Developing an Effective Assisted Outpatient Treatment Program What We’ve Learned

What is assisted outpatient treatment (AOT)? Specified in Texas Health & Safety Code 574.037 Court ordered and Court monitored services Serves individuals with severe and persistent mental illness with a history of non-compliance with outpatient services For high end users of resources such as psychiatric and medical emergency centers, jails, and psychiatric inpatient admissions

Who Is It For? Those with multiple inpatient admissions with minimal participation in outpatient services (“revolving door”) Clients who have demonstrated a lack of consistent treatment which contributes to increased time in institutions such as jails, emergency rooms, or psychiatric hospitals Represents less than .05% of a state’s population

Common Characteristics Majority have schizophrenia, schizoaffective, or severe bipolar disorder diagnoses 47% had co-occurring substance abuse disorders 47% did not comply with medications prior to AOT Most at risk of being homeless or incarcerated

Participant A: Before AOT Adult male, history of schizophrenia diagnosis and amphetamine dependence; homeless; unemployed; strained family relationships; chronic non-compliance with outpatient treatment 835 days incarcerated 32 crisis assessments 19 inpatient admissions 2 known nearly lethal suicide attempts

Participant A: Post AOT Living with family members Employed part-time Compliant with all outpatient appointments and medications (monthly injections) 100 days in jail Intermittent drug use 0 crisis presentations 0 inpatient admissions

Participant B: Before AOT Adult female; doctoral degree; diagnosed with bipolar type 1, severe, with psychotic features; no income & no benefits; strained family relationships; chronic non-compliance with outpatient treatment 115 days in county jail 1,052 days of inpatient psychiatric admissions Repeated court involvement through inpatient commitments

Participant B: Post AOT Period of outpatient treatment compliance due to “black robe” effect which has decreased over time 0 days in jail; 0 arrests Obtained disability and insurance benefits Period of improvement in community activities (social events) Decrease is hospitalizations

Participant C: Before AOT Adult male; Veteran; diagnosed with schizoaffective disorder; chronic non-compliance with outpatient treatment that commonly led to threats of violence against public officials 251 days in state or private psychiatric facility 247 days in jail Multiple contacts with court system after being found incompetent to stand trial for criminal offenses

Participant C: Post AOT 0 days in jail 0 days in state or private psychiatric facility Significant improvement with family relationships, recreational activities, & community involvement Compliant with outpatient services Compliant with medications (injections every 2 weeks) Limited insight into mental illness but willing to comply with court order (“black robe” effect)

7 Core Elements of an Effective AOT Program Program must have buy-in from key leadership Representatives of key stakeholders must meet regularly Agreed upon written policies, procedures, and developed forms Assigned professional serving as liaison between treatment teams and court AOT education provided to stakeholders & community members Patient outcomes, individual/family satisfaction, & gaps in resources are tracked for program evaluation purposes Established methods for identifying & addressing gaps in resources & areas for improvement

What We Found Buy-in from leadership is a must! Regular status hearings should occur and help serve as reminders/check-ins for everyone involved AOT served as a catalyst for bringing stakeholders to the table while improving agency cooperation and communication Tracking and data collection should occur throughout the process

What We Learned “Success” in the program may look different from one person to the next Treatment providers must redefine engagement efforts for court-ordered outpatient clients Education for stakeholders should be ongoing The AOT program is not for everyone Clients often need additional support after court dates

Limitations Does not adequately address co-occurring diagnoses of mental health and substance abuse Does not provide clear legal consequences for those who do not abide by court orders Requires court time for participating psychiatrists Funding is an issue The court can petition for LMHA participation with an AOT candidate

Benefits Reduction in crisis presentations Reduction of inpatient admissions Reduction in days incarcerated Reduction in ER visits Increased resources made available Better communication between agencies Improvement in family relationships Improvement in overall quality of life

The Treatment Advocacy Center For more information about Assisted Outpatient Treatment (AOT), go to www.treatmentadvocacycenter.org

Questions?

Presenters Beth Dalman, M.Ed., LPC-Intern supervised by J. Spillman, LPC-S Coordinator of Outpatient Crisis Services bethd@tcbhc.org Matthew LaVoie PETC Utilization Review matthewl@tcbhc.org

References Reference Material for Developing an Effective Assisted Outpatient Treatment Program (2017). Treatment Advocacy Center. www.treatmentadvocacycenter.org