The New York City healthcare systems and its consequences have been a disaster for New Yorkers. The system in place has consistently underperformed in properly carrying out the will of Kendra’s Law. If Kendra’s law was a sandcastle, the city of New York lies on the shore of a beach that is consistently decimated by the waves of the current system while New Yorkers drown in its wake. New Yorkers like Michelle Alyssa Go who was murdered being pushed in front of 42nd street station’s oncoming train.
Together we will explore:
What is Kendra’s Law?
My role and experience as a former Intensive Case Manager
The function of the activation of Kendra’s Law
The participating parties involved in the activation of Kendra’s Law
Barriers faced by providers and clients attenuating success of ongoing treatment
What is Kendra’s Law?
Kendra’s law was ratified shortly after Andrew Goldstein, pushed 32 year old Kendra Webdale into the tracks of an oncoming 7 train on 23rd street causing her immediate death (Dec. 1999). This law allows judges to authorize involuntary mental health outpatient services to people who pose a threat to themselves or others by signing off on a treatment plan that must be obliged by the person in question, and all providers listed on said treatment plan (psychiatrist, Care management agency, Care management staff, mental health housing facility, medication regimen, etc). The enactment of the treatment plan is “Assisted Outpatient Treatment (AOT)”.
The shared sentiment is that if Mr. Goldstein was engaged in adequate outpatient mental health services, this tragedy would have been avoided in 1999. Kendra Webdale would still be alive practicing her profession in journalism.
I am a former Intensive Case Manager
As a former Intensive Case Manager (ICM), my name was on several AOT treatment plans. My caseload was entirely composed of AOT clients as I was one of two people in my Manhattan team who qualified to serve the high risk population. At the time (~2017), AOT guidelines stated that an ICMs AOT cap is 12 clients. Then, an announcement was shared through mass emails saying that it is still 12, but can go up to 15 AOT clients. This meant that for quite some time I had between 12 and 15 AOT clients on my caseload at any given moment. There is also a huge financial incentive for Care Management Agencies to take as many AOT clients as possible since AOT clients bill 4x of “regular” clients.
What does an AOT ICM do?
Every day is composed of managing and prioritizing actual and perceived emergencies. An emergency can be very real to everyone, or feel very real to the client. An example of a perceived emergency I have experienced was when one of my clients called me frantically telling me that the TV waves were controlling their brain. These perceived emergencies need to be addressed, as they are signs of decompensation which can potentially lead to actual emergencies.
My mandate within the AOT court order varied but most of the time, when things were going right, included:
Meeting with client at least once a week
Assessing their adherence to court mandated medication regimen
Contacting providers to discuss client success
Develop and implement personalized care plans
Submit weekly progress reports to AOT offices by Tuesday
Submit “Significant Event” Reports to AOT to alert of incidents in real-time
Monthly service verification calls with AOT Monitor(s) to discuss all above.
The problem with this is that nothing ever goes right. Clients stop showing up to their appointments, or leave their residence for an extended period. During my time as an ICM, I often half jokingly said that I felt like a parole officer. It felt strange as client-advocacy took a backseat to adherence management as I transitioned into the AOT ICM role.
What does AOT do?
New York City AOT offices are located in Long Island City, Queens. It is broken up into 5 teams of social workers who hold the position of “AOT monitor”. Each team represents a borough. Each AOT monitor has a caseload of around 65 clients. An AOT monitor may have a caseload of 65 clients, split between 6-10 Care Management Agencies and 10-15 ICMs within those Care Management Agencies.
AOT monitor’s mandate within the AOT court order include:
Conducting monthly service verification calls which detail
Medication adherence (If medication in injection- date given, dose, and next scheduled dose date), review of all appointments, next steps, etc.
Receive and relay Significant Event Reports
Participate in treatment plan development
Assist ICMs with instruction as ICM serves as eyes and ears on the field
Communicate with other providers in treatment plan
Attend case conferences with all providers if and when things are not looking great
AOT monitors are consistently putting out fires. It is a high stress job with intense burnout causing massive turnover rates. It is an entity that is eating itself alive.
How does someone become court ordered by AOT offices?
There are several criteria that can land someone under the pen of the director of AOT as they sign the court order mandate along with a judge. A person can must exhibit one of the following:
Non-compliance to medication regimen
Multiple psych hospitalizations/Emergency room visits within a given time frame
Poses threat to self or others
Court orders vary in length of time but are usually between 6 months and 12 months long. When a court order is about to expire, the AOT monitor and the ICM discuss the overall compliance to the mandated treatment plan. The ICM also submits recommendations of providers whether to extend the court order by another 6 months to a year, or “graduate” the client. The client’s compliance and insight on their own diagnosis is a huge determinant. Notes of the discussion, and recommendations of providers, are then sent through the proper channels to schedule an “AOT examination” that takes place about a month before the current court order expires.
What happens if someone does not adhere to the treatment plan?
It is not rare for someone to fall under “non compliance” of AOT. When someone is deemed non compliant, a Significant Event Report is submitted by ICM. Non compliance can be anything from:
Consistently evading ICM for weekly meetings
Missing medication injection appointment (if injection is the primary method of medication)
Missing appointment with psychiatrist
Showing signs of decompensation
If a person is deemed non-compliant, AOT activates the Citywide Assistance Team (CAT team). The CAT team is a group of professionals serving as a crisis intervention team. It is composed of a psychiatrist, social workers, and 2-3 sheriff deputies. There is only one CAT team in the city of New York. Their responsibility is to locate the client and safely escort them to a psychiatric emergency room to undergo evaluation. If the psychiatrist does not deem the individual as a danger to self or others, the medication will be administered and they will be discharged. Sometimes, the discharge is the beginning of another string of non-compliance especially if it is the summer time.
This record of non-compliance does not favor them well during AOT examinations.
What is an AOT examination?
“Don’t worry. It's not an actual test with multiple choice questions.” That is what I used to tell my clients as I served them with a notice detailing the setting and time of the examination. Each borough has one examination site. Manhattan's examination site is in Harlem.
Waiting for you inside the examination room is a psychiatrist and a Mental Health Legal Services appointed lawyer who is there to serve the client. The psychiatrist asks the client questions regarding their insight to their own mental health diagnosis seeking the client to admit to their diagnosis. Similar to a guilty plea.They ask about the history of the client’s noncompliance during the term of current court order. The client is then asked regarding their medications, how they feel about it and its side effects. Lastly, the psychiatrist asks questions to gauge if the client would likely continue treatment after the mandate is lifted and they “graduate”.
Usually, court orders are extended. During my tenure working with AOT clients, two clients graduated. There are many barriers the providers, and most importantly, the clients face. These barriers are detrimental to the success and probability of ongoing treatment.
What are the barriers to effective treatment?
The caseload model itself. When non-profit care management agencies fight for more funding through getting more AOT clients, caseload maximums are usually where the ICMs are kept. Pushing at 100% capacity at all times. The burnout rate is high which causes a high turnover rate. The average care manager holds a position with an agency for 18 months. An intensive care manager is less than that. The high turnover rate creates inconsistency for the client. Imagine having to open yourself up again and again and answering similar questions again and again. This inconsistency can lead clients to not want to meet with the ICM.
The distribution of caseloads being borough based. For example, if a client was living at 220th street and Broadway in Manhattan, and then moved to 225th street and Broadway in the Bronx, the treatment plan is severely altered. The AOT monitor transfers the case to the Bronx team. The Care Management agency internally shifts that case to its own’ Bronx team as well. The client is then in the care of someone who does not know much about them. No matter how many notes the newly assigned people read, or how many questions they ask the predecessor, they will not know the client as well. This also may disrupt channels of communication with the existing psychiatrist, nurse, or any other providers listed on the treatment plan as everyone adjusts.
Homelessness poses an incredible logistical threat to the sustainability of the Kendra’s Law initiative. Oftentimes, people do not give the address where they stay (family, friends, etc) to psychiatric staff. They are deemed homeless. There is not much investigation that occurs due to the volume of patients. Due to this, the NYC intake shelter is listed as a residence. The main intake shelter is located near Bellevue Hospital in Manhattan. This causes a huge strain on Manhattan ICMs who are assigned essential ghosts as the client takes off the radar upon discharge from a hospital. There are also actual homeless people who, in the summer months, may prefer to sleep outside, especially those suffering from severe mental illness. This is a massive undertaking for Manhattan based ICMs, and their AOT monitor counterparts. I always said that there should be a 6th team dedicated to the homeless/suspected homeless if the current borough based distribution model is to be maintained.
Secondly, clients who are in Rikers Island are deemed to be Manhattan based. Thirdly, clients who reside on Ward Island's Manhattan Psychiatric Center or the shelters there are also considered Manhattan based. Efforts of ICMs and AOT monitors would be better served with actual Manhattan residents instead of “chasing ghosts” as it has often been said.
Drug abuse is an enormous barrier to client success within the AOT program. AOT is not a drug rehab outpatient program and can not mandate rehab, but they can mandate day programs and drug tests. AOT was not designed with drug addiction in mind but adopted strategies to better help. It is difficult for clients who are suffering from mental illness to prioritize correctly, while dealing with their addictions. Imposing forced rehab also seems immoral, and it is hard to come up with proper solutions. I have seen drug addiction keep some AOT clients within the AOT loop for years and years. Enter the doors of AOT to help with outpatient treatment, then locked inside due to drug abuse.
A new barrier to client success emerged in the advent of COVID. As COVID began stirring global panic in March 2020, providers were made to move face to face services to telehealth services. Many providers could not even identify their clients because they probably never met. This poses a huge threat to maintaining the sustainability of ongoing treatment. Telehealth sessions are perfectly designed for consumers who can function at adequate capacities.
Takeaway points
The Assisted Outpatient Program enacted by Kendra’s law has been successful in areas like Syracuse. The New York City health care system is not equipped to facilitate such an initiative with this mass of people. There are not enough beds in the psychiatric wings of hospitals. The systems in place are grossly inefficient resulting in the further detriment of some of the most vulnerable people within this city.
One thing I noticed during my time as an ICM is that if a client went “missing” (did not want to be found), they would most certainly show up in the colder months as I am alerted by a hospital staffer after they look up the client and view my name on the AOT order. There is a pattern of desperation to escape the cold and the acts people would commit are unthinkable. Remember, if a client is not deemed a danger to self or others, they are not admitted to the inpatient psychiatric unit and are discharged back outside. This alongside the moods of the holidays and how that may make others feel, can turn our subway system into a hazardous environment. Kendra Webdale died on a cold winter day being pushed onto an oncoming train. This story is awfully familiar and repetitive. Just as the seasons.
Interesting