Oversight: The Future of Psychiatric Care in New York City’s Hospital Infrastructure

Good afternoon Chairperson Rivera, Chairperson Ayala, and members of the Committee on Hospital Systems, and the Committee on Mental Health, Disabilities, and Addiction. I am Dr. Charles Barron, Deputy Chief Medical Officer for NYC Health + Hospitals (“Health + Hospitals”). Thank you for the opportunity to testify before you on the future of psychiatric care in New York City’s hospital infrastructure.

Health + Hospitals is the main provider of behavioral health and inpatient psychiatric care services in New York City, with nearly 1,500 licensed psychiatric beds – representing 48% of all psychiatric inpatient beds in the metropolitan area. As such, we provide a significant portion of behavioral health inpatient services in New York City, which underscores the need for continued stability in the public hospital system. Over the last several years, health care delivery in New York State has been undergoing a transformation – a shift from providing care in the inpatient setting to community-based care. In April 2014, the federal Centers for Medicare and Medicaid Services (CMS) approved New York State’s Medicaid waiver request in the amount of $8 billion over five years. The goal of the Delivery System Reform Incentive Payment (DSRIP) program was to achieve a 25% reduction in avoidable hospitalizations for Medicaid patients, including psychiatric hospitalizations, and restructure the health care delivery system. To that end, from 2014 – 2017 Health + Hospitals has seen a decrease in our “all-cause,” and psychiatric readmission rates by 24% and 27%, respectively.

In keeping with the hospital industry’s shift from inpatient to ambulatory care, at Health + Hospitals we are in the process of deploying a system-wide, and multi-phase expansion of integrated ambulatory behavioral health care, which we expect to complete by the end of 2020. NYC Health + Hospitals/Metropolitan will serve as a demonstration site and center of innovation, bringing together the most innovative care models and community driven strategies. Additional, and complementary initiatives will also include: 1) collaboration with community based providers focusing on depression, substance misuse, and unstable psychosis in neighborhoods especially impacted by behavioral health issues; 2) strategies to improve safety for our patients; 3) intensive outpatient programs, which allow increased frequency and customized treatment to meet each patient’s needs; and 4) use of tele-psychiatry to assist with workforce shortages, and provide increased access for patients.

Our acute care behavioral health services include seven adult, and one child & adolescent comprehensive psychiatric emergency programs (CPEPs), which include psychiatric emergency rooms, extended observation beds, mobile crisis intervention services, and access to crisis beds. Last year, there were more than 63,000 adult and 8,000 child/adolescent visits to Health + Hospitals psychiatric emergency rooms.

Our inpatient services provide individualized, therapeutic care to stabilize mental illness episodes and promote rehabilitation, recovery, a return to the community, and less restrictive modalities of care. As previously acknowledged, while inpatient care will always be needed, especially for those with serious and persistent mental illness, acute psychosis, or risk for suicide, we agree with the imperative to keep patients out of the hospital if they don’t need to be there.

Health + Hospitals provides a comprehensive array of ambulatory behavioral health care programs, including mobile crisis teams, outpatient clinics, day treatment, partial hospitalization programs, and case management mental health programs. For those patients who require significant levels of support, our facilities operate Assertive Community Treatment (ACT) Teams. The ACT Team program functions as a “clinic without walls” treating individuals in their homes and community. Of the 38 ACT Teams in New York City, Health + Hospitals operates 12 teams. Children and adolescents receive services through developmental evaluation clinics, family support programs, adolescent treatment programs, school-based programs, and outpatient clinics.

Harmful substance use is a significant population health problem in NYC, and among Health + Hospitals’ patients. There are approximately 90,000 unique patients with substance use disorder (SUD) at Health + Hospital every year. Approximately 20% of primary care patients are at moderate risk of harmful substance use or SUD. Of the patients with SUD, close to 15% have a primary diagnosis of opioid use disorder; and 45% have a primary diagnosis of alcohol use disorder.

Health + Hospitals facilities provide an extensive array of SUD services. Inpatient detoxification is provided in seven facilities, and we have 13 outpatient counseling programs, four methadone treatment programs, two halfway houses, and a number of specialized services for families, adolescents, and women.

In 2017, the Mayor and First Lady announced Healing NYC, a comprehensive effort to reduce opioid overdose deaths by 35% over the next five years. Health + Hospitals is a key partner in this initiative, reinforcing our commitment to transform into a system of excellence for opioid services. We are grateful to the City for providing nearly $5 million in funding to date, which has allowed us to implement several initiatives, including:

• Hospital-Based Opioid Overdose Prevention Programs: Seventeen of our patient care sites are now State-certified Opioid Overdose Prevention Programs that routinely dispense naloxone based on best practices, including overdose prevention training of patients and community members. This unified strategy for naloxone distribution will enable Health + Hospitals to capture system-wide data to target future overdose prevention work.
• Consult for Addiction Treatment and Care in Hospitals (CATCH): To maximize patient connections to substance use care, in the fall Health + Hospitals will initially launch CATCH at four facilities – Bellevue, Metropolitan, Lincoln, and Coney Island – followed by Elmhurst, and Woodhull in 2019. We will specifically recruit staff to form interdisciplinary teams that will engage patients with SUD who are in the hospital for any condition. The program’s target is to reach and deliver treatment to more than 8,000 patients with opioid use disorder per year across the six hospitals.
• Buprenorphine Expansion in Primary Care: In order to treat as many possible patients with opioid use disorder across our system, Health + Hospitals is expanding Medication for Addiction Treatment (MAT) in primary care clinics. By 2020, we will have increased the number of providers to 450 who are certified to prescribe buprenorphine. Through our efforts, the number of patients who received medication treatment in our system will increases to 2,500 over the next three years. Integrating primary care with behavioral health, and substance use treatment in this way will increase access to treatment and enable primary care providers to better serve this patient population.
• Emergency Department Peer Advocates Addressing Substance Use: Leveraging an initiative launched by New York Alliance for Careers in Healthcare and CUNY at Queensborough Community College, which trains and certifies peer advocates, Health + Hospitals created an integrated SUD and Care Management Peer Counselor program in three of its emergency departments with the highest volume of SUD patients – Harlem, Metropolitan, and Woodhull. Using a relational care model, peer advocates engage with patients coming to the emergency departments, and connect them to appropriate ongoing addiction care. This program will be rolled out to the remaining eight emergency departments in the next year.
• Judicious Prescribing Training and Guidance: To ensure that all possible prevention strategies are implemented, a total of 2,220 providers across Health + Hospitals received education and training in judicious opioid prescribing in FY2017. Judicious prescribing means prescribing smaller doses of opioid analgesics for shorter durations, and avoiding co-prescriptions with benzodiazepines, which can increase a patient’s risk of overdose. Additionally, prescribers will receive reminders through Health + Hospitals’ electronic health record system to ensure fidelity to these prescribing guidelines.

In 2015, the Mayor and the First Lady announced Thrive NYC – a plan of action to guide New York City to effectively and holistically support the mental health of its residents. With over $3 million in funding to date, Health + Hospitals has implemented a number of programs.

• Universal Maternal Depression Screening: As part of the Thrive Initiative, all pre-natal and postpartum patients seen at Health + Hospitals are screened for depression. Mothers are screened in both the OB-GYN and Pediatric Clinics during well-baby visits. Anyone screening positive for possible depression is then connected to ongoing mental health care. As part of this work, Health + Hospitals participates in the City’s Maternal Depression Collaborative run by the Greater New York Hospital Association and the New York City Department of Health and Mental Hygiene.
• NYC Mental Health Corps: Thirty Mental Health Service Corps members, all recently graduated Master’s and Doctoral-level clinicians, work in substance use programs, mental health clinics, and primary care practices within Health + Hospitals. When fully staffed, the Corps throughout the city will provide approximately 400,000 additional hours of service in the communities where they are needed most, including at primary care settings, which is where most New Yorkers receive their regular medical care.
• Mental Health Services in All Family Justice Centers: Health + Hospitals expanded onsite mental health services at all five of the city’s Family Justice Centers, which last year served more than 37,000 domestic violence survivors. The staff provide direct care and also offer mental health support, skill-building opportunities, and mentoring to other Family Justice Center staff. This new program will be able to accommodate 1,000 clients per year.
• Mental Health First Aid (MHFA): This groundbreaking public education program teaches the skills needed to identify, understand, and respond to signs of mental health and substance abuse challenges and crises. Thus far, 826 Health + Hospitals’ employees have been trained and certified. The course gives people the skills to help someone who is developing a mental health problem or experiencing a mental health crisis and help guide them to treatment programs. The evidence behind the program demonstrates that individuals who have completed the MHFA training have:
• A greater confidence in providing help to others;
• A likelihood of advising people to seek professional help;
• An improved concordance with health professionals about treatments; and
• A decreased stigmatizing attitude.

Health + Hospitals as the main provider of care to individuals with mental illness and substance use disorder in New York City, faces many challenges in providing high quality, patient-centered care. These challenges, which are not unique to us, include:

• Eliminating the stigma and discrimination associated with seeking care for the treatment of mental health and substance use disorders;
• A patient population that is frequently resistant to treatment and often interfaces with the criminal justice system;
• Significant numbers of uninsured individuals who lack resources to pay for their treatment and medication; and
• Inadequate reimbursement for treatment services.

Health + Hospitals cannot resolve these challenges alone and will continue partnering with government and key stakeholders to forge solutions. I would be happy to answer any questions that you may have.