NEW YORK >> It has grown into a grim ritual of late in New York City: a burst of violence in which a person with mental illness is the victim or aggressor, followed by the city mapping out breakdowns in care and pledging to stitch the safety net tighter.

But the late stages of a sick person’s struggle — medications missed, doctors’ declining last-minute appointments, hospitals that discharge patients with little follow-up care — are often only a coda to years of moving between home and a hospital bed.

A new report shows that those patients are being cared for more and more by the city’s strained public hospital system, as financial pressures on some private hospitals drive them to divert psychiatric patients and close beds.

The number of mental health admissions at public city hospitals increased sharply over the five years ending in 2014, even as private hospitals shed psychiatric inpatients over the same period, according to the report, released last month by the city’s Independent Budget Office. The share of beds that public hospitals designated for psychiatric patients was more than three times greater than in private hospitals.

The report, providing a fresh look at a long-standing issue, points to the slow churn of change in mental health care. Despite widespread agreement that many patients are better treated and treated at lower costs outside the hospital, serious alternatives to psychiatric wards remain few and far between.

Hospitals provide extensive outpatient care, but every year tens of thousands of people, many of them poor and underinsured, continue to seek help at emergency rooms that offer limited personalized attention and hardly skim the surface of the social problems that contributed to them ending up there.

“The mental health system is always behind in how they’re handling things,” said Kinsey McManus, services director at the National Alliance on Mental Illness of New York City. “Stigma is rampant on all levels, including on what’s the priority in the agenda of the government, what’s the priority of hospitals.”

The city’s public hospitals system, the Health and Hospitals Corp., said inpatient mental health stays have declined since 2014. And New York state is in the third year of a $7 billion Medicaid reform plan that encourages hospitals to avoid unnecessary hospitalizations, especially for mental illness, by instead investing in helping people manage their medications outside the hospital and integrating psychiatric care with other doctor visits.

In the first two years of the plan, the state reduced avoidable emergency room visits for mental health patients by 12 percent, said Jason Helgerson, the state’s Medicaid director. And a network of hospitals and community groups organized by the city’s public hospital system had a 5 to 9 percent decline in potentially preventable readmissions and potentially preventable emergency room visits from July 2015 to June 2016, meeting its targets.

“Historically in New York we treated the body and mind in totally separate silos,” Helgerson said. “What we’re trying to do is bring those together in clinical settings.”

But for patients who do not receive early help, public city hospitals are increasingly where they land. The consolidation of private hospitals in New York City and a reduction in costly and often unprofitable psychiatric beds there have put public hospitals in the position of providing much of the emergency care.

There were almost 25,000 mental health hospitalizations in the city’s public system in 2014, up from 20,550 in 2009, a nearly 20 percent increase. Inpatient stays declined by 5 percent at the city’s private hospitals over the same period. That was the most recent data available to the Independent Budget Office.

One hospital visit is often followed by another. Patients and mental health advocates describe them as bleak, lonely places, often reliant on medications, inattentive to people’s other ailments and severe in how they deny people of their rights and choices. Roughly 70 percent of hospital readmissions that New York state deems avoidable in the Medicaid system are for people with a primary diagnosis of behavioral health problems.

“There’s so much going on in the hospital that nobody really has the time to sit there and really dig deep into the root of the problem,” said Orlando Garcia, 43, who sought help at the city’s Bellevue Hospital Center about a decade ago. “Everything is, ‘You’re depressed, we need to give you antidepressants.’”

After seeing part of Bellevue’s psychiatric ward on that visit, he decided against being admitted.

More recently, Garcia stayed for a week at one of the city’s four respite centers, bed-and-breakfast-type alternatives to hospitals where guests receive group counseling, peer support and connections to psychiatrists. Garcia, previously a member of an antiterrorism task force in the New York National Guard, had gotten sick with Crohn’s disease, lost a squad leader who was also a close friend in a motorcycle crash, and watched his mother’s dementia worsen.

He said he needed to get help outside his home, and the respite center — run by Community Access, a nonprofit, and located in Gramercy Park — made him stronger in dealing with his problems. Now he is seeking to become a peer support specialist there.

“It wasn’t like going to the hospital,” he said. “I didn’t feel like I was being incarcerated, and I didn’t feel like I was being diagnosed with something I didn’t have.”

The city’s respite centers have been shown to reduce readmissions and save money compared with a hospitalization. Karyn Rivers, 55, said she had used stays at the Gramercy Park center to transition home after various crises: after a stay in a substance abuse rehabilitation program, after an assault, and, this month, after being released from a long surgical hospitalization. She was also planning to start seeing a psychiatrist referred to her by a public city hospital. “Not everyone needs to go to a hospital to take care of an emotional or mental crisis,” Rivers said.

There are 38 beds across the four sites, and stays were trimmed to one week under New York state guidelines after funding shifted from a federal grant to Medicaid. Mental health advocates have called for more beds.

The state’s Medicaid reform efforts are also running up against the reality that hospitalizations will be difficult to reduce without addressing the homelessness and joblessness that often accompany mental illness.

There were roughly 70,000 psychiatric visits to public hospital emergency rooms in each of the last two fiscal years. The share of inpatient care at public hospitals stemming from mental illness increased to almost 13 percent in 2014 from 9.5 percent five years earlier, while it rose very slightly in private hospitals.

The city’s Health and Hospitals Corp. said in a statement about the budget office report, “We embrace our mission to provide mental health services to all New Yorkers, regardless of insurance status, but we cannot do it alone.”

Six private city hospitals have closed a total of 166 psychiatric beds since 2012, according to data from the state health department, sometimes to use them for other, more lucrative specialties. Two public hospitals have also closed psychiatric beds, though there have been modest additions at a small number of public and private hospitals. Concentrating care at fewer facilities can have the effect of sending patients to places with greater expertise but also leads to some patients being diverted.

“The public hospitals are taking care of a lot more of the most vulnerable population,” said Anthony Feliciano, director of the Commission on the Public’s Health System, a citywide health advocacy organization. “It’s a tale of two different hospital systems.”

Like the public system, some private hospitals have also moved to reduce inpatient stays by improving their outpatient services and better coordinating treatment after someone leaves the hospital. Maimonides Medical Center in Brooklyn is one such example. It has maintained 70 psychiatric beds in recent years, and they remain nearly filled to capacity as another major Brooklyn hospital, Kings County Hospital Center, a public hospital, has closed 56 psychiatric beds amid efforts to revamp its once-troubled psychiatric ward.

“We think there’s a great need to organize better care for folks with behavioral health issues across the board in ways that can reduce the need for inpatient care,” said Kenneth Gibbs, the president and chief executive of Maimonides.

As part of ThriveNYC, an investment in mental health of more than $850 million over four years, New York City has expanded efforts to connect people to care and created programs starting in early childhood to improve social-emotional learning. After a first psychiatric hospitalization for 18- to 30-year-olds, city health department social workers and peer specialists also try to help some of them get care and return to the community.

“Hospitals are traumatic — they don’t treat people well,” said Carla Rabinowitz, who herself was hospitalized before becoming the advocacy coordinator for Community Access. “There’s a lack of respect for people’s bodies.”

But, she said, people continue to show up at emergency rooms, whether for shelter or because of a psychiatric emergency, and health authorities needed to provide more alternatives.

“The problem with the hospital model is it focuses on pills as the only treatment method,” said Steve Coe, the chief executive of Community Access. “We believe that medication isn’t the only solution, and people have to stop thinking of hospitals as the only solution.”

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