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Office of Mental Health

Kendra's Law: Final Report on the Status of Assisted Outpatient Treatment
Outcomes for Recipients during the First Six Months of AOT

Increased Participation in Case Management and Other Services
Increased Engagement in Services and Adherence to Prescribed Medication
Improved Community and Social Functioning
Reduced Incidence of Harmful Behaviors

Initial court orders for AOT recipients are usually six months long. The six month milestone is critical because it is at this juncture that decisions are made regarding renewal of the court order. Outcome findings presented in the next section focus on change between the onset of the court order and the status of recipients after six months. The results presented below are for AOT recipients for whom both baseline (onset of court order) and six-month follow-up assessments were available in the OMH evaluation database at the time of this report's preparation.

AOT was designed to ensure supervision and treatment for individuals who, without such supervision and treatment, would likely be unable to take responsibility for their own care and would be unable to live successfully in the community. For persons in AOT, the goals are to increase access to the highest intensity services and to better engage them in those services. An additional goal is to reduce the incidence of behaviors harmful to themselves or others. Participation in AOT should result in improved adherence to prescribed medication and decreased hospitalization, homelessness, arrests, and incarceration. In addition, AOT recipients should benefit through improved functioning in important community and personal activities.

Increased Participation in Case Management and Other Services

Table 5 compares participation in services by AOT recipients prior to and subsequent to the initial court order. For all categories of service, a greater percentage of individuals are participating in the service while under court order than were receiving it prior to the court order. A dramatic example is in the area of case management. As prescribed by the legislation, all individuals receiving a court order are enrolled in case management. However, prior to AOT, only 53% of these individuals were receiving this service.

In addition, the percentage of AOT recipients who are receiving substance abuse services increased by 67% as a result of their court-ordered treatment plan, increasing from 24% to 40%. Similarly, the percentage of persons in AOT who receive housing services as a result of their court-ordered treatment plan also increased from 19% to 31%. Substantial increases are also seen for urine or blood testing used to assess adherence to medication or substance abuse.

Table 5
Services Received by AOT Recipients
Participation Rates Prior to AOT and During AOT

Percentage of AOT Recipients

Service Prior to AOT At Six Months Percent Increase
Case Management 53% 100% 89%
Medication Management 60% 88% 47%
Individual or Group Therapy 51% 75% 47%
Day Programs 15% 22% 47%
Substance Abuse Services 24% 40% 67%
Housing or Housing Support Services 19% 31% 63%
Urine or Blood Toxicology
(adherence to medication)
18% 37% 106%
Urine or Blood Toxicology
(substance abuse)
17% 35% 106%

Increased Engagement in Services and Adherence to Prescribed Medication

Two important goals of AOT are increased engagement, i.e., active and regular participation in services; and increased adherence to prescribed medication, i.e., taking medications necessary to manage psychiatric symptoms as directed by the treating physician. To assess engagement, case managers were asked to rate the engagement of persons in AOT using a scale ranging from "not at all engaged in services" to "independently and appropriately uses services." Recipients were considered to have "good engagement" if they received a rating of either "good - able to partner and can use resources independently" or "excellent - independently and appropriately uses services." Data collected since the onset of AOT show the percent of individuals who exhibit good engagement in services increased significantly from 41% to 62% at six months.

To assess medication adherence, case managers were asked to rate adherence of persons in AOT using a scale ranging from "taking medication exactly as prescribed" to "rarely or never taking medication as prescribed." Recipients were considered to have "good adherence to medication" if they were rated as either "takes medication as prescribed most of the time" or "takes medication as prescribed." The resulting data show that the percent of individuals with good medication adherence increased significantly from 34% to 69% after six months. Figure 3 displays the improvement in engagement in services and adherence to medications after six months of AOT participation.

Figure 3

Changes in Service Engagement and Adherence to Medication - At Onset of Court Order vs. Six Months

Improved Community and Social Functioning

The evaluation database also documents changes in AOT recipients' day-to-day functioning. Measures that are used for this assessment are the Global Assessment of Functioning (GAF) and three sets of items that assess individuals' abilities in specific functional areas: self-care, social and community living skills, and task performance. The GAF is a commonly used measure of overall functioning. It includes social, occupational, academic, and other areas of personal performance and results in an overall numerical rating score which can range from 0 to 100. A score of 50 or below denotes serious impairment in social, occupational or school functioning. At the onset of an AOT court order, 39% of individuals had a GAF score below 50. After receiving services under an AOT court order for six months, the percentage of persons with a GAF score below 50 dropped to 33%.

AOT recipients' functioning in the area of self-care and community living also improved after six months of program participation. Table 6 displays the change in these measures. The table compares the percentage of persons in AOT who were reported as having difficulty at the onset of their court ordered treatment with the percentage reported as having difficulty six months later. For all items, there were fewer individuals rated as having difficulty, and in all measures the change was statistically significant. Although changes are relatively small in magnitude for any single measure, a consistent pattern of overall improvement (reduction in difficulties) is seen across all areas of self-care and community functioning.

Table 6
Improvements in Self Care and Community Living

Percent of AOT Recipients with Difficulties

  At Onset of AOT Court Order At Six Months Percent Reduction in Difficulties
Access community services 23% 16% 30%
Prepare meals 17% 12% 29%
Take care of own possessions 14% 10% 29%
Maintain adequate personal hygiene 7% 5% 29%
Follow through on health care advice 26% 19% 27%
Make and keep appointments 27% 20% 26%
Manage Medication 36% 27% 25%
Take care of own living space 16% 12% 25%
Maintain adequate diet 9% 7% 22%
Handle finances 29% 25% 14%
Avoid dangers 7% 6% 14%
Shop for food, etc. 16% 14% 13%
Access transportation 9% 8% 11%
Average Percent Reduction        23%

Among the items included on Table 6, some measures can be linked to the AOT program's goals of increasing adherence to medication and increasing engagement in services. In particular, the percent of AOT recipients who had difficulty managing medication decreased from 36% to 27% between the onset of the court order and six months. Similarly, the percent of recipients who had difficulty following through on health care advice and making and keeping appointments declined from 26% to 19% and 27% to 20% respectively.

Tables 7 and 8 display the changes during the initial six months of AOT in the areas of social, interpersonal and family functioning and task performance. On 15 of the 16 measures for these areas, the reduction in difficulties experienced by AOT recipients between the onset of the court order and at six months was statistically significant. For instance, the percent of recipients who had difficulty effectively handling conflict and managing assertiveness dropped from 50% to 36% and 44% to 33% respectively. Similar to the findings noted above for self care and community living, an overall pattern of reduced difficulties and therefore improved functioning characterizes the findings concerning social, interpersonal and family functioning, and task performance.

Table 7
Improvements in Social, Interpersonal, and Family Functioning

Percent of AOT Recipients with Difficulties

    At Onset of AOT Court Order At Six Months Percent Reduction in Difficulties
Ask for help when needed 28% 20% 29%
Effectively handle conflict 50% 36% 28%
Manage assertiveness 44% 33% 25%
Engage in social/family activities 34% 26% 24%
Communicate clearly 13% 10% 23%
Respond to social contact 20% 16% 20%
Maintain support network 40% 33% 18%
Manage leisure time 28% 24% 14%
Average Percent Reduction     22%

Table 8
Improvements in Task Performance

Percent of AOT Recipients with Difficulties

   At Onset of AOT Court Order At Six Months Percent Reduction in Difficulties
Understand and remember instructions 19% 14% 26%
Perform in coordination with or in proximity to others without being distracted by them 28% 21% 25%
Sustain an ordinary routine without special supervision 33% 25% 24%
Perform activities within a schedule, maintain regular attendance and be on time 33% 25% 24%
Maintain attention and concentration spans 25% 19% 24%
Complete tasks without assistance 28% 22% 21%
Perform at a consistent pace without unreasonable rest periods 27% 22% 19%
Complete tasks without errors 27% 22% 19%
Average Percent Reduction     23%

Reduced Incidence of Harmful Behaviors

Case managers also reported reductions in the incidence of harmful behaviors for AOT recipients at six months in AOT when compared with a comparable period of time prior to AOT. Table 9 shows significant declines in the incidence of behaviors harmful to self, behaviors harmful to others, and harmful behaviors directed at property. Similarly, substantial declines are also seen in alcohol and substance abuse.

Table 9
Reduced Incidence of Harmful Behaviors
Percent of Persons with One or More Events Reported in the Past 90 Days

Percent of AOT Recipients with Harmful Behaviors
   At Onset of AOT Court Order At Six Months Percent Reduction in Harmful Behaviors
Physically Harm Self/Made Suicide Attempt 9% 4% 55%
Abuse Alcohol 45% 23% 49%
Abuse Drugs 44% 23% 48%
Threaten Suicide 15% 8% 47%
Physically Harm Others 15% 8% 47%
Damage or Destroy Property 13% 7% 46%
Threaten Physical Harm 28% 16% 43%
Create Public Disturbances 24% 15% 38%
Verbally Assault Others 33% 21% 36%
Theft 7% 5% 29%
Average Percent Reduction     44%

In summary, during the first six months of court-ordered treatment, individuals in AOT showed a significant decline in the incidence of harmful behaviors.
The average percent decrease in harmful behaviors was 44%. In addition, over the same amount of time AOT recipients showed significant improvement in the areas of self care and community living, task performance, and social, family and interpersonal functioning. The average percent decrease in difficulties for all measures in these areas between the onset of the court order and six months was 23%, 23% and 22% respectively. These improvements are summarized in Figure 4.

Figure 4

Average Percent Reduction in Harmful Behaviors and Difficulties Across All Categories of Functioning

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