Robbing Peter to Pay Paul: Did New York State's Outpatient Commitment Program Crowd Out Voluntary Service Recipients?

Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Box 3071, Durham, NC 27701, USA.
Psychiatric services (Washington, D.C.) (Impact Factor: 2.41). 10/2010; 61(10):988-95. DOI: 10.1176/
Source: PubMed


This study examined whether New York State's assisted outpatient treatment (AOT) program disadvantaged voluntary service recipients by directing services toward court-ordered individuals.
Administrative data from the New York State Office of Mental Health were linked with Medicaid claims from 1999 through 2007 to compare trends in utilization of enhanced outpatient services by involuntary and voluntary service recipients with serious mental illness. Multivariable time series analysis was used to examine the likelihood that voluntary care seekers (N=3,295) either did not initiate or did not receive assertive community treatment or intensive case management during any month as a function of the number of AOT orders in the system.
New York State appropriated new resources for enhanced community-based mental health services to implement AOT. During the first three years of the AOT program, most of the expansion in enhanced services was directed toward individuals under court-ordered treatment, which appears to have affected voluntary care seekers by lowering their odds of initiating enhanced services and raising their odds of having these services discontinued or no longer receiving them. However, after the first three years of AOT, enhanced service provision expanded steadily among both voluntary and involuntary recipients.
In tandem with New York's AOT program, enhanced services increased among involuntary recipients, whereas no corresponding increase was initially seen for voluntary recipients. In the long run, however, overall service capacity was increased, and the focus on enhanced services for AOT participants appears to have led to greater access to enhanced services for both voluntary and involuntary recipients.

Download full-text


Available from: Christine M Wilder, Feb 17, 2015
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: This study examined whether persons with mental illness who undergo a period of involuntary outpatient commitment continue to receive prescribed medications and avoid psychiatric hospitalization after outpatient commitment ends. Data on Medicaid pharmacy fills and inpatient treatment were used to describe patterns of medication possession and hospitalization for persons with mental illness after they received assisted outpatient treatment (AOT) in New York between 1999 and 2007 (N=3,576). Multivariable time-series analysis was used to compare post-AOT periods to pre-AOT periods. For former AOT recipients, sustained improvements in rates of medication possession and hospitalization in the post-AOT period varied according to the length of time spent in court-ordered treatment. When the court order for AOT was for six months or less, improved medication possession rates and reduced hospitalization were sustained in the post-AOT period only when intensive case coordination services (assertive community treatment, intensive case management, or both) were kept in place. However, when the court order was for seven months or more, improved medication possession rates and reduced hospitalization outcomes were sustained even when the former AOT recipients were no longer receiving intensive case coordination services. Benefits of involuntary outpatient commitment, as indicated by improved rates of medication possession and decreased hospitalizations, were more likely to persist after involuntary outpatient commitment ends if it is kept in place longer than six months.
    Psychiatric services (Washington, D.C.) 10/2010; 61(10):982-7. DOI:10.1176/ · 2.41 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: This study examined changes in possession of guideline-recommended medication among three groups of New York State Medicaid enrollees with severe mental illness: those who received an involuntary outpatient commitment order, voluntary enhanced services, or neither of these interventions. An observational study was conducted with New York State Medicaid claims data for enrollees with bipolar, schizophrenia, or schizoaffective disorders in New York City, Long Island, and the Hudson River regions from 2000 to 2005 (N=7,762). With adjustment for clinical and demographic characteristics, logistic regression models predicted the probability of a monthly medication possession ratio (MPR) ≥ 80% for medications recommended by expert guidelines or by the U.S. Food and Drug Administration for the indicated psychiatric diagnosis. Separate models were fit by region and for patients who ever received assisted outpatient treatment (AOT), voluntary enhanced services but never AOT, or neither treatment. In all three regions, for all three groups, the predicted probability of an MPR ≥ 80% improved over time (AOT improved by 31-40 percentage points, followed by enhanced services, which improved by 15-22 points, and "neither treatment," improving 8-19 points). Some regional differences in MPR trajectories were observed. After New York implemented AOT and increased community resources for enhanced services, guideline-recommended medication possession improved among Medicaid enrollees with severe mental illness--even among those who never received these interventions or services. However, further study is needed to understand why there were different regional trajectories and why some groups did not gain similarly across regions.
    Psychiatric services (Washington, D.C.) 10/2010; 61(10):1000-5. DOI:10.1176/ · 2.41 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: This study examined whether New York State's assisted outpatient treatment (AOT) program, a form of involuntary outpatient commitment, improves a range of policy-relevant outcomes for court-ordered individuals. Administrative data from New York State's Office of Mental Health and Medicaid claims between 1999 and 2007 were linked to examine whether consumers under a court order for AOT experienced reduced rates of hospitalization, shorter hospital stays, and improvements in other outcomes. Multivariable analyses controlling for relevant covariates were used to examine the likelihood that AOT produced these effects. On the basis of Medicaid claims and state reports for 3,576 AOT consumers, the likelihood of psychiatric hospital admission was significantly reduced by approximately 25% during the initial six-month court order (odds ratio [OR]=.77, 95% confidence interval [CI]=.72-.82) and by over one-third during a subsequent six-month renewal of the order (OR=.59, CI=.54-.65) compared with the period before initiation of the court order. Similar significant reductions in days of hospitalization were evident during initial court orders and subsequent renewals (OR=.80, CI=.78-.82, and OR=.84, CI=.81-.86, respectively). Improvements were also evident in receipt of psychotropic medications and intensive case management services. Analysis of data from case manager reports showed similar reductions in hospital admissions and improved engagement in services. Consumers who received court orders for AOT appeared to experience a number of improved outcomes: reduced hospitalization and length of stay, increased receipt of psychotropic medication and intensive case management services, and greater engagement in outpatient services.
    Psychiatric services (Washington, D.C.) 10/2010; 61(10):976-81. DOI:10.1176/ · 2.41 Impact Factor
Show more