2013 APA Gold Award: Accessible Care for New York City Residents With Serious Mental Illness and a History of Homelessness: Center for Urban Community Services Janian Medical Care, New York City

In New York City alone there are more than 50,000 homeless individuals, according to Van Yu, M.D., Janian’s chief medical officer. He estimates that about 11,000 are single adults, many of whom have severe, persistent mental illness or substance use disorders that impair their ability to seek and maintain a home. Yet, many are wary of psychiatry, and only about 20% engage in psychiatric treatment in clinics and medical centers.

Engaging this population is challenging, despite clear evidence that delivering psychiatric treatment in the field improves housing and clinical outcomes. In addition, few agencies that provide services to persons who are homeless are able to find, utilize, support, or afford a staff psychiatrist.

CUCS Janian Medical Care serves as a single point of access both for agencies that need psychiatrists and for community psychiatrists who hope to find field placements working with people who are homeless. It places well-trained, dedicated, and compassionate psychiatrists on site with partner programs to become part of the existing homeless service team. The psychiatrist lends his or her expertise in mental health to the team while collaborating to provide outreach to and engage and care for the city’s most vulnerable individuals.

Currently, Janian Medical Care partners with 21 agencies at 55 locations, including shelters, soup kitchens, parks, and anywhere where persons with chronic mental illnesses can be found. Janian also provides psychiatrists to 20 supportive housing programs and has helped over 1,600 tenants with mental illness remain psychiatrically stable and stay housed. This integrated approach provides access to high-quality psychiatric care at the point of an individual’s contact with homeless service organizations, reducing the reliance on costly and time-limited emergency and acute care. Janian’s services also include direct care, advocacy, and diagnostic documentation for housing and financial assistance.

“Because one of the primary challenges of Janian psychiatrists is to outreach to and engage people who are wary of psychiatry, the program embraces a person-centered approach to its work,” according to Jose Vito, M.D., a member of the Psychiatric Services Achievement Awards Committee. “They meet people where they are and where they are comfortable, whether it be a shelter or park, and continue with making psychiatric treatment as collaborative a process as possible,” said Dr. Vito, who made a visit in July to the Christopher, one of the CUCS supported-housing locations where Janian provides services.

CUCS is also the lead support agency for the Manhattan Street Outreach Consortium (MOC), several agencies that joined forces in 2007 to reduce homelessness on the streets of New York City. Janian Medical Care is responsible for delivering all psychiatric services to MOC clients of all four Manhattan street outreach teams and of the Bronx street outreach team. In addition, by conducting the evaluations needed to secure housing and entitlements, Janian has helped these teams house approximately 650 people over the past four years. Janian also conducts training for staff of the three agencies that make up the consortium.

Currently, CUCS Janian Medical Care has an ongoing relationship with 1,125 clients. In the past year alone, staff made 16,759 face-to-face contacts with 2,708 clients and provided a total of 2,472 evaluations. The staff includes 24 full-time, part-time, or per diem psychiatrists and four volunteer psychiatrists. Assisting Dr. Yu are two associate medical directors, one for education and training and one for clinical operations. The staff also includes a director of operations and an assistant program director.

Funding for Janian’s services has been a constant challenge. Homeless service providers generally have difficulty paying for the services of psychiatrists, and the programs most in need of psychiatric services are least able to afford them. As a result, Janian has been creative in leveraging government and foundation funding to keep the cost of psychiatric services affordable and has worked aggressively to expand the number of sites at which it can provide services. The director of operations is charged with managing the fiscal operation of the program and reporting to funders. Currently, 50% of contract sites are located in nationally designated health professional shortage areas, and government and foundation grants provide an average subsidy of 59% at each site.

In January 2012, CUCS Janian Medical Care began delivering much-needed primary care to homeless and formerly homeless individuals with a mental illness. Janian’s nurse practitioner staff provides clinical assessment and care, patient education, and referrals for primary and specialty care at CUCS transitional and permanent housing program sites. “By delivering care where medically and psychiatrically vulnerable individuals reside and receive services, Janian has created a more comprehensive and effective program model for patient well-being,” according to Dr. Yu.

The nurse practitioners work with other CUCS providers to identify individuals who frequently use emergency care for major chronic illnesses, such as asthma, diabetes, and heart disease. Janian’s goal is to intervene early to facilitate clients’ participation in primary health and specialty care and reduce the rates of avoidable emergency and acute care. It also hopes to increase the frequency with which individuals with chronic and high-risk illness attend appointments and participate in treatment. An additional benefit is reducing Medicare and Medicaid expenditures for people with significant medical problems.

The expansion allows Janian Medical Care to address a critical gap in care among persons with chronic general medical and psychiatric illnesses. Access to primary health care services in community settings, particularly in supportive housing, has been scarce until now, according to Dr. Yu, and “integration of primary and psychiatric care was virtually nonexistent.” So far, the program appears to be off to a good start—in the program’s first year of operation, 419 individuals received primary care in coordination with psychiatric care.

“Practicing psychiatry on site with homeless people is not simply a matter of transplanting a psychiatrist from a hospital, clinic, or office practice to a community or street setting,” according to Dr. Yu. The streets, drop-in centers, and other nontraditional locations where Janian provides services were not designed with psychiatric practice in mind. Not only is it necessary to reorient the psychiatrist, but it is also necessary to help programs effectively utilize a psychiatrist. Janian Medical Care works with its partners to help them integrate a psychiatrist into their teams, communicate about clinical information with a psychiatrist, and safely and accurately monitor medications.

Janian provides a unique opportunity for community psychiatrists to devote themselves to full-time work with homeless people at different social service agencies. It also provides support and training for those who wish to incorporate this kind of work into their professional practice.

“We strive to be not only a single point of access for providing services, but also a single source for ongoing training,” Dr. Yu said. Staff psychiatrists attend a weekly seminar devoted to education and professional development. To help New York City psychiatrists working with the homeless population, Janian has compiled a handbook in which staff psychiatrists share experiences unique to community psychiatry. The handbook also contains current literature about homelessness and psychiatry as well as guidance for managing the variety of situations community psychiatrists face daily.

In fact, Janian’s efforts to improve the competence and effectiveness of field psychiatrists have gained national attention. “Janian is the only program in the United States that is exclusively dedicated to recruiting, employing, and training community psychiatrists to work with homeless [persons] in community-based programs,” according to Dr. Vito. “It teaches psychiatrists how to best integrate psychiatric practices into community settings to ensure that the psychiatrist and program site coordinate to provide expert psychiatric care tailored to homeless people.”

“Our model of training community psychiatrists and then embedding them at street outreach sites, shelters, and other programs serving homeless adults can be readily implemented in other large metropolitan areas,” Dr. Yu said. Each year, Janian hosts 16 residents in clinical rotations, serves as a placement site for the Columbia University Public Psychiatry Fellowship, and participates in the community psychiatry courses of a half dozen psychiatry residency and fellowship programs. The associate medical director for education and training supervises the homeless psychiatry rotation, a program of 16 psychiatry residents rotating for three hours per week during the academic year.

In addition, Janian offers an online course to residents and fellows that provides both a broad familiarity with the social, economic, and clinical issues of community psychiatry and practical guidance about the practice of psychiatry in nontraditional settings. Janian also trains nonpsychiatrist groups, including attorneys at the Urban Justice Center and staff of the Chronic Illness Demonstration Project at Bellevue Hospital Center.

On a broader level, Janian has also been invited to train groups of unionized nurses at local hospitals and conducts case management training at Hunter College. Topics of the case-management lessons include an overview of psychiatric disorders, use of DSM, and metabolic syndrome. Each year, Janian conducts a one-day course on homelessness and psychiatry at the Institute on Psychiatric Services. Recently the Medical Society of the State of New York announced it would grant up to 34 continuing medical education credits annually for completion of Janian’s seminar and case conference series for psychiatrists.

Ongoing program evaluation is an important goal. “We want to ensure that services continue to meet patients’ needs and also to continually develop best practices for psychiatry for homeless adults,” Dr. Yu said. The program keeps close track of the number of people who are evaluated and treated at each location, and it monitors the percentage who demonstrate improvement and obtain or maintain housing. It has established a formal structure to evaluate its services, including case conferencing and quality assurance and incident management committees. The associate medical director for clinical operations monitors patient satisfaction, psychiatrist performance, and program site effectiveness and is empowered to investigate incidents if necessary. In addition, the director of operations ensures adherence to practice standards.

“When someone has a voice in his or her treatment and views the psychiatrist as a partner, that person is more likely to participate and benefit from treatment,” according to Dr. Yu. Therefore, making psychiatric treatment as collaborative as possible is an important goal. To assess its performance, each year Janian asks a sample of patients to complete a satisfaction survey that examines its effectiveness at providing person-centered care. Patients generally describe their engagement with psychiatrists as respectful and productive, and every year a small number wish to see their psychiatrist more frequently.

Nearly three decades since first offering treatment to persons struggling with homelessness, Janian Medical Care has become a beacon of hope and a source of stability for thousands of persons with mental illness. By providing comprehensive and coordinated care and support of assisted living and other housing arrangements, the program has helped to rebuild the lives of homeless and disadvantaged individuals and families.

Janian’s purpose remains to provide outreach to and engage people who have significant challenges and who resist psychiatric help. “Once we make contact,” Dr. Yu said, “we can help people move closer to their goal, whether it be exiting homelessness, regaining health and wellness, finding employment, overcoming addictions, reuniting with family, or returning to school.” Because of CUCS Janian Medical Care there is a good chance they will get there. And it all begins with meeting people literally where they are, be it a shelter cafeteria or a park bench.