Clinical Services 11-17

11. Emergency Psychiatric Services, Kings County Hospital Center
The emergency psychiatric services known as the Comprehensive Psychiatric Emergency Program (CPEP) is comprised of four functional units: 1. The evaluation unit as the traditional emergency room (ER) – a 24-hours/day service. 2. The Mobile Crisis Service. 3. Extended Observation Unit which is a 6-bed unit physically located in the Evaluation Unit, where patients are admitted for a 72-hour period of treatment, the aim being stabilization and discharge. 4. Crisis Residence Beds – located in the community.

•		PGY-1 required 6-month rotation/PGY-2 required 12-month rotation. Such rotations are in the evening hours from 5 P.M.– 8 A.M and are located on the Evaluation Unit. Also a 1-3 month elective rotation is available in the Mobile Crisis Services for PGY-4 residents.
•		The CPEP is staffed with 6 full-time psychiatrists, 2 full-time psychologists, 5 full-time social workers, 7 full-time addiction counselors, 2 part-time social workers, 3 full-time caseworkers and 1 full-time community liaison worker, 1 full-time internist and 1 part-time internist.
•		Residents (PGY-1 and –2) rotate through the emergency services 5 or 6 times per month. There are 2 residents per 15-hour tour with each resident having 6 hours rest time. The CPEP is the recipient of a diverse ethnic population of which 90% is Black, 10% is White and Asian. The Black population includes West Indians, Haitians and Hispanics. All ages are serviced from 5 years old and up with majority falling the 16-45 year old range. Approximately 80% are dual-diagnosed patients (MICA). Diagnoses most often made are 40% schizophrenia, 50% mood disorders, 10% personality disorders. Residents are introduced to crisis intervention, addiction counseling, pharmacotherapy and behavior modification. Each resident is required to evaluate at least 4 new patients per shift and to respond to psychiatric problems on the inpatient services. An internist who is present on site addresses medical problems. During the first 2 months of the PGY-1 rotation, each resident is paired with a PGY-4 resident or a full-time attending for 1:1 teaching and supervision. In addition a full-time licensed attending (Bell attending) is always present in the ER for direct supervision and consultation. Supervision in the Mobile Crisis service is by a full-time attending. Children and adolescent cases are presented to a child fellow and an attending in child psychiatry. In addition an internist is available on site to address all medical problems and questions. In the emergency service residents are taught rapid evaluation and assessment of patients and family situations together with strategies of crisis intervention and management. Medico-legal issues including issues of informed consent, and criteria for involuntary hospitalization and treatment are reviewed. In addition, this rotation introduces residents to interventions employed in often-encountered-high-risk situations including acute drug reactions, seizure disorders, intoxications and addictions, acute psychoses, suicidal and assaultive patients. Such interventions include pharmacological management, psychosocial methods, and physical methods, e.g., restraints. Residents learn how to access treatment resources available within the hospital and in the community network of social agencies and learn techniques for identifying and making proper referrals. Indications for hospitalization and alternatives to hospitalization of dual-diagnosed, mentally ill and homeless patients are also discussed in daily supervision.

Inpatient Psychiatry - Nursing Station 52 - University Hospital

•		PGY-2 required 3-month rotation.
•		Three full-time faculty psychiatrists, including the Director of Clinical Services and two attending psychiatrists who serve as team leaders. There is also a full-time faculty Clinical Psychologist, two full-time psychiatric social workers and two full-time activity therapists.
•		Residents participate in daily teaching rounds and twice weekly comprehensive multidisciplinary treatment team meetings. Formal case conferences chaired by senior and visiting faculty are held twice monthly and there is a weekly clinical interview seminar conducted by senior faculty. Full-time faculty members are continuous basis to manage clinical and administrative questions and issues. Additional one-to-one supervision is provided on a weekly basis by other senior faculty to each resident. Residents also participate in a twice-weekly clinical topic presentation and discussion. The patient population is approximately 50% male and 50% female, age 18 and older with 80% being between age 20 and 55. It is multiethnic, reflecting the diverse ethnic and racial makeup of the surrounding community. There is approximately an even distribution between males and females. Most patients carry a psychotic diagnosis with schizophrenia, bipolar disorder and major depressive disorder being the most prevalent. Close to 50% have a coexisting substance abuse problem (although patients with a primary substance abuse diagnosis are not admitted to the program). Dementia and other primary organic diagnoses represent about 10% of admissions. Co-existing medical problems are present in a significant number of patients and one of the attending psychiatrists is fully trained and board-certified in internal medicine. The unit provides a full range of group and activities therapy as well as supportive individual therapy conducted by the primary therapist of each patient. Close to 100% of patients are treated with single or multiple psychotropic agents and there is daily review of the psychopharmacologic regimen of each patient. An average caseload is 3 to 4 patients for whom the resident serves as the primary therapist. Responsibilities include the generation of the psychiatric and medical data bases and discharge summaries, daily contact with each patient, participation in family therapy, interfacing with managed care reviewers, and presentation of cases at conferences. The resident is expected to derive a comprehensive biopsychosocial understanding of each patient and to be responsible for integrating all aspects of care on a daily basis. There is at least one hour of individual supervision weekly in addition to at least two hours of group supervision for cases in which residents serve as primary therapist. There is also separate supervision for family therapy and other group processes on an as needed basis. The teaching goals of this rotation include full understanding of the nature of an acute psychiatric inpatient service and the roles of each professional discipline in a multidisciplinary team, gaining a facile capacity to workup a new patient from an integrated biopsychosocial framework and an ability to formulate and initiate a treatment plan that utilizes state of the art psychopharmacologic and psychotherapeutic interventions.

Psychiatric Inpatient Unit – Child Psychiatry - Kings County Hospital Center

•		PGY-1 required 2 months.
•		Faculty consists of 4 full-time psychiatrists, 4 full-time psychologists, 5 social workers, 1 art therapist, 5 recreational therapists, as well as a complement of nurses; nurse’s aides and child care counselors.
•		Residents attend two chart rounds per week, 2 hours each, 30-minute ward rounds daily, community meetings 1 to 2 hours per week, case conference, 1-_ hours per week. Faculty provides individual supervision at least 1 to 2 hours per week and is available for consultation on a full-time basis. Trainees also receive weekly supervision on family therapy and are also individually supervised in this area. Caseload is limited and cases are selected to allow trainees to have a range of diagnoses. All trainees are members of a multi-disciplinary team. Trainees also occasionally present in a weekly meeting, which reviews cases that have particular diagnostic or treatment problems. Hospitalized youngsters are usually from ages 5 – 16. We on occasion hospitalize a child less than 5 years old. There were approximately 300 admissions for the past year; approximately 60% male and 40% female. Racially they were approximately 75% Black (Afro-American and Caribbean), 20% Hispanic, 5% others. Major diagnosis: Disruptive behavior, conduct disorder and attention deficit hyperactivity disorder – 60%. Suicide and affective disorders – 25%. Psychosis – 15%. Many of the adolescent population have organic deficits, including seizure disorder, cognitive limitations such as mental retardation and learning disabilities and pervasive developmental disorders, including autism. About 50% of the youngsters are referred from the courts for evaluation. Mean stay is 30 days, however, we have two groups of children, those with families and/or institutions that are willing to have the child return to them, and this group leaves after 2 – 4 weeks, and another group that has a longer stay because of placement problems. Many of the children with the longest stay are children with a dual diagnosis. Treatment includes a full gamut of interventions including milieu therapy, individual psychotherapy, behavioral treatment, group, family therapy and psychopharmacology. The initial first step is a comprehensive assessment. Trainees gain exposure in collaborating with social agencies. Average caseload 3 – 4 patients at any one time. Residents are fully responsible for coordinating the evaluation, treatment and discharge planning of each of their patients. Residents co-lead at least one group on both the latency and adolescent services. Individual supervision, 2 hours. Also family therapists, usually directly supervise. Comprehensive experience in diagnostic assessment and rapid stabilization of severely disturbed youngsters from often chaotic disorganized families. Trainees gain experience to liaisoning with social community agencies and schools. Referrals to residential treatment centers, group homes and foster care agencies are carried out. Trainees learn to work as a member of a multi-disciplinary team. Trainees are beginning to get experience in evaluating and treating patients who are in managed care systems and in negotiating with managed care services for approval for treatment. They are also learning to think about and work with patients who have several co-morbid diagnoses and to consider which services are necessary for patients and to plan more effective treatment follow up.

Forensic Psychiatry, Kings County Hospital Center

•		PGY-2 required 2-month rotation (1) Sixty percent assignment (60% full-time equivalent) spent on the forensic inpatient treatment service at Kings County Hospital. (2) Twenty percent assignment (20% full-time equivalent) spent on the forensic court evaluation service operating on the inpatient service at KCHC and at the courthouse clinics of Brooklyn and Queens.
•		Faculty for (1) and (2) consists of 3 full-time psychiatrists, 3 full-time psychologists, and an affiliated attorney (.20 full-time equivalent). There is an interdisciplinary complement of nursing, activities and social work staff on the inpatient treatment service.
•		Case conferences on patients posing difficult or rare treatment and/or psychological issues are conducted every two weeks. Seminars in forensic psychiatry are conducted monthly and include the following focus: Ethic practice, courtroom testimony, evolving case law, and forensic research. Residents also attend a 16-hour course on forensic psychiatry during their second year in conjunction with this rotation. (1) Residents spend 28 hours per week engaged in the supervised assessment and treatment of forensic inpatients. Treatment planning for patients is conducted with an interdisciplinary team approach involving medication, individual and group psychotherapies, community milieu, family involvement and attorney contact. Treatment caseloads for the resident are monitored and controlled for breadth and variety of forensic experience. Specifically, low-frequency cases including geriatric patients, patients with unusual organic mental disorders, and capital offender cases are assigned to enlist resident participation. (2) Residents spend 8 hours a week observing clinicians perform court ordered examinations. By law residents may not officially perform competency to proceed to trial evaluations but may perform pre-sentence or pre-pleading examinations for the court. They perform the latter with direct supervision in the presence of an experienced forensic examiner. They also observe psychiatrists testify on civil questions such as involuntary retention in a hospital or medication over a psychiatric patient’s objection. The 46-bed inpatient unit is populated by male patients, 16 years of age and older, who are in custody of the NYC Department of Correction. Approximately 95% of the patients are pretrial detainees held on misdemeanor or felony charges. Approximately 53% are Black, 23% are White, 13% are Hispanic and 11% are other. The inpatient population has ethnic and age distributions similar to that found among the 15,000 inmates confined daily in City jails. Approximately one-third of the patients are diagnosed with a schizophrenic spectrum disorder and another third as adjustment disorders. Significant but less frequent diagnoses include the affective disorders and organic mental disorders. Co morbidity with substance abuse, chronic illness and/or personality disorder is frequent in the patient population. A significant number of patients are highly suicidal on admission. All patients receive treatment in accord with hospital standards. Approximately 60% of forensic inpatients have coincidental court ordered psychiatric evaluations. (2) The offender population examined at the court clinics is 90% male and 10% female. All are age 16 and above facing legal charges before the Criminal or Supreme Courts of Kings, Queens or Richmond Counties. Only 5% of the defendants re at liberty and not in the custody of Correction. Ethnic distribution resembles that of the Forensic Inpatient Service. A greater number of defendants seen at the clinic are found fit to proceed, than on the inpatient service. A lower incidence of schizophrenia and a higher incidence of intellectual limitation (retardation or learning disorders) and transient mental disorders are seen at the clinics. The civil psychiatric population observed at Court, varies in demographics depending upon the particular hospitals participating in hearings during any given week. Efforts are made to have the resident observe and/or participate in a broad spectrum of examinations and court hearings. On average residents rotating on the inpatient treatment serve as primary therapists for a caseload of 3-4 patients. Residents also provide admission assessment on 4-6 cases per week. (2) Residents participate/observe at least 3 court proceedings for forensic and civil patients and to interact with attorneys and judges. Residents have on hour of individual supervision twice weekly for their primary therapy caseload. Attendings are present and supervising during those instances where residents conduct admission assessments. (2) Forensic examiners are present and supervise residents during pre-sentence examinations conducted by residents in response to court orders and co-sign any reports that a resident submits to the courts. A resident is expected to complete at least one such evaluation during the rotation. One hour of group discussion is provided for each of the four days that residents spend observing court proceedings. At any given time, trainees other than the PGY-2’s may be rotating on the service. Schedules for group discussions and case conferences are open to all trainees which may also include up to 2 PGY-4 psychiatric residents, up to 1 PGY-5 or 6 resident from the Child and Adolescent Program, and up to 6 psychology graduate students. All attend the same unit case conferences and meetings. Interaction between the different levels and types of trainees is encouraged. The Court Clinics are located at Brooklyn Criminal Court Building, Suite 572, 360 Adams Street Brooklyn, NY 11201 and Queens Criminal Court Building, Suite 220, 125-01 Queens Boulevard, Kew Garden, NY 11415. Both courthouses are within 8 miles of Kings County Hospital Center and convenient by car or public transportation.

Consultation-Liaison Psychiatry, Kings County Hospital Center

•		PGY-2 required 2-month rotation.
•		Faculty consists of 4 full-time psychiatrists.
•		Description of educational methods: 1. Ward Rounds: Direct observation of residents interacting with patients, families, medical, nursing and other staff and residents chart notes and presentation. 2. Individual and group supervision of residents. Residents present their cases and the cases are discussed. 3. Morning Reports: All faculty and residents on the service are present. New cases seen by the on-call resident in previous night are discussed. Other investigations or problem cases are discussed. 4. Weekly Journal Club: Each resident presents on alternate weeks. 5. Lectures on Consultation-Liaison Psychiatry. Breadth of clinical population and experience, including socioeconomic status, sex, age, ethnic/cultural mix, diagnosis and type of treatment. Age Range: 15 to 90 years Gender: About equal proportions of men and women Ethnic/Cultural Mix: African-Americans, Caribbean-Americans, Euro-Americans and Hispanics comparing the major groups. Socio-Economic Status: Wide range Health Insurance: Can range from no insurance to Medicaid, Medicare and private insurance. Diagnoses: Wide range of psychopathology and clinical problems. Depression, treatment refusal, organic mental syndromes, decisional capacity, somatoform disorders, medical illnesses mistaken for psychiatric illness, substance abuse, adjustment reactions, schizophrenic, bipolar, other psychotic and mood disorders. Treatment: Pharmacotherapy, crisis intervention, supportive psychotherapy, systems intervention including education of staff. Average caseloads and description: 1–2 new consultations/day and 3 follow up visits/day Scheduled supervision: frequency and whether individual or group Morning Rounds: Group supervision 4 days a week, 1 _ hours/day Afternoon Rounds: Bedside and office, individual or group, 1 _ hours/day, 4 days a week Individual supervision at other times as required at least once a week. Other (including any other important information relevant to clinical or educational experience). Residents are required to do literature reviews and present in a journal club bi-weekly. Residents are encouraged to publish and present at professional meetings. In the past 5 years there have been 8 publications in which resident were senior authors or co-authors. Residents also have won prizes in the Brooklyn Psychiatric Society presentation and have presented at the American Psychiatric Association and Academy of Psychosomatic Medicine Meetings.

Project for Psychiatric Outreach to the Homeless, Inc. (PPOH)

•		PGY-3 required part-time (3-4 hours per week) 12-month rotation. Residents are assigned to community-based agencies that work with mentally ill homeless persons.
•		PPOH’ s clinical staff consists of 1 full-time psychiatrist who serves as medical director and 1 full-time social worker who serves as clinical coordinator. Agencies where residents are placed generally have a multidisciplinary staff consisting of social workers, nurses, art therapists and case managers.
•		The majority of learning occurs on site as residents become integrated into the community agency. Formal group meetings are planned at the PPOH office and take place every other month. The PPOH medical director and clinical coordinator are available for consultation and to monitor caseloads, etc. Residents are assigned to the following community-based agencies: Arbor Inn – A transitional center for young mothers and their children. The women are African-American and Hispanic and range in age from 18-early 40’s. All of the children are under eight years old. Residents placed at Arbor Inn have an opportunity to do brief psychotherapy, group work and outpatient psychopharmacology. Diagnoses include depression and bipolar disorder, anxiety disorders, PTSD and some character logical disorders and substance abuse issues. Most Holy Trinity Single Room Occupancy – A permanent residence for formerly homeless individuals. Client are primarily Hispanic and middle-aged. Residents placed at the SRO perform psychiatric assessments as well as crisis intervention, outpatient psychopharmacology and short-term psychotherapy. Diagnoses include: Schizophrenia, bipolar disorder, depression, OCD, PTSD, and some character logical disorders and substance abuse issues. Oak Hall - A permanent residence for formerly homeless individuals. Clients are African-American and Hispanic, with more men than women. Residents placed at Oak Hall perform psychiatric assessments as well as crisis intervention, outpatient psychopharmacology and short-term psychotherapy. Diagnoses include: Schizophrenia, bipolar disorder, depression, OCD, PTSD, and some characterological disorders and substance abuse issues. St. Joseph’s Single Room Occupancy – A permanent residence for men and women over age 55. Most are in their 60’s and are African-American and Hispanic. Residents placed at St. Joseph’s perform psychiatric assessments as well as crisis intervention, outpatient psychopharmacology and short-term psychotherapy. Diagnoses include: Schizophrenia, bipolar disorder, depression, OCD, PTSD, and some characterological disorders and substance abuse issues. An average caseload consists of 5-7 clients and 1 group. Residents receive ongoing supervision from the medical director of PPOH and SUNY Downstate Medical Center faculty trained in community psychiatry. In addition, the PPOH clinical coordinator makes periodic site visits to assess the coordinated efforts of the resident’s education and the needs of the agency site.

17. Outpatient Psychiatry - Chapel Street Veterans Health Care Clinic (VHCC)

•		PGY-3 required part-time (two days per week) four-month rotation.
•		The one full-time board-certified clinical psychiatrist has chief responsibilities for teaching and supervising in this rotation. A didactic course on "Homelessness and other Psychosocial Issues" is taught one afternoon per week by a geriatric psychiatrist (part-time). The residents see patient from, and work with multidisciplinary team members from several distinct clinical programs in the Chapel Street Clinic. Staffing from these programs is as follows: TORCH (The Outreach and Recovery Center for the Homeless): 1 full-time coordinator (MSW), 4 full time case managers (MSW), 1 full-time Social Worker Assistant (BA). MH-ICM (Mental Health – Intensive Case Management): 1 full-time coordinator (MSW), 3 full-time case managers (MSW), 1 full-time case manager (RN), 1 full-time case manager (LPN). Mental Health Clinic: 1 full-time social worker (MSW), 1 full-time triage nurse (RN). Primary Care Clinic: 1 part-time (2/5) supervising internist (MD), 1 full-time physician assistant, 1 full-time LPN. 1 full-time clinic administrative assistant.
•		Educational methods include: didactic course (see above); journal club and discussion of selected readings; case presentations and discussions; direct observation of resident-patient interactions through informal observation, and through "mock board" sessions; weekly participation in multidisciplinary team meetings; formal and informal individual supervision; group supervision. The Chapel Street Clinic is an outpatient community-based Veterans Administration clinic located in downtown Brooklyn. The clinic is part of the VA’s NY Harbor Healthcare System, and is affiliated with both the Brooklyn VA and Manhattan VA Medical Centers. This clinic has several mental health programs including: TORCH (a treatment program for homeless veterans); MH-ICM (an intensive case management program chiefly for chronic and recidivistic psychiatric patients); VASH (a supported-housing program for veterans); SARP (a substance abuse recovery program); CWT (continuing work therapy and pre-vocational services); a Mental Hygiene Clinic; and a Primary Care Clinic. We also provide psychiatric coverage for veterans in treatment at the Vets Center on the 6th floor of this building (combat veterans, chiefly with PTSD and other service-related problems). The population is 95% male. A range of socioeconomic status is represented, from homeless and unemployed to those supported by social security and/or VA benefits, to those just entering/reentering the work force, to those fully employed. Multiple ethic/cultural/racial backgrounds are represented: African American, Caucasian, and And Hispanic. Similarly, a full range of diagnoses is seen at this clinic with most frequent diagnoses being schizophrenic-spectrum disorders, affective disorders, PTSD, and substance abuse/dependence. Residents carry an ongoing caseload and provide their patients with initial evaluations and diagnostic assessments, medication management and individual therapy in selected cases. During the first year of this rotation, the average PGY-3 resident caseload at this part-time rotation was 25.2 patients. The maximum caseload was 32, though there is no set maximum. Residents are scheduled to see at least one (occasionally two) new evaluation(s) each day of service, in addition to their scheduled follow-up/continuing patients. The description of patients is a mix of clinic patients, as described above. The design of the rotation is that of each resident having his/her own small outpatient clinic, which he/she manages under the supervision of the clinic director. The resident’s attendance at multidisciplinary team meetings, didactic sessions, and formal supervision is scheduled, and each of these is mandatory and weekly. As the clinic director is full-time and on-site, informal supervision is readily available. Scheduled supervision is weekly. Both individual and group supervision is utilized. The VA is fully networked through CPRS (Computerized Patient Record System). Each resident must learn to utilize the electronic medical record system during his or her outpatient rotation at Chapel Street.