Treatment-Law Evaluation Shows That Investment Pays Off
Abstract
An exhaustive research project shows that mandated outpatient mental health treatment is effective and can cut costs to the state providing it.
A program of court-mandated assisted outpatient treatment (AOT) in New York appears to reduce the costs allocated for mental health services, according to a study posted online in AJP in Advance July 30.
Jeffery Swanson, Ph.D.
The reduction in costs reflected fewer repeated episodes of expensive inpatient psychiatric treatment as patients instead received outpatient care and appropriate medications, said Jeffery Swanson, Ph.D., a professor of psychiatry and behavioral sciences at Duke University, and colleagues.
“Cost is important,” said Swanson in an interview with Psychiatric News. “Even if people conclude that there is some benefit to outpatient treatment, it doesn’t seal the deal if it’s too costly.”
Cost was just one issue that led to the current research by Swanson’s group. The first version of New York’s AOT law (often referred to as “Kendra’s Law”) was passed in 1999 and included a provision for evaluation by the state’s Office of Mental Health. That assessment of the law’s impact was positive but “fiercely contested,” in Swanson’s words, by those concerned either with its possible expense to the state or by civil libertarians who argued that the mandated treatment was overly coercive to patients.
That controversy led to a legislative requirement for an independent evaluation when the law was reauthorized in 2005. The task was assigned to a consortium of researchers led by Swanson and colleagues from Duke, the Policy Research Associates in Delmar, N.Y., Harvard Medical School, and the University of Virginia. Additional funding was provided by the MacArthur Foundation.
In day-to-day practice, New York’s system of assisted outpatient treatment (AOT) is a multifaceted affair.
The AOT infrastructure does not directly provide mental health services, explained psychiatrist Ryan Bell, M.D., J.D., medical director of the Steve Schwarzkopf Community Mental Health Center in Rochester.
Bell works closely with Monroe County AOT coordinator Kim Butler, M.S.W., whose staff arranges for court-mandated evaluations and sends patients designated for AOT to outpatient clinics like Bell’s.
“The success of the system depends on the coordinators,” he said. “If they’re good, the patient does not see the process as punitive.”
Once AOT is indicated, Butler explains to the patient, “We think you need extra help, and I’m here to help coordinate your care.” She and Bell discuss with the patient how that help will be provided, which may mean housing assistance or work in the courts, as well as medication and therapy.
Butler puts in the extra hours needed to follow patients wherever they are in the community, Bell said. “We want to create a relationship. They have to believe that you want the best for them, to be healthy but not to punish them.”
Earlier in his career, Bell worked in other states with forms of AOT but where resources were limited. “You can have court-ordered treatment, but you have to have treatment to send people to,” he said. The added clinical and social-service resources provided by the legislature are critical, said Bell.
New York recently amended the law to permit AOT for up to 12 months rather than the original six months. That may reflect findings from a study led by Jeffrey Swanson, Ph.D., that patients who remained in the program for at least seven months had better outcomes (see story above left).
The effort pays off for many patients, said Bell, recalling the words of one who told him: “Assisted outpatient treatment made me get the help I needed until I wanted the help I needed.”
The study compared a sample of 520 AOT participants in New York City and 114 from Albany, Erie, Monroe, Nassau, and Rensselaer counties with 255 voluntary users of intensive community-based treatment in the same areas. The AOT patients had to be at least 18 years old, unable to live safely in the community, and with a history of violence and at least two recent hospitalizations or incarcerations.
“The vast majority of AOT patients receive their order when in involuntary treatment, and it gets them into [outpatient] treatment,” added Swanson’s colleague Marvin Swartz, M.D., also a professor of psychiatry and behavioral sciences at Duke.
After patients started AOT, hospitalizations decreased, while use of case management, assertive community treatment, other outpatient services, and psychotropic prescription fills increased, they noted.
On average, annual costs per patient in the New York City sample declined from $104,753 to $52,386 in the second year after discharge to AOT. Average annual costs in the other counties fell from $104,284 to $39,142.
“The costs of AOT are an investment,” Swanson told Psychiatric News. “The state spends less, and the savings can be reallocated across systems.”
Concerns that services for voluntary patients would be crowded out when resources were shifted to AOT participants proved true only in the short run, he said. Thanks to the state’s allocation of an additional $35 million to expand capacity, service access for both groups eventually equalized.
Those added resources are critical if an AOT system is to work properly, said Swartz. New York will have to maintain that financial commitment to continue the same level of services. Other states contemplating a similar approach to mandated outpatient treatment will have to commit to similar levels of support to make AOT effective.
“The Cost of Assisted Outpatient Treatment: Can It Save Money?” is posted at http://ajp.psychiatryonline.org/article.aspx?doi=10.1176/appi.ajp.2013.12091152.
