PROGRAM DEVELOPMENT AND FINDINGS ABOUT BELLEVUE OUTPATIENT ASSISTED TREATMENT PROGRAM
(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)
PROGRAM IMPLEMENTATION
The pilot program was viewed as an opportunity for the entire mental health community to learn about the potential value of outpatient commitment in New York as well as the barriers to its optimum implementation. The Bellevue OCP was developed as a clinical program which uses a legal intervention to improve the lives of patients. This view is consistent with MHL Section 9.61 as well as with the extensive literature on outpatient commitment (see Selected Bibliography). The pilot had many unique conditions, which must be appreciated in assessing the potential benefits of outpatient commitment in New York. Implementation has been especially challenging because the clinical and legal documents, procedures and interventions had to be newly developed. Further, since the OCP was being independently studied, close collaboration with the PRA team was required, and the study significantly affected the growth and development of the pilot in many ways. Also, because the program was operated out of only one site in New York City, most consumers, providers and family members were unfamiliar with its theory and practice. A massive, ongoing educational program was required to implement the program at Bellevue and in the community.
STAFFING
The CT originally consisted of a part-time ( twenty-five hours per week) Director, who is a psychiatrist; a full-time Coordinating Manager from Psychiatry Administration; a part-time (two days per week) attorney; and a secretary.
The first Coordinating Manager left the OCP in December 1995; since then the Coordinating Manager has been a social worker. As the program developed, the service needs of the growing number of patients increased, and the PRA research created new tasks and functions for the CT. As a result, a full-time staff social worker position was added to the CT in November 1996.
The CT’s first attorney resigned in February 1996, but continued to represent the hospital at the weekly 9.61 hearings. An attorney from HHC performed many of the program’s other legal functions until a new part-time (one day per week) attorney was hired for the CT in August 1997.
A part-time (four hours per week) psychiatrist was made available to the CT in the spring of 1996, and continued working with the CT through June 1997. A part-time (seven hours per week) psychiatrist position was added to the CT in July 1998. The CT’s ability to provide direct psychiatric treatment insures that all OCP patients always have access to medical assessment and medication.
ELIGIBILITY DETERMINATION
One major function performed by the CT is verifying patient eligibility for the OCP. While CPEP and inpatient psychiatrists initiate all referrals, the CT is sometimes required to obtain additional information and perform further clinical assessments to insure that the patient is appropriate for the OCP. In assessing eligibility, the CT uses information from medical records as well as from patients, family members and clinicians.
In an effort to understand outpatient commitment in its larger context, the OCP reviewed eligibility criteria from other jurisdictions. Appendix C summarizes different state approaches to outpatient commitment eligibility. The following describes the experience of the pilot program in relation to the MHL Section 9.61 eligibility criteria.
1. Patients must suffer from a mental illness in order to be eligible for the OCP.
Almost all patients who have been referred to the OCP suffer from a severe psychotic disorder. Approximately 90% of referred patients have diagnoses of schizophrenia, schizoaffective disorder, or psychotic disorder not otherwise specified. Approximately 10% of referred patients have had diagnoses of bipolar affective disorder or depression. Approximately half of all patients referred to the OCP also have substance abuse disorders, which generally involves alcohol, cocaine, and/or marijuana. Patients with substance dependence disorders and no other major mental illness have been referred to the OCP on a few occasions; although they have been found eligible by diagnosis, none of these patients has ever been enrolled in the program for a variety of reasons.
2. MHL Section 9.61 provides that in order to be eligible, “the patient is incapable of surviving safely in the community without supervision, based on a clinical determination.”
Patients referred to the OCP have significant histories of psychotic thinking and behavior and poor compliance with outpatient care which has resulted in serious impairment in functioning. Eligible patients have clinical histories which indicate that they require treatment and services to live safely in the community. Without such care, which usually includes psychotropic medication, these patients often become dangerous to themselves and/or others and require hospitalization. Furthermore, almost half of all patients referred to the OCP are homeless.
3. A patient must be hospitalized at Bellevue in order to be initially eligible for the OCP.
Bellevue, HHC and DMH agreed at the project’s outset that the transfer of patients from other hospitals to Bellevue for the sole purpose of participation in the OCP was not routinely feasible during the pilot. As community awareness of, and familiarity with, outpatient commitment grew, the CT received many requests for assistance with obtaining outpatient commitment orders from providers and family members. Over the course of the pilot it was possible, on a few occasions, to transfer patients from other facilities to Bellevue to participate in the OCP.
Throughout the course of the pilot, providers and family members inquired about the possibility of referring individuals residing in the community to the OCP. They expressed the desire to use outpatient commitment as a tool to help prevent further decompensation and hospitalization. They also often stated that outpatient commitment should be available to patients in the community who may not have been hospitalized recently but who otherwise meet the criteria for outpatient commitment.
As a matter of policy, Bellevue chose to limit eligibility to patients who are discharged to reside within the five boroughs of New York City. This was determined to be necessary to insure that the CT could provide adequate access to, and coordination and monitoring of, services. However, over the course of the pilot, a number of patients have been followed while being treated at Rockland Psychiatric Center and its residential outpatient programs in Orangeburg, New York.
4. MHL Section 9.61 requires that a patient must have “a history of lack of compliance with treatment that has necessitated involuntary hospitalization at least twice within the last eighteen months.”
The CT is often required to obtain medical records from other institutions in order to verify both the elements of noncompliance and involuntary hospitalization for past admissions. Over the course of the pilot this process has been found to be labor intensive because patients have received treatment from many providers, and their policies regarding release of information vary considerably. Furthermore, hospital discharge summaries and other clinical materials often do not contain information regarding legal status. The CT has also found that in many instances patients who are brought to the hospital involuntarily may nonetheless be admitted to the hospital on a voluntary status. In addition, the CT has observed that patients are often unable to recollect information regarding the legal status and circumstances surrounding previous hospitalizations, and also often report information which is inconsistent with the medical records.
Clinical judgment is required for the determination that noncompliance has resulted in involuntary hospitalization. Over the course of the pilot, patients with a wide range of clinical histories have been referred to the OCP. Some patients have rejected all community services, while others have only refused one category of service, such as medication, day treatment or supervision of living arrangements. Some patients stopped treatment primarily when they abused substances. Only individuals who have had access to services and have then refused or rejected treatment have been found to be appropriate for the OCP. Patients who become ill and are involuntarily hospitalized notwithstanding compliance with treatment have been found to be ineligible for outpatient commitment.
5. MHL Section 9.61 requires that the patient, as a result of mental illness, be “unlikely to voluntarily participate in the recommended treatment.” The law also requires that the patient be likely to benefit from outpatient commitment, and be in need of it “in order to prevent a relapse or deterioration which would be likely to result in serious harm to the patient or others.”
Here the law clearly requires the referring physician to make predictions regarding a patient’s post-hospital clinical course, and the value of outpatient commitment for relapse prevention. This prognosis is based on discussions with the patient, family members and service providers, as well as a review of the medical records. Ultimately, the court must find that the referring physician’s assessment is accurate in order for a patient to be ordered to comply with outpatient care.
REFERRAL PROCESS
During the first six months of the OCP, before the PRA research project began, approximately ten patients per month were referred to the CT. Patients were referred from the inpatient units by physicians who had an opportunity to fully evaluate the patient and the care plan for the community. The CT encouraged physicians to evaluate all patients who met the OCP eligibility criteria for referral. There was no exclusion by any other criteria.
The initiation of the PRA research study in January 1996 led to the need for many more referrals to the OCP. It is important to note that once the PRA study began, physicians were explicitly making referrals for the study, not necessarily for outpatient commitment, since patients who were found appropriate for and consented to the study would only have a 50% chance of being brought to court for an outpatient commitment order. PRA indicated that the study would require 150 subjects (including patients in the court and control groups) for the research to have statistical significance.
Given the limited time frame for the pilot project, it became necessary for the CT to maximize recruitment of OCP candidates. This was accomplished primarily in two ways. First, the Bellevue Department of Psychiatry placed a strong emphasis on the need for all eligible, appropriate patients to be referred for the study. Second, beginning in May 1996, physicians attending in the Bellevue CPEP were permitted to refer patients to the OCP. While emergency room physicians did not know patients as well as inpatient physicians, there was an opportunity to insure that all patients who met the minimum eligibility criteria at least would be screened for the OCP. It was made clear that referrals could later be withdrawn if the referral to OCP was found not to be appropriate by the inpatient treating psychiatrist.
By July 1996, the CT was receiving approximately 25 referrals per month. The OCP had gained credibility as increasing numbers of orders were granted and patients were being successfully followed. In-service trainings were held frequently and departmental support continued. Nonetheless, inpatient staff identified a number of barriers which prevented potentially eligible patients from being referred to the OCP. These included:
1) the difficulty involved in obtaining the medical records required to verify a history of previous involuntary hospitalizations and noncompliance;
2) the reluctance of some already overburdened physicians to do more paperwork and to testify in court, which often required hours of waiting;
3) pressures on inpatient staff to decrease length of stay and quickly return patients to the community;
4) the belief among some inpatient staff that outpatient commitment “has no teeth” or that “nothing will work”; and
5) the lack of availability of housing specifically designed to work with high risk patients, especially substance abusers, that would provide supervision of living arrangement in conjunction with a court order.
Furthermore, only about 30% of patients referred to the program actually went to court for outpatient commitment orders or were in the control group of the study. This was a lower percentage than had originally been expected. The other 70% of patients who were referred to the OCP did not ultimately enter the program for a variety of reasons. Some patients were referred to state psychiatric centers for ongoing inpatient care, or, in far fewer cases, to other acute psychiatric or medical care facilities. On some occasions a treating physician withdrew a referral that had been made by another psychiatrist because a patient absolutely refused all services at the time he or she was ready for discharge, or no appropriate services were available. In some cases the referring physician had received inadequate or incorrect information, and the patient did not meet all of the MHL Section 9.61 eligibility criteria. Some patients on voluntary status requested discharge before they could be brought to court for an outpatient commitment order, and some patients on involuntary status went to court to request discharge from the hospital, which was then granted before an outpatient commitment plan could be put into place. Some patients eloped from the hospital, especially when they were on pass to interview at outpatient programs, and a number of patients were placed out of New York City.
In spite of the barriers, the numbers of referrals made to the OCP increased and stabilized at approximately 30 per month. As the OCP became more familiar and established, the flow of referrals continued steadily. Because of the lower than expected proportion of referred patients who entered the program, the one year extension was necessary to insure that PRA had the number of subjects it stated that it required for statistical significance.
Once PRA stopped recruiting subjects for the research study, there was less of an emphasis on insuring that all eligible patients were evaluated for referral. Since March 1998, the OCP has continued to receive a steady flow of referrals of patients who are eligible and appropriate for outpatient commitment.
ACCESS TO SERVICES
The OCP received enormous cooperation across the New York City provider community. There has been a great deal of interest in outpatient commitment as a way of working with the most resistant, noncompliant patients. In many conversations providers have said that they do not view outpatient commitment as a substitute for care. Instead, they view it as a mechanism that offers the assistance of the judicial system, as well as of Bellevue and the CT, in attempting to deliver necessary and appropriate treatment to patients whose symptoms have prevented them from accepting it.
Many undomiciled patients referred to the OCP have had difficulty gaining access to housing which provides on- site psychiatric services. If the patient does not have a history of living on the street or in a shelter, he or she is usually eligible for only a small number of supported housing options in the community. Patients with histories of incarceration, substance abuse and extreme noncompliance also have had very limited access to housing options. Fortunately, the TLC’s very often accept patients who are otherwise difficult to place. The OCP treatment plan, in many cases, includes case management and treatment services and the patient resides independently.
Patients sometimes disagree with aftercare plans that are recommended by their inpatient psychiatrists and social workers. Patients often rejected applications for supported housing because they objected to structure, money management, curfews and requirements for treatment and sobriety. In these cases, the outpatient commitment treatment plans are developed as an attempt to at least maintain case management and psychiatric services. Patients also very frequently reject substance abuse treatment and services; again, every attempt is made to at least insure that some contact with the service system is maintained.
Once the PRA study began, it was necessary to assure providers that they would receive substantial support from Bellevue and the CT, even if patients they accepted were randomized into the control group. Because providers could not be guaranteed that the patients they accepted would have a court order, they were reluctant to accept patients whom they perceived as requiring such an order to function well in the community. Nonetheless, a successful collaboration between Bellevue and over 80 other agencies was achieved by the close coordination of services and the commitment to work with a population that was very ill and perceived as very difficult to serve because of their histories of noncompliance. Appendix B is a listing of all of the programs that have provided court-ordered outpatient care in conjunction with the Bellevue OCP.
Only two community agencies refused to provide services in the context of an outpatient commitment order. One housing provider stated that it offered housing without the condition of requiring any kind of compliance with treatment. One freestanding clinic indicated that its psychiatrist did not believe in forced treatment and refused to treat a patient with an outpatient commitment order, in spite of the agency’s prior commitment and the patient’s request to receive treatment there.
Although many providers were willing to accept and work with OCP patients, some did, at times, close OCP cases because patients refused services or did not make appropriate use of the services. OCP patients generally require more outreach and staff time, and many programs are not funded to allow for these needs. Furthermore, a majority of substance abuse programs require a commitment to sobriety as a prerequisite for treatment. Since OCP patients often cannot maintain such a commitment, they require flexible clinical programs which acknowledge both the mental illness and the substance abuse disorder, and these treatment options are quite limited.
ACT resources diminished over the course of the pilot. ACT was specifically designed to work with very ill, noncompliant individuals in the community, and has been used in conjunction with outpatient commitment since it was first developed in Wisconsin in the 1970's. It was often viewed as the discharge plan of choice for OCP patients. The continued availability of ICM, and to a more limited extent, SCM services, made it possible for the CT to provide all patients with enhanced clinical services. Discharge planning was more difficult during times when housing and treatment resources were more scarce.
In a very few instances patients requested that a psychiatrist in private practice be included in an outpatient treatment plan. In those cases, upon physician consent, individual treatment provided by a private practitioner has been included on OCP orders and treatment plans.
OUTPATIENT COMMITMENT HEARINGS
During the first year of the pilot program, court hearings where testimony was presented took place for all initial commitments and almost all renewals. Judges had to learn about the new law and its procedural requirements. Increasingly, as it became clear to MHLS that treatment plans were being negotiated and eligibility requirements met, there were more and more consents to initial orders. Many judges chose not to hear testimony and to rely on a physician’s affidavit if the patient consented to all aspects of the outpatient commitment order. Most patients consented to renewal orders when the renewal was requested and such renewals were often approved by the court without a hearing. There continued to be occasional initial hearings and renewal hearings that were fully contested. At all times patients were afforded access to counsel and, when needed, MHLS had access to independent psychiatric evaluations as it does for other mental health hearings.
On occasion, the CT received complaints related to the hearings. Judges sometimes limited testimony that physicians and patients wished to offer. Judges also tended not to review all of the elements of the treatment plan in court if the patient had already consented to the plan. Other complaints regarding outpatient commitment hearings seemed similar to those made about other mental health hearings.
There were few thorough hearings regarding the issue of patient capacity in relation to outpatient commitment medication orders. As noted previously, one prerequisite under MHL Section 9.61 for an outpatient medication order is a finding by the court, based on clear and convincing evidence, "that the patient lacks the capacity to make a treatment decision as a result of mental illness . . . ." As most patients brought to court during the pilot program consented to a medication order requested by the hospital, there was rarely a dispute over the issue of capacity. It should be noted that the determination of a patient's capacity to make a treatment decision is a complex one, and is based on, among other considerations, current mental status as well as a comprehensive assessment of past history. Many hospitalized seriously and persistently mentally ill individuals are able to return to the community under supervision but still lack the capacity to make certain treatment decisions.
Every effort has been made by the CT to insure that patients have had adequate access to MHLS, and requests for rehearings or modifications of outpatient commitment orders have been promptly addressed. In fact, the CT works closely with MHLS to negotiate treatment plans that are acceptable both to the hospital and to the patient. This process of ongoing discussion within the context of a court proceeding and judicial review appears to result in patients’ receiving appropriate advocacy and protection. The fact that patients so often consent to orders may suggest that consumer choice had successfully been incorporated into the discharge planning and outpatient treatment evaluation process, and that the order is not usually viewed as being either threatening or harmful.
MEDICATION GUIDELINES AND ORDERS
The development of the Medication Guidelines required months of discussion and consensus building among the agencies represented on the Umbrella Committee. Because MHL Section 9.61 left this responsibility to the President of HHC, in consultation with SOMH, there was no detailed legislative directive for the involuntary administration of medication in the community. The document that was finally promulgated and implemented on May 1, 1996, reflects the sensitive clinical, legal and ethical issues that involuntary medication in the community raises.
Outpatient commitment orders included medication as a category of service only after the Medication Guidelines were implemented. Although requesting medication orders was a time- consuming process that required additional paperwork, most Bellevue inpatient physicians thought it was important to include medication on outpatient commitment orders. Almost two-thirds of the initial outpatient commitment applications included medication as a category of service. It is also important to note that sometimes physicians who wish to include medication on an outpatient commitment application are prevented from doing so because of the extra time required by the review procedure and the deadlines for paperwork.
Just as with voluntary outpatients, OCP patients discuss their medications with their treating psychiatrists. For patients with medication orders, the orders can provide a framework within which the consumer and psychiatrist can negotiate treatment. Outpatient commitment medication orders may include multiple medications, all of which must include a dosage range. This has permitted maximum flexibility in insuring that appropriate community treatment is delivered on a continuous basis in response to individual needs.
OCP medication orders often include the newer psychotropic medications, which are preferred by many patients. OCP medication orders reflect the appropriate treatment options for an individual patient. The medication orders have been viewed as a mechanism to insure that patients who, as a result of mental illness, are ambivalent about treatment understand the importance of taking medication.
The CT sometimes encounters situations in which providers misunderstand the function of the medication order. They sometimes believe that the patient is required to take the medication exactly as stated on the court order. It has been important to review the medication orders with treatment providers to insure their understanding of its proper meaning and use. MHL Section 9.61 specifically allows a change in the medication order with the agreement of both the patient and the hospital.
Patients who have court orders for medication which can be administered by injection also negotiate with their treating psychiatrists as to the actual medication taken. According to the Medication Guidelines, only injectable medication may be administered over objection in the community. During the entire experience of the Bellevue OCP there have been no reports of medication being forcibly administered in the community. Many physicians have expressed concerns about the clinical and legal implications of forcibly administering medication in the community. Because the law makes no provision for bringing a patient to the hospital solely to administer medication, this also has not occurred during the pilot.
There have been a number of instances where a patient who is noncompliant with an outpatient medication order has been hospitalized and continues to refuse medication as an inpatient. Under current law, the hospital has been required to go to court to obtain a new, inpatient medication order. Many inpatient psychiatrists have stated that a medication order would have more value if it could apply to both inpatient and outpatient settings.
TRANSPORT TO BELLEVUE UNDER MHL SECTION 9.61
In 1995 discussions began between attorneys and other representatives from the New York City Police Department and Bellevue, HHC and DMH concerning the procedure to transport patients to the hospital as per MHL Section 9.61. It soon became apparent that a number of aspects of the statute could be interpreted in different ways. There were questions about which agency should have primary responsibility for the transport, about whether all patients were required by the statute to be brought to Bellevue, and about the process of the examining physician reporting clinical findings to the Director of Bellevue or his Designee. The process of identifying and clarifying the issues and then negotiating and resolving the points of disagreement and building a consensus took numerous meetings that eventually involved the Mayor’s Office of the Criminal Justice Coordinator and the Sheriff’s Department. The entire process took much longer than anticipated, and the transport protocol was only finalized and made available beginning on October 26, 1998. As of January 1, 1999, the procedure has not been used.
It is important to note that during most of the OCP pilot, and throughout the entire PRA study period, there has been no procedure in place under MHL Section 9.61 to transport patients with outpatient commitment orders who are noncompliant and who may be dangerous, to the hospital for evaluation. The CT has continually received questions, comments and complaints about this issue. Some clinicians and family members stated that since the OCP did not have an operational enforcement mechanism, it had “no teeth” and its value was therefore limited. Although it was generally felt that the hospital transport procedure would rarely be used, many expressed the concern that the lack of the procedure very significantly affected the meaning of the court order to patients, judges and everyone else involved. It certainly made the experimental and control conditions in the PRA study seem much more similar than had originally been contemplated.
The transport protocol as finally implemented incorporates the requirement of MHL Section 9.61 that authorization for the Sheriff's Department to transport a patient to Bellevue can only come from the Director of Psychiatry at Bellevue or his Designee after a request from the examining physician. Many clinicians have expressed the opinion that the requirement that a designated psychiatrist serve as an intermediary between the examining physician and the Sheriff's Department is cumbersome and unwieldy. They have indicated that the MHL Section 9.61 procedure stands in contrast to the Section 9.37 and 9.58 transport procedures which provide for designated examining clinicians with the authority to call 911 and direct the police to transport the patient to a hospital for an evaluation.
As has been previously noted, MHL Section 9.61 permits the transport of a noncompliant patient to Bellevue for an evaluation only when he or she may meet hospital admission standards. Over the course of the pilot, however, many individuals expressed a desire that outpatient commitment include a mechanism to transport noncompliant patients to the hospital before they reached a point where hospital admission (requiring a finding of likelihood of serious harm to self or others) may be appropriate under the Mental Hygiene Law. Appendix D summarizes different compliance mechanisms available under the outpatient commitment statutes of other states.
Approximately half of the patients with outpatient commitment orders have, at times, required hospitalization. The CT observes patients across the clinical spectrum; some patients become noncompliant, some abuse substances, and some become ill in spite of their and everyone else’s best efforts. In all of these cases, providers, family members and strangers have used the various other mechanisms that are available under the Mental Hygiene Law to involuntarily transport to the hospital mentally ill individuals who are dangerous. (See “Involuntary Transport Sections Article 9 Mental Hygiene Law” summary table in Appendix A.)
MATERIAL CHANGES OF OUTPATIENT COMMITMENT ORDERS
Almost one in five patients with an outpatient commitment order has had at least one material change presented to the court. The majority of these changes have involved additions and deletions of categories of services; only a small minority have involved only changes in medication regimens. In addition, about one in seven patients with outpatient commitment orders have changed providers for one or more categories of service. As noted previously, MHL Section 9.61 requires that additions or deletions of categories of service be approved by the court. Many patients and providers have stated that this is an unnecessarily cumbersome process when the change is mutually agreeable.
MHL Section 9.61 provides for the right of the patient, MHLS, or anyone acting on the patient's behalf, to apply to the court for an order to stay, vacate or modify an outpatient treatment order authorizing the involuntary administration of psychotropic drugs. While this provision specifically does not limit any other right the patient has under the law, concern has been expressed that the provision should address all categories of service on an outpatient commitment order.
RENEWALS
Renewals of outpatient commitment orders have been consistently requested by psychiatrists. When patients show continued resistance and refusal of treatment due to mental illness, renewal orders have been found to offer the opportunity for continued outreach and engagement. Renewals have also been requested when patients have shown improvement and seem to benefit and not be harmed by the order. Outpatient commitment has been used as a mechanism to negotiate the conditions of treatment in an ongoing way.
Renewals are most commonly requested by the patient’s current treating psychiatrist. When a patient with an outpatient commitment order who is residing in the community does not have a psychiatrist, a CT psychiatrist assesses the patient’s need for renewal of the order and testifies at the renewal hearing if required.
It has often been noted over the course of the pilot that the wording of MHL Section 9.61 is not clear as to whether the condition of two involuntary hospitalizations during the preceding 18 months applies to a renewal petition. Bellevue takes the position that renewals are extensions of existing orders, and therefore do not require that all initial eligibility criteria be met. On the one occasion when MHLS contested this position in court, the judge found in favor of the hospital’s position.
CLINICAL FINDINGS
Many factors influence a patient’s clinical course in the community. 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.
As the administering agency, Bellevue has had the unique opportunity of observing the effect of outpatient commitment, as defined in MHL Section 9.61, on patients, families and providers in both the hospital and the community. Over the course of the pilot, some prominent clinical themes have emerged, which are outlined below.
1. Outpatient commitment orders often assist patients in complying with outpatient treatment.
This occurs in a variety of ways. 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. The order may primarily address a patient’s resistance to one category of service, such as medication, while in other cases it is intended to maintain compliance with multiple components of the service plan. Very often the order is referred to as a “contract” within which the provider and patient negotiate treatment.
2. Outpatient commitment orders are clinically helpful in addressing a number of manifestations of serious and persistent mental illness.
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 accepting 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.
3. From the CT’s perspective, patients have often responded positively to outpatient commitment, and have generally not 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, and express little apprehension about a court order. Patients generally understand that the order is meant to prevent future noncompliance. Approximately 20% of patients do, upon initial screening , express hesitation and opposition regarding the prospect of a court order.
After discharge with a court order, the majority of patients express no reservations or complaints about the orders to the CT. On many occasions patient have stated that the order is helpful in maintaining treatment. Most patients express little opposition to renewal orders.
Some patients state that they feel that the court order is restrictive and would prefer not to have it. Some patients also oppose renewal of orders, because they oppose ongoing treatment and/or they oppose the requirement of the court. Even in these cases, however, patients do not typically state that outpatient commitment is damaging or harmful.
4. Court orders have been understood and used by providers in many different ways. 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.
Providers of both transitional and permanent housing generally reports that outpatient commitment helps clients abide by the rules of the program. More importantly, they often indicate that the court order helps clients to take medication and accept psychiatric services. Housing providers state that they value the leverage provided by the order and the access to the hospital it offers.
Case management and assertive community treatment providers are generally contracted to provide outreach on an ongoing basis, even to clients who refuse services. In many cases these services are able to engage resistant individuals without an order. However, many of these providers have stated that they find outpatient commitment particularly valuable in working with patients who continue to refuse services despite significant efforts at engagement. Outpatient commitment orders provide these clinicians with the legal authority to continue to attempt to provide services when cases otherwise might be closed.
Some providers of day treatment and individual treatment also indicate that outpatient commitment can be an aid in soliciting patient compliance with medication and attendance at appointments. In many cases they have reported that but for the court order the patient would not enroll in services and would likely deteriorate. It is, however, important to note that when patients consistently fail to attend, these providers generally are eventually forced to close their cases in order to make services available to other individuals in need. Substance abuse programs particularly seem to have difficulty retaining patients with limited insight and motivation for treatment.
It is important to acknowledge some providers have stated that a court order is not helpful in soliciting patient compliance. Some have stated that the problem is the weakness of the enforcement mechanisms, while others have questioned the value of the court order itself. In a few instances providers have indicated that outpatient commitment may increase an individual’s resistance to treatment.
5. Under the auspices of the OCP, the CT was able to promote continuity of care.
In situations where patients with outpatient commitment orders have been discharged from clinical services, either due to refusal or noncompliance, the CT has taken the responsibility of attempting to secure other necessary and appropriate treatment and then soliciting the patient’s compliance. This requires advocacy as well as careful assessment of clinical needs and availability of services. Some patients refuse most services, while others end all contact with their treating providers and the CT. The CT continues to attempt to locate patients throughout the duration of their active orders.
The CT’s ability to provide direct psychiatric treatment and medication helps to minimize gaps in service. In many cases the CT’s insistence on the need of both the service system and patients to abide by outpatient commitment orders has enabled patients to maintain compliance with at least some community treatment and reduced the need for crisis and emergency services and rehospitalizations.
The CT has also helped to insure continuity of care when patients’ service plans change because they move to more independent housing or treatment, or to a new geographic location.
6. Outpatient commitment 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, and it is also clear that some patients with court orders leave the service system anyway. Bellevue has ultimately understood outpatient commitment to be 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. And, 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.
RESEARCH FINDINGS
The PRA report was published on December 4, 1998. Since it is publicly available, this report will not discuss the details of the study. Because the CT followed all patients in the control group for a period of one year, some statistical information about them is included in Chapter IV. Bellevue’s analysis of the PRA report is contained in Chapter V.
COMMUNITY INTEREST
As community awareness regarding the pilot program grew, the CT received more and more requests from families and providers to access outpatient commitment. Many described their attempts to stop the revolving door syndrome, and hoped that the assistance of the court order would allow individuals with mental illness to accept the care that they were being offered. Outpatient commitment was consistently requested as a way to help patients function in the least restrictive setting, and was seen as an alternative to longer stays in the hospital, homelessness and incarceration. Throughout the pilot, the CT has responded to many requests for information about outpatient commitment, and heard much interest expressed in making it more widely available after the pilot phase ends.
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