Outcomes for AOT Recipients
AOT was designed to ensure supervision and treatment for individuals who, without such supervision and treatment, would likely be unable to take responsibility for their own care and would be unable to live successfully in the community. For persons under AOT the goal is to increase access to the highest intensity services and to better engage them in those services. An additional goal is to reduce the incidence of behaviors harmful to themselves or others. Participation in AOT should result in improved adherence with prescribed medication and decreased hospitalization, homelessness, arrests and incarceration. In addition, individuals under AOT should bene fit through improved functioning in important community and personal activities.
Table 4
Services Received by Persons Under AOT in New York State
Rates Prior to AOT and While Enrolled in AOT
| Percentage of Persons Under AOT | ||
| Service | Prior to AOT | While Enrolled in AOT |
|---|---|---|
| Case Management | 52% | 100% |
| Medication Management | 63% | 94% |
| Individual or Group Therapy | 51% | 75% |
| Day or Partial Hospitalization | 15% | 35% |
| Substance Abuse Services | 26% | 52% |
| Housing and/or Housing Support Services | 23% | 41% |
| Urine or Blood Toxicology (adherence to medication) | 17% | 27% |
| Urine or Blood Toxicology (substance abuse) | 16% | 25% |
| Other | 4% | 9% |
Increased Participation in Case Management and Other Services
Table 4 compares participation in services by AOT recipients prior to and subsequent to the court order. For all categories of service, a greater percentage of individuals are participating in the service while under court order than were receiving it prior to the court order. The most dramatic example is in the area of case management. As prescribed by the legislation, all individuals receiving a court order are enrolled in case management. However, prior to AOT, only 52% of these individuals were receiving this service.
In addition, the percentage of AOT individuals who are receiving substance abuse services doubled as a result of their court-ordered treatment plan, increasing from 26% to 52%. Similarly, the percentage of persons under AOT who receive housing services as a result of their court-ordered treatment plan nearly doubled, increasing from 23% to 41%. Substantial increases are also seen for urine or blood testing used to assess adherence to medication or substance abuse.
Reduced Incidence of Hospitalization, Homelessness, Arrest and Incarceration
After six months of participation in AOT, the incidence of hospitalization, homelessness, arrest and incarceration had all declined significantly from their pre-AOT levels. Table 5 summarizes change in the occurrence of these events.
Table 5
Changes in Incidence of Significant
Events for Persons Under AOT
(Percent of all AOT Recipients)
| Prior to Onset of a Court Order | During AOT | |
|---|---|---|
| Psychiatric Hospitalization | 87% | 20% |
| Homelessness | 21% | 3% |
| Arrests | 30% | 5% |
| Incarcerations | 21% | 3% |
Increased Engagement in Services and Adherence to Prescribed Medication
An important goal of AOT is increased engagement, i.e., active and regular participation in services; and increased adherence to prescribed medication, i.e., taking medications necessary to manage psychiatric symptoms as directed by the treating physician. To assess engagement, case managers were asked to rate the engagement of persons under AOT using a scale ranging from “not at all engaged in services” to “independently and appropriately uses services.” Data collected since the onset of AOT show the percent of individuals who exhibit poor engagement dropped significantly from 59% to 34% at six months.
To assess medication adherence, case managers were asked to rate adherence of persons under AOT using a scale ranging from “taking medication exactly as prescribed” to “rarely or never taking medication as prescribed.” The resulting data show that the percent of individuals with poor medication adherence dropped significantly from 67% to 22% after six months. Figure 3 displays the improvement in engagement in services and medication adherence after six months of AOT participation.
Improved Community and Social Functioning
The evaluation database also documents changes in AOT recipients’ day-to-day functioning. Measures that are used for this assessment are the Global Assessment of Functioning (GAF) and three sets of items that assess individuals’ abilities in specific functional areas: self-care, social and community living skills, and task performance. The case manager serving the individual under AOT completes all functional assessment measures.
Figure 3
Changes in Service Engagement and Adherence to Medication
| At onset of court order | After 6 months receiving court-ordered services | |
|---|---|---|
| Individuals exhibiting poor engagement |
59% | 34% |
| Individuals exhibiting poor adherence to medication | 67% | 22% |
The GAF is a commonly used measure of overall functioning. It includes social, occupational, academic, and other areas of personal performance and results in an overall numerical rating score which can range from 0 to 100. A score of 50 or below denotes serious impairment in social, occupational or school functioning. At the onset of an AOT court order 38% of individuals had a GAF score below 50. After receiving services under an AOT court order for six months, the percentage of persons with a GAF score below 50 dropped to 31%.
AOT recipients’ functioning in the area of self-care and community living also improved after six months of program participation. Figure 4 displays the change in these measures. The figure compares the percentage of persons under AOT who were reported as having difficulty at the onset of their court-ordered treatment with the percentage reported as having difficulty six months later. For all items, there were fewer individuals rated as having difficulty, and in 12 of the 13 measures the change was statistically significant.
In the area of social, interpersonal and family skills and task performance, similar improvements in functioning were seen. On all measures for these areas, the changes between the onset of the court order and at six months were statistically significant. Figures 5 and 6 display the social, interpersonal and family skills and task performance data.
Decreased Incidence of Harmful Behaviors
Case managers also reported reductions in the incidence of harmful behaviors for persons under AOT. All 11 harmful behaviors rated showed declines in the percentage of individuals for whom an occurrence was reported. The reductions in 10 out of 11 harmful behaviors were statistically significant. Figure 7 presents these data.
| Figure 4 Improvement in Self Care and Community Living (Percent of Persons Reported Having Severe Difficulty) |
||
| Onset of AOT | Six Month Follow-Up | |
|---|---|---|
| Manage Medication * | 9% | 5% |
| Follow Through on Health Care Advice * | 11% | 8% |
| Access and Use Available Transportation | 8% | 6% |
| Handle Personal Finances* | 33% | 19% |
| Shop for Food, Clothing, etc* | 33% | 20% |
| Access and Use Community Services* | 44% | 29% |
| Make and Keep Necessary Appointments* | 18% | 12% |
| Prepare/Obtain Own Meals* | 16% | 9% |
| Take Care of Own Possessions* | 36% | 25% |
| Take Care of Own Living Space* | 17% | 13% |
| Recognize and Avoid Common Dangers* | 9% | 6% |
| Maintain Adequate Personal Hygiene* | 18% | 14% |
| Maintain Adequate Diet* | 29% | 16% |
| *Statistically significant change | ||
| Figure 5 Improvement in Social, Interpersonal and Family Functioning (Percent of Persons Reported Having Severe Difficulty) |
||
| Onset of AOT | Six Month Follow-Up | |
|---|---|---|
| Effectively Handle Conflicts * | 15% | 11% |
| Engage in Social and/or Family Activities* | 36% | 19% |
| Manage Assertiveness Effectively* | 23% | 16% |
| Form and Maintain a Social Network* | 43% | 35% |
| Manage Leisure Time to Personal Satisfaction* |
39% | 25% |
| Respond to Other's Initiation of Social Contact* |
56% | 35% |
| Ask for Help When Needed* | 48% | 30% |
| Communicate Clearly* | 26% | 21% |
| *Statistically significant change | ||
| Figure 6 Improvement in Task Performance (Percent of Persons Reported Having Severe Difficulty) |
||
| Onset of AOT | Six Month Follow-Up | |
|---|---|---|
| Perform within a Schedule, Maintain Regular Attendance* |
23% | 15% |
| Perform in Coordination with or in Close Proximity to Others* |
31% | 21% |
| Sustain an Ordinary Routine* | 39% | 28% |
| Maintain Attention and Concentration Spans* |
35% | 22% |
| Complete Task without Assistance* | 40% | 27% |
| Perform at a Consistent Pace Without Unreasonable Rest Periods* |
32% | 23% |
| Complete Task without Errors* | 31% | 23% |
| Understand and Remember Instructions* | 33% | 23% |
| *Statistically significant change | ||
In summary, individuals receiving AOT court orders showed improved functioning in the areas of self care, community living, interpersonal functioning and task performance during the first six months of court-ordered treatment. Incidence of psychiatric hospitalization, homelessness, arrests and incarceration decreased from pre-AOT levels. Statistically significant reductions also occurred in harmful behaviors such as substance abuse, suicide attempts, and physical harm to self.
| Figure 7 Improvement in Incidence of Harmful Behaviors (Percent of Persons for Which One or More Events in the Past 90 Days is Reported) |
||
| Onset of AOT | Six Month Follow-Up | |
|---|---|---|
| Express Suicide Threat* | 33% | 26% |
| Make Suicide Attempt* | 32% | 27% |
| Do physical Harm to Self* | 20% | 11% |
| Damage or Destroy Property* | 35% | 20% |
| Take Property without Permission* | 40% | 23% |
| Do Physical Harm to Others* | 32% | 18% |
| Abuse Alcohol* | 19% | 11% |
| Abuse Drugs* | 13% | 10% |
| Make Threat of Physical Violence to Others* | 11% | 7% |
| Verbally Assault Others* | 16% | 9% |
| Create Public Disturbances* | 19% | 13% |
| *Statistically significant change | ||