NYAPRS: Hospital Stays are only as Effective as the Discharge Plans and Community Support that Follow

NYAPRS Note: A recent forum hosted by the conservative think tank Manhattan Institute resurfaced the ongoing debate about whether we need to better fund and expand community or inpatient services….or both. Everyone agrees that our mental health service systems have been vastly underfunded but the key question is where we deploy an precious additional investments we can secure.

Steadily growing evidence continues to point to the effectiveness and cost effectiveness of a broad array of community based engagement, stabilization, wellness, relapse prevention and crisis respite and management approaches and the critical importance of investments in the social determinants of health (housing, employment, social support et al).

In recent years, the NYS Office of Mental Health has been demonstrating how to best deploy public funds that otherwise remain in our hospital systems, with enthusiastic support from groups like NYAPRS. Click on the following regional examples of these smart and strong investments:

This country is engaged in a debate in how best to serve those in the greatest need. Just based on our peer bridger initaitives, NYAPRS has had ample first hand experience in helping both people on the back wards of state hospitals or who are engaged in revolving door use of community psychiatric units can recover and integrate within our communities.

Our biggest finding is that inpatient stays are only as effective as the follow up discharge plans, which in turn entirely rely on the level and array of community services that are available after the crisis

That’s where our investments need to be: we must all work together to ensure that we continue to build on all of the progress we’ve made over the past few decades and that the pendulum doesn’t swing backwards.

Should We Bring Back Asylums?

Crain’s Health Pulse  May 9, 2018

New York has sought to invest in community-based services for mental health, but the Manhattan Institute hosted a forum Tuesday to explore whether states should be doing the opposite: building modern inpatient institutions to treat people with the most serious mental illnesses.

Proponents of the solution say that President John F. Kennedy's 1963 Community Mental Health Act, which called for states to move mental health care from institutions to community-based settings, failed to provide sufficient investment to take care of the mentally ill. As evidence, they point to the high rates of people with mental illnesses who are incarcerated or living on the street.

In 2015 Dominic Sisti, a medical ethicist at the University of Pennsylvania, helped rekindle the debate over institutionalization with an op-ed in JAMA titled "Improving Long-term Psychiatric Care: Bring Back the Asylum." On Tuesday, Sisti explained during a panel discussion that he had been referring to the asylum's original 19th-century meaning "as a place of safety and shelter for individuals who are vulnerable."

"I envision the institution, the asylum, as one point on the continuum of comprehensive care for individuals with mental illness," Sisti said. "Along that continuum, you have got outpatient treatment, day treatment, transitional treatment in the community and then inpatient treatment—just like we have for other ailments, from everything from cancer to diabetes."

While that continuum exists, Sisti said after the event, underinvestment in mental health, both inpatient and in the community, has led to a lack of capacity for the seriously mentally ill.

The shift toward outpatient care was further accelerated by the Supreme Court's 1999 Olmstead decision, which held that people with disabilities who met certain criteria were eligible to receive state-funded services in the community rather than in institutions. It has been a major barrier to a return to institutionalization, said Dr. Jeffrey Geller, director of public-sector psychiatry at the University of Massachusetts Medical School.

"They say that if you just take the people out of the institutions and put them back in the community, they are going to accrue all these benefits. The evidence is absolutely to the contrary," Geller said during the panel

Geller is the medical director of Worcester Recovery Center and Hospital, a $300 million, 320-bed behavioral health facility that has been touted as a model for 21st-century inpatient psychiatric care.

Cliff Zucker, general counsel for Disability Rights New York, an advocacy group based in Albany, said in an interview that he disagreed with the notion that community-based care isn’t effective. He said more supportive housing for people with mental illnesses is needed.

 “The ideas being put forth by these people are totally out of the mainstream,” he said. “Asylums? We tried that. It failed. They suck the joy out of life. The answer is not asylums and huge investments in hospitals. The answer is investments in community housing and community supports.”

There are about 24 state-run inpatient psychiatric facilities with more than 3,500 budgeted beds in New York. The inpatient facilities serve just 1% of the people accessing the public mental health system but represent 20% of the state mental health system’s spending.

Asked for comment, a spokesman for the state Office of Mental Health pointed to its transformation plan, which says OMH “aims to re-balance the agency’s institutional resources by further developing and enhancing community-based mental health services.”

Jason Lippman, executive vice president of the Coalition for Behavioral Health in Manhattan, acknowledged in an interview that the underfunding of the mental health system has contributed to incarceration and homelessness among people with mental illnesses. But he objected to a return to higher levels of institutionalization.

"We believe that care and services in the community works best for people to be able to live their lives and recover," he said.