Abstract
Assisted Outpatient Treatment (AOT) is a court-mandated program intended to engage adults with serious mental illness who have challenges with voluntary treatment adherence. AOT programs are designed to promote outpatient treatment participation, reduce emergency care, and decrease justice involvement. Research has found AOT programs to be effective in reducing hospitalizations and justice involvement. Yet, concerns have been raised, including limiting individual autonomy and self-determination and overrepresentation of individuals from BIPOC backgrounds. This article describes the evolution the AOT Houston Model. Through applying the social work lens, this innovative model builds on AOT strengths and addresses limitations. The Houston AOT Model has five goals guided by the core tenets of client empowerment and self-determination. This Model prioritizes six elements including housing, employment, access to public benefits, transportation, service continuity, and care coordination/communication. Implications for practice and policy are presented with strategies for successful implementation of comprehensive AOT programs in other jurisdictions.
Assisted Outpatient Treatment (AOT) Programs were originally developed in the 1980s to address the issue of treatment non-adherence in individuals experiencing serious mental illness (SMI) and concurrent justice system involvement. SMI is defined as any mental, behavioral, or emotional disorder that seriously impairs functioning across multiple domains and impacts one or more major life activities (Lamb & Weinberger, 2017). These intensive programs, which combine therapeutic interventions coupled with supervision from the court, were originally instituted to minimize the likelihood of those with unaddressed SMI engaging in violent behavior. As the years have passed, AOT programs have become more refined and have shifted their focus from societal protection to participant care. This article describes an innovative Houston AOT model that is designed to ensure treatment engagement, adherence, and social support and to facilitate improvements in participants’ overall quality of life. Implications for social work practice and policy are presented along with strategies for successful implementation of comprehensive AOT programs in other jurisdictions.
Background and Initial Development of AOT Programs
Assisted Outpatient Treatment (AOT), also referred to as outpatient civil commitment, is a court-mandated program designed to motivate adults with SMI who have challenges with voluntary treatment engagement. AOT programs are designed to focus the attention of treatment providers and those they serve on the importance of keeping participants engaged in ongoing and effective treatment (Treatment Advocacy Center, n.d.).
AOT programs are designed to reduce repeated emergency psychiatric care usage and decrease justice system involvement resulting from untreated mental illness while promoting treatment engagement and long-term recovery for those with SMI and/or substance use disorders (SUDs). Seabury and colleagues (2019) estimate the lifetime burden of SMI as $1.85 million per patient, representing a significant financial cost to the larger community, especially if emergency healthcare or justice system-based services are used instead of routine outpatient care.
AOT programs were first developed in the U.S. in the 1980s after the closing of many state and county-funded residential mental health treatment facilities (Hiday, 2003). The goals of these programs were to 1) increase outpatient treatment adherence for those with SMI, 2) reduce emergency mental health service utilization (hospitalizations), and 3) reduce interaction with the criminal justice system. Individuals with untreated SMI who have become engaged with the legal system may be mandated to participate in AOT programs where they typically receive intensive outpatient mental health and substance use treatment services, including counseling and medication management. These programs are typically administered by a state or county-based public mental health system in coordination with a local civil court system.
The inception of Kendra's Law in 1999 changed how AOT programs were conceptualized and implemented. The State of New York enacted Kendra's Law (1999/2006) following the murder of Kendra Webdale by a man with untreated SMI. As a result of this incident, civil commitment shifted from being a mental health program designed to increase ongoing treatment engagement for those experiencing SMI to a robust public safety program. Unlike prior civil commitment programs, Kendra's Law required expansion of AOT services to include intensive case management to better meet the psychosocial needs of participants, such as housing, transportation, employment, and education, that may serve as barriers to ongoing treatment adherence (Cornwell & Deeney, 2003; Swartz et al., 2009; Torrey & Zdanowicz, 2001). Similar laws, such as California’s AB 1421 also known as “Laura's Law” in (2002), were subsequently passed in response to violent deaths by individuals with untreated SMI (Swartz et al., 2009; Worthington, 2009).
Over the years, there have been a handful of AOT programs nationally, mostly located in major urban areas. However, funding for access to AOT programs was further expanded under the Protecting Access to Medicare Act (PAMA) (2014), and in 2016, the Substance Abuse and Mental Health Services Administration (SAMHSA) announced a four-year, $13 million pilot program to implement and evaluate AOT programs nationwide (SAMHSA, 2020). During the same year, the 21st Century Cures Act (2016) provided increased grant funding to strengthen state and county AOT programs.
Currently, 47 states have implemented some form of an AOT program (Swartz et al., 2009), with 45 states and the District of Columbia having civil commitment laws regarding how AOT programs should operate. Research on AOT programs has consistently found AOT programs to be effective in reducing repeated hospitalizations and decreasing criminal justice involvement (Schneeberger et al., 2017; Starks et al., 2022; Wagner et al., 2003). Studies have also shown that the availability of multiple services within an AOT program (such as housing assistance, employment, and educational assistance in addition to traditional behavioral health treatment) is significantly more influential on positive outcomes than any singular intervention on its own (Schneeberger et al., 2017). Thus, more and more jurisdictions have implemented AOT programs during the past ten years.
Defining What Constitutes an AOT Program
The majority of AOT programs may receive support from multiple funding sources, including state, county, and local funds, which are built in as a “line item” in recurring budgets. Others are funded through grant programs administered by federal entities such as SAMHSA. Current AOT programs funded through SAMSHA are required to implement nine essential elements designed to provide ongoing support and service linkage to participants (SAMHSA, 2020). These nine essential elements are:
Identification of non-adherent individuals in need of treatment for SMI who also meet AOT criteria for that state; Instead of the community acting, the mental health system gathers all evidence to petition the court for AOT programming; Due process of rights is safeguarded throughout all AOT proceedings; Clear communication between court and mental health teams to ensure the court has all clinical information needed to guide decision making; Evidence-based treatment provided with emphasis on therapeutic engagement and ongoing stability to safely re-enter the community; Routine treatment evaluation to ensure adequacy of care and to guide needed adaptations in the participant's treatment plan; Specific protocols employed for non-engaged consumers; Routine evaluation at end of commitment period to determine next steps (e.g., continuation of AOT commitment or transition to voluntary care); and Continued care coordination after transitioning out of the AOT program to maintain stability and safety.
Concerns and Controversies Related to AOT
AOT programs have frequently been criticized for having a racialized component, as historically, the majority of AOT participants have been Black, Indigenous, and other People of Color (BIPOC). Accordingly, some critics assert that AOT programs are a form of social control on the lives and choices of BIPOC individuals (Swanson et al., 2009). For example, a New York study examining racial disparities among AOT participants found that African Americans experiencing SMI were disproportionately referred to AOT services relative to White individuals with SMI. These results indicate racial disparities in SMI diagnosis as well as an increased likelihood of being referred for civil commitment.
In addition to issues of racial bias, concerns about limiting individual autonomy and self-determination within the healthcare and judicial systems are present among opponents of AOT programs. Vocal critics of civil commitment in general, and AOT programs specifically, characterize these programs as efforts to socially control individuals with SMI and further stigmatize them as violent or dangerous (Munetz et al., 2019; Swanson et al., 2009; Worthington, 2009). These critics frame AOT programs as coercive, limiting individual self-determination and promoting societal control through social policy. In a study evaluating perceptions of coercion of individuals participating in a civil commitment program in North Carolina, researchers found that individuals with more severe symptom acuity, African Americans, and individuals with co-occurring mental health and SUDs were more likely to feel coerced (Swartz et al., 2002). In addition, certain aspects of the program itself, such a case managers’ reminders of consequences for not adhering to the program were interpreted as coercive (Swartz et al., 2002), as AOT program participation is often framed as an alternative to incarceration. However, literature on the effectiveness of AOT programs considers the necessity of such programs for reducing recidivism and hospitalizations to outweigh the concerns of diminished civil liberties (Munetz et al., 2014).
Although the majority of prior research has found AOT programs to be effective (Schneeberger et al., 2017; Starks et al., 2022; Wagner et al., 2003), other research has highlighted concerns with AOT programs regarding issues of limited standardization across state and county-run programs, low fidelity in intervention delivery, inadequate resources to support full implementation, lack of enforcement for non-adherent participants, difficulty with inter-agency and cross-system collaboration, and providers’ reluctance to participate in such programs (Cripps & Swartz, 2018; Meldrum et al., 2016).
Evolution of a New AOT Model Addressing Prior Concerns: The Houston AOT Model
Given the limitations and concerns about the impact of AOT programs related to participants’ self-determination and choice, the Houston AOT Model's primary objective was to shift the focus of AOT programs from the application of a criminal justice lens focusing on public safety, to a social work lens focused on addressing the unique needs of an individual participant within his/her own social and environmental context. This requires a shift from considering AOT participants as justice-involved individuals who present a risk to society due to their treatment non-adherence to viewing them as individuals who simply have a number of unmet psychosocial needs, one of them being unaddressed mental health and/or substance use concerns. This social work focus draws from a person-in-environment perspective (Hutchison, 2018), which is then applied to meet the needs of an individual within their various complex systems.
Viewing AOT participants through a person-centered social work lens also supports key tenets of the mental health recovery model, empowering participants to be active co-creators of their treatment plans so they may become productive members of their communities. By applying this framework, the vision for the Houston AOT Model was contingent upon building a coalition of key stakeholders involved in the civil commitment process. These stakeholders included those experiencing SMI, first responders, behavioral healthcare providers, and the court system, thereby expanding existing collaborations to develop an AOT program that emphasizes an iterative partnership between the consumers and the systems rather than a unidirectional mandate. This partnership empowers the consumers to address their mental health and substance use needs more consistently by encouraging participants to be actively involved in all aspects of their treatment-related decision-making while participating in the program and beyond. Individualized treatment planning is guided by participants to best meet both their current needs and their long-term recovery goals. Participant input regarding all aspects of care is considered essential to program success and thus is elicited during all phases of the engagement and treatment process. To provide an individualized treatment experience that incorporates the participant's needs and preferences, every participant can decline one or more services. However, if a service is declined, education is provided on how these services may be useful to improve participants’ overall quality of life and meet their future recovery goals.
Through applying the social work lens, the goals of the Houston AOT Model were to 1) increase existing collaborations between public behavioral health entities and the probate/civil court system to support the development and implementation of a sustainable, evidence-based AOT program, 2) identify appropriate consumers experiencing untreated SMI to refer to the AOT program, 3) meet the individual psychiatric, social, and medical needs of each participant in the AOT program, 4) address existing concerns about prior AOT programs, and 5) evaluate the Houston AOT Model to ensure its congruence with program consumers’ needs and state law through both formative and summative evaluation components, along with continual program improvement and quality assurance efforts. Guided by the core tenets of consumer empowerment and self-determination, the Houston AOT Model prioritizes the following six elements:
Housing Incorporating housing into AOT programming is seen as an essential component for stabilization, engagement, and maintenance in treatment, as well as for future goal acquisition. The vast majority of currently implemented AOT programs do not include services to address the needs of those who are unstably housed. Through the incorporation of funding, the Houston AOT Model implemented elements of a ‘housing first’ approach to mental health treatment to ensure all program participants had access to safe and affordable housing as a part of program participation (Robbins et al., 2006; Starks et al., 2022). The housing first model asserts that it is not necessary for participants to have adequately addressed their mental health and/or substance use needs prior to providing them with housing assistance. In the Houston AOT Model, participants are often housed in personal care homes, which serve individuals with mental and/or physical healthcare concerns, and housing is available for participants for up to 12 months. Employment Participants in the Houston AOT Model with employment goals are referred to an employment specialist to provide support with employment-related activities such as resume creation and interviewing skills. These employment services are tailored to the individual, and participants are encouraged to explore multiple employment options based on their unique skill sets and challenges related to their mental health. For example, a participant who functions well in environments with lower levels of stimulation may be referred for employment at a library as opposed to a more stimulating environment such as a restaurant. Access to Public Benefits In the Houston AOT Model, all participants meet with their case managers to review which types of public benefits they may be entitled. These benefits may include food assistance in the form of Supplemental Nutrition Assistance Program (SNAP) benefits, a review and application for supplemental security income (SSI) for permanent disability related to their SMI, long-term housing vouchers, (Section 8), clothing vouchers, transportation assistance such as passes for public transportation, and other material resources. Transportation As transportation can often become a barrier to treatment, especially in cities such as Houston where public transportation options are limited and often do not extend to suburban areas of the metroplex where most of the mental health services are located, the Houston AOT Model provides enhanced transportation services. These include transportation vans that provide transportation from the participant's home to any healthcare or social services appointment. Additional means of addressing transportation issues implemented through the Houston AOT Model are the provision of ‘in-home’ services, expanded use of telehealth for medical and behavioral healthcare appointments, and holding ‘virtual’ court status hearings instead of requiring participants to attend hearings in person. Service Continuity In the Houston AOT Model, participants can choose to remain engaged with a higher level of services longer than court-mandated to ensure successful transition to routine outpatient care. To facilitate this transition, the Houston AOT Model offers a step-down option for participants to engage in Assertive Community Treatment (ACT) when they are ready to transition out of AOT, but they are not ready to engage in less intensive traditional outpatient services. Care Coordination and Communication The Houston AOT Model has an interdisciplinary and collaborative team of providers who actively promote connections between the core stakeholders. There is consistent and routine communication among team members where successes are shared and barriers are addressed in order to support problem-solving and reduce service provision siloing. A variety of service provider partners are essential to a successful AOT program. The role of each of these partners and how they work together to support favorable participant outcomes is provided in the following section.
Care Coordination Team
Each participant in the Houston AOT Model is assigned a care coordinator who forms a partnership with the participant and is involved in all aspects of their care. The care coordinator ensures that the participant has all necessities (such as toiletries, food, and clothing) and provides transportation and support during the participant's psychiatric and medical appointments. If requested by the participant, the care coordinator sits in on the participant's appointments to provide support, advocate for them, and support post appointment follow up. The care coordinator delivers psychiatric medications to the participants as directed by the psychiatrist and monitors medication adherence. The care coordinator meets with the participant at least weekly (usually more frequently) at their residence to address other aspects of the participant's treatment plan goals, such as obtaining identification, applying for food or other governmental assistance, and addressing all other individualized needs expressed by the participant. Whenever possible, a participant will have the same care coordinator for the duration of their participation in the AOT program.
Psychiatrists
In the Houston AOT Model, the majority of prospective participants are identified and referred by psychiatrists while under their care during an acute psychiatric hospitalization. Inpatient psychiatrists in conjunction with the AOT program's hospital liaison determine if AOT services may be appropriate and beneficial for a client and if AOT participation is the best approach to support them in their recovery. Inpatient psychiatrists are responsible for diagnosing the individual and beginning the process of reducing their psychiatric symptoms through medication management and other services provided in the hospital. These psychiatrists frequently communicate with the AOT program's psychiatry team about the client's progress while hospitalized to facilitate a smooth transition to outpatient care.
For ongoing support and treatment, the Houston AOT Model assigns an outpatient psychiatrist to each participant that transitions back into the community. Outpatient psychiatrists work to form a partnership with the participant, keeping them involved in all aspects of their care, and work to support self-determination and client choice regarding their treatment and ongoing medication management. Outpatient psychiatrists will also be clarifying diagnoses to better tailor a treatment plan. By confirming or identifying the most accurate diagnoses psychiatrists and the AOT team are able to deliver more appropriate therapies as well as reducing medication and/or side effect burden on participants. This has the added benefit of strengthening participant trust and alliance with psychiatrists and the AOT as a whole. In addition, the outpatient psychiatrist supports the care coordination team through frequent, often multiple times per week, team meetings to discuss participant goals, progress, and barriers to treatment. This ensures a collaborative, shared focus and approach from all members of the treatment team. The relationship between the participant and outpatient psychiatrist is designed to be long-term and will often continue long after an individual's involvement with the AOT program has ended.
Hospital Liaison
The hospital liaison is another crucial role that has increased communication and continuity of care in the Houston AOT Model. This position is housed at the inpatient psychiatric hospital, and it serves as a liaison between the inpatient and the outpatient AOT treatment teams. The hospital liaison is responsible for screening and evaluating all referrals for the program and communicating with the inpatient treatment team regarding the history and current presentation at the time of the referral. The hospital liaison supports the inpatient treatment team in completing and filing documentation required by the court for the initial commitment to the program. This individual is also responsible for encouraging awareness of the program and educating hospital staff and potential referral sources about the program, as well as providing an overview of the program to potential participants. Finally, the hospital liaison ensures a smooth transition from residential to outpatient care for new and current participants by working with the AOT treatment team to make all arrangements for housing, transportation, and aftercare following discharge from inpatient services. This process helps create a more seamless experience for participants as they transition from one level of care to another.
Court Liaison
To ensure cross-system care coordination in the Houston AOT Model, a liaison works with the court, local county psychiatric hospital, and outpatient care team. This court liaison accepts and processes all court documents required for program participation and coordinates all the necessary paperwork and other communications from the AOT treatment team and attorneys regarding the needs of participants. In addition, the court liaison provides education to and supports potential referring doctors on the AOT program, procedures, timelines, and required paperwork.
Another aspect of the Houston AOT Model considered essential to its success is the development of effective court status hearing procedures for participants with support from the AOT treatment team. These status hearings allow participants and the civil court judge to discuss the participant's current needs, progress toward their goals, and any barriers to treatment as well as work in conjunction with the participant and treatment team to address these barriers. The supportive nature of these hearings encourages participants’ participation, but it also allows for guidance from the court when a participant's behaviors do not support their safety or wellbeing. In addition to the reduced transportation burden, holding status hearings virtually has increased participation of participants in these hearings. Remote participation has also been beneficial in allowing the judge to get a better idea of the living conditions and other factors impacting treatment that would not be as readily observable if the participant was required to physically appear in court.
Peer Support Specialist/Peer Educator
The role of peer support specialist/peer educator in the Houston AOT Model provides participants with support from those who have lived experience with SMI, who are able to provide an insider perspective and other resources to support participants’ individualized recovery process. These individuals work to educate participants about their diagnosis(es) by providing materials to promote health literacy and/or sharing their own experiences of recovery. Peer support services decrease isolation, reduce stigma about mental health and substance use disorders and help to problem-solve other barriers often experienced by those in need of ongoing mental health treatment. Peer support specialists also facilitate 12-step based peer support meetings and lead skill-building groups related to emotional regulation and positive interaction with one's social environment.
Advisory Committee
In the Houston AOT Model, a meeting of an advisory committee of key internal stakeholders is held quarterly to assist with continual quality improvement efforts. This committee is comprised of clinicians and representatives from the public psychiatric hospital, court system, outpatient mental health services organization, and evaluation team, as well as former AOT program participants, and other community representatives. During these meetings, the advisory committee receives information concerning program performance, service gaps, and other program needs and provides feedback to address the issues discussed. Recommendations and feedback on the program provided by current and former AOT participants (e.g., collected through satisfaction surveys, participant reports to the court, and participant focus groups), in additional to feedback and suggestions from the AOT treatment team, are discussed during advisory committee meetings in order to guide and inform ongoing program improvement.
Evaluation Team
The Houston AOT Model has further support from an external independent university-based evaluation team to review and improve procedures and outcomes. The evaluation team provides ongoing feedback to stakeholders on program-related processes, including identification, recruitment, enrollment, and barrier identification. This team also conducts ongoing data collection on and evaluation of provider and participant burden, satisfaction, and program attrition, and examines potential racial and/or diagnostic disproportionality among AOT participants. In addition, the evaluation team has developed a fidelity guide to ensure consistent implementation across all service providers. Fidelity is essential for the appropriate delivery of evidence-based treatment (Gearing et al., 2011), and ensures that all clients receive quality care. The results of the evaluation process, which includes both an evaluation of standardized outcome measures in the electronic health record and data collected from satisfaction surveys and focus groups, is presented to The Harris Center for Mental Health and IDD leadership and the funder (SAMHSA) annually as a comprehensive evaluation report.
Success of the Houston AOT Model
In the three years since its inception in August 2020 thought July 2023, the Houston AOT Model has served 92 past and 41 current participants. The program has graduated 37 participants, and other participants have successfully transitioned into alternative programs for ongoing mental health treatment, such as ACT, Recovery Oriented Treatment Program (ROTP), IDD focused services, assisted living facilities, and residential substance treatment programs. Participants have also been observed to achieve their individual treatment goals, such as obtaining employment, sustaining abstinence from substance use, obtaining social security benefits or long-term housing, and other similar achievements. For example, 22 program participants have obtained employment. Another 14 participants have been approved for long-term benefits through social security (SSI or SSDI), and the AOT treatment team has supported an additional four participants in reinstating previously terminated benefits. A total of 78 participants engaged in at least one session of individual therapy (most attending multiple sessions), and 34 engaged in ongoing work with a Licensed Chemical Dependency Counselor to address substance use needs. One hundred past and current participants engaged in peer support services, nine participated in peer-based support groups, with another five participants receiving assistance in attending regular 12 step support meetings. Moreover, 88 program participants have received housing assistance to increase treatment stabilization and prevent experiences of homelessness. Additionally, 32 participants had zero re-hospitalizations since participating in the program, with 13 participants having only one re-hospitalization during their time in the program, potentially saving millions in healthcare costs.
Adapting and Implementing AOT in Your Community: Recommendations
When considering the adoption of an AOT program in one's community, one must first identify areas of communication, siloing, and disintegration of services that may prevent the development and implementation of such a program with a social work focus. One way to identify these challenges is to look at prior successes and areas of ongoing opportunity in relation to continuity in service provision and integrated multidisciplinary care. For example, identifying service provision siloing would be a first step to improving communication and reducing barriers within the AOT program that decrease fidelity and inter-agency collaboration. Shifting the focus to a participant-centered approach allows for the intersectionality of multiple issues related to the individual's care to surface. For example, the peer educator and the care coordinator are first-line sources to identify barriers and gaps in service needs.
Addressing Concerns Levied About Past AOT Programs
For many individuals with SMI, mental health services are not adequate, available, or suitable. Furthermore, individuals with SMI may not find traditional services to be sufficiently engaging or fully support their needs. Using a social work lens, the Houston AOT Model sought to build upon the established programmatic strengths and address known limitations specifically related to low fidelity, lack of enforcement for non-compliant participants, racial disproportionality, difficulty with inter-agency and cross-system collaboration, and limiting individual autonomy and self-determination.
To strengthen low-fidelity service delivery and standardize program processes, the Houston AOT Model integrated care coordinators, a hospital liaison, a court liaison, and an advisory committee to ensure a solid partnership and engagement for the participant across the entire program. The inclusion of an active court liaison and incorporating virtual court status hearings has enabled the Houston AOT Model to reduce barriers of location and travel thereby addressing issues related to the lack of enforcement for non-compliance. The Houston AOT Model has focused on inter-agency and cross system collaboration through the use of the advisory committee and the evaluation team. Thus, collaboration is assessed to enhance the program and limit barriers, as well as providing accountability with team members and stakeholders. Across each step in the Houston AOT Model the participant is a partner and their needs and approach to addressing their needs is incorporated through personalized treatment. Care providers and partners actively seek out and prioritize participant autonomy and self-determination in the development and any ongoing adjustment of their treatment plans.
In addition, during Year 1, the evaluation team explored the potential overrepresentation of African American participants in the AOT program. AOT participation rates were compared to rates of outpatient and emergency psychiatric services usage, and no differences were found between the AOT participation rates and rates of other types of service usage for any cultural group. This analysis was conducted to raise awareness of this important issue across stakeholders not only at the program's inception but also during subsequent years of the program in the hopes of decreasing existing race based mental health disparities.
Lessons Learned from the Implementation of the Houston AOT Model
The following lessons were learned from the work done during the first 3 years of the Houston AOT Model, which may be helpful for other jurisdictions considering implementing this type of programming.
Importance of self-determination, advocacy, and a participant-centered approach. Importance of leadership buy-in at all levels and across all systems. Importance of identifying program members focused on collaboration, trust, supportive supervision, and teamwork. Using a person-in-environment perspective to assess a participant's needs to provide a more holistic intervention. Importance of ongoing communication and collaboration between the healthcare system and the court system. Engaging all key stakeholders in the initial conceptualization and installation of the project, as well as in its ongoing implementation. Ability to pivot when necessary to improve cross system collaboration and participant outcomes. Importance of incorporating well developed, evidence-based substance use treatment services. Securing adequate funding and resources to support positive long-term outcomes for the program and for its participants to ensure long-term program success and sustainability. Need for multilingual service providers to address the needs of the local community. Autonomy for participants’ engagement and ongoing participation. Importance of requesting and incorporating the feedback of current and former participants in the ongoing process of program improvement.
Future Research
There are a number of opportunities for further research regarding the development, installation, implementation of AOT programs, in addition to research regarding program outcomes. Future research may benefit from focusing on standardizing methods to measure various aspects of AOT programs including ongoing progress and future sustainability. Development of a structured protocol for assessing and evaluating AOT programs, which includes a fidelity management tool is recommended. Additionally, there may be a need for quantifying the work of each liaison, psychiatrist, and care coordinator so that case load can be appropriately measured and scaled depending on the jurisdiction implementing the AOT program. Future researchers may also wish to conduct a comprehensive evaluation of potential overrepresentation of participants with certain diagnoses (such as schizophrenia spectrum disorders) or those from various racial/ethnic backgrounds. Also, future researchers/evaluators may wish to consider conducting a cost benefit analysis to supplement other evaluation activities to provide funders with the potential savings to the healthcare and justice systems resulting from effective implementation of an AOT program. The evolution of AOT programs offers the opportunity to address existing concerns while maximizing treatment benefits for individuals who have not responded to traditional mental healthcare.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Substance Abuse and Mental Health Services Administration, (grant number SM-20-006).
