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New York State Assisted Outpatient Treatment Evaluation: Review of Major Findings
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New York State Assisted Outpatient Treatment Evaluation: Review of Major Findings


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Marvin S. Swartz, M.D., currently serves as Interim Chair of the Department of Psychiatry and Behavioral Sciences at Duke University where he is also Professor and Head of the Division of Social and …

Marvin S. Swartz, M.D., currently serves as Interim Chair of the Department of Psychiatry and Behavioral Sciences at Duke University where he is also Professor and Head of the Division of Social and Community Psychiatry. Dr. Swartz's major research and clinical interests are in improving the care of severely mentally ill individuals. He is a Network Member in the MacArthur Foundation Research Network on Mandated Community Treatment examining use of legal tools to promote adherence to mental health treatment and leads the Duke team studying the use of Assisted Outpatient Treatment in New York. He also co-leads a North Carolina study examining the effectiveness of Psychiatric Advance Directives and co-leads the Duke team investigating the role of antipsychotic medications in treatment outcomes in schizophrenia as part of the landmark NIMH funded CATIE study. Dr. Swartz is also Director of the National Resource Center on Psychiatric Advance Directives.

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  • 1.  
  • 2. MEASUREMENT & DATA COLLECTION UNIT Policy Research Associates, Inc. H. Steadman, PhD; P. Robbins, K. Keator INTERNAL AOT EVALUATION ADVISORY GROUP MacArthur Research Network on Mandated Community Treatment J. Monahan, PhD (Dir); CONTRACT ORGANIZATION Dept. of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, NC M. Swartz, MD, Principal Investigator & J. Swanson, PhD, Co-Principal Investigator SUBCONTRACT ORGANIZATION Policy Research Associates, Inc., Delmar, NY H. Steadman, PhD, Co-Principal Investigator amd P. Robbins NYS OFFICE OF MENTAL HEALTH DATA ANALYSIS UNIT Dept. of Psychiatry & Behavioral Sciences, Duke University Medical Center M. Swartz, MD; J. Swanson, PhD, R. Van Dorn, PhD; Duke/PRA AOT Evaluation Organization Chart
  • 3. Report Outline
    • Description of AOT program and regional variations
    • Service engagement during AOT
    • Recipient outcomes
    • Recipient perceptions of AOT
    • Service engagement and outcomes after AOT ends
    • Impact of AOT on New York’s public mental health system
  • 4. Description of AOT Program and Regional Variations: Summary of Findings
    • New York’s AOT Program features more comprehensive implementation, infrastructure and oversight than any other comparable program in the U.S.
    • NY a critical test of how a comprehensively implemented program of assisted outpatient treatment can perform.
    • New York’s program design is unique, so these evaluation findings may not generalize to other states.
  • 5. Description of AOT Program and Regional Variations: Summary of Findings
    • AOT statute can be used to prevent relapse or deterioration before hospitalization is needed.
    • In nearly 3/4s of all cases used as a discharge planning tool for hospitalized patients.
    • AOT is largely used as a transition plan intended to improve the effectiveness of treatment following a hospitalization and as a method to reduce hospital recidivism.
  • 6. Description of AOT Program and Regional Variations: Summary of Findings
    • Considerable variability in how AOT is implemented across the State.
    • Difference between regions in use of enhanced voluntary service (EVS) agreements in lieu of a formal AOT court order.
    • In the New York City region: “AOT First” model.
    • In other counties: “Enhanced Voluntary Services First” model.
  • 7. Racial Bias in AOT Program? Summary of Findings
    • We find that the over-representation of African Americans in the AOT Program:
      • is a function of African Americans’ higher likelihood of being uninsured,
      • higher likelihood of being served by the public mental health system (rather than by private mental health professionals),
      • and higher likelihood of having a history of psychiatric hospitalization.
    • We find no evidence that the AOT Program is disproportionately selecting African Americans or other minorities for court orders.
  • 8. 2005 AOT order density compared to estimated total SMI population Dots represent distribution of AOT orders in 2005
  • 9.  
  • 10. Recipient Outcomes: Summary of Findings
    • During AOT:
    • Substantial reduction in psychiatric hospitalizations and in days in the hospital.
    • Modest evidence that AOT reduces the likelihood of being arrested.
    • Substantial increases in receipt of intensive case management services during AOT.
    • More likely to consistently receive psychotropic medications appropriate to their psychiatric conditions.
    • Subjective improvements in many areas of personal functioning.
  • 11.  
  • 12.  
  • 13.  
  • 14.  
  • 15. Recipient Perceptions of AOT: Summary of Findings
    • AOT recipients and non-AOT recipients have remarkably similar attitudes and treatment experiences.
    • AOT recipients feel neither more positive or more negative about their mental health treatment experiences than comparable individuals who are not under AOT.
    • Positive and negative attitudes about AOT are more strongly influenced by other experiences than AOT itself.
  • 16. Service Engagement and Outcomes after AOT Ends: Summary of Findings
    • Sustained improvement after AOT ends varies according to the length of time the recipient spends under the AOT order.
    • After 6 months, decreased rates of hospitalization and improved receipt of psychotropic medications are only sustained if recipients receive intensive services after AOT is discontinued.
    • After 12 months or longer, decreased rates of hospitalization and improved receipt of medications are sustained whether or not intensive services are continued after AOT is discontinued.
    • Improvements are more likely to be sustained if AOT continues at least12 months.
  • 17.  
  • 18.  
  • 19.  
  • 20. The Impact of AOT on New York’s Public Mental Health System: Summary of Findings
    • First several years of the AOT Program, between 1999-2003, preference for intensive case management services was given to AOT cases.
    • After 2003, new AOT orders leveled off in the state and then declined.
    • New treatment capacity then available to other individuals who needed these services, irrespective of AOT status.
    • After ramp-up of the AOT programs intensive community-based services increased for individuals on AOT and not on AOT alike.
    • New service capacity is now fully utilized, competition for services in the near future may intensify, with unknown relative effects on AOT and non-AOT recipients.
    • It is impossible to generalize these findings to states where services do not simultaneously increase.
  • 21.  
  • 22. Overall Summary of Findings (1)
    • We find that New York State’s AOT Program improves a range of important outcomes for its recipients.
    • 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.
    • It is also important to recognize that the AOT order exerts a critical effect on service providers stimulating their efforts to prioritize care for AOT recipients.
  • 23. Overall Summary of Findings (2)
    • Once AOT recipients leave the program, improvements are more likely sustained among those who continue to receive intensive treatment services or had longer periods of AOT—especially 6 months or longer.
    • Perceptions of the AOT Program, experiences of stigma, coercion and treatment satisfaction appear to be largely unaffected by participation in the program and are likely more strongly shaped by other experiences with mental illness and treatment.
    • In its early years the AOT Program did appear to reduce access to services for non-AOT recipients, but in recent years the reduction in new AOT cases has attenuated this effect.
    • Lack of continued growth of new service dollars will likely increase competition for access to services once again.
  • 24. Overall Summary of Findings (3)
    • Available data allow only a limited assessment of whether voluntary agreements are effective alternatives to initiating or continuing AOT.
    • There are relatively few voluntary agreements and they typically occur in counties that use the "EVS First" model.
    • However, we found some evidence that AOT recipients are at lower risk of arrest than their counterparts in enhanced voluntary services.
    • We also found evidence in the case manager data that receiving AOT combined with ACT services substantially lowers risk of hospitalization compared to receiving ACT alone.
  • 25. That’s all, folks!