Guide to how AOT (Assisted Outpatient Treatment) works.
Statement of need for AOT: Some people, as a result of mental illness, have great difficulty taking responsibility for their own care, and often reject outpatient treatment offered to them on a voluntary basis. These individuals often commit suicide; become homeless; end up in jail; or, on rare occasions, are involved in acts of violence. Family members and caregivers often must stand by helplessly and watch their loved ones and patients decompensate to actual “dangerousness” before they are allowed to facilitate treatment.
What is Assisted Outpatient Treatment (AOT)?
AOT Laws allow courts to order certain individuals with brain disorders to comply with treatment while living in the community. It also—very importantly– allows the courts to commit the mental health system to providing the treatment. This court-ordered treatment is called assisted outpatient treatment.
Assisted outpatient treatment is a new tool that may help in these situations. But it is not a panacea.
Assisted outpatient treatment is meant to help patients, not punish them. 43 states have some form of AOT but few implement it as widely as it should be.
Assisted Outpatient Treatment (AOT) is not an alternative to voluntary treatment. It is a way to get services to those who refuse voluntary treatment.
What are the advantages of Assisted Outpatient Treatment (AOT)?
Assisted Outpatient Treatment (AOT) has many advantages over existing law.
- It allows individuals to be ordered into treatment without ordering them into a hospital.
- The criteria to place someone in assisted outpatient treatment are easier to meet than the “imminent dangerousness” standard often required for inpatient commitment. In other words, there is no need to wait until a deteriorating patient actually is dangerous to self or others, as in the inpatient standard. under AOT you can start procedures to “prevent a relapse” that could lead to dangerousness.
- The law in some states (including NY) not only allows courts to commit the patient to accepting care, it also allows courts to commit the mental health system to providing it. This is important because programs often reject serving those with serious illness or look the other way if the patient fails to show up for services.
The law includes strict eligibility criteria and numerous patient protections.
Overview of Assisted Outpatient Treatment
Assisted outpatient treatment is only available to individuals who meet certain defined criteria. Patients can only be placed in the program by a court, which must first receive a petition from one of a defined group of individuals. The petition must give the reasons why the petitioner believes the patient meets the criteria and be accompanied by an affidavit from a physician who has examined or tried to examine the patient.
Once the court receives the petition and the physician’s affidavit it will schedule a hearing and give notice to appropriate parties. The patient is provided with free legal representation and extensive due process protections throughout the assisted outpatient treatment process.
In the hearing, the court hears testimony and takes evidence from all the parties, including a doctor who has examined the patient. If the court finds the individual meets all the criteria for placement in assisted outpatient treatment, it will have a treatment plan developed and order the patient to comply with it and the mental health system to provide it.
Patient compliance with the court’s order is monitored through case managers. If an individual fails to comply with his or her treatment plan, interventions are triggered which can ultimately result in the individual’s rehospitalization for 72 hours for treatment and evaluation to determine if he or she meets the inpatient commitment criteria.
Initial assisted outpatient treatment (AOT) orders are for a minimum of one year and each renewal can be for up to two years.
QUESTIONS & ANSWERS ABOUT ASSISTED OUTPATIENT TREATMENT (AOT) AS IT WORKS IN NEW YORK (KENDRA’S LAW)
What services can be included in an assisted outpatient treatment plan?
Assisted outpatient treatment orders have to include case management services or assertive community treatment team services and may also include:
2. blood or urinalysis tests to determine compliance with prescribed medications;
3. individual or group therapy;
4. day or partial day programs;
5. educational and vocational training;
6. supervised living;
7. alcohol or substance abuse treatment;
8. alcohol and/or substance abuse testing
9. any other services prescribed to treat the person’s mental illness and to either assist the person in living and functioning in the community or to help prevent a relapse or deterioration that may reasonably be predicted to result in suicide or the need for hospitalization.
What are the eligibility criteria for assisted outpatient treatment?
A patient may be placed in assisted outpatient treatment only if, after a hearing, the court finds that all of the following have been met. The patient must:
- be eighteen years of age or older; and
- suffer from a mental illness; and
- be unlikely to survive safely in the community without supervision, based on a clinical determination; and
- have a history of non-compliance with treatment that has:
been a significant factor in his or her being in a hospital, prison or jail at least twice within the last thirty-six months or;
vresulted in one or more acts, attempts or threats of serious violent behavior toward self or others within the last forty-eight months; and
- be unlikely to voluntarily participate in treatment; and
- be, in view of his or her treatment history and current behavior, in need of assisted outpatient treatment in order to prevent
a relapse or deterioration which would be likely to result in: a substantial risk of physical harm to the patient as manifested by threats of or attempts at suicide or serious bodily harm or conduct demonstrating that the patient is dangerous to himself or herself, or
a substantial risk of physical harm to other persons as manifested by homicidal or other violent behavior by which others are placed in reasonable fear of serious physical harm; and
- be likely to benefit from assisted outpatient treatment.
Who can petition the court for assisted outpatient treatment?
As a practical matter, it is often a hospital or criminal justice facility that files a petition. This usually happens when they identify a particular patient exhibiting a cycle of doing well in the hospital; being discharged; going off meds; and decompensating. To break the cycle, hospitals will often file for AOT [petitions. However, any of the following persons can file
- 1. any adult person living with the patient;
- 2. the parents, spouse, adult sibling, or adult child of the patient;
- 3. if the patient is an inpatient, the hospital director;
- 4. the director of a program providing mental health services to the patient in whose institution the patient resides;
- 5. a treating or supervising psychiatrist;
- 6. the director of community services, or his or her designee, or the social services official of the city or county in which the patient is present or believed to be present; or
- 7. the patient’s parole or probation officer.
What has to be in or included with the petition?
The petition must state all the criteria for outpatient treatment; and the facts supporting the belief that the patient meets all the criteria. The petition has to be accompanied by an affirmation or affidavit of a physician who examined the patient.
How is the treatment plan developed?
A patient ordered into assisted outpatient treatment is required to follow a treatment plan approved by the court. The plan is determined through consultation between the patient, the mental health system, a physician and possibly others.
If the court finds that the patient meets the criteria but a treatment plan has not been developed, the court will order the director of community services to provide one to the court.
In developing a treatment plan, the physician will provide the patient; and a person selected by the patient with an opportunity to actively participate in its development.
The physician developing the treatment plan will state:
- 1. which categories of assisted outpatient treatment are recommended and the rationale for each;
- 2. facts which establish that such treatment is the least restrictive alternative; and,
- 3. if the proposed treatment plan includes medication, the types or classes recommended, physical and mental effects of such medication (both beneficial and detrimental), and whether such medication should be self-administered or administered by a professional.
The physician should specify the types and dosage ranges of medication most likely to provide “maximum benefit,” since the court will consider what will be to the patient’s maximum benefit when ordering treatment.
What kinds of decisions can the court make?
If after hearing all relevant evidence, the court finds that the patient does not meet the criteria for assisted outpatient treatment, the court will dismiss the petition.
If the court finds by clear and convincing evidence that the patient meets the criteria for court-ordered outpatient treatment and there is no appropriate, feasible, and less restrictive alternative, the court can order the patient to receive assisted outpatient treatment.
If the petitioner is the director of a hospital that operates an assisted outpatient treatment program, the court order will direct the hospital director to provide or arrange for all categories of treatment for the assisted outpatient throughout the period of the order.
For all other persons, the order will require the director of community services to make sure that all the categories of services in the treatment order are supplied to the patient. This is very important, because not only is the patient being ordered into treatment, the director of community services is being ordered to provide treatment.
How can the assisted outpatient treatment plan be changed?
The director of an assisted outpatient treatment program needs court approval to make any material change in a treatment order unless the change was contemplated in the original order. A material change is the addition or deletion of a category of assisted outpatient treatment or any deviation, without the patient’s consent, from an existing order relating to the administration of medicines. An assisted outpatient treatment program does not need court approval to institute non-material changes.
What if a patient fails to comply with an assisted outpatient treatment order?
If someone placed in assisted outpatient treatment fails or refuses to comply with the treatment order despite efforts made to solicit compliance, a physician may request that the patient be brought to a hospital if in his or her clinical judgment, the patient “may” meet a current “inpatient”commitment standard, i.e., “danger to self or others.”
A physician may consider if a patient refuses to take medications as required by the court order, or either refuses to take, or fails a blood test, urinalysis, or alcohol or drug test as required by the court order, when determining whether the patient is in need of an examination to determine whether he or she meets the standard for placement in inpatient care.
If he or she believes that a patient may meet the current inpatient commitment standard, the physician may request a director of an assisted outpatient treatment program or certain others empowered to direct peace officers, sheriff’s deputies, ambulance services, or approved mobile crisis outreach teams to transport such patients to hospitals.
At the hospital, the patient may be retained for observation, examination and treatment for up to seventy-two hours in order to determine whether treatment in a hospital pursuant to one of the existing inpatient commitment standards is needed. Thus, if the physician decides that a patient on assisted outpatient treatment is non-compliant and “may” meet the inpatient commitment criteria, the doctor can order that person hospitalized for up to 72 hours to see if they meet inpatient commitment procedures.
If at any time during this period the person is found not to meet the involuntary inpatient commitment criteria, he or she must be released unless kept on a voluntary basis. However, continued non-compliance can result in subsequent 72-hour evaluations.
What rights and protections do patients have?
A patient has the right to:
- free legal representation
- present evidence, call witnesses and cross-examine adverse witnesses;
- move the court to stay, vacate or modify the assisted outpatient treatment order at any time
- not be deemed legally incapacitated solely on the determination that he or she is in need of assisted outpatient treatment.
A petitioner, physician, or anyone else making a false statement or providing false information in a petition or hearing is subject to criminal prosecution.
Will the mental health system petition for me?
Assisted Outpatient Treatment (AOT) laws should allow families and others to petition the court to place someone in assisted outpatient treatment. But it is easier and less costly if the mental health system, rather than relatives, files the petition. However, mental health systems are notoriously reluctant to file petitions, so you must be persistent.