This winter has seen a renewed focus on severe mental illness and discussion of how New York can best address the health and safety of these residents. As an emergency room psychiatrist, I began my career on the front line of addressing mental health crises in NYC and saw firsthand the limitations that short-term interventions have on bringing long-term health and stability to residents living with these health concerns.

In a city where an estimated 1 in 25 residents have a severe mental illness, involuntary commitment and a revolving door of emergency department visits have become a permanent stopgap for those with acute needs yet do little to alleviate the root of these residents’ troubles.

Our system for addressing severe mental illnesses desperately needs foundational support to meet the basic needs of all people, integrate and screen for mental health, and increase capacity to care for those in need of mental health services. A solution to New York’s mental health crisis won’t happen overnight — instead, we need to concentrate on proven, long-term, and multi-tiered solutions.

A population health focused approach addresses the needs of individuals with more complex mental health care needs by encompassing community-based organizations, health care systems, primary care providers, mental health specialists, community-based care management, peers, and supportive housing. It allows highly specialized mental health resources to focus on treating individuals with complex issues and coordinates with primary care providers, all while addressing social needs. It tasks the primary care system and community-based organizations with providing critical foundational mental health support for the broader population.

More than a decade ago, with state and federal support, we began to develop a model that comprehensively addresses these complex needs through coordinated care management. Over the years, we have also incorporated Critical Time Intervention, an intensive and time-limited form of care management that has become a cornerstone of addressing homelessness and severe mental illness. These severe cases receive intensive care management over a 9-month period, after which we can typically connect the patient to other community supports.

Within emergency departments and acute care units, the deployment of mental health and substance use peers have successfully engaged patients with clinical services, connecting them to treatment options in their communities and after discharge and reducing readmission and high utilization of acute care services. Community Care of Brooklyn has integrated peers from two community agencies — Baltic Street and Bridge Back to Life — in hospitals across Brooklyn since 2017, and surveys of emergency departments and providers show the positive impact peers have had on morale and reducing utilization.

Early support and screenings past a certain age are a crucial element to addressing the public mental health crisis. Programs like an Urgent Evaluation Service offer a less traumatic evaluation setting for children who experience mental health crises by sending social workers into schools to train teachers and assistant principals to better handle mental health issues. Since 2015, such programs have been implemented in 100 middle and high schools across NYC.

The collaborative care model offers mental health treatment in primary care via a social worker and backup consulting psychiatrist. This approach treats mild to moderate mental health conditions and has been shown through numerous randomized controlled trials to be superior to the traditional practice of referring every patient with mental health concerns to a mental health specialist. In addition, implementation of this model has yielded higher patient satisfaction and reduced costly emergency room visits and admissions.

In the community at large, we have built a network of community-based organizations addressing social needs like supportive housing, food accessibility, care management, and engaged them with health care providers. For example, we have partnered with the Arab American Family Support Center in Brooklyn, working on reducing stigma around mental health in the broader Arab, Middle Eastern, Muslim, and South Asian (AMEMSA) communities in NYC. The office of the mayor and city Health Department have been instrumental in funding these community-based organizations’ efforts.

Taken together, these programs offer a roadmap for how to combat severe mental illness by creating a comprehensive network of services and organizations working in tandem to support individuals’ social and health care needs. I have seen great success from such initiatives and continued proper funding would allow such efforts to expand throughout the city. Jobs would be created through the hiring and training of additional peers and care managers, and a focus on reducing preventable acute care readmissions would relieve overburdened emergency departments.

I’m hopeful that we can improve mental health outcomes by expanding foundational support and population-centered care initiatives.

Malavade is vice chair of the Maimonides Department of Population Health and chief medical officer of Community Care of Brooklyn.

Kishor Malavade

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