FLORIDA MODEL INVOLUNTARY OUTPATIENT PLACEMENT (IOP) PROGRAM EVALUATION

“I never knew I could feel so well.”
Patient in the IOP Program

“Since it was a new program I was not sure if it was going to assist my client.
The program is working and is very helpful for treatment of the client, to maintain taking meds, staying in
the program and to remain in the community…Excellent program.”
Case Manager in survey response

THE PROGRAM

On June 30, 2004, Governor Bush signed into law significant changes to Florida’s mental illness treatment law. This “Baker Act Reform” authorized judges to order Involuntary Outpatient Placement (IOP), also known as courtordered outpatient treatment, for people with severe mental illnesses who meet certain standards. Prior to the reform, Florida was one of only nine states in the country lacking some sort of IOP.

Seminole Community Mental Health Center (SCMHC), the Seminole County Sheriff’s Office and the Treatment Advocacy Center (TAC) partnered for a grant to help create a Model IOP Program in Seminole County. Using grant funding, an IOP Coordinator was hired to implement and evaluate the program. (The program utilized existing resources and services.) The grant was awarded for an 18month period that ran June 1, 2005 through November 30, 2006. We are pleased to share the following information, participant outcomes, and cost data from the Model IOP Program. We hope that other community mental health centers in Florida can learn from this experience and replicate similar results for their patients.

THE PATIENTS

Overview. When Florida passed its involuntary outpatient placement law, the hope was that it would help some of the most ill and vulnerable citizens who have severe mental illnesses to live and function better in the community. “Voluntary only” community services had not been effective nor successful for this small group of patients. As the following summary illustrates, participants in the IOP program had histories that included treatment noncompliance and a background that included multiple hospitalizations, incarcerations, or arrests.

IOP Program Participants *

Demographics

o Average age of 38
o 64% are male
o 94% are unmarried

Diagnosis

o 88% diagnosed with schizophrenia or psychotic disorder
o 12% diagnosed with bipolar disorder
o 53% reported as having coexisting mental illness and substance abuse condition

Level of impairment

o Average GAF score of 40 (severely impaired) out of 100? 5 patients had scores of 30
Treatment noncompliance
o 28 of 36 patients exhibited no service engagement or “poor” service engagement at onset of court order? no patients exhibited good service engagement (rated as either good or excellent) at onset of court order
o Only 1 of 36 exhibited good adherence to medication (rated as takes prescribed medication most of the time or exactly as prescribed) at onset of court order
Use of community mental health services prior to order
o 25 of 36 used case management services prior to their IOP order
o 29 of 36 used psychiatric medication prior to IOP order

Hospitalizations

o Patients averaged 3.4 psychiatric hospitalizations in the year prior to IOP order? one patient had a high of 14 hospitalizations in that year.
o One patient had at least 59 psychiatric hospitalizations (lifetime) prior to IOP
o Patients averaged 117 hospitalization days in the year prior to IOP order? six patients had more than 300 hospitalization days in that year

Incarcerations

o 28% were incarcerated at least once in the year prior to IOP order? one patient was incarcerated 3 times in that year
o One patient had at least 12 incarcerations (lifetime) prior to IOP
o Patients averaged 23 incarceration days in the year prior to IOP order? one patient spent 341 days incarcerated in that year
* From baseline assessments for first 36 IOP recipients in SCMHC program at the onset of their IOP orders.

THE RESULTS

Overview.

The SCMHC IOP Coordinator tracked program and participant outcomes by completing assessment forms for all IOP recipients and collected the information in a database specially designed for this purpose. In addition to compiling objective data, the IOP Coordinator conducted an informal survey with various stakeholders to learn about their experiences with the IOP program. Overall, outcomes dramatically improved for patients who participated in the program. 1

Program Outcomes.

For the 18 month grant period between June 1, 2005 and November 30, 2006, there were 51 patients referred to the program and 45 petitions filed for hearings on whether a patient should be placed in the program. 36 patients were issued orders and placed in the program and 5 placement orders were renewed.

Outcomes for IOP Recipients.

We compiled patient outcome data for the period between June 1, 2005 and January 1, 2007 (a period longer than the 18 month grant period on which the program outcomes are based). 23 IOP recipients received initial court orders before June 31, 2006, in time to complete six months in the IOP program prior to the cutoff for our data collection. Two of those patients moved out of the area and were discharged from the court orders prior to the six month expiration. We had complete data for the remaining 21 patients and were able to evaluate outcomes for this group. These outcomes include both the individuals who did complete their six months orders, and those who did not. 2

Reduction in Hospitalization Days.

The most striking outcome for program participants was the significant reduction in the number of hospitalization days for each patient. 3 The 21 recipients experienced a cumulative 1,345 hospitalization days prior to the court order and 773 hospitalization days during comparable time periods after the order, an overall reduction of 43 percent. The following table presents a breakdown of the reduction levels for different types of hospitalization.

Reduction in Hospitalization Costs.

When we reviewed comparable time periods for these 21 patients, we found that the group costs for hospitalization days after the order was $303,728 less than it was prior to the court order.

Reduction in Incarceration Days and Costs.

There also was a significant reduction in incarceration days. 4 The twenty one recipients experienced a cumulative 339 incarceration days prior to the court order and 94 incarceration days during comparable time periods after the order, an overall reduction of 72 percent. At a rate of $59.00 per day for an inmate with medical costs at the Seminole County jail, that results in a $14,455 reduction in costs for incarceration days.

1 The authors would like to acknowledge that this report is, in part, modeled after the much more comprehensive N.Y. State Office of Mental Health report, Kendra's Law: Final report on the status of assisted outpatient treatment. New York: Office of Mental Health (March 2005). We thank OMH for permitting us to mirror some of the language and charts that appear in their report.

2 Both groups were included to present a fair representation of the results for ALL program participants. If reviewed separately, the outcomes for the recipients who did complete their IOP orders would be even more impressive.

3 Method to determine the reduction in hospitalization days: We first reviewed the records for these 21 IOP recipients. We then analyzed comparable time periods before the court order was issued versus after the onset of the court order. For example, Patient X had 115 hospitalization days in the 392 days prior to the IOP order versus 16 hospitalization days in the 392 days after the IOP order.
We then added the group total hospitalization days for before and after the court order.