CONCLUSIONS REACHED BY BELLEVUE ON THE PILOT OUTPATIENT ASSISTED TREATMENT PROGRAM

1. The Bellevue Outpatient Commitment Pilot Program had many unique conditions, which must be appreciated in assessing the potential benefits of outpatient commitment in New York.

The implementation of the pilot project mandated by MHL Section 9.61 required the development of new clinical and legal documents, procedures and interventions. In a number of areas, such as the development of the Medication Guidelines and the MHL Section 9.61 transport protocol, difficult political, clinical, legal and ethical issues had to be considered and resolved. The Medication Guidelines were implemented on May 1, 1996, almost a year after the program began operating, and the transport protocol was not implemented until October 26, 1998.

Clinicians, providers, judges, consumers and family members had to be educated regarding the program. The coordination with and accommodation to the needs of the PRA further complicated the development and operation of the program. Throughout the period of the pilot project, the OCP has been understood to be a work in progress.

2. A successful collaboration between the Bellevue OCP and over eighty other provider agencies was achieved by the close coordination of services and the shared commitment to work with a population that is very ill and perceived as difficult to serve.

The OCP received enormous cooperation across the provider community in New York. There has been a great deal of interest in outpatient commitment as a way of working with the most resistant, noncompliant patients. Providers generally state that they do not view outpatient commitment as a substitute for care, but rather as a mechanism that offers the assistance of the judicial system, as well as of Bellevue and the CT, in insuring the delivery of necessary and appropriate treatment to patients whose symptoms have prevented them from accepting it.

3. Many clinicians have observed that outpatient commitment orders often assist patients in complying with outpatient treatment and services.

For some patients, the order allows initial engagement with service providers, and is rarely an issue after that time. For other patients, the order serves as an ongoing reminder that compliance with outpatient treatment is necessary to prevent relapse and rehospitalization. For patients with impaired insight and judgment, the court order asserts that both providers as well as the court system have determined that outpatient treatment is necessary and beneficial.

The court orders are also useful in addressing the ambivalence which is so often a feature of schizophrenic disorders; they assist patients with making decisions about outpatient care. For patients with substance abuse disorders, the court order sometimes serves to maintain compliance with medication and services even during episodes of active substance use. And outpatient commitment orders appear to increase feelings of accountability among patients about managing serious symptoms of mental illness such as hallucinations, paranoia and fluctuations in mood.

4. From Bellevue’s perspective, patients have often responded positively to outpatient commitment and have not generally perceived it as harmful.

Upon initial screening for the OCP, the majority of patients express a desire to leave the hospital and find services which will help them in the community; they typically express little apprehension about a court order. Patients generally understand that the order is meant to prevent future noncompliance and sometimes state very specifically that the order is helpful in maintaining treatment. Even patients who oppose initial and renewal orders have not stated that outpatient commitment is damaging; rather, they usually state that they do not require it. However, some patients state that they experience the court order as restrictive and would prefer not to have it.

5. Outpatient commitment is an order to comply with treatment and services, and these must be available, appropriate and of good quality in order for patients to do well. Outpatient commitment is not a substitute for services.

Court orders have been understood and used by providers in many different ways. They provide a legal structure within which the provider and patient may negotiate treatment and are often referred to as a “contract.” The degree to which providers are committed and capable of working with very ill and often resistant individuals very much determines how much assistance the court order provides. 

6. The monitoring and coordinating role of the CT has been invaluable to the success of the OCP. Mobilization of services in enhanced by outpatient commitment orders.

The CT works with provider agencies to develop appropriate treatment plans. After a patient is discharged to the care of providers, the CT monitors the progress of the patient and works with the providers on an ongoing basis regarding possible changes in the treatment plan and issues of noncompliance. The CT has helped to insure continuity of care when there is a need to change or find new providers. The CT continues to attempt to locate patients who leave treatment throughout the duration of their active orders. Bellevue has also found that in many cases the court order and the authority of the legal system contribute to providers’ ability to persist in outreach to patients who refuse community treatment due to mental illness. 

7. Outpatient commitment is a mechanism which may, in conjunction with good, coordinated clinical services, promote access to and compliance with outpatient care among patients who have refused and rejected treatment due to mental illness. It is not a panacea.

 Sometimes outpatient commitment has great value, while at other times it is a helpful adjunct to treatment. In some cases patients and providers indicate that it makes little difference or is unnecessary or may, at times, increase an individual’s resistance to treatment. In Bellevue’s experience, most patients, providers and families have agreed that the potential benefit offered by outpatient commitment is much greater than any harm it may cause. 

8. As community awareness regarding the OCP grew, the CT received more and more requests from families and providers to access outpatient commitment.

Many individuals contacted the CT and described their attempts to stop the revolving door syndrome; they hoped that the assistance of the court order would allow individuals with mental illness to access the care that they were being offered. Throughout the pilot the CT has received many requests for information about outpatient commitment, and heard much interest expressed in making it more widely available after the pilot program ends.

9. There are important areas of agreement and disagreement between Bellevue’s clinical and implementation experiences and PRA’s research analysis.

Bellevue is in substantial agreement with the PRA analysis on a number of points: a) that it was difficult to implement a pilot project that required the resolution of many sensitive clinical, legal and ethical issues; b) that “under the auspices of a pilot outpatient commitment program the Bellevue Coordinating Team was able to mount an effective service coordination and resource mobilization effort that proved very popular with community providers;” c) that the “terms and conditions for successful compliance under the OCP were negotiated between providers and program clients on an ongoing basis, proving the court orders to be flexible in interpretation;” d) that the CT’s service coordination and resource mobilization functions “seemed to make a substantive positive difference in the post discharge experiences of both the experimental and control groups;” and e) that OCP court procedures are often informal, although Bellevue interprets the legal process of outpatient commitment differently from PRA.

Bellevue disagrees with the PRA conclusion that the “court order itself had no discernible added value in producing better outcomes.” Bellevue believes that this conclusion must be questioned in light of the limitations of the PRA study and trends which indicate that outpatient commitment reduces time spent in the hospital. This conclusion is also inconsistent with much of the clinical experience of Bellevue and community providers. In addition, PRA confuses past and current dangerousness in its discussion of eligibility for the OCP. 

SELECTED BIBLIOGRAPHY

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