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IMPORTANT & BREAKING: FAMILIES IN MENTAL HEALTH CRISIS ACT INTRODUCED

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Incorporating the 2005-2009 Duke University research
in an improved Kendra’s Law (Assisted Outpatient Treatment)

In 2005, the NYS legislature renewed Kendra’s Law for five years so independent research could investigate claims of opponents to the law. The research was released in 2009. The results of the research showing how Kendra's Law could be improved were not incorporated by the legislature when they renewed Kendra's Law in 2010. The results are presented here in three sections:

1. Findings on claims made by anti-treatment advocates in 2004.
2. Findings on recipient outcomes.
3. Findings on impact of AOT on mental health system.

 

Section 1: Findings that address previous concerns.

 

 

2009 Duke University Research Finding

 

Amendment required to
address research finding

 

AOT recipients represent a small proportion of the total OMH adult service population. (1.7 %). (Intro. Page 3 & (Ch 6. Pg. 45)

Make law permanent. Claims that law would be overused were proven false.

(A)fter six or more months of AOT…(s)elf-harm decreased from 9 % to 4 % (44%) and harm to others decreased from 7 to 4% (57%). (Ch. 3. Pg. 25)

Make law permanent. Claims that AOT could not work because mental illness and violence are unrelated were proven false.

We find no evidence that the AOT Program is disproportionately selecting African Americans for court orders, nor is there evidence of a disproportionate effect on other minority populations. Our interviews with key stakeholders across the state corroborate these findings. (Ch 6. Pg 53)

Make law permanent. Charges of racism were proven false

(W)e find no evidence suggesting racial bias in the application of AOT to individuals. (Ch 1. Pg. 14)

Make law permanent. Charges of racism were proven false

Parallel analyses for Hispanics and other minority populations show this same pattern and no appreciable racial disparities are evident in selection of these groups for AOT. (Ch. 1. Pg. 14)

Make law permanent. Charges of ethnic bias were proven false

Recipients receiving AOT with ICM demonstrate higher levels of engagement (49%) compared to ACT alone. (Ch. 2 Pg. 18)

Make law permanent. Claims that case management versus court orders increased engagement were proven false.

(T)he chance of hospital admission was substantially reduced — from about 58% to 36% — among these AOT recipients with either ACT or ICM, compared to those receiving only ACT without AOT. (Ch 3. Pg. 27)

Make law permanent. Claims that improved services, not court orders, decreased hospitalization were proven false.

The increased services available under AOT clearly improve recipient outcomes, however, the AOT court order and its monitoring do appear to offer additional benefits in improving outcomes. (Ch 6. Pg 57)

Make the law permanent. Claims that court orders didn’t improve care were proven false.

Findings for (perceived effectiveness) showed a mixed response for non-AOT respondents and a higher, more positive response among current AOT recipients compared to those with no recent AOT (Ch. 4. Pg 35)

Make law permanent. Claims consumers in AOT oppose AOT was proven false.

(Not direct quote. Combined for simplicity): There was no difference in the AOT group and non AOT group in “personal empowerment”, “working alliance”, “treatment satisfaction”, “medication experience” or “life satisfaction” (Ch. 4. Pg. 36)

Make law permanent. Claims AOT increases stigma were proven false. Claims consumers in AOT oppose AOT was proven false.

Positive and negative attitudes about treatment during AOT are more strongly influenced by other experiences with mental illness and treatment than by
recent experiences with AOT itself (Ch 6. Pg 55)

Make law permanent. Claims that AOT increases stigma were proven false.

(Not direct quote. Combined for simplicity): There was no difference in the AOT group and EVS group in “perceived coercion”, “pressure to adhere to treatment”, “perceived effectiveness and fairness of pressure” (Ch 4. Pg. 36-37)

Make law permanent. Claims AOT increases perceived coercion were proven false.

We find that recipients report few differences in treatment experiences and attitudes in the post-AOT period. (Ch. 4. Pg. 39)

Make law permanent. Claims that being in AOT would cause consumers to avoid treatment in future were proven false.

Perceptions of the AOT Program, experiences of stigma, coercion, and treatment satisfaction appear to be largely unaffected by participation in the program (Ch. 6. Pg. 57)

Make law permanent. Claims AOT increases stigma or coercion proven false.

(C)urrent AOT recipients reporting higher perceived procedural justice than their counterparts who had not recently experienced AOT (Ch. 4. Pg. 37)

Make law permanent. Claims consumers in AOT don’t support AOT were proven false.

(W)e found some evidence that AOT recipients are at lower risk of arrest than their counterparts in enhanced voluntary services. We also found evidence …that receiving AOT combined with ACT services substantially lowers risk of hospitalization compared to receiving ACT alone. (Ch. 6. Pg. 57)

Make law permanent. Claims EVS was as effective as AOT were proven false.

(D)espite being under a court order to participate in treatment, current AOT recipients feel neither more positive nor more negative about their mental health treatment experiences than comparable individuals who are not under AOT. (Ch 6. Pg 55)

Make law permanent. Claims that fear of AOT would cause consumers to avoid the mental health system and decline voluntary services were proven false. Claims that AOT increases stigma were proven false.

New York’s AOT Program features more comprehensive implementation, infrastructure and oversight of the AOT process than any other comparable program in the US. (Ch. 6. Pg. 51)

Make the law permanent. 2010 claims that the law is not properly monitored are unfounded. The legislature has authority to continue to monitor permanent laws.


 

 

Section 2: Findings that address recipient outcomes

 

 

2009 Duke University Research Finding

 

Amendment required to
address research finding

 

Moving into the current AOT period from the pre-AOT/pre-EVS period, the likelihood of arrest in any given month is reduced from 3.7 to 1.9% (51%) per month. (Ch. 3. Pg. 23.)

Make law permanent. AOT reduces arrest rates.

We also find moderately strong evidence from lifetime arrest records of AOT and Enhanced Voluntary Services recipients that AOT reduces the likelihood of being arrested. (Ch. 3. Pg. 32 & Ch. 6. Pg 54

Make law permanent. AOT reduces arrest more than EVS.

Current EVS status was not significantly associated with reduced rates of arrest although there was a clear trend toward reduction of arrests during this period. Ch 5. Pg. 43)

Make law permanent. AOT reduces arrest rates. Enhanced Voluntary Services do not.

(H)ospitalizations were reduced by about one half among individuals who received 12 months or more of AOT (combined with either ACT or ICM), compared to their baseline hospitalization rate. (Ch 3. Pg. 27)

Make law permanent. AOT reduces hospitalization. Allow initial orders extend for up to one year (instead of 6 months).

(T)his decrease in hospital utilization…represent(s) substantial reductions in hospitalizations for AOT recipients statewide. (Ch 3. Pg. 29)

Make law permanent. AOT reduces hospitalization rates.

During AOT there is a substantial reduction in the number of psychiatric hospitalizations and in days spent in the hospital. (Ch. 3. Pg. 33; Ch. 3. Pg. 29 & Ch 6. Pg 54)

Make law permanent. AOT reduces number of hospitalizations and length of hospitalizations.

(For individuals under court orders six months or less) if ACT or ICM is also discontinued when AOT ends, the predicted probability of post-AOT hospitalization rises to 10% per month, which is comparable to the pre-AOT hospitalization rate. (Ch. 5. Pg. 40)

Make law permanent. Amend law to require provision of ACT/ICM services for minimum of one year after AOT order ends to maintain reduction in hospitalization rates (and related savings).

(I)f the initial period of AOT is longer than six months, reduction in hospitalization in the post-AOT period is sustained whether or not the recipient continues to receive intensive treatment in the form of ACT or ICM. (Ch 5. Pg. 41)

Make law permanent. Amend law to allow initial commitment orders of up to one year, since doing so cuts down on hospitalization even after order ends.

For individuals receiving six months or more of treatment, substance use rates were much lower for individuals receiving AOT plus ICM (29%) compared to those receiving AOT plus ACT (59%) or
voluntary ACT alone (61%). (Ch 3. Pg 28)

Make law permanent. AOT reduces substance abuse. Amend law to require ICMs for substance abusers since this reduces substance abuse. Allow initial orders to extend up to one year.

Over (the one year) time period, a higher proportion of recipients were rated with positive engagement in the AOT with ACT group, and in the AOT with ICM group, than in the ACT-alone group (55%, 56% and 43% respectively). (Ch. 2 Pg. 18)

Make law permanent. Allow initial orders to extend to one year. Ensure that expiring AOT orders are adequately reviewed by AOT coordinators to consider the need for renewal.

AOT recipients are far more likely to consistently receive psychotropic medications appropriate to their psychiatric conditions. (Ch 6. Pg 54)

Make law permanent.

(L)onger-term AOT combined with intensive treatment increases service engagement compared to voluntary treatment alone. (Ch. 2. Pg. 19)

Make the law permanent. Allow initial commitment orders of up to one year. Ensure that expiring AOT orders are adequately reviewed by AOT coordinators to consider the need for renewal

There was a more notable decrease in case managers’ appraisal of recipients’ non- adherence to medications –from 47% to 33% after six months of AOT. (Ch. 3. Pg. 25)

Make law permanent. AOT increases medication compliance.

Case managers reported as much as a 10% increase in the proportion of individuals able to manage their medications and personal finances …(and engagement) in pro-social behaviors such as effectively handling conflict, engaging in social activities, and asking for help. (Ch 3. Pg. 26)

Make law permanent. AOT increases medication compliance and has other positive outcomes.

(M)edication receipt (so defined) increased from 35% per month prior to AOT, to 44% during the first six months of AOT, to 50% during the 7-12 month period. (Ch 3. Pg 30)

Make law permanent. AOT enhances medication compliance.

We also find that AOT recipients are far more likely to consistently receive psychotropic medications appropriate to their psychiatric conditions compared to their experiences pre-AOT. (Ch 3. Pg. 32)

Make law permanent. AOT increased medication compliance among medication resistant. Make law permanent.

In the post-AOT period recipients reported appointment and medication adherence comparable to adherence during AOT. Community functioning and level of symptomatology were relatively similar as well. Other areas unchanged in the post-AOT period were self-report of substance abuse, violence, suicidality, homelessness, and arrests. (Ch. 5. Pg. 39)

Make law permanent. The beneficial effects of AOT last even after AOT stops.

If AOT is discontinued after six months, decreased rates of hospitalization and improved receipt of psychotropic medications are only sustained if recipients also continue to receive intensive services after AOT is discontinued. (Ch 5. Pg. 44)

Make law permanent. Require provision of ICM or ACT for one year following expiration of court order.

Thus, it appears that improvements in hospitalization and medication outcomes are more likely to be sustained if AOT continues for longer than 12 months. (Ch 5. Pg. 44)

Make law permanent. Allow initial treatment orders of up to one year (as opposed to six months).

For individuals who receive AOT for six months or less…If the recipient continues to receive post-AOT …ACT or ICM, the predicted probability of appropriate medication possession …remains improved relative to the pre-AOT period (Ch 5. Pg. 42)

Make law permanent. Amend law to require the continuing provision of case management services for one year after court order expires as that keeps medication compliance higher.

(I)f the initial period of AOT is longer than six months, improvement in rates of receipt of appropriate psychotropic medications in the post-AOT period are sustained whether or not the recipient continues to receive intensive treatment in the form of ACT or ICM. (Ch 5. Pg. 42)

Make law permanent. Amend law to allow initial treatment orders of up to one year.

If ACT or ICM is also discontinued when long-term AOT ends, the predicted probability of receiving appropriate psychotropic medications declines to 43%, which is still an improvement over the pre- AOT rate. (Ch 5. Pg 42)

Make law permanent. Amend law to ensure individuals who are only under court orders for six months or less, continue to receive case management services as it reduces hospitalizations and therefore saves money.

Compared to their experiences prior to AOT recipients are far more likely to receive intensive forms of case management under AOT. (Ch 3. Pg. 32)

Make law permanent. AOT helped force system to provide case managers to difficult to treat.

Case Managers of AOT recipients also report subjective improvements in many areas of personal functioning, such as managing appointments medications and self-care tasks. (Ch 3. Pg. 32)

Make Law permanent. AOT improves lives of consumers.

The proportion of individuals reporting at least one night of homelessness also decreased from 12% to 7-8%. (66%) (Ch. 3 Pg 25)

Make Law permanent. AOT decreases homelessness.


 

 

Section 3: Findings that address impact on mental health system

 

 

2009 Duke University Research Finding

Amendment required to
address research finding

Our interviews of county officials …yield no specific information about how county-level AOT dollars are spent. (Intro. Pg. 3)

To prevent counties from diverting AOT funding it should be capitated for AOT recipients only. This would also encourage counties to use the program.

(T)here are frequent problems with inter- county transfers and jurisdiction over AOT cases that could be addressed. (Ch 6. Pg 56)

Amend law to require that if recipient relocates to a new county, the obligation to receive and provide services also moves.

Most key informants felt that the majority of AOT recipients were appropriate for the program,
but they agreed that many who might benefit were never referred. (Ch 6. Pg 54)

Make law permanent. Expand funding and make it easier to petition and allow more officials the right to petition.

Kendra's law commits the individual to treatment and commits treatment providers to treating the individual.(Ch 6. Pg 54)

Make law permanent. It successfully gets mental health system to focus more attention on the most severely ill.

Not having a physician appear would reduce costs and scheduling difficulties, particularly for the smaller counties. (Ch 6. Pg. 53)

Amend law to allow consumers to stipulate to the psychiatrists finding if they choose.

AOT statute can be used to prevent relapse or deterioration before hospitalization…However, in nearly three-quarters of all cases, it is actually used as a discharge planning tool for hospitalized patients. (Ch 6. Pg 52)

Make law permanent. Amend law to make it easier for families and correction officials to file initial petitions and renewals.

In some counties AOT has been used rarely; in several it has not been used at all. (Ch 6. Pg 52)

Ensure that AOT funds only go to counties that use law.

(J)udges hearing AOT cases could benefit from additional mental health and AOT training, especially in counties where many judges rotate in these courts (Ch 6. Pg 52)

Amend legislation to require OMH Coordinators do better job of judicial education

(A)lmost all (counties) agreed that not having a physician appear would reduce costs and scheduling difficulties, particularly for the smaller counties that contract for physician services. Most counties were in favor of increasing the availability of stipulations in the AOT process, especially for renewals. This would reduce the court burden and costs and would reduce some of the hearing logistics and transportation burdens. (Ch 6. Pg. 53

Make law permanent. Allow consumers, on advice of counsel, to stipulate to psychiatrists finding.

(S)ome respondents stated that service and housing providers were more likely to accept clients with an AOT court order and all confirmed that AOT recipients were given priority access. (Ch 6. Pg. 55)

Make the law permanent. AOT helps eliminate the discrimination against more symptomatic consumers

AOT order exerts a critical effect on service providers, stimulating their efforts to prioritize care for AOT recipients. (Ch. 6. Pg 57)

Make law permanent.



The information on Mental Illness Policy Org. is not legal advice or medical advice. Do not rely on it. Discuss with your lawyer or medical doctor. Mental Illness Policy Org was founded in February 2011 and in order to maintain independence does not accept any donations from companies in the health care industry or government. That makes us dependent on the generosity of people who care about these issues. If you can support our work, please send a donation to Mental Illness Policy Org., 50 East 129 St., Suite PH7, New York, NY 10035. Thank you. Contact office@mentalillnesspolicy.org Contact DJ Jaffe, founder http://mentalillnesspolicy.org.