Assisted Outpatient Treatment in Los Angeles County: Implications for National Services
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Assisted Outpatient Treatment
in Los Angeles County:
Implications for Involuntary
Outpatient Services Nationally
24
TH
NIMH MENTAL HEALTH SERVICES RESEARCH CONFERENCE
CHAIR: ERIN KELLY, PH.D.
PRESENTERS: SARAH STARKS, PH.D. AND RYAN DOUGHERTY, MSW
AUGUST 1, 2018
CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
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Symposium Overview
Introduction to Assisted Outpatient Treatment (AOT)
◦
Nationally
◦
Los Angeles County AOT-LA program
AOT outreach: family involvement, barriers, and strategies
Who engages in Assisted Outpatient Treatment?
◦
Comparisons of voluntary vs. involuntary enrollment in services
Violence and victimization for participants, family members
and providers in Assisted Outpatient Treatment
CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Introduction to
Assisted Outpatient
Treatment
PRESENTING AUTHOR: ERIN KELLY
CO-AUTHORS: RYAN DOUGHERTY, MARCIA MELDRUM,
SARAH STARKS, ENRICO G. CASTILLO, CHARLOTTE NEARY-
BREMER, RONALD CALDERON, RACHEL OHMAN, PHILIPPE
BOURGOIS, & JOEL T. BRASLOW
CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
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Mental Health and Violence (1)
Inadequate access and poor adherence to mental health care receives
attention whenever high profile violent tragedies involving individuals
with or without mental health challenges occur
Typical responses:
◦
State policies supporting involuntary mental health treatment
◦
Federal mental health funding
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Mental Health and Violence (2)
Review of 5 major studies of adults with mental illnesses:
◦
23.9% of adults with mental illness reported perpetrating at least one incident of
community violence in 6 months prior
◦
30.9% reported being the victim of at least one violent act in the 6 months prior
◦
Studies: Facilitated Psychiatric Advance Directive (F-PAD) Study; MacArthur Mental
Disorder and Violence Risk (MacRisk) Study; Schizophrenia Care and Assessment
Program; MacArthur Mandated Community Treatment (MacMandate) Study;
Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Study
62.9% adults with SMI received mental health services in the past year (NAMI)
There are high levels of psychiatric treatment refusal among those with SMI.
◦
55% of those who did not participate in treatment in the prior year said it was
because they did not believe that they have an illness (National Comorbidity Survey)
◦
25-78% of patients with psychosis fail to adhere to psychiatric treatment programs
◦
Median non-refusal rate is 40% among those with bipolar disorders.
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Assisted Outpatient Treatment
Forty-six states have legally mandated the policy of Assisted
Outpatient Treatment (AOT)--also sometimes referred to as
involuntary outpatient commitment—in response.
Known by many names:
◦
Mandated Community Treatment
◦
Involuntary Outpatient treatment
◦
Community Treatment Order
◦
Kendra’s Law – New York -1999
◦
Laura’s Law – California -2002
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AOT Criteria
Be eighteen years of age or older
Be suffering from a mental illness
Be unlikely to survive safely in the community without supervision, based on a clinical determination
Have a history of non-compliance with treatment that has either:
◦
Been a significant factor in his or her being in a hospital, prison or jail at least twice within the last 36 months; or
◦
Resulted in one or more acts, attempts or threats of serious violent behavior toward self or others within the last 48 months
Have been offered an opportunity to voluntarily participate in a treatment plan by the local mental health
department but continue to fail to engage in treatment
Be substantially deteriorating
Be, in view of their treatment history and current behavior, in need of assisted outpatient treatment in order to
prevent a relapse or deterioration that would likely result in them meeting California's inpatient commitment
standard, which is being:
◦
A serious risk of harm to himself or herself or others; or
◦
Gravely disabled (in immediate physical danger due to being unable to meet basic needs for food, clothing, or shelter);
Be likely to benefit from assisted outpatient treatment; and
Participation in the assisted outpatient program is the least restrictive placement necessary to ensure the person's
recovery and stability.
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National Use of AOT
In 2014 there were 20 active programs but more have been implemented since
3 main models for recruitment*:
1)
A hospital/jail transition pathway, ordered into outpatient treatment after discharge from
an inpatient commitment (most common – in 10 states with active programs)
2)
A community gateway pathway, identifying unengaged or noncompliant individuals in the
community (8 states with active programs)
3)
Surveillance, or safety net, pathway, monitoring /treatment for those a danger to others (7
active programs)
*states can have multiple forms of pathways
Meldrum et al., 2016,
Psychiatric Services
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Does AOT Work?
Previous studies of involuntary AOT programs have found:
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lower odds of arrest (Swanson et al., 2001)
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reduced risk of victimization (Hiday et al., 2002)
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lower risk of harm to self or others (Phelan et al., 2010; Swanson et al., 2000)
◦
reductions in:
◦
Emergency visits (Munetz et al., 1996)
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Hospital admissions; length of hospitalization (Munetz et al., 1996; Swartz et al., 1999;
Swartz et al., 2010; Van Putton, Santiago, & Berren, 1988)
◦
higher quality of life (Swanson et al., 2003) - but, higher levels of perceived
coercion were inversely related with quality of life
Coercion found in voluntary and involuntary treatment
◦
72% of those court-ordered to treatment (CTO) reported high levels of
coercion but 63% in control group did too (Steadman et al., 2001)
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Limits to evidence
Most research studies focus on individuals transitioning out of inpatient or jail
settings
Evidence isn’t clear that coercion was the critical ingredient > having more resources
Can divert resources from voluntary treatment (in NYC there was evidence of
reduced resources for first 3 years then stabilization)
Methodological concerns:
◦
not having a control group (Rohland et al., 2000; Munetz et al., 1996)
◦
retrospective study designs (Gilbert et al., 2010; Van Putton, Santiago, & Berren, 1988; Swartz et
al., 2010)
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non-random assignment into AOT (Hiday et al., 2002; Swanson et al., 2000; Swartz et al., 2010)
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non-random extension of AOT orders (Swanson et al., 2003; Swartz et al., 1999)
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exclusion of persons with a history of violence (Steadman et al., 2001 ).
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Background
AOT in California
◦
58 Counties in California
◦
AOT adopted in <1/3 of counties: Alameda,
Contra Costa, Kern, Los Angeles, Mendocino,
Nevada, Orange, Placer, Santa Barbara, San
Diego, San Francisco, San Luis Obispo, San
Mateo, Stanislaus, Ventura, Yolo
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AOT in Los Angeles
Community gateway model primarily – some jail/hospital transition
◦
30 days of outreach and engagement services are required by state law
before a court order can be obtained – and voluntary agreement to services
is preferred and most common
Involuntary treatment is by civil court-order or settlement
agreement – but no consequences if court order is not followed
Even though law was passed in 2002 – LA County Board of
Supervisors approved in 2014 and AOT was implemented in May
15th, 2015.
UCLA evaluation began in October 2016
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Los Angeles AOT Program
15 person Outreach and Engagement Team
Length of outreach and engagement: M = 53.16 days, SD = 63.12 for those referred
to treatment; M = 116.33 days, SD = 115.88 for those not referred to treatment
23 agencies providing services – 20 slots per provider approximately
◦
17 Full Service Partnership providers
◦
4 Enriched Residential Service providers
“Warm handoff” process to transition from outreach and engagement to enrollment
Providers complete monthly assessments of programmatic and clinical status.
Quarterly meetings with Department of Mental Health
Program and claims data provided to evaluation on a quarterly basis
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AOT Referral Process
May 15, 2015 – January 10, 2018
Court Order
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Reasons that criteria were not met
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AOT Referral Process
May 15, 2015 – January 10, 2018
Court Order
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Reasons for Cases Closed
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AOT Referral Process
May 15, 2015 – January 10, 2018
Court Order
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Demographics at Referral to AOT
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1302 individuals referred (1378 referrals–some people had 2-3 referrals)
Demographics at Referral to AOT
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1302 individuals referred (1378 referrals–some people had 2-3 referrals)
Age: M = 37.75; SD = 13.81
AOT Services in Los Angeles
◦
Recovery-focused, strength-based
services
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Small case loads (10:1 ratio)
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300 FSP slots, 60 Enhanced
Residential Services (ERS) slots
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Intensive case management/wrap-
around-services
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Co-occurring disorder treatment
◦
24/7 on-call staff response if
needed
◦
Field-based services
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Peer-run activities
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All-encompassing continuum of
services available just as in regular
Full Service Partnership services
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Carefully tailored treatment plan
◦
Assistance with entitlements (Social
Security, Medi-Cal)
◦
Integrated Person focus (substance
use disorders, Psychiatric, Medical,
Life Skills training
◦
Community integration
CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
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AOT outreach:
family involvement,
barriers, and strategies
PRESENTING AUTHOR: SARAH STARKS, PH.D.
CO-AUTHORS: RYAN DOUGHERTY, ERIN KELLY, MARCIA
MELDRUM, ENRICO G. CASTILLO, CHARLOTTE NEARY-
BREMER, RONALD CALDERON, RACHEL OHMAN, PHILIPPE
BOURGOIS, & JOEL T. BRASLOW
CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
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Post-Outreach Surveys
Completed by Outreach and Engagement (O&E) Team at the
end of outreach for each outreached client, to:
◦
Provide a clearer picture of all clients who receive outreach,
including those who do not enroll in treatment
◦
Understand the outreach and engagement process
Survey Development:
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Developed with input from O&E staff
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Programmed into REDCap (UCLA CTSI; UL1TR001881)
Survey is ongoing:
◦
Rolled out in July 2017
◦
320 surveys completed to date (7/24/2018)
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158 surveys included in this analysis (through 1/24/18)
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Outreach Sample Demographics (n=158)
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Outreach Sample Diagnoses (n=158)
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Source of Referral to AOT (n=156)
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Reasons Outreach Ended (n=157)
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Family
involvement
FROM POST-OUTREACH SURVEYS COMPLETED BY
EOB OUTREACH AND ENGAGEMENT STAFF
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Family Involvement (n=158)
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Family and Client Openness to
Family Involvement in Treatment (n=119)
CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Green:
Opportunities for involvement.
Yellow:
Involvement unlikely.
Red:
Involvement unlikely; client and family wishes conflict.
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Family Support to Client (n=119)
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Family Issues with Client (n=119)
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Barriers to engaging
clients in treatment
FROM POST-OUTREACH SURVEYS COMPLETED BY
EOB OUTREACH AND ENGAGEMENT STAFF
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Barriers to Engagement
Outreach staff were asked to:
◦
Indicate whether an issue was present for a client.
◦
List of issues was developed in collaboration with O&E staff.
◦
Also option to enter “other” issues that weren’t pre-listed.
◦
If the issue was present, rate the degree to which it was
barrier to treatment for that client.
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Barriers to Engagement (Fig. 1)
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Barriers to Engagement (Fig. 2)
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Barriers to Engagement (Fig. 3)
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Summary, Barriers to Engagement
Client mental health was frequently an issue, and serious/moderate barrier.
◦
Lack of insight, paranoia, anger issues, substance abuse, lack of motivation.
Threatening words or behaviors could pose a serious barrier.
Barriers related to mental health treatment were common:
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Past psychiatric hospitalizations.
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Distrust of mental health providers.
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Resistance to medication; often serious/moderate barrier.
Client circumstances are challenging: homelessness; legal issues; lack of
resources; complicated family situations.
Housing placement barriers, insurance status:
◦
Loom large in logistical discussions.
◦
Relatively infrequent, but could be serious problems.
CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Outreach strategies
FROM POST-OUTREACH SURVEYS COMPLETED BY
EOB OUTREACH AND ENGAGEMENT STAFF
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Where Outreach Took Place (n=144)
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Outreach Strategies
Outreach staff were asked to:
◦
Indicate whether they used a particular strategy.
◦
List of strategies was developed in collaboration with O&E staff.
◦
Also option to enter “other” strategies that weren’t pre-listed.
◦
If the strategy was used, rate whether it was effective for
that client.
Strategies fell into 3 categories:
◦
Services provided to client during outreach
◦
Services advertised to client as benefits of treatment
◦
Legal strategies
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Outreach Strategies (Fig. 1a, n=158)
Services provided to client during outreach (a)
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Outreach Strategies (Fig. 1b, n=158)
Services provided to client during outreach (b)
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Outreach Strategies (Fig. 2, n=158)
Services advertised to client as benefits of treatment
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Outreach Strategies (Fig. 3, n=158)
Legal strategies
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Summary, Outreach Strategies
Wide array of strategies used. Some very effective with one client,
counterproductive with another.
O&E staff often exhausted all options to find a way to connect.
Predominant strategies were providing support to client and families
and telling them about the benefits of treatment.
When these strategies were not enough, legal strategies were used,
including discussion/use of:
◦
Court-ordered AOT
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Psychiatric hold
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Mental health treatment as jail diversion
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AOT Outreach: Discussion
AOT-referred population is extremely challenging to engage.
◦
Many barriers to engagement; often severe.
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On the positive side, many AOT-referred clients have extensive family support.
◦
Providing this support can be extremely taxing for their families.
Outreach process:
◦
Wide array of strategies used.
◦
What works for one person won’t work for everyone.
◦
O&E staff often exhausted all options to find a way to connect.
Extensive efforts to engage clients in treatment voluntarily. Of 158 outreached clients:
◦
50% enrolled voluntarily
◦
9% were court ordered or signed settlement agreement
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8% conserved.
The possibility of involuntary treatment often played a role in the outreach process.
◦
Over 50% were advised that a court order could be pursued.
CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Who engages in Assisted
Outpatient Treatment?
Comparisons of voluntary versus
involuntary enrollment in services
PRESENTING AUTHOR: ERIN KELLY
CO-AUTHORS: RYAN DOUGHERTY, MARCIA MELDRUM, SARAH
STARKS, ENRICO G. CASTILLO, CHARLOTTE NEARY-BREMER,
RONALD CALDERON, RACHEL OHMAN, PHILIPPE BOURGOIS, &
JOEL T. BRASLOW
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Background
The majority of research on AOT has
been on Involuntary AOT without an
option for voluntary services
◦
Exception: Evaluation in NY state of 181
participants in AOT (23% voluntary, 77%
involuntary) found that the court order
reduced the likelihood of arrest, OR =
.39, compared to the pre-AOT period of
participants (Gilbert et al., 2010). Arrest
data collected 1999-2008
◦
Interestingly, the process for voluntary
option is not part of Kendra’s Law
statute. Many local AOT programs offer it
a) before initiation of AOT or b) after
some period of AOT (Robbins et al.,
2010)
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Research Questions
1) Does a court–order influence whether those referred to treatment
enroll in services?
2) Does a court-order influence whether those who have completed
treatment graduate or discontinue services early?
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AOT Referral Process
May 15, 2015 – January 10, 2018
Court Order
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Full Service Partnership Enrollments and Outcomes
May 15, 2015 – January 10, 2018
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Days to Graduation M = 242.96, SD =
98.06
Days to Discharge M = 166.03, 11.95
Reasons for FSP Discharge
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Enriched Residential Services Enrollments and
Outcomes May 15, 2015 – January 10, 2018
Graduated: M = 207.62 days, SD = 70.79
Discharged M = 65.19 days, SD = 63.21
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Reasons for ERS Discharge
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Demographics at Referral of All Referred
Persons, n =1302
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Age: M = 37.75; SD = 13.81
Demographics for those Referred to Treatment
Full Service Partnership (n=478)
Gender:
37% Female, 62% Male,
1% Transgender
Housing:
33% Homeless, 34%
Family, 20% Apartment, 10%
Rehab/MH Facility, 4% Jail
Race/Ethnicity:
23% Black, 32%
Hispanic, 33% White, 11%
Asian/Pacific Islander, 1% Other
Current Substance Use:
36%
Age:
M = 35.93, SD = 12.41
Enriched Residential Services (n=152)
Gender:
40% Female, 58% Male, 2%
Transgender
Housing:
45% Homeless, 14% Family,
24% Apartment, 6% Rehab/MH Facility,
11% Jail
Race/Ethnicity:
21% Black, 35%
Hispanic, 37% White, 7% Asian/Pacific
Islander, 1% Other
Current Substance Use:
50%
Age:
M = 34.68, SD = 11.86
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Involuntary Commitment Petition Process
110 Conserved at some point after Referral
104 Court orders pursued
◦
9 filed and awaiting determination
◦
16 cancelled
◦
18 possible petitions
A total of 61 court orders/settlement agreements
◦
26 court order; 35 settlement agreement
◦
Increasing over time:
◦
2015: None
◦
2016: 16
◦
2017: 45
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Court Orders
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Court Orders and Enrollment
Court orders are obtained before treatment for those refusing to enroll
or after enrollment but refusing to engage in treatment.
◦
35 individuals enrolled with a court-order obtained before the start of
treatment
◦
12 individuals never enrolled but were court-ordered
◦
14 individuals had a court order obtained after they were enrolled
164 individuals never enrolled in services (204 referrals processed)
291 individuals enrolled voluntarily (320 referrals processed)
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Demographics and Court Orders
Gender:
2/3 were male, 1/3 female (transgendered n =1), Fisher’s exact
p=.68.
Race/Ethnicity:
31% White (n =19), 30% Latino/Hispanic (n=18), 28%
African American (n=17), and 11% were Asian (n =7), Fisher’s exact p=.80.
Housing:
31% homeless (n =19), followed by those living with family (28%; n
=17), those in an apartment (25%; n =15), in a mental health facility (11%; n
=7), and jail at the time of referral (5%; n =3). Housing status unrelated to
the likelihood of a court–order or settlement agreement.
Age:
No significant age differences for the likelihood of court supervision,
Fisher’s p =.43.
Substance Use:
41% currently using substances, Fisher’s exact p = .21
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Court Orders and Outcomes
Graduates
◦
Involuntary – 7%
◦
5% graduates of FSP/ERS services were under a court-order before they enrolled
◦
2% graduates of FSP/ERS services were under a court-order after they enrolled
◦
Voluntary
◦
93% graduates of FSP/ERS services were voluntary
Discharged
◦
Involuntary – 10%
◦
5% discharged from FSP/ERS services were under a court-order before they enrolled
◦
5% discharged from FSP/ERS services were under a court-order after they enrolled
◦
Voluntary
◦
90% discharged from FSP/ERS services were voluntary
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Demographics and Enrollment
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Demographics and Graduation
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Court Order as Predictor of Enrollment in AOT
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Court Order as Predictor of Likelihood of
Graduation from AOT
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Discussion
Results are highly preliminary
◦
Multiple, complex pathways through the AOT program
◦
Homelessness, substance use, and the role of the court are all important
elements to consider for enrollment and treatment success
◦
Gradual whittling away of individuals who are homeless from the program
◦
Family support may be an important factor in completing treatment goals
CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
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Violence and victimization for
participants, family members
and providers in Assisted
Outpatient Treatment
PRESENTING AUTHOR: RYAN DOUGHERTY
CO-AUTHORS: ERIN KELLY, MARCIA MELDRUM, SARAH STARKS, ENRICO G.
CASTILLO, CHARLOTTE NEARY-BREMER, RONALD CALDERON, RACHEL
OHMAN, PHILIPPE BOURGOIS, & JOEL T. BRASLOW
CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
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69
Introduction
Assisted Outpatient Treatment as a response to violence
◦
Residential settings (Desmarais et al., 2014)
◦
Family members in our data
High rates of victimization
◦
17.0% to 56.6% (Desmarais et al., 2014)
◦
Lam & Rosenheck, 1998:
◦
Associated with psychotic symptoms
◦
Increased homelessness & lowered quality of life
CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Violence to others,
n
= 668
:
77% had least one instance
Self-harm,
n
= 514
:
49% had at least one
Referral
Treatment
ERS
FSP
May 2015 - December 2016
•
No incidents of victimization or violence
reported
January 2017 - January 2018*
•
No incidents of victimization
•
4 individuals had at least one instance of
violent behavior
May 2015 - December 2016
•
2 formal reports of victimization (2
individuals)
•
14 reports of violence (10 individuals)
January 2017-January 2018
•
9.7% (23 individuals) were victimized
•
32.4% (77 individuals) had at least one
instance of violent behavior
70
CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
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Introduction
CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Unique challenges to delivery
◦
New to services
◦
Less resources
Perpetration & victimization as influential factors
72
)
SMI in Los Angeles County
•
2018 Greater Los Angeles Homelessness Count total: 52,765
•
Sheltered: 13,369
•
Serious mental illness
: 12,748 (24%)
•
Sheltered: 1,353
•
The incarceration system
•
LAC has the “
n
ation’s largest mental institution” (Montagne, 2008)
•
Daily average, Jan–Feb 2018: 4,970 (Los Angeles Sheriff’s Department)
CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
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Methods
Ethnography
◦
“On the ground”
◦
Explore beliefs, practices, processes
Research design
◦
Data collection
◦
Participant-observation
◦
Semi-structured interviews
◦
Participants
◦
Clients referred & enrolled in AOT
◦
Family members
◦
Service providers
◦
Signed consent process
◦
Analysis
◦
Thematic analysis
◦
Interdisciplinary team
◦
Iterative collection & analysis
CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
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The Referral Process
Perpetration and referral
◦
Protection from violent behaviors
◦
Address instability caused by violence
◦
As potentially the solution otherwise missing
Victimization and referral
◦
Shelter to decrease vulnerabilities associated with homelessness
◦
Provide monitoring for medical safety
◦
As potentially the solution otherwise missing
CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
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Within Treatment: Kristi
Competing interests:
◦
Within housing = concerns of perpetration
◦
Homelessness = concerns of victimization
Past experiences of victimization
◦
Difficulties discussing
◦
Rapport
& trauma
CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
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Within Treatment: David
•
06/06/2017: arrested on misdemeanor charges
•
Served 0 days
•
06/20/2017: arrested on misdemeanor charges
•
Sentenced 90 days
•
Served 30 days in county jail
•
4/27/2018: arrested on felony charges
•
Transferred to state prison
•
Remains there today
CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
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Interviewer:
Do you know what reason why? Did she give you a specific
reason?
Darian:
Yeah, she said that I was acting up, that I was being very
aggressive…horse-playing, not following staff instructions…
Interviewer:
How do you feel about that? Do you feel like –
Darian:
Uh, I kinda was doing that…But, uh, I don’t know, like for me I was
just…in my mind, I was like gonna be in a place where there were gonna
be…pretty grown men…I was sure that one of ‘em were gonna try and punk
me, you hear me? So I gotta show ‘em, nobody gonna punk me, y’know?
Within Treatment: Darian
CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
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Discussion
Role of perpetration & victimization:
◦
Competing concerns of multiple stakeholders
◦
Balancing public health concerns (Choe, Teplin,
Abram, 2008)
Expanding definitions of victimization:
◦
Criminalization of homelessness
Perpetration & victimization as cyclic
◦
Trauma & psychosis
(
Muenzenmaier, 2015)
◦
Trust/distrust as barrier to reporting
CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
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References
Choe, J. Y., Teplin, L. a., & Abram, K. M. (2008). Perpetration of Violence, Violent Victimization, and
Severe Mental Illness: Balancing Public Health Concerns. Psychiatric Services, 59(2), 153–64.
https://doi.org/10.1176/appi.ps.59.2.153
Desmarais, S. L., Van Dorn, R. A., Johnson, K. L., Grimm, K. J., Douglas, K. S., & Swartz, M. S. (2014).
Community violence perpetration and victimization among adults with mental illnesses. American
Journal of Public Health, 104(12), 2342–2349. https://doi.org/10.2105/AJPH.2013.301680
Lam, J., & Rosenheck, R. (1990). The Effect of Victimization on Clinical Outcomes of Homeless Persons
with Serious Mental Illness. Communication Disorders Quarterly, 49(5), 678–683.
https://doi.org/10.1176/ps.49.5.678
Los Angeles Sheriff's D. LASD Mental Health Count. Facilitated by Joseph Ortego, Chief Psychiatrist,
Correctional Health Services. Men's Central Jail, Twin Towers Mental Health Unit, Los Angeles: Data
Report; March 14, 2018.
Montagne R. Inside the nation’s largest mental institution. National Public Radio [NPR]. Aug 13 2008,
2008.
Muenzenmaier, K. H., Seixas, A. A., Schneeberger, A. R., Castille, D. M., Battaglia, J., & Link, B. G. (2015).
Cumulative effects of stressful childhood experiences on delusions and hallucinations. Journal of
Trauma & Dissociation, 16(4), 442-462.
CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
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UCLA AOT-LA Evaluation Team
PIs:
◦
Joel Braslow, MD, PhD; Psychiatrist and Historian
◦
Philippe Bourgois, PhD; Anthropologist
Data Collection and Analysis:
◦
Erin Kelly, PhD; Psychologist
◦
Marcia Meldrum, PhD; Historian
◦
Sarah Starks, PhD; Health Services Researcher
Ethnography:
◦
Ronald Calderon; Ryan Dougherty; Blake Erickson;
Victoria Lewis; Charlotte Neary-Bremer; Rachel Ohman
Supported by:
◦
DMH AOT-LA Contract MH050178
◦
UCLA CTSI Grant UL1TR001881
CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Thank you to all the Los Angeles
County, FSP, and ERS Staff who
make this evaluation possible:
Director of the Los Angeles
Department of Mental Health:
Dr. Jonathan Sherin
Linda Boyd
Mary Marx
Jacqueline Yu
Amany Anis
Monique Padilla
Nicole Nunez
Dr. Enrico Castillo
The symposium discusses Assisted Outpatient Treatment (AOT) in Los Angeles County, exploring topics such as family involvement, barriers, voluntary vs. involuntary enrollment, violence, and victimization. Presenters highlight the importance of addressing inadequate access to mental health care and poor adherence, emphasizing the need for state policies and federal funding to support involuntary treatment. Studies reveal concerning rates of violence among adults with mental illnesses and the challenges in psychiatric treatment adherence.
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Assisted Outpatient Treatment in Los Angeles County: Implications for Involuntary Outpatient Services Nationally 24THNIMH MENTAL HEALTH SERVICES RESEARCH CONFERENCE CHAIR: ERIN KELLY, PH.D. PRESENTERS: SARAH STARKS, PH.D. AND RYAN DOUGHERTY, MSW AUGUST 1, 2018 1 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Symposium Overview Introduction to Assisted Outpatient Treatment (AOT) Nationally Los Angeles County AOT-LA program AOT outreach: family involvement, barriers, and strategies Who engages in Assisted Outpatient Treatment? Comparisons of voluntary vs. involuntary enrollment in services Violence and victimization for participants, family members and providers in Assisted Outpatient Treatment 2 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Introduction to Assisted Outpatient Treatment PRESENTING AUTHOR: ERIN KELLY CO-AUTHORS: RYAN DOUGHERTY, MARCIA MELDRUM, SARAH STARKS, ENRICO G. CASTILLO, CHARLOTTE NEARY- BREMER, RONALD CALDERON, RACHEL OHMAN, PHILIPPE BOURGOIS, & JOEL T. BRASLOW 3 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Mental Health and Violence (1) Inadequate access and poor adherence to mental health care receives attention whenever high profile violent tragedies involving individuals with or without mental health challenges occur Typical responses: State policies supporting involuntary mental health treatment Federal mental health funding 4 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Mental Health and Violence (2) Review of 5 major studies of adults with mental illnesses: 23.9% of adults with mental illness reported perpetrating at least one incident of community violence in 6 months prior 30.9% reported being the victim of at least one violent act in the 6 months prior Studies: Facilitated Psychiatric Advance Directive (F-PAD) Study; MacArthur Mental Disorder and Violence Risk (MacRisk) Study; Schizophrenia Care and Assessment Program; MacArthur Mandated Community Treatment (MacMandate) Study; Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Study 62.9% adults with SMI received mental health services in the past year (NAMI) There are high levels of psychiatric treatment refusal among those with SMI. 55% of those who did not participate in treatment in the prior year said it was because they did not believe that they have an illness (National Comorbidity Survey) 25-78% of patients with psychosis fail to adhere to psychiatric treatment programs Median non-refusal rate is 40% among those with bipolar disorders. 5 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Assisted Outpatient Treatment Forty-six states have legally mandated the policy of Assisted Outpatient Treatment (AOT)--also sometimes referred to as involuntary outpatient commitment in response. Known by many names: Mandated Community Treatment Involuntary Outpatient treatment Community Treatment Order Kendra s Law New York -1999 Laura s Law California -2002 6 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
AOT Criteria Be eighteen years of age or older Be suffering from a mental illness Be unlikely to survive safely in the community without supervision, based on a clinical determination Have a history of non-compliance with treatment that has either: Been a significant factor in his or her being in a hospital, prison or jail at least twice within the last 36 months; or Resulted in one or more acts, attempts or threats of serious violent behavior toward self or others within the last 48 months Have been offered an opportunity to voluntarily participate in a treatment plan by the local mental health department but continue to fail to engage in treatment Be substantially deteriorating Be, in view of their treatment history and current behavior, in need of assisted outpatient treatment in order to prevent a relapse or deterioration that would likely result in them meeting California's inpatient commitment standard, which is being: A serious risk of harm to himself or herself or others; or Gravely disabled (in immediate physical danger due to being unable to meet basic needs for food, clothing, or shelter); Be likely to benefit from assisted outpatient treatment; and Participation in the assisted outpatient program is the least restrictive placement necessary to ensure the person's recovery and stability. 7 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
National Use of AOT In 2014 there were 20 active programs but more have been implemented since 3 main models for recruitment*: 1) A hospital/jail transition pathway, ordered into outpatient treatment after discharge from an inpatient commitment (most common in 10 states with active programs) 2) A community gateway pathway, identifying unengaged or noncompliant individuals in the community (8 states with active programs) 3) Surveillance, or safety net, pathway, monitoring /treatment for those a danger to others (7 active programs) *states can have multiple forms of pathways Meldrum et al., 2016, Psychiatric Services 8 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Does AOT Work? Previous studies of involuntary AOT programs have found: lower odds of arrest (Swanson et al., 2001) reduced risk of victimization (Hiday et al., 2002) lower risk of harm to self or others (Phelan et al., 2010; Swanson et al., 2000) reductions in: Emergency visits (Munetz et al., 1996) Hospital admissions; length of hospitalization (Munetz et al., 1996; Swartz et al., 1999; Swartz et al., 2010; Van Putton, Santiago, & Berren, 1988) higher quality of life (Swanson et al., 2003) - but, higher levels of perceived coercion were inversely related with quality of life Coercion found in voluntary and involuntary treatment 72% of those court-ordered to treatment (CTO) reported high levels of coercion but 63% in control group did too (Steadman et al., 2001) 9 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Limits to evidence Most research studies focus on individuals transitioning out of inpatient or jail settings Evidence isn t clear that coercion was the critical ingredient > having more resources Can divert resources from voluntary treatment (in NYC there was evidence of reduced resources for first 3 years then stabilization) Methodological concerns: not having a control group (Rohland et al., 2000; Munetz et al., 1996) retrospective study designs (Gilbert et al., 2010; Van Putton, Santiago, & Berren, 1988; Swartz et al., 2010) non-random assignment into AOT (Hiday et al., 2002; Swanson et al., 2000; Swartz et al., 2010) non-random extension of AOT orders (Swanson et al., 2003; Swartz et al., 1999) exclusion of persons with a history of violence (Steadman et al., 2001 ). 10 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Background AOT in California 58 Counties in California AOT adopted in <1/3 of counties: Alameda, Contra Costa, Kern, Los Angeles, Mendocino, Nevada, Orange, Placer, Santa Barbara, San Diego, San Francisco, San Luis Obispo, San Mateo, Stanislaus, Ventura, Yolo 11 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
AOT in Los Angeles Community gateway model primarily some jail/hospital transition 30 days of outreach and engagement services are required by state law before a court order can be obtained and voluntary agreement to services is preferred and most common Involuntary treatment is by civil court-order or settlement agreement but no consequences if court order is not followed Even though law was passed in 2002 LA County Board of Supervisors approved in 2014 and AOT was implemented in May 15th, 2015. UCLA evaluation began in October 2016 12 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Los Angeles AOT Program 15 person Outreach and Engagement Team Length of outreach and engagement: M = 53.16 days, SD = 63.12 for those referred to treatment; M = 116.33 days, SD = 115.88 for those not referred to treatment 23 agencies providing services 20 slots per provider approximately 17 Full Service Partnership providers 4 Enriched Residential Service providers Warm handoff process to transition from outreach and engagement to enrollment Providers complete monthly assessments of programmatic and clinical status. Quarterly meetings with Department of Mental Health Program and claims data provided to evaluation on a quarterly basis 13 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
AOT Referral Process May 15, 2015 January 10, 2018 35% Criteria Not Met (n = 484) Court Order Committee Determines if Criteria Met Referred to AOT (n = 1302 individuals, 1378 cases) 1% Pending Determination (n =14) 31% Cases Closed (n =269) 16% Ongoing Outreach and Engagement (n = 99) 64% Criteria Met (n = 880) Full Service Partnership (FSP) (n = 478) 69% Outreach and Engagement Offered (n = 611) 84% Assigned to Treatment Provider (n = 512) Enriched Residential Services (ERS) (n = 152) 14 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Reasons that criteria were not met 40% 35% 34% 35% 30% 25% 20% 15% 8% 7% 10% 5% 5% 2% 2% 1% 1% 5% 0% 15 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
AOT Referral Process May 15, 2015 January 10, 2018 35% Criteria Not Met (n = 484) Court Order Committee Determines if Criteria Met Referred to AOT (n = 1302 individuals, 1378 cases) 1% Pending Determination (n =14) 31% Cases Closed (n =269) 16% Ongoing Outreach and Engagement (n = 99) 64% Criteria Met (n = 880) Full Service Partnership (FSP) (n = 478) 69% Outreach and Engagement Offered (n = 611) 84% Assigned to Treatment Provider (n = 512) Enriched Residential Services (ERS) (n = 152) 16 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Reasons for Cases Closed 45% 40% 40% 35% 30% 25% 19% 20% 14% 15% 9% 10% 6% 5% 4% 2% 5% 1% 0% 17 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
AOT Referral Process May 15, 2015 January 10, 2018 35% Criteria Not Met (n = 484) Court Order Committee Determines if Criteria Met Referred to AOT (n = 1302 individuals, 1378 cases) 1% Pending Determination (n =14) 31% Cases Closed (n =269) 16% Ongoing Outreach and Engagement (n = 99) 64% Criteria Met (n = 880) Full Service Partnership (FSP) (n = 478) 69% Outreach and Engagement Offered (n = 611) 84% Assigned to Treatment Provider (n = 512) Enriched Residential Services (ERS) (n = 152) 18 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Demographics at Referral to AOT 1302 individuals referred (1378 referrals some people had 2-3 referrals) Referring Party Substance Use 1%Gender 1% 12% 27% 33% 36% 26% 63% 61% 9% 18% 13% Male Female Transgender Treatment provider Family Current Use Past Use Police Roommate Suspected Use Never Used Missing 19 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Demographics at Referral to AOT 1302 individuals referred (1378 referrals some people had 2-3 referrals) Age: M = 37.75; SD = 13.81 Housing Status RACE/ ETHNICITY 50% 43% Other, 3% 40% 30% 25% Asian/Pacific Islander, 9% White, 34% 18% 20% Black, 26% 9% 6% 10% 0% Hispanic, 28% Homeless With Family Apartment Rehab / MH Facility Jail 20 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
AOT Services in Los Angeles Recovery-focused, strength-based services Small case loads (10:1 ratio) 300 FSP slots, 60 Enhanced Residential Services (ERS) slots Intensive case management/wrap- around-services Co-occurring disorder treatment 24/7 on-call staff response if needed Field-based services Peer-run activities All-encompassing continuum of services available just as in regular Full Service Partnership services Carefully tailored treatment plan Assistance with entitlements (Social Security, Medi-Cal) Integrated Person focus (substance use disorders, Psychiatric, Medical, Life Skills training Community integration 21 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
AOT outreach: family involvement, barriers, and strategies PRESENTING AUTHOR: SARAH STARKS, PH.D. CO-AUTHORS: RYAN DOUGHERTY, ERIN KELLY, MARCIA MELDRUM, ENRICO G. CASTILLO, CHARLOTTE NEARY- BREMER, RONALD CALDERON, RACHEL OHMAN, PHILIPPE BOURGOIS, & JOEL T. BRASLOW 22 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Post-Outreach Surveys Completed by Outreach and Engagement (O&E) Team at the end of outreach for each outreached client, to: Provide a clearer picture of all clients who receive outreach, including those who do not enroll in treatment Understand the outreach and engagement process Survey Development: Developed with input from O&E staff Programmed into REDCap (UCLA CTSI; UL1TR001881) Survey is ongoing: Rolled out in July 2017 320 surveys completed to date (7/24/2018) 158 surveys included in this analysis (through 1/24/18) 23 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Outreach Sample Demographics (n=158) Number Percent Gender Male Female Race/Ethnicity Asian Black Hispanic White Multiple/Other Age (roughly; by birth year) 18-30 31-40 41-50 51-60 61-70 100 59 63% 37% 11 30 54 57 6 7% 19% 34% 36% 4% 51 51 27 22 7 32% 32% 17% 14% 4% 24 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Outreach Sample Diagnoses (n=158) Number Percent 46% 16% 18% 13% Schizophrenia Schizoaffective Psychotic Disorder Bipolar Mood Disorder Conduct Disorder; ODD Major Depression; r/o Lewy Body Dementia Schizoaffective; Autism Spectrum DO 72 25 28 21 9 1 1 1 6% 1% 1% 1% 25 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Source of Referral to AOT (n=156) Referral Source Clinician/hospital Family member Mobile Crisis Team: Psychiatric Mobile Response Team or DMH-Law Enforcement Team Social service agency Law enforcement/probation officer Roommate Other: DMH Homeless Outreach & Mobile Engagement Number Percent 29% 29% 25% 47 46 39 15 10% 4% 1% 1% 7 1 1 26 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Reasons Outreach Ended (n=157) N Percent 50.3% 4.5% 4.5% 8.3% 1.9% 2.6% 14.7% 13.4% 1.3% 1.9% 3.8% 0.6% 3.2% 0.6% 1.3% 0.6% AOT, Voluntary AOT, Involuntary via Court Order AOT, Involuntary via Settlement Agreement Conservatorship MIST or FIST (incompetent to stand trial; community-based restoration) Long-Term Incarceration Can t Find Client Other Deceased Living or extended travel outside of LAC Other treatment Private insurance; can t switch due to medical condition Refused, not deteriorating Referral withdrawn Unable to meet client Very high-functioning 79 7 7 13 3 4 23 21 2 3 6 1 5 1 2 1 27 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Family involvement FROM POST-OUTREACH SURVEYS COMPLETED BY EOB OUTREACH AND ENGAGEMENT STAFF 28 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Family Involvement (n=158) Number Percent Does the client have contact with their family? (n=158) No contact Limited contact or only by phone Contact but live separately Contact and lives with family member(s) Don t know How would you characterize the quality of the client's relationship with their family? (n=119) Primarily positive interactions A mix of positive and negative interactions Primarily negative interactions Don t know How involved is the family in the client's mental health care? (n=119) Family not involved in care Family is somewhat or inconsistently involved Family is very involved Don t know 21 27 31 61 18 13% 17% 20% 39% 11% 21 58 17 23 18% 49% 14% 19% 7 33 63 16 6% 28% 53% 13% 29 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Family and Client Openness to Family Involvement in Treatment (n=119) Client Family openness to being involved Actively opposed to involvement Involvement 6 (100% of C) (5% of F) 0 (0% of C) (0% of F) 1 (16% of C) (2% of F) 0 (0% of C) (0% of F) 5 (15% of C) (83% of F) openness to having family involved Strongly prefers involvement 44 (100% of C) (37% of F) 7 (16% of C) (35% of F) 19 (43% of C) (38% of F) 13 (30% of C) (87% of F) 5 (11% of C) (15% of F) Open to Don t know 24 (100% of C) (20% of F) 3 (13% of C) (15% of F) 4 (17% of C) (8% of F) 1 (4% of C) (7% of F) 16 (67% of C) (47% of F) TOTAL 119 (100% of C) (100% of F) 20 (17% of C) (100% of F) 50 (42% of C) (100% of F) 15 (13% of C) (100% of F) 34 (29% of C) (100% of F) 45 TOTAL (100% of C) (38% of F) 10 (22% of C) (50% of F) 26 (58% of C) (52% of F) 1 (2% of C) (7% of F) 8 (18% of C) (24% of F) Actively opposed to involvement Open to involvement Strongly prefers involvement Don t know Green: Opportunities for involvement. Yellow: Involvement unlikely. Red: Involvement unlikely; client and family wishes conflict. 30 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Family Support to Client (n=119) Number 20 61 54 59 39 23 8 9 1 1 2 1 1 1 1 1 Percent 17% 51% 45% 50% 33% 19% 7% 8% 1% 1% 2% 1% 1% 1% 1% 1% None Housing Money Emotional support Transportation Medication assistance Representative payee Other (free response; see below) Allow to live in yard Employment Food/groceries Caregivers for client s children Occasional meal out; Facebook contact Legal assistance Advocate for conservatorship Update outreach team about client s location, behavior 31 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Family Issues with Client (n=119) Number 45 60 13 6 12 1 2 1 1 4 1 1 1 1 1 Percent 38% 50% 11% 5% 10% 1% 2% 1% 1% 3% 1% 1% 1% 1% 1% None Concerns for family safety Restraining/protective order against client Concerns about theft by client Other (see below; free response by outreach worker) Concerns for safety of family members' neighbors Concerns for client safety Need for conservatorship Ability to care for self; substance use DCFS/custody/visitation issues (client s children) DCFS issues (family s children; don t want client there due to open case) DCFS issues (restraining order advised due to case; case closed) Client resistance to treatment and medications Too exhausted to deal with client Client goes looking for kids he claims to have in other cities 32 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Barriers to engaging clients in treatment FROM POST-OUTREACH SURVEYS COMPLETED BY EOB OUTREACH AND ENGAGEMENT STAFF 33 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Barriers to Engagement Outreach staff were asked to: Indicate whether an issue was present for a client. List of issues was developed in collaboration with O&E staff. Also option to enter other issues that weren t pre-listed. If the issue was present, rate the degree to which it was barrier to treatment for that client. 34 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Barriers to Engagement (Fig. 1) 0 10 20 30 40 50 60 70 80 90 100 MENTAL HEALTH Lack of insight Paranoia Anger issues Substance use Lack of motivation Grave disability Cognitive impairment Not a barrier Minor barrier Suicidality Moderate barrier Homicidal ideation Developmental disability Traumatic brain injury Serious barrier TRAUMA Past psychiatric hospitalizations Physical abuse history (victim) Sexual abuse history (victim) 35 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Barriers to Engagement (Fig. 2) 0 10 20 30 40 50 60 70 80 90 100 ATTITUDES/BEHAVIORS Resistance to medication Distrust of mental health providers Threatening words or behaviors Immaturity Not a barrier CIRCUMSTANCES Lack of housing Legal issues Minor barrier Moderate barrier Lack of financial resources Family mental health issues Family interference with treatment Immigration status Serious barrier BACKGROUND Cultural issues Language barriers 36 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Barriers to Engagement (Fig. 3) 0 10 20 30 40 50 60 70 80 90 100 HOUSING PLACEMENT BARRIERS Medical issues Arson history Lack of medical clearance Not a barrier Sex offender Minor barrier Manufacturing or sale of drugs Moderate barrier Serious barrier INSURANCE Privately insured Uninsured Medicare Out-of-county Medicaid 37 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Summary, Barriers to Engagement Client mental health was frequently an issue, and serious/moderate barrier. Lack of insight, paranoia, anger issues, substance abuse, lack of motivation. Threatening words or behaviors could pose a serious barrier. Barriers related to mental health treatment were common: Past psychiatric hospitalizations. Distrust of mental health providers. Resistance to medication; often serious/moderate barrier. Client circumstances are challenging: homelessness; legal issues; lack of resources; complicated family situations. Housing placement barriers, insurance status: Loom large in logistical discussions. Relatively infrequent, but could be serious problems. 38 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Outreach strategies FROM POST-OUTREACH SURVEYS COMPLETED BY EOB OUTREACH AND ENGAGEMENT STAFF 39 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Where Outreach Took Place (n=144) N 54 33 26 19 10 7 6 4 3 2 2 10 Percent 38% 23% 18% 13% 7% 5% 4% 3% 2% 1% 1% 7% In the client s home In a hospital On the street In jail (or juvenile hall, in one instance, via Other) At a family member s home In a caf /restaurant At a supported living facility At an emergency shelter Court (via Other) In a hotel/motel Park (via Other) Other 40 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Outreach Strategies Outreach staff were asked to: Indicate whether they used a particular strategy. List of strategies was developed in collaboration with O&E staff. Also option to enter other strategies that weren t pre-listed. If the strategy was used, rate whether it was effective for that client. Strategies fell into 3 categories: Services provided to client during outreach Services advertised to client as benefits of treatment Legal strategies 41 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Outreach Strategies (Fig. 1a, n=158) Services provided to client during outreach (a) 0 10 20 30 40 50 60 70 80 90 100 Assistance accessing medical care Assistance accessing other program (SUD, etc.) Assistance gaining ID or benefits (GR, etc.) Assistance with housing Counterproductive Assistance with family relationships Not Effective Assistance with police, justice system, other legal matters Somewhat Effective Assistance with transportation Very Effective Family/client assistance with relationship Family/client reconnection (after estrangement) Family referral to NAMI Leverage of family connection to access client Leverage of family connection to engage client in services 42 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Outreach Strategies (Fig. 1b, n=158) Services provided to client during outreach (b) 0 10 20 30 40 50 60 70 80 90 100 Motivational interviewing Psychoeducation to client Psychoeducation to family Purchase food or coffee Purchase items/services (bike, clothing, personal items, Counterproductive Support, crisis Not Effective Support, emotional Somewhat Effective Support, informational (linkage) Very Effective Support during incarceration (transition) Support during legal proceedings OTHER: Language-concordant outreach OTHER: Assistance during eviction process (referrals) OTHER: Continued client/family contact while client out 43 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Outreach Strategies (Fig. 2, n=158) Services advertised to client as benefits of treatment 0 10 20 30 40 50 60 70 80 90 100 Assistance with employment Assistance with going back to school Assistance with reintegration (life skills training, Benefits (SSI, GR, SSDI, etc.) Counterproductive Not Effective Case management services Somewhat Effective Groups, socialization opportunities Very Effective Housing Psychiatric medication Substance abuse services Therapy 44 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Outreach Strategies (Fig. 3, n=158) Legal strategies 0 10 20 30 40 50 60 70 80 90 100 Advised client would/could pursue court-ordered AOT Pursued court order to AOT Advised client that 5150 would be pursued Counterproductive Pursued 5150 Not Effective Advised client that s/he might face jail or probation violation Somewhat Effective Very Effective Reported client to law enforcement or probation officer Provided documents, advocated, or supported conservatorship Suggested MH services as jail diversion or worked with public defender to divert Suggested participation might prevent future arrests, jail time, hospitalizations 45 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Summary, Outreach Strategies Wide array of strategies used. Some very effective with one client, counterproductive with another. O&E staff often exhausted all options to find a way to connect. Predominant strategies were providing support to client and families and telling them about the benefits of treatment. When these strategies were not enough, legal strategies were used, including discussion/use of: Court-ordered AOT Psychiatric hold Mental health treatment as jail diversion 46 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
AOT Outreach: Discussion AOT-referred population is extremely challenging to engage. Many barriers to engagement; often severe. On the positive side, many AOT-referred clients have extensive family support. Providing this support can be extremely taxing for their families. Outreach process: Wide array of strategies used. What works for one person won t work for everyone. O&E staff often exhausted all options to find a way to connect. Extensive efforts to engage clients in treatment voluntarily. Of 158 outreached clients: 50% enrolled voluntarily 9% were court ordered or signed settlement agreement 8% conserved. The possibility of involuntary treatment often played a role in the outreach process. Over 50% were advised that a court order could be pursued. 47 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Who engages in Assisted Outpatient Treatment? Comparisons of voluntary versus involuntary enrollment in services PRESENTING AUTHOR: ERIN KELLY CO-AUTHORS: RYAN DOUGHERTY, MARCIA MELDRUM, SARAH STARKS, ENRICO G. CASTILLO, CHARLOTTE NEARY-BREMER, RONALD CALDERON, RACHEL OHMAN, PHILIPPE BOURGOIS, & JOEL T. BRASLOW 48 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Background The majority of research on AOT has been on Involuntary AOT without an option for voluntary services Exception: Evaluation in NY state of 181 participants in AOT (23% voluntary, 77% involuntary) found that the court order reduced the likelihood of arrest, OR = .39, compared to the pre-AOT period of participants (Gilbert et al., 2010). Arrest data collected 1999-2008 Interestingly, the process for voluntary option is not part of Kendra s Law statute. Many local AOT programs offer it a) before initiation of AOT or b) after some period of AOT (Robbins et al., 2010) 49 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
Research Questions 1) Does a court order influence whether those referred to treatment enroll in services? 2) Does a court-order influence whether those who have completed treatment graduate or discontinue services early? 50 CENTER FOR SOCIAL MEDICINE AND HUMANITIES, SEMEL INSTITUTE, UNIVERSITY OF CALIFORNIA, LOS ANGELES
