Who Is the “Ideal” Candidate for Involuntary Outpatient Commitment? Analysis of Referral Data Vs. Provider Perceptions

Background and Purpose: Involuntary Outpatient Commitment (IOC) refers to court-ordered, community treatment for severely mentally ill consumers meeting criteria for potential dangerousness and exhibiting a history of noncompliance with treatment and medication. While there have been several rigorously controlled studies of IOC effectiveness, less information exists about implementation of IOC in real-world settings. One particularly understudied issue is the impact of how IOC referrals are selected and who constitutes the “ideal” candidate for IOC success; this issue is important because “cherrypicking” easier-to-treat individuals can strongly influence program outcomes. The purpose of this multi-method study is to compare provider reports of what they consider an “ideal” consumer (well-suited to IOC) with actual referral vs. acceptance patterns into programs in a 6-site rollout of IOC in one state.

Methods: IOC programs within six initially funded counties were evaluated over three years as part of a multi-method, state funded evaluation. Two data sources were used: 1) abstractions from program records for referred and accepted cases; and 2) qualitative interviews with program staff (n=31) and community providers (n=5). Interviews were transcribed, coded using atlas.ti, and analyzed for themes for the ideal, and less than ideal, consumer characteristics. Bivariate analyses aimed to compare characteristics of admitted vs. rejected program referrals.

Findings: Providers reported that typical referrals to IOC are made by inpatient hospital units and typically are persons diagnosed with a serious mental illness, who exhibit a history of multiple hospital admissions and psychiatric ER visits, treatment noncompliance, and co-occurring substance abuse.  Of such referrals, however, they considered as “inappropriate” those who were homeless, acutely dangerous, unwilling to participate in IOC, unwilling to seek treatment, those with Axis II diagnoses, and those whose substance abuse problem appeared to be the primary presenting problem. They also preferred not to accept consumers who had no history of successful psychiatric treatment and treatment compliance in the past. Quantitative program data show that the most common reason provided for non-acceptance into IOC was “inappropriate referral” (32%). Comparison of accepted (n=789) vs. rejected (n=242) referrals indicated that those accepted were significantly more likely to have Medicaid insurance, a co-occurring substance abuse diagnosis, and a history of criminal justice activity.  In contrast, referred persons lacking a permanent address were less likely to be accepted. Accepted vs. rejected clients did not differ by presence of suicidal ideation, rate of uninsurance, age, or presence of a serious mental illness.

Conclusion and Implications:  Results suggest that rejected vs. accepted consumers are relatively comparable, and where differences existed, the accepted referrals that were more likely to be characterized by challenges such as co-occurring substance abuse and history of criminal justice activity.  Qualitative information gathered from providers showed that the screening and referral process takes into account both clinical acuity (perceived dangerousness) and motivational factors such as stated willingness for treatment and projected compliance with the treatment order. Given that IOC is designed to treat high risk yet non-compliant consumers, the findings suggest the need for greater attention to standardization of admission criteria in IOC programs.