Despite advances in psychopharmacology, many individuals with schizophrenia remain too impaired to be discharged from the state hospitals. One response to this problem in New York State was the establishment of a unique partnership among a private hospital, the New York Presbyterian Hospital-Payne Whitney Westchester (NYPH-PWW), the New York State Office of Mental Health (OMH), and four community residence providers in New York City. The goal of this partnership was to develop an alternative treatment model for those “untreatable” patients who had been in state hospitals for more than three years, or who had otherwise been unable to establish any substantial tenure in the community.
Such patients would be placed in what was called the “Second Chance Program,” a specialized 30-bed inpatient unit at NYPH-PWW. The program was initially conceived and developed by Rami Kaminski, MD who was the Director of the Family Liaison Bureau at OMH, Ken Terkelsen, MD who was the director of the day treatment program at the time at NYPH-PWW, and Michael Friedman, LMSW who was doing program development at NYPH-PWW. The program opened its doors in the winter of 1998.
Patients are identified by the staff at the state hospitals as potential candidates for Second Chance. All prospective patients are then interviewed for clinical appropriateness, to make sure they understand the nature of the program, that they and their families have had all of their questions answered, and that they are willing to participate voluntarily in the program.
In the Fall of 1999 Steve Silverstein, PhD came to NYPH-PWW from the University of Rochester to become the Program Director of Second Chance. His primary mission at the time was to introduce a comprehensive behavioral treatment program that has long been known to be effective in treating the severe and persistently mentally ill (SPMI) population. Recognizing that behavioral problems as well as symptoms can be major impediments to many patients’ ability to live successfully in the community, behavioral interventions to address behavior excesses (e.g., aggression) and deficits (e.g., social isolation) were implemented at the milieu, group, and individual treatment levels. A point system based on comprehensive observational ratings of both socially inappropriate and appropriate behavior is used for determining on-ward and off-ward privileges. Patients receive daily ratings, and feedback, for appearance and grooming, room cleanliness, behaviors during mealtimes, and preparation for sleep. These specific behaviors were targeted because we knew that the community residences placed a high premium on these skills, as well as that consumers with these skills have longer community tenures than those without them. The program also uses a token economy, which can be thought of as a prosthetic environment for people with severe cognitive deficits. Patients earn tokens for meeting specific behavioral targets: such targets may be for the behaviors noted above or for aspects of group therapy, including arriving on time, participating and staying for the entire session. These are skills that are important for the patients to have as they re-enter the community and participate in day treatment or prevocational programs. Tokens provide immediate reinforcement for positive, prosocial behaviors and provide a daily sense of success and mastery for even the most impaired individuals. As a patient’s behavior begins to approach community standards the external reinforcers (tokens) are used less, and social and internal controls are relied on more.
Adam Savitz, MD, has been the Unit Chief since July 2001 and has been dedicated to the social learning program as well as to overseeing the psychopharmacology for the patients. The general philosophy is to not over-sedate the patients with medication, for two very important reasons. First, over-sedation simply masks problem behaviors and symptoms which need to be addressed more actively in treatment; and second, the emphasis of Second Chance is to help the patients learn essential skills needed to live in the community, and it is very difficult to learn when over-sedated on medication.
The Second Chance Program model has proven to be quite effective for treating patients who were considered unlikely to be discharged from state hospitals. We have discharged over 350 individuals since the program’s inception and have been able to successfully transition 80% into the community, and 80% of these individuals are out in the community at any given time. Increasingly over the past 1-2 years, we have been working with individuals who would otherwise have been transferred to a state facility for intermediate level of care, and the social learning and token economy has been effective in preventing state hospital transfer for many of these individuals. We have demonstrated that when intensive behavioral treatment is combined with appropriate pharmacology, the number of patients deemed to have treatment refractory psychosis is far lower than when medication alone or medication plus traditional milieu approaches are used.
At the program’s inception, forethought was given to the need for available community residence beds where the patients could be placed once they were ready for re-integration into the community. OMH used reinvestment monies at the time to provide the program with 30 supported housing beds dedicated to Second Chance patients being discharged who needed the support and structure provided by a community residence. This was a vital component of the program as many of our patients have comorbid medical problems such as diabetes and high blood pressure, serious substance abuse histories, as well as histories of involvement with the criminal justice system that make them very difficult to place in the community.
We obtained a commitment from four well-established housing providers in New York City to prioritize the Second Chance Program patients. It was decided at the time to concentrate the 30 beds among fewer housing providers to promote closer and more intensive working relationships between the inpatient setting and housing providers taking the patients, and this proved to be a good decision. We also wanted to use housing providers that were close to where the patients had family and/or other community supports. To date, many of the 30 dedicated beds have been filled with individuals who have graduated from Second Chance. The housing providers have done an excellent job supporting the patients in the community and continue to teach the community living skill in vivo that were reinforced in the inpatient setting.
We are currently discharging the patients through the SPOA system, mostly in New York City, competing with other hospitals for limited openings in the community residences. Initially there were regularly scheduled meetings with OMH, NYPH-PWW, and the housing providers to discuss the newly developing working relationships and to facilitate a better understanding of the special needs and perspectives of the partners. There was genuine excitement and enthusiasm amongst the partners embarking on this new relationship, and a trust developed as we worked together in the service of providing the best transition for the patients whom had been institutionalized for many years.
Andrew Bloch has been the liaison between Second Chance, OMH and the housing providers since the program opened its doors, and having one contact as the “point person” has facilitated the smooth transition of patients from one level of care to another.
Housing providers find working with Second Chance advantageous from several perspectives. They know that the patients being referred have been through a comprehensive rehabilitation program that maximizes the acquisition of community living skills. They also know that the patients have been stabilized on a medication regimen that best addresses their psychotic and affective symptoms while minimizing troubling side effects. The housing agency gets “credit” toward their requirement for taking state hospital patients, when they take a Second Chance patient. Our patients are also eligible for NY/NY III status through the New York City Human Resources Administration. The agencies work closely with Second Chance to have someone readmitted to the hospital for stabilization if that should be required. This provides a supportive safety net for the housing agencies when working with individuals with such challenging difficulties.
Establishing these partnerships between the inpatient setting and the housing providers has clearly been beneficial to the consumers of these services. On occasion a clinician from Second Chance has been asked to consult with a particular residence to strategize together on how to use some of the behavioral interventions at the residence as they attempt to address troublesome behaviors effectively. Unfortunately, limited resources of time and personnel do not allow for this potentially very useful service to occur often. It would greatly benefit the consumers if there could be even greater coordination of the treatments being used across treatment settings, from inpatient, to residential and day treatment programs.
It remains a curious phenomenon that while some of the best evidence on treatment effectiveness involves rehabilitative treatment of seriously mentally ill persons; these interventions are rarely used outside of academic medical centers. Creating a system wherein evidence-based interventions are used across the continuum of care for individuals with disabling psychiatric conditions would have major public health and financial benefits, including lowered relapse rates. It is, therefore, an extremely important next step to dedicate monies to the training and supervision of staff at both the housing provider and day treatment settings to provide a more seamless continuum of care. The Second Chance Program is an important first step in returning long-stay hospital patients to the community, but much work still needs to be done.
Adam J. Savitz, MD, PhD, is Assistant Professor of Psychiatry at the Weill Medical College of Cornell University. For further information on the Second Chance Program, please contact Andrew Bloch, MSW, Program Coordinator at email@example.com.