Although currently living upstate, I’ve closely followed news of Mayor Eric Adams’ policy for removing residents who appear mentally ill on city streets. As a nurse with a background in health care administration, I find this policy ethically problematic. As a PhD candidate studying how organizations collaborate to transition patients lacking homes at discharge, I know the complexities of implementing this policy.

Mayor Adams is proposing a close read of section 9.58 of Article 9 of the New York State Mental Hygiene law, which is the state’s legislation pertaining to involuntary hospitalization of people experiencing acute mental illness. To “939” someone, as it is often informally termed, means to place them under involuntary psychiatric hospitalization because they pose an imminent threat to themselves or others; ‘imminent threat’ is usually interpreted to mean active suicidal ideations or homicidal threats or actions. What Mayor Adams proposes is to allow peace officers and mobile outreach units to apply a wider interpretation of this clause such that it includes any behavior that might threaten an individual’s ability to take care of their daily living needs.

I believe that housing first policies are the bare minimum for giving a person with serious mental illness or any significant chronic disease a chance at achieving well-being. But with thousands of New Yorkers living on the streets, many with serious mental illness, Mayor Adams’ argument for intervention based on an individual’s capacity to care for themselves, even in the absence of tangible solutions to the housing crisis, might at least provide individuals in psychiatric crisis with better access to necessary stabilizing treatments. At the same time, the influx of potentially lower-acuity patients into emergency departments could exacerbate the shortcomings of our hospital-to-community care transitions systems.

What happens after admission?

Photo credit: Luke Stackpoole/Unsplash

When I worked as a nurse in New York City, it wasn’t uncommon to walk past recently discharged people wearing hospital bands and yellow socks asking for change on street corners adjacent to the hospital. I often felt a sense of guilt that we couldn’t find a place for them when they no longer required hospital-level care, and bewilderment about what the incredibly complex process of successful community transition might entail—or if it was even possible, in some cases.

Mayor Adams’ policy places a heavy responsibility on hospital administrators, who will have to strategize ways to better transition the influx of people with serious mental illness to hospitals under this policy. Once these individuals make their way through various clinical paths toward discharge, what happens? Discharging medically complex people who lack homes is time-consuming, leading to longer discharge delays than for housed counterparts, higher rates of readmissions, and increased costs.

The need for cross-sector collaboration.

I’ve been studying cross-sector collaboration in the city of Buffalo, where I currently live. Care fragmentation is most extreme in patients experiencing high social complexity, like homelessness, alongside medical needs. I work in a cross-sector network of providers to sustain a 13-bed medical respite unit for men experiencing homelessness at hospital discharge. This is a care transitions unit intended for patients with care needs that might be managed in a home-based setting, like extensive wound care by visiting nurses, but lack a home for this treatment.

In our project, we have found that helping our patients transition from hospital to shelter-based medical respite requires cross-sector collaboration that includes intricate, case-by-case communication between providers across the care continuum.

The success of our team in facilitating care transitions to our medical respite unit depends on several factors related to communication and relationships, themes prominent in the framework that is central to my own dissertation research, relational coordination theory. In weekly case conferences, representatives from the discharging hospitals, homeless shelter, academic partners, home health agencies, primary care, and behavioral health care meet to discuss our patient roster, new referrals, and troubleshooting. But even after almost three years of working together to launch and sustain our program, we still struggle together when faced with problem-solving and the intensity of communication it requires—something that we are always refining our shared cross-sector structure, process, and protocols to improve.

Cross-sector collaboration has been much studied, but its effectiveness remains difficult to measure, and we don’t often understand its actual impact. There are many barriers to its successful implementation, such as time, lack of infrastructure, vast differences between the roles and cultures of organizations, and fear of reputational impact. These challenges are common within the walls of the hospital, but imagine them spanning multiple boundaries between organizations that serve clients in different capacities and lack incentives or tools to systematically coordinate.

My point here is that even in a small group of providers with established relationships, cross-sector collaboration, which is vital to the success of patients with serious mental illness, homelessness, and other care complexities, is challenging and requires ongoing improvement strategies from intake to discharge to permanent housing and beyond. While Mayor Adams’ policy clearly outlines steps that exhibit cross-sector elements for the intake of people who may be at risk of undue harm to themselves, his initiative stops at their drop-off at the hospital. And while he is calling for increased accountability for hospitals to share information with community-based agencies at hospital discharge, a more developed and intentional strategy that appropriately addresses cross-sector needs spanning the care continuum for successful community transition is a necessary care threshold that all New Yorkers deserve.

Amanda Anderson, MPA, MSN, RN, is a PhD candidate and research project assistant at the State University of New York University at Buffalo School of Nursing and a fellow in Clinical Scholars, a national leadership program supported by the Robert Wood Johnson Foundation. She is also on the editorial board of AJN.