Thank you for the opportunity to submit testimony on behalf of the 5BORO Institute — a think tank dedicated to advancing innovative and implementable solutions to tackle NYC’s most challenging problems.
We write to express support for Int 1022-2023, sponsored by Councilmember Kevin Riley, to create a pilot program that would establish community centers or “Clubhouses” for individuals with severe mental illness in high-need areas of New York City.
Background
New York City is experiencing a mental health crisis worsening before our eyes. Several high-profile tragedies involving people experiencing psychiatric distress in public spaces — including Simon Martial pushing a woman in front of a train and the recent death of Jordan Neely at the hands of another straphanger — have led to a new sense of urgency for the City to develop a productive path forward.
These horrific deaths share a common denominator: the individual experiencing severe mental illness interacted multiple times with our city’s mental health system before the incident occurred. It is critical we stop the revolving doors of our mental health system and go further to aid people in need. Clubhouses cannot solve this alone, but they provide core features that aid in mental health stabilization and recovery, including job and educational opportunities and a sense of community that can help a person to eventually function successfully on their own and hopefully avoid hospitalization altogether.
We are fully in support of this bill, but also believe more needs to be done to deepen connections between community-based providers and medical providers to create stronger accountability for the care of individuals who cycle in and out of the mental health system. Without adequate referrals and oversight, many people who receive limited emergency treatment during a crisis are forced to return to shelters or the streets where symptoms are further exacerbated. This pilot is an opportunity to formalize Clubhouses as a tool to bridge the gap between desperately needed social services and more traditional medical treatment.
Clubhouses: Purpose and intention
Clubhouses are recovery centers for people with serious mental illness that help provide the building blocks to successfully reintegrate into society after mental illness has disrupted their ability to function. Clubhouses emphasize and acknowledge the role that social context plays in serious mental illness — termed the “social determinants of health.” These are defined by the World Health Organization as: “the conditions in which people are born, grow, live, work and age that affect health and the rates of illnesses within populations…” Literature has recognized that a lack of socioeconomic opportunities, inability to afford basic needs like housing, food and transportation, and a sense of isolation contribute to poor health outcomes, especially behavioral outcomes. Clubhouses provide skills training and a sense of belonging to aid in long-term success.
There is an amount of stigma for people living with serious mental illness about their dangerousness to the “general public,” and Clubhouses actively work to combat that. Clubhouses work to disrupt that stigma and present a sense of “people, place, purpose” to the lives of members. In contrast to traditional day program models, Clubhouse participants are called “members” (as opposed to “patients” or “clients”), and restorative activities focus on their strengths and abilities, not their illness. The organizing principle of the Clubhouse model lies in its creation of an intentional peer community where members are invited to cooperate or participate in the decision-making of every Clubhouse operation, supported by Clubhouse professional staff known as social practitioners. Membership in a Clubhouse is open to anyone with a serious mental illness, is voluntary, free, and never expires.
Clubhouses: Resolving the failure of multiple systems
Many people with serious mental health challenges have been failed by a series of intersecting issues and a lack of adequate programming. The unique Clubhouse model can help mitigate some of the consequences.
Erik Blutinger, MD, MSc, FACEP is an emergency physician and public health specialist who oversees a Community Paramedicine program in the greater New York City area and serves as a board member of the 5BORO Institute.
“This particular pilot program really drives at the heart of why many people suffer with mental illness — they have nowhere to go for medical care nor support,” Dr. Blutinger said. “Many have no social support available and cannot easily seek medical care due to a lack of outpatient psychiatrists and challenging social determinants. There’s a significant boarding issue in emergency departments, too, with many patients waiting for days. There are very few inpatient psychiatric beds available, so these people are unfortunately being squeezed on both ends despite having complex medical problems that really need assistance across multiple disciplines.”
Clubhouses are able to offer necessary support, improve self-sufficiency, help boost socioeconomic circumstances and provide more access to traditional medical treatments. These are crucial benefits that are necessary to improve the behavioral health landscape.
Strengthening social support
Studies have shown the impact that social support has on improving mental health. Social networks can aid in offering needed advice and a sense of empathy and understanding for one’s situation, especially when provided amongst peers. Social integration — the participation in social relationships — provides a sense of belonging and can protect against maladaptive behaviors. Community has recently been recognized as a major dimension of recovery, which Clubhouses are able to provide. Individuals are able to socially rehabilitate amongst people with shared experiences.
Improving social determinants
Key social determinants that can compound mental illness are the inability to pay for one’s most basic needs and to find meaningful employment and educational opportunities. While the proposed wrap-around services in Councilmember Riley’s pilot are not delineated, Clubhouses across the City vary in size and scope of services offered.
Fountain House, established in 1948, was the originator of this model of psychosocial rehabilitation and provides the founding principles of Clubhouses that exist all over the city and U.S. Fountain House offers a variety of services and supports in continuing education, housing, and benefits support, amongst other activities. Some proof points from Fountain House include the following: members avoid re-hospitalizations at higher rates, resulting in cost savings of over 20% to Medicaid (versus highest-risk serious mental illness population), nearly 40% of members come in with a recent history of homelessness and within a year of membership over 95% are stably housed, and 30% of members are employed (versus 15% of the general population with serious mental illness).
Making traditional medical treatment more accessible
There are about 100,000 adults in the city with severe mental illness that is untreated. The reasons were probed by a RAND study with support from the NYC Mayor’s Office. Patients described having difficulty finding services, navigating systems to access services and connecting with a trusted provider. Within a Clubhouse people can find a warm environment through which to seek referrals to clinical medical interventions.
Yet, many people experiencing severe mental health challenges may not be aware of existing services they can access, including Clubhouses that already exist in New York City. This gap is highlighted in the City Council Mental Health Roadmap and the importance of public outreach and education campaigns is the focus of a recent bill introduced by City Councilmember Erik Bottcher (Int 1006-2023). The Clubhouse is an excellent entrypoint for behavioral health services, but only if a person is aware of the Clubhouse.
Complex Medical Treatment
As Dr. Blutinger describes above, people are squeezed on both ends of the mental health system because in addition to the issues in the social context, there are a multitude of problems with traditional psychiatric care in emergency settings. If psychiatric beds are not available then people cannot get access to emergency acute treatment, meaning it is very difficult to then transition them to a place like a Clubhouse. On average, psychiatric patients wait over five hours in New York for treatment at emergency rooms.
When an emergency treatment experience is negative that can deter a person suffering from mental illness from seeking further treatment, which continues a cycle of mental illness. We believe additional efforts are needed to resolve these critical issues with acute medical care as we know emergency treatment is key to helping solve our mental health crisis.
Urgency of addressing the crisis and standing up more Clubhouses
The lack of an appropriate safety net on the front-end and the inadequacy of our medical system in treating psychiatric crises at the back-end has reached a crisis. In fact, polling has found 90% of Americans believe we are in a mental health crisis. The situation demands a call-to-action from the community including medical providers, mental health outreach workers, and other individuals who may fall outside of the “mental health” field, but play a big role in the success of mental health.
In many ways Clubhouses act as a sort of small-scale safety net and allow people to grow their skill sets and social capital. We are not alone in our strong support of them. Bi-partisan polling has demonstrated strong public favor for this model, and over 70% of people in the U.S. believe that this country is spending too little on mental health services and wellness.
Recommendation: Use Clubhouses to help break down silos
Too many people fall through the cracks in the mental health system. The City needs to reduce siloes so that at the end of an emergency mental health episode, psychiatric treatment providers are able to properly refer individuals to community-based programs to encourage long-term recovery. The City also needs an entity or group of individuals to oversee the high-risk individuals who are undergoing repeated treatment and failing to improve.
An individual may be treated during an acute mental health crisis through a number of programs like the emergency room, a crisis respite center or through Community Paramedicine. In Community Paramedicine, a paramedic is dispatched to the person’s home where they receive urgent evaluation and treatment, connecting with a virtual physician by way of telemedicine. According to Dr. Blutinger, the challenge comes when it is time to provide a “warm handoff” for the patient.
“Once that medic leaves it is hard to provide additional support without fully understanding the patient’s local geographical context. Examples include understanding their ability to find a job, friends, and/or educational opportunities.”
We need emergency room practitioners to be aware of exactly where to send a patient so that they are not returning to circumstances that may have contributed to their original psychiatric crisis, such as a homeless shelter. This is no small task. At minimum, it requires establishing appropriate assessments, determining who administers these assessments, cataloging the available community-based resource centers and ensuring the right “warm handoff” successfully occurs.
Fountain House, for example, helps members connect to housing and operates some housing units of their own (staff estimates roughly 350-400 units). But not all Clubhouses provide this service, and it can vary from Clubhouse to Clubhouse. If housing is not provided, Clubhouses should have their own network of referrals.
To a certain extent, the City Council’s Mental Health Roadmap recognizes the need to break down silos amongst healthcare and social service systems. For example, City Councilmember Linda Lee proposed legislation (Int 1019-2023) to create a comprehensive dataset of outpatient facilities that are behavioral health providers to make it easier for referrals.
However, we need to actualize systems across both public and private hospitals to create whole-person treatment based on the unique needs of the patient. Every patient admitted to the emergency room or for short-term care under psychiatric distress should be able to be sent to a program or institution that addresses the underlying cause of their episode so that they are not cycling in and out of medical care.
Further, we need to establish ways or entities to monitor these individuals to help ensure they are on a continued road to recovery over the long-term. Expanding the Clubhouse model is an ideal way to start because the program bridges the critical intersection between the disease and the social determinants that drive severe mental illness. Clubhouses can help coordinate the separate entities an individual might have to navigate to access medical support and social services. We truly need a unified system where people such as Simon Martial and Jordan Neely are not receiving piecemeal care and falling through the cracks.