Kendra's Law: Final Report on the Status of Assisted Outpatient Treatment
AOT Program Administration
Following the enactment of Kendra's Law in August of 1999, OMH AOT program staff developed and disseminated guidelines to counties to assure the appropriate implementation and operation of AOT statewide. In November of 1999, when the law became effective, local governments began to operationalize their AOT programs. OMH promulgated AOT program standards in 2002 and in 2004, providing further guidance to local AOT programs.
In counties other than in New York City, the county Mental Health Directors operate, direct and supervise their AOT programs, either directly or by designation to other local mental health officials. In New York City, the Clinical Director for the New York City Department of Health and Mental Hygiene oversees implementation of the City's AOT program, which is administered by designated teams of employees of the New York City Health and Hospitals Corporation. These local AOT programs accept and investigate reports of persons who may be in need of AOT, prepare and file petitions for AOT in local supreme or county courts, and prepare and/or approve proposed AOT treatment plans. In those instances where an AOT order is granted, the Director of the local AOT program is required to provide or arrange for all categories of assisted outpatient treatment included in the order.
Local AOT programs are responsible for the oversight and monitoring of service providers, including case management services and ACT team services. It is the case management or ACT team which directly monitors the recipient's level of compliance, as well as delivery of services by other providers pursuant to the order. The case manager or ACT Team routinely report to the local AOT Program Director with respect to each recipient's treatment status.
OMH is responsible for statewide oversight and monitoring of the AOT Program. The OMH Statewide Director of AOT, appointed by the Commissioner of OMH, is responsible for administering the program. Pursuant to section 7.17(f) of the Mental Hygiene Law, the Commissioner of OMH has also appointed OMH AOT Program Coordinators, who report to the Director of AOT, and who monitor and oversee operation of local AOT programs across New York State. The AOT Program Coordinators are located in each of the five OMH Field Offices in different geographic regions throughout the State, and work closely with the local AOT Program Directors in the counties in their respective region. The AOT Program Coordinators oversee and monitor the local AOT programs, provide information and support pertaining to the petition process, and support the local AOT programs in their efforts to provide or arrange for court-ordered services.
As part of its oversight and monitoring efforts, OMH has developed and implemented a system of Verification of Service Delivery. Each calendar quarter, 5% of all active AOT cases across the State are chosen randomly and a detailed review is conducted to verify that the local AOT Programs have fulfilled their service delivery obligations. For each case reviewed, OMH AOT Program Coordinators, or their staff, conduct verification visits to all service providers for the AOT service recipient, where they review medical charts and interview employees of the providers. In some instances, local AOT Program staff accompany the AOT Program Coordinator on verification visits creating even more effective coordination between service providers, and State and local AOT program officials.
Counties and stakeholder groups statewide have reported that the implementation of processes to provide AOT to individuals under court orders has resulted in beneficial structural changes to local mental health service delivery systems. New mechanisms for identifying, investigating, and assessing individuals, developed in order to fulfill the requirements of AOT, have enhanced accountability in local mental health service systems. AOT implementation has improved access to services for high need individuals, treatment plan development, discharge planning, and coordination of service planning. The implementation of AOT has also supported the development of more collaborative relationships between the mental health and court systems.
Enhanced Accountability and Improved Access to Services
AOT has been instrumental in increasing accountability at all system levels regarding delivery of services to high need individuals. Community awareness of AOT has resulted in increased outreach to individuals who had previously presented engagement challenges to mental health service providers. Local mental health systems began to identify the potential risk posed by not responding to individuals in need, and as a result, those systems improved their ability to respond more efficiently and effectively.
Improved Treatment Plan Development, Discharge Planning, and Coordination of Service Planning
Processes and structures developed for AOT have resulted in improvements to treatment plans that more appropriately match the needs of individuals who have had difficulties using mental health services in the past. AOT is designed to bring service providers and county administrators together in a collaborative attempt to most efficiently deliver appropriate services to these individuals. Case managers, ACT Team staff, other clinical service providers, county personnel and attorneys, recipient advocates, and family members are all among the participants in AOT related service planning.
Improved Collaboration between Mental Health and Court Systems
Implementation of AOT involved the development of a petition process with specific eligibility criteria designed to identify at-risk individuals, prompted novel legal issues, and required greater interaction between the court system and the community mental health services delivery system. As AOT processes have matured, professionals from the two systems have improved their working relationships, resulting in greater efficiencies, and ultimately, the conservation of judicial, clinical, and administrative resources.
In addition to these improvements, consultations with officials of local AOT programs have identified the following improvements in collaboration:
- There is now an organized process to prioritize and monitor individuals with the greatest need;
- Local AOT program staff and local service providers meet regularly regarding treatment of AOT recipients;
- AOT ensures greater access to services for individuals whom providers have previously been reluctant to serve;
- The AOT treatment plan serves as a comprehensive planning tool to ensure that all providers and the recipient are on the 'same page';
- Positive treatment outcomes have been noted;
- Decreases in the frequency and duration of hospitalizations, incarcerations, and alcohol and substance abuse have also been noted; and
- There is now increased collaboration between inpatient and community-based mental health providers.
Local directors of mental health services have reported progress in their implementation of Kendra's Law. Initially, many felt challenged to manage their obligations under the Law and were unsure how to proceed. With guidance and technical assistance from OMH, local governments have established systems to address the aspects of Kendra's Law for which they maintain primary responsibility.
Over time, many local mental health directors have implemented structural changes within their existing systems to accommodate their new role as Directors of AOT programs. These changes include the development of screening teams to evaluate and investigate referrals for AOT; the establishment of mechanisms for easy collaboration between case management and ACT services and the local AOT program's clinical personnel; and the development of service alternatives for individuals who were not appropriate candidates for AOT, but for whom it was felt that some more intensive intervention was required.
Figure 1 illustrates a hypothetical AOT case, from referral to investigation, assessment, service delivery, and monitoring.