Hospital Utilization Outcomes Following Assignment to Outpatient Commitment

Abstract

Outpatient civil commitment (OCC) requires people with severe mental illness (SMI) to receive needed-treatment addressing imminent-threats to health and safety. When available, such treatment is required to be provided in the community as a less restrictive alternative (LRA) to psychiatric-hospitalization. Variance in hospital-utilization outcomes following OCC-assignment has been interpreted as OCC-failure. This review seeks to specify factors accounting for this outcome-variation and to determine whether OCC is used effectively. Twenty-five studies, sited in seven meta-analyses and subsequently published investigations, assessing post-OCC-assignment hospital utilization outcomes were reviewed. Studies were grouped by structural pre-determinants of hospital-utilization and OCC-implementation-i.e. deinstitutionalization (bed-availability), availability of a less restrictive alternative to hospitalization, and illness severity. Design quality at study completion was ranked on causal-certainty. In OCC-follow-up-studies, deinstitutionalization associated hospital-bed-cuts, when not taken into account, ensured lower hospital-bed-day utilization. OCC-assignment coupled with aggressive case-management was associated with reduced-hospitalization. With limited community-service, hospitalizations increased as the default option for providing needed-treatment. Follow-up studies showed less hospitalization while on OCC-assignment and more outside of it. Studies using fixed-follow-up periods usually found increased-utilization as patients spent less time under OCC-supervision than outside it. Comparison-group-studies reporting no between-group differences bring more severely ill OCC-patients to equivalent use as less disturbed patients, a success. Mean evidence-rank for causal-certainty 2.96, range 2-4, of 5 with no study ranked 1, the highest rank. Diverse mental health systems yield diverse OCC hospital-utilization outcomes, each fulfilling the law's legal mandate to provide needed-treatment protecting health and safety.

Keywords: Community treatment order; Involuntary treatment; Law and psychiatry; Outpatient civil commitment.