Mental health providers
Community Mental Health and other providers
Many individuals living with a serious mental illness (SMI) do not adhere to outpatient treatment, often resulting in increased rates of suicide and self-harm, violent behavior, insecure housing, high utilization of ERs, and frequent contact with law enforcement. These behaviors and vulnerabilities lead to high rates of inpatient psychiatric hospitalization and incarceration.
Assisted outpatient treatment (AOT) is a legal mechanism for providing outpatient treatment to individuals living with SMI whose non-adherence places them at risk for negative outcomes. AOT works by compelling the recipient to receive specific treatment that will prevent their condition from worsening and by committing the mental health system to provide treatment. AOT orders allow concerned parties (such as families and treatment providers) to intervene on behalf of an individual living with an SMI without having to wait until that individual reaches a crisis, increasing the individual's ability to function in the community.
AOT and the role of the Community Mental Health system
AOT is an evidence-based intervention targeting individuals with an SMI who struggle with treatment compliance resulting from their inability to recognize they are ill. Due to their non-compliance with treatment many of these individuals experience adverse events including frequent hospitalizations, housing instability, contact with law enforcement, suicidal behavior, and substance use disorders. Many times, they are relatively unknown to community mental health because a significant portion have Medicare, so they do not benefit from the services necessary to manage their illness. AOT orders are designed to help people with untreated SMI get connected to outpatient treatment, reduce ED and inpatient psychiatric hospital use, and function independently.
Statutorily, the responsibility for implementing and monitoring AOT belongs to the Community Mental Health (CMH) authority and their contracted service providers. AOT orders may mandate case management, medication (often via long-acting injectable formularies), outpatient therapy, Assertive Community Treatment (ACT), SUD testing and/or treatment and other services that may help prevent relapse or deterioration of the person's mental health. AOT research shows that there were significant increases in medication adherence , reductions in suicidal behavior, homelessness, inpatient psychiatric hospitalizations and reductions in both drug and alcohol use for people under an AOT order. Additionally, AOT research shows promising cost savings to hospitals, courts, CMH and provider agencies and law enforcement. AOT provides a legal mechanism to help people with SMI access and be accountable for the care they receive.
- Assume responsibility of implementing and monitoring AOT order.
- Develop individual plan of service (IPOS) with the individual within 30 days of the order being issued.
- Connect to and deliver of ordered services either directly or through contracted providers.
- Collect baseline data with specific metrics, and follow-up data at regular intervals.
- Comprehensive documentation of engagement, services, and progress.
- Coordinate with system of care to facilitate warm hand-offs.
- Communicate with the court about progress and/or any issues that arise.
- Evaluate and assess the individual's current and past mental health condition and treatment history to determine appropriateness of AOT.
- Provide court testimony.
- Collaborate with other parts of the support team, and the individual for treatment planning.
- Medication management and review when necessary.
Action steps for CMH and provider agencies:
- Train staff on changes to the mental health code and AOT, including eligibility and best candidates.
- Develop internal process for identifying and screening patients for appropriateness of AOT.
- Train staff on filing petitions and all court forms.
- Educate staff on court processes, requirements to testify and court etiquette.
- Train staff on monitoring AOTs and providing services to members on AOTs.
- Have procedures in place with probate court, hospitals, emergency rooms, prosecutor's office, and law enforcement regarding various aspects of the AOT processes.
Frequently asked questions for providers
- How is adherence to an AOT order enforced?
Ideally, the individual’s case manager will be the primary contact for concerns over AOT adherence. It is imperative that the treatment provider find a way to engage the member. If the individual is not voluntarily coming into treatment, and it is incumbent upon the treatment provider to creatively find ways to engage them. An AOT order requires treatment and does not allow for people to choose not to receive services. Family/ friends should reach out to the individual’s case manager if they are concerned about the person’s adherence to treatment. If efforts to reach the case manager are unsuccessful, the concerned party can file a notice of non-compliance (PCM 230) with the court. For case managers, if an individual is not adhering to their treatment plan, their case manager should first try to engage them directly and/or through other contacts before filing a notice of non-compliance (PCM 230) with the court. At that point, an Order for Examination/ Transport (PCM 209a, often referred to as a “transport order”) may be employed to facilitate reassessment of the individual at a designated screening location. From there, modifications to the order can be recommended to the court if necessary.