Implementation of Assisted Outpatient Treatment

Kendra’s Law established new mechanisms for identifying individuals who, in view of their treatment history and circumstances, are likely to have difficulty living safely in the community without close monitoring and mandatory participation in treatment; and for ensuring that local mental health systems give these individuals priority access to case management and other services necessary to ensure their safety and successful community living. The statute created a petition process, found in Mental Hygiene Law section 9.60, designed to identify at-risk individuals using specific eligibility criteria, assess whether court-ordered outpatient treatment is required and if so, develop and implement mandatory treatment plans consisting of case management and any other necessary services. Kendra’s Law required that each county in New York State and New York City establish a local AOT program to implement the statute’s requirements, and charged OMH with responsibility for developing AOT program guidelines and monitoring AOT statewide. Thus, implementation of Kendra’s Law and AOT has been a joint responsibility and collaboration between OMH and local mental health authorities.

Eligibility Criteria for AOT

Kendra’s Law contains the following summary description of the AOT target population:

“...mentally ill people who are capable of living in the community with the help of family, friends and mental health professionals, but who, without routine care and treatment, may relapse and become violent or suicidal, or require hospitalization.”

The statute further defines specific eligibility criteria, which are listed below:

An individual may be placed in AOT only if, after a hearing, the court finds that all of the following have been met. The individual must:

1. be eighteen years of age or older; and
2. suffer from a mental illness; and
3. be unlikely to survive safely in the community without supervision, based on a clinical determination; and
4. have a history of non-adherence with treatment that has:
   1. been a significant factor in his or her being in a hospital, prison or jail at least twice within the last thirty-six months; or
   2. resulted in one or more acts, attempts or threats of serious violent behavior toward self or others within the last forty-eight months; and
5. be unlikely to voluntarily participate in treatment; and
6. be, in view of his or her treatment history and current behavior, in need of AOT in order to prevent a relapse or deterioration which would be likely to result in:
   1. a substantial risk of physical harm to the individual as manifested by threats of or attempts at suicide or serious bodily harm or conduct demonstrating that the individual is dangerous to himself or herself, or
   2. a substantial risk of physical harm to other persons as manifested by homicidal or other violent behavior by which others are placed in reasonable fear of serious physical harm; and
7. be likely to benefit from AOT; and
8. if the consumer has a health care proxy, any directions in it will be taken into account by the court in determining the written treatment plan. However, nothing precludes a person with a health care proxy from being eligible for AOT.

Resources to Provide Court-Ordered Services

The Governor’s budget for FY2000-2001 included $32 million for implementation of Kendra’s Law. This appropriation supported case management and other services aimed at keeping recipients in a treatment program, including psychiatric medication as required. Shortly after Kendra’s Law went into effect, Governor Pataki acted to expand access to case management and other key community-based mental health services that would be needed by individuals receiving court-ordered treatment, as well as many other individuals with severe mental illness who have less intensive, but still substantial, service needs. The Governor’s budget for FY2000-2001 also included $125 million in new funding for such services. This “New Initiatives” funding, which comprised the largest single investment in the public mental health system in NYS history, was used to both improve and expand the capacity of the existing community-based mental health system and to strengthen the cohesiveness and coordination of that system. More specifically, the New Initiatives were designed to steer the NYS mental health system toward a more person-centered, recovery-oriented service delivery approach. The New Initiatives were targeted for the following purposes:

• to expand case management, Assertive Community Treatment (ACT), and housing services to support community integration;
• to develop Single Points of Access (SPOA) to better manage service access and utilization; and
• to increase the availability of other services that enhance community participation and improve the engagement, quality of life, and satisfaction level of service recipients.

AOT Program Administration

During the period between enactment of the legislation and the effective date of New York State Office of Mental Health January 2003 November 7, 1999, OMH staff developed and disseminated guidelines necessary for implementation and operation of AOT statewide. In November 1999 counties across NYS created and operationalized the mechanisms necessary to implement AOT locally.

At the local level, County (or City of New York) Mental Health Directors operate, direct and supervise their AOT programs. Local Mental Health Directors coordinate delivery of court-ordered services, file petitions, and receive and investigate reports of persons who may be in need of AOT. They also insure AOT service delivery by directly providing services, coordinating with OMH services, and/or utilizing not-for-profit programs.

OMH plays a key role in the oversight of AOT. The OMH Commissioner appoints Program Coordinators who monitor and oversee operation of AOT across NYS. Each OMH Field Office has an AOT Program Coordinator. The OMH AOT Program Coordinator works with local mental health directors, oversees and monitors care provided to persons under AOT, and can require local Directors of AOT programs to take corrective action if court-ordered services are not delivered in a timely manner. In addition, OMH’s oversight role is enhanced by data collected on an ongoing basis for the evaluation of AOT.

Common Components of Local AOT Programs

During the first year of the program OMH conducted an evaluation of AOT implementation in a geographically representative sample of localities. The study was conducted in eight counties and New York City with full collaboration of local mental hygiene directors in those localities. Data were collected through interviews with multiple stakeholders and observation of processes associated with the implementation of AOT. Stakeholders included mental health care coordinators, other mental health service providers, county government personnel, court system staff, family members of persons with mental illness, persons under AOT and other mental health service recipients.

Visits to each study site allowed for direct observation of the mechanisms localities developed to implement AOT. Figure 1 depicts a schematic representation of the major components (personnel and processes) of the AOT program as it has been implemented in each of the nine study sites. Discussions with OMH regional AOT Coordinators and local AOT program staff from counties not included in the study suggest that the model displayed in Figure 1 is representative of AOT as implemented in most areas of NYS.

As illustrated in Figure 1, the AOT program consists of four core phases or processes - referral, investigation, assessment and service delivery/monitoring. In the referral phase, an individual becomes known to the local AOT coordinator either through a direct referral from the community, or through a referral made by a local hospital or correctional facility. Upon referral, the AOT coordinator or an AOT Team (usually led by the AOT coordinator) initiates an investigation. This is conducted to ascertain an individual’s potential eligibility for AOT. If an individual is determined to meet the eligibility criteria, an AOT case review panel assesses the needs of the individual and determines whether a court-ordered treatment plan or a non-court-ordered service enhancement should be pursued. If a court-ordered treatment plan is determined to be appropriate, the court is petitioned to consider issuing a court order requiring the individual to adhere to a treatment plan. Upon issuance of the court order, the individual receives a care coordination service (case management or ACT) and other court mandated services needed to help insure success in the community. Initial court orders last six months and upon expiration, can be renewed for up to one year.

As localities began to identify individuals who were in need of AOT, they also identified other individuals who did not require court-ordered treatment but nevertheless had unmet service needs. Many of these individuals were willing to voluntarily participate in necessary services. In some areas of New York State these “service enhancements” can also include a signed service agreement, special reporting requirements for assigned case managers and increased monitoring of cases by the county. These voluntary service enhancements represent an additional unanticipated benefit from the implementation of Kendra’s Law.

Figure 1, below, links to a full-size version of the schematic diagram. To return to this page, use your browser back button.

Impact of AOT on Local Mental Health Systems

Stakeholder interview data from the AOT implementation study document the perceived impact of AOT on local service delivery from a variety of perspectives. Below, we present major themes that emerged from analysis of interview transcripts. In each locality included in the study, and across multiple stakeholder groups, there was broad recognition that the implementation of processes to provide AOT to high risk/high need recipients has resulted in beneficial structural changes to local mental health service delivery systems.

New mechanisms for identifying, investigating and assessing individuals, developed in order to fulfill the requirements of AOT, represent new points of accountability in local mental health service systems.

Some areas of NYS have established sitting AOT Teams that are staffed by individuals who can effectively exert “clout” within their service systems. These are individuals who, through personal contact with providers, can ensure either initial access to services or can intercede on behalf of an individual who is not receiving the appropriate attention. They can move the system to meet the needs of persons who come to the attention of the team either as new persons under AOT or individuals who are being monitored while under court order or receiving enhanced services. Specific enhancements reported by stakeholders across counties include:

• Enhanced Accountability and Improved Access to Services. AOT has increased accountability at all levels regarding delivery of services to individuals who have high needs or who are at high risk to themselves or others. Community awareness of AOT has resulted in increased outreach to individuals who were previously difficult to engage (or had difficulty becoming engaged) in mental health services. By alerting local mental health systems to the potential risk posed by not responding to an individual’s situation, those systems improved their ability to mobilize around the needs of these individuals.

• Improved Treatment Plan Development and Discharge Planning . There was general agreement among stakeholders that processes and structures developed for AOT have resulted in improved treatment plans which more appropriately match the challenging needs of individuals who had been previously difficult to engage. The AOT processes put in place have increased attention to the needs of individuals who are referred. Clinicians are carefully considering the needs of individuals and are developing sound comprehensive treatment plans that will best ensure success in the community.

• Improved Coordination of Service Planning. AOT provides a mechanism to bring together high-level representatives of appropriate service providers to consider eligibility and strategies for service delivery to AOT eligible individuals. The make-up of these panels varies and reflects local conditions. AOT coordinators and care coordination (e.g., case management, ACT) gatekeepers are consistently present. In some areas ongoing coordination efforts are expanded to include county attorneys, recipient advocates, and psychiatrists.

• Improved Collaboration between Mental Health and Court Systems. Over time, staff from the mental health system have developed better relationships with the court system. In speaking to study participants associated with both systems, it was clear that a certain level of uneasiness in the relationship between these two systems was common. As AOT processes matured, professionals from these two systems learned how to improve needed interactions. Mental health practitioners learned how to negotiate the court systems in which they were required to operate. They confronted the challenge of rotating judges by learning how to best prepare for court proceedings. These adjustments have led to an enhanced efficiency in the conduct of AOT hearings, an efficiency that will more likely result in meeting the clinical needs of individuals. In summary, the AOT implementation study found that important changes to local mental health systems have come about as a result of the AOT program. More specifically, there was general agreement that AOT has led to enhanced service system structures that promote better accountability, improved access to services for high need individuals, improved treatment plan development and discharge planning, improved coordination of service planning and a more collaborative relationship between mental health and court systems.

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