A Healthy Place to Rest Your Head

The Second Chance Program at NewYork-Presbyterian Westchester Division is an in-patient psychiatric rehabilitation program for men and women with difficult to treat psychotic disorder illnesses. Most of the individuals referred to the Second Chance Program (SCP) have struggled with being able to remain in the community. In addition, they have often had numerous hospital admissions to acute units that have failed to break the cycle of repeated hospitalizations or to provide the necessary structure, safety and support needed to help these individuals increase community tenure and begin to thrive outside of the hospital setting. The goal of the SCP is to teach the adaptive skills needed to live safely in a community setting, reducing the need for hospitalization and improving the ability to thrive.

In a general inpatient behavioral health hospital setting the focus is on crisis stabilization, and the treatment teams on the acute units are more limited in their scope of interventions. They will usually discharge patients back to where they were residing prior to admission. For those with difficult to treat psychotic disorder illnesses, these may have been inadequate to provide the needed additional structure and support. A housing application is completed by the social worker and handed off to Assertive Community Treatment teams or care coordinators to follow-up on once the individual is back in the community. While a reasonable plan, our experience tells us that such a plan is fraught with numerous pitfalls for this population that make the successful transition to more supportive and stable housing unlikely. These include skills deficits such as how to manage residual symptoms, impaired problem-solving skills that can lead to impulsive decision-making and a return to maladaptive coping strategies that have failed to work in the past.

More than half of the patients referred to Second Chance Program (SCP) are either street homeless, residing in shelters or transitional living residences, or patients who would benefit from a higher level of supportive housing than they currently have. The focus of the program’s treatment is rehabilitative, with up to 90-120 days for our patients to learn and practice skills that will improve overall functioning. This sense of accomplishment and growth instills pride and a hope that they are finallyon the road to recovery with a chance to stay out of the hospital and achieve their personal goals for the future. A big part of the recovery process includes working to match a housing option that meets the needs of the individual to support the gains made while in the hospital.

While at SCP, patients and staff work together to practice community living skills including basic safe cooking skills, budgeting, shopping, medication management, and social skills. The recovery process can be a fragile one, but we find that with each passing day, week and month, our patients develop a more solid foundation in order to succeed with the life goals they are hoping to accomplish. These include developing meaningful relationships, returning to school, or thinking about working in a desired field. The support and structure provided by stable housing is a cornerstone to making this all possible. We would like to illustrate this by sharing the story of one of our former Second Chance patients, SG, and the role housing played to help him thrive in the community.

SG arrived to the Second Chance Program a reclusive yet willing participant. He was a 38 year old male referred due to his history of non-compliance with treatment and continued hospitalizations. His pattern over the past several years was walking away from his transitional living residence (TLR), resulting in missed treatment appointments and rapid decompensations. Negative symptoms, paranoid thoughts, and a quiet disposition made him a difficult person to deeply know at first. The treatment team focused energy on building a rapport, eventually leading to a more trusting relationship. He was eventually referred back to his TLR after completing the social learning program and demonstrating an improvement in his negative symptoms, attending groups, and taking medications. The treatment team felt that by addressing some core functional skills and providing community reintegration activities as part of the program, he would have an increased chance of success upon discharge. Given that he had a housing provider already in place, had demonstrated improvement in his functional skills, and was seemingly willing to return to the residence, new housing was not sought out. Immediately after his first discharge from the unit, however, he fell into old patterns and did not even spend the first night at his residence, resulting in a rapid re-hospitalization. It became clear that housing placement would be the linchpin clinical intervention to make a real difference in SG’s life.

Upon his second admission to Second Chance, SG began going on trips with staff into the community, both individually and as part of a group to help immerse him into life outside of the hospital and to assess where he struggled. He accompanied staff on housing interviews scheduled for other patients to further strengthen the working relationship and to see how he would respond to various environments. SG was most functional in small, quiet settings where he would not easily slip into the shadows. In focusing efforts primarily on finding the most suitable housing placement, the team was addressing the core clinical issue behind his poor community tenure.

Because securing the most appropriate housing placement was the goal, additional factors related to placement were also addressed. A trip to the Social Security Administration resulted in him being awarded a large sum of money in back disability checks as he had not received his Social Security benefits in quite some time due to his elopement history. Finally, the treatment team helped him obtain a Social Security card, copy of his birth certificate, a state identification card and a bank account where his benefits could be directly deposited so he would not be out of funds in the future.

At this point in his treatment, his symptoms had remitted and functioning had improved enough to secure an appropriate housing placement through a specific Community Residence/Single Room Occupancy (CR/SRO) program, Concern for Independent Living. This agency could meet his needs in that it provided a feeling of safety – his own studio apartment that was much quieter than the TLR he had previously stayed in. A final personalization of care came on the day of his discharge when staff helped SG select a new wardrobe, electronics and furnishings for his new home. SG settled in well and has been living at the CR/SRO since. He has been adherent to his medication regimen and has consistently attended treatment. He has not had one hospitalization since his discharge from the Second Chance Program over two years ago.

As evidenced by SG’s case, the benefits of suitable housing to the patient’s assessed needs and strengths are vast. Implementing a housing plan such as his, however, presents challenges on several levels, including the heterogeneity of the patients at the residence, the expectations of providers, and the larger systems involved.

Due to the complexity of mental illnesses, each person being placed in the supportive housing network has an individual set of symptoms and clinical needs. Often a patient’s disorganization, lack of insight into their illness, struggle to accept their need for medications or delusional content can impact his or her ability to interview for housing. Patients may walk into an interview convinced they do not have a psychiatric diagnosis and have no need for psychotropic medication. Learning how to assist patients in accepting help without fully challenging their world view is a method that allows patients to partner with their clinical team. Focusing on functioning – instead of symptoms and stigmatizing labels – brings a level of compassion to this task that is ultimately in the patient’s best interest. In SG’s case, his poor ability to appropriately communicate his reasons for leaving residences was a large factor in his repeated hospitalizations. Encouraging patients such as SG to engage in the process helps clinicians understand how to meet their patients’ needs by finding appropriate placement. Working with an individual’s clinical picture is one of several factors imperative to the process.

Housing providers themselves add a level of difficulty in this endeavor. They expect patients to be able to speak to their illness, diagnosis, and sometimes checkered histories. In addition, they will also ask for patient to have various forms of identification, which patients might not have readily available. They understandably want to know who they are taking responsibility for and where they came from. SG would barely speak when he first arrived to the Second Chance Program, let alone have a full discussion about his illness, symptoms and history of elopements from residences. For this reason, preparing housing providers for the interviews is as important as preparing the patients. When sending housing applications, calling ahead of scheduled interviews to discuss an individual’s clinical picture, bolstering the paperwork by contextualizing a patient’s history and highlighting the reasons specific placements have been selected can prepare providers for an otherwise unproductive interview. Finding appropriate matches for housing and allowing for transitional visits can also prove effective in increasing the comfort level of both providers and patients. SG’s move-in day is a prime example of such work. Helping him furnish his room turned his housing placement into a home. All of this takes a significant amount of care, coordination, and understanding of both the patients and providers. It also requires clinicians to bear in mind that the housing providers do not work in a vacuum. There are larger systems at play, which also must be navigated carefully.

Anyone working to house patients in the New York metropolitan area is governed by larger agencies at the city, county and state levels. These bodies are designed to ensure fair treatment of patients but also add a layer of effort required to appropriate place patients. Before a patient can move in to one of the scarce available beds, SSI benefits must be in place and Medicaid needs to be active (or at least pending). Agencies such as the New York City Human Resources Administration or Westchester County’s Department of Community and Mental Health will prioritize some patients over others based on histories of documented homelessness or clinical need. The shortage of available beds at various levels of care further speaks to the insufficient resources for this most vital of services. In working with SG, it became clear he was one of the many who had fallen through the cracks in the system. Hospitals were forced to discharge him before understanding the motivating forces behind his repeated hospitalizations. The Social Security office had not known of his whereabouts for years. Without being able to look at the full picture, SG would have been doomed to continue his cycle of institutionalization. As SG’s case highlights, a clinician’s thorough understanding of the systems within which they interact is paramount to best advocate for the patient’s needs.

Social workers placing patients in the supportive housing system find themselves at the junction of several impediments to housing placement. It is no easy task, however, when the right fit is found, the results can be life changing.

Andrew Bloch, LCSW, is Program Coordinator; Marcie Katz, LCSW, is Social Work Advanced Clinician; and Fabricio Loza, is Social Work Resource Liaison, in the Second Chance Program at NewYork-Presbyterian Westchester Division in White Plains, New York. For more information on NewYork-Presbyterian’s Second Chance Program, please contact Andrew Bloch, MSW, LCSW-R, at (914) 997-5738.

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