PROGRAM DESCRIPTION OF PILOT OUTPATIENT COMMITMENT PROGRAM AT BELLEVUE HOSPITAL IN NYC
PROGRAM PLANNING AND OVERSIGHT
Bellevue began preparing to operate the OCP during the first months of 1995. In addition, a series of planning and oversight meetings were held during that period, which included representatives from Bellevue, HHC, DMH and the New York State Office of Mental Health (SOME). These were called “Umbrella Committee” meetings and were intended to guide the enormously complex process of interpreting and implementing a new mental health law and program. The Umbrella Committee became responsible for negotiating and finalizing a range of policy decisions that were made during the planning process. After PRA was hired, it also participated in the Umbrella Committee.
The OCP began operating in July 1995. The Umbrella Committee has continued to meet throughout the duration of the pilot program since important elements of the law were not yet in place, and because policy questions continued to arise as the program took shape.
THE OCP COORDINATING TEAM
The Bellevue OCP is staffed by an interdisciplinary Coordinating Team (CT). The CT has been responsible for implementing the clinical program and insuring that all of the elements of the law have been effectuated. The CT performs a variety of clinical, administrative and medico-legal functions. In addition, the CT was responsible for working closely with PRA to provide access to patients, medical records and clinical and administrative meetings.
PATIENT ELIGIBILITY
In order to be eligible for the OCP, individuals must meet all of the criteria set forth in MHL Section 9.61. These criteria include that:
“(I) the patient is eighteen years of age or older;
“(ii) the patient is suffering from a mental illness;
“(iii) the patient is incapable of surviving safely in the community without supervision, based on a clinical determination;
“(iv) the patient 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;
“(v) the patient has a history of lack of compliance with treatment that has necessitated involuntary hospitalization at least twice within the last eighteen months;
“(vi) the patient is, as a result of his or her mental illness, unlikely to voluntarily participate in the recommended treatment pursuant to the treatment plan;
“(vii) in view of the patient’s treatment history and current behavior, the patient is in need of involuntary outpatient treatment in order to prevent a relapse or deterioration which would be likely to result in serious harm to the patient or others. . .;
“(viii) it is likely that the patient will benefit from involuntary outpatient treatment. . . .”
REFERRAL PROCESS
A referral to the OCP must indicate that the patient meets all of the above stated criteria. Any psychiatrist attending at the Bellevue Comprehensive Psychiatric Emergency Program (CPEP) or on the Bellevue inpatient service may refer a patient to the OCP. Once a referral form is received, CT staff verify that the patient meets the eligibility criteria, which requires the review of medical and legal records, and often requires obtaining information from other hospitals. CT staff then screen eligible patients and serve those who are clinically appropriate with notice that they are being considered for the OCP. During the screening, patients are encouraged to actively participate in the development of their community treatment plans. Patients are also asked if they would like to have a family member or friend formally notified, and involved in the development of the treatment plan.
DISCHARGE PLANNING
An OCP candidate’s inpatient treatment team is responsible for developing the comprehensive discharge plan, as is the case for any other psychiatric inpatient. CT staff provide ongoing consultation and assistance in developing optimal outpatient plans for these patients. Each treatment plan is individually tailored to achieve the best fit of consumer and services, and to maximize consumer choice and the likelihood of compliance and successful outcomes. This process takes into account supports and resources already in place in the community, the patient’s choices and preferences for housing and services, the patient’s past history and current clinical needs, and the availability of services. At any one time he CT typically follows between 20 and 40 patients on Bellevue’s adult inpatient psychiatric units.
OUTPATIENT COMMITMENT ORDERS
MHL Section 9.61 provides that the court may order a patient to comply with outpatient mental health treatment and services for a period of up to 180 days. Additional court orders for up to 180 days at a time may subsequently be requested.
MHL Section 9.61 defines “involuntary outpatient treatment” as any of the following categories of service which have been ordered by the court:
1) medication
2) individual or group therapy
3) day or partial day programming activities
4) services and training, including education and vocational activities
5) supervision of living arrangements
6) intensive case management services
7) and “any other services within the local plan prescribed to treat the person’s mental illness and to assist the person in living and functioning in the community, or to attempt to prevent a relapse or deterioration that may reasonably be predicted to result in the need for hospitalization.”
MEDICATION
MHL Section 9.61 provides that the court may order medication as a category of service only if specific criteria are met. In addition to demonstrating the patient’s eligibility for outpatient commitment, the hospital must show by clear and convincing evidence that:
1) “the patient lacks the capacity to make a treatment decision as a result of mental illness;”
and
2) “the proposed treatment is narrowly tailored to give substantive effect to the patient’s liberty interest in refusing medication, taking into consideration all relevant circumstances, including the patient’s best interests, the benefits to be gained from the treatment, the adverse side effects associated with the treatment and any less intrusive alternative treatment.”
A patient’s treating physician must complete an application to the court verifying the above and indicating the type and amount of each psychotropic medication being requested. A second physician must then evaluate the patient, with the Mental Hygiene Legal Service (MHLS) present, if requested, to affirm that all of the criteria are met. The Director of Psychiatry or his Designee must review the request before it becomes part of the hospital’s outpatient commitment application.
TREATMENT AND SERVICES
Because appropriate clinical services are the basis of good care, patients in the OCP must have some form of psychiatric treatment, housing, and case management included in their discharge plans. An OCP discharge plan is complete when providers have been identified for each and every service that has been included on the treatment plan. Because MHL Section 9.61 states that the OCP must be “willing and able to provide the involuntary outpatient treatment ordered,” providers must formally accept patients in order to be included in completed discharge plans.
Individual, group and day treatment are provided by many different hospital and community-based agencies throughout New York City. In addition, the Bellevue POWER day treatment program was developed in conjunction with the OCP to work with very ill patients who have histories of noncompliance and substance abuse, and for whom more traditional programs are not appropriate.
Supervision of living arrangement is provided by many types of supported and supervised housing programs which are available throughout New York City. Community residences, supervised single room occupancy hotels, apartment programs and adult homes provide varying levels of structure, monitoring and outreach to clients. Transitional living communities (TLC), are shelter-based programs which provide both housing and treatment services on site to seriously mentally ill patients who are also homeless; their goal is to help patients achieve psychiatric stability and to find permanent housing in the community. Providers of all of the above types of programs have worked with patients who have orders to comply with supervision of living arrangements.
Case management provides linkage to and coordination of services, including housing, benefits, psychiatric and medical treatment, and rehabilitation services. Case managers also provide outreach, support, therapeutic activities and crisis intervention services. In New York State, supportive case management (SCM) typically provides two meetings per month, while intensive case management (ICM) provides four meetings per month. Assertive community treatment (ACT) teams provide a full range of case management, treatment and rehabilitation services on an outreach basis in the community; they typically consist of a psychiatrist, a nurse, a social worker, a substance abuse counselor, a social work assistant and a peer specialist. Intensive case management, supportive case management and assertive community treatment can all be ordered as categories of service on outpatient commitment orders.
NOTICE AND HEARINGS
When there is a plan to request an outpatient commitment order, the CT serves the patient and MHLS with written notice. The patient may also choose to have a relative or friend notified. Separate notice is served for requests for medication orders. Once an Order to Show Cause is generated, the patient is notified by a process server of the scheduled court date. Outpatient commitment hearings are held once a week in the courtroom on the Bellevue campus. In order to issue an outpatient commitment order, the court must find by clear and convincing evidence that “the proposed treatment is the least restrictive treatment appropriate and feasible for the patient.”
The court may only order categories of service and medications which have been included in the OCP treatment plan. Since an outpatient commitment order requires a patient to comply with categories of service, not with individual providers, the court order lists categories of service, while the treatment plan lists the specific providers. Patients have a right to be represented at the hearings, and MHLS is responsible for providing such representation. The patient can also choose to retain a private attorney.
MHL Section 9.61 provides patients for whom outpatient commitment is ordered with the right to appeal. A court-ordered patient also has the right to apply for an order to stay, vacate or modify an order for psychotropic medication. It is also possible to modify outpatient commitment orders once they are in effect. Additions or deletions of categories of service from an outpatient commitment order, and changes in a medication order without the patient’s consent must be brought before the court.
Changes of provider within a category of service do not require court hearings. Therefore, an outpatient care plan may be changed at any time as long as there is a provider for each category of service in the order and any necessary court approval is obtained.
OUTPATIENT CARE
After the court issues an outpatient commitment order, the patient is discharged to the care of the outpatient providers included in the OCP treatment plan. Outpatient providers have responsibility for providing ongoing treatment and services to their court-ordered patients according to the standards of care of their organizations and agencies.
The CT is available to assist with any aspects of patient care, and remains in regular contact with all providers to insure that services remain coordinated and appropriate. In addition, when patients leave or are discharged from clinical programs, the CT works actively to insure that patients have access to other appropriate services, so that they may remain compliant with community treatment. In some instances, the CT provides direct psychiatric services, which insures that patients always have access to medication and other needed medical treatments. The CT follows patients as long as an outpatient commitment order is in effect.
NONCOMPLIANCE
Outpatient providers are responsible for assessing compliance with treatment and services for their OCP patients. The CT provides assistance in evaluating compliance and reassessing outpatient care plans. The CT also provides ongoing consultation regarding appropriate clinical interventions for noncompliance. Furthermore, when outpatient providers have discharged patients because they are not utilizing services, the CT is responsible for continued outreach throughout the duration of the court order.
Noncompliance is not, in and of itself, grounds for hospital readmission under MHL Section 9.61. Patients may only be admitted to a hospital if they meet the appropriate legal standard for admission. The law does, however, provide a mechanism for facilitating an appropriate evaluation. It states that if an examining physician determines that a patient under court order has been noncompliant and may meet admission criteria, that physician may contact the Bellevue Director of Psychiatry or his Designee. Such individual may then direct the New York City Sheriff’s Office to transport the patient to Bellevue for evaluation for admission.
The law provides a second possible consequence of noncompliance for patients with outpatient medication orders. If an examining physician determines that a patient is noncompliant with medication, and efforts have been made to solicit compliance, the medication specified on the court order may be administered over the patient’s objection. This may be done according to the “Guidelines for Administration of Medication to Patients Who Fail to Comply with Court Ordered Medication” which have been issued by the President of HHC, in consultation with SOMH. These “Medication Guidelines” may be found in Appendix A.
It is significant that the Medication Guidelines require that the forcible administration of medication to a refusing patient may only be done safely in a hospital. However, the statute does not provide for the transport of patients to the hospital explicitly for this purpose.
It is important to note that MHL Section 9.61 explicitly states that “failure to comply with an order of involuntary outpatient commitment shall not be grounds for involuntary civil commitment or a finding of contempt of court.” No aspect of MHL Section 9.61 involves the criminal courts or the criminal justice system.
It is ultimately the responsibility of the CT to attempt to insure that patients have access to services and are in compliance with them, as outlined in the court order. Within that framework, however, there is a broad range of flexibility to allow each individual situation to be assessed by clinicians in a clinical context, and to emphasize the preservation of therapeutic relationships and to maximize consumer choice. Noncompliance is a complex phenomenon, which may have many causes, and which must be assessed on an ongoing basis taking all factors into consideration. Outpatient commitment orders permit the CT to do extensive outreach and follow up, and to emphasize to patients the necessity and value of staying in treatment in the community.
ADDITIONAL PERIODS OF OUTPATIENT COMMITMENT
MHL Section 9.61 provides that the hospital may apply for extensions of a patient’s outpatient commitment order if the patient’s condition requires it. Each additional outpatient commitment order may be for a period of up to 180 days. Patients have all of the same rights regarding the renewal request and hearing process as they do when outpatient commitment orders are initiated.
RESEARCH PARTICIPATION
During the first six months of operation, all patients enrolled as OCP candidates were brought to court for outpatient commitment orders, as per the treating physician’s request, if and when comprehensive discharge plans were completed.
The PRA research study formally began in January 1996. Patients were recruited into the PRA study from January 1996 through February 1998. The outcome study compared patients who received court orders with those who received enhanced, coordinated clinical services without court orders. The goal of the study was to determine the effect of the court order on community tenure of mentally ill individuals whose noncompliance had previously resulted in involuntary hospitalization.
From January 1996 through February 1998, all patients who became candidates for the OCP were referred to PRA staff. The PRA team then assessed the patients and attempted to gain informed consent from those were thought to be appropriate for the study. Patients who did not consent or were not chosen to participate in the research were brought to court for outpatient commitment orders; all of those patients are followed by the CT for the duration for the court order. Patients whom PRA found appropriate and who then consented to participate in the study were randomly assigned by PRA to two groups: 50% were brought to court for outpatient commitment orders and 50% did not go to court, and thus served as “controls” in the study.
Patients in the control group were discharged to the care of the outpatient providers included in their discharge plans, just like the patients with court orders. The CT follows control patients for one year after discharge from the referring inpatient hospitalization. In these cases the CT also coordinates and monitors services, and attempts to insure that patients continue to have access to needed services. The CT has authority to do extensive outreach, but there is no requirement that the patient complies with the services.
Since March 1998, all OCP candidates have been brought to court for outpatient commitment orders, as per the treating physician’s request, if and when a comprehensive discharge plan is completed.
(Excerpted from REPORT OF THE BELLEVUE HOSPITAL CENTER OUTPATIENT COMMITMENT PILOT PROGRAM prepared by:Howard Telson, M.D. Richard Glickstein, Esq. Manuel Trujillo, M.D., MARCH 1, 1999 Bellevue Hospital Center, Department of Psychiatry, 462 First Avenue, New York, NY 10016)
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