AACP Newsletter, Volume 13,
Number 4, Autumn 1999
Regional Report - New York
Bellevue Pilots Outpatient Commitment Program
Forty states now permit some form of court ordered outpatient psychiatric treatment. Much of the available research suggests that it can be effective in reducing hospital utilization and dangerousness in the community. It is important to note that there are wide variations between jurisdictions regarding eligibility, consequences of noncompliance, and patient protections. Furthermore, the use of outpatient commitment laws varies greatly, and depends on the availability of necessary services and administrative structure for its implementation.
Outpatient commitment was first proposed in New York in 1989, but was opposed by civil liberties and consumer advocacy groups. Over the following years there was significant attention to the problem of ‘revolving door” patients in the media, and efforts to pass legislation increased. In 1994 the legislature agreed to establish an outpatient commitment pilot program in one New York City public hospital. The law also required an independent research study to determine the program’s effectiveness in preventing rehospitalization and improving patient quality of life, and to study patient satisfaction.
The Bellevue Outpatient Commitment Pilot Program began in July 1995. Our experience at Bellevue has been that outpatient commitment can be an effective means to improve compliance with outpatient services when it is used cautiously in conjunction with good clinical programs. We learned that family members and providers value outpatient commitment, and that consumers objected to it much less than was anticipated. While it is by no means a panacea, outpatient commitment can increase accountability among patients as well as the service system.
Policy Research Associates presented its study of the Bellevue pilot to the New York City Department of Mental Health in December 1998. The report indicated that all of the patients studied benefited from the enhanced coordination and mobilization of services. While the data were not statistically significant, the research also showed that patients under outpatient commitment spent far fewer days in the hospital than patients who had equally enhanced outpatient services without court orders.
A public hearing was held on December 16, 1998 to discuss the future of outpatient commitment in New York. Just a few weeks later the debate intensified after Kendra Webdale was pushed to her death in front of a subway train in Manhattan by Andrew Goldstein, a man known to have a history of psychosis, repeated hospitalization and outpatient medication noncompliance. Elliot Spitzer, the state’s new Attorney General, proposed a statewide outpatient commitment statute, which was titled “Kendra’s Law.” By late spring 1999 there were nine bills in the state legislature addressing the continuation and expansion of the state’s outpatient commitment initiative. In August 1999 Governor Pataki signed a version of “Kendra’s Law” which was the result of much political negotiation. It had strong bipartisan support, and was opposed by only six legislators. The mental hygiene law was amended to enhance “the supervision and coordination of care of persons with mental illness in community-based settings.” It specifically calls for a statewide mechanism for the provision of court-ordered outpatient treatment, known as “assisted outpatient treatment” (AOT).
In order to be eligible for AOT an individual must be over age 18, suffering from a mental illness, and be unlikely to survive safely in the community without supervision, based on a clinical determination. The individual must have a history of noncompliance that has resulted in two hospitalizations (or episodes of treatment in a correctional setting) over the prior 36 months, or one or more acts or threats of serious violence toward self or others in the prior 48 months. The individual must also be unlikely to voluntarily participate in the recommended treatment, and must be in need of and likely to benefit from AOT.
The law allows a variety of petitioners to initiate a request for AOT, including relatives, roommates, probation and parole officers, treating psychiatrists and the directors of agencies in which clients reside. A psychiatrist must testify in support of an AOT petition / proposed treatment plan before an order can be issued, and a judge may not order services which have not been requested. Patients have a right to legal representation and appeal, and there are substantial due process protections at every step.
Under the new law, a physician may determine that a patient with an AOT order is noncompliant, that efforts have been made to solicit compliance, and that the patient MAY need hospital admission. Such physician may then request that the patient be involuntarily transported to a hospital for an evaluation of up to 72 hours. After that time the patient must meet that standard dangerousness criteria in order to be admitted involuntarily.
New York’s new law also calls for the expanded use of health care proxies for psychiatric patients and the expanded use of conditional release from state psychiatric centers. Although no funding was included at the time of passage, there is a plan to include money in next year’s budget for case management and assertive community treatment services, service coordination and medication for uninsured individuals being discharged from hospitals and correctional settings. The new law is quite ambitious, and there is much speculation about how it will be used, and whether it will be effective. Opponents have been vocal about their concerns regarding patient rights and the availability of adequate services. It is too soon to tell what effect this will have on New York’s mental health system (the law takes effect November 8, 1999).
The legislation, however, provides a basis for optimism. The legislature noted that ‘if such court ordered treatment is to achieve its goals, it must be linked to a system of comprehensive care, in which state and local authorities work together to ensure that outpatients receive case management, and have access to treatment services. The legislature therefore finds that assisted outpatient treatment ... is compassionate, not punitive, will restore patients’ dignity, and will enable mentally ill persons to lead more productive and satisfying lives.”
Community psychiatrists in New York will play an important role in facing this historic opportunity.
Howard Telson, M.D.
March 30, 2003 - Web Editor's Note: The AACP's Position Paper on Involuntary Outpatient Committment is in the Findings/Products section of the AACP Homepage. Or, to go directly go to it, use this URL. http://www.wpic.pitt.edu/aacp/finds/ioc.html.The Bazelon Center website also has information on Involuntary Outpatient Committment at http://www.bazelon.org/issues/commitment/index.htm.
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