New Yorkers Involved with the Criminal Justice System Get Needed Mental Health Care

Having spent the majority of her adolescence on the streets and involved in the criminal justice system, Teisha battled depression and a growing sense of hopelessness at the age of 18.

In an effort to establish some stability and support in her life, she rushed into a marriage with a man she met at a homeless shelter. The relationship soon turned abusive, however—forcing Teisha back onto the streets and into renewed encounters with the justice system. After one particular arrest, Teisha was mandated to the Center for Alternative Sentencing and Employment Services (CASES), an innovative alternative sentencing program in New York City.

Although vivacious and remarkably resilient, Teisha struggled with undiagnosed mental illness. CASES staff identified symptoms in Teisha and referred her to the Nathaniel Clinic for treatment. The first of its kind in New York State, the Nathaniel Clinic is uniquely designed to serve youth and adults who have mental illness and are involved with the criminal justice system. Operated by CASES, this State-licensed clinic, located in Central Harlem, began offering services in September 2014 with support from an NYHealth grant.

Prior to visiting the Nathaniel Clinic, Teisha had never received any mental health treatment. Once at the clinic, she underwent a comprehensive clinical screening and began attending regular therapy sessions to help work through the feelings of hopelessness and anxiety she had developed through years of uncertain, transient living. The Nathaniel Clinic staff also helped Teisha pursue one of her long-time dreams: going to college. A year later, Teisha—now age 20—is a student at the Borough of Manhattan Community College, where she is working toward an associate degree in science.

The Nathaniel Clinic provides services—typically unavailable at traditional clinics—that specifically address the risks faced by and needs of people involved with the criminal justice system. The clinic developed a treatment model that integrates mental health, substance use, and physical health treatment with criminal justice-related coordination and rehabilitation services to improve health outcomes and reduce recidivism. It accepts clients ages 13 years old and up from all five New York City boroughs and provides a range of services, including individual and group counseling/therapy; psychiatric evaluations; medication management; health physicals and monitoring; integrated treatment for substance use; and crisis intervention.

Despite experiencing significantly higher rates of medical, behavioral health, and substance use problems than the general population, most people involved with the criminal justice system have had extremely limited access to effective mental health treatment in the community. For many years, New York City and State officials have grappled with how to address the intersection between mental illness and criminal justice involvement.

While CASES’ primary focus is on alternatives to incarceration, it is ramping up efforts to provide its participants with greater access to evidence-based behavioral health services—a measure strongly endorsed by policymakers in both the health care and criminal justice fields.

“We have seen such a great need for mental health services every day since opening the clinic,” says Ann-Marie Louison, director of adult behavioral health programs, CASES. “The youth and adults we are treating have experienced many difficulties and present with complex histories. Many have been long disconnected from school or work and reside in neighborhoods disproportionately impacted by poverty and violence. Many also have difficult family backgrounds, struggle with substance use, and have significant past experiences of trauma—including the trauma that comes with being incarcerated,” says Ms. Louison. “Our approach to treatment not only helps clients recover, but also allows them to learn different responses when faced with challenges so as to help them avoid new crimes and other poor outcomes.”

Since opening its doors, Nathaniel Clinic has seen a growing demand for services—in its first six months of operation, the clinic has served more than 160 clients, including more than 50 young people ages 13–24. As it reaches capacity, the clinic expects to serve 400 clients annually, offering a much-needed resource for Teisha and others as they work to regain their emotional and physical health and reconnect with the community.

Children Struggling with Mental Illness Get Help at the Pediatrician’s Office

More than 200,000 children in New York State live with serious mental health conditions; untreated or undertreated mental illness can have a devastating impact on children and their families, leading to school failure, encounters with the criminal justice system, and suicide. To better meet the needs of children and adolescents struggling with mental health issues, an innovative program on Long Island is integrating mental health services into primary care settings for youth.

With support from an NYHealth grant, South Oaks Hospital has embedded mental health therapists on-site at pediatrician offices—allowing for a convenient, trusted setting for children and their families to get mental health treatment in a timely manner.

Transportation difficulties, a lack of capacity to provide pediatric mental health services, and long waiting lists for clinicians who do treat children with mental health issues have limited the ability of children to seek and receive treatment for their mental health conditions on Long Island. To ease this burden, South Oaks Hospital has worked to house mental health clinicians at two pediatrician offices in Levittown and East Hampton, which are now treating a combined total of more than 100 children with mental health issues.

“Families become more engaged because there’s less stigma in going to the pediatrician,” says Susan Jayson, program director of comprehensive outpatient behavioral services, South Oaks Hospital. “It’s a known, comfortable environment for families and kids.”

Under the model, pediatricians identify children in need of mental health services through intake questionnaires and surveys or through speaking with the child or parents to find out if there are any mental health issues. If there is a concern or need, the pediatrician can refer them to the on-site mental health clinician, often times by taking the child and the family down the hall directly to meet the therapist. This on-site integration of services makes it easier and more likely for families to follow through with mental health appointments, allowing for early intervention and effective treatment for the child that in turn can minimize the effects of mental health issues.

“Our 13-year-old daughter has been struggling for years; in one visit she mentioned to her doctor that she was feeling anxious, and we were immediately introduced to someone who could help us,” says the parent of a patient at the Levittown office. “Now, we visit the office weekly for her to speak with the therapist there and monthly to get her medication. It is so nice to be able to go to the one place we trust the most to get all of our needs met. Today, our daughter is beginning a new school year and is finally off and running.”

This integrated approach to care is helping set the precedent for addressing behavioral health issues in primary care settings for children and ensuring that each child’s physical and mental health needs are appropriately met.

“The pediatricians are on board with this and anecdotally we’re hearing from them about a decrease in visits related to stomachaches, headaches, and other psychosomatic symptoms from patients who are now receiving mental health care,” says Ms. Jayson.

House Calls Help Homebound Patients Reconnect with Primary Care

Dr. Kevin Dooley uses a silver 2006 Volkswagen Jetta as his office.

It’s not that Dooley, a family physician for more than 15 years, can’t find the office space in the Albany region—rather, his vehicle is what gets him to the homes of the 15–20 patients he sees each week through the Home Visiting Physicians program administered by St. Peter’s Health Partners Medical Associates (SPHPMA) and its affiliate, the Eddy Visiting Nurse Association (EVNA).

The program, funded in part by NYHealth, sends health care providers on medical house calls to visit homebound, chronically ill patients who can’t get to a physician’s office for primary care services. Without regular care, many of these patients end up cycling in and out of emergency rooms or are frequently admitted to hospitals—a costly and inefficient use of the health care system.

In contrast, the Home Visiting Physicians program—serving Albany, Rensselaer, and Saratoga counties—reconnects patients with a primary care provider to receive at-home care and services, which in turn improves their quality of life, reduces unnecessary hospital visits and readmissions, and lowers health care costs.

“This model provides a beautiful bridge for people who can’t get to an office or just don’t know how to use the health care system efficiently and they end up in the emergency room instead,” said Dr. Dooley, who is part of a small team of doctors and nurse practitioners that has treated nearly 300 patients since the program began operating in November 2013. “What we’re doing every day is a huge solution to this problem.”

Participating patients—many of whom are elderly—are homebound and struggle with a host of chronic conditions that keep them from easily accessing outside primary care, including Alzheimer’s or dementia; Parkinson’s disease; multiple strokes; diabetes; respiratory illnesses, such as COPD and pneumonia; spinal injuries; and cardiac issues, such as congestive heart failure.

Dr. Dooley recalled visiting Anne*, a patient with an autoimmune disease who had not been feeling well. Lab work revealed very high blood sugar levels, which would have required Anne’s hospitalization if left unchecked. Instead, Dr. Dooley put together an action plan with Anne’s pharmacist and visiting nurse to give her insulin. Anne stabilized and remained at home, thus avoiding a trip to the hospital.

Another patient, Tara*, had been struggling with a serious lung disease for some time. Prior to being accepted into the Home Visiting Physicians program, she had been to the emergency room six times in six months for her condition. After Tara came under his care, Dr. Dooley discovered through a home visit that she did not have a nebulizer and arranged for one to be brought into the home. In the ensuing seven months, Tara’s hospital trips dropped off dramatically, with no returns at all during that time period. She has since become more emotionally calm in addition to feeling physically better.

The house call team provides a full range of primary care services to homebound patients from the routine, such as checking blood pressure and other vitals and refilling medications, to the more complex, such as administering ultrasounds, EKGs, and X-rays using a mobile imaging unit. The house call team can bring much of the equipment and instruments typically found at a primary care office or hospital directly into the home, according to Dr. Christopher Domarew, one of the program’s physicians.

Through regular home visits and proper primary care, providers can keep health problems from spiraling out of control and prevent unnecessary hospital visits and readmissions—major drivers of health care costs. (The average cost of a U.S. hospital stay in 2010 was $9,700, according to the Agency for Healthcare Research and Quality.) Eight months after its launch, the Home Visiting Physicians program has led to 84 averted emergency room visits and hospitalizations. If a patient does go to the hospital, the house call provider immediately works with the hospital to develop a care plan to get the patient back home as quickly as possible.

“This is serving the need of a population that has fallen to the wayside, but that also utilizes a major part of the health care system,” said Dr. Domarew. “We’ve made a major reduction in hospital readmissions, and if we can avoid even just one admission, that’s a huge impact.”

Home visits also allow the house call team to evaluate the safety of the home or observe any hazardous circumstances that can have a negative effect on patients’ health, such as pest infestations, pets, mold, or unused prescriptions—all issues that would otherwise go unnoticed but can now be rectified, according to Dr. Domarew.

SPHPMA and EVNA are putting in place expansion plans for program and also intend to share the model with other upstate health systems.

“We have so many sick, disabled, disadvantaged people; this has to be the new model of care to deal with this and it’s part of the solution to address the disconnect between primary care providers and the hospitals,” said Dr. Dooley.

*Name changed to protect patient’s privacy


What Makes the Model Work

Strong communication and collaboration among the house call team and area hospitals, visiting nurses, physical therapists, and other health care professionals involved with the patients are key to the model’s success. The house call team regularly checks in with their patients’ other health care providers to streamline care and learn more about how a patient is eating, sleeping, and taking medications, and other health indicators. The program also helps to alleviate some of the stress of family members and caregivers struggling to care for loved ones.

Bronx Teens Lose Weight and Gain Self-Esteem from Community Program

Michael outwardly laughed off or ignored the teasing and bullying he endured at his Bronx high school for being overweight, but the psychological effects were damaging.

A nutrition and fitness program to improve the health and self-esteem of overweight/obese youth in the Bronx has given new hope to Michael and other high school students and their families.

In November 2006, NYHealth funded the Mosholu Montefiore Community Center, in partnership with The Children’s Hospital at Montefiore, to support the B’N Fit program, which addresses the epidemic of obesity among New York high school students.

The New York City Department of Health and Mental Hygiene reports that almost one in three high school students in New York City is obese. Obese children are prone to serious health risks, including high blood pressure and cholesterol; adult onset diabetes; obstructive sleep apnea; worsening of asthma; and obesity-related kidney, liver, and bone disease.

This video takes an in-depth look at the B’N Fit program and its impact on Kevin and other overweight/obese adolescents and their families.

Families with Asthma Learn How to Make Homes Healthier

Cecilia’s grandson Javier suffered from asthma and had symptoms every night until the family got help from the NYHealth-supported Healthy Homes initiative of Make the Road New York. This program engaged community health workers to conduct home visits to help nearly 200 residents of Bushwick—which has one of the highest asthma rates in the nation—address the asthma triggers in their home, including dust, rodents, mold, mites, and lead. The program also provided legal services and advocacy; connected participants to health care coverage and services; and conducted community education and outreach. Make the Road staff helped Cecilia persuade her landlord to fix the mold and a bathroom leak in the family’s apartment. These changes resulted in a significant decrease in Javier’s asthma symptoms—he experienced symptoms only monthly, rather than daily—and improvements in his overall health.

This video takes an in-depth look at the project and the families it has helped.

caret-down