Enhancing Implementation of a Multi-System AOT Program to Support Positive Mental Health Outcomes for Individuals Living with Serious Mental Illness

Background: Assisted Outpatient Treatment (AOT) is a civil commitment program incorporating intensive case management and other services to support adults with a serious mental illness (SMI) experiencing difficulties with treatment adherence and sustained treatment engagement (Phelan et al., 2010; Stettin et al., 2019; 2022) The overarching goal of AOT programs is to minimize participants’ use of emergency psychiatric care, while increasing their consistent use of community-based care to reduce their potential for involvement with the legal system resulting from untreated mental health concerns. However, effectively coordinating multiple systems of care to best meet AOT client’s needs can be challenging, leading to challenges with implementation and sustainability. Often programs such as AOT involve collaboration among multiple public serving systems subsequently fail due to lack of coordination, poor communication, system and provider burden, and competing expectations among key stakeholders (Bonfine et al., 2020; Meldrum et al, 2016).

Primary research question: “Does the incorporation of multi-system liaisons practicing from a social work perspective improve program implementation and outcomes for AOT program participants?”

Methods: To better support high need clients with SMI, the [City masked for review] AOT program incorporated the use of multi-system liaisons, mostly trained as social workers, to coordinate referral, enrollment, liaison between systems, and ongoing service provision within the AOT program. These liaisons worked closely with behavioral health providers at the local public health authority along with local Probate Court Judges and their staff handling civil mental health commitment.

Comprehensive formative and summative evaluation of the [City] AOT Program was conducted by a multidisciplinary team of scholars from social work and engineering across the 4 years of program implementation using a modified Implementation Outcomes Framework (Proctor et al., 2011). Key outcomes assessed by this model were acceptability, appropriateness, adoption, costs, feasibility, fidelity, penetration and sustainability. The evaluation incorporated elements of the Lean Six Sigma methodology (Schroeder et al., 2008) supplemented by qualitative (focus groups, individual interviews) and quantitative (exception reporting, pre/post intervention standardized outcome measures) evaluation methods to assess program implementation and participant outcomes.

Results: Results indicate that incorporation of multi-system liaisons into the [City] AOT Program was associated with a reduction in provider burden related to hospital and court documentation requirements and more effective program implementation. Client outcomes associated with [City] AOT program participation (n = 175) included increased outpatient mental health treatment adherence, reduced use of emergency mental health care services, decreased experiences of homelessness and decreased involvement with law enforcement.

Conclusions/Implications: It is essential for jurisdictions seeking to launch an AOT program to identify which type of liaisons are needed to successfully implement the program and consider social workers these liaison roles. Program structure should be based on factors such as the AOT program size, current and ongoing program budget, an assessment of degree of integration between judicial and healthcare systems prior to AOT program installation, program location, state laws governing the civil commitment process, and the needs and preferences of key stakeholders in their jurisdiction.