Evaluation of the NYC Out-patient Commitment Pilot Program

Evaluation of the New York City (Bellevue) Involuntary Outpatient Commitment Pilot Program

Center Co-investigator: Kim Hopper, Ph.D., in collaboration with Principal Investigator: Henry J. Steadman, Ph.D.(Policy Research Associates); Co-investigators: Jeanne Dumont, Ph.D., David L. Shern, Ph.D., Marvin Swartz, M.D.(Duke University Dept. of Psychiatry).

A patient group court-committed to out-patient treatment was compared with a control group attending treatment voluntarily where participants in both groups received intensive, enhanced services. The researchers found no significant statistical difference between the two groups on any outcome measure and concluded legal coercion may not play a significant role in keeping individuals in treatment.

PROJECT GOALS

In its 1994 term, the New York State Legislature passed enabling legislation for a pilot program to test involuntary outpatient commitment orders. The Involuntary Outpatient Commitment Pilot Treatment program targets persons who have had two involuntary admissions in the last 18 months and are judged clinically to be incapable of surviving safely in the community without supervision. New York City designated Bellevue Hospital as a test site.

The enabling legislation also provided for an evaluation of the pilot program. In response to a city issued request for proposals, a team of researchers from Policy Research Associates, of Delmar, NY (Steadman, Dennis, Gounis), Duke University (Swartz, Swanson, Burns), and the Center (Hopper, Shern, Dumont) successfully bid for the contract. A six member recipient and family advisory panel (including Center faculty member Mary Auslander) was convened to meet regularly and to review all aspects of the research.

RESEARCH ACTIVITIES AND RESULTS

The evaluation design included interviews with consumers at baseline and three follow-up points; an implementation evaluation that documented how the program took shape; interviews with providers in the community regarding the OCP subjects, program characteristics and the service system; ethnographic follow-up of subjects to assess their functioning in the community and their "careers" as part of OCP; and focus groups to examine further the perspectives of family members and subjects. The evaluation component was integrated directly into the treatment services (pre- and post-discharge) and the court proceedings. Beginning in January 1996 (after the program had been operating for six months), subjects were enrolled and randomly assigned to two groups: experimentals (or court-ordered), who would go to court to determine eligibility and, if found eligible, would be "committed" to outpatient treatment including enhanced services; or controls who received the enhanced services only. Of the 142 subjects enrolled, 78 were in the experimental and 64 were in the control condition.

The core finding of the study was that there were no statistically significant differences between the two groups on any outcome measure, including re-hospitalization. But there was a difference between the two groups in total time re-hospitalized (less time for the experimental group), which some critics cite as evidence of the added value of the order. That difference, however, did not quite reach conventional levels of statistical significance, meaning that chance could not be ruled out as responsible for the finding. Court-ordered subjects, in fact, were slightly more likely to be hospitalized, but stayed for briefer periods and were less likely to be transferred to a state facility. (It is possible that inpatient staff may have perceived the order as added leverage and undertaken community return.)

Both groups -- court-ordered and control -- were hospitalized less often while receiving enhanced services, as compared with their own records for the prior year when they were not receiving enhanced services. It is difficult to attribute that decrease in both groups to an order only one group received; more plausibly, the enhanced, community-based services made the difference. Although the OCP program did not include persons seen as being at high risk of violence in the community, it is notable that in neither group was there a documented instance of violence toward another person in the 11 month follow-up period.

That substance abuse complicates compliance is also clear; persons with psychosis and substance abuse assigned to the court-ordered group were nearly twice as likely to be re-hospitalized as their counterparts without the order. Closer examination of the data on participation in follow-up interviews suggests that those in the court group were more likely to drop out of treatment.

Clinicians participating in the Bellevue program told the researchers that they viewed court orders as useful leverage for only a fraction of the subjects.

SIGNIFICANCE OF FINDINGS/POLICY IMPLICATIONS

The project presented an unusual instance in which the State Legislature passed conditional enabling legislation, the renewal of which was made dependent upon the outcome of an independent evaluation of the pilot program. Neatly complementing the findings of the Duke Outpatient Commitment study, the Bellevue Pilot Outpatient Commitment evaluation yielded methodologically sound and ethnographically rich evidence of the problems and promises of mounting such a program. The study was limited, however, by the fact that no concrete enforcement measures - such as "pick-up" orders in the event of non-compliance for the court-ordered group - were ever negotiated with the New York Police Department during the three years that the pilot program operated.

Publication:

Policy Research Associates, Research Study of the New York City Involuntary Outpatient Commitment Pilot Program, December 1998.

Project Completed

Entered: April 12, 1999

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