Start AOT in Your Community

Launching an AOT program begins with bringing together key leaders of the treatment system, the court, the mental health advocacy community, and other stakeholders with knowledge of the community and its existing resources and challenges. The purpose of the initial meeting is to secure buy-in from each of them to explore the feasibility of establishing a program in the community. At a minimum, these leaders include:

• Public mental health authority administrators,
• Civil court judges or magistrates,
• Mental health professionals representing community-based, inpatient and psychiatric crisis services,
• District Attorney/Prosecutors,
• Public Defenders,
• Sheriffs and/or Police Chiefs, and
• Mental health advocacy organization directors.

Each of these stakeholders represents a link in the chain of a well-functioning AOT program. Their buy-in is crucial.

While support of top organizational leadership is critical, some participants in the initial planning should be middle management staff more directly involved in the day-to-day functioning of the system. Although top leaders may know how things are supposed to work, those with direct supervisory roles know how things actually work, which is critical to inform the planning.

Begin by thoroughly reviewing the civil commitment laws and regulations in your state, with certain key questions in mind:

• What are the legal criteria for outpatient commitment?
• What are the procedures for petitioning the court and obtaining an AOT order?
• Who can start the petition process?
• What information needs to accompany the petition?
• What is the maximum length of an AOT order and what is the process to seek continuation if a participant needs more time in the program?
• Are there any other guidelines imposed by state law?

Funding:

While it is difficult to universally estimate the financial costs associated with AOT implementation, at some point in the planning process there may very well be a need to identify sources of funding. Ideally, these costs can be absorbed within existing budgets by the participating stakeholder entities and viewed as wise investments: a little spending up front to activate savings on various forms of crisis response. But if that proves impossible, thoughtful planning should at least give you a sense of how much new money must be found to launch the program. This is not the time to think big. If funding is scarce, work to establish a small-scale pilot to prove the power of AOT locally. Compelling results with a small number of participants — especially if those results include substantial savings on treatment costs — will make it infinitely easier to find the funding to ramp up to meet a larger need.

All AOT programs rely on the court to issue court orders, safeguard participants’ due process rights, and make required rulings at certain junctures. The most extensively studied AOT programs, in New York and North Carolina, limit the role of the court to the performance of these essential judicial functions.

In some AOT programs, the judge also has a role to play in motivating participants to engage with their treatment plans. Active court AOT programs seek to leverage what has come to be known as the “black robe effect.” This is the proposition that an AOT participant’s respect for the authority of the court, and sense of accountability to the court developed through personal interaction, will provide additional motivation for treatment engagement.

Under the full “active court” model, this is accomplished through periodic status conferences, which afford the judge opportunities to “check in” with the participant and treatment team. But the choice between models need not be binary. In many AOT programs, for example, the judge will attempt to impart motivation at the initial AOT hearing, but will not typically hold status conferences.

Which path to follow, or whether to choose one in between, is a fundamental question the planning team must grapple with at an early stage of the planning process.

The public mental health authority is generally responsible for monitoring the status of AOT participants. How exactly this is achieved varies widely among programs. In larger urban programs, this might best be accomplished by a monitoring team that stands apart from, but in close communication with, the treatment team. Many AOT programs in smaller jurisdictions assign this function to a single individual who serves as program monitor. In programs where courts retain active interest in each participant’s progress, the monitor often functions as a liaison between the court and treatment team — maintaining communication between them and serving as a point of contact for each.

Regardless of how they fill the role, each AOT program needs reliable means to:

• Monitor the progress and welfare of each participant,
• Ensure that resources are flowing as expected to each participant and aligned with each participant’s needs,
• Address barriers to service access,
• Ensure timely evaluations for possible court order renewal, and

Track directives from the court.

Prior to program launch, an implementation team work group should finalize basic policies and procedures. Locally tailored documents should set forth criteria for AOT as well as processes for involuntary commitment and continuity of treatment during transitions between levels of care and providers or to another jurisdiction.

Forms for participant tracking, assessment, and monitoring progress are also vital to successful AOT programs. Similar to a patient record, documentation regarding a participant’s progress can tell a story and assist with planning. A well-developed tracking system facilitates routine data collection at critical junctures in time for each participant.

These may include task flow diagrams, job descriptions, organizational charts, contact lists, sample educational materials, and any anticipated pathways of care, written in a manner understandable to all involved.

At a minimum, these should include:

• Admission criteria for the program and clinical assessment forms,
• Procedures for obtaining a court order,
• Procedures and forms for participant oversight and tracking, and
• Procedures to ensure continuity of treatment upon transitions

They might also include:

• Task flow diagrams, including anticipated pathways of care,
• Job descriptions, organizational charts, and contact lists, and
• Sample educational materials

Examples are available in our AOT Resource Library.

Once an AOT program is launched, a group representing all of the stakeholder organizations comprising the planning team — but not necessarily the same top leaders — should continue to meet periodically for purposes of program improvement and evaluation. Each meeting agenda should focus on ensuring that appropriate individuals are being referred to AOT and identifying gaps in services, with ongoing discussion of ways to improve the program.

Participants are sometimes committed to AOT during a psychiatric crisis or with great anxiety and confusion about their rights and responsibilities. Some AOT programs have found it helpful to provide participants with a standardized pamphlet or handbook when they join the program. The materials should:

• be written simply;
• be offered in all languages commonly spoken in the jurisdiction;
• provide a basic explanation of the program and the legal implications of the court order;
• assure participants of their rights to due process and high-quality treatment in conjunction with their responsibilities to adhere, and provide guidance on how to seek redress for perceived rights violations; and
• list contact information for key members of the program team.

A customizable example is available in our AOT Resource Library.

Community engagement regarding the potential benefits and the process of AOT should be initiated prior to program launch and repeated periodically. This will deepen stakeholder investment in the success of the program and facilitate identification of proper AOT candidates from all referral sources. Target audiences include:

• Staff at health care facilities and agencies serving potential AOT participants,
• Family, caregivers,
• National Alliance on Mental Illness (NAMI) affiliates and other advocacy groups,
• Law enforcement,
• Peer-support services, and

Psychiatrists in private practice.

Tracking tools can assist with measuring success, identifying opportunities for improvement, and performing program cost/benefit analysis. Teams should consider data tracking capacity during the planning stages. It is recommended that participant data continue to be tracked after AOT graduation to measure the sustainability of gains achieved under the program. Key data include:

• Hospitalizations and emergency room / crisis center visits (psychiatric and otherwise),
• Civil commitments,
• Criminal justice interactions,
• Housing maintenance,
• Employment, and
• Treatment costs

Evaluation of participant and family satisfaction is also important in sustaining the program in the long term. A neutral third party should be engaged to conduct an analysis of program feedback. Areas of evaluation may include:

• Interactions during court proceedings,
• Interactions during treatment team meetings,
• Quality of information about the program provided to participants,
• Perceptions as to whether the program upheld standards of participant dignity/privacy,
• Perceptions of coercion,
• Perceived benefits of participation, and
• Suggestions for improvement.

AOT programs must not only collect information, but also use it. The tracking and surveys called for above should be utilized to identify deficiencies in the program and should lead to the development and execution of improvements. Developing improvement strategies is a primary purpose of regular stakeholder meetings.

Participant and community needs change over time. Programs must expect to adapt continually to maintain good outcomes.

Given that AOT requires considerable effort to initiate at the program level, successful AOT programs should assist their neighboring communities in developing their own AOT programs. Having a regional network of linked AOT programs will facilitate continuity of care for participants who relocate while still under court order.

Building this network will take time, as successful early adopters help and serve as models to their nearby counterparts. The goal should not be for each new program to be a carbon-copy of the neighboring jurisdictions. For participants who relocate and transition between AOT programs, the important constant is for court-ordered care to yield maximum treatment engagement.

Possible strategies for mentorship include:

• Presentations to stakeholder groups in neighboring counties;
• Inviting teams from neighboring counties to visit and observe the program in action;
• Publishing reports touting the program’s clinical and fiscal successes;
• Seeking local media coverage of the AOT program; and
• Freely sharing court forms, policy documents, budgets, staffing models, etc.

New York State’s AOT data collection provides a good example of such a system.