A measure in the New York State Assembly has been introduced by Northern Brooklyn representative Joseph Lentol that would establish mental health community clinics across New York State. The bill aims to increase accessibility to care, especially for those living in poverty. But there are other challenges that clinicians alone may not be able to help.
The concept of this proposed bill was birthed from a straightforward problem in Brooklyn.
“Right now, what we have is homeless shelters being the place where the mentally ill can go for treatment if they get any there or in the prisons if they get any there it seems. And that’s not good and that’s not fair to this population,” said Assemblyman Lentol.
Lentol wants to add mental health professionals to existing places like substance abuse clinics, which currently may not be allowed to treat mental health patients.
New York State closed Willowbrook in 1987 and other places that took in the mentally ill with the promise they would provide mental health clinics at a later date.
“That never happened. The State never fulfilled that promise,” Lentol said.
The office of mental health has contacted Lentol’s office and told him they already doing some of this in certain areas.
“If they can do it and it’s working and they have psychiatrists and psychologists on staff and social workers who have the skill to do it and they have the facilities,” Lentol said. “That would save the state an awful lot of money from building mental health clinics like they said they were going to do if they already had the place to go and all they have to do is expand the services that they offer.”
The issue was brought to Lentol’s attention from community members who have had experience at addiction treatment centers like Outreach Greenpoint in Brooklyn.
“Technically they have to deal with people only with substance abuse, but some of those people who only come in with substance abuse also have mental health disorders. They know that, but they are not allowed to treat them. Or they don’t have the expertise to treat them,” Lentol said. “Why not have the facilities available? Right now all we have our hospitals and we don’t have that many that have expertise in treating mental illness.”
Neal Sheehan worked in the addiction field for over 35 years. Now he runs a mobile soup truck called the North Brooklyn Angels. He says just having Medicaid isn’t enough if the accessibility isn’t there.
“In our community in North Brooklyn, if you don’t have lots of money, the only clinics that exist are kind of private clinics that exist are kind of private clinics that don’t take any kind of insurance for mental health issues whereas opposed to public clinics existing for substance abuse,” Sheehan said.
Sheehan said part of the disparity is caused by the gentrification in Brooklyn.
“It’s like Brooklyn went from being a scary place to Disneyland. Houses go for $2,000,000 apiece now that used to go for like $100,000,” he said. “What happens is the high end private clinics operate for those who have a lot of money, but the working-class people are looking for a public clinic like they would for substance abuse and they can’t find one.”
At the soup truck, it’s common for them to give referrals to housing and social service employees.
“People are eating at my mobile soup kitchen three blocks from the office [with Lentol] talking about putting services in,” Sheehan.
Sheehan said this measure could address the need and save money doing it.
“You don’t have to go opening mental health clinics, renting places in gentrified communities for $400,000 dollars for an office, you know 8,000 square feet,” he laughed.
While the bill would allow for more integrated care throughout communities, Sheehan emphasized the importance of holistic care. This includes basic physiological needs.
“You talk to them and they say, well I stopped taking my meds. The idea of having services in a community. Maybe they had an episode and they were in a hospital somewhere. They were supposed to take meds. Then they are living in a shelter or they’re living in an SRO and all of a sudden they stop taking their meds and then they regress. Then I’m talking to them in the street and giving them a meal,” Sheehan said. “The drug and alcohol services is extremely intensive on the front end, but it comes to a conclusion. And then people tend to go in to twelve step. But mental health clinics, many of them are in a maintenance situation. If they are not on their medication, they don’t follow the regimen, then they lose that regiment of care.”
There are places across the state who, like the state’s office of mental health told Lentol, are addressing substance abuse and mental health issues at the same time. But in reality, they are doing much more.
WHAT'S THE JOB OF A MENTAL HEALTH PROFESSIONAL IN THESE SETTINGS?
Throughout Western New York, Horizon Health Services is the largest provider of outpatient mental health and substance use treatment.
People coming into Horizon will be evaluated for their specific service needs, where then a path would be created for them to be able to differentiate their individual needs.
So how do you address access issues? They, like some other services in WNY, have an offsite team.
“We have folks who suffer from medical conditions and that might leave them homebound,” said Horizon Vice President of Clinical Operations Judy Tejada. “That offsite team will go out in to the community and meet that person where they can deliver services more convenient for the patient. That can be because of medical reasons, it could be because I suffer from an anxiety disorder and I tend to be more homebound and I’m easier treated within the confines of my safe place (rather) than having to go to a clinic.”
In this day and age, there are many people who are transitioned from the hospital into the community for care. Tejada says a lot of time they get lost in the shuffle and meeting in homes instead of a clinic can make that transition easier.
“Our goal always, when we treat somebody in the community, is to be able to be able to transition them into clinic, because we just have a wider array of services then to offer,” she said.
First contact can be through a home visit or a tele visit (which is becoming more popular). A computer screen may be less intimidating for some rather than having them come in to the clinic.
Tejada said there are services and there are deliverables.
“And how we deliver them I think is where we are choosing to spend a lot of our focus these days because we know there are people who don’t ever make it into clinic,” she said. “Whether that’s because they are in rural areas and they don’t have access or transportation. Whether it’s because stigma is still as much an issue as it has been that coming into a clinic means something about me in a pejorative sense. And I don’t want to be identified that way so if I can meet you in your own space, is that a less intimidating, less stigmatizing way to start our journey.”
But even with alternative methods, a lack of access to something like internet could prevent patients from receiving the care they need.
It’s clear the role of a place like Horizon in clinical care has changed over the years. The majority of their emphasis Tejada said is now on stabilization.
“By history when you had places where a person could go to the hospital and be contained for a period of time so that they got stable before they went into the community, I think that was how it used to work,” she said.
Tejada said hospitalization now is not typically utilized with a lot of frequency. Patients Horizon see often are in for 24 to 72 hours before entering clinic.
“Clinic is still in the process of stabilizing that person in the community to ensure safety. To ensure that they are on the right medication to be able to then receive therapy,” Tejada said. “But I would say the first six to eight weeks, what we do here is work on safety and stabilization. That’s the totality of the services that tend to be provided in that shorter duration.”
Tying back in to holistic care, it’s imperative for Horizon to work often with primary care. Tejada said most of who Horizon works with also have medical comorbidities. It’s something extremely important to consider alongside behavioral treatment.
“If we’re providing some kind of medication and you have diabetes, is that medication potentially going to make your medical condition of diabetes worse? Because some of them do,” she said.
Tejada said they work with health homes, which are available to all patients who have Medicaid. They can provide care coordination services for social determinants of health. This includes things like transportation, housing, food and child care.
“If I come in to treatment and I see you for care and I’m going home and home consists of a hotel room with no food, little heat, and my kids are there and I have to worry about who is going to take care of them so I can go to treatment, treatment is kind of null and void. It isn’t the priority. The things that I have to take care of are my safety and stabilization needs first,” said Tejada.
Typically when Horizon does any outreach visit, they take a care coordinator with them to be able to ensure at least on the first visit, if there are additional resources that somebody needs they get signed up with health homes right away.
Tejada said while the proposed measure could help by adding a clinician on site, the care coordinator may have a more important job.
“If I’m seeing you in a food bank, a shelter or whatever it may be, that’s already indicative of the fact that I need some additional services probably laid out for me first. Then as a result of that, I can link up and feel like I can now start to take care of my mental illness or start taking care of my substance use,” Tejada said. “I absolutely believe that community services are going to be the way we have to go through right? Because there are too many people that are not able to access care in the traditional formatted way of call admissions, get an appointment, come in, sit down with a clinician. That’s great for what—50% of the population? The other 50% of the population maybe doesn’t have the means to get in that way.”
Hope is a word you often hear used when discussing mental health care. Tejada thinks that’s a base component for someone to accept and maintain mental health care.
“If I go to bed under a bridge every night, I don’t have an awful lot of hope. So why am I worrying about whether I’m drinking or why am I worrying about whether I take those meds? Where would I keep them? How would they not get stolen? I don’t know,” Tejada said. “It’s a difficult conundrum. I suppose if people’s mental health or their substance abuse were stabilized, they would be more likely, theoretically to join the workforce. To be able to better themselves futuristically. That’s great in theory. And I don’t know how the most marginalized and the most disenfranchised ever get out of the place they’re in without a significant push on all levels.”
Tejada believes Community support, financial support, and mental health support have to be done together
“We’re going to have to have a concerted effort to take care of the marginalized in our society. That’s got to be a priority,” she said.
How do you approach accomplishing that moving forward? Tejada said something has to change from a reimbursement perspective considering the cost Horizon receives barley covers the cost of providing care.
“Everybody is looking for us to do more with less. We can’t continue to do that because we are killing our workforce,” she said. “Our workforce is already challenged with accidental overdoses, suicides, deaths. So emotionally it takes a toll on them. Then we are asking them to do more and more and more with time that they don’t have. With time that has to be allocated to sit and seat and see a patient. But somehow they are expected to do all of this other work to help take care of the marginalized. And of course. The workforce we have is passionate. They care. They want to be able to do all of those things. And you know how long they stay in that seat? About 18 months to two years before they can’t do it anymore they are so burned out from trying to be all things to all people that they can’t continue to do that work. Things have to change.”
Tejada more master level programs to focuses on treating general behavioral health disorders.
“People get in here thinking they are going to be doing one thing and they are doing something entirely different. They are not doing therapy. Not for a long time. Not until that patient is safe and stable,” Tejada said. “If what we are going to be doing is talking about safety and stabilization and basic Maslow-ian level one care, then we have to have the resources to be able to take care of people that way and we don’t.”
Tejada said they have to be able to access those in need and allow them to access Horizon in a different way.
“If that’s putting a clinician in a shelter that’s great. I don’t know how we are paying for all of that because the workforce is a problem and reimbursement rates are a problem and that’s going to make what I would say is an idyllic plan a little difficult to implement,” she said.
Lentol said he thinks they can make the bill work through Medicaid.
“I think it will be good for the system because if we can solve some of these mental health issues it would be a blessing in disguise,” he said.
LETS TALK ABOUT MEDICAID
An expansion of Medicaid in this thought could very well help. According to Horizon Insurance Coordinator Candace Hudson, Medicaid has improved greatly over the past few years.
When a patient calls in to admissions at Horizon who wants services but doesn’t have insurance, a team of New York certified assistors (six according to Hudson) will help with the process of applying for assurance. That will end up being Medicaid or the Essential Plans which is the old Family Health Plus.
Horizon has had what used to be called a resource advocate. Those resource advocates would go to DSS and represent the patient because you need face to face interviews.
New York was impacted in a major way by the Affordable Care Act and in conjunction with it expanded their Medicaid program.
When everybody was going for exchanges, some states decided to use the federal exchange. New York State decided to build their own exchange and manage it themselves.
Hudson said the Medicaid guidelines for eligibility typically across the country is 133% above the federal poverty level.
“We used to be 133%, New York State. We were allocated by federal. [The state] could do an additional 5%. Now, more people are eligible than they ever were before,” Hudson said.
When the New York State of Health exchange opened, Horizon gained access to do Medicaid through the State.
“We’re able to do this remotely with them as certified assistors and do the application process with them and get their eligibility back within 72 hours. Sometimes less,” Hudson said. “We can actually get their eligibility back the same day and be active within 72 hours if they qualify for Medicaid. In the old world of going through DSS, it was 45 days.”
To clarify, that meant no access to medication and no coverage whatsoever for 45 days.
“Now, if there are no issues, no problems, it can be automatic. We can set them to Medicaid pending if we have that confirmation directly from the state,” Hudson said. “That gives them access to care where they can walk in that same day… because by the end of January, all of our clinics will have same-day access hours. They can walk in and meet a clinician.”
The Essential Plans in New York State are in addition to all of this, which are government based state plans that sometimes can come with no copay and no premium, which is similar to Medicaid. Or it may come with a $20 a month premium with a $15 copay. All of it is income-based.
“They’re two wonderful programs that I think only 15 states offer this type of plan. In New York I think we are very liberal with our insurance coverage,” Hudson said. “Somebody could be at a soup kitchen, pick up a phone and be able to have insurance right on the spot. Which is really amazing. They can actually call New York State themselves, but a lot of people feel a little intimidated with that process. So that’s what we’re here for. To help them along and do all that for them.”
Hudson said while the program is much better than it used to be, there’s still some barrier including what she believes is a technical issue on the state’s part.
“They no longer give us recertification months when the patient needs to recertify. Those used to be readily available to us and then we could be proactive and schedule them with us and recertify them before they lose their Medicaid. Now we have to wait,” Hudson said.
Recertification happens yearly. Hudson said this presents a huge issue.
“You just know you have Medicaid and I’m good to go. You know you have to recertify it sometime, but that’s way down the road—is what they’re thinking. We can no longer track that,” Hudson said.
There are also qualified health plans, which cover all the mandatory benefits of the Affordable Care Act. Hudson said some of those plans are not affordable if you pick the highest level plan.
If you are single, working full time and making over $25,000 a year you may be pushed into Qualified Health Plans.
“You can chose a low premium and may have to pay $120 a month or $60 a month or whatever it may be, but then you are going to have a high deductible on that plan,” Hudson said. “But it’s all income-based. It can get very pricey. I have seen where some of them for a family is over a $1,000 a month. And that’s for the highest level plan. So it’s not a black and white answer because there is so many different variables. I mean New York State makes that determination based on the information the patient gives us on their income, on their household size and we plug all of that into the application process and they make the determination and it’s made up on the spot.”
Outside of the reduced fee plan, some hospitals have charity care which will allow services for some medications. There’s also coupons.
“We have clinical staff, they’re called CCS’ (Clinical Care Specialists) who will search out coupons. Different prescription programs,” Hudson. “Some of them are free. To be able to at least get that cost down. These are little things that they do behind the scene that nobody really talks about, but they are able to do that for them. So we have those resources.”
Hudson said a lot of times employers do offer insurance for those full time making over $25,000, but it can be just as expensive.
“You have almost a no-win situation in that case. It’s almost what they call the ‘working poor’. You can spend all of your extra income on your medical coverage. That’s something we still need to work on. How much these insurance premiums are out there. And kind of work together. Providers, members and the insurance companies all need to work together to come up with a better plan,” Hudson said.
For Lentol, mental health care is a right for all. He said he hopes people will latch on and build on the idea.
“I hope this is an answer. It may not be the only answer, but I think it is part of the answer to deal with people who are crying out for help.”