Reportable Diseases and Conditions (Article 11)
Proposed Rules: Closed to Comments
Statement of Basis and Purpose
These amendments to the Health Code are promulgated pursuant to §§558 and 1043 of the Charter. Sections 558(b) and (c) of the Charter empower the Board of Health to amend the Health Code and to include in the Health Code all matters to which the authority of the Department of Health and Mental Hygiene (the “Department” or “DOHMH”) extends. Section 1043 grants the Department rule-making authority.
The Department is responsible under the Charter for supervising matters affecting the health of New Yorkers. This includes supervision of the reporting and control of chronic diseases and conditions hazardous to life and health. 1 The Department also has specific responsibilities with regard to mental health. Pursuant to section 552 of the Charter, the Department’s Division of Mental Hygiene (MHy) is the local government unit (LGU) for the City of New York under New York State Mental Hygiene Law, and the executive deputy commissioner who directs the Division is the City’s director of community services. As the LGU, MHy is responsible for administering, planning, contracting, monitoring, and evaluating community mental health and substance abuse services within the City of New York. It also is charged with identifying needs and planning for the provision of services for high-need individuals, such as persons with schizophrenia and other psychotic illnesses.
Overview of Psychotic Illness
Schizophrenia and other psychotic illnesses, which include schizoaffective disorder, substance-induced psychotic disorder and psychosis NOS (not otherwise specified), include symptoms such as hallucinations, delusions, confused and disturbed thoughts, and a lack of self-awareness. 2,3 These illnesses usually begin in young adulthood 4,5 and often place a significant quality of life and financial burden on both the individual with the illness as well as their families and loved ones. 6 While previously thought to be chronically impairing, evidence now shows that early, high-quality treatment can reduce the risk of relapse and increase chances for long-term remission for affected individuals, decreasing the likelihood of debilitation and other risks to themselves or others.
DOHMH estimates that approximately 60,000 New Yorkers currently have psychotic illnesses. 7 Despite evidence that treatment improves outcomes, we estimate only 40-50% of these New Yorkers receive ongoing psychiatric care following discharge from a psychiatric hospitalization. 8,9
Approximately 2,000 new cases of psychotic illness are expected to develop annually in New York City. 10,11 Without follow-up treatment, more than one quarter of these individuals will be expected to relapse and to be re-hospitalized within one year. 12,13,14,15 With treatment, the risk of relapse can be reduced by approximately 50%. 16,17
The ‘duration of untreated psychosis’ (DUP), the period from the first onset of psychotic symptoms to the start of treatment, is associated with both treatment effectiveness and long-term outcomes. 18,19,20 Despite the fact that shorter DUP is associated with better response to antipsychotic treatment, indicated by reduction in symptoms and better overall functioning, the average DUP is long (between one and three years in national studies). 21,22,23,24 In the medium and longer term (6 month, 12 month and multi-year follow-ups), longer DUP is associated with poorer outcomes for overall functioning, symptoms, and quality of life. 25,26
DUP can be reduced by enhancing early detection, treatment and referral. Early detection programs can bring people to treatment sooner, at lower symptom levels, and reduce DUP. 27,28
Implementing an early intervention model is also associated with better clinical and functional outcomes for individuals experiencing psychotic illness. This model involves a team-based approach (psychiatrists, social workers, peers) that includes community treatment, cognitive behavioral therapy, low-dose medication, family counseling, social skills training and vocational strategies. 29,30,31 The effectiveness of early intervention programs has been demonstrated in a growing body of research. 32,33,34,35,36
Adequacy of Current Links to Care
New Yorkers with psychotic illnesses often do not seek care or become disengaged from care. This is due, in part, to:
- fragmentation in the current mental health treatment system (patients being lost to care in transitions from hospitalization;
- exchange of patient information unsupported by technology infrastructure or current administrative practices);
- mental health treatment providers lacking resources to ensure links are established between patients and community supports; and
- challenges such as stigma, denial, fear, lack of support, and confusion related to benefits and insurance.
As a result, there are many people who do not become engaged in care until years after the early stages of their illness. 37
It is well-established that linking patients to care improves both health and economic outcomes for the individual and their loved ones and reduces the burden on the healthcare system. Numerous studies, conducted with a variety of patient populations, highlight the importance and efficacy of linkage-to-care programs in improving post-hospitalization outpatient engagement, reducing the rate of re-hospitalization and decreasing associated costs. 38,39,40
To improve linkages to care and outcomes for New Yorkers experiencing first episodes of psychosis, the Department proposes the Board of Health amend Article 11. The proposed changes would facilitate enrollment in treatment by requiring hospitals to report when adults over 18 and under 30 years of age are admitted with a first episode of psychotic illness.
Reporting will be required within 24 hours of admission and will include hospital name, patient name, age, gender, address, telephone, date of admission, insurance type and diagnosis. All patient information will be confidential and used only for the purposes of linking patients to care. Patient name, address, date of admission and telephone number will not be retained by the Department for longer than 30 days. Information about patients agreeing to participate in the linkage-to-care program will subsequently be maintained in a program chart that is separate and apart from the information received from the reporting hospital.
The de-identified data (hospital name, age, gender, month of admission, insurance type and diagnosis) in the reporting database will be used to describe characteristics of the aggregate population admitted with first-episode psychosis, in order to guide mental health system planning efforts.
1 Charter §556(c)(2).
2 Barbato, A. (1998) WHO/MSA/NAM/97.6
3 New York State Office of Mental Health (NYS OMH)(2012). Schizophrenia. Retrieved August 22, 2013 from: http://www.omh.ny.gov/omhweb/booklets/schizophrenia.html.
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5 Kleinhaus K et al. J Psych Res 2011;45:136-141.
6 Wu EQ, et al. J Clin Psych 2005;66:1122-1129.
7 NYC DOHMH analysis of NYS OMH Patient Characteristics Survey, 2011.
8 NYC DOHMH analysis of NYS Medicaid claims data, 2012.
9 Buchanan RW, et al. Schiz Bull. 2010;36(1):71-93.
10 Kirkbride JB et al. Int J Epi. 2009; 38-1255-64.
11 Bladwin P et al. Schiz Bull 2005 31;3, 624-38.
12 NYC DOHMH Medicaid analysis.
13 Zhomitsky S, et. al. Schiz Res Treatment. doi:10.1155/2012/407171
14 Ram R, et al. Schiz Bull 1992;18:185-207.
15 NYC DOHMH analysis of NYS Statewide Planning and Research Cooperative System, 2009.
16 Alvarez-Jimenez M, et al. Schiz Bull. 2011:37:619-630.
17 Marshall M et al. Arch Gen Psych 2005; 62:975-983.
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21 Marshall M et al. Arch Gen Psych 2005; 62:975-983.
22 Perkins D, et. al. Am J Psych 2005;162:1785–1804
23 Hass G, et al. Schiz Bull. 1992; 18:373-386.
24 Ho B, et al. Am J Psych 2000;157:808-815.
25 Perkins D, et. al. Am J Psych 2005;162:1785–1804
26 Petersen L, et al. BMJ 2005;331:602.
27 Melle I, et al. Arch Gen Psych 2004;61:143–150.
28 Hegelstad W, et al. Am J Psych 2012;169:374-380.
29 Grawe RW, et al. Acta Psych Scand 2006;114:328-336.
30 Mental Health Network NHS Confederation. 2011 Issue 219.
31 Singh SP. Br J Psych 2010; 196:343-345.
32 Alvarez-Jimenez M, et al. Schiz Bull. 2011:37:619-630.
33 Hastrup LH, et al. Br J Psych 2013;2002:35-41.
34 Mihalopoulos C, et al. Schiz Bull 2009; 35:909-918.
35 Norman RMG, et al. Schiz Research 2011;129: 111-115.
36 Lieberman J, et al. JAMA 2013;310:689-690.
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38 Jack BW, et al. Ann Intern Med. 2009; 150(3): 178-87.
39 Coleman EA, et al. Arch Intern Med. 2006; 166(17):1822-8.
40 Naylor MD, et al. JAMA. 1999; 281(7):613-20.