The Impact of Program Structure on IOC Client Outcomes: Implications for Involuntary Treatment and Care Coordination Service Models

Background and Purpose: In order to increase the number of individuals with SMI actively engaged in mental health care, many states have implemented Involuntary Outpatient Commitment (IOC) programs, which provides court ordered treatment to individuals that have a history of poor treatment engagement. One essential function of these programs is to provide care coordination services by monitoring medication and appointment compliance, overseeing transitions in care, and managing referrals to ensure care is continuous and comprehensive. Despite this common function, IOC programs differ in how care coordination services are delivered. One common source of variation is the proximity of ancillary services; while some programs are embedded within a larger organization and primarily refer internally, others function as stand alone service that coordinates with and refers to external community providers. While such diversity is common among programs providing care coordination services, it has been identified as a barrier to widespread dissemination of the model, as it becomes difficult to determine whether specific program components are particularly essential for its success or failure. The objective of this study is to explore the impact of onsite services on client outcomes. Examining this relationship is expected to help inform future structure and implementation of both IOC programs specifically, and similar care coordination programs in general.

Methods: The present analysis was completed as part of a larger evaluation of a newly implemented involuntary outpatient commitment (IOC) program. The sample (N=789) includes all consumers enrolled in any of the six pilot IOC sites during the first three years of operation. Data was collected through a combination of chart abstraction and quarterly reporting completed by program sites. The primary independent variable of interest is the presence of on-site services. Outcome variables included the total number of hospitalizations occurring during IOC enrollment, and whether consumers were successfully discharged from the program. Logistic and linear regression models were run in order to test the relationship between the presence of on-site services and these outcome variables. Relevant covariates were also included in the fully adjusted models.

Results: The presence of onsite services was associated with a decrease in the number of hospitalizations (B=-.47, p<.001) and an increase in the likelihood of a successful discharge (OR=2.1, p<.05). Commitment lengths longer than 3 months also predicted fewer hospitalizations (B=.-.29, p<.001) and a greater chance of successful discharge (OR18.57, p<.001). Conversely, consumers who were readmitted to the program were both more often hospitalized (B=1.10, p<.001) and less likely to be discharged successfully (OR-.39, p<.001). Lastly, consumer receiving IOC services in rural counties were hospitalized less often than those in urban settings (B=-.33, p<.01), while consumers referred to ICMS services in addition to IOC were hospitalized more often than those without this service (B=.14, p<.05).

Conclusions and Implications: These findings suggest that the proximity and accessibility of medical and mental health services may positively impact client outcomes. This has particular implications for the structure of IOC programs, and indicates that integrated care coordination programs may be optimal for individuals with SMI receiving involuntary services.