AOT from the Psychiatrist’s Perspective Marvin Swartz, MD Professor of Psychiatry Duke University School of Medicine AOT Communities of Practice – Psychiatry July 13, 2018 3:00pm – 4:00pm ET

Disclaimer The views, opinions, and content expressed in this presentation do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services (CMHS), the Substance Abuse and Mental Health Services Administration (SAMHSA), or the U.S. Department of Health and Human Services (HHS).

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If You Have Seen One AOT Program…. It is important to recognize the different elements of and variations in Assisted Outpatient Treatment (AOT).

Key Elements of Outpatient Commitment or AOT Civil court order that requires certain patients with a serious mental illness to comply with recommended outpatient treatment and receive services. Also “commits the system” to the patient, creates accountability. “Treatment plan wrapped in a legal order.” Services under AOT typically include intensive case management or assertive community treatment (ACT), medication, psychosocial treatment, and access to subsidized housing. Monitoring of non-adherence. Non-criminalizing police transport to a mental health facility for evaluation, hopeful persuasion, or involuntary hospitalization if needed. No forced medication in outpatient setting.

Types of Outpatient Commitment Statutes Conditional release from hospital (40 states1) Also known as “trial visit” or “visit to discharge” Alternative to hospitalization for people meeting inpatient commitment criteria, i.e., dangerousness (16 states2) Least restrictive alternative Preventive outpatient commitment (35 states and DC2) Court-ordered treatment authorized at a lower threshold than inpatient commitment criteria with the purpose of preventing further deterioration No outpatient commitment (4 states: MA, CT, MD, NM) 1 Melton et al., 2007; 2LawAtlas.org, 2016;

AOT programs varied considerably… Style of implementation Meldrum et al.: Survey of AOT Implementation in 20 States With “Active AOT Programs” AOT programs varied considerably… Style of implementation Statutory criteria applied Agency responsible Use of a treatment plan Monitoring procedures Numbers of participants involved SOURCE: Meldrum ML, Kelly EL, Calderon R, Brekke JS, Braslow JT (2016). Implementation status of assisted outpatient treatment programs: A national survey. Psychiatric Services, 67, 630–635.

Three implementation models Meldrum et al.: Survey of AOT Implementation in 20 States With “Active AOT Programs” Three implementation models Community gateway Hospital transition Surveillance (or safety net) SOURCE: Meldrum ML, Kelly EL, Calderon R, Brekke JS, Braslow JT (2016). Implementation status of assisted outpatient treatment programs: A national survey. Psychiatric Services, 67, 630–635.

Uneven implementation of AOT programs within and across states Meldrum et al.: Survey of AOT Implementation in 20 States With “Active AOT Programs” Common problems Inadequate resources Lack of enforcement power Inconsistent monitoring Weakness of interagency collaboration Uneven implementation of AOT programs within and across states Ambivalence in the community among judicial officials and mental health clinicians about the role and scope of AOT Difficulties of implementation under existing funding constraints and statutory limitations SOURCE: Meldrum ML, Kelly EL, Calderon R, Brekke JS, Braslow JT (2016). Implementation status of assisted outpatient treatment programs: A national survey. Psychiatric Services, 67, 630–635.

Is Assertive Community Treatment (ACT) an essential element of AOT?

Key finding from 1990s Duke Mental Health Study randomized trial of outpatient commitment in NC Odds ratio for hospital readmission during any given month of 1-year trial Odds Ratio 95% CI p value Control (n=135) [1.00] OPC (n=129) 0.64 (0.46 – 0.88) p<0.01 (n=135) (n=85) (n=47) Swartz MS, Swanson JW, Wagner HR, Burns BJ, Hiday VA, Borum WR (1999). Can involuntary outpatient commitment reduce hospital recidivism? Findings from a randomized trial in severely mentally ill individuals. American Journal of Psychiatry, 156(12), 1968-1975

Swartz MS, Swanson JW, Wagner HR, Burns BJ, Hiday VA, Borum WR (1999) Swartz MS, Swanson JW, Wagner HR, Burns BJ, Hiday VA, Borum WR (1999). Can involuntary outpatient commitment reduce hospital recidivism? Findings from a randomized trial in severely mentally ill individuals. American Journal of Psychiatry, 156, 1968-1975.

New York State Assisted Outpatient Treatment Program Evaluation.   First 180 days 181 days or more (renewed period) Receipt of ACT/Intensive Case Management (ICM) + 242% + 282% Medication possession + 47% + 88% Hospital admission - 23% - 41% Days hospitalized - 10% - 16%

Perceived Barriers to Psychiatrist Involvement with AOT

Perceived Barriers to Involvement with AOT Too much paperwork Many are under pressure to discharge from inpatient units or to be productive as outpatient doctors. Too coercive Adversarial relationship harms therapeutic alliance. Court processes seem intimidating. Little enforcement authority No forced medications Liability concerns

Enlisting Psychiatrist Buy-in for AOT

Enlisting Buy-in Show the evidence of AOT’s effectiveness. Few other effective tools are available to stop cycle of recidivism. AOT can work to stabilize high-utilizing patients—worth a try. May become critical tool in capitated and value-based care.

Engaging the Community in Your AOT Program Betsy Johnson Legislative and Policy Advisor Treatment Advocacy Center AOT Communities of Practice – Psychiatry July 13, 2018 3:00pm – 4:00pm ET

Potential Assisted Outpatient Treatment (AOT) Program Allies AOT Program Graduates Family Members and Friends of AOT Participants Behavioral Health Agency Staff Mental Health Advocacy Organizations Law Enforcement Jail Administrators

Potential AOT Program Allies County Commissioners State Legislators Children’s Services Boards Transit Authorities Library Directors Emergency Department Personnel

Potential AOT Program Allies Small Business Owners Religious Leaders Educators Art Center Directors Others?

Some Reasons for Engagement Desire to give back Meets organization’s mission Great human interest story Cost savings Improved safety Fewer arrests/disturbances Keeps families together Recognition Others?

Ideas for Engaging Allies in Your AOT Program Identify an AOT graduate and family member willing to share their story. Contact the local paper and invite them to report their story. Nominate your AOT judge or other member of the AOT team for a state or national award for going above and beyond. Issue a press release calling attention to the achievement.  

More Ideas for Engaging Allies in Your AOT Program Develop an infographic that shows the cost savings of your AOT program, including reductions in ER visits, hospital days, jail days, and improved safety in terms of reductions in arrests and homelessness rates. Share the infographic with the media, lawmakers, and other allies. Contact civic organizations and religious groups and tell them about your program. Ask them to support it by sponsoring a social event or activity for AOT participants.

More Ideas for Engaging Allies in Your AOT Program Ask local businesses to contribute items such as movie passes as “rewards” for AOT participants who follow their treatment plan. Give recognition for contributions. Work with the local arts center and ask them to host an art exhibit featuring work by those in the AOT program.

More Ideas for Engaging Allies in Your AOT Program Educate the transit authority about the program. Ask them to issue free bus passes to show their support for the program. Other ideas?

Q & A Lisa 27

Communities of Practice Each community of practice will have four (4) quarterly webinar/conference calls that will focus on topics of interest. 1.5 office hours/month will be available for one-on-one technical assistance and guidance by each expert consultant. To schedule one-on-one office hours with Dr. Marvin Swartz or Betsy Johnson, please contact: Amelia Allen aallen@prainc.com (518) 439-7415 Ext. 5237 Lisa 28

Marvin Swartz, MD Email: Marvin.Swartz@duke.edu Thank You Marvin Swartz, MD Email: Marvin.Swartz@duke.edu Betsy Johnson Email: Johnsonb@treatmentadvocacycenter.org

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