AOT must be our highest quality service: recipe to make it blooming marvelous
25-Mar-2019 by Jeanne Nelson, NAMI El Dorado County
AOT must be our highest quality service priority: time to make it blooming marvelous!
When engineers face a quality problem, they tend to start with the final product and reverse engineer it to find the source of the problem. The premise is to develop standard work flows that include deep knowledge of each work element and measure quality at each step in the flow of work.
With AOT we can do the same! AOT can literally be the best defensive strategy for those living with schizophrenia, Bi-Polar 1 or other psychotic disorders. AOT has been available in El Dorado County for over a year. It is intended to prioritize the segment of the most seriously mentally ill population; the population that is typically the most ignored.
Breakdown, A Clinician’s Experience in a Broken System of Emergency Psychiatric, Nov 2018: provides some terrific solution ideas. Our affiliate has ordered several copies and will be donating some to the county library this week so they should be available for check-out within 3-4 weeks. A must read for community leaders working to improve services and supports for those with serious mental illness.
At the start of 2019 there was just 1 person in the EDC AOT Program (and yet we have over 7,200 seriously mentally ill in El Dorado County.). One family who applied for AOT on behalf of their 24-year old son living with untreated schizophrenia shared their profound disappointment in the current AOT program citing “it is a joke; they came and assessed him citing he is a fit for AOT then did just one follow-up; no treatment; no medication; no going before the court; and no additional service or support. He has literally been in psychosis for months, lost 40 pounds rapidly because he thinks his food is poisoned.”
This AOT program must quickly evolve to a program that is offered before our loved one’s brains deteriorate. It must also be organically provided to those being discharged from in-patient hospitals and to those transitioning out of jail with psychotic disorders.
Recipe for Success: When there is a history of psychosis reported by the family – provide AOT – obviously adhering to the AOT acceptance criteria. When in doubt – provide AOT; when in transition out of PHF or jail – provide AOT; when deemed not appropriate for in-patient psychiatric but family/caregivers have reported psychosis – provide AOT. Let’s err on the conservative side of saving brains and ultimately lives. The truth is that while most people with mental illness are not a danger to others those living with untreated psychotic disorders can become violent. AOT is a crucial component of treatment.
If a family/caregiver have called PERT or 911 for a psychiatric emergency and provided history of psychosis (typically using AB 1424 family history form), has shared history of incarcerations, and then the county deems that in-patient hospitalization is notappropriate then AOT must be built into the workflow. If we are not providing an AOT referral as a matter of a quality standard workflow – this must be viewed as a failure in process. Transition metrics must be established to measure the linkage to service(s) and the quality outcome of such linkages. Such AOT governance is essential to the quality of the program but more important is “the” solution for anosognosia that is so common in psychotic disorders.
AOT was passed in California in 2002. The law provides an avenue to treatment. However it is important to understand that CA’s AOT law does not allow “court-ordered medication/treatment.” However, court-ordered medication/treatment can be ordered by a judge as part of a criminal proceeding or Behavioral Health Court process.
AOT can be used as an alternative to involuntary hospitalization when deeply skilled AOT program resources are proactive and prompt to monitor and provide support. AOT does not increase cost for outpatient agencies as agencies already provide the outpatient treatment services. AOT is proven to save lives and money (by reducing arrests, in-patient hospitalizations, and homelessness.) This is why our county’s board of supervisor’s requested full implementation of AOT.
Implementation isn’t just hiring staff and establishing a form for referrals. It must include success metrics, communication and marketing plans, and a quality improvement plan. Failures thus far should be celebrated as opportunities to improve. Invite and welcome improvement ideas!
Counties who are picking and choosing easier cases over the complex challenging exceptionally tough cases of schizophrenia where perhaps there is minimal to no family support system in place are at risk. A civil liberties violation could be construed if selection bias to not welcome a seriously mentally ill individual into a program such as AOT.
- AOT does not violate civil liberties.
- AOT provides intense case management and supervision. How is this intense case management defined and measured?
- AOT mental health professionals work to persuade our loved ones to adhere to prescribed medication and attend their clinical outpatient treatment appointments.
- With AOT, admission to inpatient psychiatric are timelier in theory because the patient is already known to a case manager and outpatient providers.
- AOT can absolutely include court influence to help encourage treatment. How are we measuring court effectivity? What percentage of AOT cases include utilization of the court?
Family members whose loved ones are part of AOT report that the psychiatrists arrange for involuntary transfers to hospitals whenever their treatment plans, particularly medication orders, are not followed. Where is the metrics on this for our AOT program? Violating a judge’s court order usually leads to involuntary transfer to a hospital emergency department where inpatient admission is considered. This is the whole point of AOT and a current source of frustration that has been expressed repeatedly at our community’s monthly Behavioral Health Commission meetings.
AOT is a preventive program for those who do not promptly qualify for in-patient treatment. AOT should be used to lessen brain damage caused by psychosis and prevent danger. How can this be measured and communicated? To-date we have not observed the use of “court-ordered” treatment! This is a low hanging fruit opportunity.
- 18 years of age or older
• Diagnosed with a serious mental illness as defined by California law [how can we help guide families towards how to obtain a diagnosis as defined by CA law when a loved one has anosognosia and is unable to see the need for treatment? How can we more effectively promote PERT or ICM or mobile assessment of some sort?]
• Clinically assessed as being unlikely to survive safely in the community without supervision
• Have a history of failing to comply with treatment for his or her mental illness as demonstrated by at least one of the following: 1) The person’s mental illness has resulted in them being hospitalized or receiving services in a mental health unit of a state or local correctional facility at least twice in the past 36 months; or 2) The person’s mental illness has resulted in one or more serious or violent acts, threats or attempts to cause physical harm toward themselves or others within the past 48 months.
|El Dorado County AOT||San Mateo County AOT|
|EDC REFERRAL FORM states: Please note that the AOT Program does not have the authority to mandate medication or involuntary long-term hospitalization/conservatorship.
Please fax completed form to (530) 303-1526 or mail to: EDC HHSA, Behavioral Health, ATTN: Utilization Review, 768 Pleasant Valley Road, Suite 201, Diamond Springs, CA 95619 *INSUFFICIENT DETAILS MAY DELAY THE REFERRAL PROCESSVery unwelcoming form and isn’t championing the county’s passion to help.
|Wonderful descriptive inviting service: http://www.smchealth.org/sites/main/files/file-attachments/aotflyer.pdf
Contact the AOT Team at (650) 372-6125 or AOT@smcgov.org to make a referral.
Very welcoming webpage!
NOTE: an email address is provided and governed
WHAT IF WE ADDED A GRAPH TO THE MONTHLY REPORTING PROCESS SHOWING REFERRAL SOURCES? Probation, Family/Caregiver, PHF, PES, Outpatient mental health agencies, law enforcement supervisors, who else? Showing PHF AOT referrals is an essential measure of their performance. Adding law enforcement supervisor referrals demonstrates collaboration by law enforcement.
How has the availability of AOT been communicated to “outpatient mental health agencies” such as A Balanced Life or private Clinical Psychologists or Shingle Springs Health & Wellness, etc.?
What if we add a metric to this slide showing PES measures for AOT referrals? After all, those that are not hospitalized and have been given a crisis assessment are primary candidates for a prompt AOT referral.
Where are the 2017 monthly line comparisons? Any “Prior 12 month Period” graph will benefit from the prior year’s data side-by-side for trend analysis.
Measure, monitor, manage
AOT programs vastly improves the quality of life for recipients. But we must be passionately hunting for ways to improve our AOT program. What if the AOT case manager interviewed the family members that referred their loved one to assess perspective about the program and where the program can improve.
What if our AOT program modeled San Mateo County’s?
What if we leveraged San Mateo County’s language on their webpage describing AOT? NAMI facilitated getting the source files from San Mateo County’s 911 calling cards. Web pages: cut and paste.
How have we measured AOT’s impact on better compliance and cooperation with outpatient treatment, improved medication adherence and a reduction in in-patient hospitalizations or incarcerations?
NAMI El Dorado County is grateful that AOT has been piloted this past year in our community. We are passionate supporters of the medical model coupled with a recovery model in that order. Proper medication management is the cornerstone for those living with anosognosia and untreated psychosis It allows individuals to stabilize so that recovery treatments such as behavioral therapies can occur. Relapse in symptoms means medication adjustments – essential for psychotic disorders. For those in psychosis – the right antipsychotic medication in the right amount can prevent brain damage and preserve long-term cognition.
Not allowing weeks, months or years to pass without promptly working towards treatment adherence is our collective goal. Treating psychosis with the same promptness as a stroke is a healthy goal. Spring is on the way and our community’s AOT has the opportunity to bloom.