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I write pursuant to your request for feedback on programs funded under the Mental Health Reform Act of 2016. Specifically, I wish to share the views of the Treatment Advocacy Center (“TAC”) on the Assisted Outpatient Treatment Program (42 U.S.C. §290aa), which was initially authorized under the Protecting Access to Medicare Act of 2014 after originating as a 2013 TAC proposal in the wake of the Sandy Hook tragedy. As a technical assistance provider working closely with most of the 40 jurisdictions awarded grants by SAMHSA under this program to date, TAC is well-positioned to assess whether the program has lived up to the hopes that inspired its creation. 

TAC is a national non-profit established in 1998 to remove barriers to the treatment of severe mental illness. Since its inception, a top priority of the organization has been to make “assisted outpatient treatment” (“AOT”) a universal tool of every state and local public mental health system in the nation. AOT is the practice of providing community-based mental health treatment under civil court commitment, as a means of: (1) motivating treatment adherence among individuals with mental illness who have demonstrated great difficulty following prescribed treatment and avoiding hospitalization and/or arrest; and (2) focusing the attention of treatment providers on the need to work diligently to keep such individuals engaged in effective treatment. A substantial body of research establishes that AOT, when appropriately implemented and resourced, leads to significantly improved outcomes for its vulnerable target population, enhances public safety, and reduces costs for overburdened public mental health systems. 

Historically, TAC has advanced the cause of AOT through state-level legislative advocacy, helping more than 20 states establish new laws to authorize AOT (including New York’s “Kendra’s Law” and California’s “Laura’s Law”) or make existing AOT laws more workable. Having reached the point where only three states (Massachusetts, Connecticut and Maryland) remain without AOT as a legal option, we have also encountered disappointment that state-law reforms have not always led to the flourishing of AOT as a community-level practice. 

Confronting this reality was the impetus for our initial proposal of a national AOT demonstration grant program. Our primary aim was simply to bring the life-saving power of AOT to more communities, in order to rescue a greater number of Americans trapped in the “revolving doors” of the public mental health and criminal justice systems. Beyond that, we hoped a modestly scaled national grant program would catalyze the spread of AOT into many more communities than could possibly receive funding -- by attracting the attention of neighboring jurisdictions to the grantees’ achievements, and by adding significantly to our national knowledge base as to what specific practices and policy choices make AOT programs effective. 

Today, we are more than five years from SAMHSA’s announcement of the first 17 jurisdictions to be awarded grants under the Assisted Outpatient Treatment Program. These grantees (aside from two that left the program prematurely) completed their four-year grant cycle in October, 2020. In 2018, three more grantees were added from the original applicant pool; a new Funding Opportunity Announcement was issued and a new class of 17 grantees was announced in 2020; and three more were added earlier this year from the 2020 applicant pool. Having worked closely with a large majority of these 40 grantees as a technical assistance provider (including multi-day visits to all of the sites awarded pre-COVID), I am grateful for this opportunity to share TAC’s perspective on the impact of this vital grant program so far. 

Most importantly, I am delighted to report that the Assisted Outpatient Treatment Program is succeeding in helping participants avert the tragic cycles of repeat hospitalization and criminalization. Naturally, some grantees have done better than others in this regard, but the overall results for the initial class of grantees are undeniable, as per the aggregated data SAMHSA reported to Congress in 2018: 

• Psychiatric Visits to Emergency Departments: Participant visits to the local hospital emergency department declined 25.9 percentage points from the time of intake into the AOT program to the most recent reassessment period, a percent change of more than 78%. 

• Inpatient Hospitalizations for Mental Health Care: The proportion of AOT grant program participants that were hospitalized for mental health reasons dropped by 55.5 percentage points from the time of intake into the AOT program to the most recent reassessment period, a percent change of almost 85%. This number declined for all four inpatient hospital lengths of stay, including short 1-2 day hospital stays and longer-term 11-30 day hospital stays. 

• Incarceration Rates: The percentage of participants who spent one or more nights in jail decreased by 5.6 percentage points from the time of intake into the AOT program to the most recent reassessment period, a percent change of more than 44%.

• Homeless Nights: The percentage of participants who spent one or more nights homeless decreased by 6.6 percentage points from the time of intake into the AOT program to the most recent reassessment period, a percent change of about 48.5%. 

• Participant Satisfaction: 91.8% of participants agreed or strongly agreed with the statement “I liked the services I received here.” 

These findings comport with what we have consistently been told by the grantees we work with. There is strong consensus that AOT helps an extremely challenging subset of individuals with severe mental illness – those who are chronically non-adherent to treatment, usually due to inability to recognize their own illness – to internalize habits of treatment engagement and reach a point in their recovery where a court order is no longer needed. We eagerly await further data from SAMHSA on the effectiveness of AOT among the 2020 grantee class. In the meantime, I have attached to this letter a sampling of comments TAC has received from stakeholders at several of the grant sites, attesting to the value AOT has brought to their communities.

There is also reason to believe that the Assisted Outpatient Treatment Program is having the desired effect of inspiring other jurisdictions to pursue AOT implementation. A report issued earlier this year by the Georgia Behavioral Health Reform and Innovation Commission cites the federal grant program as a model, in recommending that Georgia establish an AOT grant program of its own. In Pennsylvania, the state Office of Mental Health and Substance Abuse Services (OMHSAS) released a SFY211-22 Community Mental Health Services Block Grant Funding Opportunity which included AOT implementation as one of four potential purposes, for which five counties were awarded funding in September. These breakthroughs would be unlikely without a clear signal from Washington that AOT is a piece of the puzzle in repairing public mental health. 

This progress, of course, is only a beginning. There remains a long road ahead to reach the dream of universal nationwide routine practice of AOT, and we hope we can continue to find bipartisan support in Congress for these efforts. To that end, TAC recommends that the Assisted Outpatient Treatment Program, currently authorized to continue through 2025, be extended for at least an additional four years with the following improvements to the authorizing legislation: 

• Direct SAMHSA to distribute the funds allocated among a larger pool of grantees. A surprise to TAC in how SAMHSA has chosen to administer the Assisted Outpatient Treatment Program has been the size of individual grants -- up to $4 million over four years, with the average grant awarded in 2020 totaling more than $3.78 million over four years. Quite frankly, we view this as much more money than it takes to practice AOT effectively, in all but the largest jurisdictions. To clarify, that is because we do not consider it appropriate to include the cost of treatment itself as a component of the cost of practicing AOT. Providing treatment is a pre-existing responsibility of public mental health systems, largely funded through Medicaid, which does not become more expensive when the AOT legal process, court order and attendant monitoring are added to the equation. From what we have observed, the effect of SAMHSA’s large grant amounts has been to encourage grantees to develop enhanced services for individuals under AOT court orders, which has the unintended consequence of creating an artificial incentive for individuals who no longer need the court order for added motivation (or perhaps never did) to remain in the AOT program, because they correctly view AOT participation as the only path to the highest quality care. Within mental health systems, this also leads to a false perception of AOT as an expensive intervention, making the challenge of sustaining the program after the grant expires more daunting, and causing neighboring jurisdictions to see little hope of establishing their own AOT programs without such generous federal support. While TAC is of course strongly in favor of federal investment in community-based mental health care, we would prefer for that to happen outside the context of an AOT grant program. We would be eager to work with you to develop a legislative framework to make individual AOT grants no larger than necessary to fund AOT, so that the limited funding appropriated for this program may be spread to fund a much larger pool of grantees.

• Limit the statutory definition of “assisted outpatient treatment” to exclude criminal mental health diversion courts. AOT is a civil-court intervention. It is a form of civil commitment, based on a judicial determination that the individual is ill-equipped to adhere independently to the treatment they need to survive safely in the community. As such, AOT certainly does not require a person to have committed a crime to qualify for help. This makes it fundamentally different from the practice known as “mental health court,” which is a criminal-court intervention designed to divert individuals with pending criminal charges stemming from their mental illness into treatment rather than punishment. While TAC regards mental health court as an equally essential tool for any jurisdiction, we also recognize how much more deeply rooted this practice already is in our nation’s court systems and how much more funding support already exists for the implementation of that model. We therefore do not want to see the very modest Assisted Outpatient Treatment Program used to fund the creation of mental health courts. Regrettably, the definition of “assisted outpatient treatment” in the authorizing legislation does not make clear that the funding should only be available to courts practicing outpatient civil commitment. This has led to a number of AOT grants being awarded over the years to jurisdictions whose applications articulated plans to establish criminal mental health diversion courts. This should be prevented in the next iteration of the grant program. 

• Require more illuminating data collection and reporting. The data cited above has added another layer to what is now a mountain of evidence that AOT is an effective intervention for its target population. While this is always welcome, we also see a missed opportunity to fill gaps in our current AOT knowledge base. In our view, the myriad differences in how AOT is implemented across program sites – many of which are driven by differences in AOT eligibility criteria under the various state laws – create intriguing possibilities to conduct comparative research and learn a great deal more about the impact on outcomes of various practices and policy choices. (In particular, we are eager to learn more about what difference it makes, if any, to have an actively engaged AOT judge who expects participants to return to court for periodic check-ins during the period of the order.) Information of this nature could lay the groundwork for the eventual creation of an AOT fidelity scale. There is currently nothing in the authorizing legislation requiring SAMHSA to conduct this sort of comparative research. We would be eager to work with you to draft language on this for a future extension of the program. 

In closing, on behalf of the Treatment Advocacy Center I extend our gratitude to both of you for your leadership and vision in making the Assisted Outpatient Treatment Program the life-saving reality it has been for Americans with severe mental illness who struggle to maintain treatment adherence. We look forward to working with your staffs to ensure that this vital program becomes even more impactful in the years to come. Please don’t hesitate to contact me if I can be of any further assistance. 

Sincerely, 

Brian Stettin 

Policy Director 

Addendum to Letter: 

Selected comments received from AOT Program Grantee Stakeholders

Whitney Harrington, AOT Administrator, Pecan Valley Centers, Parker/Johnson Counties, Texas:

“We started an AOT program through Pecan Valley Centers last year. We have just finished our first program year, and found that the program was successful in decreasing hospitalizations, homelessness, and arrests in the clients in our program. We have seen a tremendous improvement in not only the stability of our clients, but also in their ability to achieve their personal goals and pursue their wants and needs more independently as their mental health issues have become less severe.” 

Allison Booth, AOT Coordinator, The Andrews Center, Smith County, Texas: 

“The federal dollars allocated to start-up this legal process and design structure around an outpatient avenue to frequent utilizers of state programming/funds has substantially decreased the frequency of repeat hospital admissions, initialized a stabilizing support system in the community, and changed the way participants view the court system where they have often repeatedly experienced trauma related to criminal interactions. AOT ideally will become a core service offering since the demand for outpatient intensive supports overwhelms the current services available to our vulnerable mental health population.” 

Cindy Gipson, Ph.D., Dir. of Adult Intensive Svcs, AltaPointe Health, Baldwin County, Alabama:

“The SAMHSA AOT grant gave us the ability to develop an ideal program that was able to effect change in an historically difficult-to-engage population and served as a model for neighboring counties. Hospitalizations, emergency room visits, arrests, and use of force incidents decreased significantly, demonstrating efficacy. The program is still in operation two years after the end of the grant and is now being used in a large metropolitan city, Mobile.” 

Randy Fletcher, Parent of AOT Participant, St Tammany Parish, Louisiana:

“AOT was a godsend, to get my son to take medication and monthly counseling. He has an aversion to drugs/alcohol because his mother abused them, until she jumped from MS River Bridge. My son respects law enforcement, and AOT was just the thing to get him to accept the one medication that works with schizoaffective disorder (via monthly injection). Prior to AOT, my son was abusing everyone who tried to help him, since he was angry with his situation, but didn't know how to change it. Three months since his Invega Sustenaa regimen started, he is a totally different individual, acting as close to normal as can be expected, considering his history.” 

Victoria Garcia, Behavioral Health Specialist, Tarrant County MHMR, Tarrant County, Texas:

“AOT is a HUGELY beneficial program to our patients. Our patients that are involved with AOT have a much higher chance of performing well outpatient and transitioning outside of the hospital and have a much lower rate of readmission. The staff is fantastic, our patients love working with them, and we are so, so appreciative of this resource in our community.”