Community Mental Health and other providers

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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.

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.