Can New York’s Plan for Mentally Ill Homeless People Make a Difference?

People with severe, untreated mental illness on the streets and subways have been a heartbreaking feature of life in New York City for decades. But last month, Mayor Eric Adams announced an end to the days of ignoring the problem, and to the revolving doors between hospitals, jails and the street.

To help New Yorkers who are a danger to themselves get the help they need, Mr. Adams said, they will be taken to hospitals, even if they don’t want to go. He has said he wants hospitals to hold people until a workable plan is in place for their care on the outside.

In short, he wants the system to work the way it is supposed to but never has. It seems like an enormous task, and similar efforts by previous mayors have largely foundered.

But Mitchell Katz, the director of the city’s public hospitals, says it is doable. In an interview this month, he said there were perhaps 1,000 people, out of the tens of thousands of homeless people in New York, who needed such a drastic intervention. “One thousand people is not an insurmountable number,” he said.

Since taking office in January, Mr. Adams has moved aggressively to take down street encampments and convince homeless people to go to shelters, and the news site Gotham Gazette reported this week that so far this year, the police had already removed 1,300 people suffering from mental illness from the transit system and had them transported to hospitals, often involuntarily. Mayor Adams and Gov. Kathy Hochul have also flooded the transit system with police officers in recent weeks — something they have done several times already this year.

But as of Sept. 30, the number of people in a city database of those living unsheltered who had contact with outreach workers was 10 percent higher than it was a year before — 2,163 people, up from 1,974. And while the vast majority of people with serious mental illness are not violent, Mr. Adams has said that an increase is “being driven by people with mental health issues.”

What is new about New York’s plan?

The laws about involuntary hospitalization have not changed. Mental health workers, paramedics and the police have long been able to forcibly take people to the hospital if they appear mentally ill and are endangering themselves or others, and New York courts have held since the 1980s that being a danger to oneself includes not being able to take care of basic needs such as food, shelter and health care.

What the mayor has mandated is a shift in practice, training and discretion. City officials said that workers would be instructed on state guidelines that say people can be taken to hospitals “even when there is no recent dangerous act.”

The plan is being phased in gradually — training for the police on how to deal with mentally ill people under the new policy is beginning this week. To help the police determine whether someone should be involuntarily taken to the hospital, officers will be able to call a hotline staffed by mental health professionals, the mayor said.

The mayor is also pushing for much heavier use of Kendra’s Law, which lets courts order people into outpatient treatment if they have histories of hospitalization, violence and noncompliance with treatment plans. The law does not permit forcible medication, but people who go off their meds and relapse can be ordered to appear for a status hearing or brought to a hospital for evaluation.

A 2010 study based on data from the first eight years of the law’s existence found that people under Kendra’s Law orders were nearly 25 percent less likely to be hospitalized, spent 20 percent fewer days in the hospital and were 47 percent more likely to be receiving medications in the first six months after getting an order, compared to the period before.

How does the system work now?

Homeless people in the throes of a psychotic episode are often taken by ambulance to psychiatric emergency rooms, where they can be held for observation. If deemed a danger to themselves or others, they can be admitted for a short-term involuntary hospitalization — often lasting up to 15 days.

But there is a shortage of inpatient psychiatric beds in New York City, meaning that many languish in psychiatric emergency rooms for longer. Some inpatient psychiatric wards take few Medicaid patients, which can make it harder to find beds for homeless people.

For patients ultimately admitted to a psychiatric ward, the median stay in New York City is only about 11 days. Among the homeless, most psychiatric hospitalizations are for schizophrenia and schizoaffective disorder, doctors say.

The search for the right antipsychotic medication for a particular patient can involve some trial and error. There are more than a dozen such medications available, but a single hospitalization of 15 days or less might only afford enough time to try one. Patients who show improvement are discharged back home — or to the streets.

Without more supportive housing, many doctors and social workers say that for many homeless patients, the cycle of hospitalizations will continue.

How do city workers identify who to take to hospitals?

For police officers, training on assessing whether someone needs to go to a hospital has largely focused on situations where someone is threatening to hurt themselves or others.

A training manual on how to deal with what the police call “emotionally disturbed persons,” or E.D.P.s., that was in use in the 2010s included such questions as “Who or what is the E.D.P. angry at, afraid of, or stressed about?” and “How long has the E.D.P. been acting irrationally?”

For mental health workers, there are extensive guidelines. They involve engaging with the person in order to ascertain over a dozen indicators of psychological health, from affect and thought process to expressions of suicidal or homicidal ideation.

Those guidelines may remain largely the same. However an employee of the Bowery Residents’ Committee, which does outreach in the transit system, said last week that its workers were instructed by their supervisors to lower the threshold for having the clinicians who accompany them on subway platforms assess people for possible hospitalization. (The Bowery employee was not authorized to speak to reporters and requested anonymity.)

The old standard required that the person be so mentally ill that they could not care for themselves and also physically sick or injured; the new standard no longer requires physical injury or illness.

How have police handled mentally ill homeless people?

The policies have varied over time.

Consider the Homeless Outreach Unit, which began as a transit police squad in 1982. Its overarching goal was to get homeless people out of the subway system and into shelters and social service programs, though often the officers succeeded mainly in expelling homeless people from subway tunnels and forcing them above ground, and into parks.

By 2010, the unit’s stated mission was sometimes eclipsed by a different imperative: arresting homeless people for petty violations, like being in a park at night or putting their feet up on a subway seat, according to interviews and court records. Some years the unit arrested more than 2,000 people, before a shift in policy under the previous mayor.

Police officers themselves often feel they are ill-suited to help fill the cracks in the system for delivering psychiatric care.

Will the plan work?

Experts say that bringing homeless people in a mental health crisis to a hospital will undoubtedly help some of them receive desperately needed treatment. But they warn that bringing more people to emergency rooms will lead mainly to the same people cycling more often through a system that isn’t working for them.

Though there is a shortage of inpatient psychiatric beds, the far bigger systemic problem, experts say, is that there are inadequate services and support for patients following their discharge from a hospital. A system that returns homeless psychiatric patients to the street or shelter system — as often happens now — is unlikely to result in lasting care.

In recent years, the city has expanded the number of teams of psychiatrists, nurses and social workers who visit people with serious mental illness and a history of hospitalizations, many of whom are homeless.

Mr. Adams has said that for his plan to work, the city will not only need more hospital beds, supportive housing apartments and outpatient treatment options; it will also need Albany to deliver some changes.

These include, according to a “legislative agenda” recently released by the city:

• Requiring hospitals to consider a patient’s history and likelihood to stick with outpatient treatment in making admission and discharge decisions, and to take steps to ensure “coordinated handoffs between inpatient and outpatient providers” before discharging someone.

• Requiring hospitals to screen all psychiatric patients for eligibility for a Kendra’s Law order before discharge.

• Making it easier to force former Kendra’s Law patients back into mandated outpatient treatment if their conditions decline.

Mr. Adams has pushed back against critics who have warned that the city’s policy could result in mass, indiscriminate roundups. If someone is walking around without shoes, or without a jacket in cold weather, “that is not grounds to place you in a hospital,” he said last week. “That’s grounds for us to talk to you and see if you need shoes, if you need shelter.”