successful resulting in helpful paths to recovery.

How do we unstrain the system?

The number one word you hear when talking about mental health is ‘strain’.  Hospitals are strained, the workforce is strained, providers are strained, housing programs are strained, families and peers are strained, law enforcement is strained, and prisons are strained.

How do we ‘unstrain’ the system? There are no easy answers but let’s start with workforce.

1) Workforce, Workforce, Workforce

Throughout the expose, issues of workforce have led to a crisis in care.

Examples Include:

“A shelter intake process that relies on low paid workers who lack the mental health training and tools to identify psychiatric issues’

“The volume of patients we see is so high, and the science is inexact”

ACT Teams—“Nonprofit providers have felt pressure to keep costs down…Many contractors who run the teams have underpaid their workers and sometimes failed to give them adequate training’

Justin Pena—‘The team, which was supposed to offer round the clock support, said no one was available to visit on the weekend’

These examples are all preventable if you have a decently paid mental health system where providers are not ‘strained’ to provide services because they are unable to pay for the staff needed for the outcomes.

Recommendations

1. Fund this year’s human services Cost of Living Adjustment (COLA) at 3.2% based on the Consumer Price Index (CPI).
2. Invest $500 million in behavioral health. Over the last 17 years the statutory COLA provides for a CPI increase, the Executive for the most part has chosen to ignore this sensible annual increase, meaning until these last few years under Governor Hochul, there has been no necessary allowance for staff increases for 15 years. This has resulted in over $500 million dollars lost to the behavioral health care system alone. It is very possible that many of these tragic cases included in this article would not have occurred if the promised $500 million dollars had been earmarked to provide effective community-based mental health services.

2) Change the Funding Dynamic: 

There is a tired narrative that throwing money at the mental health system doesn’t change anything. The bottom line is that is not true. Things would have changed if New York had invested in community providers and not inpatient hospital beds.

Policy makers tout that New York’s Mental Health system is one of the best financed system in the world.  By total dollars spent, this may be true, but by priority, it is not true at all.

Though the data is almost ten years old, the percentages have not dramatically changed in regard to inpatient care versus community funding.   According to that data, there were 715,000 people in New York’s community public mental health system. Of that number, less than 10,000 reside in State Psychiatric hospitals. Yet, $1.3 billion is spent on those individuals while $4.3 billion is spent on the other 705,000 individuals.

This makes no sense. New York operates 24 State hospitals while no other State has more than eight.  New York spends one fifth of its overall mental health budget to maintain these number of psychiatric hospitals which houses a total of less than 4,000 people according to 2023 census findings. In the 1950’s, these facilities housed over 90,000 people

In the 1990’s, New York had the wherewithal to close five state psychiatric and was able to invest millions of dollars of savings to the community providers where it was needed. Sadly, not much has been done since then despite a 2013 report from OMH itself calling for closing of state hospitals to create OMH Regional Centers of Excellence.

Why is all this relevant to the Times expose?

Very simple.  We often hear that you can’t throw money at the problem. At the core of the failure of our mental health system is money.  You don’t throw it at institutions but you can invest it in workforce to create the warm hand off between hospitals, prisons and the social safety net.

Governor Hochul has implemented some real funding changes. She has chosen to invest in the right and needed programs—crisis services, housing, Critical Time Intervention Teams, peer services, youth services and mental health literacy.

Recommendation

1. Create a Mental Health Finance Commission comprised of State Officials, Legislators and Stakeholders to review the Financing of New York’s Mental Health System and have the enforcement powers to close state operated mental health hospitals and/or hospital beds. The powers of the Commission would be similar to the 1998 Federal Base Realignment and Closure Commission that resulted in several military bases consolidations and closures.

3) Housing:

New York has made a large commitment to mental health housing—larger than most other states combined with almost 50,000 units of housing.  Governor Hochul and Commissioner Sullivan have been champions of housing, increasing the stock while also providing much needed increases for housing providers.

Despite these commitments, the reality is that we are nowhere near the unmet housing need.  There are now over 900,000 people in the public mental health system and yet public housing is only a small percentage of that number.

There are large populations of homeless individuals, people coming from prisons and jails, from detox units, from adult homes, from nursing homes, from emergency rooms and for those living with their aging parents that all desperately need a place to live.

Recommendations

1. Make Housing a Top Priority for the Mental Health Finance Commission. Utilize savings from hospital closures to provide funding for community housing
2. Create a Housing Wait List Bill. This bill would provide number to identify what the housing need is statewide. It would create a planning tool for public officials and housing providers. Though several Governors have vetoed this bill when it came to the desk, given Governor Hochul’s support for mental health, she very well could support this language.

4) Use the 1115 Waiver for Behavioral Health Needs

As we anticipate the Federal 1115 waiver’s approval, we are urging State Government to not look at the waiver as a way just to create large provider networks.  The thrust of this is to focus on social determinants of health and working with community based providers.

The waiver provides opportunities for community behavioral health providers to be involved in the planning process to ensure that necessary funding to the community.  Those poor handoffs as documented by the Times should be the precursor for leveraging money to address these problems through the 1115 waiver.

The governing structure must have members that are existing providers in mental health. Decisions around prevention, primary care, cultural competence, should not be made without prioritizing mental health.

Recommendations

1. Mandate that governing structures in 1115s include mental health providers, peers and families
2. Invest 1115 funding into mental health workforce, criminal justice system and housing.
3. Align mental health with hospitals and emergency rooms ensuring that mental health workers are at the front door when people get into emergency room and at the back door when people are discharged.

5) All About Community Mental Health—Training and Public Awareness

One of the key narratives in the Times Story in the constant stigma the general public has about people with mental health issues.

We are not clinicians and we are not meant to diagnose people who appear dangerous.  We are people who want to protect ourselves and those who we love from someone we don’t understand.

What we do need is a softer touch for the general public to have a better understanding of mental health and to know what to do in response to a crisis.

So many people would not be at a crisis level of care if we had the preventative tools available so that someone would never end up in the public mental health system.

Recommendations

1. Schools have been in the front line of the youth mental health crisis. We have to normalize mental health in schools through teacher instruction, school environments and school based mental health clinics.  Invest in school programs that utilize innovative models that are supportive of mental health and suicide prevention.
2. Colleges are also in the forefront of the mental health crisis. Students and other stakeholders should be trained in mental health literacy and have a greater understanding of mental health.
3. Schools and Communities should develop ‘pipeline’ strategies to ensure that more young people may develop careers in mental health and that there are opportunities in place so that paraprofessionals can have career ladders.

6) Provide Statewide Mental Health First Aid Training

There are over four million people trained in the United States on Mental Health First Aid.  This training is universal in its fidelity to a model that provides basic mental health literacy and also identifies a crisis response to those in need of mental health services.

If you are able to train your community about mental health and normalize mental health conversations than you will have people that are more than willing to help support and assist individuals in mental health need before it reaches a crisis.

Recommendation

1. New York should develop a Statewide program that provides the opportunity to engage all New Yorkers in Mental Health First Aid.

7) Peers and Families:

The void in our community is that we do not always embrace peers and their families as part of our workforce. They are invaluable in helping to mitigate a crisis. Families are often on the front line and they can see their loved one deteriorating but they have nowhere to send them because there is limited funding for community services. Also it has been well documented in regard to the role of peers in fostering environments of support and recovery

The NYSOMH should be credited for providing funding for peer and families support.

Recommendation

1. Ensure that all treatment plans include components of peer support, family engagement (when requested), cultural competence and trauma informed care.  All of these ingredients are part of MHANYS Care Path Training Program.

8) 988

Governor Hochul and the Legislature have funded the first two years of 988 implementation. In addition, they along with the Federal Government have provided funding for Crisis Stabilization Centers.

While sadly many of the tragic stories in the Times article might have occurred, more robust and synchronized crisis teams could be a strength in future situations

The notion of calling a 988 operator with expertise in behavioral health combined with a referral source to a crisis stabilization center (essentially Urgent Care for behavioral health) should greatly help.

Recommendation

1. Ensure that the Governor’s budget include a tax enhancement to mobile phones to help support ongoing funding for 988 and the Stabilization Center. Estimates of increases in phone bills are less than a dollar per phone. It is certainly worth the cost of having a statewide behavioral health crisis response.

Summary:

Fixing the Strained Mental Health System

The Times did a thorough investigation of too many sad examples of people falling through our cracks in care.  While some might call for greater enforcement or additional hospital beds, the real solutions lie in changing perceptions of mental health.

If we could wave a magic funding wand, we would:

Provide a 3.2% COLA for the Human Service Workforce; Invest $500 million in behavioral health; Change the State’s Funding stream for mental health to better align with community support prioritizing housing; Support Governor  Hochuls’ investment in CTI, ACT Teams and community services; Infuse the 1115 waiver with calls for greater mental health engagement in Governance’s Boards;  Support funding in k-12 schools and colleges for mental health, support the voice of families and peers;  and support funding for 988 and Crisis Stabilization Centers.

If we were to implement these changes moving forward, hopefully, stories as recounted in the Times will be greatly diminished.