Category: NYC

Categories
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.

Categories
Consult-Liaison Education NYC

D5 Hold.

I had arrived in New York City only six weeks prior. It was the fifth week of my fellowship. I still couldn’t find some of the units in Bellevue Hospital.

“There’s a new consult,” the attending told me. “The patient is on a D5 hold. It could be interesting.”

I learned many new acronyms during my first few weeks in New York:

A PES is a Psychiatric Emergency Service. It means that psychiatric services are available in an emergency department. This, however, does not guarantee that the PES has its own dedicated space.

“There’s a PES in the city that is literally an open hallway of the emergency room. They put pink gowns on all the psychiatric patients,” a resident told me. “Can you imagine? No one wants to wear a pink gown. Patient privacy is out the window, too!”

A CPEP is a Comprehensive Psychiatric Emergency Program, which is part of a hospital system. As its name suggests, it offers comprehensive services: a mobile crisis unit (think of something like a Batmobile, holding a combination of social workers, nurses, and psychiatrists, that responds to urgent mental health situations in the community); a dedicated physical space that provides emergency psychiatric services in a hospital; and EOB beds.

“What are EOB beds?”

“Emergency observation beds. It’s like a mini-psychiatric unit in the emergency room. If someone gets hospitalized involuntarily and there aren’t any inpatient beds available, he can stay in an EOB bed. Or if someone comes in drunk, he can stay in an EOB bed until he sobers up. He doesn’t need to take up a bed in the hospital. It’s quieter in the EOB. They don’t have to see and hear all the stuff that happens in emergency room, like when a lot of nine-three-nines come in.”

“And a 9.39 is when someone is involuntarily committed to the hospital for psychiatric reasons, right?”

“Yup.”

I didn’t know what a “D5 hold” was.

The attending said, “A D5 hold is when someone is held involuntarily in the hospital because they haven’t been able to finish a course of treatment for tuberculosis. There are different levels. D5 is the most restrictive. Patients on D5 holds couldn’t—or wouldn’t—take the tuberculosis medications as outpatients or even under ‘directly observed therapy’, which is when they have to show up at a clinic and a nurse watches them take the medication.”

“Oh.”

“These patients on D5 holds often have severe substance abuse problems and personality disorders. They can be here for a long time.”

“Like how long?”

The attending chuckled.

There was a security guard posted outside the door. He glanced up at me.

“Hi, my name is Dr. Yang”—I pointed to my ID badge—”and I’m here to see—”

As he started to look away, he mumbled, “Talk to the nurses inside.”

I shut my mouth and peered through the thick glass windows. I saw open doors, but no people. As I was turning around to point this out to the guard, a nurse passed by. I shook my hand at her. After looking at my ID, she unlocked the door and let me in.

“Hi, my name is Maria Yang, I’m one of the psychiatric consult fellows and—”

“Oh, you’re from psych!” she said, pulling her glasses down while peering up at me. “You’re here to see George?”

“Yes—”

“—in that room.”

“How long have you been here, George?”

“Too long.”

“How long is ‘too long’?”

“I was stupid when I first got here, I was dicking around, I don’t know, I just didn’t think it was a big a deal. I was okay, ya know? I’m better now. I think I got six months left.”

“Six months left, okay. But how long have you been here?”

George was reclining on his bed. He looked up at the images he had taped to the wall; they were glossy magazine photos of slender women in bikinis. He sighed.

“When I was outside, I talked to women who looked like that all the time. They liked me. They wouldn’t leave me alone.”

“When’s the last time you had a conversation like that?”

He pushed himself up into a sitting position.

“Almost two years.”

For the next two months, I saw George on a weekly basis for informal psychotherapy. Thankfully, he was housed in the unit that didn’t require respiratory precautions. We didn’t have much privacy. His roommate offered to leave each time we met.

George told me that the last time he had been physically outside was the day he was forced to enter the hospital.

“I coulda left over a year ago, Doc, but some guy brought in dope and planted it in my pillow and told everyone else that I was dealing. I coulda killed him, I really coulda. They drew my blood around that time, Doc, ‘cuz they thought I was using, too. My rifampin level was low, it was too low, so they made me stay longer. And then this other thing happened and I couldn’t get out.”

He told me about the special Friday night meals: They had Chinese take-out last week. It was probably going to be tacos this week. He liked fried chicken the best.

“They give you these tokens if you do stuff. You make your bed, you clean up, you get tokens. Tokens get you chips and candy. They get you magazines sometimes, too.” He pointed at his paper harem.

He told me about all the different doctors involved in his care.

“I’ve trained a lot of the docs here, I met them when they were interns and now they’re big residents! They’re only here for a lil’ bit, though.”

Soon, my time came to rotate off service.

“Okay, see you, Doc. I only got four months left. Maybe you’ll see me outside, that’d be nice, right? You can meet all of my girls.” He winked at me.

Our paths never crossed again during my time in New York. And, thereafter, I never took for granted the daily opportunity to breathe fresh air.

References:

Categories
Education Homelessness NYC

How Long Do People Stay Here?

Let’s visit a homeless shelter in New York City.

There’s no sign on the building. On the sidewalk outside of the unmarked entrance are several men. Three of them are chatting with each other. Two others are leaning against the wall, taking drags from their cigarettes. After you pass, one of them coughs up a wad of phlegm and spits it out. A man sitting on the sidewalk asks, “Spare some change?” He shakes a tattered coffee cup at you. The few coins inside jangle.

You try to pull the door open. It’s locked. Through the glass you see a few people looking out at you. They’re not smiling. Finding the doorbell, you press the white button. A few seconds pass. A harsh, steady buzz suddenly fills the air, informing you that you may now enter.

“Sign in!” a man barks at you. Behind the splintered desk is a man in a security uniform. He’s pointing at a log book, the page nearly filled with names in blue ink.

As you write in your information, he asks, “Who are you? Where you from?”

“Empty your pockets.”

“Open your bag.”

Satisfied with your answers and confident that you don’t have weapons, drugs, or alcohol, he steps out from behind the desk with a metal detector wand. After he waves it over your body, he says, “Go. You’re fine.”

Before you see the thick, plastic chairs in the main room, you smell the odor of fetid sweat. Seated in the chairs are men wearing unwashed jeans, oversized shirts, baggy jackets, and generic baseball caps. Some of them are reading newspapers and books. A few older women are sleeping upright, their chins nearly resting on their chests. One of them is wearing sandals; her toenails are discolored and misshapen from fungus. Her ankles look like eggplants. A young man seated in a wheelchair tries to drink his coffee, but his tremulous hand cannot keep the cup steady. Next to him is a man wearing a porkpie hat, red lipstick, two winter coats, board shorts over torn tuxedo pants, and yellow sandals. Three women are shouting at each other; one of them reaches for the neck of another and screams, “I’M GONNA KILL YOU, YOU—”

“How long do people stay here?” you ask, realizing that the room is filled with people. You can’t imagine living like this; you’d get out of here as soon as you could.

They feel the exact same way.

But you ask an excellent question. What is the average length of stay in a homeless shelter?

Some caveats: Data on homelessness is almost always incomplete and inaccurate:

  1. Researchers can only collect data that is available. People who stay in homeless shelters are available. People who live in cars, abandoned lots, and in transit stations—away from researchers—are generally unavailable.
  2. Researchers often must rely on the information homeless individuals share (“self report”). For a variety of reasons, people who are homeless may not share much about themselves… if they consent to interviews at all.

That being said, available evidence suggests that people stay in homeless shelters anywhere from two [1. “The average length of stay in emergency shelter was 69 days for single men, 51 days for single women, and 70 days for families.”] to seven months. [2. “In a survey of 24 cities, people remain homeless an average of seven months…”] (I read a paper within the last year that I now cannot find—of course—that demonstrated that the majority of people who experience homelessness are homeless for less than six months. Furthermore, of those people, most of them are homeless for only one day!)

This suggests that the majority of people in shelters do not experience chronic homelessness. Emergency shelters, then, are arguably used just for that: emergencies. Those who enter shelters obtain the help and resources (either within or outside of the shelter) to get them back on their feet. They exit the shelter system in less than a year—sometimes within a few months—and never use the system again.

However, there are individuals in shelters who meet the definition of “chronically homeless”. Some researchers have “identified that approximately 10 percent of users account[ed] for 50 percent of the annual nights of shelter provided”. [3. See page 1-10 of this document for the statistic that 10% of shelter users account for 50% of annual nights of shelter provided.] These numbers should sound familiar to those of you who follow health care policy discussions, where “5% of patients use 50% of all health care spending dollars”. [4. More about “A Small Proportion of the Total Population Accounts for Half of All U.S. Medical Spending” here.]

So what’s going on with these individuals who experience chronic homelessness? Are there risk factors for chronic homelessness? If so, what do you think they are?

Categories
Education Homelessness NYC

Do All New Yorkers Have a Home?

Before I write about “homeless psychiatry”, let’s talk about homelessness.

In New York City, most people are familiar with the sight of people who are clearly homeless. These men and women, sometimes pushing carts and often saddled with several overflowing bags, are in city parks, on subway cars, and under bridges. People grow so accustomed to the homeless that, after a while, they don’t see them anymore, even if they’re looking directly at them. (Once you are actively looking for them, however, you will see them everywhere—and where they sleep, even if they aren’t there.)

Would you believe that New York City has one of the lowest ratios of street homeless individuals in the country? (Please note that there are differences between people who are homeless on the street and people who are homeless in shelters. More about this below.) In New York City, there is one street homeless person for every 2,688 people in the general population. In Los Angeles, there is one street homeless person for every 154 people. [1. See the last page of the document that compares street homeless populations of different US cities. Briefly, this data comes from volunteers who survey the city on one single night, usually during the coldest month of the year.]

What could explain this? Maybe it’s because of the cold, snowy winters and the sweltering summers. Perhaps people who are homeless leave the city and move to places with temperate climes. Those who have worked in hospitals too long might argue that many of the homeless aren’t on the streets; they’re in the hospitals. Those who work in the correctional system may make the same argument, except they replace the word “hospitals” with “jails”. Or maybe they’re hiding somewhere to avoid encounters with the police.

While those reasons may hold true for some people, one major reason that explains the low ratio of street homeless people in New York is the class action lawsuit Callahan v. Carey. The result of this lawsuit decreed that the City and State of New York must

provide shelter and board to all homeless men [and, later on, women] who met the need standard for welfare or who were homeless “by reason of physical, mental, or social dysfunction.” Thus the decree established a right to shelter for all homeless men in New York City, and also detailed the minimum standards which the City and State must maintain in shelters, including basic health and safety standards. [2. Excellent summary of Callahan v. Carey.]

As far as I know, New York is the only state where people have a legal right to shelter.

Even though New York City has a low ratio of unsheltered homeless individuals, there are many people who are homeless who stay in shelters. The Department of Homeless Services in New York (which also shares the acronym “DHS”) keeps a count of homeless individuals throughout the city.

Take a guess: How many people stay in a New York City shelter on an average night?

Those of you who have witnessed the New York City Marathon can attest to the endless waves of people who are running (plodding, whatever) in the streets. Tens of thousands of people make their way towards the finish line. About 45,000 people finished the marathon in 2010.

New York City’s Department of Homeless Services publishes the shelter census every day. The number has recently been around 37,000 people. While there is a difference between the shelter census number and the marathon finisher number, you now have a sense of the size of the shelter population.

Take another guess: How many of those 37,000 people are children?

About 16,000. [3. Statistics about the population of homeless people and children in New York.]

That’s right: In New York City shelters, there are more homeless children than homeless single adults.

These numbers tell us only about people who are willing and able to go through the process of registering for and staying in shelter beds. There are people who are homeless who either cannot or choose not to stay in shelters. [4. Here is a literary example.] As far as I know, there is no literature that describes the differences between these two populations, though I suspect that the differences are significant.

Furthermore, there are major differences between people who are homeless for a shorter period of time versus those who are “chronically” street homeless.

But before we get into those distinctions, let’s think about the definition of “homeless”. Many scholars, politicians, and advocates have tried to provide an accurate description of this word. How would you define it?

Categories
NYC

5:30am in the Financial District.

Prior to my departure from New York, my boss there granted me permission to freely write about the work I did in Manhattan. Though there are many psychiatrists in New York, very few work literally in the streets of the city. Future (original) posts will describe in greater detail my experiences as a “homeless psychiatrist”. As an introduction, here is a post that I originally wrote the following in December 2009.

The moon still floats in the sky at 5:30am and the wind coming off of the river feels like a cold pickle against the skin.

A parade of vehicles make their way south on Broadway, their tail lights glowing red in the dark ink of the yet unwritten day. Large trucks, the kind with eight or ten large wheels, roaring engines, and rattling cargo, rumble slowly along, their unoiled brakes screeching with each push of the drivers’ brakes. Taxis wander along the road, veering to the right, then to the left, then back to the right, of these large trucks, like flies looking for a place to rest their wings. Impatience overtakes the taxi drivers and intermittent honking ensues.

Underground, the subways are filled with people. Most of them are not Caucasian. Most of them are men. Many of them wear construction belts and boots. When the subway reaches the last stop, most of the people file off. A dozen or so, however, remain in each car. These individuals are wearing multiple layers of clothing, are surrounded by pieces of luggage and plastic bags stuffed with what look like more plastic bags, and are fast asleep in postures that look uncomfortable. These are the homeless who have found shelter, warmth, and relative peace for the night.

Back above ground, the sidewalks are almost empty. A young woman wearing tech clothing on her body and ear buds in her ears jogs past, her exhalations light, wispy, and grey. An older man in a dark suit, a yarmulke on his head, and a beard on his face ambles past, following the lead of his golden retriever. The space in front of the New York Stock Exchange, usually filled with tourists, chain-smoking day traders in bright coats, seemingly important men in three-piece suits, and police officers touting assault weapons, is completely empty.

The tiny trailers filled with pastries, bagels, and coffee are already set up and on site. The men inside, however, are napping, their chins tucked into their chests, their crossed arms resting on their abdomens that gently rise and fall with each breath.

A woman approaches one tiny trailer and giggles when she realizes that the merchant inside is sleeping. The man suddenly awakens upon hearing her and bolts upright.

“I’m sorry,” he sheepishly says. “What would you like?”

A few delivery men hoist boxes onto their hand carts. They swiftly push the cart into motion and easily steer the cargo along the sidewalks. Some of them whistle. Some of them frown.

A man sits on a rolling luggage cart, which is purposely positioned above a heated grate. His tattered clothes gently flap from the heat emitting from the vent. His nails are thick and yellow from growing yeast and grime is packed in the ridges of his fingers. To his left is a shopping cart, packed with plastic bags filled with newspapers, aluminum cans, and styrofoam containers. To his right is a lidless jar of peanut butter. A white plastic spoon or fork sits inside.

He faces the street and large trucks rumble past, their bright white headlights slicing through the darkness. Farther out, the lights along the river glow peach-orange, their reflections wobbling and choppy in the water.

The man’s lips move, though no sound comes forth. He shrugs his shoulders and then reaches over to the jar of peanut butter. He deftly pulls out the spoon, opens his mouth, and puts a glob of peanut butter in. He is missing many teeth.

The moon will set, the sun will rise, and the city will wake up. And the man eating the peanut butter will disappear.