Thursday, August 22, 2013

Suggestions on how Kentucky can improve their AOT law

NAMI-Kentucky State Conference Louisville, KY

"The Untapped Power of AOT"

July 20, 2013

By: Brian Stettin, Policy Director
Treatment Advocacy Center 

The Consequences of Non-Adherence: Budgetary Impact
n Lawenforcement,incarceration,and hospitalization are enormously expensive.
n Patientscaughtintherevolvingdoor are stressing the CJ & MH systems beyond the breaking point. 

Constitutionality Upheld
“The restriction on a patient's freedom affected by a court order authorizing assisted outpatient treatment is minimal, inasmuch as the coercive force of the order lies solely in the compulsion generally felt by law-abiding citizens to comply with court directives.”
Matter of K.L., 1 N.Y.3d 362 (2004)

Linking Anosognosia and Non-Adherence
Psych. Services 2/06:
• Of300patientswithnon-adherence tracked, 32% found to lack insight.
• Those32%hadsignificantlylonger non-adherent episodes, more likely to completely cease meds, have severe symptoms, be hospitalized

Lessons from the Field
AOT works
Fears of negative consequences are unfounded
Court order matters
Length of AOT period impacts sustainability of gains
Patient engagement is critical

AOT Works:Harmful Behaviors
2005 NYS-OMH study compared 1st 6 mos. under AOT to 6 mos. prior:
55% fewer recipients engaged in suicide attempts or physical harm to self; 
49% fewer abused alcohol; 
48% fewer abused drugs; 
47% fewer physically harmed others; 
46% fewer damaged or destroyed property; and 
43% fewer threatened physical harm to others

AOT Works:Arrest and Hospitalization
2009 NY study results (Duke et. al.):
Likelihood of arrest over 1-month period cut in half (3.7% to 1.9%)
Likelihood of hospital admission over 6-month period cut in half (74% to 36%)
“Substantial reductions” in hosp days (most expensive form of treatment)
44% decrease in harmful behaviors

Fears of AOT are Unfounded
AOT recipients no more likely to feel coerced by mental health system
AOT recipients report no greater sense of stigma
Impact on quality of voluntary services was POSITIVE

The Court Order Matters
Comparison of AOT patients to AOT-eligible “voluntaries,” with equal quality of services, found:
“Highly statistically significant” difference in the likelihood of a hospital admission over six months (36% vs. 58%). 
AOT patients less likely to be arrested than “voluntaries” (1.9% per month vs. 2.8%) 
AOT patients had a substantially higher level of personal engagement in their treatment (55% “good” or “excellent” vs. 43 percent).

AOT in Kentucky??
Implied in the KY INPATIENT commitment standard:
• 202A.026: Invol hosp requires finding:
Mental illness
Danger (or threat thereof)
Can “reasonably benefit from tx”
Hospital is “least restrictive alternative mode of treatment presently available.”

AOT in KY: Limitation #1
AOT only available to person who meets the first 3 criteria for INPATIENT commitment, including current danger.
“substantial physical harm or threat of substantial physical harm upon self, family, or others[.]” § 202A.011(2)

AOT in KY: Still More Limitations! (§ 202A.081)
Tiny window of availability (“Following prelim hearing but prior to completion of final hearing”)
Super-short period of AOT     ...    (60 days, renewable 1x for 60 more)
No consequence for non-adherence

2013 HB78 (Burch) / SB33 (Denton)
“Following the prelim hearing but prior to the completion of the final hearing”
Increases max length of INITIAL AOT  (not renewal) from 60 to 180 days
Non-adherence “may result in invol hosp, provided the criteria set forth in this chapter are met.”
Providers “shall use evidence-based practices.”

A Better KY Bill in 2014?
Establish AOT eligibility criteria distinct from inpatient criteria, so person need not be presently dangerous.
Separate AOT and inpatient processes
1 year order period, always renewable
Non-adherence as presumptive grounds for need for evaluation

NAMI KY presented the 'Legislator of the Year Award' to Rep Tom Burch and Sen Julie Denton