Mandatory Outpatient Treatment: An Overview of Virginia’s Law and Utilization

Sarah Leser, B.A.
ILPPP Research Assistant
MPP/MPH Candidate, Class of 2019

Context

Forty-six states, including Virginia, utilize a form of outpatient civil commitment to provide treatment to individuals in need of mental health care. (1) Though mandatory outpatient treatment (MOT) was authorized in Virginia in 1976, it was not until recently that the practice was implemented widely. (2) In 2008, the Virginia General Assembly established detailed procedures for ordering, delivering, and monitoring MOT, thus making it a feasible option for providing mental health treatment. (3)   

What is MOT?

Virginia Code § 37.2-817 authorizes judges and special justices to order mandatory outpatient treatment for individuals who are severely mentally ill and meet hospitalization criteria, but may be better served through a less restrictive alternative such as receiving services in their community. The Virginia Code authorizes two main types of MOT orders: direct and step-down. A direct MOT order is issued if an individual is not currently under a commitment order at the time of the commitment hearing but is found to meet commitment criteria and a less restrictive alternative to hospitalization is deemed appropriate. (4)

A step-down MOT order is issued to allow an individual who is hospitalized to return to their community and continue receiving ordered outpatient treatment. This form of MOT went into effect fiscal year (FY) 2011. (2) A step-down MOT order may be initialized upon discharge or at a new hearing. A discharge MOT order is initiated when a special justice orders MOT concurrently with inpatient treatment either at an initial commitment hearing or recommitment hearing (5). This means that after an individual has been hospitalized for a predetermined amount of time, they can be discharged to continue their commitment on an outpatient basis. (2) A discharge MOT order authorizes the physician in charge of an individual’s treatment to discharge the person for outpatient treatment under the MOT plan without an additional hearing. (5) MOT may also be initiated at a hearing not associated with an initial commitment or recommitment. In this case, a physician, family member, or the community service board may motion for a hearing to be held at any point prior to a person’s discharge from involuntary commitment or voluntary commitment following a TDO to determine if MOT should be ordered upon discharge. (5, 6). For either type of MOT, an initial commitment order cannot exceed 90 days (7). A summary of MOT types and a chart depicting the various pathways to MOT can be found below.

Summary of MOT Types
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1. Direct: Issued to an individual not currently under a commitment order, at the time of the commitment hearing
2. Step-Down: Issued in order to allow an individual to “step down” from an inpatient hospitalization order to an order for MOT
• Discharge – Initial: Issued concurrently with a commitment order at the time of an initial commitment hearing
• Discharge – Recommitment: Issued concurrently with a recommitment order at the time of a recommitment hearing
• New Hearing: Issued at a standalone hearing motioned for by a treating physician, family member, or CSB

In addition to allowing individuals with severe mental illness to receive treatment in their communities, MOT also functions to enhance adherence to treatment and address revolving-door syndrome, a cycle in which people are hospitalized, discharged, and re-hospitalized soon after, often because they have discontinued their medication. (8) While any individual meeting commitment criteria may be given a direct MOT order, to qualify for step-down MOT, a person must have been hospitalized involuntarily or voluntarily following a TDO twice in the previous 36 months. (5)

MOT can only be ordered if the services a person requires are available in the community. (3) The Community Service Board (CSB) in the location in which the individual resides is responsible for developing a detailed MOT plan, though the services required may be provided by the CSB or a private mental health professional. (9) The individual to whom an MOT order is issued must agree to the treatment plan, and the plan must be approved by the court. (3) Regardless of who provides services, the local CSB is responsible for monitoring MOT compliance and reporting any non-compliance to the court. (10) If an individual is found to be non-compliant, the court can modify or withdraw the MOT order, or, if necessary, the person may be hospitalized under a TDO. (10)

MOT Use Across VA

General District Courts maintain records of civil commitment cases concerning adults using the General District Court Case Management System (GDC-CMS). This system is maintained by the Office of the Executive Secretary of the Supreme Court. (11) Using these records, the ILPPP is able to track the number of MOT orders issued each year. Generally, the number of MOT orders issued each year has risen since the practice was solidified in the Virginia Code, especially after step-down MOT was introduced in 2011. In FY 2017, a total of 238 MOT orders were issued. Figure 1, found below, depicts the annual frequency of MOT orders from FY 2010 through FY 2017. Figure 2 shows the frequency of the type of MOT orders issued quarterly from FY 2010 though quarter 2 of FY 2018. The most commonly issued type is direct MOT, followed by step-down MOT orders issued at new hearings.  

Evidence from other States: Benefits of MOT

Because MOT is still a fairly new practice in Virginia, it is too early to draw state-specific conclusions about effectiveness. However, in states that have longer-established MOT programs, there is strong evidence that this treatment option produces benefits. New York has one of the most well-established outpatient commitment programs in the country. Known as Kendra’s Law, legislation authorizing assisted outpatient treatment (an alternative name for MOT) was passed in New York in 1999, and the state’s programs have been evaluated many times since. A long-term evaluation of assisted outpatient treatment (AOT) in New York found that AOT is associated with increases of 89% in use of case management, 67% in use of substance abuse treatment services, and 106% in medication adherence. (12) Higher engagement with and adherence to treatment resulting from AOT was found to be associated with reductions of 87% in incarceration, 83% in arrest, 77% in psychiatric hospitalization, and 74% in homelessness rates. (12) Another study out of New York found that AOT is associated with significant decline in hospitalizations, and this decline was sustained over a three-year study period. (13) It is important to note that New York has seen such positive results largely because of the state’s financial investment in expanding mental health service availability that accompanied Kendra’s Law. While this expansion was associated with large upfront costs, reductions in medical and criminal justice expenses stemming from AOT were found to produce net cost declines of 49% in the first year and 27% in the second year after AOT began across New York. (13) Moving forward, as MOT becomes more established and widely used, the ILPPP hopes to conduct similar evaluations to identify benefits specific to Virginia.      

References

1. “Assisted Outpatient Treatment.” Treatment Advocacy Center, http://www.treatmentadvocacycenter.org/component/content/article/1336

2. Allen, AA. and TM Ko. Annual Statistical Report Adult Civil Commitment Proceedings in Virginia FY 2016, University of Virginia Institute of Law, Psychiatry and Public Policy, 2017

3. Hickey, J. and Allyson Tysinger. “New Era Begins: Mental Health Law Reform in Virginia.” Richmond Public Interest Law Review, 2008.

4. Virginia Code § 37.2-817(D)

5. Virginia Code § 37.2-817(C)

6. Virginia Code § 37.2-805

7. Virginia Code § 37.2-817(E)

8. “Report of the Task Force on Future Commitment Reforms.” Virginia Commission on Mental Health Law Reform, 2009.

9. Virginia Code § 37.2-817(F)

10. Virginia Code § 37.2-817.1

11. Faris, KM. Brief Report on Mandatory Outpatient Treatment for Adults, FY 2010 – FY 2017, University of Virginia Institute of Law, Psychiatry, and Public Policy, 2018.

12. Geller, J.L. “The evolution of outpatient commitment in the USA: From conundrum to quagmire.” International Journal of Law and Psychiatry, 2006.

13.  Swanson, J. W., Van Dorn, R. A., Swartz, M. S., Robbins, P. C., Steadman, H. J., McGuire, T. G., & Monahan, J. “The Cost of Assisted Outpatient Treatment: Can It Save States Money?” American Journal of Psychiatry, 2013.