Who are the essential players in a successful AOT program? What are their roles?
Can AOT work in areas where community-based services are scarce?
Is AOT an alternative to “Assertive Community Treatment” (ACT)? Can the two programs co-exist?
What are the costs associated with AOT? Who bears them?
What are the savings associated with AOT? Who realizes them?
How do AOT programs monitor participants?
How specific must the AOT treatment plan be?
After issuing the court order, does the judge stay involved in an AOT case?
How does an AOT program handle a non-adherent patient?
Who are the essential players in a successful AOT program? What are their roles?
A typical AOT program is a collaboration between the local court with jurisdiction over civil commitment cases and the local publicly-funded agency or organization responsible for community-based mental health services. Program success starts with full buy-in from the judge who will preside over AOT cases (and any supervising judge to whom the AOT-court judge may report), and the agency director who will dedicate the resources necessary to make meaningful treatment and case management available to recipients.
But of course, program success doesn’t end there. Just as essential to making AOT work are the hospital treatment team members who identify patients who will need AOT upon discharge; the attorneys and agency staff who compile and present the evidence in court; and the community-based outpatient service providers, case managers and CIT officers who support AOT recipients in the community.
Many AOT programs have also found it useful to station one person as a “central command,” employed either by the court or the mental health agency, and serving as a liaison between the judge and the various professionals relied upon to provide care and support to AOT patients.
Can AOT work in areas where community-based services are scarce?
Where there is no meaningful community-based treatment available, there would be little point in placing an individual under an AOT court order. A local mental health system that dysfunctional should probably focus on developing resources before considering an AOT strategy.
However, few local mental health systems today are utterly bereft; more typically, they are struggling to meet needs with scarce resources. This scarcity is exacerbated by the wildly disproportionate share of resources consumed by a small subset of patients who do not adhere to prescribed treatment and cycle endlessly through the system’s “revolving door.” In such areas, the scarcity of resources makes it imperative to prioritize the needs of the most severely ill and markedly improve treatment adherence among those who have demonstrated difficulty with it. In other words, AOT is an essential tool in making scarce resources go further.
To be sure: the richer the package of attached services, the greater the potential impact of the AOT court order. AOT should never be regarded as a substitute for adequate care and support of highly vulnerable individuals. But the experience of many AOT programs has been that success builds on itself. A program can start with a small number of recipients, who perhaps have some existing community support to leverage. Over time, the savings realized by helping this group stay under treatment makes it possible to bolster service offerings and expand numbers.
Is AOT an alternative to “Assertive Community Treatment” (ACT)? Can the two programs co-exist?
Assertive Community Treatment (ACT) is an evidence-based practice widely regarded as the gold-standard approach to helping individuals with severe mental illness live safely in community settings. Under ACT, participants receive a broad range of services from a low-caseload, highly-mobile “core services team.” ACT teams have proliferated across the United States, most funded fully by Medicaid or other public insurance programs.
Far from being alternative or competing approaches to meeting the needs of the highest-risk patients, AOT and ACT are highly complementary.
AOT is designed for a specific subset of individuals with severe mental illness: those who struggle with voluntary treatment compliance (often due to anosognosia, a symptom of brain dysfunction which prevents the sufferer from recognizing his own illness and need for treatment.)
Most mentally ill outpatients in need of ACT are not in need of AOT. But virtually all mentally ill outpatients who need AOT would stand to benefit from ACT as their service delivery model. Thus, for any jurisdiction with the good fortune to have one or more ACT teams in place, AOT should be thought of as nothing more than “ACT plus a court order” for those deemed more likely to cooperate with their ACT team if court-ordered to do so. There is no need to segregate such patients into a separate service program. A single ACT team can service court-ordered and voluntary clients alike.
What are the costs associated with AOT? Who bears them?
Discussions of AOT often start from the premise that the greatest cost associated with the program is that of providing comprehensive community-based services to recipients. But this overlooks the fact that the individuals who meet AOT criteria will be in the community, desperately needing services, whether they receive AOT or not. Launching an AOT program won’t cause new consumers of services to magically appear at a community’s doorstep. It is therefore intellectually dishonest to talk about the “cost” of serving AOT patients as if this same financial obligation of mental health systems would not otherwise exist. (And, it should be noted, these costs are largely covered by Medicaid and other insurers.)
In truth, the upfront costs associated with AOT are modest. It mainly comes down to the staffing needs within public mental health agencies and courts to investigate whether identified patients meet AOT criteria, file petitions as warranted, conduct examinations and hearings, and maintain contacts between the court and treatment team. There are also legal costs associated with preparing and presenting evidence in court of patients’ qualification for AOT and with providing counsel to indigent patients.
The specific bearers of these costs vary according to arrangements made during the budgeting process of each AOT program, but are typically paid by public mental health agencies funded by state and county governments (often with specific appropriations for AOT), and by courts from their own general operating funds and indigent defense funds.
What are the savings associated with AOT? Who realizes them?
Research confirms that AOT produces significant savings for public mental health systems.
For example, a 2013 comprehensive cost analysis found that in New York City, overall service costs for tracked patients declined 43% in the first year after AOT initiation, and an additional 13% in the second year. In an identical analysis of five other New York counties, service costs dropped 49% in the first year after AOT initiation and an additional 27% in the second year. (This despite respective first-year increases of 40% and 44% in medication costs, as one might expect with improved medication compliance.) The declines were attributed mainly to reduced need for hospitalizations. While the study also found significant declines in service costs among patients participating voluntarily in intensive services, the cost declines associated with AOT were about twice as large.
There is also good reason to expect the use of AOT will yield savings for the criminal justice and correctional systems through reduced emergency calls, arrests, prosecutions and incarcerations. (See here for summaries of multiple studies showing AOT reduces the risk of arrest, incarceration, violence, crime and victimization.)
For the courts, the additional burden of conducting AOT hearings is likely to be offset by a reduction in the need to conduct inpatient commitment hearings for the same individuals.
How do AOT programs monitor participants?
An AOT treatment plan typically includes intensive case management in addition to whatever direct services are deemed necessary to allow the individual to live safely in the community. An intensive case manager, who may or may not serve as a member of an Assertive Community Treatment (ACT) team, assists the individual in accessing services, facilitates solutions to problems that may arise, and generally keeps tabs on the person’s condition through frequent communication with the individual, family members or others close to the individual, and treatment providers. Intensive case managers maintain caseloads of no more than 20 clients.
AOT programs also rely on doctors, other treatment providers and, in many cases, CIT-trained police officers to monitor patients and take appropriate action when non-compliance with the court order is detected or suspected.
Under some AOT program models, judges may also check in on the patient’s progress at periodic status conferences. (See FAQ below on continued court involvement.)
How specific must the AOT treatment plan be?
State AOT laws vary in their requirements of the treatment plan that gets incorporated into the order of the court.
Many states do not require the court to approve a treatment plan at all.
At the other end of the spectrum are those that require the submission of a proposed plan in writing, to be followed by medical testimony at the hearing explaining each category of recommended service (including medications) and why such service is the least restrictive appropriate alternative to meet the patient’s needs. If the burden of proof is met, the court will then incorporate all or some of the proposed treatment plan into the order.
Even in states that do not require treatment plan approval, it is a good practice to ask the court to do so anyway. This heightens the “black robe effect” of the court order, and impresses upon the patient that AOT imposes more than a general responsibility to be treatment-adherent. A court-approved detailed plan makes crystal clear to the patient and provider alike that each has specific responsibilities to the other.
That said, there is also a danger of making the approved treatment plan too specific. In psychiatry it is often necessary to tweak medications during the course of treatment. It is a burden to all parties if every uncontroversial adjustment must be reported to the court and updated in the AOT order. To the extent state law allows, the original treatment plan should be written in terms of medication types rather than specific medications, and dosage ranges rather than specific dosages. It is also possible to anticipate the need to change the treatment plan during the term of the order and pre-authorize some degree of leeway for the treating psychiatrist to make changes without court approval.
After issuing the court order, does the judge stay involved in an AOT case?
At a minimum, AOT requires a judge to hold a hearing on a petition, and -- if supported by the evidence presented – direct a mentally ill individual to adhere to prescribed outpatient treatment. Practices vary on how much the judge remains involved in the case beyond that.
Under most program models, the judge is only called upon again during the period of AOT if a party wishes to modify the order, or if the patient’s deteriorating condition warrants a transition to hospital commitment. At the end of the order term, nearly all states allow for a petition for renewal. If renewal is sought, the court must hold a new hearing and determine anew whether the patient continues to meet statutory criteria.
Some AOT program models build in a more active role for the judge, capitalizing on the judicial prerogative to assemble the parties and counsel for “status conferences” during the pendency of a matter before the court. Periodic meetings with the judge can powerfully reinforce the “black robe effect” upon program participants.
What happens at the end of the period of the AOT court order? Is the patient expected to continue with treatment independently?
While the maximum length of AOT orders varies widely by state, almost all states allow the petitioner to seek renewal of an expiring order. Whether it is appropriate to do so is a decision that must be made individually for each patient.
Research suggests that a period of AOT longer than 6 months is more likely to lead to sustained gains in treatment adherence than a shorter period of AOT. In states that limit AOT orders to 90 days, this may suggest it is generally a good practice to renew court orders at least once. But renewal requires a new court finding that the person continues to meet AOT criteria. Thus, in every case, the critical question for the treatment team is whether the person seems to have acquired sufficient insight to “graduate” from AOT and continue with treatment on a voluntary basis.
There is no universal answer to this question. The important thing is for the decision on whether to renew to be based entirely on clinical findings. In some cases, a single term of AOT will be sufficient to change patterns of behavior. For others, a series of renewals may be necessary for life.
Whenever a decision is made to allow an AOT order to lapse, the program design should ensure that the person is not cut off from the services that remain essential to his maintenance of stability. The only thing that should go away is the court order.
How does an AOT program handle a non-adherent patient?
Before explaining how AOT programs handle court order violations, it is important to make clear what doesn’t happen.
In other legal contexts, a court order relies on the judge’s power to enforce it by holding a person in contempt of court – resulting in jail, fines or both. People placed under order understand they must obey or face punishment. In the AOT context, contempt of court should never be invoked. Many state AOT laws explicitly prohibit it. Even where legally permissible, it would make little sense to jail someone for violating an order which was intended in large part to keep him out of jail.
Nor is it feasible to make hospital commitment an automatic consequence of an AOT order violation. This would essentially make hospitalization a punishment. Ultimately, a person may only be committed to hospital care if he is found to meet the state’s criteria for inpatient commitment. That requires current dangerousness or deterioration. Constitutionally speaking, non-adherence to treatment is itself not enough.
Of course, non-adherence to treatment is very likely to lead to dangerousness or deterioration – particularly among those who qualified for AOT precisely because they have fallen down that chute before. Thus, as soon as substantial non-adherence is suspected or detected, it should put all members of the AOT patient’s treatment team on high alert. Their first duty is to make all reasonable efforts to get him back into compliance. But simultaneously, they must be ready to take action at the first sign of alarming behavior. Once there is reason to believe the patient may be in need of hospital commitment, there is cause for action.
From here, the next step differs according to the procedures of each state’s AOT law.
Some states require a motion to the court, calling for a hearing to determine whether there is a need to move the patient to inpatient status. Upon receipt of such motion, the court will typically order that the patient be taken into custody for a short period of evaluation.
Other states empower a treatment professional to independently direct the patient to be held for evaluation. In these states the court will become involved only if the evaluation finds a need for inpatient commitment.
Whichever the procedure, it must be acknowledged that these are results that can also be obtained in the absence of AOT. Every state has laws allowing for the short-term detention for evaluation of any person suspected of meeting criteria for hospital commitment. AOT modestly streamlines that process in some states. But the true value of the court order lies not in its “teeth,” but in the impression it makes upon the patient from the day it is issued. Non-adherence becomes less likely to occur, because the patient is made to understand that there are serious expectations of him and many eyes upon him.
My state has an AOT law, but my local mental health system does not use it at all. How do I start an AOT program from scratch in my community?
The possibility of an AOT program sparks to life when there is a consensus for action between the director of the local public mental health service agency and the local judge with jurisdiction over civil commitments.
If you happen to be one of those people, congratulations! You are halfway to achieving that critical consensus.
If you are neither agency director nor civil commitment judge, you need a strategy to get them to the table. How best to go about it depends on many variables.
Whoever you may be, if you are interested in seeing an AOT program launched in your community, your first move should be to call or e-mail the Treatment Advocacy Center. We are committed to the nationwide implementation of AOT, with many ways to help at every stage of the process. We stand ready to travel as necessary and charge nothing for our services.
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