This report describes the experience of the Bellevue Hospital Center (Bellevue) Department of Psychiatry in implementing and administering the New York State pilot program in “Involuntary Outpatient Treatment of Mentally Ill Persons.” It represents the collective work of scores of Bellevue clinicians. It also reflects the participation and cooperation of many, many mental health consumers and providers, government officials, family members and advocates.

Although outpatient civil commitment was new to New York in 1995, it has existed for many years in other jurisdictions, and this report will discuss its historical context. This report will then provide a program description, a discussion of the program experience and findings, and a statistical summary covering the first three and one half years. Because the Policy Research Associates Final Report on the pilot was published on December 4, 1998, this report will offer Bellevue’s observations about it. Bellevue will also offer conclusions regarding its experience in operating the pilot program.

I. BACKGROUND

HOSPITALS AND COMMITMENT

During America’s colonial period individuals with serious and persistent mental illness were left to wander from town to town or lived in almshouses, jails, and private homes, where they often were treated poorly and worse. In the early nineteenth century a number of small, private hospitals were built to care for individuals with mental illness. These hospitals were founded on both scientific and humanitarian principles. These “asylums” used traditional medical treatments, but also promoted “moral treatment” which emphasized therapeutic and vocational activities, exercise and non-restraint.

Admission to the hospitals was almost always initiated by family members and was dependent on their ability to pay for the care. Patients who were so ill that they required hospitalization were presumed to lack the capacity to make treatment decisions and were often taken to and treated in the hospital involuntarily. A physician’s certification of the patient’s need for treatment was adequate for commitment. The government was not at all involved in the process.

The early hospitals reported excellent outcomes, and were perceived as being highly successful. As a result, a movement arose which urged the states to build public asylums to care for those who were mentally ill and indigent; it essentially advocated for the right of this population to treatment. In 1833, Massachusetts built the Worcester State Hospital, which soon became a model for other states because its success was reported to be similar to that of the older hospitals. Thirty years later, there were 62 American psychiatric hospitals, most of which were state supported.

Such extensive state involvement in the care of individuals with mental illness brought the need for legislation regarding commitment and a degree of governmental control. When the family agreed to pay for care, commitment to a public institution generally required only medical certification, just as in a private asylum. However, when the government was required to pay for the care, judges were required to certify an individual’s need for psychiatric treatment and judicial commitment processes were put in place throughout the country.

There were two legal theories that supported the judge’s power to commit a person to a hospital. The first was police power: this principle asserts that the state may intervene if an individual is dangerous. The second theory was parens patriae: this notion derives from Roman and English law, and in American law asserts that the state should care for those who cannot care for themselves. Psychiatric hospitals were viewed to be optimal for the care of individuals with mental illness, and judges were permitted to commit those individuals because they were in need of treatment. Psychiatric hospitals were explicitly developed as a therapeutic alternative to poor care, neglect and abuse in the community.

There had been allegations of unwarranted and improper commitments since the first asylums opened, but the criticisms sharply increased in the late nineteenth century. This ultimately led to commitment law reform which was intended to protect patients’ rights. The safeguards that were put into place to protect patients who were involuntarily hospitalized, such as jury trials and formal notification, were usually borrowed from the criminal justice system. Furthermore, the private hospitals came under governmental regulation, and mechanisms to allow for voluntary hospitalization were put into place for the first time.

Over the following decades psychiatric hospitals were built in even larger numbers and the state became responsible for caring for hundreds of thousands of individuals with serious and persistent mental illness. There were periodic modifications to the procedures whereby individuals could be civilly committed to psychiatric hospitals. When public attention focused on the obstacles to rapid hospitalization and treatment of the mentally ill, there was a tendency to diminish the criminal- style protections. On the other hand, when reports of abuses of civil liberties, especially within hospitals, were widely publicized, the government provided greater oversight of the institutions and commitment procedures. However, the traditional principles underlying civil commitment, i.e., police power and need for treatment, remained the basis of the law.

DEINSTITUTIONALIZATION AND COMMUNITY CARE

The post World War II period saw a profound shift in thinking regarding the chronically mentally ill. This was the result of a number of factors, including the introduction of new psychiatric medications, criticisms of traditional institutional psychiatry, and an increased emphasis on civil liberties in American courts. These forces converged in the new “community psychiatry,” which asserted that many chronic psychiatric patients could leave large institutions and return to live safely in their communities. This was the basis of the social policy of deinstitutionalization, which crystallized during the Kennedy Administration. Deinstitutionalization was to be done in tandem with the creation of community mental health centers, where patients would receive their medications and other needed therapies.

As deinstitutionalization was put into effect, the first major changes in commitment laws in over a century were being passed and implemented. Courts were ruling that a patient must be dangerous to self or others to warrant involuntary commitment to a hospital. The traditional standard of need for treatment was no longer enough to allow the state to restrict an individual’s liberty in an institution; it was believed that treatment could be received in the community.

The effectiveness of deinstitutionalization was predicated both on the availability of effective treatment in the community and on the willingness of patients to receive the treatment voluntarily. As a result of deinstitutionalization, the majority of patients were able to access and were willing to accept treatment and did well in the community.

In many cases, however, the assumptions underlying deinstitutionalization were incorrect. Many of the community mental health centers were never funded as originally planned, and even those which became operational usually did not focus on providing services to seriously and persistently mentally ill individuals. Some individuals objected to or could not tolerate side effects to medications or other aspects of community treatment. And some individuals had negative experiences with the mental health system which led to rejecting further involvement.

In a many other individuals, however, the reason for refusing available treatment and services was mental illness itself. Some former inpatients lacked the capacity to seek treatment or rejected treatment due to their symptoms once they were discharged to the community. They had hallucinations, delusions, paranoia, disturbances of thinking and mood, and problems with motivation, concentration and functioning that interfered with their ability to understand the nature of their illness and their need for treatment.

The problems of the thousands of deinstitutionalized patients who either had no access to or refused outpatient treatment soon became apparent throughout society. Many of these individuals suffered significant functional deterioration in the community. Changes in housing availability and policies contributed to the fact that large numbers of seriously mentally ill individuals becoming homeless.

By the late 1970's, the problems of deinstitutionalization and stricter commitment laws had also resulted in a new phenomenon known as the “revolving door syndrome.” This occurred both among formerly institutionalized patients as well as in young chronic patients who never had spent long periods in hospitals. These patients could often be treated effectively and stabilized in the hospital. However, upon discharge they either could not access or became noncompliant with outpatient treatment, and rapidly deteriorated to the point of becoming dangerous and requiring involuntary hospitalization.

A variety of clinical interventions have been developed in response to the revolving door syndrome. These interventions are intended to improve compliance with outpatient psychiatric treatment and reduce rehospitalization. They include various kinds of housing programs which provide on site supervision and services, such as community residences, serviced single room occupancy hotels, apartment programs and adult homes. They also include various case management and assertive community treatment programs, which provide outreach services in the community on a consistent, continuous basis, as well as providing support and crisis intervention.

OUTPATIENT COMMITMENT

While these clinical programs were being put into place, a number of legal interventions were developed to insure the delivery of the services and to promote compliance when patients continued to refuse treatment due to their illness, notwithstanding the availability of appropriate clinical care. Outpatient commitment is one such intervention which was specifically developed to address the revolving door syndrome and to help patients consistently access community services and treatment. Outpatient commitment occurs when a judge formally orders a patient to comply with a plan for outpatient psychiatric treatment and services in the community in order to prevent the deterioration that predictably results. Outpatient commitment is intended to provide appropriate, necessary psychiatric treatment in the least restrictive setting.

Outpatient commitment became increasingly widespread in the 1970's and ‘80's. It is now available in 35 states and the District of Columbia. It is important to note that there are wide variations among the different statutes, and that outpatient commitment does not exist in any one form. In some states outpatient commitment may be permitted only after a period of inpatient hospitalization; in others it may be initiated on an outpatient basis. The standard for outpatient commitment may require a specific prior history of involuntary treatment or it may be based only on certain conditions of the individual’s illness and mental status. The standard for outpatient commitment may be similar to or different from the jurisdiction’s standard for inpatient admission. Finally, the manner of handling noncompliance in the community varies; the law may allow rehospitalization, or require another hearing, or provide no consequences for noncompliance at all. Some states permit court ordered outpatient medication and some do not.

In 1990, Dr. Jeffrey Geller published a paper titled “Clinical Guidelines for the Use of Involuntary Outpatient Treatment”[1] which has been widely accepted and has guided the development of the New York pilot. First, Dr. Geller addressed the appropriate selection of patients for outpatient commitment. The patient must have a history of failing in the community and must currently express an interest in living in the community. The patient must have that degree of competence necessary to understand and abide by the stipulations of the court order. Finally, the patient must not be dangerous to self or others when complying with the ordered treatment.

Dr. Geller’s guidelines also define a set of requirements for the service system, which are necessary to provide for effective outpatient commitment. The treatments being ordered must have demonstrated efficacy when used properly with that individual patient. The outpatient system must be capable of delivering the necessary outpatient services, which must be sufficient for the patient’s needs and necessary to sustain community tenure. The psychiatric outpatient system must be capable and willing to provide, monitor and enforce compliance with the ordered treatment. And, finally, the public sector inpatient system must support the outpatient system’s participation in the provision of involuntary community treatment.

Much of the research over the past twenty years has indicated that outpatient commitment is effective in reducing the rate of hospitalization, the length of stay of hospitalizations, and dangerousness in the community. Most of the research is only suggestive because the studies have had small numbers of patients, short follow-up periods and a lack of controls or nonequivalent controls. Also, many outpatient commitment programs were put into place with enhanced community services, and the study designs did not distinguish the effects of the legal interventions from those of the clinical services. Nonetheless, the research has been consistent with much clinical experience that has found outpatient commitment to help patients remain in community treatment and out of the hospital.

OUTPATIENT COMMITMENT IN NEW YORK

While most states have experimented with and implemented some form of outpatient commitment over the past twenty years, a number of others have had no provision for outpatient commitment, and that had been the case in New York. Outpatient commitment was first proposed in New York after Project HELP[2] caused the review of commitment laws and firmly established the precedent that individuals who were so gravely disabled as to be dangerous to themselves could, indeed, be involuntarily hospitalized. Outpatient commitment was first proposed in 1989 as the next logical step in using legal mechanisms to assist in insuring that the gains made by these patients in the hospital could be sustained in the community.

Outpatient commitment did not become a reality, however, until New York State adopted the Community Mental Health Resources Act, more commonly known as the Community Reinvestment Law, in 1993. This legislation continued the state’s longstanding policy of reducing beds at state psychiatric centers, but required that the money saved be invested in a wide array of community-based services for individuals with serious and persistent mental illness. Soon thereafter, the New York State Legislature conducted hearings which found that some individuals who require mental health treatment and services to survive safely in the community “frequently reject the care and treatment offered to them on a voluntary basis and decompensate to the point of requiring repeated psychiatric hospitalizations.” The Legislature also found that a number of other jurisdictions, including Illinois, Michigan, Pennsylvania, North Carolina, Vermont, Hawaii and Washington, D.C., permit outpatient civil commitment.

Section 9.61 was added to the Mental Hygiene Law in 1994. It called for a three year pilot program to be funded through the Reinvestment Law and operated out of one hospital in New York City. It also required an independent research study to determine the program’s effectiveness in preventing rehospitalization and improving the patients’ quality of life. The legislation also required that the study assess participant satisfaction regarding outpatient commitment.

In late 1994, the New York City Department of Mental Health, Mental Retardation and Alcoholism Services (DMH) contracted with Bellevue to implement the pilot program. Bellevue was chosen because of its long commitment to treating individuals with psychiatric disabilities, its wide scope of mental health programs and its experience in handling forensic mental health issues. In the spring of 1995, DMH contracted with Policy Research Associates (PRA) to conduct the research study. In June 1997, the law was amended to extend the pilot program and the research study for one year. The Bellevue Outpatient Commitment Program (OCP) is authorized by the legislation to operate through June 1999.

II. PROGRAM DESCRIPTION

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, New York City Health and Hospitals Corporation (HHC), DMH and the New York State Office of Mental Health (SOMH). 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 joined the project, it also participated in the Umbrella Committee.

The OCP began operating in July 1995. The Umbrella Committee continued to meet after operations commenced, because important elements of the law were not yet in place, and because policy questions continued to arise as the program took shape. The Umbrella Committee has continued to meet throughout the duration of the pilot program.

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 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 criteria stated above. 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 patients 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 that are 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. The CT typically follows between twenty and forty patients on Bellevue’s adult inpatient psychiatric units at any one time.

OUTPATIENT COMMITMENT ORDERS

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.

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

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. A discharge plan is complete when providers have been identified for each and every service that has been included on the treatment plan. Because 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.

Supported and supervised housing programs are available in many parts of New York City; they provide varying levels of structure, monitoring and outreach to clients. Supervision of living arrangement may be ordered in conjunction with community residences, supervised single room occupancy hotel, apartment programs and adult homes. 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.

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 are all 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 a formal Order to Show Cause is generated, the patient is notified by a process server of the scheduled court date. Outpatient commitment hearings are held one day each 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.

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 are providers 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 and all 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 re-assessing 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 re-admission under 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 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 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

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 who PRA found appropriate and then consented to participate in the study were randomly assigned by PRA into 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.

III. PROGRAM DEVELOPMENT AND FINDINGS

PROGRAM IMPLEMENTATION

The Bellevue OCP was developed with the view that it is a clinical program which uses a legal intervention to improve the lives of patients. This view is consistent with Section 9.61 as well as with the extensive literature on outpatient commitment (see Selected Bibliography). The implementation has been especially challenging because all of the clinical and legal documents, procedures and interventions had to be newly developed. In addition, since the OCP is a pilot which was being independently studied, it also required close collaboration with the PRA team, and the study requirements significantly affected the growth and development of the pilot in many ways. The development of the Bellevue OCP would not have been possible without the support and cooperation of HHC, DMH and SOMH. The model of ongoing oversight, dialogue, and assistance that existed for this project from the early planning phase enabled such a complex and highly scrutinized enterprise to proceed as smoothly as it did. The OCP 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.

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. Thus, the pilot phase had many unique conditions, which must be appreciated in assessing the potential benefits of outpatient commitment in New York.

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 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.

2. 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 referring individuals who were 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. 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. 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. 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. The court ultimately 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, and 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 emphasize 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 OCP was not found 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 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, 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. Seventy per cent 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 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 stated 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.

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. In many cases the OCP treatment plan 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 free-standing 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.

Notwithstanding the general willingness of providers to accept and work with OCP patients, providers may close cases because patients refuse services or do 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 there were private psychiatrists whom referred patients had seen in the past and chose to return to upon discharge. 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 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. Patients at all times 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 to be 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 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 . . . ."[3] 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, the 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 is understood to 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 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 felt that 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 deadlines for paperwork.

OCP patients discuss their medications with their treating psychiatrists, as is usual for outpatients. For patients with medication orders, the orders provide a framework within which the consumer and psychiatrist can negotiate treatment. Outpatient commitment medication orders may include multiple medications, all of which must have a dosage range included. 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. 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.

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 in many different situations. 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 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 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 report that outpatient commitment help clients abide by the rules of the residence. 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 received many requests for information about outpatient commitment, and heard much interest expressed in making it more widely available after the pilot phase ends.

IV. PROGRAM STATISTICS

The following statistical summary covers the period from the beginning of the OCP on July 1, 1995 through January 1, 1999.

REFERRAL OUTCOME

As of January 1, 1999, the OCP had received a total of 789 referrals. The outcome is as follows:

206 (26%) initial outpatient commitment order granted

138 (17%) patient was transferred to a state psychiatric center for ongoing inpatient care

115 (15%) treating physician withdrew the referral

66 (8%) randomized into the control group of the PRA study

39 (5%) patient eloped from the hospital (including while on pass for an outpatient interview)

37 (5%) both hospitalizations within the prior 18 months were not involuntary

37 (5%) patient was placed out of New York City

36 (5%) patient was on voluntary status and requested discharge

31 (4%) patient did not have a history of noncompliance prior to both involuntary hospitalizations

26 (3%) patient’s petition to the court for hospital release was granted

17 (2%) CT was unable to verify patient eligibility due to inadequate information

12 (2%) patient had no other psychiatric hospitalization in the prior 18 months

10 (1%) active referral

10 (1%) patient was transferred to another acute psychiatric care facility

6 (<1%) patient was discharged to an acute care medical unit

1 (<1%) hospital’s request for an outpatient commitment order was denied

1 (<1%) patient arrested for assault on the inpatient unit and incarcerated

1 (<1%) patient expired

CHARACTERISTICS OF PATIENTS WITH 9.61 ORDERS

As of January 1, 1999, a total of 198 patients had been court-ordered to comply with categories of outpatient psychiatric care and treatment.

The following describes demographic features of the patients:

126 (64%) male

72 (36%) female

71 (36%) African descent

67 (34%) European descent

46 (23%) Spanish Caribbean and Mexican descent

13 (7%) Asian descent

1 (<1%) Native American

INITIAL COURT ORDERS AND CLINICAL SERVICES

All initial 9.61 orders were granted for a period of 180 days. In all but one case (see below) the court ordered the patient to comply with all categories of services requested by the hospital.

Upon discharge with an initial court order, patients resided in the following settings throughout the five boroughs of New York City:

51 (26%) supervised living arrangements ordered in conjunction with residential placement

48 (24%) with one or more family members

40 (20%) own apartment

38 (19%) supervised living arrangements ordered in conjunction with shelter-based transitional housing

12 (6%) single room occupancy hotel

8 (4%) in apartment with partner or friend

1 (<1%) supervised living arrangements ordered in conjunction with skilled nursing facility

Upon discharge with an initial court order, patients received the following categories of case management ordered by the court:

84 (42%) supportive case management

68 (34%) intensive case management

43 (24%) assertive community treatment (this category also includes psychiatric treatment)

Upon discharge with an initial court order, patients received the following other categories of psychiatric treatment ordered by the court:

65 (33%) day treatment (hospital or community based)

54 (27%) individual treatment

36 (18%) day treatment (on site at transitional shelter)

Orders for medication were granted after May 1, 1996. Outpatient commitment orders were requested for 161 patients after that date. Of those, 101 (63%) had medication as a category of service on the initial order. One initial request for medication was denied by the court.

RENEWAL ORDERS

As of January 1, 1999, the court had granted a total of 276 renewal orders and denied one hospital petition. Three renewals were granted for 90 days; all the rest were granted for 180 days. All categories of services requested by the hospital were granted on all renewal orders except for one case in which day treatment and supervision of living arrangements were ordered but requested medication was not.

As of January 1, 1999, 37 patients had initial outpatient commitment orders and were not yet eligible for renewal. The following describes the renewal history of the 161 patients who have been eligible for renewal of outpatient commitment orders:

53 (33%) No renewals

32 (20%) One renewal

29 (18%) Two renewals

18 (11%) Three renewals

6 (4%) Four renewals

5 (3%) Five renewals

6 (4%) Six renewals

5 (3%) First renewal requested, hearing pending

1 (<1%) Case closed after one renewal; two subsequent initial outpatient commitment orders

2 (1%) Case closed after one renewal; one subsequent initial order and one renewal

1 (<1%) Not renewed at the time of first order; second initial order, renewed three times

1 (<1%) Not renewed at the time of first order; second initial order, renewed twice

1 (<1%) Not renewed at the time of first order; second initial order, renewed once

1 (<1%) Not renewed at the time of first order; second initial order, renewal pending

CHANGES OF SERVICES

The hospital requested material changes of outpatient commitment orders for a total of 38 patients, which represents 19% of patients who received orders.

A total of 29 patients changed one or more providers on the OCP treatment plan without modifying the court order; this represents 15% of patients who received orders.

ACTIVE ORDERS

As of January 1, 1999, there were 114 patients with active outpatient commitment orders. Their status is as follows:

33 (29%) supervised living arrangements ordered in conjunction with residential placement

31 (27%) with one or more family members

22 (19%) own apartment

9 (8%) supervised living arrangements ordered in conjunction with shelter-based transitional housing

8 (7 %) hospitalized

4 (4%) single room occupancy hotel

4 (4 %) missing

1 (<1%) in apartment with partner or friend

1 (<1%) supervised living arrangements ordered in conjunction with skilled nursing facility

1 (<1%) incarcerated

The 114 patients receive the following categories of case management ordered by the court:

30 (26%) supportive case management

47 (41%) intensive case management

28 (25%) assertive community treatment (this category also includes psychiatric treatment)

The 114 patients receive the following other categories of psychiatric treatment ordered by the court:

38 (33%) day treatment (hospital or community based)

29 (25%) individual treatment

6 (5%) day treatment (on site at transitional shelter)

CLOSED CASES

As of January 1, 1999, the CT had closed a total of 84 outpatient commitment cases for the following reasons:

25 (30%) patient doing well and renewal not requested by treating psychiatrist

19 (23%) hospitalized and no plan for discharge to the community

13 (15%) missing

11 (13%) refusing services, not eligible/appropriate for OCP

5 (6%) moved out of New York City

5 (6%) incarcerated

3 (4%) medically ill, inpatient care required

2 (2%) deceased

1 (1%) hospital’s renewal request denied

CONTROLS

Patients in the control group of the PRA study were followed by the CT for a period of one year from the date of discharge from the referring hospitalization. PRA was unable to follow two of the 66 patients who were randomized into the control group. The CT followed a total of 65 patients who were randomized into the control group.

The following describes demographic features of these 65 patients:

41 (63%) male

24 (37%) female

28 (43%) European descent

25 (38%) African descent

9 (14%) Spanish Caribbean and Mexican descent

3 (5%) Asian descent

Upon initial discharge into the control group patients resided in the following settings throughout the five boroughs of New York City:

26 (40%) shelter-based transitional housing

14 (22%) residential placement

11 (17%) own apartment

10 (15%) with one or more family members

4 (6%) single room occupancy hotel

Upon initial discharge into the control group patients received the following case management services:

38 (58%) supportive case management

15 (23%) intensive case management

12 (18%) assertive community treatment (this category also includes psychiatric treatment)

On initial discharge into the control group patients received the following other kinds of psychiatric treatment:

14 (22%) day treatment (hospital or community based)

14 (22%) individual treatment

25 (38%) day treatment (on site at transitional shelter)

As of January 1, 1999, 60 control patients’ OCP cases have been closed. The status of these patients at the time their cases were closed was as follows:

14 (23%) missing

10 (17%) residential placement

8 (13%) own apartment

7 (12%) hospitalized

7 (12%) with one or more family members

6 (10%) shelter-based transitional housing

3 (5%) refusing services

2 (3%) single room occupancy hotel

2 (3%) moved out of New York City

1 (2%) deceased

These patients received the following case management services at the time of discharge from the OCP:

17 (28%) supportive case management

13 (22%) intensive case management

14 (23%) assertive community treatment (this category also includes psychiatric treatment)

These patients received the following other kinds of psychiatric treatment at the time of discharge from the OCP:

6 (10%) day treatment (hospital or community based)

13 (22%) individual treatment

5 (8%) day treatment (on site at transitional shelter)

As of January 1, 1999, five patients in the control group were still being followed by the CT. Their status as of that date was as follows:

1 living with a family members, being referred from treatment

1 at a state operated community residence

1 moved out of New York City

1 refusing services

1 missing

STATISTICAL SUMMARY

The following table indicates the number of referrals received and initial and renewal court orders granted each month through the end of December 1998. It also indicates the number of patients discharged as controls in the outcome study between January 1996 and February 1998.

Month

Referral

received

Initial court orders granted

Discharged as controls

Renewal orders granted

June 1995

July 1995

August 1995

September 1995

October 1995

November 1995

December 1995

January 1996

February 1996

March 1996

April 1996

May 1996

June 1996

July 1996

August 1996

September 1996

October 1996

November 1996

Month

Referrals received

Initial court orders granted

Discharged as controls

Renewal orders granted

December 1996

January 1997

February 1997

March 1997

April 1997

May 1997

June 1997

July 1997

August 1997

September 1997

October 1997

November 1997

December 1997

January 1998

February 1998

March 1998

April 1998

May 1998

June 1998

July 1998

August 1998

September 1998

October 1998

November 1998

December 1998

V. OBSERVATIONS REGARDING THE POLICY RESEARCH ASSOCIATES FINAL REPORT

PRA released its Final Report on the OCP pilot on December 4, 1998. It contains PRA’s findings from its client outcome study, program implementation evaluation, and patient, family and provider interviews and focus groups.

Because of its role in developing and implementing the OCP, Bellevue is able to evaluate the PRA study from a unique perspective. Bellevue was responsible for ensuring an adequate number of referrals, and, ultimately, of eligible and appropriate patients, so that PRA’s stated study size requirements for statistical significance could be met. The CT was also responsible for ensuring that all appropriate patients were referred to PRA for participation in the study. The CT also ensured that, during their time in the research, patients in the control group received the same priority access to consultation and services as did patients with court orders.

The following analysis sets forth Bellevue’s view of the PRA report. These observations are intended to highlight specific areas of agreement and disagreement between Bellevue’s clinical and implementation experiences and PRA’s research analysis.

AREAS OF SUBSTANTIAL AGREEMENT BETWEEN BELLEVUE AND PRA

1. The PRA report accurately states that “the terms and conditions for successful compliance under OCP were negotiated between providers and program clients on an ongoing basis, proving the court orders to be flexible in interpretation.”[4]

PRA found that the court orders provided a structure around which providers and patients constantly negotiated the terms of treatment. This is consistent with the intent of Section 9.61, which allows the court to order categories of services, and contemplates that providers will attempt to solicit compliance and monitor noncompliance and dangerousness. This is also consistent with Bellevue’s observation that outpatient commitment orders often engage severely mentally ill individuals with histories of noncompliance in a dialogue about the need for treatment when they are still outpatients, and therefore assist in soliciting patient compliance in the community and preventing relapse.

2. PRA’s conclusion that the CT’s service coordination and resource mobilization functions “seemed to make a substantial positive difference in the post-discharge experiences of both the experimental and control groups”[5] is important.

The PRA report states that both groups of patients in the research study showed improved clinical outcomes because a statistically significant lower proportion of patients in both groups were hospitalized in the 11 months of follow-up as compared to the year preceding the target admission.[6] Both groups had access to a wide array of community services, which were coordinated through the CT. Bellevue’s clinical experience has been that a wide array of services and their effective coordination are necessary to establish good patient outcomes.

Bellevue has also found that in many cases the court order and the authority of the legal system contribute to positive patient outcomes. To the extent that patients in the control group and their providers felt that the CT had access to and imposed the authority of the legal system on them, control patients may have benefitted from the outpatient commitment pilot in ways similar to those of patients with court orders. In analyzing the research findings, it is important to acknowledge that patients in the control group received the maximum amount of resource mobilization as well as monitoring in the community that was legally possible.

3. PRA reached the important conclusion 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.”[7]

It is indeed Bellevue’s experience that the CT is popular with providers because it operates under the auspices of a pilot outpatient commitment program that has the legal authority to closely monitor patients, to attempt to ensure that they have access to treatment and, to the extent possible to solicit their compliance. Service coordination involves treatment planning and the sharing of medical information between multiple programs and agencies. While case management programs typically attempt to perform this function, the OCP is especially effective because of its legal authority.

More importantly, the CT is able to “mobilize” resources because providers feel empowered by the legal system to work with patients who have historically been noncompliant and service refusing. Sometimes even the most assertive outreach is ineffective in the face of severe symptoms of mental illness; outpatient commitment orders allow providers to maintain engagement efforts without feeling that they are intruding inappropriately on a refusing patient’s privacy.

Since Bellevue could not insure that all patients participating in the study would have court orders it was essential that the CT made its consultation and coordination services available to all providers who agreed to participate. These services have been appreciated, and it appears that they lead to improved outcomes and quality of care.

The purpose of the study was to determine the degree of added benefit provided by outpatient commitment. In this regard it is worth noting that the PRA report shows trends which suggest that the CT has even greater value when it has the authority of a court order. The report indicates that when patients had court orders 77% of their providers were very satisfied with the support of the CT vs. 59% of providers of control patients. The report also indicates that 71% of providers reported that OCP helped their work with court ordered patients vs. 56% of providers of control patients. Fewer than 10% of providers for both groups of patients felt that OCP hindered their work with the client.[8]

It is also important to note that providers of patients in the control group to some extent felt that the CT had access to and imposed the authority of the legal system both on them and their patients. The degree to which this phenomenon affected the PRA study is not explored, and may significant. If there had been two coordinating teams, one with access to outpatient commitment orders, and one only doing hospital discharge planning and service coordination, this methodologic flaw would have been eliminated, and the specific effect of the court order might have been clearer.

AREAS OF PARTIAL AGREEMENT BETWEEN BELLEVUE AND PRA

4. PRA’s conclusion that a comprehensive outpatient commitment program was difficult to implement[9] is generally consistent with Bellevue’s experience.

Bellevue had anticipated difficulties in implementing a pilot outpatient commitment program in New York City. Given the amount of time it took for outpatient commitment legislation to be passed, and the many sensitive clinical, legal and ethical issues that had to be resolved, it is clear that program implementation was a process that had to unfold through time and experience.

The PRA report correctly states that the lack of a Section 9.61 hospital transport procedure during the research period was one factor that made the OCP different from the Legislature’s intended model.[10] PRA also concludes that in extrapolating from evidence, it must be remembered that the program tested was not a “fully executed, clinicians-working-with-the-law-enforcement officers”[11] outpatient commitment program. PRA also indicates that this contributed to its difficulty in measuring “any leverage or negative consequences of coercion that may have been added by Section 9.61 over existing emergency intervention procedures.”[12]

In spite of the time it took to fully implement the 9.61 enforcement mechanisms, however, the Bellevue OCP has functioned effectively. The pilot has shown that many government and provider agencies can collaborate to help patients. The program has credibility in the eyes of providers and has brought leverage to bear on the problems of noncompliance. Furthermore, in its assurance of due process and access to MHLS, the program is attuned to patients’ rights and the balance that must be struck between autonomy and social control in the area of mental health treatment.

PRA is not completely accurate in indicating that the program was difficult to implement because “community treatment resources (especially for co-occurring mental disorder and substance abuse) . . . proved insufficient to the demand.”[13] While the availability of different specific resources waxed and waned over time, the OCP was fortunate to have had access to a wide range of services throughout New York City during the whole pilot. Any access difficulties were experienced by the entire mental health system, and did not only affect OCP. Furthermore, while it is true that resources for mentally ill chemical abusers (MICA’s) are insufficient, it is important to recognize that the problem is not just one of numbers. Most programs for MICA’s require patients to express a desire to stop using substances, and such services were as available to OCP patients as any others. However, many OCP patients express neither a desire nor a willingness to achieve abstinence. Developing services for MICA’s who do not want substance abuse treatment presents many complex challenges to our treatment system and our entire society, which are far from being solved.

5. Bellevue agrees with PRA’s conclusion that OCP court procedures are often informal, but interprets the legal process of outpatient commitment differently.

PRA documents the fact that initial 9.61 hearings became routine after the first year of the pilot. [14] Physicians most often presented their case to the court with affidavits, and patients most often consented to the orders. Renewals also became informal, and patients very often communicated their consent to their MHLS attorney on the telephone.

It is possible that a different procedure for granting orders might alter the effect of outpatient commitment. PRA indicates that, based on their interviews, patients who received court orders appeared to understand their outpatient commitment status despite abbreviated court hearings.[15] Furthermore, all patients who contested the hospital’s request for an outpatient commitment order or renewal had the right to a hearing. While there indeed were very few hearings in relation to the total number of orders granted, PRA hardly mentions the hearings that did take place.

PRA states that the “easy informality” of the hearings served to “mute perception of the essentially coercive nature of the intent behind such proceedings.”[16] Yet this view fails to appreciate the degree to which the success of outpatient commitment depends on enlisting the patient’s cooperation in developing a treatment plan. Section 9.61 requires that the patient, and, at the patient’s request, a person significant to the patient, be given an opportunity to actively participate in the development of the treatment plan.

The hearings can perhaps be better understood as the formalization of the outpatient commitment process, which is a mandate for the patient to comply with treatment in order to prevent deterioration and relapse. When PRA questions “the putative symbolic or moral power that may be ascribed to the legal vehicle (the court hearing)”[17] it does not appreciate that the authority of outpatient commitment is based not only on the hearing, but on the entire process that comes with it. The orders provided a structure around which treatment issues were continuously negotiated between patients and providers.

It is also possible that the lack of 9.61 enforcement procedures during the research period affected the nature of the hearings. As PRA noted, during the first hearing the testifying psychiatrist had difficulty describing how the OCP plan differed from previous discharge plans for the patient.[18] It is possible that the testimony would have been quite different had the Medication Guidelines and the 9.61 hospital transport procedure been in place. It is also likely that a statute with less sensitivity to patient choice and more of an emphasis on coercion than Section 9.61 would result in more formal and contested hearings.

AREAS OF DISAGREEMENT BETWEEN BELLEVUE AND PRA

6. PRA’s conclusion that “the court order itself had no discernible added value in producing better outcomes”[19] must be questioned in light of the limitations of the study. Further, PRA’s conclusion is inconsistent with some of its study’s own results, as well as much of the clinical experience of Bellevue and community providers.

1. The PRA report acknowledges that “the modest size of our study group” is a “limit on our ability to draw wide-ranging conclusions. [20]

The report also states that an analysis of “for example, which subjects if any might have been more likely to benefit from a court order is not possible, because the size of the subgroups becomes too small to reach acceptable levels of statistical rigor.”[21]

2. The “experimental” and “control” conditions were much more similar than had originally been contemplated.

This was the case both because there was no Section 9.61 transport procedure in place, and because of the likelihood that some of the OCP’s legal authority affected the control group. Furthermore, the PRA report describes how much the difference between the conditions was misunderstood by patients and providers, especially before 1997, when the paperwork was modified to address the problem.[22] The similarities of the two conditions limits the meaning of the comparison.

3. PRA minimizes its own statistical trends which suggest that outpatient commitment did reduce hospital days considerably.

The research showed that patients in the court-ordered group spent a median of 43 days in the hospital during the study year, while patients in the control group spent a median of 101 days in the hospital.[23] PRA states that there is “no statistically significant difference”[24] between these numbers, but fails to provide an adequate analysis of this trend. There is also no discussion of the trend showing that non- substance abusing psychotic patients were re-hospitalized far less if they had outpatient commitment orders (25%) than if they were in the control group (45%).[25]

4. PRA does not adequately examine the “trend for controls to be transferred to state hospitals more frequently than the court-ordered group.” [26]

PRA explains that “nothing in the baseline or follow-up measures of symptoms and functioning, or the ethnographic study of OCP, or indeed in the modalities of case management to which they were assigned, suggests that differences in the clinical picture or service packages of the two groups might explain the much longer hospital stays and greater likelihood of state transfers of the controls.” [27] PRA hypothesizes that the court order may have permitted the CT “to act in such ways as to reduce both the number rehospitalized and their likelihood of being transferred to a state psychiatric facility”[28], but does not provide evidence for this conclusion. Furthermore, by speculating that the difference was only due to the CT’s behavior, PRA ignores the very important possibility that patients with outpatient commitment orders decompensate less severely in the community than control patients. The way in which court orders affect both provider behavior and patients’ clinical courses are questions for future research.

5. The randomization was not completely successful.

The report indicates that the court-ordered group of psychotic patients had a statistically significant higher percentage of substance abusers than psychotic patients in the control group.[29] Therefore, although otherwise similar, the two groups of patients in the study are not comparable.

This is particularly notable since PRA found that substance abusers had a statistically significant greater rehospitalization rate than non substance abusers in both court-ordered and control patients.[30]

PRA also found that patients with court orders were significantly less likely than controls to have been homeless prior to the referring hospitalization.[31] This demographic difference may have had implications regarding differences in treatment planning between court-ordered and control patients.

6. The PRA report does not evaluate patients in relation to their own histories.

This is especially important because, as noted above, the two groups were different in important respects. PRA did not measure and evaluate the number of days patients spent in the hospital in the 18 months prior to the study. PRA also did not assess which services patients already had in place, or which services patients had failed to comply with, prior to inclusion in the study. This information is crucial in assessing the specific effectiveness of outpatient commitment as compared to community services alone, and without such an analysis a comparison of two non-equivalent groups has very limited value.

7.. PRA’s findings only reflect a proportion of program participants.

Court-ordered patients completed five or eleven month follow-up interviews 77% of the time, and control patients completed them 66% of the time.[32] Many patients were therefore not studied at all. It is likely that these patients’ attitudes and responses to treatment are different from those of the patients whom PRA studied.

Further, PRA states that “we were somewhat more able to locate and interview the experimental subjects, who less often moved out of the New York City area and were easier to locate.”[33] The reason for this phenomenon is not explored, although PRA notes that “a logistical regression analysis showed no biasing across the two study groups as a result of differential attrition,”[34]

8. The PRA study is limited to patients who were determined to be capable of consenting to participate in the research, and who then consented.

Approximately 15% of patients who were approached by PRA refused to consent to participate in the study.[35] These patients all were brought to court, and they all received outpatient commitment orders and were followed by the CT. The report states that PRA had limited knowledge of these patients, but then goes on to say that research refusers were no more uncooperative, resistant or dangerous” than patients who consented to the research.[36] In the judgment of the CT this conclusion is questionable.

It is also worth noting that PRA judged a small number of patients to be incapable of consenting to the research, or not appropriate for the study.

9. PRA does not discuss the effect on its conclusions of limitations in its own ability to perform data collection.

The report indicates that “our research team determined some subjects to be too impaired to do interviews.”[37] While roughly 10% of patients were included in this group, the report does not analyze the nature or the effect of the impairment. The report also states that “some subjects refused to do the interviews . . . even after agreeing to do them at the Baseline Interview.”[38] Although outpatient commitment was specifically developed for patients who consent and subsequently refuse, there is no further discussion of how these patients might differ from patients who agreed to all of the interviews.

10. PRA does not fully consider clinicians’ views of the effectiveness of outpatient commitment.

Many providers throughout the community have consistently stated to the CT that outpatient commitment orders promote patient compliance with treatment. The PRA report states that many providers believed that the court order was potentially helpful in improving patient compliance.[39] PRA also notes that once the research recruitment ended, “Bellevue clinicians and community providers are not as reluctant to do the extra work required by the OCP now that they are certain that the patient will be going to court” and not be randomized into the control group.[40]

In a number of instances, however, PRA minimizes the positive views of providers regarding outpatient commitment. PRA incorrectly describes the “high demand for renewals” among providers as being exclusively due to the support and assistance received by the OCP Coordinating Team.[41] In fact, providers consistently described the value of the court orders themselves when requesting renewals.

PRA also understates the extent to which psychiatrists believe that outpatient medication orders are appropriate and valuable. The PRA report notes that the CT encouraged psychiatrists to request that medication be included in outpatient commitment petitions and assisted in the preparation of such medication requests.[42] The PRA report minimizes the belief among many inpatient psychiatrists that medication noncompliance was the heart of the problem for many patients, and that an outpatient medication order might improve medication compliance in the community. Although approximately two-thirds of initial requests for outpatient commitment included medication as a category of service, the PRA report only discusses reasons that the psychiatrists do not include orders, not why they do.[43]

7. The PRA report is confused in its discussion of the OCP and violence.

The PRA report states that the OCP “did not target patients perceived as being at high risk of violence in the community.”[44] This is only accurate to the extent that it refers to patients who remain at high risk even while they are receiving treatment in the hospital. Such patients, however, were never defined as the target population for outpatient commitment. This is clear in Dr. Geller’s Clinical Guidelines for the Use of Involuntary Outpatient Treatment,[45]and was the position of all agencies responsible for implementing the New York pilot. Indeed, it would have been unethical to allow mentally ill individuals presently at high risk for violence to be discharged to the community. It is also unclear how many such patients would be capable of providing informed consent for a randomized research study in which only half received outpatient commitment orders.

PRA seems to confuse current with past dangerousness. PRA is incorrect in stating that a “standard of low perceived dangerousness seems to have been consistently applied for all OCP referrals.”[46] Patients were required to have a history of two involuntary hospitalizations in order to even be eligible for OCP, and these require dangerousness to self or others. A high proportion of patients referred to the OCP had histories of agitation, threatening behavior and fights with friends, relatives, providers or strangers. Patients were never excluded from the OCP due to prior histories of violence or incarceration. The majority of patients had histories of repetitive dangerousness, but of the kind which were due to treatment noncompliance and which resulted in psychiatric hospitalization rather than arrest. Many patients who were known to be at high risk of dangerousness, when untreated, in the community, were referred to and followed by the OCP.

For similar reasons PRA is not accurate in its discussion of the CT’s view of Larry Hogue. PRA quotes the OCP Director as discussing Larry’s Hogue’s case over the course of the pilot, and stating that “Mr. Hogue would not have been approved for referral to court.”[47] However, PRA does not elaborate fully on the way in which the case was used for instruction. In fact, Mr. Hogue was often discussed as an example of a patient who had done well in the community for long periods, at different times, on a conditional release legal status. He was presented as an example of a mentally ill individual who was dangerous to others when noncompliant with treatment and intoxicated on cocaine, but who was not dangerous when complying with treatment and abstinent. Therefore, Mr. Hogue was often discussed in the context of explaining the spectrum of legal interventions that might be used to assist dangerous mentally ill individuals to accept treatment and live safely in the community.

8. The PRA report contains a number of other inaccuracies.

First, PRA misrepresents the message that was given to patients regarding the relationship between outpatient commitment and clinical services. PRA states that “it was not uncommon for patients to labor under the (usually uncorrected) impression that renewing the court order would secure them continued enhanced services, and that, without it, those same services would be withdrawn.”[48] This was not the case; patients were told clearly by the CT that access to services was unrelated to the outpatient commitment order. The message was the same at the time of renewing orders, and whenever patients contacted the CT with questions on this issue.

PRA also incorrectly states that “basically, no one is put forward for a court hearing by the Coordinating Team who has not already agreed to participate in the OCP.”[49] Patients generally are required to agree to participate in clinical services before they can be accepted, but patients were by no means required to accept the order. The CT requested outpatient commitment orders in every case in which a patient had a community treatment plan in place but refused to consent to the order.

The PRA report is also inaccurate in its discussion of the case of Billy Boggs. PRA correctly notes that she was a gravely disabled mentally ill homeless woman who became a focus of public attention. However, the PRA report states that she “successfully fought efforts in the early 1980's by city officials to have her hospitalized.[50] In fact, Billie Boggs was hospitalized at Bellevue on the Project HELP unit soon after it was established in 1987. Most importantly, the clinical staff at Bellevue successfully secured a court order to retain Billie Boggs in the hospital because of the continued risks she posed to herself as a result of her mental illness. It was only the hospital’s petition to the court to administer medication over the patient’s objection that was denied.

VI. CONCLUSIONS

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 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 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 on-going basis regarding possible changes in the treatment plan and issues of non-compliance. 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. 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.

Outpatient commitment is not a panacea. Sometimes is 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

Appelbaum PS: Almost a revolution: Mental health law and the limits of change. New York: Oxford University Press, 1994.

Appelbaum PS: Outpatient commitment: The problems and the promise. Am J Psychiatry 143: 1270-2, 1986.

Dennis DL and Monahan J, eds: Coercion and aggressive community treatment: A new frontier in mental health law. New York: Plenum Press, 1996.

Dwyer E: Civil Commitment Laws in Nineteenth-Century New York. Behavioral Sciences and the Law 6: 79-98, 1988.

Geller JL: Clinical Guidelines for the Use of Involuntary Outpatient Treatment. Hosp Community Psychiatry 41: 749-755, 1990.

Geller JL: Rights, wrongs and the dilemma of coerced community treatment. Am J Psychiatry 143: 1259-1264, 1986.

Geller JL: The quandaries of enforced community treatment and unenforceable outpatient commitment statutes. J Psychiatry and Law 14: 149-58, 1986.

Group for the Advancement of Psychiatry: Forced into treatment: the role of coercion in clinical practice. Washington, DC: American Psychiatric Press, 1994.

Hiday VA, Scheid-Cook T: The least restrictive alternative to involuntary hospitalization, outpatient commitment: Its use and effectiveness. J Psychiatry and Law 10: 81-96, 1982.

Lidz CW: Coercion in psychiatric care: What have we learned from research? J Am Acad Psychiatry Law, 26: 631-7, 1998.

Miller RD: Commitment to outpatient treatment: A national survey. Hosp Community Psychiatry 36: 265-7, 1985.

Miller RD: Involuntary civil commitment of the mentally ill in the post-reform era. Springfield, Ill: Charles C Thomas Publisher, 1987.

Miller RD: Outpatient civil commitment of the mentally ill: an overview and an update. Behavioral Sciences and the Law 6: 99-118, 1988.

Miller RD, Fiddleman PB: Outpatient commitment: treatment in the least restrictive environment? Hosp Community Psychiatry 35: 147-51, 1984.

Munetz, MR, Grande T, Kleist J, Peterson GA: The effectiveness of outpatient civil commitment. Psych Services 47: 1251-3, 1996.

Mulvey EP, Geller JL, Roth LH: The promise and peril of involuntary outpatient commitment. American Psychologist 42: 571-84, 1987.

Schmidt MJ, Geller JL: Invountary administration of medication in the community: the judicial opportunity. Bull Am Acad Psychiatry and the Law 17: 283-92, 1989.

Starrett D, Miller RD, Bloom J, Weitzel WD, Luskin RD: Involuntary commitment to outpatient treatment: Report of the task force on involuntary outpatient commitment. Washington, DC: American Psychiatric Association, 1987.

Swanson JW, Swartz MS, George LK, Burns BJ, Hiday VA, Borum R, Wagner HR: Interpreting the effectiveness of involuntary outpatient commitment: A conceptual model. J Am Acad Psychiatry Law 25:5-16, 1997.

Swartz M, Burns B, Hiday V, George L, Swanson J, Wagner H: New Directions in research on involuntary psychiatric outpatient commitment. Hosp Community Psychiatry 46: 381-5, 1995.

Torrey, EF, Kaplan RJ: A national survey of the use of outpatient commitment. Psych Services 46: 778-84, 1995.

Treffert, DA: The obviously ill patient in need of treatment: A fourth standard for civil commitment. Hosp Community Psychiatry 36: 259-264, 1985.

APPENDIX A - MEDICATION GUIDELINES

GUIDELINES FOR ADMINISTRATION OF MEDICATIOIN

TO PATIENTS WHO FAIL TO COMPLY WITH

COURT ORDERED MEDICATION

These guidelines are prepared in accordance with the requirements of Section 9.61, relevant sections of which are outlined below. They apply only to instances where the court, in the context of an outpatient commitment order, has ordered that a patient accept psychotropic medication, and the patient nevertheless refuses to accept the medication. Because the law in certain instances allows for the administration of medication over the objection of the patient, these guidelines are mandated. The guidelines rely on the discretion the examining physician to determine that the manner and place where the medication is administered is clinically appropriate, safe, and consistent with the dignity and privacy of the patient.

The guidelines incorporate the standards of the medical community for the administration of medication in voluntary circumstances, and involuntary circumstances on inpatient units, but recognize that because there is no precedent in New York for medicating over objection in the community, these guidelines necessarily define the only existing acceptable standards.

Applicable Statute - 9.61 of the Mental Hygiene Law

b) …The president of the New York City Health and Hospitals Corporation in consultation with the State Office of Mental Health shall issue guidelines pertaining to the manner and place for the administration of medication under subdivision (k) of this section.

(c)(2) A court may order the involuntary administration of psychotropic drugs as part of an involuntary outpatient treatment program if the court finds the hospital has shown by clear and convincing evidence that the patient lacks the capacity to make a treatment decision as a result of mental illness and the proposed treatments 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 interest, the benefits to be gained from the treatment, the adverse side effects associated with the treatment and any less intrusive alternative treatments. Such order shall specify the type and amount of such psychotropic drugs and the duration of such involuntary administration.

(k) Failure to comply with involuntary outpatient treatment. (1) Where in the examining physician’s clinical judgment, the patient has failed or has refused to comply with the treatment ordered by the court, and in the examining physician’s clinical judgment, efforts were made to solicit compliance, and, in the clinical judgment of such physician, such patient has a mental illness for which immediate observation, care and treatment in a hospital may be necessary pursuant to 9.39 or 9.40 of this article, such physician may request the director of such hospital, or the director’s designee, to direct the removal of such patient to such hospital for an examination to determine if such person has a mental illness for which immediate observation, care and treatment in a hospital is necessary pursuant to section 9.39 or 9.4-0 of this article. Upon the request of such physician, the director of such hospital or the directors designee may direct peace officers, when acting pursuant to their special duties, or police officers who are members of an authorized police department or force or of a sheriff’s department to take into custody and transport any such person.... 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.

(2) While the order for outpatient commitment is in effect, and if in the examining physician’s clinical judgment the patient has failed or has refused to take such medication as the patient may be required to take pursuant to the order and in the examining physician’s clinical judgment efforts were made to solicit compliance, the patient may be medicated over his or her objection by such examining physician. Such medication shall be administered in a manner and place that, in the best judgment of the physician administering such medication and consistent with the standards of the medical community in which he or she practices, is clinically appropriate safe, consistent with the dignity and privacy of the patient, and is in accordance with the guidelines issued pursuant to subdivision (b) of this section.

II. Standard for Seeking Authority to Medicate Over Objection from the Court:

A. The hospital must show by clear and convincing evidence that: