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Adopted Rules: Closed to Comments

Adopted Rules Content: 
 

Statement of Basis and Purpose

 

Statutory Authority

The Board’s authority to codify these proposed amendments is found in Sections, 556, 558, and 1043 of the New York City Charter (the “Charter”). Sections 558(b) and (c) of the Charter empower the Board to amend the Health Code and to include all matters to which the Department’s authority extends. Section 556 of the Charter provides the Department with jurisdiction to protect and promote the health of all persons in the City of New York. Section 1043 grants the Department rule-making authority.

Background

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 use 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. In 2013, the Board of Health amended the Health Code to require hospitals to report when persons between the age of 18 and 30 are first admitted with a psychotic illness so that DOHMH can make appropriate linkages to services through the NYC Supportive Transition and Recovery Team (NYC START).  The Department of Health and Mental Hygiene has successfully implemented hospital reporting with time-limited linkage to care for individuals 18 to 30 years of age with a first-episode psychosis hospital admission. However, in order to best account for and intervene in episodes of early psychosis and address health disparities, it is necessary to expand the age criteria for the reporting requirement to those aged 16 and over, collect data on race and ethnicity, and retain collected information past the current 30-day time limit.

Current Linkages to Care for First-Episode Psychosis

When the Health Code was amended in 2013 to address inadequate linkages to care for people with first-episode psychosis, we pointed out that New Yorkers with psychotic illnesses often do not seek care or become disengaged from care in part due 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

While NYC START has improved these linkages to care for those who are reported with first-episode psychosis and accept services, the Board is further amending the Health Code to improve the health of all New Yorkers with first-episode psychosis. In particular, there were three areas that needed to be addressed in order to more fully account for the needs of individuals with psychosis:

  1. Until the adoption of these amendments to Health Code Section 11.04, MHy could retain identifiable information of individuals reported with first-episode psychosis for only 30 days unless they accepted care through NYC START, making psychosis the only reportable illness that placed a limit on the amount of time the information can be seen by the Department. After 30 days, this information had to be de-identified and could not be used to follow up with the individual or to identify possible re-reporting. Given the many reasons that people with first-episode psychosis disengage from care, it is necessary to retain this information past 30 days to ensure that outreach can continue to those who have been unreachable during the initial 30-day period, to comprehensively assess the needs of communities, and to work with providers to develop successful interventions.                                                                    
  2. DOMMH estimates that approximately 2,000 new cases of psychotic illness develop each year in New York.[2],[3]  Our analysis of NYC hospital admissions found that six percent of probable first-episode admissions occurred among persons between 16 and 17 years of age.[4]  There has been an expansion in the availability of specialized services for individuals 16 to 30 years of age.  However, due to past restrictions in the Health Code limiting the reporting age to between 18 and 30, we did not account for individuals who developed first-episode psychosis before the age of 18.                                                            
  3. Race and ethnicity were not among the factors that hospitals identify when making a report of first-episode psychosis. Because there are racial disparities in the diagnosis and treatment of psychotic disorders, however, this information is especially pertinent to collect and utilize to improve interventions and address health inequity.[5]

 Amendments

To improve interventions, linkages to care, and outcomes for New Yorkers experiencing first-episodes of psychosis, the Board of Health is amending Article 11 of the Health Code. The changes will facilitate participation in early intervention services by requiring hospitals to report when individuals over 16 and under 31 years of age are admitted with a first-episode of psychotic illness. The changes will further facilitate the creation of a database of reported cases of first-episode psychosis that will permit the Department to monitor trends of the illness.

Evaluating these trends can be used to:

  • Develop targeted, culturally-competent interventions in the NYC START program
  • Measure outcomes of first-episode psychosis care, and thereby direct more efficient interventions to health care institutions, health care providers and people with psychosis.

Reporting will continue to be required within 24 hours of admission and will include hospital name, patient name, age, gender, address, telephone, date of admission, insurance type, diagnosis, race, and ethnicity. All patient information reported to the Department will be kept confidential and will not be shared with unauthorized individuals.

The amendments have been revised to include the name and contact information of a parent or guardian among information to be reported when the patient is a minor; to clarify the exception to the reporting requirement; to clarify confidentiality provisions; and to include an effective date of January 1, 2019.




[1] Charter §556(c)(2).

[2] Kirkbride JB et al.  Int J Epi.  2009; 38-1255-64.

[3] Baldwin P et al. Schiz Bull 2005 31;3, 624-38.

[4] DOHMH internal analysis of NYC hospital admissions in 2009 for probable first-episode psychosis among 16 – 29 year olds.

[5] Schwartz, R et al. World J Psychiatry. 2014 4(4): 133-140

 
Effective Date: 
Tue, 01/01/2019

Adopted Rules: Closed to Comments

Adopted Rules Content: 

Statement of Basis and Purpose

 

Background

 

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 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, decrease the likelihood of debilitation, and increase chances for long-term remission for affected individuals.

 

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]

Impact of Duration of Untreated Psychosis and Early Intervention on Psychotic Illness

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]  Wespite 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]

 

Amendment of Article 11

 

To improve linkages to care and outcomes for New Yorkers experiencing first episodes of psychosis, the  Board of Health is amending Article 11by requiring hospitals to report when persons  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.

 

Epidemiologic analysis

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.

[4]Lewine RR. Amer J Orthopsychiat 1980;50:316-322.

[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.

[18]Marshall M et al. Arch Gen Psych 2005; 62:975-983.

[19] Perkins D, et. al. Am J Psych 2005;162:1785–1804

[20]AddingtonJ.  Early Interv Psych 2007;1:294-307.

[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.SchizResearch 2011;129: 111-115.

[36] Lieberman J, et al. JAMA 2013;310:689-690.

[37]Thornicroft G, (Commentary) Epi and Psych Sci. 2012;21:59-61

[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.

Effective Date: 
Tue, 01/21/2014