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Assisted Outpatient Treatment (AOT)

Statement of the PAIMI Advisory Council

Kentucky Protection and Advocacy (P&A) is a client-directed agency that protects and promotes the rights of persons with disabilities. The Protection and Advocacy for Individuals with Mental Illness (PAIMI) Advisory Council, required by federal law and consisting of persons with serious mental illness and their family members, reviewed Senate Bill 91, the 2017 proposed Assisted Outpatient Treatment (AOT) bill. The PAIMI Advisory Council states that the current statutes remain sufficient, emphasizing that AOT is a choice; that the bill, if passed, would have costs; and that an infrastructure of more voluntary community services and evidence-based practices is needed.

Proposed amendments to the current laws will:

Call the current community based outpatient treatment a “Patient Agreed Order” which lasts for 60 days
Require the person’s attorney to be present when the Patient Agreed Order is entered
Allow peer support specialists to be present
Require an outpatient provider agency (usually the Community Mental Health Center (CMHC)) to gather a multi-disciplinary team and create a proposed written treatment plan which includes the individual’s participation, a crisis plan and evidence-based practices
Allow the Court to incorporate the treatment plan into the Patient Agreed Order with the CMHC to monitor compliance with the plan
Result in involuntary hospitalization if the individual fails to comply with the Patient Agreed Order, but only if the individual meets KRS 202A.026 criteria (danger to self or others)
Allow the Court to order the 60-day Patient Agreed Order two additional times

Involuntary AOT has also been proposed. The major provisions of the bill will:

  • Allow anyone to file a Petition for Involuntary AOT of a person
  • Establish criteria for involuntary AOT which would require:
  • Two or more involuntary commitments in the previous 12 months (there were 2,300 people involuntarily committed two or more times in fiscal year 2016)
  • A serious mental illness diagnosis
  • Unlikely compliance with voluntary treatment
  • A need for AOT as the least restrictive treatment mode
  • Allow the Court if it finds probable cause to believe the individual meets criterion to order an examination and set a hearing within six days of the examination
  • Allow the Court to issue a summons and if the individual does not appear, order police to transport the person for the evaluation
  • Provide at the hearing that the individual be represented by counsel, be accompanied by a peer support specialist, and be able to present evidence, call witnesses and cross examine witnesses
  • Allow the Court to conduct the hearing without the person’s presence if the individual does not appear  
  • Allow the Court to order the individual to Involuntary AOT for up to 360 days with the Court incorporating the treatment plan as created by the CMHC
  • Require the treatment plan to include the individual’s participation, a crisis plan and evidence-based practices
  • Give an authorized staff physician the ability to order a 72-hour emergency admission for substantial non-compliance  
  • Allow the person to request the Court to stay, vacate, or modify the AOT Order
  • Allow the Court to order an additional 360-day AOT Order after the original order expires

The bill is not necessary

There is already the ability to provide for AOT.  Kentucky statues currently permit an individual to enter into an outpatient treatment order following a preliminary commitment hearing. The individual can choose outpatient treatment instead of going forward with the final hearing. After release on court-ordered outpatient treatment, the individual can be re-hospitalized.  The order is limited to 60 days but can be extended by agreement. Further, another statute, Convalescent Leave Status, permits a hospital to release a patient after commitment if continued medical supervision in the community would prevent the person from being a danger to himself or herself, or others. The hospital and outpatient provider must develop a plan for follow-up care.

The bill will cost money

According to Fiscal Note attached to last legislative session’s AOT bill that is similar to SB 91, there will be substantial costs in implementing AOT.  These costs include moneys for the Department of Public Advocacy, the Department for Behavioral Health (DBH), the Department for Medicaid Services (DMS), and the CMHCs.  Included in this equation is the issue of whether court-ordered treatment would automatically be covered by Medicaid and the Medicaid Managed Care Organizations (MCOs) which require a finding of medical necessity prior to authorization of treatment. 

There is insufficient infrastructure in place to provide AOT services

The current infrastructure is not sufficient to provide or pay for the services contemplated in the bill.  Services would be provided by DBH, DMS (often though the MCOs), and the CMHCs.  Kentucky is attempting to provide more intensive community-based services to individuals with serious mental illness due to the Amended Settlement Agreement between the Cabinet for Health and Family Services (CHFS) and P&A regarding persons living in personal care homes. The needs of those individuals are similar to those who could be subject to this legislation. The infrastructure is still being built and is not yet adequate or robust. More voluntary intensive community based services are the answer to assisting individuals with mental illness in their recovery, not the expansion of Assisted Outpatient Treatment (AOT) orders.

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