• AOT Implementers
• Start Out Right
• Build a Stable Infrastructure Before Launch
• Keep the Momentum Going

Reach a shared understanding of the law and the funding landscape

Begin by thoroughly reviewing the civil commitment laws and regulations in your state, with certain key questions in mind:

• What are the legal criteria for outpatient commitment?
• What are the procedures for petitioning the court and obtaining an AOT order?
• Who can start the petition process?
• What information needs to accompany the petition?
• What is the maximum length of an AOT order and what is the process to seek continuation if a participant needs more time in the program?
• Are there any other guidelines imposed by state law?

Funding

While it is difficult to universally estimate the financial costs associated with AOT implementation, at some point in the planning process there may very well be a need to identify sources of funding. Ideally, these costs can be absorbed within existing budgets by the participating stakeholder entities and viewed as wise investments: a little spending up front to activate savings on various forms of crisis response. But if that proves impossible, thoughtful planning should at least give you a sense of how much new money must be found to launch the program. This is not the time to think big. If funding is scarce, work to establish a small-scale pilot to prove the power of AOT locally. Compelling results with a small number of participants -- especially if those results include substantial savings on treatment costs -- will make it infinitely easier to find the funding to ramp up to meet a larger need.

Determine the appropriate level of judicial engagement

All AOT programs rely on the court to issue court orders, safeguard participants’ due process rights, and make required rulings at certain junctures. The most extensively studied AOT programs, in New York and North Carolina, limit the role of the court to the performance of these essential judicial functions.

In some AOT programs, the judge also has a role to play in motivating participants to engage with their treatment plans. Active court AOT programs seek to leverage what has come to be known as the “black robe effect.” This is the proposition that an AOT participant’s respect for the authority of the court, and sense of accountability to the court developed through personal interaction, will provide additional motivation for treatment engagement.

Under the full “active court” model, this is accomplished through periodic status conferences, which afford the judge opportunities to “check in” with the participant and treatment team. But the choice between models need not be binary. In many AOT programs, for example, the judge will attempt to impart motivation at the initial AOT hearing, but will not typically hold status conferences.

Which path to follow, or whether to choose one in between, is a fundamental question the planning team must grapple with at an early stage of the planning process.

Establish a mechanism for oversight of participants

The public mental health authority is generally responsible for monitoring the status of AOT participants. How exactly this is achieved varies widely among programs. In larger urban programs, this might best be accomplished by a monitoring team that stands apart from, but in close communication with, the treatment team. Many AOT programs in smaller jurisdictions assign this function to a single individual who serves as program monitor. In programs where courts retain active interest in each participant’s progress, the monitor often functions as a liaison between the court and treatment team -- maintaining communication between them and serving as a point of contact for each.

Regardless of how they fill the role, each AOT program needs reliable means to:

• Monitor the progress and welfare of each participant
• Ensure that resources are flowing as expected to each participant and aligned with each participant’s needs
• Address barriers to service access
• Ensure timely evaluations for possible court order renewal
• Track directives from the court

Create written policies, procedures and forms

Prior to program launch, an implementation team work group should finalize basic policies and procedures. Locally tailored documents should set forth criteria for AOT as well as processes for involuntary commitment and continuity of treatment during transitions between levels of care and providers or to another jurisdiction.

Forms for participant tracking, assessment and monitoring progress are also vital to successful AOT programs. Similar to a patient record, documentation regarding a participant’s progress can tell a story and assist with planning. A well-developed tracking system facilitates routine data collection at critical junctures in time for each participant.

These may include task flow diagrams, job descriptions, organizational charts, contact lists, sample educational materials, and any anticipated pathways of care, written in a manner understandable to all involved.

At a minimum, these should include:

• Admission criteria for the program and clinical assessment forms
• Procedures for obtaining a court order
• Procedures and forms for participant oversight and tracking
• Procedures to ensure continuity of treatment upon transitions

They might also include:

• Task flow diagrams, including anticipated pathways of care
• Job descriptions, organizational charts, and contact lists
• Sample educational materials

Examples are available in our document archive.