BELLEVUE HOSPITAL OUTPATIENT COMMITMENT STUDY
The PRA Executive Summary
In 1994, the New York State Legislature passed a bill directing the New York City Department of Mental Health, Mental Retardation, and Alcoholism Services (NYC DMHMR&AS) and the Health and Hospital Corporation to establish a three-year pilot project of involuntary outpatient mental health treatment at Bellevue Hospital to begin on July 1, 1995. The legislation required that the City contract for a study to determine the effectiveness of the pilot project. NYC DMHMR&AS contracted with Policy Research Associates, Inc. (PRA) of Delmar, NY, to conduct the research study of the program.
The design of the pilot project integrated an evaluation component directly with the treatment services and court processes. The goal was to provide as definitive feedback to the State Legislature as possible while protecting the rights of the individuals participating in the program. The plan was straightforward. During the research period, half of the eligible participants would receive "enhanced" treatment that included careful review by the Bellevue Hospital Outpatient Commitment Program (OCP) Coordinating Team to assess their clinical and legal appropriateness, a full discharge treatment plan, court review for an outpatient commitment order and release to intensive community treatment, if the court agreed on the order. The other half of eligible participants would be in the "control" condition which would include the same assessment, comprehensive discharge planning and release to intensive community treatment but without a court order. The evaluation plan called for a client outcome evaluation focusing on how program participation varied in the two groups and a process evaluation of the Bellevue program, the court procedures, and community treatment activities.
Patients eligible for the Bellevue Hospital OCP, who were ready for discharge and who consented to participate in the study, were randomly assigned to the experimental group (i. e., to go to court to determine if they would be committed to outpatient treatment) or the control group (i. e. to be discharged with an equivalent package of enhanced treatment services). Subjects were interviewed in the hospital prior to discharge and in the community at one, five and 11 months after discharge. Ultimately, 142 people entered into the research with 78 assigned to the court condition and 64 assigned to enhanced services without a court order.
There were five study components: (1) a client outcome study; (2) a program implementation evaluation; (3) community provider interviews; (4) ethnographic follow-up; and (5) consumer and family focus groups.
KEY FINDINGS FROM THE CLIENT OUTCOME STUDY
No statistically significant differences were found between the experimental and control groups for acute or state re-hospitalizations in terms of the proportion re-hospitalized or the amount of days spent hospitalized in the 11-month follow-up.
For both the experimental and control subjects, a statistically significantly smaller proportion were re-hospitalized during 11 month follow-up in OCP as compared to the year preceding the target admission. For the experimental subjects the proportion went from 87.1% to 51.4% and for the controls from 80.0% to 41.6% with a hospitalization (Table 6).
Arrests during the follow-up period (Table 7), revealed no violence against persons for either group and relatively few subjects arrested overall, 16% for controls and 18% for experimental. There were no differences between the control and experimental group on indicators for any arrest, multiple arrests, number of arrests, or most serious charge.
The control and experimental groups overall were not significantly different on any quality of life or symptomatology outcome measures (Table 8).
There were no significant differences in the number of clients in the two groups who discontinued treatment - - 27% for the experimental group and 26% for the control group (Table 9).
In summary, the experimental and control groups were remarkably similar on all outcome measures over the follow-up period. There is no indication that, overall, the court order for outpatient commitment produces better outcomes for clients or the community than enhanced services alone. However, both groups appeared to profit from the enhanced services and vigorous work of the Bellevue Coordinating Team, despite an inadequate amount of community treatment options for subjects with co-occurring mental disorders and substance abuse.
KEY FINDINGS FROM THE PROCESS EVALUATION
The Bellevue OCP had a major positive impact on the mobilization, coordination and follow-through of community treatment services.
The enhanced services included in the Bellevue OCP, particularly coordination of community resources and assertive community treatment, appear to be critical to the effectiveness of who these people might be.
The terms and conditions for successful compliance under OCP were negotiated between providers and program clients on an on-going basis, proving the court order to be flexible in interpretation.
OCP court procedures have become increasingly informal to the point that initial hearings were perfunctory and renewal orders most often occur without a formal hearing.
In assessing the effectiveness of the Bellevue OCP it is important to acknowledge that it did not target patients perceived as being at high risk of violence in the community.
The comprehensive outpatient commitment program - attuned to the rights of patients, credible in the eyes of providers, and bringing new leverage to bear on problems of non-compliance - that was the legislative intent for the Bellevue OCP proved difficult to implement.
The service coordination/resource mobilization function of the Coordinating Team seemed to make a substantial positive difference in the post-discharge experiences of both experimental and control groups. The court order itself had no discernible added value in producing better outcomes.
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.
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.
OCP court procedures have become increasingly informal to the point that initial hearings are perfunctory and renewal orders most often occur without a formal hearing.
In assessing the effectiveness of the Bellevue OCP it is important to acknowledge that it did not include patients seen as being at high risk of violence in the community.