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

2. 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).

3. Reminders Noise control Recording
Please keep your phones on mute if not taking part of the discussion.
Please do not put your phones on hold!
Recording
This webinar is being recorded.

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

5. 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.

6. 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;

7. 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.

8. 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.

9. 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.

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

11. 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 % CI p value
Control (n=135) [1.00]
OPC (n=129) (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),

12. 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,

13. 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%

14. Perceived Barriers to Psychiatrist Involvement with AOT

15. 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

16. Enlisting Psychiatrist Buy-in for AOT

17. 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.

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

19. 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

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

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

22. 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?

23. 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.

24. 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.

25. 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.

26. 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?

27. Q & A
Lisa 27

28. 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
(518) Ext. 5237
Lisa 28

29. Marvin Swartz, MD Email: Marvin.Swartz@duke.edu
Thank You
Marvin Swartz, MD
Betsy Johnson

30. Contact Us 345 Delaware Avenue Delmar, NY 12054 PH: (518) 439-7415
FAX: (518)