2010 Studies of Kendra’s Law
PSYCHIATRIC SERVICES published a special section on the recent, legislatively mandated evaluation of New York State’s assisted outpatient treatment (AOT) in October 2010.
(Read PDF of complete summary of the 2009 Study on AOT )
In the first article, Robbins and colleagues (4) report evidence of the variable implementation of Kendra’s Law across New York State. The use of AOT in practice varies considerably across counties and regions in New York State. Notable regional differences were found in the use of two distinct models of AOT: AOT First and Enhanced Voluntary Services First. Data from interviews with key informants documented regional differences in how the AOT program has been implemented and administered, which raises questions about the fairness of the application of the statute.
In the second article my colleagues and I (5) report on a study of whether New York State’s AOT program improves a range of policy-relevant outcomes for individuals while they are under court order. Our analysis of Medicaid claims and state records showed that compared with their pre-AOT experience, AOT participants experienced reduced rates of hospitalization, improved receipt of psychotropic medications, and improved receipt of intensive case management services. Analysis of data from case manager reports showed similar reductions in hospital admissions and improved engagement in services.
Van Dorn and coauthors (6) report on outcomes for AOT participants after their court order ended. They found that if the court order was kept in place longer than six months, the improved rates of medication possession and decreased hospitalizations were likely to persist after involuntary outpatient commitment ended. Although receipt of intensive case coordination services (assertive community treatment, intensive case management, or both) in the post- AOT period improved hospitalization and medication possession outcomes, individuals who had previous longterm court orders (more than six months) experienced these positive outcomes even when they did not receive ongoing intensive case coordination services. Finally, these data showed that former AOT recipients were not deterred from voluntarily seeking and receiving intensive services once the court order was lifted.
The article by Swanson and colleagues (7) explores the issue of “queue jumping” raised by the AOT program. In the context of scarce resources for community-based services, a question arises about whether an involuntary treatment program, such as that mandated by Kendra’s Law, diverts needed resources from individuals who seek services voluntarily. The authors report that initially the AOT program may have crowded out some individuals with serious mental illness who did not meet criteria for outpatient commitment. However, after the first three years of the AOT program, the increased service capacity funded during the start-up of the program also expanded services for those who did not qualify for cour tordered treatment.
Involvement in the criminal justice system has become an important outcome measure for community treatment programs that serve consumers at high risk of incarceration. The study by Gilbert and colleagues (8) compared arrest rates of consumers in the AOT program and consumers receiving voluntary treatment. They found a relative reduction in the odds of being arrested among AOT consumers. A reduction in arrests may be an important benefit of AOT as part of an effort to improve community- based treatment outcomes and reduce involvement in the criminal justice system.
In a companion study that was not included in the legislative report but that appears in this issue of Psychiatric Services, Busch and colleagues (9) examined regional changes in guideline-recommended medication possession among individuals with severe mental illness after implementation of the AOT program, including consumers who did not receive either AOT or intensive outpatient services. Although these authors observed improvements in medication possession in all three regions and across all treatment groups (those who ever received AOT, those who never received AOT but received enhanced services, and those who never received either intervention), they also found that trajectories of improvement differed by region and that the treatment groups did not make similar gains across regions.
Taken as a whole these articles and the full legislative report suggest that New York State’s AOT program can improve a range of important outcomes for consumers, apparently without feared negative consequences, such as dissatisfaction with services received under court-ordered treatment.
PDF of complete summary of the 2009 Study on AOT