Assessing Outcomes for Consumers in New York's Assisted Outpatient Treatment Program

ArticleinPsychiatric services (Washington, D.C.) 61(10):976-81 · October 2010with37 Reads
Impact Factor: 2.41 · DOI: 10.1176/ · Source: PubMed

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.


Available from: Christine M Wilder, Feb 17, 2015
PSYCHIATRIC SERVICES o o October 2010 Vol. 61 No. 10
nvoluntary outpatient commit-
ment, also known as assisted out-
patient treatment (AOT), is a civ-
il legal procedure whereby a judge
can order a person with mental illness
who meets certain criteria to follow a
court-ordered treatment plan in the
community. Involuntary outpatient
commitment is a contested policy.
Proponents assert that it provides ac-
cess to needed treatment for people
with severe mental illness; opponents
contend that the practice is coercive
and unwarranted (1–3). Effectiveness
research should help clarify the bene-
fits and drawbacks of the practice, but
the results of existing studies are
mixed and are also contested.
The study reported here further in-
forms involuntary outpatient commit-
ment policy—with new findings on
hospitalization outcomes, utilization
of case management services, and
medication possession—from a leg-
islatively sponsored evaluation of
New York’s “Kendra’s Law,” the
largest and best-funded state pro-
gram of its kind ever to be imple-
mented (4).
Forty-four states currently have in-
voluntary outpatient commitment
laws. Several states, including New
York, California, Florida, Michigan,
New Jersey, and Maine, have enacted
such statutes over the past decade (1).
Use of involuntary outpatient com-
mitment varies widely across and
within states. (An article in this spe-
cial section by Robbins and col-
leagues [5] describes these differ-
ences.). Effective implementation of
involuntary outpatient commitment
programs—and the question of
whether they actually work for con-
sumers and provide a public bene-
fit—remains a concern to policy mak-
ers and stakeholders. The tragic
shooting deaths at Virginia Tech at
the hands of an individual with men-
tal illness for whom outpatient com-
mitment was ordered but never im-
plemented is a grim reminder that
passing a law alone does not necessar-
Assessing Outcomes for Consumers in New
York’s Assisted Outpatient Treatment Program
MMaarrvviinn SS.. SSwwaarrttzz,, MM..DD..
CChhrriissttiinnee MM.. WWiillddeerr,, MM..DD..
JJeeffffrreeyy WW.. SSwwaannssoonn,, PPhh..DD..
RRiicchhaarrdd AA.. VVaann DDoorrnn,, PPhh..D
PPaammeellaa CCllaarrkk RRoobbbbiinnss,, BB..AA..
Dr. Swartz, Dr. Wilder, Dr. Swanson, Dr. Moser, and Dr. Gilbert are affiliated with the De-
partment of Psychiatry and Behavioral Sciences, Duke University Medical Center, 238 Civ-
itan Bldg., Box 3173, Durham, NC 27710 (e-mail: Dr. Van Dorn
is with the Department of Mental Health Law and Policy, University of South Florida, Tam-
pa. Ms. Robbins and Dr. Steadman are with Policy Research Associates, Inc., Delmar, New
York. Dr. Monahan is with the University of Virginia School of Law, Charlottesville. This
article is part of a special section on New York’s assisted outpatient treatment program. Dr.
Swartz served as guest editor of the special section.
Objective: This study examined whether New York State’s assisted outpa-
tient treatment (AOT) program, a form of involuntary outpatient commit-
ment, improves a range of policy-relevant outcomes for court-ordered in-
dividuals. Methods: 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 covari-
ates were used to examine the likelihood that AOT produced these effects.
Results: On the basis of Medicaid claims and state reports for 3,576 AOT
consumers, the likelihood of psychiatric hospital admission was signifi-
cantly 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. Conclusions: Consumers who received court orders for AOT ap-
peared to experience a number of improved outcomes: reduced hospital-
ization and length of stay, increased receipt of psychotropic medication
and intensive case management services, and greater engagement in out-
patient services. (Psychiatric Services 61:976–981, 2010)
HHeennrryy JJ.. SStteeaaddmmaann,, PPhh..DD..
LLoorrnnaa LL.. MMoosseerr,, PPhh..DD..
AAlllliissoonn RR.. GGiillbbeerrtt,, PPhh..DD..,, MM..PP..HH..
JJoohhnn MMoonnaahhaann,, PPhh..DD..
SSppeecciiaall SSeeccttiioonn oonn AAssssiisstteedd OOuuttppaattiieenntt TTrreeaattmmeenntt iinn NNeeww YYoorrkk
Page 1
ily mean that needed services are pro-
vided to persons with severe mental
illness in the community, and there is
considerable variability within and
across states in how such statutes are
implemented (6–8).
Under outpatient commitment, a
judge may order a person with mental
illness to adhere to recommended
outpatient treatment, but statutes
stop short of permitting forced med-
ication. Under these laws, nonadher-
ence with a treatment plan may lead
to a request that law officers transport
the consumer to a treatment facility
for encouragement to comply with
treatment or evaluation for inpatient
commitment (7). This relatively weak
enforcement authority has led some
to argue that the law “has no teeth”;
on the other hand, many mental
health consumer advocacy groups ve-
hemently oppose these statutes as in-
trusive and counterproductive (7).
Recent legislation on involuntary out-
patient commitment reflects at-
tempts by advocates and opponents
to draft laws with greater or more lim-
ited statutory authority (9–12).
Randomized controlled trials of
the effectiveness of involuntary out-
patient commitment in North Caroli-
na (7,13–18) and in New York City
(19) reached contrary conclusions,
and the positive outcomes reported
for the North Carolina study have
been criticized on methodological
grounds (19). Noncontrolled evalua-
tions of the effects of these statutes
have generally concluded that they
may improve treatment outcomes
and decrease hospital readmission
rates and lengths of stay (7). The
New York State Office of Mental
Health (OMH) reported on the
largest noncontrolled study of AOT
after the initial five years of experi-
ence with more than 3,000 patients
under Kendra’s Law (20). The state
evaluation reported that treatment
adherence more than doubled
among consumers who received
AOT and that these individuals expe-
rienced far fewer hospitalizations
(77% fewer), less homelessness
(74%), and fewer arrests (83%) and
incarcerations (87%) than they did in
the three years before initiation of
their court-ordered treatment (20).
The study reported here revisited
the question of the effectiveness of
AOT by analyzing services utilization
data collected for a large sample be-
tween 1999 and 2007. Data included
paid Medicaid claims and case man-
ager reports of inpatient and outpa-
tient services as well as ratings of
treatment engagement. We made
two kinds of comparisons. Compared
with their own pre-AOT experience,
to what extent were consumers in the
AOT program more likely to receive
intensive case management services
and psychotropic medications and to
what extent were they less likely to be
hospitalized and more likely to spend
fewer days in the hospital? Com-
pared with consumers who were par-
ticipating in assertive community
treatment (ACT) but not in the AOT
program, to what extent did con-
sumers participating in both the AOT
program and ACT or intensive case
management demonstrate higher
levels of engagement in outpatient
services and experience decreased
rates of hospitalization?
The AOT evaluation project (4) used
multiple sources of data to address
the main study objectives, each of
which are described in the articles in
this special section (5,21–24). We
used two main sources of data in this
analysis: Medicaid claims and case
manager reports. This project was ap-
proved by the institutional review
boards of Duke University, Policy Re-
search Associates, New York State
OMH, and Biomedical Research Al-
liance of New York.
Medicaid claims and state
hospitalization records
Dependent variables. Service en-
counter data were obtained for 3,609
individuals who received court-or-
dered outpatient treatment under the
program and who were enrolled in
Medicaid at any time between Janu-
ary 1, 1999, and March 14, 2007.
Medicaid mental health services for
consumers with severe mental illness-
es are largely provided on a fee-for-
service basis in New York. During this
period, a total of 5,634 individuals
(unique cases) in the state were given
AOT orders; the sample analyzed for
this study represents the 64% of these
individuals (N=3,609) who were also
enrolled in Medicaid. Once enrolled,
on average they remained enrolled
for 81% of the months that they were
on AOT. Data were incomplete for 33
persons, which left a sample of 3,576
AOT recipients.
Hospitalizations and the number of
days hospitalized per month were
measured by using dates of admission
for inpatient stays paid by Medicaid.
Additional hospitalizations and the
associated lengths of stay were identi-
fied in a database of admissions to
state psychiatric hospitals that were
not covered by Medicaid. Most state
hospital admissions in New York are
upon referral from a local inpatient
psychiatry unit. The state hospital ad-
missions data and the Medicaid inpa-
tient service claims were merged into
a single database of psychiatric hospi-
talizations for consumers before, dur-
ing, and after their receipt of AOT.
Paid claims for psychotropic med-
ications were used to create the med-
ication possession ratio (MPR), a val-
idated proxy indicator of pharma-
cotherapeutic continuity and adher-
ence (25). By using the dates that pre-
scriptions were filled, it was possible
to calculate the proportion of days in
each month that the consumer would
have possessed a supply of medica-
tion. The MPR was calculated only
for medications that were indicated
for treatment of the patient’s primary
psychiatric disorder as diagnosed by a
psychiatrist during an inpatient stay,
outpatient treatment visit, or emer-
gency department visit. For example,
for patients diagnosed as having
schizophrenia, the MPR was calculat-
ed on the basis of prescriptions for an
antipsychotic medication, and pre-
scriptions for other medications not
indicated for schizophrenia were ex-
cluded. The MPR was dichotomized
at 80% or greater, on the basis of find-
ings of prior studies that this level is
significantly associated with de-
creased hospitalization of persons
with severe mental illness (25–27).
We grouped utilization of case
management services to allow several
sets of comparisons. In the Medicaid
claims analyses, ACT and intensive
case management were first grouped
together in a single measure of re-
PSYCHIATRIC SERVICES o o October 2010 Vol. 61 No. 10
Page 2
ceiving any enhanced or intensive
services. A general measure of receipt
of any case management was also ex-
amined, which included ACT, inten-
sive case management, and “blended”
and “supportive” case management.
For the analysis of case manager–re-
ported services utilization, ACT and
intensive case management were ex-
amined as stand-alone service modal-
ities and in combination with AOT.
Independent variables. AOT sta-
tus—whether a consumer was under
a court order in any given month—
was obtained from an administrative
database that tracked the initiation,
expiration, and renewal dates of all
court orders. Observations were then
grouped by duration of AOT, creating
four categories for comparison:
months preceding AOT, initial six
months of AOT, seven or more
months of AOT, and no longer under
an order.
All multivariable models controlled
for region (New York City, Long Is-
land, Hudson River, Central, and
Western New York), race-ethnicity
(Hispanic ethnicity, black or African-
American race, Caucasian race, Asian
race, and other), sex, age (at or above
the median of 43 years), Medicare el-
igibility, and diagnosis.
Propensity scores. We used pro-
pensity score weighting to adjust the
data for possible selection bias associ-
ated with nonrandom assignment to
AOT and renewal of the court orders.
The probabilities of initiation of court
orders and renewal were estimated in
two multivariable models. The pre-
dicted probabilities from these mod-
els were used to create propensity
scores. Weighting the sample by the
inverse of these propensity scores bal-
anced the distribution of baseline
predictors of initiation and renewal
across sample observations preceding
AOT, during the initial AOT period,
and under renewed AOT, thus allow-
ing a simulated random comparison
between these groups of observa-
tions. Our propensity regression
models included all available demo-
graphic and clinical variables, MPR,
and hospitalization history.
Analysis approach for claims data.
We used logistic regression for re-
peated measures to model the proba-
bility of binary outcomes; the analysis
controlled for time, relevant covari-
ates, and multiple observations for
each individual; our unit of analysis
was the person-month. Length of
stay—a count outcome—was evaluat-
ed with a negative binomial regres-
sion model because of overdispersion
of the data. All analyses were con-
ducted with SAS, version 9.1.
Case manager reports
Through the Child and Adult Inte-
grated Reporting System, case man-
agers in New York complete a stan-
dardized assessment for all AOT and
ACT consumers at the initiation of
services and every six months there-
after. With these data, we assessed
the likelihood of inpatient admissions
and levels of case manager–reported
engagement in treatment for all indi-
viduals who received at least 12
months of ACT treatment alone (N=
952), ACT plus AOT (N=852), or in-
tensive case management plus AOT
(N=1,734) between January 1, 1999,
and July 30, 2007. (Note that this is a
different sample than employed for
the Medicaid claims analysis de-
scribed above.) Baseline information
for each individual was carried for-
ward for every six-month person-pe-
riod. Our analyses included person-
periods beginning with case man-
agers’ retrospective reports at the 12-
month follow-up visit—that is, re-
ports covering the period from six to
12 months and including every six
months thereafter.
Dependent variables. Case man-
agers reported whether individuals
had experienced psychiatric hospital-
ization in the prior six months and rat-
ed the individuals’ motivation to en-
gage in services every six months.
Motivation to engage in services was
defined by case managers’ responses
to the 5-point scale question: “Indi-
cate which option best characterizes
consumer’s engagement in services.”
Choices ranged from 1, not engaged,
no contact with provider(s), does not
participate in services at all; to 5, ex-
cellent, independently and appropri-
ately uses services. Scores of 4 or 5
were considered to reflect engage-
ment in treatment.
Independent variables. The treat-
ment status of consumers was report-
ed by case managers at six-month in-
tervals. These services could include
receipt of ACT without a court order
for AOT, receipt of ACT with an AOT
order, and receipt of intensive case
management with an AOT order.
Baseline engagement was deter-
mined from the initial case manager
report for each individual and was in-
cluded with demographic and related
data in models as a covariate. Sub-
stance use, Global Assessment of
Functioning score, and medication
adherence were also included in the
models, but unlike the single baseline
score for engagement these varied at
each six-month report. Substance use
was defined as positive if the case
manager reported that the consumer
had used any alcohol or illicit drugs
within the past month.
Analysis approach for case manag-
er data. As with the claims data analy-
sis, we used logistic regression for re-
peated measures to model the proba-
bility of binary outcomes; the analysis
controlled for time, relevant covari-
ates, and multiple observations for
each individual. Our unit of analysis
was the person-month. To adjust for
missing data, we used multiple impu-
tation techniques. All variables had
5% missing data, and sensitivity
analyses that omitted records con-
taining missing data did not substan-
tially change the results we obtained.
We calculated odds ratios and pre-
dicted probabilities from our result-
ing logistic regression models for
each dependent variable.
Characteristics of
the Medicaid sample
As shown in Table 1, approximately
three-quarters of AOT consumers
were located in the New York City re-
gion of New York State (76%). The
second largest proportion was in
Long Island (12%). The remaining
three regions of the state had sub-
stantially fewer AOT consumers. (For
a discussion of these regional differ-
ences, see the article by Robbins and
colleagues [5] in this special section.)
The average age of AOT consumers
was 42 years, and approximately two-
thirds (68%) were male. Forty-two
percent of AOT consumers were
African American, and just under
one-third (31%) were white. Twenty
PSYCHIATRIC SERVICES o o October 2010 Vol. 61 No. 10
Page 3
percent of AOT consumers were His-
panic. Approximately four-fifths of
AOT consumers had a diagnosis of
schizophrenia (82%); the next most
prevalent diagnoses were bipolar dis-
order (12%), major depressive disor-
der (4%), and other diagnoses (2%).
Table 2 summarizes findings from
the multivariable analysis of associa-
tions between duration of AOT (one
to six months and seven months or
more) and the main outcome vari-
ables—hospitalization and days hos-
pitalized, medication possession, and
receipt of ACT or intensive case
management. [More detailed find-
ings from this analysis, by demo-
graphic and clinical characteristics,
are presented in an online supple-
ment to this article at ps.psychiatry]
Outcome analyses for Medicaid
and OMH claims data
AOT consumers’ likelihood of psychi-
atric hospitalization was significantly
lower compared with their pre-AOT
experience. During the first six
months of an initial order, hospital ad-
missions were reduced by roughly
25% from the pre-AOT period
(OR=.77) (Table 2). During any six
months of a renewal, the likelihood of
an inpatient admission was reduced
even further (OR=.59) compared
with the pre-AOT period.
To test whether AOT also reduced
the average duration of hospital stays,
we calculated the average number of
days hospitalized during months in
which a hospitalization occurred and
used this average to compare pre-
AOT, short-term AOT, and longer-
term AOT periods. (We excluded
from this analysis the initial hospital-
ization when a court order was initiat-
ed.) During the pre-AOT period, in
months with any hospitalization, the
mean±SD number of days hospital-
ized per month was 18.0±1.5. This av-
erage was reduced to 11.0±1.1 days
per hospitalized month during months
one through six of court-ordered
treatment, and 10.0±1.1 days per hos-
pitalized month during continuing
months under AOT. Reductions in
the number of days hospitalized dur-
ing any given month were evident in
the initial court order and in subse-
quent renewals of an order (OR=.80
and .84, respectively) (Table 2).
The likelihood of possessing med-
ication for 80% or more of the days in
any month was higher during the
AOT period. Specifically, the likeli-
hood increased by nearly 50% from
the pre-AOT period to the initial six-
month period of court-ordered treat-
ment (OR=1.47) and by nearly 90%
during the subsequent renewal of the
six-month court order (OR=1.88)
(Table 2). Similarly, compared with
the likelihood in the pre-AOT period,
the likelihood of receiving ACT serv-
ices increased roughly fourfold for
both the initial six months (OR=4.13)
and the subsequent six-month renew-
al of the court order (OR=4.03). In-
creases were also noted in the likeli-
hood of receiving either ACT or in-
tensive case management in any given
month of an initial order or a renewal
(OR=2.42 and 2.82, respectively) and
in the likelihood of receiving any form
of case management services during
an initial order or renewal (OR=2.65
and 3.48, respectively).
Outcomes for inpatient admissions,
length of stay, and medication posses-
sion were also examined separately
for each region and were essentially
unchanged (data available from the
authors upon request).
Outcome analyses for
case manager data
Analyses of case manager data from
the Child and Adult Integrated Re-
porting System provided an opportu-
nity to compare outcomes for ACT
PSYCHIATRIC SERVICES o o October 2010 Vol. 61 No. 10
TTaabbllee 11
Characteristics of 3,576 recipients of
assisted outpatient treatment
Characteristic N %
Region of New York State
Central 65 2
Hudson River 242 7
Long Island 434 12
New York City 2,734 76
Western 101 3
Age (M±SD) 41.80±11.52
Female 1,157 32
Male 2,416 68
White 1,105 31
African American 1,499 42
Hispanic 717 20
Asian or Pacific
Islander 143 4
Other 102 3
Schizophrenia 2,927 82
Bipolar disorder 423 12
Major depressive
disorder 145 4
Other 78 2
TTaabbllee 22
Multivariable regression models of duration of assisted outpatient treatment (AOT) as a predictor of six outcomes among
3,576 AOT recipients
Medication Number of
possession days per month Receiving Receiving any
ratio 80%
Receiving ACT
case management
Current duration
of AOT OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI
1–6 months .77 .72–.82 1.47 1.40–1.55 .80 .78–.82 4.13 3.26–5.23 2.42 2.25–2.59 2.65 2.49 –2.83
7–12 months .59 .54–.65 1.88 1.75–2.01 .84 .81–.86 4.03 3.16–5.14 2.82 2.59–3.08 3.48 3.22 –3.75
All multivariable models include controls for relevant covariates. Reference group: no current or previous AOT. ACT, assertive community treatment;
ICM, intensive case management. [Tables presenting more detailed results are available as an online supplement to this article at]
N=88,333 person-period observations
N=25,115 person-period observations
Page 4
consumers who were not subject to
AOT with those of consumers who
received ACT or intensive case man-
agement under an AOT court order.
(A comparison of the demographic
characteristics of these groups is
available from the authors upon re-
quest.) As seen in Table 3, compared
with receipt of ACT alone (that is,
ACT without AOT), the addition of a
court order to receive ACT signifi-
cantly reduced the likelihood of hos-
pitalization (OR=.43) during any six-
month period after the first six
months of AOT. The combination of
AOT with other forms of intensive
case management was associated
with a 43% reduction in the likeli-
hood of hospitalization (OR=.57)
compared with receipt of ACT
alone. Compared with receipt of
ACT alone, receipt of AOT com-
bined with ACT or AOT combined
with intensive case management sig-
nificantly increased the likelihood of
high engagement in services as rated
by case managers (OR=2.13 and
1.98, respectively).
This study used data from New
York’s AOT program to examine
whether consumers made meaning-
ful gains during outpatient commit-
ment. We used two sources of data to
examine key consumer outcomes. In
the first approach, based on Medic-
aid and New York State OMH claims
data, outcomes for consumers were
compared with their own experi-
ences before receiving AOT. Com-
pared with the pre-AOT period, con-
sumers under a court order were sig-
nificantly less likely to be hospital-
ized for psychiatric treatment, spent
fewer days when hospitalized, were
more likely to possess an adequate
supply of psychotropic medication
appropriate to their diagnosis, and
were more likely to receive ACT, in-
tensive case management, or other
forms of case management in the
community—all important and poli-
cy-relevant outcomes.
However, this analytic approach
was limited by its lack of a contempo-
raneous comparison group. To ad-
dress this limitation, we used another
approach, building a natural compar-
ison group from data available in the
state’s case manager reporting sys-
tem. All persons who receive ACT or
AOT are evaluated every six months
by case managers. Because most AOT
consumers are also served by ACT or
intensive case management, the data
allowed for a comparison of outcomes
of those who received ACT alone
with those who received ACT plus
AOT or intensive case management
plus AOT. In these more direct com-
parisons, the court order reduced
hospitalizations over and above the
effect for ACT alone. These results
more directly demonstrate that AOT
itself offers benefits in addition to
those of ACT—the exemplar of evi-
dence-based community treatment.
There are additional limitations to
this study. The analysis did not con-
trol for all the reasons that some in-
dividuals received longer or shorter
periods of AOT or the myriad rea-
sons for ending the court order at a
given time. We were able to control
for some but not all theoretically rel-
evant covariates. The outcomes se-
lected for evaluation, such as hospi-
talization, may not be universally ac-
cepted as the most relevant or im-
portant outcomes for evaluating the
effectiveness of involuntary outpa-
tient commitment; some stakehold-
ers would place higher value on oth-
er outcomes. In addition, inpatient
admissions could show regression to
the mean over time, given the high
rate of admissions experienced by in-
dividuals who eventually receive
AOT. However, these analyses in
most cases incorporated long periods
of observation before a court order,
which would include many periods
of illness exacerbation and improve-
ment; thus regression to the mean is
PSYCHIATRIC SERVICES o o October 2010 Vol. 61 No. 10
TTaabbllee 33
Multivariable regression of potential predictors of hospitalization and
engagement in services as reported by case managers for 3,519 individuals
Hospitalization in services
OR 95% CI OR 95% CI
Services received (reference: ACT without
AOT with ICM .57 .38–.83 1.98 1.35–2.93
AOT with ACT .43 .29–.62 2.13 1.45–3.12
Female (reference: male) .84 .72–.98 .95 .83–1.10
Race (reference: Caucasian)
African American 1.04 .88–1.22 1.08 .88–1.32
Hispanic 1.20 .98–1.47 .90 .70–1.15
Asian .97 .67–1.38 .87 .55–1.37
Psychiatric hospitalizations at baseline 1.75 1.49–2.06 .88 .77–1.00
Engagement in services at baseline 1.50 1.23–1.84
Arrests at baseline 1.08 .86–1.35 .90 .68–1.19
Age 1.00 1.00–1.01 1.02 1.02–1.03
Living independently (reference: not) .93 .77–1.12 1.11 .90–1.36
High school graduate or GED
(reference: less than high school) .98 .81–1.18 1.24 1.07–1.43
Married (reference: not married) 1.18 .90–1.54 .97 .78–1.21
Substance use (reference: no use) 2.02 1.74–2.34 .63 .56–.72
Engaged in services (reference: not) .54 .50–.59
Diagnosis (reference: bipolar disorder)
Major depressive disorder .65 .41–1.04 1.12 .67–1.86
Schizophrenia .95 .78–1.16 .77 .61–.99
Global Assessment of Functioning score .98 .97–.98 1.03 1.03–1.04
Time .96 .92–1.00 1.00 .96–1.04
Region (reference: New York City)
Central .72 .38–1.35 1.38 .79–2.43
Hudson River 1.03 .79–1.34 .94 .75–1.19
Long Island .60 .49–.73 .87 .73–1.03
Western .99 .72–1.34 1.90 1.44–2.51
N=4,452 person-period observations. ACT, assertive community treatment; ICM, intensive case
Page 5
PSYCHIATRIC SERVICES o o October 2010 Vol. 61 No. 10
Reliance on Medicaid claims data
for many of these analyses may fail to
reflect the experience of consumers
not enrolled in the Medicaid program
or fail to reflect experiences during
periods of ineligibility. In addition,
AOT consumers may have been more
likely to be consistently enrolled in
Medicaid. Data from the case man-
agers offers a partial remedy, in that
their reporting is unaffected by Med-
icaid eligibility, but it may be subject
to several other sources of bias. Be-
cause New York’s AOT program is
unique in its comprehensive imple-
mentation and infusion of new service
dollars into a relatively well-funded
mental health system, these findings
may not generalize to other states. Ul-
timately the most stringent and
methodologically sound test of the ef-
fectiveness of New York’s involuntary
outpatient commitment program
would require a carefully conducted
randomized trial.
This study conducted several comple-
mentary analyses of the largest data
repository available on an involuntary
outpatient commitment program.
Findings associated with AOT include
reductions in psychiatric hospitaliza-
tions, improved rates of psychotropic
medication possession, enhanced case
management services, and improve-
ments in related outcomes.
Acknowledgments and disclosures
The study is funded by the New York State Of-
fice of Mental Health, with additional support
from the John D. and Catherine T. MacArthur
Foundation Research Network on Mandated
Community Treatment. The authors gratefully
acknowledge the contribution of numerous in-
dividuals in collecting, synthesizing, and re-
porting the data for this effort. At Policy Re-
search Associates, they thank Karli Keator,
Wendy Vogel, M.P.A., Roumen Vesselinov,
Ph.D., Jody Zabel, Steven Hornsby, L.M.S.W.,
and Amy Thompson, M.S.W. They also ac-
knowledge the extensive reviews and critical
feedback provided by the MacArthur Research
Network on Mandated Community Treatment,
which served as an internal advisory group to
the study. Although the findings of the study
are solely the responsibility of the authors, they
gratefully acknowledge the support and assis-
tance of the New York State Office of Mental
Health in completing the report, including
Steve Huz, Ph.D., Chip Felton, M.S.W., Peter
Lannon, Susan Shilling, J.D., L.C.S.W., Qing-
xian Chen, Michael F. Hogan, Ph.D., Bruce E.
Feig, and Lloyd I. Sederer, M.D.
The authors report no competing interests.
1. Swartz MS, Swanson JW: Outpatient com-
mitment: when it improves patient out-
comes. Current Psychiatry 7:25–35, 2008
2. Monahan J, Swartz M, Bonnie R: Mandat-
ed treatment in the community for people
with mental disorders. Health Affairs
22(5):28–38, 2003
3. Geller JL: The evolution of outpatient
commitment in the USA: from conundrum
to quagmire. International Journal of Law
and Psychiatry 29:234–248, 2006
4. Swartz MS, Swanson JW, Steadman HJ, et
al: New York State Assisted Outpatient
Treatment Program Evaluation. Durham,
NC, Duke University School of Medicine,
June 2009. Available at www.omh.state.
5. Robbins PC, Keator KJ, Steadman HJ, et
al: Regional differences in New York’s as-
sisted outpatient treatment program. Psy-
chiatric Services 61:970–975, 2010
6. Swartz MS: Can mandated outpatient
treatment prevent tragedies? Psychiatric
Services 58:737, 2007
7. Swartz MS, Swanson JW: Involuntary out-
patient commitment, community treat-
ment orders, and assisted outpatient treat-
ment: what’s in the data? Canadian Journal
of Psychiatry 49:585–591, 2004
8. Ridgely S, Borum R, Petrila J: The Effec-
tiveness of Outpatient Commitment. Santa
Monica, Calif, RAND, 2002
9. Appelbaum PS: Ambivalence codified:
California’s new outpatient commitment
statute. Psychiatric Services 54:26–28,
10. Christy A, Petrila J, McCranie M, et al: In-
voluntary outpatient commitment in Flori-
da: case information and provider experi-
ence and opinions. International Journal of
Forensic Mental Health Services 8:122–
130, 2009
11. Petrila J, Christy A: Florida’s outpatient
commitment law: a lesson in failed reform?
Psychiatric Services 59:21–23, 2008
12. Petrila J, Christy A: Florida’s outpatient
commitment law: effective but underused
[letter]. Psychiatric Services 59:328–329,
13. Hiday VA, Swartz MS, Swanson JW, et al:
Impact of outpatient commitment on vic-
timization of people with severe mental ill-
ness. American Journal of Psychiatry
159:1403–1411, 2002
14. Swanson JW, Swartz MS, Elbogen EB, et
al: Effects of involuntary outpatient com-
mitment on subjective quality of life in
persons with severe mental illness. Behav-
ioral Sciences and the Law 21:473–491,
15. Swanson JW, Borum R, Swartz MS, et al:
Can involuntary outpatient commitment
reduce arrests among persons with severe
mental illness? Criminal Justice and Hu-
man Behavior 28:156–189, 2001
16. Swanson JW, Swartz MS, Borum R, et al:
Involuntary out-patient commitment and
reduction of violent behaviour in persons
with severe mental illness. British Journal
of Psychiatry 176:324–331, 2000
17. Swartz MS, Swanson JW, Hiday VA, et al:
A randomized controlled trial of outpatient
commitment in North Carolina. Psychi-
atric Services 52:330–336, 2001
18. Swartz MS, Swanson JW, Wagner RR, et
al: Can involuntary outpatient commit-
ment reduce hospital recidivism? Findings
from a randomized trial in severely men-
tally ill individuals. American Journal of
Psychiatry 156:1968–1975, 1999
19. Steadman HJ, Gounis K, Dennis D, et al:
Assessing the New York City outpatient
commitment pilot program. Psychiatric
Services 52:330–336, 2001
20. Kendra’s Law: Final Report on the Status
of Assisted Outpatient Treatment. Albany,
New York, Office of Mental Health, Mar
2005. Available at
21. Van Dorn RA, Swanson JW, Swartz MS, et
al: Continuing medication and hospitaliza-
tion outcomes after assisted outpatient
treatment in New York. Psychiatric Ser-
vices 61:982–987, 2010
22. Swanson JW, Van Dorn RA, Swartz MS, et
al: Robbing Peter to pay Paul: did New
York State’s outpatient commitment pro-
gram crowd out voluntary service recipi-
ents? Psychiatric Services 61:988–995,
23. Gilbert AR, Moser LL, Van Dorn RA, et al:
Reductions in arrest under assisted outpa-
tient treatment in New York. Psychiatric
Services 61:996–999, 2010
24. Busch AB, Wilder CM, Van Dorn RA, et
al: Changes in guideline-recommended
medication possession after implementing
Kendra’s Law in New York. Psychiatric
Services 61:1000–1005, 2010
25. Karve S, Cleves MA, Helm M, et al:
Prospective validation of eight different
adherence measures for use with adminis-
trative claims data among patients with
schizophrenia. Value in Health 12:989–
995, 2009
26. Valenstein M, Copeland LA, Blow FC, et
al: Pharmacy data identify poorly adherent
patients with schizophrenia at increased
risk for admission. Medical Care 40:630–
639, 2002
27. Svarstad BL, Shireman TI, Sweeney JK:
Using drug claims data to assess the rela-
tionship of medication adherence with
hospitalization and costs. Psychiatric Ser-
vices 52:805–811, 2001
Page 6
    • "The low case load and the shared responsibility within the teams imply that assertive outreach workers have more time, and more opportunities to monitor medication use and to more actively involve patients in treatment planning decisions [53, 54]. Some studies have shown that when CTOs were combined with intensive services (ACT) for more than six months, there was a substantial decrease in hospital admissions rates, total days hospitalized, and improved rates of psychotropic medication use [22, 55]. Our study is in line with other studies that show that patients' lives seem modestly improved under ACT [56] and that being coerced does not necessarily negatively influence patients satisfaction with treatment [57, 58]. "
    [Show abstract] [Hide abstract] ABSTRACT: Since 2009, 14 assertive community treatment (ACT) teams have started up in Norway. Over 30 % of the patients treated by the ACT teams were subject to community treatment orders (CTOs) at intake. CTOs are legal mechanisms to secure treatment adherence for patients with severe mental illness. Little is known about patients’ views and experiences of CTOs within an ACT context. The study was based on qualitative in depth interviews with 15 patients that were followed up by ACT teams and that were currently subjected to CTOs. The data were analyzed by using a modified grounded theory approach. While some participants experienced the CTO as a security net and as an important factor for staying well, others described the CTO as a social control mechanism and as a violation of their autonomy. Although experiencing difficulties and tensions, many participants described the ACT team as a different mental health arena from what they had known before, with another frame of interaction. Despite being legally compelled to receive treatment, many participants talked about how the ACT teams focused on addressing unmet needs, the management of future crises, and finding solutions to daily life problems. Assistance with housing and finances, reduced social isolation, and being able to seek help voluntarily were positive outcomes emphasized by many patients. The participants had different views of being on a CTO within an ACT setting. While some remained clearly negative to the CTO, others described a gradual transition toward regarding the CTO as an acceptablesolution as they gained experience of ACT. Many of the participants valued the supportive relationship withthe ACT team, and communication with the care providers and the care providers’ attitudes could make a significant difference. The study shows that the perception of coercion is context dependent, and that the relationship between care providers and patients is of importance to how patients interpret the providers’ behavior and the restrictive interventions. Although some patients focused on loss of autonomy and being compelled to take medications, other patients emphasised the supportive relationships they had with the ACT teams and that they had received help with housing, finances, and other daily life problems. Thus, being on mandated community treatment could be acceptable in the opinion of several of the patients, provided that they received other services that they found beneficial.
    Full-text · Article · Sep 2015 · BMC Health Services Research
    0Comments 2Citations
    • "The former has typically examined the effects upon outcome in terms of symptoms, functioning, and hospital use (Swartz et al., 2001) whereas the last two have tended to focus on civil liberties, the role of the state and arguments for and against coercive intervention (Eastman, 1997). Recently there have been attempts to take interdisciplinary approaches to the subject (Kallert et al., 2005; Swartz et al., 2010). While there is relatively little empirical research published, there is no shortage of opinion and comment. "
    [Show abstract] [Hide abstract] ABSTRACT: Background Coercion has always existed in psychiatry and is increasingly debated. The ‘move into the community’ in many countries over recent decades and the evolution of community services have substantially altered the locus of coercion. In many countries psychiatric services remain poorly funded and patchy. Substantial differences between regions and countries in the provision of services, the role of the family, and the wider economic and political climate are likely to lead to different sources and experiences of coercion. Discussion This paper explores a number of factors that may affect the prevalence and type of coercion in psychiatric services and in society and their impact upon those with severe mental illnesses. Differences in service provision are explored and wider societal issues that may impact are considered along with relevant evidence. Conclusions Coercion is commonly experienced by those with severe mental illnesses but is poorly understood. The vast majority of research relates to High Income Group countries with developed community services and formal mental health legislation that adopt the so-called ‘medical model’. Further research and collaboration is urgently required to increase our understanding of these issues, which are difficult to define and measure. An evidence base that is relevant worldwide, not just to a small group of countries, is needed to inform training and the care of all patients. A particular focus must be expanding our knowledge and understanding of coercion in cultures outside those where such research has traditionally taken place to date.
    Full-text · Article · Apr 2014 · Asian Journal of Psychiatry
    0Comments 3Citations
    • "The three studies that investigated medication adherence all reported that CTO use was associated with increased rates of adherence202122. All three based their analysis on the New York dataset and used a proxy measure for adherence called the medication possession ratio (MPR). "
    [Show abstract] [Hide abstract] ABSTRACT: The evidence regarding community treatment order effectiveness has been conflicting. This systematic review aims to bring up to date the review performed by Churchill and colleagues in 2005 by assessing and interpreting evidence of CTO effectiveness defined by admission rates, number of inpatient days, community service use, and medication adherence published since 2006. Databases were searched to obtain relevant studies published from January 2006 to March 2013. 18 studies including one randomised controlled trial were included. There remains lack of evidence from randomised and non-randomised studies that CTOs are associated with or affected by admission rates, number of inpatient days or community service use. The most recent and largest RCT is included in this review and found no significant impact on admission rate (RR = 1.0, 95 % CI 0.75-1.33) or number of days in hospital (IR = 0.90, 95 % CI 0.65-1.26). Results from the two largest longitudinal datasets included in this review do not concur. Studies using the New York dataset found that CTOs were associated with reduced admission rates and inpatient days, while studies using the Victoria dataset generally found that they were associated with increased admission rates and inpatient days. There is now robust evidence in the literature that CTOs have no significant effects on hospitalisation and other service use outcomes. Non-randomised studies continue to report conflicting results. Distinguishing between CTO recall and revocation and different patterns of community contact is needed in future research to ensure differentiation between CTO process and outcome.
    Full-text · Article · Oct 2013 · Social Psychiatry
    0Comments 24Citations
Show more

Similar publications

Discover more