Category: NYC

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Education Lessons NYC Policy PPOH

Assertive Community Treatment.

While at PPOH, I spent two days a week working with an Assertive Community Treatment (ACT) team.

ACT is somewhat like a psychiatric hospital outside of a hospital. It is an evidence-based practice[1. From the New York State Office of Mental Health: “When comparing recipients before and after receiving ACT services, studies have shown ACT recipients experience greater reductions in psychiatric hospitalization rates, emergency room visits and higher levels of housing stability after receiving ACT services. Research has also shown that ACT is more satisfactory to recipients and their families and is no more expensive than other types of community-based care.”] that features a multidisciplinary team (social workers, psychologists, psychiatrists, nurses, case workers) that works with a small group of patients who often experience impairing psychiatric symptoms. It provides comprehensive and flexible psychiatric services. All of the care occurs in the community.

The ACT team I worked on was staffed with:

  • one program director (social worker)
  • one team leader (social worker)
  • one MICA (“mental illness and chemical addiction”) specialist (social worker)
  • one vocational specialist (social worker)
  • one entitlements specialist (almost-graduate from social work school)
  • two case workers (one who had recently earned a social work degree)
  • one registered nurse
  • one secretary (who did much more than clerical work)
  • two psychiatrists (our combined hours did not fill a full-time position)

During my time there, I provided care for about 35 patients. (The other psychiatrist provided care for the other 35 patients.) The staff to patient ratio is purposely kept low, as ACT is considered an intensive intervention.

Patients who are referred for ACT services must have been psychiatrically hospitalized (often involuntarily) at least four times in the past year. They often have multiple emergency room or mobile crisis visits. Other outpatient services have often failed or have been insufficient to prevent crises and hospitalizations.

Thus, a chief goal of ACT is to keep people out of the hospital.

The ACT model dictates that the team (as a whole) must make a total of at least six contacts with each client[2. There is a movement in mental health—and in other parts of medicine—to move away from the term “patient”. In this particular ACT setting, patients were called “clients”. Sometimes they are called “consumers”.] every month, preferably in the community. One of these visits should be a meeting with the psychiatrist. Some patients regularly came to the office for their visits. Others, however, could not or would not come in. We thus went out to them. (Hence the adjective “assertive”, which, in some cases, could be construed as “coercive”. More about coercion later.)

If I did not see patients in the office, I often saw them in their apartments. (Limits and boundaries do not blur, but they certainly shift. My experiences in these residential settings inspired this post. To be clear, there were a few individuals who I never met alone. I insisted they meet me outside or in the clinic. Some of this was due to their past behaviors; some of this was my gut instinct.) For those who did not feel comfortable meeting in their apartments, we met in lobbies, parks, or chatted during walks. (During my time on ACT, I came to value talking and walking as a therapeutic intervention.)

ACT was formerly deemed “long term care”; some patients have been on ACT teams for over a decade. (This is often due to repeated psychiatric hospitalizations despite ACT services.) Most of the patients had psychotic disorders (such as schizophrenia) and, surprisingly, many of them had actively involved family members. I suspect that this impacted who was referred to ACT; family members were often the ones bringing people to the hospital for care (versus calling the police, etc.) Most patients “graduate” from ACT within a few years: They stay out of the hospital, become more involved in the community, and no longer need that level of care.

I learned in this position that people with chronic psychotic disorders can get better. Their symptoms decrease. They learn how to temper their behavior so that they do not attract undue attention while out in the community. They set and reach personal goals, like earning high school and college degrees, securing employment, getting sober from alcohol and drugs, and taking care of their physical health. They stop smoking! Sometimes they need a lot of support and a number of years need to pass before things settle down, but people with diagnoses of schizophrenia are not doomed to a life of poverty and “low function”.[3. The public rarely hears about positive outcomes for people with schizophrenia. There is research that suggests that a significant number of people with diagnoses of schizophrenia either experience improvement or recovery of their condition. Anecdotally, I agree.]

I also learned the importance of seeing patients in their environments. So much of contemporary medicine now occurs outside of a person’s living situation. That is often appropriate and fair (e.g. patients shouldn’t undergo surgery in their own homes). Because of the intimate nature of medicine, meeting in a “third” location can help preserve privacy and security. However, we can learn so much about how people function (or do not function) when we see their living spaces. We also realize strengths that we would otherwise overlook. A neat home, a sack full of old prescription pills, vinyl records of classical music, papers all over the floor, photographs of friends and family, roaches climbing over dozens of empty cans of soda: All of that is information that doctors often never have.

It is amazing how people live their lives. It is remarkable how much people will tolerate. And it is humbling that people are willing to share their lives with you.

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NYC Observations Seattle

The Sound of Rain.

The rainy season had started and we were out for a run.

“I like the sound of rain in Seattle.”

The droplets falling from the pewter sky collected on the red, orange, and yellow leaves that still clung to the trees. Thin streams of water slid down the street. The falling water whispered through the air, a serene accompaniment to our footfalls on the wet sidewalk.

“The rain sounds gentle and quiet here. Remember what it sounded like in New York?”

“UMBRELLA! UMBRELLA! FIVE DOLLARS! FIVE DOLLARS! UMBRELLA! UMBRELLA!”

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Education Homelessness NYC Policy PPOH

The Homeless Outreach Team.

During my time at PPOH, I spent one and a half days per week with a homeless outreach team.

In 2004, the mayor of New York wanted to reduce the number of people who experience homelessness in the city.[1. Mayor Michael R. Bloomberg Announces Citywide Campaign to End Chronic Homelessness] National data suggests that the vast majority of people who become homeless are only homeless for a short period of time (less than one month) and never become homeless again.[2. From a National Alliance to End Homelessness fact sheet.] Thus, the mayor’s plan focused on people who experience chronic homelessness.[3. “In general, a chronically homeless person is an unaccompanied disabled individual who has been continuously homeless for over one year.”] Of that population, between half to two-thirds of them have significant psychiatric conditions.[3. Page 4-4 of The 2007 National Symposium on Homelessness Research.]

Before describing further details of this plan, let me explain “housing first”:

Traditional housing models for the homeless are built on “merit”. The entry points for housing are generally homeless shelters (which excludes those who are homeless on the streets). Once these individuals connect with housing services, they must follow certain steps to “earn” housing. These steps include regular meetings with staff, taking medications (if indicated) as directed, abstaining from drug and alcohol use, and abiding by other (sometimes arbitrary) rules. Thus, people will only secure housing if they “follow the program”. Unfortunately, many people are unable to “follow the program” (due to psychiatric symptoms, drug and alcohol use, etc.).

“Housing first” is a model where chronically homeless individuals are given housing first. People only need to accept housing.[4. To be clear, people who are enrolled in “housing first” programs are not getting “free” housing. They sign leases, are expected to pay rent, etc. Their rent is generally one-third of their total income. If they receive entitlements, rent is usually taken directly from their monthly cheques.] There are no requirements to take psychiatric medication, to abstain from drugs and alcohol, etc. The underlying premise is people must have homes before they can address their other problems.[5. See Maslow’s hierarchy to learn a view about the importance of housing.] There is evidence that the “housing first” model saves significant health care dollars and improves health outcomes (decrease in number of homeless people; decrease in ER visits and hospitalizations; less time spent in jail).

Major social service agencies in New York City came together to form consortia (consortiums?) to house the chronically homeless according to the “housing first” model. Some agencies built or provided the physical housing; others supplied the staff to work in the residences. Still others provided the manpower to perform actual outreach to the homeless.

Each borough has its own consortium. I was assigned to work on a team in the consortium for Manhattan.

The borough of Manhattan was initially divided into seven sections, though these were ultimately condensed into five. Each section has its own outreach team. The outreach team I worked with was comprised of:

  • a program director (social worker)
  • a team leader (social worker)
  • five housing workers (high school graduates to social workers)
  • a receptionist (who also answered 311 calls about homeless individuals in Manhattan)
  • and a psychiatrist (me)

The section we worked in was bounded by the southern tip of Manhattan, the East River, the Hudson River, and Houston Street. Our job, as a group, was to identify chronically homeless individuals, build rapport and encourage them to accept housing, and shepherd them through the housing process until they moved in.

Two of the housing workers were on duty from 5:30am to 1:30pm. They would travel throughout our designated section, either by car or on foot, and seek out people who were “bedded down”—those individuals who were sleeping on the street (or in other public spaces). After rousing people and introducing themselves, the workers would ask for homeless histories to learn if people were eligible for the program. If the individuals could tolerate it, the workers would then start to build rapport with the ultimate goal of encouraging them to accept housing.

You can imagine the reception they often got. Few people want their sleep disturbed, let alone by strangers. Furthermore, homeless individuals are only too familiar with police officers and people with malicious intent waking them while they are sleeping.

Housing workers who worked the day shift from 9:30am to 5:30pm also engaged in outreach, though they generally worked with homeless individuals who had already established connections with the team. They often helped people secure birth certificates, identification, and entitlements. They accompanied individuals on housing interviews, provided transportation for appointments, and advocated for them in various contexts.

There were also evening and overnight teams, though I never worked with them directly.

The team leader and program director provided supervision and support for the rest of the team. They also compiled data about housing placements. The more people a team housed, the more funding that team would receive. Despite the productivity expectation, we reminded ourselves that these people were people, not merely numbers.

The psychiatrist’s official job was to administer psychiatric diagnostic interviews to determine if the person had any psychiatric or substance use disorders. The diagnosis (or lack of one) would determine what type of housing the person was eligible for. (There were always more people than available housing. Yes, this is where a psychiatrist can become an agent of social control. More about this later.) Though I could meet with people in the office for interviews, I often went out with different workers to talk with people wherever they were. (Some people had significant psychiatric symptoms that interfered with their ability to meet anyone at a specific time or place, so I would often find them in subway stations, in public parks, behind garbage bins, on stoops, etc.)

I also provided education to the outreach workers, did regular outreach myself with a few clients whose psychiatric symptoms (often delusions) interfered with their ability to even consider housing, and provided informal supervision to the staff members. These housing workers, particularly the ones who work early in the morning, have tiring and often thankless job.

Of all the positions I had at PPOH, this was by far the most challenging for psychological and ethical reasons. Some people had severe psychiatric conditions. Many individuals lived in squalor. A lot of people experienced terrible things at the hands of their fellow human beings. People suffered.

As a team, we interacted with a lot of people. These included not only homeless individuals, but also police officers, ambulance crews, emergency rooms, hospitals, private property owners, homeless shelters, medical clinics, government agencies, staff at supportive residences, and the general public. Working with and in all of these different systems was often taxing and frustrating. Everyone in all these different arenas wanted to do “the right thing”, except people often had contradictory ideas as to what “the right thing” was.

In this position, I witnessed human dignity, creativity, and resilience. No one wants to be homeless. Many homeless people, whether they have psychiatric conditions or not, feel shame about their circumstances. They want things to be different, but they don’t know what to do. They try their best with what they’ve got. Sometimes their strategies work, sometimes they don’t. We can all recognize that in ourselves. And that’s how the line between “us” and “them” dissolves.

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Education Homelessness Lessons NYC PPOH

The Geriatric Adult Home.

During my time at PPOH, I spent one day a week working at a geriatric adult home.

An adult home is a residence that generally houses people with psychiatric conditions. They can be run by either public or private agencies. At best, they provide services and supports for the residents so they can live independently. At worst, they provide very little other than shelter; they just take people’s money. (The latter has resulted in a court order to shut down adult homes in New York.)

This particular adult home was small and housed people over the age of 60. My oldest patient was close to 100 years old. Before I started working there, I assumed that most of my patients would have cognitive impairment, such as mild to moderate dementia.

Well, I was wrong.

Certainly some of them had cognitive problems, but the majority of my patients had psychotic conditions, such as schizophrenia. Some of them had worked with numerous psychiatrists during their lifetimes, taken astounding amounts and types of psychiatric medication, and spent months to years in state psychiatric hospitals. A few of them reportedly underwent procedures like insulin shock therapy.

That they were still willing to talk to any psychiatrist humbled me.

Some of them had significant alcohol problems. Thankfully, most of them had stopped drinking by the time I met them. A few of them achieved sobriety after the age of 70.

Some of them had extensive homeless histories. Several had lived indoors for only a few years when I met them. Can you imagine people in their 60s and 70s who are homeless? plucking food from trash cans with their arthritic fingers? sleeping on disassembled cardboard boxes placed over heating grates?

This particular adult home was near a major New York City tourist attraction. People walked past it all the time without realizing what it was or who lived inside.

The residence itself featured a common area on the lower floor. There was a dining room that served three meals a day (8am, noon, and 5pm, with “tea time” at 3pm). Two clocks, one of which was broken, and an out of tune piano adorned the space. Chefs clattered around in the kitchen for 12 hours a day.

A large TV, a random collection of chairs, a pudgy sofa, and a leaning bookcase were in the living room. A computer over ten years old sat on an even older desk against the wall.

Halfway down the hallway—which had handrails every few feet—was the medication room. Against one wall were rows of shallow drawers, each labeled with the name and photo of a resident. The medication cart occupied one corner of the room. Underneath the large clamshell lid were circular slots that held small paper cups. Inside each cup were pills. A staff member would push the cart around during meals to administer medications.

If people did not attend meals, sometimes staff would go upstairs with the medication to the rooms of the residents. And sometimes the line between administering medication and coercion was blurred.

The rooms themselves resembled small hotel rooms. They each came furnished with a twin-sized bed and a pillow. Some of them also had a small writing desk and a chair. Residents were free to decorate and furnish their rooms as they wished. Almost all of them (who could afford it) bought televisions. Some hung framed art on the walls. Tchotchkes sat on nightstands. Others tacked photos of people—some they knew personally, some not—onto the worn walls.

Then there were residents—often those who had significant psychiatric symptoms—who did nothing to decorate their rooms. The walls were bare, the tiled floor was exposed, and when one sat in the solitary chair in the room, it looked like a scene from an institution.

They shared bathrooms, which were located out in the hall. There were no kitchens. If people could afford it, they put mini fridges and electric kettles in their rooms. The delivery guys from the local bodega routinely dropped off sodas, candy bars, meatballs, potato chips, and fruit.

Though a lot of people worked at the residence, there never seemed to be enough staff. Chefs cooked large quantities of food (that most of the residents did not like). Personal care staff performed thankless jobs: They helped residents shower, use the toilets, and dress themselves. Visiting nurses injected insulin and monitored blood pressures. Physical therapists encouraged people to walk more and taught them to walk safely, especially if they had walkers. Social workers helped coordinate appointments and offered informal counseling. An internist spent one day a week there.

The space I used for my office was literally the storage room for the recreational therapist. Amidst holiday decorations, arts and crafts supplies, and boxes of stuff, patients sat with me for 20 to 30 minutes. They would tell me about bedbug and cockroach infestations; deceased husbands; alcoholic mothers; instructions from God; “the one who got away”; the lack of fresh veggies and fruits with meals; the KGB officers in Times Square; constipation; bones in arms and legs dissolving overnight; talented children; the first time they were mentioned in the New York Times; the burden of using a walker; loneliness; the problems with liberals; the problems with conservatives; fears of death.

Though the internist and I worked there on different days, we worked together. He told me that I made his job easier. He definitely made my job easier. That experience alone strengthened my belief in the necessary collaboration between primary care and mental health (more on that later).

I am grateful that I had the chance to work with and learn from those patients. They taught me how to listen more and talk less. They demonstrated dignity in the midst of illness and aging. They showed me that people still want to learn and change, regardless of age. They reminded me not to take my youth and health for granted. They highlighted the value of laughter.

I learned that people, regardless of age, are just people. No one thinks that they will be 75 years old. Then, one day, you are.

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Education Funding Homelessness NYC Policy PPOH

Project for Psychiatric Outreach to the Homeless.

In New York, I worked for an organization called Project for Psychiatric Outreach to the Homeless (PPOH). It has a humble history: Over 20 years ago, a group of psychiatrists were sitting around and discussing the need for psychiatric services for the homeless. They decided to volunteer their time and skills to this population.

The organization grew and, for both administrative and financial reasons, eventually became part of another social service organization, CUCS. At this point, PPOH serves more formerly homeless individuals than people who are currently homeless.

PPOH is not a big outfit. By the time I left, there were about 12 full-time psychiatrists, several part-time and per diem psychiatrists, and a handful of psychiatric residents. As a group, we worked at nearly 60 sites in three boroughs of New York City.

The job is atypical in many ways. PPOH psychiatrists are paired with different social service agencies to provide psychiatric services. The rationale is that social service agencies often don’t have the resources to employ psychiatrists. Furthermore, these agencies often do not know how to provide the support and supervision to psychiatrists. What they do have, however, are patients who would benefit from psychiatric services, but the patients either cannot or will not visit a psychiatrist in a clinic or other typical setting.

Thus, PPOH brings psychiatrists to the patients.

Funding for PPOH differs from funding for “mainstream” psychiatric services. PPOH receives funding from state and city agencies (government money), grants (from organizations like Robin Hood and van Ameringen), and fees from the social service agencies themselves. These fees are usually lower than what it would cost to hire a per diem psychiatrist directly.

Because PPOH did not receive money from Medicaid, it did not have to follow Medicaid rules and regulations. (PPOH would not be able to fulfill its mission if it did accept Medicaid funds, as Medicaid has requirements that physicians see patients in a physical locations designated as clinics. This contradicts the organization’s mission. While at PPOH, I often saw patients on sidewalks under scaffolding, in their apartments, etc.)

I was one of the few psychiatrists in the group who worked with an agency who worked with Medicaid, though because of the nature of the program (an Assertive Community Treatment program; more on that later), the regulations had little effect on my actual clinical work. It did influence the documentation I had to provide.

PPOH does not have any contracts with insurance companies (as the target population often did not have traditional insurance), which also means that there were no negotiations about reimbursement rates or discussions about concessions to have access to the patients on an insurance panel.

Thus, I essentially had a job outside of the US healthcare system, which, in many ways, was appropriate: The population I worked with was also generally outside of the US healthcare system. Despite this, we often viewed ourselves as “hot spotters“, as a few of our patients often crossed into the US health care system through ERs and hospitals.

Because of this funding structure, I worked as a salaried employee. There were no productivity expectations or bonuses. While this arrangement can result in people slacking off, my boss chose his employees carefully to prevent this problem.

Psychiatrists who choose to work at PPOH, however, do not work there for the money. The median salary for a psychiatrist in New York is apparently $228,815. During my time at PPOH, over 90% of psychiatrists in New York earned more money than me.

(Yes, the specter of student loans continues to haunt me and, of course, it would be nice to make more money, but let’s be honest: I was earning enough money to live comfortably in New York. Not everyone who lives there can say that.)

In exchange, I had the time and opportunity to work with those who often do not receive care. Many of these individuals had significant psychiatric conditions that contributed to their lack of employment, homelessness, and poverty. I had more control over how often and how long I got to see patients. Patients had easier access to me and I had the flexibility in my schedule for urgent appointments.

The idealist in me finds the fiscal realities of health care demoralizing. I don’t like thinking about how economics affects the relationships I have with patients. I didn’t go into medicine to think about that stuff. However, I do firmly believe that physicians should have a basic understanding of their clinic or department budgets. Form follows function. And form follows funds.

Next: What my job at PPOH actually looked like.