Outpatient Commitment Pilot in New York Shows Program Works

New York State's historic skepticism about involuntary outpatient commitment is being challenged by some early successes within its first program for court-ordered treatment. The state's pilot outpatient commitment program (OCP) is now entering its final year (it expires in June 1999), and several practitioners presented an overview of it last month at APA's annual meeting in Toronto.

The Bellevue Hospital Center department of psychiatry OCP is run by the Coordinating Team in the Psychiatric Ambulatory Care Clinic. The team is made up of a psychiatrist, two social workers, a manager, and a supervisory social worker. The team is responsible for implementing the clinical program in accordance with Section 9.61 of the New York State Mental Hygiene Law and for administering the legal aspects of the program. In addition, the team works with a private company called Policy Research Associates to study the OCP.

Bellevue's OCP has received 673 referrals since it was instituted on July 1, 1995. Of the 160 court orders the program has requested, 159 were granted. Sixty-five patients were discharged as controls, and 109 patients are now active in the program.

Manuel Trujillo, M.D., director of psychiatry at Bellevue Hospital, said the OCP is a complex program that has been created and implemented despite many obstacles. New York's liberalism and strong civil rights history sometimes hindered sound professional judgment about the need for involuntary commitment, he said. Government systems, regulatory bodies, and forensic groups were all skeptical about involuntary commitment.

About 36 other states already had statutes making involuntary outpatient commitment legal when New York enacted legislation in 1994. Chapter 560 of the New York State Laws of 1994 amended both the judiciary and mental hygiene laws to allow the establishment of a three-year pilot program to provide for "involuntary outpatient treatment of mentally ill persons." It also called for a study to determine the effectiveness of the program.

Managing the OCP's development has involved finding ways to include government, mental health professionals, and consumer advocates in planning, said Trujillo. It takes a tremendous amount of organization as well as an effort to educate policymakers about the program and its benefits and to motivate community mental health providers to work with Bellevue in caring for discharged patients, he noted.

"We will have success if we're able to ally the structures of incentives with the extraordinary demands of a program like this," he said.

Running the OCP itself is a complex task, said Howard Telson, M.D., director of the outpatient coordinating team (OCT). Clinicians in inpatient services and the emergency room refer patients to the program. The team evaluates them, does clinical screenings to ascertain that the patient is not complying with recommended treatment, and then works with the unit staff responsible for treatment. If after treatment the team determines that the patient can return to the community, the team creates a discharge plan and connects the patient with services in his or her own community.

The court may order a patient to comply with outpatient mental health services for a period of 180 days, and the OCT can request a court order for an additional 180 days. Categories of patient services include medication, individual or group therapy, day or partial day treatment activities, supervision of living arrangements, intensive case-management, supportive case management, and assertive community treatment.

To be eligible for the OCP, individuals must meet all of the following criteria as listed in the legislation:

1. The patient is 18 years of age or older and


2. is suffering from a mental illness;


3. is incapable of surviving safely in the community without supervision, based on a clinical determination;


4. is hospitalized at Bellevue or, in the case of an application for an additional period of treatment, the patient is currently receiving involuntary outpatient treatment;


5. has a history of lack of compliance with treatment that has necessitated involuntary hospitalization at least twice within the last 18 months;


6. as a result of his or her mental illness, is unlikely to participate voluntarily in the recommended treatment pursuant to the treatment plan;


7. is in need of involuntary outpatient treatment to prevent a relapse or deterioration, which would be likely to result in serious harm to the patient or others; and


8. is expected to benefit from involuntary outpatient treatment.

According to Telson, "Research strongly suggests that court-ordered outpatient treatment is effective in reducing the rate of rehospitalization, reducing length of stay of subsequent rehospitalizations, and reducing danger to the community."

The problem with prior research on outpatient commitment, he said, is that most studies were not prospective and not randomized, and were based on only small numbers of patients. Most OCP's were put into places with enhanced clinical services to do follow-up, and there was more case management and outreach. Prior research, therefore, didn't address the question of what is making the program work-coercion, clinical services, or both. The PRA/Bellevue study made sure the groups studied were matched in terms of clinical services.

At this point in time, said researchers from PRA, the patients who have been treated through the OCP have improved and the program looks quite promising. Meanwhile, the Bellevue OCT has gained vital experience running the pilot outpatient commitment program that it can then apply to creating a permanent OCP, said Telson. Psychiatrists at Bellevue hope the model they have used can be implemented throughout the state.