NEW YORK STATE
ASSISTED OUTPATIENT TREATMENT
PROGRAM EVALUATION

U

Duke University
School of Medicine

Marvin S. Swartz. MD. Principal Investigator
Jeffrey W. Swanson. PhD. Co-Principallnvestigetor
Department of Psychiatry and Behavioral Sciences
Duke University School of Medicine
Durham, NC

II

Henry J. Steadman, PhD. Co·Principallnvestigator
POLICY RESEARCH ASSOCIATES

Pamel. Clark Robbins. Project Director
Policy Research Associates, Inc.
Delmar, NY

u"'....'n.!
VIRGINIA
SCIlOOt OF LAW

John Monahan. PhD. Director
The MacArthur Foundation Research Network on
Mandated Community Treatment
University of Virginia School of Law
Charlottesville. VA

June 30, 2009

Table of Contents
Foreword (Acknowledgements) ...................................................................................................iii
Executive Summary ..................................................................................................................... v
Introduction ................................................................................................................................... 1
Chapter 1. Description of the Assisted Outpatient Treatment Program ........................................ 3
Chapter 2. Engagement in the Assisted Outpatient Treatment Program.................................... 17
Chapter 3. Recipient Outcomes.................................................................................................. 21
Chapter 4. Recipient Perceptions of the Assisted Outpatient Treatment Program ..................... 33
Chapter 5. Service Utilization and Outcomes After Assisted Outpatient Treatment Ends .......... 39
Chapter 6. Impact of Assisted Outpatient Treatment on the New York Service System ............ 45
Summary and Conclusions ......................................................................................................... 51
Appendix A: Kendra’s Law Overview and Statute ..................................................................... 59
Appendix B: Methods Overview................................................................................................. 91

Suggested citation:
Swartz, MS, Swanson, JW, Steadman, HJ, Robbins, PC and Monahan J. New York State
Assisted Outpatient Treatment Program Evaluation. Duke University School of Medicine,
Durham, NC, June, 2009.

New York State Assisted Outpatient Treatment Program Evaluation

i

ii

New York State Assisted Outpatient Treatment Program Evaluation

Foreword
Acknowledgements
We gratefully acknowledge the contribution of numerous individuals in collecting, synthesizing,
and reporting the data for this effort.
At the Services Effectiveness Research Program in the Department of Psychiatry and
Behavioral Sciences at the Duke University School of Medicine, we acknowledge the
considerable efforts of: Richard Van Dorn, Ph.D.; Christine Wilder, M.D.; Lorna Moser, Ph.D.;
and Allison Gilbert, Ph.D., M.P.H.
At Policy Research Associates, we wish to express our gratitude to: Karli Keator; Wendy Vogel,
M.P.A.; Roumen Vesselinov, Ph.D.; Jody Zabel; Steven Hornsby, L.M.S.W; and Amy
Thompson, M.S.W.
We also wish to acknowledge the extensive reviews and critical feedback of the MacArthur
Research Network on Mandated Community Treatment, who served as an internal advisory
group to the study.
Finally, although the findings of the study are solely our responsibility, we gratefully
acknowledge the valuable involvement of our project liaison Steven Huz, Ph.D. and the support
and assistance of the New York State Office of Mental Health in completing the report including:
Michael F. Hogan, Ph.D., Bruce E. Feig; Susan Shilling, Esq., L.C.S.W; Lloyd I. Sederer, M.D.,
Peter Lannon; and Qingxian Chen.

New York State Assisted Outpatient Treatment Program Evaluation

iii

iv

New York State Assisted Outpatient Treatment Program Evaluation

Executive Summary
Introduction
In 1999, New York State created a program
authorizing court-ordered treatment in the
community for people with severe mental
illness at risk of relapse or deterioration
absent voluntarily compliance with
prescribed treatment. To be eligible for this
Assisted Outpatient Treatment (AOT)
Program—popularly known as “Kendra’s
Law,” named after Kendra Webdale, a
young woman who was killed by a person
with untreated mental illness—individuals
must be at least 18 years of age, diagnosed
with mental illness and assessed to be
unlikely to live safely in the community
without supervision. In addition, recipients
must have a history of treatment
noncompliance that has resulted in (1)
psychiatric hospitalization or incarceration at
least twice in the past 36 months, or (2)
committing serious acts or threats of
violence to self or others in the past 48
months. Finally, these individuals must be
found, as a result of their mental illness, to
be unlikely to voluntarily participate in
treatment and to be in need of AOT to
prevent deterioration that would likely result
in harm to themselves or others. Once an
AOT order is finalized by a court, recipients
are engaged in a comprehensive
community-based treatment plan and
extensively monitored for adherence to the
plan.
The 2005 reauthorization of the AOT
Program required an independent
evaluation of its implementation and
effectiveness, specifically addressing
several areas of investigation. The New
York State Office of Mental Health issued a
competitive Request for Proposals, and the
contract for the evaluation was awarded to
the Services Effectiveness Research
Program in the Department of Psychiatry
and Behavioral Sciences at Duke University
Medical Center with a subcontract to the

Policy Research Associates, Inc. of Delmar,
NY, and with additional support from the
John D. and Catherine T. MacArthur
Foundation Research Network on Mandated
Community Treatment.
The contract requires study and reporting
on the following areas:
Description of AOT Program and
regional variations: Are there regional
and cultural differences across the state
in AOT programs and their
implementation?
Service engagement: What is the level
of service engagement of recipients of
mental health services during AOT?
Recipient outcomes: What are the outcomes for people with mental illness
who are mandated into AOT versus
those who receive voluntary enhanced
outpatient services?
Recipient perceptions of AOT: What
are the opinions of a representative
sample of AOT recipients regarding their
experiences with AOT?
Service engagement and outcomes
after AOT ends: What is the level of
service engagement of recipients of
mental health services post-AOT?
The impact of AOT on New York’s
public mental health system: What is
the impact of AOT programs on the
availability of resources for individuals
with mental illness and perceived
barriers to care?
To address these areas of investigation we
studied existing records from several extensive data sources, described in the
appendices, including: AOT Program
administrative data, New York State Office
of Mental Health client profile surveys,
hospital admissions records, case manager

New York State Assisted Outpatient Treatment Program Evaluation

v

reports on AOT recipients and Assertive
Community Treatment recipients, Medicaid
claims, arrest records, U.S. Census, and
Mental Health Needs Estimation Project
data. In addition, we conducted statewide
in-person interviews among key
stakeholders to gain insight into the
operation of the AOT Program and
interviewed service recipients in six counties
to assess attitudes about treatment,
treatment experiences, and treatment
outcomes.
Findings
Description of the New York AOT
Program and Its Regional Variations
The introduction of New York’s AOT
Program was accompanied by a significant
infusion of new service dollars and currently
features more comprehensive
implementation, infrastructure and oversight
of the AOT process than any other
comparable program in the United States. It
is, therefore, a critical test of how a
comprehensively implemented and wellfunded program of assisted outpatient
treatment can perform. However, because
New York’s program design is unique, these
evaluation findings may not generalize to
other states, especially where new service
dollars are not available. This report
addresses whether AOT can be effective
and under what circumstances, not whether
it will always be effective wherever or
however implemented.
As designed, AOT can be used to prevent
relapse or deterioration before
hospitalization is needed. However, in
nearly three-quarters of all cases, it is
actually used as a discharge planning tool
for hospitalized patients. Thus, AOT is
largely used as a transition plan to improve
the effectiveness of treatment following a
hospitalization and as a method to reduce
hospital recidivism.
Most of New York State’s experience with
AOT originates in the New York City region

vi

where approximately 70% of all AOT cases
are found. AOT was systematically
implemented citywide in New York City with
well-delineated city-wide policies and
procedures. In the remainder of the state,
AOT was implemented and utilized at the
discretion of counties. In some counties
AOT has been rarely used; in several it has
not been used at all.
Based on key stakeholder and recipient
interviews and on AOT Program data, we
found considerable variability in how AOT is
implemented across the state, but strong
uniformity in how it is implemented in New
York City. One important difference among
regions was the use of enhanced voluntary
service (EVS) agreements (sometimes
referred to as “enhanced services”) in lieu of
a formal AOT court order. (Note that the
term “enhanced voluntary services” or
‘EVS’ was developed to describe these
agreements and is not an official
designation.) Under a voluntary agreement,
the recipient signs a statement that he or
she will adhere to a prescribed community
treatment plan. In the New York City region,
voluntary agreements are usually
implemented following a period of AOT
when a recipient is judged to be ready to
transition from an AOT order to voluntary
treatment; we refer to this as the “AOT First”
model. In other counties, largely outside of
New York City, voluntary agreements are
more frequently used as trial periods before
initiating a formal AOT order; we refer to this
pattern as the “EVS First” model. If the trial
period proves unsuccessful, an AOT
proceeding is then initiated. Across the
state, AOT First is used far more frequently
than EVS First since the majority of AOT
orders occur in New York City.
Racial Disparities in AOT: Are They
Real?
An April 2005 report on statewide
demographic data from the New York
Lawyers for the Public Interest found that
African Americans were overrepresented in
the AOT Program. Whether this over-

New York State Assisted Outpatient Treatment Program Evaluation

representation is discriminatory rests, in
part, on whether AOT is generally seen as
beneficial or detrimental to recipients and
whether AOT is viewed as a positive
mechanism to reduce involuntary
hospitalization and improve access to
community treatment for an under-served
population, or as a program that merely
subjects an already-disadvantaged group to
a further loss of civil liberties.
We find that the overrepresentation of
African Americans in the AOT Program is a
function of African Americans’ higher
likelihood of being poor, higher likelihood of
being uninsured, higher likelihood of being
treated by the public mental health system
(rather than by private mental health
professionals), and higher likelihood of
having a history of psychiatric
hospitalization. The underlying reasons for
these differences in the status of African
Americans are beyond the scope of this
report. We find no evidence that the AOT
Program is disproportionately selecting
African Americans for court orders, nor is
there evidence of a disproportionate effect
on other minority populations. Our
interviews with key stakeholders across the
state corroborate these findings.
Service Engagement
A key goal of the AOT Program is to
motivate consumers to actively engage in
treatment during and after their involvement
with the program. We find that during the
first six months on AOT, service
engagement was comparable to service
engagement of voluntary patients not on
AOT. After 12 months or more on AOT,
service engagement increased such that
AOT recipients were judged to be more
engaged than voluntary patients. This
suggests that after 12 months or more,
when combined with intensive services,
AOT increases service engagement
compared to voluntary treatment alone.
Recipient Outcomes

We find consistent evidence that during
AOT there is a substantial reduction in the
number of psychiatric hospitalizations and in
days in the hospital if a person is
hospitalized. We also find moderately strong
evidence from lifetime arrest records of AOT
and EVS recipients from the NYS Division
of Criminal Justice Services that AOT
reduces the likelihood of being arrested.
We find substantial increases in receipt of
intensive case management services during
AOT. We also find that AOT recipients are
far more likely to consistently receive
psychotropic medications appropriate to
their psychiatric conditions. Case managers
of AOT recipients also report subjective
improvements in many areas of personal
functioning, such as managing appointments, medications, and self-care tasks.
Recipient Perceptions of AOT
Participants were assessed on scales
measuring a wide range of AOT-related
attitudes and treatment experiences,
including: their understanding of AOT;
whether they believe it beneficial or harmful;
whether they find it stigmatizing; whether it
affects their sense of autonomy or
empowerment; satisfaction with treatment,
perceived coercion related to treatment;
perceived pressures to engage in treatment;
whether it increases perceived barriers to
treatment; and how it affects their sense of
being treated fairly.
On the whole, AOT recipients and non-AOT
recipients report remarkably similar attitudes
and treatment experiences. That is, despite
being under a court order to participate in
treatment, current AOT recipients feel
neither more positive nor more negative
about their mental health treatment
experiences than comparable individuals
who are not under AOT. This suggests that
positive and negative attitudes about
treatment during AOT are more strongly
influenced by other experiences with mental
illness and treatment than by recent
experiences with AOT itself.

New York State Assisted Outpatient Treatment Program Evaluation

vii

Service Utilization and Outcomes After
AOT Ends
We examined whether selected gains made
during AOT are sustained over time by
examining two key outcomes that improved
during AOT: reduced rates of hospitalization
and increased receipt of psychotropic
medications appropriate to the individual’s
diagnosis. We find that sustained improvement after AOT ends varies according to the
length of time the recipient spends under
the AOT order. If AOT is discontinued after
six months, these decreased rates of
hospitalization and improved receipt of
psychotropic medications are sustained only
if recipients continue to receive intensive
case management services. However, if
AOT continues for longer than 6 months,
reduced rates of hospitalization and
improved receipt of medications are
sustained whether or not intensive case
management services are continued after
AOT is discontinued. Thus, it appears that
improvements are more likely to be
sustained if AOT continues for longer than 6
months.
Impact of AOT on New York’s Public
Mental Health System
It is unclear whether resources have been
diverted away from other adults with severe
mental illness as a consequence of AOT
implementation. We examined the impact of
AOT Programs on the availability of
resources for all adult individuals with
severe mental illness by focusing on access
to high intensity case management
services.
The implementation of AOT was
accompanied by a large increase in funding
for mental health services, which over time
increased the availability of intensive
services for all service recipients, even
those who never got AOT. In the first
several years of the AOT Program, between
1999 and 2003, preference for intensive
case management services was given to
AOT cases, a finding corroborated by our

viii

key stakeholder interviews. This meant that
in the first several years of the AOT
Program, non-AOT recipients were less
likely to receive intensive case management
services than their AOT counterparts,
especially outside of New York City. This
may have been because the treatment
capacity was greater in New York City, and
thus it was able to absorb a greater volume
of new AOT cases with less impact on other
service recipients with severe mental
illness.
After 2003 new AOT orders leveled off in
the state and then declined. The new
treatment capacity that accompanied the
implementation of AOT was apparently then
available to other individuals who needed
these services, irrespective of AOT status.
Thus, following the initial ramp-up of the
AOT Programs throughout the state,
intensive community-based services
increased for individuals on AOT and those
not on AOT alike. Because the new service
capacity created during the implementation
of the AOT Program is now fully utilized,
competition for services in the near future
may intensify, with unknown effects on AOT
relative to non-AOT recipients. Because the
implementation of the AOT Program in New
York was accompanied by an infusion of
new services, it is impossible to generalize
these findings to states where services do
not simultaneously increase.
Summary
We find that New York State’s AOT
Program improves a range of important
outcomes for its recipients, apparently
without feared negative consequences to
recipients. The increased services available
under AOT clearly improve recipient
outcomes, however, the AOT court order,
itself, and its monitoring do appear to offer
additional benefits in improving outcomes. It
is also important to recognize that the AOT
order exerts a critical effect on service
providers stimulating their efforts to prioritize
care for AOT recipients.

New York State Assisted Outpatient Treatment Program Evaluation

Available data allow only a limited
assessment of whether voluntary
agreements are effective alternatives to
initiating or continuing AOT. There are
relatively few voluntary agreements and
they typically occur in counties that use the
"EVS First" model. However, we found
some evidence that AOT recipients are at
lower risk of arrest than their counterparts in
enhanced voluntary services. We also found
evidence in the case manager data that
receiving AOT combined with ACT services
substantially lowers risk of hospitalization
compared to receiving ACT alone.
Recipients appear to fare better during and
after AOT if the AOT order lasts for six
months or more. Once AOT recipients leave
the program, improvements are more likely
sustained among those who continue to
receive intensive treatment services or
received longer periods of AOT.
Perceptions of the AOT Program,
experiences of stigma, coercion, and
treatment satisfaction appear to be largely
unaffected by participation in the program
and are likely more strongly shaped by
other experiences with mental illness and
treatment.
In its early years, the AOT Program did
appear to reduce access to services for
non-AOT recipients. However, in recent
years the reduction in new AOT cases has
attenuated this effect. Lack of continued
growth of new service dollars will likely
increase competition for access to services
once again.

New York State Assisted Outpatient Treatment Program Evaluation

ix

Introduction
The New York State Legislature in 1999
enacted the state’s involuntary outpatient
commitment statute, named “Kendra’s Law”
in memory of a young woman killed by a
man with untreated mental illness.1 Beyond
passing a new law to address a perceived
public safety need, the Legislature funded a
new statewide program – Assisted
Outpatient Treatment (AOT) – designed to
ensure that people with severe mental
illness receive the array of services they
need in the community.
Kendra’s Law was seen as a legislative
model for involuntary outpatient commitment in the United States. The intent of the
statute was not simply to authorize courtordered community treatment but to also
provide the resources and oversight
necessary for a viable, less restrictive
alternative to involuntary hospitalization.
The goal was to provide a definitive remedy
for the costly “revolving door syndrome.”
Whether Kendra’s Law and the AOT
Program have succeeded in these terms –
and at what cost to the liberty of AOT
recipients and the public resources they
consume – is a matter of ongoing debate.
Kendra’s Law was initially authorized for a
period of five years with continuation made
contingent on an internal evaluation of the
AOT Program. The Mental Health
Commissioner and New York State Office of
Mental Health (OMH) submitted reports on
the implementation and status of the AOT
Program. The Interim Report (2003) and
Final Report (2005) highlighted encouraging
evidence of AOT’s effectiveness,2 and the

Legislature reauthorized AOT for a second
five-year period.
The 2005 reauthorization of Kendra’s Law
required an independent evaluation of the
implementation and effectiveness of the
AOT Program, specifically addressing
several areas of investigation. Beginning in
2006, the Commissioner was also to issue
both an annual fiscal and descriptive AOT
Program report.
OMH issued a competitive Request for Proposal, and the contract was awarded to the
Services Effectiveness Research Program
(SERP) in the Department of Psychiatry and
Behavioral Sciences at Duke University
Medical Center (DUMC) with a subcontract
to Policy Research Associates, Inc. (PRA)
of Delmar, NY. This project also received
funding from the John D. and Catherine T.
MacArthur Foundation Research Network
on Mandated Community Treatment. This
evaluation team is led by Principal
Investigators Marvin Swartz, M.D., and
Jeffrey Swanson, Ph.D., of DUMC and
Henry Steadman, Ph.D., and Pamela Clark
Robbins of PRA.
The evaluation team analyzed AOT administrative records and clinical services data
spanning nearly a decade (1999 – 2007).
The team also collected and analyzed new
data from key informant interviews
throughout the state, and from structured
interviews with a new sample of AOT and
voluntary service recipients in six selected
counties. This report presents the findings
from these analyses, following an overview
of the AOT Program and study methods.

1

Appendix A contains an overview of Kendra’s Law and the statute.
OMH’s Interim Report on Kendra’s Law is available on the OMH Web site at
http://www.omh.state.ny.us/omhweb/Kendra_web/interimreport/ and the Final Report is at
http://www.omh.state.ny.us/omhweb/Kendra_web/finalreport/index.htm
2

New York State Assisted Outpatient Treatment Program Evaluation

1

Overview of Evaluation Report
The New York State Legislature’s authorization of Kendra’s Law and the accompanying
AOT Program is contingent on the evaluation of its effectiveness. The following
specific research questions were posed in
the evaluation solicitation:
1. 	 Description of AOT Program. The
process by which AOT is implemented
across the state is characterized and
described, and fundamental questions
of the fairness of the AOT program are
investigated. Specifically, are there
regional and cultural differences across
the state in AOT programs and their
implementation?
2. Service engagement.	 One of the
primary aims of AOT is to encourage
recipients to engage in community
treatment so as to avoid treatment in the
more restrictive inpatient setting. What
is the level of service engagement of
consumers in mental health services
during AOT, and does the duration of
AOT influence engagement?
3. Recipient outcomes.	 The
effectiveness of AOT is examined.
What are the outcomes for people with
mental illness who receive enhanced
outpatient services versus those who
are in AOT?
4. 	 Recipient perceptions of AOT. What
are the opinions of a representative
sample of AOT recipients regarding their
experiences with AOT?
5. 	 Post-AOT service utilization and
outcomes. The purpose of AOT, and

2

the optimal duration of AOT to achieve a
given purpose, likely varies across
recipients. AOT may be used to link
some people into treatment that they
will, once stabilized, accept voluntarily.
For others, AOT is an ongoing tool of
leverage intended to maintain treatment
adherence in persons who, due to the
nature of their illness, are otherwise
unwilling or unable to participate consistently in mental health services.
What is the level of service utilization of
AOT recipients following the termination
of the court order, and how does
utilization vary as a function of AOT
duration and recipient characteristics?
6. 	 Impact of AOT on service system. An
impressive amount of resources have
been allocated to support the AOT
Program, and individuals under AOT are
assured access to services. It is uncertain whether, as a consequence of AOT
implementation, resources have been
diverted from other adults with severe
mental illness in need of treatment.
What is the impact of AOT Programs on
the availability of resources for
individuals with mental illness, and what
are the perceived barriers to care?
Summary
An independent evaluation of New York
State’s AOT Program was a stipulation of
the 2005 reauthorization of Kendra’s Law.
This report presents the findings of the
evaluation, which examined nearly a
decade of administrative and service data
as well as newly collected interview data.
The report is organized around the six areas
of investigation that were outlined in the
evaluation request.

New York State Assisted Outpatient Treatment Program Evaluation

Chapter 1: What Does the Implementation of the Assisted Outpatient
Treatment (AOT) Program Look Like, and Are There Regional and Cultural
Differences Across the State in AOT Programs and Their Implementation?
In this chapter we describe the volume and
distribution of AOT orders across New York
State and discuss the variations in AOT
across local programs, regions, and target
populations. In addition to quantitative
analysis of administrative data collected by
OMH, we present qualitative data gathered
in our interviews with key stakeholders. A
major finding of our research is that
implementation and operations of the AOT
Program are not uniform across the state;
two discrete programs emerge in different
parts of the state. In addition, some
counties do not have an AOT Program at
all.
Implementation of the AOT Program
A total of 8,752 initial AOT orders and 5,684
renewals were granted from the inception of
the AOT program in 1999 through midyear
2007.3 AOT recipients represent a small
proportion of the total OMH adult service
population. For example, in 2005, of the
138,602 OMH adult service recipients with
severe mental illness, only 2,420 (1.7 %)
were AOT recipients. And yet, despite their
small numbers, persons under AOT receive
disproportionate attention, given their
serious needs, high cost to the service
system, and the public’s concern about the
target population for Kendra’s Law.
Under Kendra’s Law, a local AOT Program
was to be created to monitor and oversee
AOT implementation for each county and
New York City. In our interviews with key
stakeholders, we found that some counties
have an AOT Program but never use it.
Instead, these counties use their local
Single Point of Access (SPOA) program to

coordinate services for high need
populations. We also found that some
counties have no AOT Program at all.
Among the common reasons cited for not
utilizing AOT are the lack of infrastructure to
support court orders in smaller counties; the
belief that mental health problems should
not be dealt with by the legal system; and
the position that court orders are for the
benefit of providers rather than clients.
These quotes from key informant
administrators in counties that do not
routinely use AOT demonstrate various
local views on the use of AOT:
AOT is a reactionary approach to a high
publicity incident.
The law is implemented—we just don't
let it get to court.
I don't think anybody would benefit from
AOT. If I thought it would make a
difference, I would do it. I've gotten
close.
All counties receive AOT Program funding
and service dollars, regardless of whether
they actually have an AOT Program in
place. Although some counties do not use
the money for AOT recipients, they may use
these funds to serve high-risk clients in
other ways. Our interviews of county
officials indicate that AOT Program funding
is very important to the local service system
but yield no specific information about how
county-level AOT dollars are spent.
Exhibit 1.1 displays the distribution of 2005
AOT orders by county, with counties shaded

3

Throughout this report, unless specified otherwise, our data analysis goes through midyear 2007. While OMH continues to
collect AOT program data and publishes updated program statistics on its website, our formal evaluation required a cut-off point
to standardize the period of observation across datasets and to allow time to complete the extensive analyses presented herein.

New York State Assisted Outpatient Treatment Program Evaluation

3

according to the size of the population of
individuals with serious mental illness (SMI).
It is evident that a higher proportion of
individuals with SMI are located in New
York City and the surrounding counties,
along with the upstate metropolitan areas.
Likewise, there is a higher density of AOT
recipients in these areas. However, there

are some areas where the number of AOT
orders is inconsistent with the SMI
population density, which suggests other
sources of variation. Regional differences
emerged when we examined how AOT is
applied, the duration of the court order, and
the origination of petitions.

Exhibit 1.1 AOT Order Density and Estimated Serious Mental Illness Population
New York City
region enlarged

1 DOT = 1 AOT Order
8MI Populati
by Quintiles on per County
<

•

2000

2001-2600

.2601.4600
.4601-10000

•

10001 ·90000

New York City
region

Source: Combined analysis of data from OMH, the U.S. Census, and estimates from epidemiological surveys.

4

New York State Assisted Outpatient Treatment Program Evaluation

~
~

Regional variation in AOT
Which Comes First, Court-Mandated
AOT or Enhanced Voluntary Services
(EVS)?
For AOT to be ordered, individual
candidates who are petitioned for AOT must
meet legal eligibility criteria, and AOT must
be deemed the least restrictive alternative.
However, for some petitioned individuals, an
alternative plan may be drafted in which the
individual agrees to receive Enhanced
Voluntary Services (EVS); in most cases,
this plan includes being assigned to
intensive case management (ICM) or
assertive community treatment (ACT).
Although voluntary, the agreement may
have conditions of treatment participation
designed to avoid a court order for AOT.
The process for initiating voluntary
agreements and drafting enhanced service
plans are not statutory elements of Kendra’s
Law. However, they are used by many
county AOT Programs either prior to
initiating AOT or after a period of AOT.
Some counties instituted formal procedures
for voluntary agreements (i.e., legal
documents), and other counties use less
formal written or verbal agreements. While
counties do not report to OMH the individual
or identifying data on persons served under
these voluntary agreements, the number of
voluntary agreements has been
acknowledged and reported in earlier
program reports.
EVS First is primarily used in upstate
counties and is thought to satisfy the least
restrictive alternative requirement.
The extent to which EVS agreements were
used varied across counties, and varied in
the timing of the order. Some county AOT
Programs seek the court mandate before
moving towards a voluntary agreement after
some success under the mandate (i.e., AOT
First); these programs use voluntary
agreements as a path out of AOT. Other

county AOT Programs first elicit voluntary
participation in enhanced services before
resorting to the court mandate. They seek a
court order only if the individual does not
comply with the treatment specified in the
voluntary agreement (EVS First). A
psychiatrist from an upstate county
discussed this approach to providing EVS
First in the following way:
We don't do it like downstate or like
OMH wants. We use the voluntary
order first. We don't approach it in an
adversarial way.
But a psychiatrist working with a downstate
AOT program took a much different view.
If you meet criteria it would be foolish to
do less [than a court order].
We found notable regional differences in the
use of these two distinct models of AOT.
EVS First is primarily used in upstate
counties and is thought to satisfy the least
restrictive alternative requirement (inpatient
psychiatric hospitalization being the most
restrictive). AOT First is the predominant
model downstate where court orders are
usually given prior to discharge from an
inpatient setting. Liability concerns are
generally cited as the rationale for this
model; that is, the hospital is more
comfortable discharging the patient knowing
that an AOT court order is in place.
However, limited service slots and housing
availability are also influential in the decision
to use this model as court-ordered
individuals are given priority for these
scarce resources.
AOT First is the predominant model
downstate where court orders are usually
given prior to discharge from an inpatient
setting.
We examined patterns of AOT among
service recipients interviewed in six selected
counties. As seen in Exhibit 1.2, the EVS
First pattern was extremely rare in the
downstate counties of New York, Queens,

New York State Assisted Outpatient Treatment Program Evaluation

5

and Nassau. In contrast, this pattern was
quite frequent in two of the upstate counties
(Erie and Monroe). The majority of current
AOT recipients started the program under a
court order (AOT First). However, while
40% of recipients in the upstate AOT
Programs began with a voluntary
agreement (EVS First), only one individual

in the downstate programs followed this
pattern. Similarly, of those interviewed who
were currently under an EVS agreement,
89% located upstate had started out on the
voluntary agreement, whereas only 7% of
downstate EVS participants had started on
a voluntary agreement.

Exhibit 1.2. Program type by Assisted Outpatient Treatment
(AOT) and Enhanced Voluntary Services (EVS) in upstate and
downstate counties

EVS First
Program
Step
up
Step
dow n
AOT First
Program

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Ups tate (n=35)

D ow nstate (n=63)
AO T

Ups tate (n=53)

D ow ns tate (n=40)
EVS

Source: 6-county interviews

How Long Does An AOT Order Last?
Statewide, 32% of AOT orders last 6
months or less, while 68% last longer than
6 months. A small minority of orders—
14%—are kept in place for longer than 30
months. Regions vary to some extent in
the duration of AOT recipients’ orders, for
example, with the Central Region tending to
terminate orders sooner (48% end at 6
months), and Long Island extending orders
longer (81% last longer than 6 months).
Where Do AOT Petitions Originate?
The vast majority (84%) of petitions are filed
while the subject of the petition (the AOT

6

respondent) is an inpatient at a psychiatric
hospital. A small proportion of petitions
(13%) are filed while the respondent is in
the community, and an even smaller
proportion (3%) are filed by correctional
facilities. The proportion of AOT orders
originating in hospitals, prisons/jails, or
communities has varied over time, with a
slight increase in the proportion of orders
originating in jail or prison since the
beginning of the program. As shown in
Exhibit 1.3, there is notable regional
variation in the source of petitions. The
Central Region had proportionately more
AOT orders originating in jails or prisons
(21%), while the Western Region had

New York State Assisted Outpatient Treatment Program Evaluation

proportionately more orders originating in
the community (43%).

AOT has some carrot—not the teeth.
The fact is this statute has no teeth and
adversarial situations don't work with no
teeth. 9.60 (AOT) is gums but no teeth.

Interviews with key informants provided
several reasons for variation in the source
of AOT petitions—several driving factors
may vary by region and from case to case.
One important factor is regional differences
in rates of involuntary hospitalization and
incarceration due to bed capacity and
location of facilities in large metropolitan
areas. In some regions, a greater
proportion of the AOT target population may
be hospitalized, and thus, more accessible
to the AOT initiation process. Second, the
cost of petitioning for AOT can be
prohibitive for smaller hospitals and
individuals (i.e., family members). Third,
inpatient doctors in some facilities tend to
use AOT more routinely as part of a
discharge plan and as a form of risk
management, although several key
informants doubted AOT was an effective
risk management strategy. For example:

Fourth, family members may not wish to
initiate the petition, fearing that it will disrupt
their relationship with their loved one, and
prefer instead to wait until a petition follows
from a hospitalization. Fifth, petitions from
jail can be problematic given the uncertainty
of inmate release times.

Exhibit 1.3. Origin of AOT orders, 2002-2007, for various regions of New York.
100%

Percent total AOT orders

80%

60%

40%

20%

0%
Total

n=2068

Central

n=29

Hudson

Long Island

New York

West

n=264

n=1551

n=38

n=186
Hospital

Prison/Jail

Community

Source: Tracking for AOT Cases and Treatments

New York State Assisted Outpatient Treatment Program Evaluation

7

Other Regional Variations in AOT
Implementation
We found many other differences in how the
AOT Program is implemented. Some
counties integrated AOT with Single Point of
Access (SPOA) to facilitate the process and
provide highly coordinated services. One
key informant noted:
Central point of access for care coordination is key.
Other counties established formal
administrative procedures, including
standardized forms and reporting policies to
expedite administration of the law. In the
New York City boroughs, there is a formal
pick-up procedure when individuals are
noncompliant with the court order, making it
easier to execute a Removal Order for
someone under AOT who becomes
noncompliant with services. Other
variations in AOT Program implementation
stem from the court proceedings
themselves such as the continuity and
interest of the presiding judge and the
attitudes of the Mental Hygiene Legal
Service (MHLS) attorneys.
First, counties vary in whether they have a
single judge appointed to preside over all
AOT hearings or whether this position is
rotated among several judges. Judges’
interest in mental health law also varies.
Second, MHLS attorneys’ attitudes
regarding the AOT Program varied across
regions.
In some MHLS departments, lawyers
tended to view AOT as the least restrictive
alternative to hospitalization and as a
gateway to receiving needed community
services. These lawyers were likely to foster
a collaborative, and whenever possible, a
non-adversarial relationship with the
hospitals’ clinical staff – working together in
using AOT as a tool to obtain early
discharge for patients who had been
involuntarily committed to longer stays in
psychiatric facilities.
4

In other MHLS departments, lawyers were
likely to view their legal role as appropriately
adversarial with respect to the AOT
petitioners, representing their client’s own
wishes rather than “best interest” per se
defined by clinicians’ or family members.
These divergent views from MHLS
attorneys are illustrative:
We see AOT as a way for some clients
to get what they need. They are
severely mentally ill and need good
follow-up treatment in the community.
This is a way for them to get out of the
hospital much sooner.
The job of MHLS is to just give clients
the facts—their rights. We are not best
interest advocates. If they want a
hearing, so be it.
A judge in one area where MHLS attorneys
were known to hold the latter view noted
how their advocacy was a major strength of
the program.
Trends in the Use of AOT
At the beginning of the AOT Program in
1999, the number of AOT investigations
accelerated rapidly and remained much
higher than the number of resulting petitions
and court orders (see Exhibit 1.4).4
However, the number of investigations
began declining after 2001 as more eligible
referrals were made to the AOT Program.
Over time, program administrators and
service providers developed a keener ability
to identify candidates likely to meet the legal
eligibility requirements for AOT.

Data on the number of investigations was only recorded and reported to OMH until 2003.

8

New York State Assisted Outpatient Treatment Program Evaluation

Exhibit 1.4. AOT investigations, petitions, hearings, and orders during the initial
years of the program
6000

Num
Investigations
ber o f
Investigations

Hearings not

Number per year

5000

Num
ber o f in AOT
resulting
Petitions
orders Filed
Num
ber
o f New
New
AOT
orders
Orders

4000

Renewal AOT

Num ber o f
orders
Renew al Orders

3000

2000

1000

0
1999

2000

2001

2002

Source: Tracking for AOT Cases and Treatments and AOT Evaluation database

If an investigation does reach court, it is
very likely to result in an AOT order; out of
9,307 AOT hearings held, 8,752 (94%)
resulted in a court order. Thus, it appears
that ineligible AOT requests are largely
screened out before investigations reach
court. Exhibit 1.5 shows a steep start-up
curve in AOT hearings, orders, and
renewals from 1999 to 2002. After that,

however, the volume of AOT cases leveled
off as counties refined policy and
procedures. Also, as more people were
placed on AOT over time, and as more AOT
orders were renewed, the remaining pool of
AOT-eligible individuals shrank. Meanwhile,
AOT renewal orders increased and reached
a peak in 2005 with 1,236 renewal orders.

New York State Assisted Outpatient Treatment Program Evaluation

9

Figure
hearings,
orders,
renewals,
1999
– 2006.
Exhibit
1.51.5
AOTAOT
hearings,
orders,
andand
renewals,
1999
to 2006
1600
Number of Hearings Filed
1400

Number of New Orders

Number per year

Number of Renewal Orders
1200
1000
800
600
400
200
0
1998

1999

2000

2001

2002

2003

2004

2005

2006

Source:
OMH evaluation database.
Results based on TACT database.

The volume of AOT orders and renewals is
inevitably affected by local service capacity,
which is more limited in rural areas. For
example, many AOT treatment plans
specify ACT as the appropriate service
modality for the AOT recipient. However,
smaller programs may not have ACT teams
or may have no available caseload
openings on existing teams; ACT caseloads
are capped at 48 or 68 clients. Because of
limited service capacity, scarce resources
are selectively used for individuals most in
need, often defined as those at highest risk
for violent behavior. Most of the county
program personnel we interviewed indicated
that their AOT Programs had reached
capacity. They were now faced with
deciding which individuals would be most
appropriately served in the limited number
of slots made available through attrition or
“graduation” from AOT. Comments from an
AOT Director and ICM provider illustrate the
problem:

10

There have been (AOT) capacity issues
for some time now.
AOT really does work—but sometimes
people get stuck in AOT longer than
need to be—almost punishing them.
Some programs indicated that when
individuals meet AOT criteria but are not
deemed “high risk,” they do not receive AOT
until another recipient graduates from AOT.
According to aggregate data provided by
the counties, the rate per 100,000 of EVS
agreements initially was much higher than
the rate of AOT orders, as shown in Exhibit
1.6. However, AOT orders eventually
outpaced EVS orders —especially in
downstate counties—so that by 2006 the
rate of AOT orders was much higher than
that for EVS orders.
One important difference between AOT and
EVS that emerged in our key informant
interviews is that EVS recipients are very

New York State Assisted Outpatient Treatment Program Evaluation

rarely renewed in their voluntary
agreements. It is highly unlikely, particularly
downstate, that a client would remain on a
voluntary agreement for longer than six
months. In the AOT First model, AOT courtordered individuals are moved to a
voluntary agreement when they transition
from AOT, maintaining the same level of en-

hanced service for 6 months, and then are
entirely moved off the formal AOT Program
(though they may continue to receive case
management and other services as
needed). This then makes some room for
new AOT court orders.

Exhibit 1.6 Trends in rates of Assisted Outpatient Treatment (AOT) orders and
Enhanced Voluntary Services (EVS) agreements across New York counties
12.00
Voluntary enhanced

Rate per 100,000 population

AOT orders

10.00

8.00

6.00

4.00

2.00

0.00
2000

2003

2006

Source: OMH administrative data on AOT program

Enhanced Services: ACT and ICM
Kendra’s Law requires that the written
treatment plan include case management
services, typically ICM or ACT services,
while the individual is under the court order.
These enhanced services are also provided
to individuals on EVS agreements. ACT
teams and intensive case management
services are the cornerstones of the AOT
treatment plan and have received the

majority of the AOT ancillary funding
statewide. A look at the distribution of
treatment type among all individuals who
received AOT orders between 1999 and
mid-year 2007 (N=14,127) shows 20% of
cases received ACT and 74% received ICM.
The remaining 6% may have also received
ICM within the context of a blended case
management team5 or may have received
the less intensive supportive case
management.

5
Blended case management programs comprise both intensive case managers, who carry a smaller client caseload, and
supportive case managers.

New York State Assisted Outpatient Treatment Program Evaluation

11

Nearly half (47%) of AOT recipients also
have a co-occurring substance use
disorder. Equal proportions (34%) of AOT
recipients are white and black, meaning that
African Americans are overrepresented in
AOT from a population perspective. This
racial disproportionality is investigated
below.

Demographic Profile of AOT Recipients
A demographic description of all AOT
recipients6 is provided in Exhibit 1.7.7 The
most typical AOT recipient is a 38-year-old
single male in New York City who is
diagnosed with schizophrenia and living
with others or in a supervised residence.

Exhibit 1.7. AOT recipient characteristics


All AOT orders from 1999 to January 22, 2009
(n=7,368)

Age in years
Mean

38 years

Gender
Male

67%

Race/ethnicity 
White

34%

Black
Hispanic

34%
30%

Other
Marital status

2%

Single
Divorced

76%
8%

Married
Living situation

16%

Alone
With others
Supervised setting

14%
38%
36%

Psychiatric diagnosis
Schizophrenia 73%



Bipolar
Co-occurring substance use

18%
47%

Region
Central

2%

New York City
Hudson

71%
10%

Long Island
Western

11%
4%

Source: AOT Evaluation database

6

Although NY OMH systematically collects data on individuals on a court order, they do not collect data on individuals who
receive EVS. Descriptive information for a subsample of individuals receiving EVS is presented in Chapter 4.
7
The most up-to-date demographic data were derived for the OMH AOT website.


12

New York State Assisted Outpatient Treatment Program Evaluation

Racial Disparities in AOT: Are They
Real?
Since 1999 about 34% of AOT recipients
have been African Americans who make up
only 17% of the state's population, while
34% of the people on AOT have been
whites, who make up 61% of the
population.8 Thus, overall, African
Americans are more likely than whites to
receive AOT. However, candidates for AOT
are largely drawn from a population where
blacks are overrepresented: psychiatric
patients with multiple involuntary
hospitalizations in public facilities. The
answer to the question of whether AOT is
being applied fairly must take into account
all of the available data.9
To answer this question, we estimated and
compared rates of AOT for black and white
individuals using several alternative

denominators. These denominators can be
thought of as a series of concentric circles
encompassing relevant target populations,
from the broadest to the narrowest
definitions of who is “at risk” for receiving
AOT.10 We then conducted a multivariable,
longitudinal analysis of the association
between race and AOT at the county level
to see whether the relationship may be
accounted for by other underlying factors
that co-vary with race and AOT. Details
regarding methodology and statistical
analysis can be found in Appendix B.
Exhibit 1.8 displays the results graphically
for six counties and the state total.11 This
analysis shows that in the total population,
AOT affects African Americans 3 to 8 times
more frequently than whites – about 5 times
more frequently on average statewide.

8

Data updated from M. Cooper, “Racial Disproportion Seen in Applying ‘Kendra’s Law’,” New York Times, 7 April
2005.
9
Our investigation of this question involved multiple data sets including: OMH
administrative and clinical records on persons receiving AOT; OMH data on all service
recipients’ characteristics and hospital admissions; U.S. Census estimates of county population by race and
poverty status; county estimates of the prevalence of severe mental illness, applying epidemiological survey data to
the demographic profile of each county.
10
Relevant populations used as denominators included: 1) the general population; 2) those
with severe mental illness (SMI) in the community; 3) people with SMI receiving mental health services; 4) the
public mental health system’s adult services recipient population; 5) people with SMI who have been hospitalized
during a given year; 6) those who have been involuntarily committed to inpatient facilities more than once in the
previous year.
11

State totals were weighted by region.

New York State Assisted Outpatient Treatment Program Evaluation

13

Exhibit 1.8 AOT racial parity indices in 6 representative New York counties and statewide: Black to
white ratios of AOT case rates (2003 period-prevalence) using selected alternative denominators
Ratio of AOT rate for blacks to AOT rate for whites

9.00
Albany

8.00

Erie
Monroe

7.00

Nassau
New York

6.00

Queens
Weighted state mean

5.00
4.00
3.00
2.00

Parity line
(ratio = 1.0)

1.00
0.00

County
population

County SMI
population

County SMI
population
in OMH
services

County SMI
population in
OMH services
and hospitalized
in year

County SMI
population with
>1 involuntary
hospitalizations
in year

AOT case rate denominator
* Source: AOT Evaluation database, Tracking for AOT Cases and Treatments, US Census, Mental Health Needs
Assessment Project, OMH Patient Characteristics Survey, OMH hospital admissions data.

However, the analysis also shows that
these differences are dependent on context.
When the most relevant target populations
for AOT are considered, this ratio moves
closer to 1 leaving no appreciable racial
disparities in selection to AOT. The ratio is
reduced substantially when the
denominators used are the numbers of
black and white individuals who are
estimated to have SMI. These county SMI
estimates incorporate poverty status, which
is statistically associated both with SMI and
with African American racial background.12
This ratio declines even further when publicsector service recipients are considered as
12

the denominator. Finally, there is no
difference in black and white rates of AOT
among those who have been involuntarily
hospitalized at least twice. Parallel analyses
for Hispanics and other minority populations
show this same pattern and no appreciable
racial disparities are evident in selection of
these groups for AOT.
This analysis implies that the AOT rate is
influenced by a number of “upstream” social
and systemic variables such as poverty that
may correlate with race. However, we find
no evidence suggesting racial bias in the
application of AOT to individuals. Defining

E. Silver et al., “Neighborhood structural characteristics and mental disorder: Faris and Dunham revisited.” Social
Science and Medicine. 55 (2002): 1457-1470. C.E. Holzer et al., “Ethnicity, Social Status and Psychiatric Disorder:
Evidence from the Epidemiologic Catchment Area Survey.” In R. Price, B. Shea, & H. Mookherjee (Eds.) Social
Psychiatry Across Perspectives. (New York: Plenum, 1995): 93-104.

14

New York State Assisted Outpatient Treatment Program Evaluation

We find no evidence suggesting racial
bias in the application of AOT to
individuals. 
the target population as public mental health
system clients with multiple hospitalizations,
the rate of application of AOT to white, black
and other minority recipients approaches
parity.
Summary
AOT court orders rapidly increased since
the program’s inception but appear to be
leveling off in recent years. This trend may
be due to filled capacity in AOT Programs
and lack of new program funding. Across
the state, the highest number of AOT orders
tends to be found in areas with a greater
concentration of adults with severe mental
illness; New York City and surrounding
areas represent the majority of AOT orders

in the state. We found regional differences
across several elements of AOT
implementation and administration,
including upstate New York’s more
prominent use of EVS First model before
resorting to court-mandated AOT.
Downstate New York programs use AOT
First almost exclusively, only rarely using
voluntary agreements as a transition from
AOT. Although a large proportion of AOT
recipients are black, there is no apparent
racial bias in the program when target
population factors are taken into account.

New York State Assisted Outpatient Treatment Program Evaluation

15

16

New York State Assisted Outpatient Treatment Program Evaluation

Chapter 2. Engagement in Assisted Outpatient Treatment (AOT): What is
the Level of Engagement in Mental Health Services Among AOT
Recipients?
Introduction
A key goal of the AOT Program is to
motivate service recipients to actively
engage in their treatment during and after
their involvement with AOT. “Engagement”
here means motivation to actively
participate in regular community-based
treatment and services. As part of their
assessment of AOT recipients every six
months, case managers are asked to rate
the recipients’ level of engagement in
services on a scale ranging from “not at all
engaged in services” to “independently and
appropriately uses services.” For the
purposes of our data analysis, recipients
were considered to be positively engaged in
services if rated either “good—able to partner and can use resources independently”
or “excellent—independently and
appropriately uses services.”
Findings
Case Manager Ratings of Service
Engagement
At entry into the AOT Program, case
managers rated 33% of AOT recipients to
have positive service engagement, as
defined above. Rates of engagement
modestly improved over time on AOT: by
six months in the AOT Program, 45% were
rated as having positive engagement.
Similarly, among recipients with 12 months
of AOT or more, 46% were rated as
positively engaged. However, unless we
compare AOT recipients to similarly situated
individuals who did not receive AOT, it is
difficult to assess whether the court order
was a key ingredient in promoting
engagement or whether comparable gains
in engagement would have occurred over
time with voluntary treatment alone.

Comparing Case Manager Ratings of
Service Engagement for AOT and
Assertive Community Treatment (ACT)
Recipients
Most consumers in the AOT Program
receive one of two forms of case
management; ICM (74% of AOT recipients)
or ACT (20% of recipients). ACT is an
evidence-based treatment delivery model
designed to provide intensive communitybased services to persons with severe
mental illness who are difficult to serve in
conventional outpatient mental health
programs. While ACT is regarded by many
experts as an appropriate treatment
alternative to the use of AOT, it is also used
in conjunction with AOT for some recipients.
Hence, in New York the OMH case
managers systematically collect comparable
outcome data for all AOT and ACT
recipients but not for voluntary ICM
recipients.
It is thus possible to compare levels of
engagement among consumers who
receive ACT alone, AOT plus ACT, or AOT
plus ICM. This comparison allows us to
examine whether AOT adds any benefit in
engaging recipients in services when
compared to voluntary treatment with ACT
alone. Unfortunately, there is no voluntary
ICM group for comparison in this data
source and thus, no rigorous method to
compare voluntary versus court-ordered
ICM. In addition, recipients who receive
ACT versus ICM and the case managers
who assess them may not be comparable,
even when statistical adjustments to
improve their comparability are attempted.
Comparisons should not be made between
ACT and ICM outcomes in these analyses.
We compared levels of engagement across
these groups using multivariable analyses

New York State Assisted Outpatient Treatment Program Evaluation

17

offers no additional benefit in service
engagement compared to ACT alone (37%
versus 32% respectively). Recipients
receiving AOT with ICM demonstrate higher
levels of engagement (49%) compared to
ACT alone.

with statistical controls for potential
underlying differences that might have been
independently associated with higher engagement. Exhibit 2.1 displays the results
of this analysis. For recipients receiving six
months or more of treatment, AOT with ACT

Exhibit 2.1. Adjusted* percent with “good” or “excellent” service engagement by
treatment and legal status. Results contain all observations for 6 or more months of
treatment
60%

50%
49%

Adjusted percent

40%
37%
30%

32%

20%

10%

0%
ACT

AOT + ACT

AOT + ICM **

*Adjusted probability estimates were generated from repeated measures regression models controlled for time, region,
race, age, sex, diagnosis, baseline hospitalizations, baseline service engagement, education level, marital status,
substance use, medication adherence, and GAF. Statistical models used multiple imputation of missing data.
** Odds are less than 1 in 1000 that the difference between AOT + ICM and the other groups would occur by chance.
Sources = AOT Evaluation database and Child and Adolescent Integrated Reporting System

However, AOT of longer duration is
associated with modestly higher rates of
engagement. Exhibit 2.2 shows these
results for the subgroup of recipients with
AOT lasting at least 12 months. Over this
longer time period, a higher proportion of

18

recipients were rated with positive
engagement in the AOT with ACT group,
and in the AOT with ICM group, than in the
ACT-alone group (55%, 56% and 43%
respectively).

New York State Assisted Outpatient Treatment Program Evaluation

Exhibit 2.2. Adjusted* percent with “good” or “excellent” service engagement by treatment and legal
status. Results contain observations for 12 or more months of treatment only
60%
55%

50%

Adjusted percent

40%

56%

43%

30%

20%

10%

0%
ACT **

AOT + ACT

AOT + ICM

*Adjusted probability estimates were generated from repeated measures regression models controlled for time, region,
race, age, sex, diagnosis, baseline hospitalizations, baseline service engagement, education level, marital status,
substance use, medication adherence, and GAF. Statistical models used multiple imputation of missing data.
** Odds are less than 1 in 1000 that the difference between ACT and the other groups would occur by chance. Data
Source = AOT Evaluation database and Child and Adolescent Integrated Reporting System

Summary
Over all, when short-term AOT was included
in the analysis, we find that service
engagement was comparable for AOT and
non-AOT recipients on ACT teams.
However, after 12 months or more on AOT,

a higher proportion of AOT recipients in an
ACT program were judged to be positively
engaged than voluntary recipients of ACT
services. This suggests that longer-term
AOT combined with intensive treatment
increases service engagement compared to
voluntary treatment alone.

New York State Assisted Outpatient Treatment Program Evaluation

19

20

New York State Assisted Outpatient Treatment Program Evaluation

Chapter 3. Recipient Outcomes: What are the Outcomes for People with
Mental Illness who are Mandated into Assisted Outpatient Treatment (AOT)
Versus Those who Receive Enhanced Voluntary Services (EVS)?
Introduction
Comparing AOT to EVS
An important question in evaluating AOT is
whether court-ordered treatment with
enhanced services is more effective than
EVS. Some candidates for AOT are given
the opportunity to avoid a court order by
signing a voluntary agreement to participate
in EVS. Do AOT recipients experience
better outcomes than their counterparts
being served under EVS? As detailed in
Chapter 1, we found that EVS agreements
were relatively uncommon. Nonetheless,
where possible, we have drawn
comparisons between outcomes under EVS
versus AOT court orders. Arrest is one
important outcome where a direct
comparison was possible, due to the
availability of lifetime arrest records for
individuals enrolled in the study from six
counties.
As noted previously, most recipients in the
AOT Program receive one of two forms of
case management: Intensive Case Management (ICM) or Assertive Community
Treatment (ACT). A natural comparison
can be made between AOT and ACT, in
particular, because ACT is considered a
less coercive alternative to AOT for persons
with severe mental illness who need
intensive outpatient services. Because
case managers collect data using a
common form for AOT and ACT recipients
(but not for voluntary ICM recipients), it is
possible to compare case manager
assessments of outcomes among three
groups of service recipients: (1) ACT alone,
(2) AOT plus ACT, and (3) AOT plus ICM.
These comparisons allow us to address
whether AOT is more effective than a
voluntary intensive treatment program
(ACT) for similarly situated individuals with

severe mental illness. Moreover, these data
allow comparison of AOT implementation in
conjunction between two different models of
intensive case coordination: AOT with ACT,
compared to AOT with ICM. Unfortunately
there is no voluntary ICM group for
comparison in this data source and thus no
rigorous method to compare voluntary
versus court-ordered ICM. In addition,
recipients who receive ACT versus ICM and
the case managers who assess them may
not be comparable, even when statistical
adjustments to improve their comparability
are attempted. Comparisons should not be
made between ACT and ICM outcomes in
these analyses.
We first present an analysis of selected
recipient outcomes using data from 211
interviews with individuals in six selected
counties. For self-reported outcomes such
as violence, suicidality, and homelessness,
we compare individuals currently receiving
AOT to those who never had AOT or had it
longer ago than six months. For arrest, we
use official records of lifetime arrests to
conduct a more powerful longitudinal
analysis, comparing AOT recipients to EVS
recipients in the six counties. For these
arrest analysis, we used data from 181
individuals and 9,229 person-month observations.
Second, using case manager ratings for
5,634 AOT recipients, we also present
descriptive data comparing pre-AOT and
during-AOT periods regarding services
utilization, functioning, and selected
negative outcome events.
Using case manager ratings for AOT and
ACT recipients, we conducted a more
detailed statistical analysis of selected
outcomes in which we compared three
service conditions: voluntary ACT alone,

New York State Assisted Outpatient Treatment Program Evaluation

21

six counties: Albany, Erie, Monroe, Nassau,
New York, and Queens. A total of 277
interviews were conducted with three
groups of these service recipients: 115
individuals currently on AOT; 134
comparable individuals who had never
received AOT or received it more than six
months ago; and 28 individuals who had
completed a period of AOT six months ago.
About one third of the sample entered the
study in one group, thus later became
eligible for the second group; therefore, they
were interviewed more than once.

ACT plus AOT, and AOT plus ICM.
Analyses of the effects after 6 months used
data from 3,073 individuals with 7,611
person-period observations. Analyses of
effects after 12 months used data from
2,325 individuals with 5,581 person-period
observations. As explained in Appendix B,
we also used multiple imputation techniques
to handle missing data.
Third, using Medicaid claims data and other
OMH records, we assess important
outcomes including hospitalization, receipt
of medications, and receipt of case
management. These analyses examine outcomes for AOT recipients prior to and
during their AOT experience. The final
Medicaid analyses were conducted on a
sample of 2,839 AOT recipients with 84,089
person-months of data. (The method of
analysis is explained in Appendix B.)

The main descriptive results of the sixcounty interview study are presented in
Chapter 4. Here we examine some
selected outcomes for the 115 recipients
who were currently on AOT, compared to
the 134 recipients with no recent AOT.
Exhibit 3.1 shows that current AOT recipients and those with no recent AOT report
comparable rates of violence, suicidality,
homelessness, involuntary commitment,
and being picked up by police for transport
to mental health treatment. However, a
slightly lower percentage of current AOT
recipients report these negative outcome
events.

Findings
Client Outcomes From Direct Recipient
Interviews in Six Counties
Structured interviews regarding AOT and
related treatment experiences, attitudes,
and outcomes were conducted in a sample
of 211 persons with severe mental illness in

Exhibit 3.1. Six-county study sample recipient characteristics
No current or recent AOT
(n=134)

Current AOT
(n=115)

Outcome events (past six months)
N

%

N

%

Violent behavior*

21

(15.7)

12

(10.4)

Suicidal thoughts or attempts

22

(16.4)

17

(14.8)

(9.7)

6

(5.2)

Homelessness 13
Involuntary commitment

54

(43.2)

46

(41.4)

Mental health pick-up/removal

25

(18.7)

16

(13.9)

* As defined by the MacArthur Community Violence Interview. See Appendix B for description of instruments.
Source: 6-county interviews.

22

New York State Assisted Outpatient Treatment Program Evaluation

AOT/pre-EVS, current AOT, and current
EVS (results for post-AOT and post-EVS
are presented in Chapter 5--Exhibit 5.5). A
total of 9,225 person-month observations
were available for the multivariable timeseries analysis.

Arrest Outcomes Comparing Current
AOT and Current EVS Recipients In Six
Counties
Lifetime arrest records were obtained for
181 individuals who either received AOT or
EVS in six counties. The AOT Programs
identified the individuals receiving EVS
through their programs and specified the
periods during which they were receiving
EVS. Recipients of EVS are persons who
would have qualified for AOT orders but
signed voluntary agreements to receive
intensive services as an alternative to a
court order.

Exhibit 3.2 summarizes the results for
current AOT and current EVS compared to
pre-AOT/EVS. Moving into the current AOT
period from the pre-AOT/pre-EVS period,
the likelihood of arrest in any given month is
reduced from 3.7 to 1.9 percent per month.
This result is statistically significant; it would
have occurred less than 5 times in 100 by
chance alone. The effect for current EVS
was not statistically significant, although
there was a clear trend toward reduction of
arrests during EVS.

Using EVS and AOT tracking information
combined with arrest records, we examined
longitudinally whether people had been
arrested in a given month, by period: pre-

Adjusted percent arrested in month

Exhibit 3.2. Adjusted* percent arrested in month by current receipt of
AOT and EVS
4
3.5

3.7

3
2.8

2.5
2
1.9

1.5
1
0.5
0
Pre-AOT and Pre-EVS

Current AOT

Current EVS

*Adjusted arrest rate estimates were produced using multivariable time-series regression analysis, controlling for time,
region, age, sex, race, education, and diagnosis. Months spent in hospital are excluded from analysis.
Source: 6-county interviews and Division of Criminal Justice Services.

New York State Assisted Outpatient Treatment Program Evaluation

23

Client Outcomes from Case Manager
Reports
Treatment Planning: Care Coordination,
Medication Management, Substance
Abuse Services, and Housing Support
Services
Case managers were asked to report all
services that were explicitly identified in
AOT recipients’ treatment plans before and
after initiation of AOT orders. Because AOT
often started a new case management
relationship, many case managers had

limited knowledge of recipients’ status and
service history before AOT began; thus,
some of the information in the case
managers’ baseline reports should be
qualified as uncertain. With that caveat,
however, services included in recipients’
treatment plans appear to have increased
after initiation of AOT (Exhibit 3.3). In
particular, care coordination and psychiatric
medication management were included in
treatment plans for virtually all AOT
recipients after six months (99% and 96%,
respectively.) About half of AOT treatment
plans addressed substance abuse and
housing support services.

Exhibit 3.3. Service components of treatment plan prior to and during AOT order, 1999 – 2007,
n = 5634 recipients
100%
99% 99%

90%
80%

Prior to AOT,
per case report

96% 98%

On AOT,
6 m onths

82%

On AOT,
12 or more months

70%
60%

68%

50%

51%

55%
48%

40%

42%
37%

30%

29%

20%
10%
0%
Care coordination

Medication for psychiatric
condition

Substance abuse
services

Housing support services

Percents are unadjusted and based on case manager report at 6-month intervals.
Source: Child and Adolescent Integrated Reporting System and AOT Evaluation database

24

New York State Assisted Outpatient Treatment Program Evaluation

Recipient Functioning: Adverse Events
and Behaviors

There was a more notable decrease in case
managers’ appraisal of recipients’ nonadherence to medications – from 47% to
33% after six months of AOT. However,
non-adherence increased again to 43% in
the group of individuals who had been on
AOT 12 months or more. This could reflect
a retention bias in which individuals who
were less adherent were more likely to have
their AOT order renewed. Indeed, in the
Medicaid data analysis, we found that
individuals with lower medication
possession rates and higher hospitalization
rates during their initial AOT period were
significantly more likely to have their AOT
orders renewed.

Case managers reported a slight decrease
in adverse events after six or more months
of AOT (Exhibit 3.4). Self-harm decreased
from 9 % to 4 % and harm to others
decreased from 7 to 4%. The proportion of
individuals reporting at least one night of
homelessness also decreased from 12% to
7-8%. Because of the low incidence of
these events in general and the difficulty
case managers may have had in estimating
the frequency of events prior to AOT,
conclusions are limited from these data
regarding the effect of AOT in reducing
adverse events.

Exhibit 3.4. Adverse events or behaviors prior to and during AOT order, 1999 – 2007, n = 5634
recipients
50%
45%

Prior to AOT,
per case report

47%

On AOT,
6 m onths

43%

40%
35%
30%

On AOT,
12 or more months

33%

25%
20%
15%
10%

12%
9%

5%

7%
4%

0%
Did not adhere to
medication regimen

4%

Harmed self or
attempted suicide

7%
4%

8%

4%

Harmed another
person

Experienced
homelessness

Percents are unadjusted and based on case manager report at 6 month intervals. Non-adherence was defined as a score
of 1 or 2 on a 4 point scale, where 1=rarely or never takes medication as prescribed and 4=takes medication exactly as
prescribed. Experiencing homelessness was defined as being homeless for at least one night in the past 6 months.
Source: Child and Adolescent Integrated Reporting System and AOT Evaluation database.

New York State Assisted Outpatient Treatment Program Evaluation

25

without substantial help. Case managers
likewise reported as much as a 10%
increase in individuals who typically
engaged in pro-social behaviors such as
effectively handling conflict, engaging in
social activities, and asking for help when
needed.

Recipient Functioning: Life Management
Skills

Recipients showed modest improvements in
a variety of life skills after at least six
months of AOT, as assessed by case
managers (Exhibit 3.5). Case managers
reported as much as a 10% increase in the
proportion of individuals able to manage
their medications and personal finances

Exhibit 3.5. Recipient functioning prior to and during AOT order, 1999 – 2007, n = 5634 recipients
90%

Prior to AOT,
per case report

80%
74%

70%
60%

77%

80%
76% 76%

67%

83%

On A OT,
6 months

79%

On A OT,
12 or more months

74% 74%

75%

68%

62%
58%

50%

52%

40%
30%
20%
10%
0%
Manages
medication without
substantial help

Handles personal
finances without
substantial help

Typically handles
conflict effectively

Typically engages
in social and/or
family activities

Typically asks for
help when needed

Percents are unadjusted and based on case manager report at 6 month intervals. All ratings are based on a 5 point
scale.
Source: Child and Adolescent Integrated Reporting System and AOT Evaluation database.

Psychiatric Hospitalization Rates from
Case Manager Reports

comparable outcome data for all AOT and
ACT recipients, but not for voluntary ICM
recipients. Thus, it is possible to compare
reported outcomes for recipients of ACT
alone, AOT plus ACT, or AOT plus ICM.

As mentioned in Chapter 2, individuals
under AOT typically receive one of two
forms of case management: ICM (74% of
AOT recipients) or ACT (20% of recipients).
Case managers systematically collect

To examine hospitalization outcomes with
these case manager data, we conducted a
multivariable repeated-measures analysis,
controlling for a range of underlying
variables that could have affected hospitali-

Comparing AOT to Voluntary Intensive
Treatment Alternatives

26

New York State Assisted Outpatient Treatment Program Evaluation

zation independently of AOT. As shown in
Exhibit 3.6 below, hospitalizations were
reduced by about one half among
individuals who received 12 months or more
of AOT (combined with either ACT or ICM),
compared to their baseline hospitalization
rate. Also, the chance of hospital admission
was substantially reduced — from about
58% to 36% — among these AOT recipients
with either ACT or ICM, compared to those
receiving only ACT without AOT.

we find highly statistically significant
differences in the likelihood of hospital
readmission; the odds are less than 1 in
1000 that these results would occur by
chance. A limitation of these results is that
hospitalizations here are reported by case
managers and are not independently
verified. (Results using hospital records will
be reported later in this chapter.)

Thus, whether we compare AOT recipients
at two points in time (baseline and 12
months), or compare AOT-plus-ACT
recipients to those receiving ACT alone,

Exhibit 3.6. Adjusted* percent hospitalized per 6 months, by AOT status at baseline and after 12
months of treatment
80%

Adjusted percent

60%

ACT

74%

70%

AOT + A CT
AOT + ICM

63%

62%

58%

50%
40%
36%

30%

36%

20%
10%
0%
Baseline

12 m onths

*Adjusted probability estimates were generated from repeated measures regression models controlled for time, region,
race, age, sex, diagnosis, baseline hospitalizations, baseline arrests, living situation, education level, presence of
dependent children, marital status, substance use, service engagement, medication adherence, and Global Assessment
of Functioning (GAF). Statistical models used multiple imputation of missing data.
Source: Child and Adolescent Integrated Reporting System and AOT Evaluation database.

New York State Assisted Outpatient Treatment Program Evaluation

27

voluntary ACT alone (61%). These results
should be viewed with caution; differences
in identifying and treating substance use in
ACT and ICM programs could account for
these differences.

Substance Abuse Rates From Case
Manager Reports

For individuals receiving six months or more
of treatment, substance use rates were
much lower for individuals receiving AOT
plus ICM (29%) compared to those
receiving AOT plus ACT (59%) or

Exhibit 3.7. Adjusted* percent using substances in last 6 months, by treatment and
legal status. Results contain all observations for 6 or more months of treatment.
70%
60%

61%

59%

50%

Adjusted percent

40%
30%

29%

20%
10%
0%
ACT **

AOT + ACT **

AOT + ICM **

*Adjusted probability estimates were generated from repeated measures regression models controlled
for time, region, race, age, sex, diagnosis, baseline hospitalizations, baseline service engagement,
education level, marital status, substance use, medication adherence, and GAF. Statistical models
used multiple imputation of missing data.
**Odds are less than 1 in 100 that the difference between the AOT + ICM and the AOT + ACT groups,
or between the AOT + ICM and the ACT groups, is due to chance.
Source: Child and Adolescent Integrated Reporting System and AOT Evaluation database.

For recipients who underwent 12 months or
more of AOT, substance use outcomes
were very similar to those reported for six
months or more of treatment.
Outcomes Analysis Using Medicaid and
OMH Records

Using Medicaid and OMH records, we are
able to assess three important outcomes for
AOT recipients: psychiatric hospital
admissions, receipt of psychotropic medications, and receipt of case management

28

services. These analyses compared outcomes for AOT recipients before and during
their AOT experience, and for short-term
AOT (one to six months) and longer-term
AOT (12 months or more.) Findings are
based on repeated measures multivariable
analyses, with statistical controls for
potential underlying differences between
individuals in these different groups. The
Medicaid analyses were conducted on a
sample of 2,839 AOT recipients with 84,089
person-months of data. (The method of
analysis is explained in the Appendix B.)

New York State Assisted Outpatient Treatment Program Evaluation

might appear modest, it would represent
substantial reductions in hospitalizations for
AOT recipients statewide. Regarding statistical significance, these differences between
the pre-AOT state and each of the other two
periods of AOT experience would have
occurred less than one time in 1000 by
chance alone.

Psychiatric Hospitalization Rates and
Days in Hospital from Medicaid and OMH
Records

Compared to the pre-AOT monthly hospitalization rate of 14%, the probability of
hospital admission was reduced to 11% per
month during the first six months of AOT
and to 9% during the 7-12 month period of
AOT. Exhibit 3.8 displays these results.
While this decrease in hospital utilization

Exhibit 3.8. Adjusted* percent with psychiatric inpatient treatment in month,
by AOT status
16%
14%

14%

12%

11%

Adjusted percent

10%

9%

8%
6%
4%
2%
0%

Pre-AOT

AOT 1-6
months

AOT 7-12
months

*Adjusted probability estimates were generated from repeated measures regression models controlled
for time, region, race, age, sex, diagnosis, and co-insurance status. Models were also weighted for
propensity to initially receive AOT and to receive more than 6 months of AOT.
Source: Medicaid claims and OMH admissions database

Exhibit 3.9 presents comparable results for
the average number of days hospitalized
per six month period. During the period
prior to AOT, recipients on average
experienced 18 days of hospitalization over
the course of six months, excluding the
hospitalization when AOT was initiated. In
contrast, during AOT, recipients spent 11

days in the hospital during the first six
months of AOT and 10 days during the 7-12
month period of AOT. While this decrease in
hospital days per six month period might
appear modest, it would again represent
substantial reductions in hospital days
statewide.

New York State Assisted Outpatient Treatment Program Evaluation

29

Exhibit 3.9. Adjusted* average inpatient days during any 6 month period, by
AOT status
20
18

Average number of days

16

18

14
12

11

10

10

8
6
4
2
0
Pre-AOT

AOT 1-6 months

AOT 7-12 months

*Adjusted mean estimates were generated from repeated measures regression models controlled for
time, region, race, age, sex, diagnosis, and co-insurance status. Models were also weighted for
propensity to initially receive AOT and to receive more than 6 months of AOT.
Source: Medicaid claims and AOT Evaluation database.

Receipt of Psychotropic Medications
from Medicaid and OMH Records

We also used Medicaid claims data to
examine changes in receipt of psychotropic
medication under AOT. Medication receipt
was defined as having filled a prescription
for a medication appropriate to the diag-

30

nosed psychiatric condition and having a
sufficient supply during 80% or more of the
days in a given month. As shown in Exhibit
3.10, medication receipt (so defined)
increased from 35% per month prior to
AOT, to 44% during the first six months of
AOT, to 50% during the 7-12 month period.

New York State Assisted Outpatient Treatment Program Evaluation

Exhibit 3.10. Adjusted percent* with at least 80% medication possession in month by AOT status
55%

Adjusted percent

50%

50%

45%

44%

40%
35%

35%

30%
25%
20%

Pre-AOT

AOT 1-6
months

AOT 7-12
months

*Adjusted probability estimates were generated from repeated measures regression models controlled
for time, region, race, age, sex, diagnosis, and co-insurance status. Models were also weighted for
propensity to initially receive AOT and to receive more than 6 months of AOT.
Source: Medicaid claims and AOT Evaluation database.

Receipt of Case Management from
Medicaid and OMH Records

Finally, we used Medicaid data to examine
monthly receipt of intensive case
management services (ACT and ICM)
during AOT. These results are shown in
Exhibit 3.11. Monthly receipt of ACT
services increased from 1% in the pre-AOT
period to 8% in the first six months of AOT

and 10% during the 7-12 month period.
Receipt of ACT or ICM services increased
from 11% in the pre-AOT period to 28% in
the first six months and 33% during the 7-12
month period. Receipt of any case
management services increased from 18%
in the pre-AOT period to 44% in the first six
months and 53% during the 7-12 month
period.

New York State Assisted Outpatient Treatment Program Evaluation

31

Exhibit 3.11 Adjusted* percent receiving case management services in month by AOT status
60%
Pre-AOT
AOT 1-6 months

Adjusted percent

50%

53%

AOT 7-12 months
44%

40%
30%

33%
28%

20%
18%
10%
0%

1%

8%

10%

11%

ACT

ACT-ICM

Any case mgt.

*Adjusted probability estimates were generated from repeated measures regression models controlled
for time, region, race, age, sex, diagnosis, and co-insurance status. Models were also weighted for
propensity to initially receive AOT and to receive more than 6 months of AOT.
Source: Medicaid claims and AOT Evaluation database.

Summary

The outcomes detailed heretofore should be
understood and interpreted in the context of
other findings in the remaining chapters.
For example, elsewhere we examine how
recipients fare when AOT ends and how
AOT affects the treatment experiences of
recipients. These and other results are
synthesized in the Executive Summary and
the final chapter of the report.
During AOT there is a substantial reduction
in the number of psychiatric hospitalizations
and in days spent in the hospital if a person
is hospitalized. We also find moderately
strong evidence from lifetime arrest records
of AOT and Enhanced Voluntary Services

32

recipients that AOT reduces the likelihood of
being arrested. In addition, we find
substantial increases in receipt of intensive
case management services during AOT.
Compared to their experiences prior to AOT
recipients are far more likely to receive
intensive forms of case management under
AOT. We also find that AOT recipients are
far more likely to consistently receive
psychotropic medications appropriate to
their psychiatric conditions compared to
their experiences pre-AOT. Case Managers
of AOT recipients also report subjective
improvements in many areas of personal
functioning, such as managing
appointments medications and self-care
tasks.

New York State Assisted Outpatient Treatment Program Evaluation

Chapter 4. Participants’ Perceptions of Assisted Outpatient Treatment
(AOT) and Related Treatment Experience and Attitudes
This chapter presents survey results
regarding recipients’ perceptions of AOT,
treatment experiences, and related attitudes
in a sample of 211 persons with severe
mental illness in six counties including
Albany, Erie, Monroe, Nassau, New York,
and Queens. Structured interviews were
conducted with three groups of service
recipients:
•	 Current AOT: (n=115) consists of
individuals currently on AOT or receiving
AOT during the previous six months (the
interview reporting period).
•	 No recent AOT: (n=134) consists of
comparable individuals who had not
received AOT in the past or had AOT
that ended longer ago than six months.
This group included some individuals
who were about to embark on a new
period of AOT but had not been on AOT

during the previous six months, i.e., the
interview reporting period. Of those with
any AOT history in this group, nearly
80% had not had AOT in at least 12
months.
•	 AOT in the recent past: (n=28)
consists of individuals who had
completed a period of AOT six months
ago but were not on AOT during the
immediately preceding six months
leading up to the interview.

Sample selection in the six counties was
designed to obtain information about the
AOT experience throughout the state.
However, the sample does not reflect the
actual regional distribution of AOT cases.
Exhibit 4.1 presents descriptive
characteristics of these sample groups.

New York State Assisted Outpatient Treatment Program Evaluation

33

Exhibit 4.1. Six-county interviews sample characteristics
No current or recent
past AOT
Current AOT
(n=134)
(n=115)
Age
Age in years at index
hospitalization mean:
38.8
(sd: 11.3)
mean: 39.4
(sd: 11.6)
n
%
N
%
Sex
Male
80
50.7
76
66.1
Female
54
49.3
39
33.9
Race/Ethnicity
White
67
50.0
52
45.2
Black
59
44.0
50
43.5
Hispanic
17
12.7
10
8.7
Asian
6
4.5
2
1.74
Other
9
6.7
18
15.6
Education
Completed high school
100
74.6
90
78.9
Employment
Worked for pay
25
18.7
20
17.4
Clinical characteristics
Schizophrenia 103
77.4
84
73.0
Affective disorder
31
22.6
31
27.0
Any substance abuse
36
26.9
32
27.8
County
Albany
13
9.7
13
11.3
New York
22
16.4
31
27.0
Nassau
19
14.2
32
27.8
10.4
8.2
12
Queens
11
Erie
43
32.1
8
7.0
Monroe 26
19.4
19
16.5
Source: Interviews with AOT program recipients in six selected counties

The three groups were similar in their
demographic and clinical characteristics.
The majority were male; about half were
white;13 about three quarters had completed
high school; and less than one in five was
employed even part time (any paid work).
About three-quarters of the sample had a
diagnosis of schizophrenia or other
psychotic disorder; about one quarter had a
co-occurring substance abuse problem, i.e.,
reported symptoms of alcohol use disorder
and/or were using illicit drugs. (Case
manager assessments of substance abuse
comorbidity in this population are higher –
around 40%; see Chapter 3.)

Recent past AOT
(n=28)
mean: 41.6
n

(sd: 13.2)
%

18
10

64.3
35.7

16
11
0
1
2

57.1
39.3
0.0
3.6
7.1

23

82.1

6

21.4

21
7
5

75.0
25.0
17.9

4
5
11
1
1
6

14.3
17.9
39.3
3.6
3.6
21.4

Exhibit 4.2 displays mean item scores
across a range of attitudinal scales for the
three subsamples. These scales are meant
to capture subjective perceptions of AOT
and comparable treatment experiences for
people with SMI in New York. The scales
are grouped into areas: (1) AOT
understanding, perceived benefits, and
stigma; (2) personal autonomy, treatment
relationships, and satisfaction; and (3)
coercion, pressures, barriers to treatment,
and procedural justice.14

13

The proportion of whites is higher in this sample than the statewide AOT sample because of the incorporation of
several upstate counties.
14
Specific information about the measures used is provided in Appendix B.

34

New York State Assisted Outpatient Treatment Program Evaluation

Exhibit 4.2. AOT recipients’ attitudes and experience by AOT period
No current or recent AOT
(n=134)1
Item Mean
St. Dev.
AOT beliefs and attitudes
AOT understanding
0.89
0.29
AOT stigma
0.19
0.40
AOT perceived effectiveness
0.60
0.46
Treatment autonomy, relationships and satisfaction
Empowerment 3.70
0.43
Working alliance
4.06
0.79
Treatment satisfaction
3.90
0.74
Attitudes about taking medication
0.74
0.21
Life satisfaction
4.81
1.51
Coercion, pressures, and barriers
Coercion
2.76
0.96
General pressures to adhere to
0.30
0.15
treatment
Pressures-warnings
0.35
0.18
Pressures-sanctions
0.15
0.19
Pressures-med oversight
0.48
0.39
Pressures-commitment
0.27
0.33
Perceived effectiveness/fairness of
2.68
0.56
pressures
Procedural justice
1.80
0.65
Mandate-related treatment barriers
0.28
0.31
Nonmandate-related treatment
0.42
0.34
barriers
Fear of commitment
0.37
0.48
1

Current AOT
(n=115)
Item Mean
St. Dev.

Recent past AOT
(n=28)
Item Mean
St. Dev.

0.97
0.26
0.81

0.05
0.44
0.31

0.97
0.07
0.90

0.05
0.26
0.25

3.66
3.99
3.74
0.72
4.84

0.43
0.79
0.84
0.20
1.71

3.70
4.16
4.17
0.78
4.57

0.31
0.55
0.47
0.17
1.32

2.97
0.31

1.15
0.16

2.76
0.22

0.90
0.12

0.36
0.16
0.48
0.28
2.79

0.20
0.18
0.38
0.33
0.57

0.28
0.05
0.36
0.09
2.40

0.17
0.09
0.36
0.24
0.34

1.96
0.28
0.33

0.32
0.33
0.32

2.02
0.17
0.30

0.29
0.27
0.33

0.37

0.49

0.36

0.49

group n=110 for AOT understanding and procedural justice

Source: Interviews with AOT program recipients in six selected counties

AOT Beliefs and Attitudes

Knowledge and understanding of AOT
provisions—what AOT legally requires—
was measured with 12 true/false items.
Mean item scores ranged from 0 (none
correct) to 1 (all correct), with higher scores
indicating more accurate understanding of
legal requirements under AOT. A sample
item included: “When they have an AOT
order, people are required to go to mental
health treatment appointments that are part
of the treatment plan [true].” Among current
and recent past AOT participants, mean
item scores approached 1 for this 12-item
scale, indicating a high percentage of
correct answers and a good understanding
of AOT across groups. The mean score
was also high (0.89) for participants with no
recent AOT experience.

Perceived AOT stigma was measured with
a single yes/no question: “When people are
under AOT, do you think that most other
people think less of them?” Fewer than 1 in
4 participants answered this question
affirmatively. However, endorsement was
slightly higher among current AOT
participants than non-AOT or post-AOT
participants.
AOT perceived effectiveness was measured
with three yes/no items. Item means
ranged from 0 (all no) to 1 (all yes), with
higher scores indicating greater agreement
that AOT was effective in helping people
keep scheduled outpatient treatment
appointments, take prescribed medication,
and remain in the community without being
hospitalized. Findings for this scale showed

New York State Assisted Outpatient Treatment Program Evaluation

35

a mixed response for non-AOT respondents
and a higher, more positive response
among current AOT recipients compared to
those with no recent AOT (mean=0.60 vs.
0.81.). The highest mean item score was
found for the recent AOT graduates
(mean=0.90).
Personal Empowerment, Treatment
Relationships, and Satisfaction

Empowerment was measured with a 15item standardized scale, with mean item
scores ranging from 1 to 5, from “strongly
disagree” to “strongly agree.” A sample
item included: “When I make plans, I am
almost certain to make them work.” All
three sample subgroups scored in the
positive middle range—above neutral but
not agreeing strongly with these items.
There were no differences between
samples (mean=3.7 in each group).
Working alliance is a construct that captures
the quality and strength of the therapeutic
relationship between the service recipient
and case manager. The Working Alliance
Inventory (short version) was administered
as an 8-item standardized instrument, with
responses ranging from 1 to 5, from
“strongly disagree” to “strongly agree.” A
sample item included: “[Case manager] and
I are working toward mutually agreed upon
goals.” All three groups scored on average
about 4 out of a possible 5 on these items,
indicating positive perceived working
alliance, with little or no differences between
groups.
Treatment satisfaction was measured using
a 9-item standardized scale, with mean item
scores ranging from 1 to 5 from “strongly
disagree” to “strongly agree.” A sample
item included: “I liked the services that I
have received in the past six months.”
Findings on this scale indicate similarly
positive levels of satisfaction with treatment
across all three subsamples—close to 4 out
of 5 on average.

36

Attitudes and experience with taking
medication for mental health problems was
captured with the Drug Attitudes Inventory
(DAI-modified), a standardized 18-item
scale (the original had 10 items), with mean
item scores ranging from 0 (no items
endorsed) to 1 (all items endorsed). Higher
scores indicated more positive attitudes
towards medication, higher perceived
effectiveness of medication, and fewer
problems with side effects. A sample item
included: “By staying on medications, I can
prevent getting sick.” Scores on the DAI
across the three subsamples averaged
about 0.75 on the 0 to 1 mean item scale,
indicating similar and mostly positive
attitudes about taking medication for mental
health problems.
Life satisfaction or subjective quality of life
was measured with a single item—“How do
you feel about your life as a whole?”—on a
7-point scale from “terrible=1” to
“delighted=7.” Mean scores on this item
varied little across all three subsamples—
from 4.6 to 4.8—indicating moderately
positive perceived quality of life in each
group.
Coercion, Pressures, Barriers to
Treatment, and Procedural Justice

Perceived coercion was measured with a 5item standardized scale, with mean item
scores ranging on a scale of 1 to 5 from
“strongly agree” to “strongly disagree.” A
sample item included: “I felt free to do what
I wanted about getting treatment.” Strong
disagreement with this and similar items
indicated greater perceived coercion.
Findings on this scale showed moderate
levels of coercion—just under 4 out of a
possible 5—across all three subsamples.
General pressures to adhere to treatment
were measured with a 33-item standardized
scale of yes/no questions. Mean item
scores ranged from 0 (all no) to 1 (all yes),
with 1 indicating more pressure being
exerted. The scale also included 4
subscales: warnings, sanctions, medication

New York State Assisted Outpatient Treatment Program Evaluation

oversight, and commitment pressure.
Sample items included: “Did anyone tell
you that you may lose your housing if you
don’t follow your treatment plan”?
[warnings]; “Did anyone report on your
behavior to a probation/parole officer?”

anyone watch you take
[sanctions]; “Did
your medication to make sure you took it
regularly?” [oversight]; and “Did anyone try
to commit you to a hospital against your
will?” [commitment
pressure]. The pattern

of responses on these subscales again
showed no differences between
subsamples. Across all groups, similarly
low levels of pressures were reported, with
the highest being for “oversight” pressure.

Perceived effectiveness and fairness of
pressures to adhere to treatment was
measured with a 9-item standardized scale,
with mean item scores ranging on a scale of
1 to 5 from “strongly agree” to “strongly
disagree,” lower scores indicating greater
perceived effectiveness and fairness
regarding pressures to adhere to treatment.
A sample items included: “Overall, the
pressures or things people have done were
for my own good.” Findings on this scale
across all three groups were in the positiveneutral range, between 2.4 and 2.8 on the 1
to 5 mean item scale, indicating similarly
mixed views within each group about
whether pressures to adhere to treatment
were effective and fair.
Procedural justice was measured on a sixitem standardized scale. Mean item scores
varied on a scale from 1 to 3, from “not at
all” to “somewhat” to “definitely.” A sample
item included: “When you received the AOT
court order, did they treat you respectfully?”
Results for this scale showed some
difference between groups, with current
AOT recipients reporting higher perceived
procedural justice than their counterparts
who had not recently experienced AOT
(1.96 vs. 1.80).
Barriers to treatment were measured with
six true/false items. Item mean scores
could vary from 0 (all false—no barriers

reported) to 1 (all true—all barriers
reported); higher scores, closer to 1,
indicated more barriers. The items were
divided into mandate-related and nonmandate related barriers. Sample items
included: “Did you delay getting help
because you think that if you went for
treatment you might be forced to take some 
medicine or treatment that you don’t want?” 
[mandate-related barrier]; and “Did you
delay getting help because you… [non
mandate-related barrier such as believing
not in need]. Current AOT recipients were
less likely to report non-mandate related
barriers than those with no recent AOT
(mean=0.33 vs. 0.42).
Current AOT participants apparently did
not experience more adverse subjective
conditions around mental health
treatment than comparable individuals
who were not under AOT. 

Participants were also asked a single
yes/no question about fear of involuntary
commitment and treatment seeking. “Has
fear of being involuntarily committed ever
caused you to avoid treatment for mental
health?” The mean score could vary from 0
(if everyone had answered “no”) to 1 (if
everyone had answered “yes”). The mean
score for this variable in Exhibit 4.2 is the
same as the percentage of the sample who
answered “yes” – approximately one third of
participants in each subsample.
Summary

Face-to-face, structured interviews were
conducted with 277 persons with severe
mental illness in six counties in New York:
115 current AOT recipients, 134 persons
with no recent AOT, and 28 persons with
recent AOT experience. Participants were
assessed on standardized scales
measuring a wide range of AOT-related
attitudes and treatment experiences in three
general areas: (1) AOT understanding,
perceived effectiveness, and stigma; (2)
personal empowerment, treatment

New York State Assisted Outpatient Treatment Program Evaluation

37

relationships, and satisfaction; and (3)
coercion, pressures, barriers to treatment,
and procedural justice. For the most part, no
differences were found among groups;
findings were remarkably similar
irrespective of AOT status. However,
current AOT participants reported lower
levels of non-mandate related treatment
barriers and greater perceived effectiveness
of AOT, as summarized in Exhibit 4.3.
Previous studies of coercion have found
that when recipients have had an
opportunity to voice their concerns about

involuntary treatment and have their
concerns heard, it attenuates their feeling of
being coerced and this may bear on these
findings wherein recipients have their “day
in court.” The overall importance of the sixcounty survey findings is that, despite being
under a court order for treatment, current
AOT participants apparently did not
experience more adverse subjective
conditions around mental health treatment
than comparable individuals who were not
under AOT.

Exhibit 4.3. Perceived AOT effectiveness and treatment barriers by AOT Status
100
90
80

Percent

50

Currently on AOT

81%

70
60

No recent AOT

90%

Recently had AOT

60%

40

42%

30

33%

20

30%

10
0

Report AOT Effectiveness

Report Barriers to treatment

Source: 6-county interviews.

38

New York State Assisted Outpatient Treatment Program Evaluation

Chapter 5. Service Engagement and Outcomes After Assisted Outpatient
Treatment (AOT) Ends: What are the Levels of Service Engagement and
Outcomes for Post-AOT Recipients?
Introduction

An additional important area of investigation
is what happens to AOT recipients after
they leave the program. Past research
provides little information about post-AOT
outcomes. If consumers do make gains
during AOT, are these gains sustained over
time?
To address this question we used two
sources of data: direct interviews with postAOT recipients and Medicaid claims data.
Our sample of post-AOT recipients is quite
small (N=28), and therefore, these results
are descriptive in nature. In contrast, results
reported from Medicaid data contain a large
number of recipients and allow a rigorous
evaluation of key post-AOT outcomes.
Findings
Post-AOT Outcomes: Direct Recipient
Interviews

As presented in Chapter 4, direct in-person
interviews regarding AOT and related
treatment experiences and attitudes were
conducted with 115 individuals currently on
AOT; 134 comparable individuals who had
never received AOT, or had it longer ago
than 12 months; and 28 individuals who had
completed a period of AOT within the
previous twelve months. Here we compare
the interview results for the 28 recipients
who had recently completed a period of
AOT to the other two sample groups.
We find that recipients report few
differences in treatment experiences and
attitudes in the post-AOT period. Compared
to recipients currently on AOT (see Exhibit
4.2), there were few differences in a wide
range of AOT-related attitudes and
treatment experiences after AOT ended.
These post-AOT recipients resembled those

on AOT in their understanding of AOT, their
perceptions of AOT effectiveness, and their
awareness of social stigma associated with
AOT. Post-AOT recipients also did not
differ in their sense of personal
empowerment, satisfaction with treatment,
perceived coercion related to treatment, or
perceived informal pressures to engage in
treatment. Finally, they did not differ in their
reported barriers to treatment and their
sense of being fairly treated.
In the post-AOT period recipients reported
appointment and medication adherence
comparable to adherence during AOT.
Community functioning and level of symptomatology were relatively similar as well.
Other areas unchanged in the post-AOT
period were self-report of substance abuse,
violence, suicidality, homelessness, and
arrests.
Post-AOT Psychiatric Hospitalization
Rates and Days in Hospital from
Medicaid and OMH Records

Using Medicaid and OMH records, we
assessed recipient outcomes such as
hospitalization, receipt of medications, and
utilization of case management. These
analyses compare outcomes for AOT
recipients before, during, and after their
AOT experience. We also compare postAOT outcomes for recipients who had shortterm AOT (one to six months) versus
longer-term AOT (7 to 12 months), and
between those who continued to receive
Assertive Community Treatment (ACT) or
intensive case management (ICM) services
after their AOT order ended and with those
who did not continue to receive these
services.
Findings in Chapter 3 detailed reductions in
rates of psychiatric hospitalization during

New York State Assisted Outpatient Treatment Program Evaluation

39

AOT. Here we explore whether these
reductions in rates of psychiatric hospitalization persist once AOT is terminated.
Findings are based on multivariable
analyses with statistical controls for
potential underlying differences among
recipients across these different groups.
For individuals who receive AOT for a
period of six months or less, we find that the
likelihood of subsequent hospitalization
depends on whether intensive outpatient
services utilization continues after the AOT
order ends. If the recipient continues to

receive post-AOT intensive case coordination services in the form of ACT or ICM,
the predicted probability of hospitalization
within any post-AOT month is substantially
reduced relative to the pre-AOT period (7%
vs. 11% per month). However, if ACT or
ICM is also discontinued when AOT ends,
the predicted probability of post-AOT
hospitalization rises to 10% per month,
which is comparable to the pre-AOT
hospitalization rate. These results are
displayed in Exhibit 5.1.

Exhibit 5.1. Adjusted* percent with psychiatric inpatient treatment in any given month over
short-term** AOT course
14%

Before AOT

Adjusted percent

12%

10%

During
short-term AOT

After short-term AOT ends

11%

No ACT-ICM
ACT &
ACT-ICM

8%

8%

10%

ACT-ICM
7%

6%

4%

2%

0%

Pre-AOT, no ACT or ICM

AOT w ith ACT-ICM for 1-6
months

Discontinues AOT after 6
months, b ut remains o n
ACT-ICM

Discontinues both AOT and
ACT-ICM af ter 6 months

*Adjusted probability estimates were generated from repeated measures regression models controlled for time, region,
race, age, sex, diagnosis, and co-insurance status.
** Short-term AOT defined as receiving a total of 6 months or less.
Source: Medicaid claims and AOT Evaluation database.

40

New York State Assisted Outpatient Treatment Program Evaluation

In contrast, we find (as seen in Exhibit 5.2
below) that if the initial period of AOT is
longer than six months, reduction in
hospitalization in the post-AOT period is
sustained whether or not the recipient
continues to receive intensive treatment in
the form of ACT or ICM. For these longer-

term AOT recipients, the predicted
probability of post-AOT hospitalization
remains at substantially reduced level
relative to the pre-AOT period, even without
continued ACT or ICM services utilization
(7% compared to 11%).

Exhibit 5.2. Adjusted* percent with psychiatric inpatient treatment in month over long-term*
AOT course
14%

Before AOT
12%

Adjusted percent

10%

During
long-term AOT

After long-term AOT

11%

ACT &
ACT-ICM

8%

8%

ACT-ICM
7%

6%

No ACT-ICM
7%

4%

2%

0%
Pre-AOT, no ACT or ICM

AOT w ith ACT-ICM for 7-12 Discontinues AOT after 7-12
months
months, but remains on ACTICM

Discontinues both AOT and
ACT-ICM after 7-12 months

*Adjusted probability estimates were generated from repeated measures regression models controlled for time, region,
race, age, sex, diagnosis, and co-insurance status.
** Long-term AOT defined as receiving AOT for > 6 months. Source: Medicaid claims and AOT Evaluation database.

Post-AOT Receipt of Case Management
Services from Medicaid and OMH
Records

Post-AOT Receipt of Psychotropic
Medications from Medicaid and OMH
Records

Receipt of intensive case management in
the form of ACT or ICM rose from 5% prior
to AOT to 45% during AOT. These rates
declined modestly when AOT was
discontinued: after six months or more of
AOT, 28% of recipients continued to receive
ACT or ICM. However, after 12 months or
more of AOT, 35% of recipients continued
to receive ACT or ICM services.

Findings in Chapter 3 also detail
improvement in rates of receipt of
appropriate psychotropic medications during
AOT. Do these improved rates of receipt of
psychiatric medications persist once AOT is
terminated?
For individuals who receive AOT for a
period of six months or less, we find that the
likelihood of receiving medications
consistent with their diagnosis depends on
whether intensive outpatient services

New York State Assisted Outpatient Treatment Program Evaluation

41

utilization is also continued after the AOT
order ends. If the recipient continues to
receive post-AOT intensive case
coordination services in the form of ACT or
ICM, the predicted probability of appropriate
medication possession within

any post-AOT month remains improved
relative to the pre-AOT period (45% vs.
37%). However, if ACT or ICM is also
discontinued when AOT ends, the predicted
probability of post-AOT medication
possession declines to 33%, which is
comparable to the pre-AOT level. These
results are displayed in Exhibit 5.3.

Exhibit 5.3. Adjusted* percent with at least 80% medication possession in
any given month over short-term AOT course
80%

Before AOT

70%

During
short-term AOT

After short-term AOT

Adjusted Percent

60%

50%

49%

45%

40%

30%

ACT-ICM
No ACT-ICM

37%

33%

20%

10%

0%
Pre-AOT, no ACT or ICM

AOT w ith ACT-ICM for 1-6
months

Discontinues AOT after 6
months, but remains on A CTICM

Discontinues both AOT and
ACT-ICM af ter 6 months

*Adjusted probability estimates were generated from repeated measures regression models controlled for time, region,
race, age, sex, diagnosis, and co-insurance status.
Source: Medicaid claims and AOT Evaluation database.

In contrast, we find (as seen in Exhibit 5.4
below) that if the initial period of AOT is
longer than six months, improvement in
rates of receipt of appropriate psychotropic
medications in the post-AOT period are
sustained whether or not the recipient
continues to receive intensive treatment in
the form of ACT or ICM. For these longerterm AOT recipients, the predicted
probability of post-AOT medication

42

possession remains at a substantially
improved level relative to the pre-AOT
period, even without continued ACT or ICM
services utilization (50% compared to 37%.)
If ACT or ICM is also discontinued when
long-term AOT ends, the predicted
probability of receiving appropriate
psychotropic medications declines to 43%,
which is still an improvement over the preAOT rate.

New York State Assisted Outpatient Treatment Program Evaluation

Exhibit 5.4. Adjusted* percent with at least 80% medication possession in
any given month over long-term AOT course
70%

Before AOT

During
long-term AOT

After long-term AOT

60%

Adjusted percent

ACT-ICM

52%

50%

50%

No ACT-ICM

43%

40%

37%
30%

20%

10%

0%
Pre-AOT, no ACT or ICM

AOT w ith ACT-ICM for 7-12
months

Discontinues AOT after 7-12
months, but remains on ACTICM

Discontinues both AOT and
ACT-ICM after 7-12 months

*Adjusted probability estimates were generated from repeated measures regression models controlled for time, region,
race, age, sex, diagnosis, and co-insurance status.
Source: Medicaid claims and AOT Evaluation database.

Arrest Outcomes Comparing Post AOT
and Post EVS Recipients In Six Counties

Findings in Chapter 3 reported significant
reductions in arrest rates while recipients
were on AOT compared to their preAOT/EVS period of observation. (Current
EVS status was not significantly associated
with reduced rates of arrest although there
was a clear trend toward reduction of
arrests during this period.) Exhibit 5.5

shows that the post-AOT and post-EVS
conditions were not significantly associated
with lowered probabilities of arrest
compared to the pre-AOT/EVS period
(current AOT and current EVS periods are
included for reference).

New York State Assisted Outpatient Treatment Program Evaluation

43

Exhibit 5.5 Adjusted percent arrested in month by receipt of AOT and Enhanced
Voluntary Services
4
3.5

3.7
3.4

3

3.3
2.8

Percent

2.5
2

1.9

1.5
1
0.5
0
Pre-AOT and
Pre-EVS

Current AOT

Post-AOT

Current EVS

Post-EVS

Number of individuals=181; Number of person-month observations=9,229. Adjusted arrest rate
estimates were produced using multivariable time-series regression analysis, controlling for time,
region, age, sex, race, education, and diagnosis. Months spent in hospital are excluded from
analysis.
Source: 6-county interviews and Division of Criminal Justice Services

Summary

We examined whether selected gains made
during AOT are sustained over time,
continuing into the post-AOT period. We
examined three key outcomes that
improved during AOT: reduced rates of
hospitalization, increased receipt of
psychotropic medications appropriate to the
individual’s diagnosis, and reduced
likelihood of arrest. For the hospitalization
and medication outcomes, which were
assessed via the Statewide Medicaid data,
we find that sustained improvement after
AOT ends varies according to the length of
time the recipient spends under the AOT

44

order. If AOT is discontinued after six
months, these decreased rates of
hospitalization and improved receipt of
psychotropic medications are only sustained
if recipients also continue to receive
intensive services after AOT is
discontinued. However, if AOT continues
for 12 months or longer, reduced rates of
hospitalization and improved receipt of
medications are sustained whether or not
intensive services are continued after AOT
is discontinued. Thus, it appears that
improvements in hospitalization and
medication outcomes are more likely to be
sustained if AOT continues for longer than
12 months. However, the post-AOT group
did not maintain their reduced rate of arrest
that was evident during AOT.

New York State Assisted Outpatient Treatment Program Evaluation

Chapter 6. Impact of Assisted Outpatient Treatment (AOT) on New York
State’s Public Mental Health Service System
This chapter describes the impact of the
AOT Program on the public mental health
system in New York State. Clearly, AOT
had some direct effects on the several
thousand individuals who received court
orders, as discussed in previous chapters.
However, key features of the system of care
in which AOT has been implemented—its
capacity, resource allocation, and patterns
of service utilization—were altered by AOT
in ways that may have indirectly affected
other persons with severe mental illness
(SMI) who were not candidates for AOT.

resources vary over time and by region
during the years since AOT was initiated?
We examine these questions by focusing on
trends in Medicaid claims for Intensive Case
Management (ICM) and Assertive
Community Treatment (ACT). These two
modes of service operationally define a key
requirement for intensive case coordination
that underlies AOT court-ordered treatment
plans; they also function as indicators of
met need for service among comparable
individuals with SMI who do not receive
AOT orders.

We examine potential system effects of
AOT by addressing three questions:

To put AOT in a system perspective,
recipients of AOT include only a small
proportion—about 2%—of the service
population with severe mental illness in New
York. However, AOT recipients account for
about one quarter of those receiving ACT or
ICM services as shown in Exhibit 6.1.

(1) Did AOT increase service capacity for
all recipients?
(2) Did AOT offset, or divert, intensive
services from other SMI individuals who
would not qualify for AOT?
(3) How did the impact of AOT on system

Exhibit 6.1 Putting AOT in Population Perspective: 2005 snapshot

New York state
population
N=19,262,545

Population with
severe mental
illness
N=577,876

Estimated number
of persons with SMI
(3%)

OMH services
recipients with
SMI
N=138,602

OMH services
recipients with SMI
(24%)

Recipients on
ICM or ACT
N=8,860

Recipients
on ICM or
ACT:
(6%)

AOT
recipients
N=2,420
(27%)

Source: OMH administrative and service data, Patient Characteristics Survey, US census, Mental Health Needs
Assessment Project

New York State Assisted Outpatient Treatment Program Evaluation

45

Exhibit 6.2 Number of clients being served on ACT and ICM by year:
New York State Office of Mental Health Patient Characteristics Surveys
10000
ACT

9000

ICM

Number of Clients

8000
7000
6000
5000
4000
3000
2000
1000
0
1999

2001

2003

2005

2007

Year

Source: Medicaid claims and OMH administrative data.

New York State provided substantial new
funding to implement AOT Programs
statewide and to build service capacity in
the public mental health system over the
past decade. An annual total of $32 million
was appropriated for direct support of AOT
Programs. This appropriation included
$9.55 million per year to fund new case
management slots anticipated for by AOT
recipients. The new funding also included
$15 million for a medication grant program;
$4.4 million for prison and jail discharge
managers; $2.4 million for oversight
programs; and $0.65 million for drug
monitoring.

46

In addition, and in tandem with the AOT
Program, the state allocated $125 million
yearly for enhanced community services;
these funds were used to develop a Single
Point of Access Program (SPOA) and to
increase ACT and ICM capacity. Exhibit 6.2
illustrates the increase in volume of ACT
and ICM service delivery during the years
following the start of AOT in 1999. Clearly,
ACT teams have been on the increase,
effectively replacing ICM for many recipients
after 2001. For purposes of this chapter, we
combined ACT and ICM into one category
of intensive case coordination services.

New York State Assisted Outpatient Treatment Program Evaluation

Exhibit 6.3 illustrates the impact of these
new resources on service utilization for AOT
recipients and a comparable population of
non-AOT service recipients.15 The overall
increase in services is seen in the upward
trend in the total number of monthly paid
Medicaid claims for ACT or ICM: the

volume of these services increased 400%
between 2000 and 2007. However,
important differences in the trend emerge in
the comparison of time periods for AOT
recipients (before, during, and after AOT),
and in the quite different pattern for ACTICM recipients who did not receive AOT.

Exhibit 6.3 Distribution of ACT/ICM services by month and AOT status
2000
1800

Post-AOT
Current AOT

Number of ACT/ICM claims

1600

Pre-AOT
Never AOT

1400
1200
1000
800

AO

600
400

T

nts
pie
i
c
re

Non-AOT recipients

200
0
1

(2000)

13

25

37

Month

49

(2003)

61

73

85

(2007)

Source: Medicaid claims and OMH administrative data.

15

Selection criteria for comparison group: OMH service recipients with history of 2 or more psychiatric
admissions in any year since 1999; schizophrenia or affective disorder as billing diagnosis for inpatient
admission; total of 14 or more inpatient days in any single year; did not receive AOT but received ACT
or ICM services at any time since 1999.

New York State Assisted Outpatient Treatment Program Evaluation

47

those who never received AOT. As a result,
by 2007 ACT-ICM monthly claims were
almost evenly distributed between post-AOT
and non-AOT participants with a small and
diminishing share of the services going to
current AOT participants.

ACT-ICM services doubled in the first three
years after AOT began (2000-2003), but all
of that increase went to AOT recipients.
There was no increase in ACT-ICM services
to non-AOT recipients as a group during the
first three years of AOT implementation.
However, between 2003 and 2007, the
trend shifted as non-AOT recipients saw an
increase in ACT-ICM services that
paralleled that for AOT recipients.

Exhibit 6.4 displays the effect of this pattern
in terms of the “non-AOT share” of ACTICM claims. Specifically, this is the trend in
the proportion of monthly claims for services
that went to individuals who were not on
AOT orders.

After the first three years of AOT
implementation, ACT-ICM services
increased both for post-AOT recipients and

Exhibit 6.4. Non-AOT share of ACT-ICM services by month
Percent of total
ACT-ICMof
Medicaid
claims for
non-AOT recipients
Number
ACT/ICM
claims

100
90
80
70
60
50
40
30
20
10
0
1

13

25

37

49

Month

(2000)

61

73

85

(2007)

Source: Medicaid claims and AOT Evaluation database.

Between 2000 and 2003, the non-AOT
share of monthly Medicaid claims for ACTICM services was cut in half—from 100% to
less than 50%. After that, however, the
decline in non-AOT share stabilized and
gradually reversed. By 2007, three-quarters
of ACT-ICM services were going to nonAOT recipients—the same proportion as in
2001. The increase in ACT-ICM services to
non-AOT recipients coincided with the

48

decrease in new AOT orders (as described
in Chapter 1.)
To examine at the individual level whether
the AOT Program in effect diverted services
from non-AOT recipients, we conducted
multivariable time-series analyses of factors
affecting receipt of ACT-ICM in any given
month for non-AOT recipients. The sample
for the analyses consisted of 3,170 persons
with SMI who never received AOT, but

New York State Assisted Outpatient Treatment Program Evaluation

received ACT-ICM during some period
between 2000 and 2007 as indicated by
paid Medicaid claims. The time series
analysis included 66,833 person-month
observations for these individuals.
By 2007 ACT-ICM monthly claims were
almost evenly distributed between post-
AOT and non-AOT participants with a
small and diminishing share of the
services going to current AOT
participants. 

The first outcome in the analysis was
whether, in any given month, the non-AOT
individual initiated ACT-ICM, not having
received these services previously. The
second outcome was whether a non-AOT
individual discontinued ACT-ICM—or was
no longer receiving these services in a
given month—after having received them
previously. Control variables included time
(year), region, age, sex, race, diagnosis,
and co-insurance status.
In the first analysis, we found that
increasing the number of AOT orders in the
system was significantly associated with a
decreasing chance that non-AOT individuals
would initiate receipt of ACT or ICM.
Specifically, during months when the
number of AOT orders exceeded 200, the
odds were approximately cut in half that a
non-AOT individual would initiate ACT-ICM
services.16

Specifically, during months when the
number of AOT exceeded 200, the odds of
non-AOT individuals discontinuing ACT-ICM
were increased by about 50% compared to
months with fewer AOT orders in the
system.17 When the number of AOT orders
in the system exceeded 400 in a given
month, the odds of discontinued ACT-ICM
for non-AOT recipients doubled.18
Finally, we examined whether the impact of
AOT varied by region, comparing the New
York City region to other regions in the
state. We found a similar pattern in New
York City and in other regions with two
exceptions. First, the effect of discontinuing
ACT-ICM for non-AOT recipients occurred
more slowly in New York City. Specifically,
outside of New York City a significant
increase in ACT-ICM discontinuation was
seen among non-AOT recipients in the third
year after AOT started. In New York City a
significant increase in discontinuation for
ICM-ACT among non-AOT recipients was
not seen until the sixth year following AOT.
Second, increasing AOT had a sharper
impact on discontinuing ACT-ICM for nonAOT individuals in the non-NYC regions
compared to the New York City Region.19
Exhibit 6.5 displays adjusted percents from
these analyses.

In the second analysis, we found that
increasing AOT orders in the system
significantly increased the odds of non-AOT
recipients discontinuing of ACT-ICM.

16

Adjusted Odds Ratio = 0.50; 95% confidence interval = 0.43 - 0.57.
Adjusted Odds Ratio = 1.45; 95% confidence interval = 1.18 – 1.78.
18
Adjusted Odds Ratio = 2.22; 95% confidence interval = 1.76 – 2.79.
19
Adjusted odds ratio = 1.67 vs. 1.36 when monthly AOT orders in the system were between 201 and 400, compared
to between 0 and 200.
17


New York State Assisted Outpatient Treatment Program Evaluation

49

Exhibit 6.5. Adjusted* percent of non-AOT recipients discontinuing ACT-ICM in any given
month, by system AOT volume and region
AOT Cases

50%
45%
43%

40%

0-200
201-400
More than 400
38%

35%
30%
29%

25%

24%

20%
15%

19%

18%

10%
5%
0%
Non-NYC Counties

NYC Counties

*Adjusted probability estimates were generated from repeated measures regression models controlled
for time, race, age, sex, diagnosis, and co-insurance status.
Source: Patient Characteristics Survey, US Census, Mental Health Needs Assessment Project, AOT
Evaluation database.

Summary

The implementation of AOT coincided with a
large increase in mental health services
through OMH, which eventually increased
the availability of ACT teams and ICM for all
service recipients with SMI—even those
who never received AOT. In the process of
implementing the AOT Program, preference
was initially given to new AOT cases in
allocation of ACT and ICM. This meant
that, even accounting for overall time-trend,
region, patient demographics and diagnosis,
the increasing number of AOT cases in the
system significantly affected ACT-ICM
service delivery to non-AOT recipients.
Specifically, when AOT cases increased,
non-AOT recipients had a significantly lower
chance of initiating ACT-ICM services and a
significantly higher chance of discontinuing
these services if they were previously
receiving them. These indirect
consequences of the AOT Program
occurred more slowly and were not as
50

pronounced in the New York City region
compared to other regions of the state;
perhaps because the service volume and
system capacity was greater in the New
York City Region, and thus, it was able to
absorb a greater volume of new AOT cases
with less impact on other service recipients
with SMI. Also, the apparent impact of AOT
in diverting services from non-AOT service
recipients was concentrated mostly in the
first three years of AOT implementation,
between 2000 and 2003. During those
years, there was essentially no growth in
ACT-ICM services to non-AOT individuals;
however, following 2003, as the number of
new AOT orders stabilized and then
declined, the new service capacity that
accompanied the implementation of AOT
was apparently available to other individuals
who needed these services, irrespective of
AOT status. Thus, following the initial rampup of the AOT Programs throughout the
state, intensive community-based services
increased for SMI individuals on AOT and
non-AOT individuals alike.

New York State Assisted Outpatient Treatment Program Evaluation

Summary and Conclusions
To address the six areas of investigation
requested,, we studied existing records from
several extensive data sources described in
Appendix B including: AOT Program, New
York State Office of Mental Health
hospitalization, Medicaid claims, U.S.
Census, and Mental Health Needs
Estimation Project data. In addition, we
conducted statewide in-person interviews
with key stakeholders to gain insight into the
operation of the AOT Program and
interviewed service recipients to assess
attitudes about treatment, treatment
experiences, and treatment outcomes.

recipients receiving voluntary treatment.
Given a number of alternative data sources,
the large volume of data, and careful use of
statistical approaches, these analytic
approaches have substantial strengths, but
these analytic approaches are not as
definitive as a rigorously conducted
randomized controlled trial.
New York’s AOT Program features more
comprehensive implementation,
infrastructure and oversight of the AOT
process than any other comparable
program in the United States.

Limitations

While this evaluation approach has
substantial strengths because of its reliance
on multiple sources of data, each data
source also has limitations. Case managers
provide extensive data about recipient
functioning captured in the Child and Adult
Integrated Reporting System (CAIRS).
However, given heavy clinical and
administrative demands on case managers
and limited time for training on completing
the CAIRS, reporting on this instrument may
be inconsistent. Because CAIRS has
variable amounts of missing data, we only
utilized CAIRS when the level of missing
data was acceptable. Case managers may
also have unknown biases in reporting of
outcomes of recipients in their respective
programs. Reliance on Medicaid claims
data also has limitations in that Medicaid
eligibility may fluctuate, claims may be
inconsistently submitted, and Medicaidineligible recipients may be different in ways
we can not measure. Our analysis approach
limits analyses to periods of Medicaid
eligibility and may fail to detect differences
in outcomes for recipients who are Medicaid
ineligible. Wherever possible we have
carefully drawn matched comparison groups
to examine whether AOT differentially
affects outcomes when compared to

We summarize findings and conclusions
from each area or investigation below. In
addition, we provide a summary table
indicating the sources and strengths of
findings in each area of investigation.
Summary and Conclusions
Description of the New York AOT
Program and Regional Variations

The introduction of New York’s AOT
Program was accompanied by a significant
infusion of new service dollars and currently
features more comprehensive
implementation, infrastructure and oversight
of the AOT process than any other
comparable program in the United States. It
is, therefore, a critical test of how a
comprehensively implemented and wellfunded program of assisted outpatient
treatment can perform. However, because
New York’s program design is unique, these
evaluation findings may not generalize to
other states, especially where new service
dollars are not available. This report
addresses whether AOT can be effective
and under what circumstances, not whether
it will always be effective.

New York State Assisted Outpatient Treatment Program Evaluation

51

As designed, the AOT statute can be used
to prevent relapse or deterioration before
hospitalization is needed. However, in
nearly three-quarters of all cases, it is
actually used as a discharge planning tool
for hospitalized patients. Thus, AOT is
largely used as a transition plan to improve
the effectiveness of treatment following a
hospitalization and as a method to reduce
AOT is largely used as a transition plan to
improve the effectiveness of treatment
following a hospitalization and as a
method to reduce hospital recidivism.

hospital recidivism. To quote one Mental
Health Legal Service (MHLS) attorney on
his view of AOT:
We see AOT as a way for some clients
to get what they need. They are
severely mentally ill and need good
follow-up treatment in the community.
This is a way for them to get out of the
hospital much sooner.

Most of New York State’s experience with
AOT originates in the New York City region
where approximately 70% of all AOT cases
are found. AOT was systematically
implemented citywide in New York City with
well-delineated citywide policies and
procedures. In the remainder of the state,
AOT was implemented and utilized at the
discretion of counties. In some counties
AOT has been used rarely; in several it has
not been used at all.
Based on our key stakeholder and recipient
interviews and on AOT Program data, we
found considerable variability in how AOT is
implemented across the state but strong
uniformity in how it is implemented in New
York City. One important difference among
regions was the use of voluntary
agreements (sometimes referred to as EVS)
in lieu of a formal AOT court order. Under a
voluntary agreement, the recipient signs a
statement that he or she will adhere to a
prescribed community treatment plan. In the

52

One important difference among regions
was the use of voluntary agreements in
lieu of a formal AOT court order.

New York City Region, an AOT court order
almost always precedes an agreement for
EVS. Voluntary agreements are usually
implemented following a period of AOT as a
“step-down” arrangement when a recipient
is judged to be ready to transition from an
AOT order to voluntary treatment, usually
with the same enhanced service package.
In one of the key informant interviews, an
AOT Program staff remarked:
Voluntary agreements are used (in New
York City) as part of the clinical "stepdown"
process.

In other counties, largely outside of New
York City, voluntary agreements are more
frequently used before an AOT court order
as trial periods before initiating a formal
AOT order. If the trial period proves
unsuccessful, an AOT proceeding is then
initiated. A psychiatrist from an upstate
county discussed this approach to providing
EVS in the following way:
We don't do it like downstate or like
OMH wants. We use the voluntary
order first. We don't approach it in any l
way.

Statewide, use of EVS First is far less
common because the majority of AOT
orders occur in New York City where
voluntary agreements typically come as a
trial AOT termination. Because the regions
in which these two very different
approaches to voluntary agreements occur
differ so much in population characteristics
and in the availability of treatment services,
it is not possible to directly compare their
relative effectiveness.
The other major difference across the state
lies in the consistency of the AOT court
process. There was widespread agreement
that judges hearing AOT cases could

New York State Assisted Outpatient Treatment Program Evaluation

benefit from additional mental health and
AOT training, especially in counties where
many judges rotate in these courts. In
some counties hearings may be waived, or
the client may waive his or her appearance.
In uncontested hearings there may be no
perceived need to have a doctor present at
the hearing because the facts are stipulated
and the outcome agreed upon. This results
in some significant procedural variations
across courts. To quote several judges:
In a situation where the patient agrees
with the plan, no doctor is needed. If
the plan is contested — that's different.
You can always waive a hearing.

Even in the counties that mandated
appearances by the physician, almost all
agreed that not having a physician appear
would reduce costs and scheduling
difficulties, particularly for the smaller
counties that contract for physician services.
Most counties were in favor of increasing
the availability of stipulations in the AOT
process, especially for renewals. This
would reduce the court burden and costs
and would reduce some of the hearing
logistics and transportation burdens.
Not having a physician appear would
reduce costs and scheduling difficulties,
particularly for the smaller counties.

In some counties the programs were small
enough such that the level of service
coordination was maximized with everyone
“at the table” working on the AOT treatment
plan. Some of the county differences we
observed may be due to the fact that some
counties are structured differently in their
service delivery approach. To quote one
Director of County Services:
A big piece of how it works or does not
work across New York State is the
county structure — are they a service
providing department or contracting
agency?

Racial Disparities in AOT: Are They
Real?

An April 2005 report on statewide
demographic data from the New York
Lawyers for the Public Interest found that
African Americans were overrepresented in
the AOT Program. Whether this overrepresentation is discriminatory rests, in
part, on whether AOT is generally seen as
beneficial or detrimental to recipients and
whether AOT is viewed as a positive
mechanism to reduce involuntary
hospitalization and improve access to
We find no evidence that the AOT Program
is disproportionately selecting African
Americans for court orders.

community treatment for an under-served
population, or as a program that merely
subjects an already-disadvantaged group to
a further loss of civil liberties.
We find that the overrepresentation of
African Americans in the AOT Program is a
function of African Americans’ higher
likelihood of being poor, uninsured, higher
likelihood of being treated by the public
mental health system (rather than by private
mental health professionals), and higher
likelihood of having a history of psychiatric
hospitalization. The underlying reasons for
these differences in the status of African
Americans are beyond the scope of this
report. We find no evidence that the AOT
Program is disproportionately selecting
African Americans for court orders, nor is
there evidence of a disproportionate effect
on other minority populations. Our
interviews with key stakeholders across the
state corroborate these findings.
Service Engagement

A key goal of the AOT Program is to
motivate consumers to actively engage in
treatment during and after their involvement
with the program. We find that during the
first six months on AOT, service

New York State Assisted Outpatient Treatment Program Evaluation

53

engagement was comparable to service
engagement of voluntary patients not on
AOT. After 12 months or more on AOT,
service engagement increased such that
AOT recipients were judged to be more
engaged than voluntary patients. This
suggests that after 12 months or more,
when combined with intensive services,
AOT increases service engagement
compared to voluntary treatment alone.

Recipient Outcomes

Clearly one of the reported strengths of the
AOT Program, evidenced in our key
informant interviews, was improved
recipient access to needed services. Even
key informants who had been initially
opposed to AOT have come to realize that
the additional service dollars associated
with the AOT Program provide needed
services, although respondents report that
the paucity of integrated co-occurring
substance abuse services is still
problematic. Nonetheless, some
respondents still feel that if adequate
consumer-driven services were available,
there would no need to engage recipients
through the mechanism of the AOT process.
Comment by a psychiatrist and peer
advocate illustrate this:

During AOT there is a substantial
reduction in the number of psychiatric
hospitalizations and in days in the hospital
if a person is hospitalized.

Kendra's law commits the individual to
treatment and commits treatment
providers to treating the individual.
AOT would not be needed if services
were compassionate and coordinated.
Consumers would come.

We find consistent evidence that during
AOT there is a substantial reduction in the
number of psychiatric hospitalizations and in
days in the hospital if a person is
hospitalized. We also find moderately strong
evidence from lifetime arrest records of AOT
and EVS recipients from the Division of

Criminal Justice Services that AOT reduces
the likelihood of being arrested. We find
substantial increases in receipt of intensive
case management services during AOT. We
also find that, under AOT, recipients are far
more likely to consistently receive
psychotropic medications appropriate to
their psychiatric conditions. Case managers
of AOT recipients also report subjective
improvements in many areas of personal
functioning such as managing
appointments, medications, and self-care
tasks.
Selection of recipients for the AOT Program
was a source of considerable discussion
among key informants who suggested that
particular kinds of recipients may or may not
benefit from the AOT Program. Most key
informants felt that the majority of AOT
recipients were appropriate for the program,
AOT reduces the likelihood of being
arrested.

but they agreed that many who might
benefit were never referred. They felt that
the recipients’ deference to the authority of
the judge might significantly affect the
success of the order. Many respondents
believe that recipients with substance
abuse, personality disorders, or extensive
criminal histories were the least likely to be
successful in the program. They suggested
this might be due to the scarcity of
54

New York State Assisted Outpatient Treatment Program Evaluation

appropriate services for these conditions, or
in the case of substance abuse, the
perceived lack of enforceability of
nonadherence to substance abuse
treatment. Comments by a psychiatrist and
AOT coordinator illustrate this:
I don't know that AOT doesn't work for
substance abusers- it might be more
that appropriate services are not always
available.
AOT doesn't work well with the
seriously drug involved because it's
hard to make the case manager
connection and with people with
antisocial personality, because the
court scene doesn't affect them. —
Recipient Perceptions of AOT

Participants were assessed on scales
measuring a wide range of AOT-related
attitudes and treatment experiences,
including their understanding of AOT;
whether they believe it beneficial or harmful;
whether they find it stigmatizing; whether it
affects their sense of autonomy or
empowerment; satisfaction with treatment;
perceived coercion related to treatment;
perceived pressures to engage in treatment;
whether it increases perceived barriers to
Positive and negative attitudes about
treatment during AOT are more strongly
influenced by other experiences with
mental illness and treatment than by
recent experiences with AOT itself.

treatment; and how it affects their sense of
being fairly treated. On the whole, AOT
recipients and non-AOT recipients have
remarkably similar attitudes and treatment
experiences. That is, despite being under a
court order to participate in treatment,
current AOT recipients feel neither more
positive nor more negative about their
mental health treatment experiences than
comparable individuals who are not under
AOT. This suggests that positive and
negative attitudes about treatment during

AOT are more strongly influenced by other
experiences with mental illness and
treatment than by recent experiences with
AOT itself.
Service Utilization and Outcomes After
AOT Ends

We examined whether selected gains made
during AOT are sustained over time by
examining two key outcomes that improved
during AOT reduced rates of hospitalization
and increased receipt of psychotropic
medications appropriate to the individual’s
diagnosis. We find that sustained
improvement after AOT ends varies
according to the length of time the recipient
spends under the AOT order. If AOT is
Sustained improvement after AOT ends
varies according to the length of time the
recipient spends under the AOT

discontinued after six months, these
decreased rates of hospitalization and
improved receipt of psychotropic
medications are sustained only if recipients
continue to receive intensive case
management services. However, if AOT
continues for 12 months or longer, reduced
rates of hospitalization and improved receipt
of medications are sustained whether or not
intensive case management services are
continued after AOT is discontinued. Thus,
it appears that improvements are more
likely to be sustained if AOT continues at
least 12 months.
Impact of AOT on New York’s Public
Mental Health System

It is uncertain whether, as a consequence of
AOT implementation, resources have been
diverted away from other adults with severe
mental illness. We examined the impact of
AOT Programs on the availability of
resources for all adults with severe mental
illness. We focused on access to high
intensity case management services.

New York State Assisted Outpatient Treatment Program Evaluation

55

The introduction of AOT was accompanied
by a large increase in funding for mental
health services, which, over time, increased
the availability of intensive services for all
service recipients, even those who never
got AOT. In the first several years of the
AOT Program, between 1999 and 2003,
preference for intensive case management
services was given to AOT cases—a finding
corroborated by our key stakeholder
interviews. In fact, some respondents
stated that service and housing providers
were more likely to accept clients with an
AOT court order and all confirmed that AOT
recipients were given priority access. An
AOT coordinator made this observation:
AOT doesn't make a big difference in
some people’s compliance, but does
help with community mental health
providers’ willingness to provide
services to people.

This meant that in the first several years of
the AOT Program, non-AOT recipients were
less likely to receive intensive case
management services than their AOT
counterparts. These indirect consequences
of the AOT Program occurred more slowly
and were not as pronounced in New York
City compared to other regions of the state.
This may have been because the treatment
capacity was greater in New York City, and
thus it was able to absorb a greater volume
of new AOT cases with less impact on other
service recipients with severe mental
illness.
After 2003, new AOT orders leveled off in
the state and then declined. The new
treatment capacity that accompanied the
implementation of AOT was apparently then
available to other individuals who needed
these services, irrespective of AOT status.
Thus, following the initial ramp-up of the
AOT Programs throughout the state,
intensive community-based services
increased for individuals on AOT and those
not on AOT alike. However, because the
new service capacity created during the
introduction of the AOT Program is now fully

56

utilized, competition for services in the near
future may intensify, with unknown effects
on AOT relative to non-AOT recipients.
Several key informant respondents
commented on the lack of new resources
for the AOT Program and treatment
services. They were concerned about the
relatively flat funding for the AOT Program
since its inception. And while some service
dollars may have increased in categories
not directly designated as AOT, the program
administration dollars have not changed
according to these respondents. These
points are emphasized by two AOT
personnel:
Money has been consistent over time—
to the same counties—even those
without AOT.
You can not expect people to be paid
the same amount of money seven years
later.

Because the implementation of the AOT
Program in New York was accompanied by
an infusion of new services, it is impossible
to generalize the findings of this Report to
states where services do not simultaneously
increase.
Other Issues to Consider

Key stakeholders we interviewed suggested
the state should consider how much
consistency it wishes to see in the AOT
Program. While the entire state may not opt
to adopt policies and procedures used in
New York City, common statewide
procedures could be more fully developed,
while still allowing local flexibility. For
example, court procedures across the state
could be more uniformly standardized.
Some courts allow greater leeway in
stipulations, some hearings are waived, and
occasionally physicians/examiners are not
required to testify in person. These
variations in court procedures, if deemed
appropriate, could be used to streamline
court procedures and reduce court

New York State Assisted Outpatient Treatment Program Evaluation

expenses. Standardization should be
considered for forms used throughout the
AOT process and the issuance of removal
orders and the access to certified records
could be made more efficient. In addition,
there are frequent problems with intercounty transfers and jurisdiction over AOT
cases that could be addressed. Key
stakeholders also suggested the state
consider the status of voluntary
agreements, which are not codified in the
AOT statute or regulation. They feel that the
state should consider whether it wishes to
create formal voluntary agreement options.
Overall Summary and Conclusions

We find that New York State’s AOT
Program improves a range of important
outcomes for its recipients, apparently
without feared negative consequences to
recipients. The increased services available
under AOT clearly improve recipient
outcomes, however, the AOT court order
and its monitoring do appear to offer
additional benefits in improving outcomes. It
is also important to recognize that the AOT
order exerts a critical effect on service
providers, stimulating their efforts to
prioritize care for AOT recipients.
Available data allow only a limited
assessment of whether voluntary
agreements are effective alternatives to
initiating or continuing AOT. There are
relatively few voluntary agreements and
they typically occur in counties that use the
"EVS First" model. However, we found

some evidence that AOT recipients are at
lower risk of arrest than their counterparts in
enhanced voluntary services. We also found
evidence in the case manager data that
receiving AOT combined with ACT services
substantially lowers risk of hospitalization
compared to receiving ACT alone.
Recipients appear to fare better during and
after AOT if the AOT order lasts for six
months or more. Once AOT recipients leave
the program, improvements are more likely
sustained among those who continue to
receive intensive treatment services or have
longer periods of AOT.
Perceptions of the AOT Program,
experiences of stigma, coercion, and
treatment satisfaction appear to be largely
unaffected by participation in the program
and are likely more strongly shaped by
other experiences with mental illness and
treatment.
In its early years, the AOT Program did
appear to reduce access to services for
non-AOT recipients. However, in recent
years the reduction in new AOT cases has
attenuated this effect. Lack of continued
growth of new service dollars will likely
increase competition for access to services
once again.
If New York extends the AOT Program,
consideration should be given to further
strengthening statewide policies and
procedures to achieve a more consistent
program.

New York State Assisted Outpatient Treatment Program Evaluation

57

AOT Report: Summary and Strength of Findings
Data Source & Analysis Approach

Area and Finding
Description of AOT
Program
Regional differences in
AOT Program
Absence of racial disparities
in AOT Program
administration
Positive service
engagement of AOT
recipients
Recipient Outcomes
Reduced hospitalization
Increased receipt of
medication
Increased receipt of case
management
Improved functioning
Decreased arrests
Recipient Perceptions of
AOT
Improved autonomy
Improved treatment
satisfaction
Increased coercion
Service Utilization and
Outcomes Post-AOT
Reduced hospitalization
Increased receipt of
medication
Increased receipt of case
management
Impact of AOT on Service
System
Increased receipt of case
management for AOT
recipients
Decreased receipt of case
management for non-AOT
recipients

Summary:
Combined
Measures1

Key
Informant
Interviews

Recipient
Interviews,
Chart
Reviews
and Arrest
Records

Case
Manager
Reports
(CAIRS)

Case Manager
Reports:
Controlled
Statistical
Analyses

+++

+++

+++

na

na

+++

+++

+++

na

na

na

+++

+++

+++

na

Medicaid
and OMH
Data:
Controlled
Statistical
Analyses

+++

na +/-

+++
+++

++
na n

+/a

+++
na

+++
na

+++
+++

+++

+++

na

+++

na

+++

+
++

na
na ++

+/-

+
+/-

na
+/-

na
na

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na
na

na
na

na
na

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na

+/-

na

na

na

+++
+++

+++
na n

+/a

+++
++

na
na

+++
+++

+++

+++

na

+++

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+++
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+/na

58

very strong evidence
moderately strong evidence
some evidence
equivocal findings
Not applicable, no evidence for or against

New York State Assisted Outpatient Treatment Program Evaluation

Appendix A
Kendra’s Law Overview and Statute
[full text of Mental Hygiene Law * § 9.60 is appended at the end of Appendix A]
Keith J. Brennan, Esq., Assistant Counsel
New York State Office of Mental Health
(Brennan, K. J. (2009). Kendra's Law: Assisted Outpatient Treatment in New York. Unpublished
revision of Brennan, K. J. (2005). Kendra's Law: Final Report on the Status of Assisted
Outpatient Treatment Appendix 2.)
Introduction
On January 3, 1999, an event occurred which galvanized the mental health community, and
served as a catalyst for an effort to identify and address the needs of the small population of
persons who respond well to treatment when hospitalized, but who have trouble maintaining
their recovery once back in the community. On that date, Andrew Goldstein, a man with a
history of mental illness and hospitalizations, pushed Kendra Webdale onto the subway tracks
in a tunnel beneath the streets of Manhattan. Ms. Webdale lost her life as a result. What
followed was a bi-partisan effort, led by Governor George Pataki, to create a resource delivery
system for this population, who, in view of their treatment history and present circumstances,
are likely to have difficulty living safely in the community. 1 Kendra’s Law was scheduled to
sunset, or expire, on June 30, 2005, absent legislative action to extend the law in its original or
amended form. Shortly before the law expired, the legislature re-enacted the law. The statutory
scheme is largely unchanged, but there were a few substantive changes, which are
incorporated into the discussion of the appropriate statutory provisions. 2
On August 9, 1999, Governor Pataki signed Kendra’s Law, creating a statutory framework for
court-ordered assisted outpatient treatment (“AOT”), to ensure that individuals with mental
illness, and a history of hospitalizations or violence, participate in community-based services
appropriate to their needs.3 The law became effective in November of 1999. Since that time,
7624 court orders have been issued for AOT statewide, together with 4189 renewal orders.4
The majority of orders and renewals have been issued in New York City.
The statute creates a petition process, found in Mental Hygiene Law (“M.H.L.”) section 9.60,
designed to identify those persons who may not be able to survive safely in the community
without greater supervision and assistance than historically has been available. A description of
many aspects of the petition process follows, and is in turn followed by a review of some of the
more important court decisions concerning Kendra’s Law.
Filing the Petition
Kendra’s Law establishes a procedure for obtaining court orders for certain patients to receive
and accept outpatient treatment.5 The prescribed treatment is set forth in a written treatment
plan prepared by a physician who has examined the individual.6 The procedure involves a
hearing in which all the evidence, including testimony from the examining physician, and, if
desired, from the person alleged to need treatment, is presented to the court.7 If the court
determines that the individual meets the criteria for assisted outpatient treatment ("AOT"), an
order is issued to either the director of a hospital licensed or operated by the Office of Mental

New York State Assisted Outpatient Treatment Program Evaluation

59

Health ("OMH"), or a director of community services who oversees the mental health program of
a locality (i.e., the county or the City of New York mental health director). The initial order is
effective for up to six months8 and can be extended for successive periods of up to one year.9
Kendra’s Law also provides a procedure for the removal of a patient subject to a court order to a
hospital for evaluation and observation, in cases where the patient fails to comply with the
ordered treatment and poses a risk of harm.10
The process for issuance of AOT orders begins with the filing of a petition in the supreme or
county court where the person alleged to be mentally ill and in need of AOT is present (or is
believed to be present). The following may act as petitioners:11
1.)
2.)
3.)
4.)
5.)
6.)
7.)
8.)

an adult (18 years or older) roommate of the person;
a parent, spouse, adult child or adult sibling of the person;
the director of a hospital where the person is hospitalized;
the director of a public or charitable organization, agency or home that provides
mental health services and in whose institution the person resides;
a qualified psychiatrist who is either treating the person or supervising the treatment
of the person for mental illness;
the director of community services, or social services official of the city or county
where the person is present or is reasonably believed to be present;
a licensed psychologist, or a licensed social worker, who is treating the subject of the
petition for a mental illness; or
a parole officer or probation officer assigned to supervise the person.12

The petition must include the sworn statement of a physician who has examined the person
within ten days of the filing of the petition, attesting to the need for AOT.13 The examining
physician must be appointed by the director of community services, and must develop a written
treatment plan, in consultation with such director, which is submitted as part of the petition. All
service providers listed in the written treatment plan must receive of their inclusion.
If the examining physician’s attempts to examine the subject of the petition are unsuccessful,
the affidavit may state that unsuccessful attempts were made in the past ten days to obtain the
consent of the person for an examination, and that the physician believes AOT is warranted. If
the court finds reasonable cause to believe the allegations in the petition are true, the court may
request that the patient submit to an examination by a physician appointed by the court, and
ultimately may order peace officers or police officers to take the person into custody for
transport to a hospital for examination by a physician. Any such retention shall not exceed
twenty-four hours.14
The petitioner must establish by clear and convincing evidence that the subject of the petition
meets all of the following criteria:
1.)
2.)
3.)
4.)

60

he or she is at least 18 years old; and
is suffering from a mental illness; and
is unlikely to survive safely in the community without supervision; and
has a history of lack of compliance with treatment for mental illness that has:
a. at least twice within the last 36 months been a significant factor in necessitating
hospitalization or receipt of services in a forensic or other mental health unit in a
correctional facility or local correctional facility, not including any current
period, or period ending within the last six months, during which the person
was or is hospitalized or incarcerated, or

New York State Assisted Outpatient Treatment Program Evaluation

5.)
6.)

7.)
8.)

b. resulted in one or more acts of serious violent behavior toward self or others, or
threats of or attempts at serious physical harm to self or others within the last 48
months, not including any current period, or period ending within the last six
months, during which the person was or is hospitalized or incarcerated; and
is, as a result of his or her mental illness, unlikely to voluntarily participate in the
recommended treatment pursuant to the treatment plan; and
in view of his or her treatment history and current behavior, the person is in need of
assisted outpatient treatment in order to prevent a relapse or deterioration which
would be likely to result in serious harm to self or others; and
it is likely that the person will benefit from assisted outpatient treatment; and
if the person has executed a health care proxy, any directions included in such proxy
shall be taken into account by the court in determining the written treatment plan.15

In addition, a court may not issue an AOT order unless it finds that assisted outpatient treatment
is the least restrictive alternative available for the person.16
Notice of the petition must be served on a number of people or entities, including the person, his
or her nearest relative, and the Mental Hygiene Legal Service ("MHLS"), among others.17 The
court is required to set a hearing date that is no more than three days after receipt of the
petition, although adjournments can be granted for good cause.18
If the court finds by clear and convincing evidence that the subject of the petition meets each of
the criteria and a written treatment plan has been filed, the court may order the subject to
receive assisted outpatient treatment. The order must specifically state findings that the
proposed treatment is the least restrictive treatment that is appropriate and feasible, must
include case management or Assertive Community Team services and must state the other
categories of treatment required. The court may not order treatment which is not recommended
by the examining physician and included in the treatment plan.19 Appeals of AOT orders are
taken in the same manner as specified in M.H.L. section 9.35 relating to retention orders.20
If in the clinical judgment of a physician the assisted outpatient has failed or refused to comply
with the treatment ordered by the court, efforts must be made to achieve compliance. If these
efforts fail, and the patient may be in need of involuntary admission to a hospital, the physician
may request the director of community services, his designee, or other physician designated
under section 9.37 of the M.H.L. to arrange for the transport of the patient to a hospital. If
requested, peace officers, police officers or members of an approved mobile crisis outreach
team must take the patient into custody for transport to the hospital. An ambulance service may
also be used to transport the patient. The patient may be held for up to 72 hours for care,
observation and treatment and to permit a physician to determine whether involuntary
admission under the standards set forth in Article 9 of the M.H.L. is warranted.21 If, during the
72-hours a determination is made that the patient does not meet the standard for inpatient
hospitalization, then the patient must be released immediately.
When a patient subject to an AOT order meets the standard for removal from the community for
examination under this subdivision, and the director of community services responsible for his or
her care and treatment has ordered such removal, but the assisted outpatient has been located
in another county, language added by the 2005 legislation authorizes the director of community
services in the county where the assisted outpatient has been located to direct the removal of
the patient.

New York State Assisted Outpatient Treatment Program Evaluation

61

The legislation also provides for the exchange of clinical information pertaining to AOT patients,
and that hospitals and local government officials may share confidential patient information, in
certain circumstances where such sharing is necessary to facilitate AOT.22
Subdivision 9.60(k) permits a local Director of Community Services to file petitions for additional
periods of treatment under this section.23 Such petitions must be filed within thirty days prior to
the expiration of an order. The filing of such a petition automatically stays the expiration of an
order for assisted outpatient treatment. Orders for additional treatment may be for periods up to
one year.
Legal Developments
Since the legislation became effective, New York courts have addressed a number of issues
related to the statute, and have rendered decisions regarding the constitutionality of the statute,
as well as decisions construing statutory provisions concerning the criteria for AOT orders, and
the evidentiary standard under the statute.
Constitutional Challenges
Kendra’s Law was signed into law by Governor George Pataki on August 9, 1999, and became
effective on November 9, 1999. Even before the law was implemented, there emerged a
focused debate concerning the issue of whether the law achieved its goal of creating a
mechanism to insure that individuals who met the statutory criteria remained treatment
compliant while in the community, in a way that was consistent with the Constitutional rights of
those individuals.
On one side of the debate, proponents of the law recognized the numerous procedural aspects
of the law which were included specifically to meet constitutional standards, many of which were
deliberately modeled after other provisions of the Mental Hygiene Law, and which themselves
had survived prior judicial scrutiny and had been found to be constitutional. The supporters of
the law argued that any compulsion occasioned by the law was justified by the law’s important
objective of helping individuals with a history of treatment non-compliance resulting in violent
acts and/or repeated hospitalization to live safely in the community.
On the other side of the debate, opponents of the law primarily relied upon prior judicial
decisions which found that forcible medication over objection required a finding of incapacity.
The opponents of the law read into these decisions a much broader proscription of any
measures which might influence an individual’s decision to comply with treatment, even when
those measures fall far short of forcible medication over objection.
This theoretical debate would not be resolved without judicial intervention and inevitably found
its way into the courts. In In re Urcuyo,24 the first court challenge to the constitutionality of
Kendra’s Law, the Mental Hygiene Legal Service (“MHLS”) moved for dismissals on behalf of
two respondents to Kendra’s Law petitions in Supreme Court, Kings County. Respondents
argued that Kendra’s Law violated the due process and equal protection guarantees of the New
York State and the United States Constitutions because the statute did not require a judicial
finding of incapacity prior to the issuance of an order requiring the respondent to comply with
the AOT treatment plan. The court rejected all of respondents’ arguments, and held that the
statute was in each respect constitutional.

62

New York State Assisted Outpatient Treatment Program Evaluation

The challenge was based largely upon the Court of Appeals decision in Rivers v. Katz.25 The
Rivers court acknowledged that all patients have a fundamental right to determine the course of
their own treatment, but also that there may be circumstances where it is necessary to
administer treatment to a psychiatric inpatient over the patient’s objections, pursuant to either
the State’s police power or parens patriae power. Rivers established a procedural due process
standard for medication over objection, requiring a judicial finding that the patient lacks the
capacity to make competent decisions concerning treatment. This is a judicial determination,
not a clinical determination, and recognizes that there is a cognizable deprivation of liberty
resulting from a decision to forcibly medicate a person who has been involuntarily committed.
Respondents in Urcuyo urged the court to equate the infringement of a patient’s liberty interest
as a consequence of an AOT order with the Rivers situation, where a psychiatric inpatient is
forcibly medicated against his or her will. Respondents pointed to the compulsive nature of
court orders, and reasoned that the threat of removal for observation as a result of noncompliance is so akin to the forcible medication situation in Rivers, that identical due process
safeguards are constitutionally required.26
The court answered by stating that AOT patients are not involuntary inpatients, and therefore
are not even subject to medication over objection. There is no threat of medication over
objection because there is no authorization in the statute for such measures, and that “[e]ven if
a patient is eventually retained in a hospital after the seventy-two hour evaluation period
[pursuant to 9.60(n)], he or she still cannot be forcibly medicated absent a judicial determination
of incapacity or under emergency circumstances.”27
With respect to respondents’ attempts to draw analogies between forcible administration of
medication over objection, and the more remote possibility of clinical intervention in the event of
non-compliance, the response was equally succinct:
This court rejects respondents’ argument that an assisted outpatient order, while not
providing for the forcible administration of medication, unreasonably violates the
patients’ right to refuse medication by threatening arrest upon non-compliance with the
plan. . . . the court does not agree with respondents’ argument that a failure to take
medication results in the summary arrest of the patient. Rather, the patient’s failure to
comply with the treatment plan, whose formulation the patient had the opportunity to
participate in, leads to the heightened scrutiny of physicians for a 72-hour evaluation
period, but only after a physician has determined that the patient may be in need of
involuntary admission to a hospital.28
Ultimately, the 72-hour observation period was held to be “a reasonable response to a patient’s
failure to comply with treatment when it is balanced against the compelling State interests which
are involved.”29 Furthermore, the removal and 72-hour observation provisions of the statute
were held to be in accord with earlier judicial constructions of the dangerousness standard
embodied in the M.H.L. provisions concerning involuntary commitment.
One such precedent was Project Release v. Provost,30 which held that M.H.L. provisions
authorizing involuntary observation periods of up to 72 hours satisfy constitutional due process
standards. Reference was also made to prior decisions permitting clinicians, and courts, to
consider a patient’s history of relapse or deterioration in the community, when weighing the
appropriateness of an exercise of the police power or the parens patriae power. For example,
Matter of Seltzer v. Hogue31 involved a civilly committed patient whose behavior improved in the
hospital, but who would not comply with treatment, and whose condition would deteriorate in the

New York State Assisted Outpatient Treatment Program Evaluation

63

community. The Hogue court considered evidence of the patient’s behavior in the community,
and pattern of treatment failures, and ordered his continued retention under M.H.L. section 9.33.
Relying on Hogue, the Urcuyo court held that it was appropriate to consider the patient’s
behavior in the community, and any history of treatment failures, when making a determination
regarding dangerousness in a proceeding pursuant to Kendra’s Law.32
Reviewing the specific criteria that must be shown by a petitioner, the high evidentiary standard
requiring that those criteria be shown by clear and convincing evidence, and the prior judicial
acceptance of other Mental Hygiene Law provisions which are analogous to the 72-hour
observation provision of Kendra’s Law, the court found respondents’ constitutional due process
rights are sufficiently protected.
Although the constitutional issues considered by the court were sufficiently significant that an
appeal of the decision would appear to have been a certainty, the particular facts of the case
resulted in a withdrawal of the petition prior to a final decision on the merits. Consequently the
parties were deprived of standing to bring the court’s decision concerning the issue of the law’s
constitutionality before the Appellate Division, and thus appellate review of the issue would have
to wait for a more suitable case.
It did not take long for such a case to arise for in the wake of the decision in Matter of Urcuyo,
the Supreme Court, Queens County, was presented with another constitutional challenge to
Kendra’s Law. In Matter of K.L.,33 the MHLS moved for dismissal of a petition on behalf of
respondent, arguing that the statute was unconstitutional on two grounds -- that the statute
unconstitutionally deprived patients of the fundamental right to determine their own course of
treatment, and that the statutory provisions concerning removal for observation following noncompliance with the AOT order are facially unconstitutional. The Attorney General of the State
of New York, in his statutory capacity under N.Y. Exec. Law s. 71 intervened to support the
constitutionality of the statute. In turn, an amici brief was submitted in support of the
respondent’s constitutional challenge, representing a number of advocate groups.
The first challenge brought by the respondent in Matter of K.L. echoed the constitutional
challenge in Matter of Urcuyo, and asked the court to equate AOT with the type and degree of
deprivation of liberty implicated in Rivers, which involved the forcible medication of a psychiatric
inpatient over the patient’s objection.34 Respondent argued that in those cases where the
treatment plan included a medication component, the court could avoid finding the statute
unconstitutional by construing it to require a judicial finding that the patient lacked the capacity
to make reasoned decisions concerning his medical treatment. Respondent offered that the
procedural safeguards developed in Rivers could be imported into the AOT procedure, and
preserve the patient’s right to control his course of treatment.
Respondent’s characterization of Kendra’s Law orders as tantamount to medication over
objection was rejected, and the Rivers facts distinguished from the AOT situation. Notably,
Rivers reaffirmed the right of every individual to determine his or her own course of treatment,
but also recognized that “this right is not absolute, and must perforce yield to compelling state
interests when the state exercises its police power (as when it seeks to protect society), or its
parens patriae power (to provide care for its citizens who are unable to care for themselves
because of mental illness).”35 The court then rejected the Rivers analogy:
However, there is a fundamental flaw in respondent’s position in this
regard. Under Kendra’s Law, the patient is not required to take any
drugs, or submit to any treatment against his will. To the contrary, the

64

New York State Assisted Outpatient Treatment Program Evaluation

patient is invited to participate in the formation of the treatment plan.
When released pursuant to an assisted outpatient treatment order, no
drugs will be forced upon him if he fails to comply with the treatment
plan.36
After dismissing the Rivers analogy, the court went on to analyze whether any deprivation of a
patient’s liberty interests occasioned by a Kendra’s Law order was the result of the constitutional
exercise of the State’s police or parens patriae powers. The court first noted that for the state to
exercise the police power where an individual’s liberty interest may be infringed, a compelling
state interest must be identified. The court found such a compelling state interest:
Certainly, the state has a compelling interest in preventing emergencies and protecting
the public health. Thus the objective of Kendra’s Law, the outpatient treatment of the
mentally ill who, without treatment, “may relapse or become suicidal,” may be viewed as
a reasonable motive for the exercise of the state’s police power.37
The court noted that the statute requires that a history of non-compliance leading to repeated
hospitalizations, or serious violent behavior toward the individual himself or others, and that a
relapse in the individual’s illness would be likely to result in serious harm to the patient or others,
and concluded that “[t]hese considerations are not trivial.”38 Ultimately, the court found that
these considerations demonstrated the appropriateness of the state’s exercise of its parens
patriae powers as well.39
In light of exhaustive legislative findings, and “elaborate procedural safeguards to insure the
protection of the patient’s rights,”40 the court concluded:
Given that the purpose of Kendra’s Law is to protect both the mentally
disabled individual and the greater interests of society, the statute is
narrowly tailored to meet its objective. In view of the significant and
compelling state interests involved, the statute is not overly broad, or in
any way unrelated to, or excessive in light of those interests.41
Respondent’s second constitutional challenge was based upon the contention that, in order for
the removal provision (M.H.L. section 9.60(n)) to pass constitutional muster, the patient must be
afforded notice and an opportunity to be heard prior to any removal for observation. Or stated
differently, “it is urged that only a court may order such confinement or detention, rather than a
physician, as set forth in the statute.”42 This argument was also rejected.
Contrary to respondent’s position that the statute permits summary arrest without any due
process, for an AOT order to issue in the first instance there must have been a judicial finding,
based on clear and convincing evidence, that in the event of a failure to comply with treatment,
the patient will likely present a danger to himself or others. In addition to this prior judicial
finding, failure to comply does not automatically result in the immediate confinement of the
patient. In fact, the court went to great lengths to articulate the significant procedural
requirements which must be met prior to any effort to remove the patient who has failed to
comply with his treatment plan:
Before a physician may order [removal] of a patient to a hospital for
examination, the following must take place:
1. The physician must be satisfied that efforts were made to solicit the
patient’s compliance; and

New York State Assisted Outpatient Treatment Program Evaluation

65

2. In the clinical judgment of the physician, the patient (a) may be in
need of involuntary admission to a hospital pursuant to section 9.27 of
the mental hygiene law; or (b)”immediate observation, care and
treatment of the patient may be necessary pursuant to Mental
Hygiene Law sections 9.39 or 9.40.”
3. The physician may request “the director,” or certain other specific
person, to direct the removal of the patient to an appropriate hospital
for examination, pursuant to specific standards.
4. The patient may be retained only for a maximum of 72 hours.
5. If at any time during the 72-hour period the patient is found not to
meet the involuntary admission and retention provision of the Mental
Hygiene Law, he must be released. 43
With reference to other provisions of the Mental Hygiene Law which permit the involuntary
removal of a person to a hospital, and which have all been constitutionally upheld,44 the court
noted that the removal provisions in Kendra’s Law contemplate even greater procedural
protections. For example, removal under Kendra’s Law requires a prior judicial finding that
removal may be appropriate in the event of failure to comply.
Having had his constitutional challenge to Kendra’s Law denied by the supreme court in Queens
County, and having had that court also grant the petition for assisted outpatient treatment as to
him, the Respondent in Matter of K.L appealed the decision to the Appellate Division, Second
Department. Although the order for assisted outpatient treatment had expired by the time the
appeal was heard, the Second Department found that the issues raised justified invocation of an
exception to the mootness doctrine.45 The Appellate court also rejected arguments by the
Attorney General that Respondent lacked standing to challenge the removal provisions of the
law, because he had failed to allege that he had actually been removed pursuant to that
provision in violation of his constitutional rights.46
In an opinion notable for its succinctness, the Second Department also rejected the argument
that the additional procedural due process created by Rivers v. Katz applicable to forcible
medication over objection also to preclude court-ordered assisted outpatient treatment such as
is permitted by Kendra’s Law. In a unanimous opinion, the court held:
In contrast to Rivers, however, Kendra's Law is based on a legislative finding [5] that there are
some mentally-ill persons who are "capable of living in the community with the help of family,
friends and mental health professionals, but who, without routine care and treatment, may
relapse and become violent or suicidal, or require hospitalization". . . . Any compulsion that the
patient feels to comply with the treatment plan is justified by the court's finding, by clear and
convincing evidence, that the patient needs AOT in order to prevent a relapse or deterioration
which is likely to cause serious harm to the patient or others (see Mental Hygiene Law §
9.60[c][6]). Under these circumstances, a judicial finding of incapacity is not warranted . . . .47
The Second Department then identified three separate challenges to the removal provision of
Kendra’s Law. First, Respondent alleged that the removal provision failed to meet constitutional
procedural due process standards, because it did not require a pre-removal judicial hearing.
The court applied the test established by the U.S. Supreme Court in Mathews v. Eldridge,48
which requires the weighing of three factors: 1.) The private interest that will be affected, 2.) The
risk of an erroneous deprivation through current procedures and probable value of substitute
procedures, and 3.) The government’s interest, including the function involved and the burdens
associated with any substitute procedures. Applying this test, the law was found to comport
with constitutional due process standards:

66

New York State Assisted Outpatient Treatment Program Evaluation

Here, the brief detention of a noncompliant assisted outpatient for a psychiatric evaluation does
not constitute a substantial deprivation of liberty, and the additional safeguard of a judicial
hearing will not significantly reduce the possibility of an erroneous removal decision. Moreover,
the government has a strong interest in avoiding time-consuming judicial hearings, which
require mental health professionals to defend their clinical decisions and divert scarce resources
from the diagnosis and treatment of the mentally ill . . . . Also, any detention beyond the initial 72
hours is governed by the statutory provisions for involuntary commitments, which contain
sufficient notice and hearing provisions to meet "procedural due process minima" (Project
Release v Prevost, 722 F.2d 960, 975).49
Respondent next challenged the removal provision by arguing that since CPL 330.20(14)
provides criminal defendants who are found not guilty by reason of mental disease or defect
with the right to a hearing before being recommitted to a secure psychiatric facility, that a person
subject to a Kendra’s Law order is deprived of their equal protection rights because they do not
have a similar right to a hearing. This position was quickly rejected, because the situation of an
insanity acquittee is sufficiently distinct from that of an individual subject to civil commitment.50
Finally, the argument that removal pursuant to the statute violates the Fourth Amendment to the
United States Constitution because it does not require a finding of probable cause was also
rejected. The statute requires a physician to make several determinations based upon clinical
judgment, mirroring the provisions of M.H.L. 9.13, which in turn contains a “reasonable grounds”
standard, and that the assisted outpatient has a documented history of non-compliance leading
to violent acts or hospitalizations, concluding ;
Under these circumstances, a physician's clinical judgment based on the statutory
criteria is sufficient to justify the removal and detention of a noncompliant assisted
outpatient for a 72-hour psychiatric evaluation.51
Respondent was unsatisfied with the Appellate Division’s rejection of his constitutional
challenges, and made a final appeal to the New York State Court of Appeals. In February of
2004 in a unanimous opinion written by chief judge Judith Kaye, the highest court, like the trial
court and the Appellate Division before it, rejected all of Respondent’s challenges and upheld
the constitutionality of the statute in all respects.52
Once again, Respondent argued that the law could be saved if the court read into it the
requirement that AOT was only permissible if there was a judicial determination that the subject
lacked capacity to make treatment decisions. This argument has as its fundamental premise
the notion that AOT is in fact a type of medication over objection, and equates the impact of
AOT on the subject’s liberty interest with the infringement of liberty suffered by a psychiatric
inpatient who is subject to forcible medication over objection. In other words, respondent
argued that AOT is prohibited by Rivers v. Katz, in the absence of the additional procedural due
process mandated by that case.
The Court of Appeals rejected this argument, acknowledging that limiting AOT to those who
lacked capacity “would have the effect of eviscerating the legislation,” and that “a large number
of patients potentially subject to assisted outpatient treatment would be ineligible for the
program if a finding of incapacity were required.”53 The very impetus for the law was the finding
by the Legislature that many patients are capable of living safely in the community only with the
benefit of the structure and supervision of AOT, and to require a finding of incapacity would in
essence exclude most of the individuals the Legislature sought to assist.

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67

The Court of Appeals quickly identified the critical flaw in Respondent’s reasoning - the failure to
recognize that the additional due process required by Rivers is not applicable to AOT simply
because medication over objection is not authorized by Kendra’s Law:
Since Mental Hygiene Law § 9.60 does not permit forced medical treatment, a showing of
incapacity is not required. Rather, if the statute's existing criteria satisfy due process -- as in this
case we conclude they do -- then even psychiatric patients capable of making decisions about
their treatment may be constitutionally subject to its mandate.
. . . As we made clear in Rivers, the fundamental right of mentally ill persons to refuse treatment
may have to yield to compelling state interests (67 NY2d at 495). The state "has authority under
its police power to protect the community from the dangerous tendencies of some who are
mentally ill" (Addington v Texas, 441 US 418, 426 [1979]). Accordingly, where a patient
presents a danger to self or others, the state may be warranted, in the exercise of its police
power interest in preventing violence and maintaining order, in mandating treatment over the
patient's objection. Additionally, the state may rely on its parens patriae power to provide care
to its citizens who are unable to care for themselves because of mental illness (see Rivers, 67
NY2d at 495).54
Respondent also urged the court to adopt the position that even if Kendra’s Law did not permit
forcible medication over objection and because AOT subjects are ordered by a judge to take
their medication may prompt a subjective response from the individual amounting to coercion
which is so substantial as be considered equivalent to forcible medication. This argument was
likewise summarily rejected:
The restriction on a patient's freedom affected by a court order authorizing assisted
outpatient treatment is minimal, inasmuch as the coercive force of the order lies solely in
the compulsion generally felt by law-abiding citizens to comply with court directives. For
although the Legislature has determined that the existence of such an order and its
attendant supervision increases the likelihood of voluntary compliance with necessary
treatment, a violation of the order, standing alone, ultimately carries no sanction.
Rather, the violation, when coupled with a failure of efforts to solicit the assisted
outpatient's compliance, simply triggers heightened scrutiny on the part of the physician,
who must then determine whether the patient may be in need of involuntary
hospitalization.55
Considering the high evidentiary burden faced by AOT petitioners, and the detailed criteria in
the statute and the considerable and important interests of the state in insuring the safety of the
AOT subject as well as others in the community, the court concluded that the individual’s right to
refuse treatment was not unconstitutionally infringed:
In any event, the assisted outpatient's right to refuse treatment is outweighed by the state's
compelling interests in both its police and parens patriae powers. Inasmuch as an AOT order
requires a specific finding by clear and convincing evidence that the patient is in need of
assisted outpatient treatment in order to prevent a relapse or deterioration which would be likely
to result in serious harm to self or others, the state's police power justifies the minimal restriction
on the right to refuse treatment inherent in an order that the patient comply as directed.
Moreover, the state's interest in the exercise of its police power is greater here than in Rivers,
where the inpatient's confinement in a hospital under close supervision reduced the risk of
danger he posed to the community. In addition, the state's parens patriae interest in providing
care to its citizens who are unable to care for themselves because of mental illness is properly

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invoked since an AOT order requires findings that the patient is unlikely to survive safely in the
community without supervision [and] . . . the patient is in need of assisted outpatient treatment
in order to prevent a relapse or deterioration which would be likely to result in serious harm to
the patient or others . . .In requiring that these findings be made by clear and convincing
evidence and that the assisted outpatient treatment be the least restrictive alternative, the
statute's procedure for obtaining an AOT order provides all the process that is constitutionally
due.56
The argument that an individuals constitutional equal protection rights are violated in the
absence of a finding of incapacity, because persons subject to guardianship proceedings, and
involuntarily committed inpatients must be accorded such a hearing prior to medication over
objection, was also rejected. Reiterating that Kendra’s Law simply does not authorize
medication over objection, the court held that “[t]he statute thus in no way treats similarly
situated persons differently.”57
Respondent also challenged the removal provision of Kendra’s Law, contending that because
the law does not require a pre-removal hearing that the individual’s constitutional due process
rights are violated. The statute permits the temporary removal of an individual subject to an
AOT order, if the individual is non-compliant with treatment, efforts to solicit compliance have
failed, and a physician determines that as a result the individual may be in need of inpatient
care and treatment. The individual may be retained for up to 72 hours to determine whether he
or she meets the standards for further retention found in any of a number of other provisions of
the Mental Hygiene Law. If at any time during the 72 hours it is determined that the individual
does not meet the standards for further retention, he or she must be released.
The Court of Appeals, like the Appellate Division, applied the balancing test announced in the
United States Supreme Court case, Mathews v. Eldridge. The court balanced the interest
affected, the risk of deprivation through the procedures in the law and the burden of alternative
procedures, and the governments interests served by the law.
Applying the first factor of this test to the removal provision of Kendra’s Law, the Court of
Appeals voiced disagreement with the Appellate division, and found that the 72 hour retention
did constitute a substantial deprivation of liberty. However, the Court of Appeals affirmed the
lower court’s ultimate conclusion that considering the Mathews factors together, any
infringement is outweighed by the considerable procedural safeguards and the very important
governmental interest at stake.58
With respect to the second factor, the risk of an erroneous deprivation is minimized by the fact
that there must be a judicial finding, by clear and convincing evidence that, among other things,
“the patient is unlikely to survive safely in the community without supervision; has a history of
noncompliance resulting in violence or necessitating hospitalization; and is in need of assisted
outpatient treatment in order to prevent a relapse or deterioration which would be likely to result
in serious harm.” In addition, the law allows the individual’s treating physician to determine the
need for observation and inpatient care, which are clinical determinations, and not a judge, as
Respondent urged. Considering these features of the law, the court concluded that “[a] preremoval hearing would therefore not reduce the risk of erroneous deprivation.”59
Lastly, the governmental interest in reducing the risk of harm to the individual or others in the
community was considered to be significant, and the addition of a pre-removal hearing to the
already substantial procedural safeguards would have the undesired effect of frustrating that
intent:

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In addition, the state's interest in immediately removing from the streets noncompliant
patients previously found to be, as a result of their noncompliance, at risk of a relapse or
deterioration likely to result in serious harm to themselves or others is quite strong. The
state has a further interest in warding off the longer periods of hospitalization that, as the
Legislature has found, tend to accompany relapse or deterioration. The statute
advances this goal by enabling a physician to personally examine the patient at a
hospital so as to determine whether the patient, through noncompliance, has created a
need for inpatient treatment that the patient cannot himself or herself comprehend. A
pre-removal judicial hearing would significantly reduce the speed with which the patient
can be evaluated and then receive the care and treatment which physicians have reason
to believe that the patient may need. Indeed, absent removal, there is no mechanism by
which to force a noncompliant patient to attend a judicial hearing in the first place.60
The last argument raised by Respondent alleged that removal pursuant to the law as violated of
the fourth amendment prohibition against unreasonable searches and seizures, because the
statute does not specify that a physician must have probable cause to believe that an individual
meets the criteria for removal. The court in essence concluded that the proper exercise of
clinical judgment by the physician implies that such judgments will conform to the
reasonableness standard:
It is readily apparent that the requirement that a determination that a patient may need
care and treatment must be reached in the "clinical judgment" of a physician necessarily
contemplates that the determination will be based on the physician's reasonable belief
that the patient is in need of such care.61
As a result of the Court of Appeals decision, it is now well settled that Kendra’s Law is in all
respects a constitutional exercise of the states police power, and its parens patriae power.
Further, the removal provisions of the law have withstood constitutional scrutiny. Because this
opinion was rendered by the Court of Appeals, which is the highest court in New York, the
doctrine of stare decisis should preclude similar facial challenges to the constitutionality of
Kendra’s Law in the future.
Decisions Construing the Statutory Criteria
In addition to the decisions concerning constitutional issues in Matter of K.L., and Matter of
Urcuyo, there is now some guidance from the courts concerning the statutory criteria for
Kendra’s Law orders, M.H.L. section 9.60(c).
Soon after the statute became effective, an issue arose with respect to the proper construction
of the alternative criteria concerning a respondent’s prior need for hospitalization, or prior violent
acts. Among other criteria, a Kendra’s Law petitioner must demonstrate under M.H.L. section
9.60(c)(4):
[that] the patient has a history of lack of compliance with treatment for mental
illness that has:
(i)
at least twice within the last thirty-six months been a
significant factor in necessitating hospitalization in a
hospital, or receipt of services in a forensic or other mental
health unit of a correctional facility or a local correctional
facility, not including any period during which the person
was hospitalized or incarcerated immediately preceding
the filing of the petition or:

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(ii)

resulted in one or more acts of serious violent behavior
toward self or others or threats of, or attempts at, serious
physical harm to self or others within the last forty-eight
months, not including any period in which the person was
hospitalized or incarcerated immediately preceding the
filing of the petition . . .

The Two Hospitalization Criteria
The first prong of 9.60(c)(4) is satisfied when a petitioner demonstrates that a patient has been
hospitalized twice, as a result of treatment failures, within the past thirty-six months (referred to
as the “two hospitalizations” criterion). The thirty-six month look-back period excludes the
duration of any current hospitalization.
In June of 2000, a Kendra’s Law petition was brought in Supreme Court, Richmond County,
alleging that the respondent had been hospitalized on two occasions within the statutory lookback period -- within the time period of the current hospitalization plus thirty-six months.
In Matter of Sarkis, 62 the respondent moved to dismiss the petition, arguing, among other
grounds, that the petition was deficient because it counted the current hospitalization as one of
the two hospitalizations required to satisfy 9.60(c)(4)(i). Respondent reasoned that the statutory
language which excluded the duration of the current hospitalization from the look-back period
must also be construed to exclude the current hospitalization from being counted as one of the
two hospitalizations required.
The court relied on the specific language of the statute, and rejected respondent’s
argument:
[R]espondent’s position is based on a flawed interpretation of the statutory provision,
which reads [9.60(c)(4)(i)] as modifying the single word “hospitalization” appearing in the
first clause of Mental Hygiene Law 9.60(c)(4), rather than the grammatically more
consistent “thirty-six months” period during which the noncompliance resulting in such
hospitalizations must occur.63
It is the duration of the current hospitalization which is excluded from the look-back period. In
any event, it is the need for hospitalization as a result of noncompliance which is at the bottom
of the two hospitalization requirement. “The triggering event for purposes of Mental Hygiene
Law 9.60(c)(4)(i) is not the hospital admission but rather the noncompliance with treatment
necessitating the hospitalization, and is complete before the hospitalization begins.”64
Respondent appealed the denial of his motion to dismiss, and the Appellate Division, Second
Department affirmed, writing:
[W]e agree with the Supreme Court’s interpretation of Mental Hygiene
Law s. 9.60(c)(4)(i) . . . The appellant interprets this provision as
precluding the consideration of his hospitalization immediately preceding
the filing of the petition as one of the two required hospitalizations due to
noncompliance with treatment within the last 36 months. . . we reject the
appellant’s interpretation . . . which would inexplicably require courts to
disregard the most recent incident of hospitalization due to
noncompliance with treatment in favor of incidents more remote in time.65

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The decision in Matter of Dailey,66 is in accord with Matter of Sarkis. In Dailey, the court
rejected an argument identical to that offered by respondent in Sarkis, holding that reading the
statutory language, together with the legislative history, Aleads to the conclusion that the section
seeks only to expand the number of months which a petitioner can look back to thirty-six months
prior to the current hospitalization and does not exclude the acts of non-compliance with
treatment and the current hospitalization itself from consideration for an AOT order.67
In a decision further clarifying the two hospitalization criteria, Supreme Court, Suffolk County
held that in determining whether a particular hospitalization falls within the statutory look back
period, a petitioner may rely upon the latest date of the hospitalization, and not the starting date.
In Matter of Anthony F., the earlier hospitalization began more than thirty-six months prior to the
petition, but ended less than thirty-six months prior to the petition. The court stated that as long
as the petitioner can establish a nexus between the continued hospitalization and a lack of
compliance with treatment, the “thirty-six month period is to be measured from the final date of
the earlier hospitalization.” 68
The Violent Act Criteria
The second prong of 9.60(c)(4) is satisfied when a petitioner establishes that a patient has
committed one or more acts of serious violent behavior toward self or others or threats of, or
attempts at, serious physical harm to self or others within the last forty-eight months (referred to
as the “violent act” criterion). However, in language which is similar to the two hospitalizations
requirement discussed above, the forty-eight month look- back period excludes the duration of
any current hospitalization or incarceration.
This provision of the statute was the subject of an appeal to the Second Department. In Matter
of Hector A.,69 the trial court had dismissed the petition because the violent act relied upon to
satisfy the statutory criteria occurred while the patient was hospitalized. The respondent
stabbed a hospital worker during his current hospitalization, and the outcome of the case hinged
on whether the stabbing could be used to satisfy the violent act criterion of 9.60(c)(4). On
appeal, petitioner argued that the forty-eight month exclusion applies only to the duration of the
look-back period, and should not be read to exclude violent acts occurring during the current
hospitalization. The respondent argued that the language excluding the duration of the current
hospitalization from the forty-eight month look-back period also required the court to exclude
evidence of any violent acts or threats during the current hospitalization. The Second
Department reversed the trial court’s dismissal, and held that the evidence related to the
stabbing was admissible to satisfy the violent act requirement:
There is no merit to the patient’s argument that the violent act he committed against a
hospital employee must be disregarded under Mental Hygiene Law s. 9.60(c)(4)(ii). This
provision simply extends the 48 month period for considering the patient’s violent
behavior by the duration of his hospitalization or incarceration “immediately preceding
the filing of this petition.” This provision in no way eliminates from consideration violent
acts occurring during the hospitalization or incarceration.70
Hector A. cited with approval the rationale articulated in Julio H.,71 where Respondent sought
dismissal of an AOT petition, and argued for a construction of 9.60(c)(4)(ii) which would
exclude violent acts which occur while a person is hospitalized from being used to satisfy the
requirements of that section in an AOT petition.

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The respondent in Julio H. moved for dismissal of the AOT petition on two grounds: First, he
argued that the exclusion of the current hospitalization from the forty-eight month look back
period also excludes any violent acts during the current hospitalization. Second, he urged the
Court to accept the premise that a person who is currently hospitalized is receiving treatment, is
therefore deemed compliant, and thus violent acts occurring during hospitalization could never
be the result of non-compliance with treatment.
Both arguments were rejected, with the result that respondent’s violent act occurring during his
current hospitalization could be used to satisfy the violent act criterion of M.H.L. 9.60(c)(4)(ii).
Further, there is no irrebuttable presumption of compliance during hospitalization, and the issue
of whether a patient has been non-compliant with treatment while in a psychiatric hospital “is a
fact to be determined at the AOT hearing.”72 This is significant, because the petitioner must
establish a nexus between the patient’s violent behavior and his failure to comply with
treatment. By denying respondent’s argument that compliance in the hospital is presumed, the
court created an opportunity for petitioners to demonstrate a nexus between non-compliance,
and violence, based on the patient’s behavior while hospitalized.73
Decisions on the Applicability of the Physician-Patient Privilege
In addition to challenges to the constitutionality of Kendra’s Law, and clashes over the
appropriate construction of the two hospitalizations and violent act criteria, there have been
challenges involving the type of evidence which may, or must be offered in support of an AOT
petition.
One significant evidentiary challenge involved the practice of having a patient’s treating
physician testify at the mandatory hearing on the petition. The practice prompted objections
based on the physician-patient privilege, which is codified in N.Y. Civ. Prac. L. & R. (CPLR)
4504.
Supreme Court, Queens County, was faced with such a challenge in the Spring of 2000, in
Matter of Nathan R.,74 and ultimately ruled that the statutory privilege did not operate to prevent
a treating physician from also fulfilling the role of examining physician in a Kendra’s Law
proceeding.
To meet the statutory requirements for AOT, a petition must be accompanied by an affidavit by
an “examining physician,” who must state that he or she has personally examined respondent
no more than 10 days prior to the submission of the petition, that such physician recommends
AOT, and that the physician is willing and able to testify at the hearing on the petition.75 The
examining physician is also required to testify at the hearing on the petition concerning the facts
underlying the allegation that the respondent meets each of the AOT criteria, that it is the least
restrictive alternative, and concerning the recommended treatment plan.76
In Nathan R., the examining physician was also respondent’s treating physician. Respondent
moved to dismiss the petition, on the basis that “the physician-patient evidentiary privilege
codified in CPLR 4504 absolutely prohibits a treating psychiatrist from submitting an affidavit or
giving testimony in support of [an AOT] petition.”77 The motion to dismiss was denied:

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CPLR 4504 does not prevent a treating physician from disclosing information about the
patient under all circumstances. . . . The protection of the physician-patient privilege
extends only to communications and not to facts. A fact is one thing and a
communication concerning that fact is an entirely different thing.78
The decision allowed that there may in fact be specific communications which are entitled to
protection, but the burden is on the movant to demonstrate the existence of circumstances
justifying the recognition of the privilege. Even in such cases, the privilege will only be held to
attach to specific communications, and broad, conclusory claims of privilege, such as those
made by respondent’s counsel in Nathan R., will not suffice.79
Respondent also suggested that because a treating physician is among those enumerated who
may bring a petition, and a petitioner cannot also act as the examining physician, a treating
physician is statutorily prohibited from fulfilling the role of examining physician. This argument
was also rejected:
It is unclear whether the [respondent] is also claiming that Mental Hygiene Law s.9.60
prohibits a treating psychiatrist from being the examining physician. It does not. It only
prevents a treating psychiatrist from being the petitioner if the treating psychiatrist is the
examining physician.
80

Supreme Court, Queens County, was faced with an identical argument, in a motion to dismiss a
Kendra’s Law petition shortly after Nathan R. was decided. In Amin v. Rose F.,81 respondent
urged the court to dismiss the petition as insufficient, because the respondent’s treating
physician was also the examining physician, and therefore his testimony in support of the
petition would be prohibited by the physician-patient privilege. In denying the motion, the court
looked at, among other things, the legislative history of Kendra’s Law, and held:
[I]t is clear that the legislature intended and desired for the subject’s treating physician to
be intimately involved with the various aspects of assisted outpatient treatment, and
thereby implicitly waived the physician-patient privilege for the purposes of assisted
outpatient treatment. . . . Indeed, it would serve no useful purpose to insist on the
physician-patient privilege under M.H.L. 9.60, and, in fact, would frustrate the clear
intention of the legislature to keep mentally ill persons in the community and out of
inpatient psychiatric hospitalization. Furthermore, once the privilege is waived, it is
waived for all purposes . . . This clearly includes allowing the treating psychiatrist to
examine the subject of the AOT proceeding, and to testify as to his findings at that
hearing.
82

Therefore, although the statute prohibits a treating physician from being both the petitioner and
the examining physician with respect to a particular patient, the statute does not prohibit the
treating physician from also being either the examining physician or the petitioner.
The respondent in Amin appealed the decision denying her motion to dismiss. The original
petitioner did not file a responsive brief or otherwise oppose the appeal, because by the time of
the appeal, the respondent was no longer in petitioner’s care, and therefore petitioner did not
identify itself as having any real stake in the outcome. The Attorney General was granted
permission by the Appellate Division to file an amicus brief, and argued for an affirmance, based
on the reasoning in Nathan R., and Amin. However, because the respondent in Amin entered
into a voluntary agreement upon expiration of the original order, the appeal was dismissed as

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academic.83 It is thus left to a future litigant to challenge the concurrent reasoning of Nathan R.
and Amin.
Other Decisions
In Matter of Jason L.,84 a case before the Supreme Court, Monroe County, a dispute evolved
concerning whether a respondent has the right to a hearing before an order can issue for his
removal to a hospital for the purposes of the examination. Even after the court formally
requested that respondent submit to such an examination, he refused. Instead, respondent
objected to the request, demanding that he be provided with a hearing prior to any courtordered examination, and that to do otherwise would violate his constitutional due process
rights. Relying on M.H.L. 9.60(h)(3), which governs situations where a patient refuses to permit
an examination by a physician, the court ordered the removal for examination:
The court rejects respondent’s contention that the statute implies the
requirement of such a hearing, although in some cases it may be
appropriate to do so. [The petition] sufficiently sets out grounds
establishing reasonable cause to belief that the petition is true. The
respondent was given ample opportunity to be heard at oral argument
with respect to the petition and, indeed, plans to submit written opposition
to the petition itself. However, this court feels that the statute authorizes
the court to make a finding on the papers submitted when appropriate
and empowers the court to authorize the police to take respondent into
custody for purposes of the physician examination.85
Jason L. provides guidance on the issue of the procedure for pre-hearing examinations, but
leaves open the possibility that judges may find it appropriate in certain circumstances to
conduct a hearing prior to ordering the removal of a patient for examination. The governing
standard remains whether the affidavits and other clinical evidence offered by the petitioner
establish reasonable grounds to believe that the petition is true. This is a standard which is
decidedly lower than that applicable to a decision on the merits of the petition, and the court in
Jason L. was prudent in not allowing the hearing on the examination issue to expand into a
hearing on the petition itself.
Questions regarding the evidentiary standard applicable to AOT hearings have also found their
way into the courts. For example, in Matter of Jesus A.,86 respondent moved to dismiss the
petition, arguing that petitioner failed to offer facts sufficient to establish that an AOT order was
appropriate. The court was critical of the affidavit of the examining physician, which merely
paraphrased the criteria, concluding:
Clearly, these allegations, which are nothing more than conclusions, not facts, are
insufficient. It thus is the holding of this court that, as in all other cases, allegations
which are nothing more than broad, simple conclusory statements are insufficient to
state a claim under section 9.60 of the Mental Hygiene Law. 87
The petitioner submitted a supplemental affidavit in an attempt to cure the deficiencies found in
the original. This effort also failed, because it was not based upon “personal knowledge or upon
information and belief in which event the source of the information and the grounds for the belief
must be provided.”88
If it was not clear prior to Jesus A., the fog has now lifted -- the petition must contain specific
evidence, whether in the form of documents, affidavits or testimony, that all of the criteria are

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met. This burden must be carried by reference to facts, and the mere paraphrasing of the
statutory language will not suffice.
There has been some controversy surrounding the question of whether the right to counsel
provision of Kendra’s Law89 applies to the pre-hearing examination, which inevitably takes place
prior to the filing of the petition and the official commencement of the proceeding. In Matter of
Nancy H., Supreme Court, Dutchess County held that the right to counsel attaches only after
the proceeding is commenced. Because the examination took place prior to the filing of the
petition, which commenced the proceeding, the patient did not have the right to have her
attorney present during the examination.90 A different conclusion was reached by Supreme
Court, Otsego County in Matter of Noah C.91 In Noah C. the petitioner failed to provide notice to
the respondent’s counsel prior to an examination in anticipation of a renewal petition. The court
held that the proceeding had been commenced by the filing of the original petition, and that
therefore the right to counsel had long since attached. In dicta, the court suggested that it
shouldn’t matter whether the petition is for an original order or for a renewal, and that in either
instance the patient’s counsel should receive notice prior to any pre-hearing examination.
This controversy culminated in a case decided by Supreme Court, Sullivan County, captioned
Matter of David A. 92 The court reasoned that since the purpose of the examination was to allow
the examining physician to develop the affirmation which would be submitted as part of the
petition, and to testify at the hearing itself, the right to counsel attached. Relying on earlier
decisions, the court made clear that the attorney is entitled to notice, and may observe the
examination, but must not interrupt or interfere with the examination. This allows the attorney to
identify any issues pertaining to the examination, which may be raised later at the hearing.
There has also been controversy surrounding petitions for rehearing and review pursuant to
M.H.L 9.60(m). Specifically, there have been disputes concerning whether the service
provisions of M.H.L. 9.60(f) apply to such petitions. The most common example is the situation
where a petition was brought by a private hospital, the petition was granted, and the individual
was discharged into the community with the AOT order. Subsequent to discharge, a petition for
a rehearing and review is filed, but only the original petitioner – the private hospital - is served.
This is a problem because the hospital in nearly every case has had no contact with the patient
following discharge, because the AOT treatment plan is implemented by the local Director of
Community Services, and monitored by the Office of Mental Health program coordinator. In
other words, the hospital is put in the position of having to defend the appropriateness of the
AOT order when it is no longer involved with the individual’s treatment, and often has no
connection to the patient in the community. At the same time, the local Director, who has
responsibility for the delivery of care pursuant to the AOT order, is left out of the proceeding.
By failing to serve the local Director and the OMH program coordinator, the petitioner for
rehearing and review deprives those officials of a meaningful opportunity to fulfill their statutory
duties, and deprives the court considering the petition for rehearing and review of the most
current and crucial clinical information about the individual. Recognizing the need to avoid
these unwanted outcomes, Supreme Court, Suffolk County in Matter of Weinstock,93 held that a
petitioner for rehearing and review must satisfy the service requirements of M.H.L. s. 9.60(f),
and that both the local Director of Community Services, and the OMH program coordinator must
be afforded a reasonable opportunity to participate in the proceeding.
A very recent case which considered the question of whether categories of service which are
not technically clinical services may be included in the treatment plan was Matter of William C.,
which was decided by the Appellate Division, Second Department in May of 2009.94 The case

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originated in Supreme Court, Suffolk County, and involved a challenge to the inclusion of the
appointment of a representative payee, which is a form of financial management, in the AOT
treatment plan.95 Acknowledging that the statute does not specifically authorize the
appointment of a representative payee, the court concluded that “[i]t cannot be seriously
disputed that money management is a service which would assist a mentally ill person in “living
and functioning” as a productive member of the community.”96 While only explicitly authorizing
the inclusion of financial management in the treatment plan, this case suggests the possibility
that other traditionally non-clinical services may be included in an AOT treatment plan, at least
to the extent that such services are essential to the ultimate goal of the treatment plan – for the
patient to remain safely in the community.
One last issue worthy of discussion is the amount of discretion a court may exercise in
fashioning relief when deciding a Kendra’s Law petition. In In re Application of Manhattan
Psychiatric Center,97 the Appellate Division, Second Department, held it is within the authority of
a trial court to grant or deny a Kendra’s Law petition, but is beyond its authority to order
retention pursuant to other sections of the M.H.L., or order treatment other than what is included
in the treatment plan.
The case involved an AOT petition for a patient who, as well as having a history of mental
illness and treatment failures, had a criminal history resulting from violent behavior. After the
required hearing, and upon consent of the parties, the petition was granted. However, the court
held the order in abeyance, pending an independent psychiatric evaluation of respondent.
Although an AOT order ultimately was issued for the patient, the trial court at one point denied
the petition, based on its own determination that the patient met the criteria for continued
inpatient retention (the “dangerousness standard”), and should not be returned to the
community, with or without AOT.
Respondent appealed, and the Second Department decided a number of issues raised by the
lower court concerning the scope of that court’s authority under the statute.98 The first issue
was whether the court may make its own determination of whether the patient meets the
dangerousness standard, and was therefore beyond the reach of AOT. The Second
Department responded in the negative, and held that the authority of the trial court was limited
to deciding whether the statutory criteria had been met, and then either granting or denying the
petition. The decision whether to release the patient is a clinical determination left, in this case,
to the director of the hospital. Kendra’s Law does not provide an avenue for the subordination
of that clinical judgment to a judicial determination that the patient should remain hospitalized.99
The second issue was whether M.H.L. section 9.60(e)(2)(ii), which permits the court to consider
evidence beyond what is contained in the petition, also implicitly provides the authority for the
court to make a judicial determination with respect to the dangerousness standard. The Second
Department answered again in the negative, and held that section 9.60(e)(2)(ii) only permits the
consideration of additional facts in deciding whether the statutory criteria have been met, “[i]t is
not an invitation to the court to consider the issue of dangerousness in respect of a decision to
release the patient.”100
An issue was also raised concerning whether a court has discretion to deny a petition, where
the statutory criteria have been met. Noting that a court must deny the petition if the criteria
have not been met, The Second Department concluded:
Thus, the court’s discretion runs only to the least restrictive outcome. In
other words, a court may decide not to order AOT for a person who meets

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the criteria, but it may not decide to order AOT for a patient who does not
meet the criteria. . . . In any event, no measure of discretion would be
sufficient to permit a court to bar the release of a hospitalized patient (or,
by extrapolation, to order the involuntary admission of an unhospitalized
patient) as an alternative to ordering AOT, because Kendra’s Law does
not place that decision before the court. 101
Accordingly, it is now the case that clinical decisions, such as determinations of dangerousness,
are not before the court during Kendra’s Law proceedings. Judicial discretion is limited to
deciding whether a petitioner has carried its burden of demonstrating that the statutory criteria
are met by clear and convincing evidence, and then either granting or denying the petition.102
Conclusion
While there are still many issues that may want for the clarity provided by judicial review, a
number of threshold issues have been resolved since Kendra’s Law became effective. Most
importantly, the statute survived constitutional challenges based upon the right to control one’s
treatment. Court-ordered AOT has been distinguished from forcible medication over objection,
and any fears that such forced treatment would proliferate under Kendra’s Law should be
allayed by judicial recognition of the fact that forced medication over objection is never
appropriate in an AOT treatment plan, and in any event cannot occur absent sufficient due
process pursuant to Rivers v Katz.
It is currently the law that in meeting the two hospitalizations criterion, although the duration of
the current hospitalization is excluded from the respective look-back period, the current
hospitalization itself can be used to meet the criterion. When deciding whether a prior
hospitalization falls within the statutory look-back period, a petitioner may rely upon the latest
date of the hospitalization, rather than the date of admission. Similarly, in meeting the violent
act criterion, although the duration of the current hospitalization is excluded from the respective
look-back period, the violent acts occurring during the current hospitalization can be used to
meet the criterion.
The petitioner must marshal facts and evidence, such as testimony from those with actual
knowledge, in support of the petition. Mere recitations of the criteria, in affidavit form, will not
suffice. In addition, while a patient’s treating physician cannot be both the petitioner and the
examining physician in an AOT proceeding, the treating physician can be one or the other. If a
patient refuses to submit to an examination, the court can order the removal of the patient to a
hospital for the purposes of the examination. In such a circumstance, the petitioner must meet
specific criteria justifying the removal, but the patient does not have an absolute right to a preremoval hearing.
Finally, Kendra’s Law does not authorize courts to make independent determinations
concerning the issue of whether a patient meets involuntary inpatient criteria, during a Kendra’s
Law proceeding. Statutory authority extends only to the judicial determination of whether the
petitioner has met its burden of proving by clear and convincing evidence that the statutory
criteria have been met, and then the court may either grant or deny the petition.
Endnotes

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Prior to the enactment of Kendra’s Law, and prior to the tragic event involving Ms. Webdale, a pilot
program for assisted outpatient treatment which was operated out of Bellevue Hospital in New York
City. The pilot program was enacted in 1994 and codified as Mental Hygiene Law section 9.61. The
pilot program expired in 1998. Although the pilot and the current law differ in many details, the basic
framework for the current statute was based upon the pilot.
Chapters 137 and 158 of the Laws of 2005.
1999 N.Y. Laws 408.
Office of Mental Health Statewide AOT Report as of June 9, 2009.
Much of the information concerning the petition process in this article can be found at the New York
State Office of Mental Health official web page, www.omh.state.ny.us, which contains a great deal of
useful information about Kendra’s Law.
M.H.L. section 9.60(i)(1).
M.H.L. section 9.60(h).
M.H.L. section 9.60(j)(2).
M.H.L. section 9.60(k).
M.H.L. section 9.60(n).
The 2005 legislation modified subdivision (b) of section 9.47 of the Mental Hygiene Law to require
counties to conduct timely investigations of reports of persons who may be in need of assisted
outpatient treatment; establish procedures to provide timely notice of the completion of such
investigations to reporting persons and OMH program coordinators; and document such
investigations. Further, directors of community services are responsible for documenting petition filing
dates and dates of court orders, and coordinating and documenting the timely delivery of services.
M.H.L. section 9.60(e) (1).
M.H.L. section 9.60(e) (3) (i). Subdivision 9.60(e)(4) was is amended as part of the 2005 legislation
to authorize the Office of Mental Health to make available to counties with a population of less than
seventy-five thousand, a qualified physician for the purposes of making affirmations and affidavits as
required under subdivision (e)(3) of this section. The amendment does not require OMH to provide
examining physicians for every petition developed by a qualifying county, but simply authorizes the
OMH to make such clinical resources available when appropriate and necessary.
M.H.L. section 9.60(h)(3). There has been some debate concerning the issue of whether the
hearing, is a right which waivable by the patient. Although some courts may grant petitions where all
parties agree to waive the hearing, the language of 9.60(h)(2), and 9.60(i)(3), which expressly prohibit
the court from granting an AOT order absent the examining physician’s testimony at the hearing,
suggests that the hearing itself is non-waivable. Other provisions, such as 9.31 and 9.35 which
create the right to a hearing in the inpatient retention context provide a procedure for the patient to
request a hearing, and in the absence of such a request the hearing is deemed waived.
M.H.L. section 9.60(c).
M.H.L. section 9.60(j)(2).
M.H.L. section 9.60(f).
M.H.L. section 9.60(h).
M.H.L. section 9.60 (j)(2).
M.H.L. section 9.60(m).
M.H.L. section 9.60(n).
In December of 2000, the federal Department of Health and Human Services promulgated regulations
pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) establishing
standards for the privacy of individually identifiable health information (45 C.F.R. Parts 160 and 164).
The general rule established in these regulations is that individually identifiable health information
cannot be used or disclosed by covered entities (e.g. providers who engage in electronic
transactions) without patient consent or authorization. However, several of the listed exceptions to
this requirement would permit covered entities to continue to exchange clinical information without
patient consent or authorization as required by Kendra's Law and Kendra's Law court orders.
The 2005 legislation also provides standing to certain original petitioners (family members and
persons who live with patients) to file petitions for additional periods of treatment, provided that the
original petitioner retains his or her original status pursuant to subparagraphs (e)(1)(i) or (e)(l)(ii).

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24

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In re Urcuyo, 714 N.Y.S.2d 862 (Sup. Ct. Kings County, 2000).
Rivers v. Katz, 67 N.Y.2d 485 (1986).
In re Urcuyo, 714 N.Y.S.2d at 841-42.
Id., at 872, n., 3 (citations omitted).
Id., at 869-70.
Id., at 870.
Project Release v. Provost, 772 F.2d 960 (2d Cir., 1983)
Matter of Seltzer v. Hogue, 187 A.D.2d 230 (Second Dept. 1993)
See also, In re Francis S., 206 A.D.2d 4 (First Dept. 1995), aff’d 87 N.Y.2d 554 (1995). Francis S.,
like the patient in Hogue, was not dangerous in the structured environment of a hospital, but in the
community failed to comply with treatment and decompensated to the point of dangerousness.
In the Matter of the Application of Glenn Martin, For an Order Pursuant to Section 9.60 of the Mental
Hygiene Law (Kendra’s Law) Authorizing Assisted Outpatient Treatment for K.L., 500748/00 (Sp. Ct.,
Queens County, 2000), (Order Granting Kendra’s Law Petition).
Id., at 7.
Id.
Id.
Id., at 8.
Id., at 9.
Id., at 10.
Id., at 8.
Id., at 9.
Id., at 10
Id., at 11.
For example, M.H.L. section 9.37, which provides for removal for a 72-hour observation period upon
certification by a Director of Community Services was upheld in Woe by Woe v. Cuomo, 729 F.2d 96
(2nd Cir. 1984), cert. den. 469 U.S. 936. The court also cited Thomas v. Culberg, 741 F.Supp. 77
(S.D.N.Y. 1990), upholding section 9.41 of the M.H.L., which permits police officers to take into
custody a person who appears to be mentally ill. The court in Matter of K.L. noted that these
warrantless detention provisions were upheld, even though, unlike detentions pursuant to Kendra’s
Law, they do not follow from earlier judicial findings.
Matter of K.L., 302 A.D.2d 388, 389 (Second Dept., 2003)
Id.
Id., at 390 (citations omitted).
424 U.S. 319.
Matter of K.L., 302 A.D.2d 388, 391.
Id.
Id., at 391-392
Matter of K.L., 1 N.Y.3d 362 (2004).
Id., at 369.
Id., at 370.
Id.
Id., at 371-372.
Id., at 372.
Id.
Id.
Id., at 373-374
Id., At 374
Matter of Sarkis, (NYLJ, Aug. 18, 2000, at 29, col 6).
Id.
Id.
In the Matter of South Beach Psychiatric Center, etc., respondent; Andre R., 727 N.Y.S.2d 149, 150
(Second Dept. 2001), (citations omitted).
Matter of Dailey, 713 N.Y.S.2d 660, (Sup. Ct. Queens County, 2000).
Matter of Dailey, 713 N.Y.S.2d at 663 (emphasis in original).

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. In the Matter of Pilgrim Psychiatric Center v. Anthony F., 18601/01 (S.Ct. Suffolk Cty, 2002), (Order
Denying Motion to Dismiss Kendra’s Law Petition).
69
. In the Matter of Weinstock, appellant: Hector A. (Anonymous), respondent, 733 N.Y.S.2d 243
(Second Department, 2001).
70
. Id., at 245.
71
. In the Matter of Weinstock, for an order Authorizing Outpatient treatment for Julio H., 723 N.Y.S.2d
617 (Sup. Ct. Kings County, 2001).
72
. Id., at 619.
73
. See, In the Matter of Weinstock, for an Order Authorizing Assisted Outpatient Treatment for Shali K.,
742 N.Y.S.2d 447 (Sup.Ct., Kings County 2002), where the court accepted the argument that a
violent act in the hospital may count under the statute, but denied the petition because petitioner
failed to establish a nexus between the violent act and respondent’s treatment failures.
74
. In the Matter of Sullivan, for an Order Authorizing Outpatient Treatment for Nathan R., 710 N.Y.S.2d
804 (Sup Ct. Queens County, 2000).
75
. M.H.L. section 9.60(e)(3)(i).
76
. M.H.L. section 9.60(h)(4).
77
. Matter of Nathan R., 710 N.Y.S.2d at 805 (quoting respondent’s counsel).
78
. Id., at 805.
79
. Id., at 806.
80
. Id.
81
. Amin v. Rose F., (NYLJ, December 7, 2000, at 31, col 1).
82
. Id.
83
. In the Matter of Rose F. v. Amin, 739 N.Y.S2d 834 (Second Dept. 2002).
84
. Matter of Director of Community Services, for an Order Authorizing Assisted Outpatient Treatment for
Jason L., 715 N.Y.S.2d 833 (Sup. Ct. Monroe County, 2000).
85
. Id., at 189.
86
. In the Matter of Sullivan, for an Order Authorizing Outpatient Treatment for Jesus A., 710 N.Y.S.2d
853 (Sup. Ct. Queens County, 2000).
87
. Id., at 857 (citations omitted).
88
. Id. (Citations omitted).
89
. M.H.L. section 9.60(g).
90
. Matter of Nancy H., No. 125/2000 - MI (Dutchess Cty, 2000), (Order Denying Motion to Dismiss for
Lack of Subject Matter Jurisdiction).
91
. Matter of Noah C., No. 8598 (Otsego Cty, 2003), (Order Granting Motion to Dismiss for Failure to
Notice Patient’s Counsel Prior to Examination).
92
. No. 981-05 (Sup. Ct. Sullivan County, June 2, 2005).
93
. No. 21474/04 (Sup. Ct. Suffolk County, March 16, 2005
94
. 2009 Slip. Op. 04232, Appellate Division, Second Department.
95
. “Representative Payee Status” refers to the mechanism whereby a representative is appointed to
receive certain funds on behalf of the patient, and use those funds to pay specific financial obligations
for the patient, such as rent.
96
. Id., at 7.
97
. In re Application of Manhattan Psychiatric Center, 728 N.Y.S.2d 37 (Second Dept., 2001).
98
. Because the court did eventually sign an AOT order for the patient, the matter would appear to be
beyond appellate review, based on the mootness doctrine. The Second Department accepted the
case as an exception to the mootness doctrine, because it is Alikely to be repeated, it involves a
phenomenon which typically evades review, and it implicates substantial and novel issues. Id., at 39.
99
. Id., at 42.
100
. Id., at 43.
101
. Id., at 43, 44 (citations omitted).
102
. See also In the Matter of Endress, for an order Authorizing Outpatient Treatment for Barry H., 732
N.Y.S.2d 549 (Sup. Ct. Onieda County, 2001). The court in Endress believed that the patient should
not be released into the community at all, but citing Matter of Manhattan Psychiatric Center,
reluctantly granted the AOT petition, as the most appropriate outcome, given its limited alternatives.

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Kendra’s Law Statute
Text of Mental Hygiene Law * § 9.60 Assisted outpatient treatment.
(a) Definitions. For purposes of this section, the following definitions shall apply:
(1) "assisted outpatient treatment" shall mean categories of outpatient services which have
been ordered by the court pursuant to this section. Such treatment shall include case
management services or assertive community treatment team services to provide care
coordination, and may also include any of the following categories of services: medication;
periodic blood tests or urinalysis to determine compliance with prescribed medications;
individual or group therapy; day or partial day programming activities; educational and
vocational training or activities; alcohol or substance abuse treatment and counseling and
periodic tests for the presence of alcohol or illegal drugs for persons with a history of alcohol or
substance abuse; supervision of living arrangements; and any other services within a local or
unified services plan developed pursuant to article forty-one of this chapter, prescribed to treat
the person's mental illness and to assist the person in living and functioning in the community,
or to attempt to prevent a relapse or deterioration that may reasonably be predicted to result in
suicide or the need for hospitalization.
(2) "director" shall mean the director of community services of a local governmental unit, or the
director of a hospital licensed or operated by the office of mental health which operates, directs
and supervises an assisted outpatient treatment program.
(3) "director of community services" and "local governmental unit" shall have the same
meanings as provided in article forty-one of this chapter.
(4) "assisted outpatient treatment program" shall mean a system to arrange for and coordinate
the provision of assisted outpatient treatment, to monitor treatment compliance by assisted
outpatients, to evaluate the condition or needs of assisted outpatients, to take appropriate steps
to address the needs of such individuals, and to ensure compliance with court orders.
(5) "assisted outpatient" shall mean the person under a court order to receive assisted
outpatient treatment.
(6) "subject of the petition" or "subject" shall mean the person who is alleged in a petition, filed
pursuant to the provisions of this section, to meet the criteria for assisted outpatient treatment.
(7) "correctional facility" and "local correctional facility" shall have the same meanings as
provided in section two of the correction law.
(8) "health care proxy" and "health care agent" shall have the same meanings as provided in
article twenty-nine-C of the public health law.
(9) "program coordinator" shall mean an individual appointed by the commissioner of mental
health, pursuant to subdivision (f) of section 7.17 of this chapter, who is responsible for the
oversight and monitoring of assisted outpatient treatment programs.
(b) Programs. The director of community services of each local governmental unit shall operate,
direct and supervise an assisted outpatient treatment program. The director of a hospital
licensed or operated by the office of mental health may operate, direct and supervise an

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assisted outpatient treatment program, upon approval by the commissioner. Directors of
community services shall be permitted to satisfy the provisions of this subdivision through the
operation of joint assisted outpatient treatment programs. Nothing in this subdivision shall be
interpreted to preclude the combination or coordination of efforts between and among local
governmental units and hospitals in providing and coordinating assisted outpatient treatment.
(c) Criteria. A person may be ordered to receive assisted outpatient treatment if the court finds
that such person:
(1) is eighteen years of age or older; and
(2) is suffering from a mental illness; and
(3) is unlikely to survive safely in the community without supervision, based on a clinical
determination; and
(4) has a history of lack of compliance with treatment for mental illness that has:
(i) prior to the filing of the petition, at least twice within the last thirty-six months been a
significant factor in necessitating hospitalization in a hospital, or receipt of services in a forensic
or other mental health unit of a correctional facility or a local correctional facility, not including
any current period, or period ending within the last six months, during which the person was or
is hospitalized or incarcerated; or
(ii) prior to the filing of the petition, resulted in one or more acts of serious violent behavior
toward self or others or threats of, or attempts at, serious physical harm to self or others within
the last forty-eight months, not including any current period, or period ending within the last six
months, in which the person was or is hospitalized or incarcerated; and
(5) is, as a result of his or her mental illness, unlikely to voluntarily participate in outpatient
treatment that would enable him or her to live safely in the community; and
(6) in view of his or her treatment history and current behavior, is in need of assisted outpatient
treatment in order to prevent a relapse or deterioration which would be likely to result in serious
harm to the person or others as defined in section 9.01 of this article; and
(7) is likely to benefit from assisted outpatient treatment.
(d) Health care proxy. Nothing in this section shall preclude a person with a health care proxy
from being subject to a petition pursuant to this chapter and consistent with article twenty-nine-C
of the public health law.
(e) Petition to the court. (1) A petition for an order authorizing assisted outpatient treatment may
be filed in the supreme or county court in the county in which the subject of the petition is
present or reasonably believed to be present. Such petition may be initiated only by the
following persons:
(i) any person eighteen years of age or older with whom the subject of the petition resides; or
(ii) the parent, spouse, sibling eighteen years of age or older, or child eighteen years of age or
older of the subject of the petition; or

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(iii) the director of a hospital in which the subject of the petition is hospitalized; or
(iv) the director of any public or charitable organization, agency or home providing mental health
services to the subject of the petition or in whose institution the subject of the petition resides; or
(v) a qualified psychiatrist who is either supervising the treatment of or treating the subject of the
petition for a mental illness; or
(vi) a psychologist, licensed pursuant to article one hundred fifty-three of the education law, or a
social worker, licensed pursuant to article one hundred fifty-four of the education law, who is
treating the subject of the petition for a mental illness; or
(vii) the director of community services, or his or her designee, or the social services official, as
defined in the social services law, of the city or county in which the subject of the petition is
present or reasonably believed to be present; or
(viii) a parole officer or probation officer assigned to supervise the subject of the petition.
(2) The petition shall state: (i) each of the criteria for assisted outpatient treatment as set forth in
subdivision (c) of this section;
(ii) facts which support the petitioner's belief that the subject of the petition meets each criterion,
provided that the hearing on the petition need not be limited to the stated facts; and
(iii) that the subject of the petition is present, or is reasonably believed to be present, within the
county where such petition is filed.
(3) The petition shall be accompanied by an affirmation or affidavit of a physician, who shall not
be the petitioner, stating either that:
(i) such physician has personally examined the subject of the petition no more than ten days
prior to the submission of the petition, recommends assisted outpatient treatment for the subject
of the petition, and is willing and able to testify at the hearing on the petition; or
(ii) no more than ten days prior to the filing of the petition, such physician or his or her designee
has made appropriate attempts but has not been successful in eliciting the cooperation of the
subject of the petition to submit to an examination, such physician has reason to suspect that
the subject of the petition meets the criteria for assisted outpatient treatment, and such
physician is willing and able to examine the subject of the petition and testify at the hearing on
the petition.
(4) In counties with a population of less than seventy-five thousand, the affirmation or affidavit
required by paragraph three of this subdivision may be made by a physician who is an
employee of the office. The office is authorized to make available, at no cost to the county, a
qualified physician for the purpose of making such affirmation or affidavit consistent with the
provisions of such paragraph.
(f) Service. The petitioner shall cause written notice of the petition to be given to the subject of
the petition and a copy thereof to be given personally or by mail to the persons listed in section
9.29 of this article, the mental hygiene legal service, the health care agent if any such agent is

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known to the petitioner, the appropriate program coordinator, and the appropriate director of
community services, if such director is not the petitioner.
(g) Right to counsel. The subject of the petition shall have the right to be represented by the
mental hygiene legal service, or privately financed counsel, at all stages of a proceeding
commenced under this section.
(h) Hearing. (1) Upon receipt of the petition, the court shall fix the date for a hearing. Such date
shall be no later than three days from the date such petition is received by the court, excluding
Saturdays, Sundays and holidays. Adjournments shall be permitted only for good cause shown.
In granting adjournments, the court shall consider the need for further examination by a
physician or the potential need to provide assisted outpatient treatment expeditiously. The court
shall cause the subject of the petition, any other person receiving notice pursuant to subdivision
(f) of this section, the petitioner, the physician whose affirmation or affidavit accompanied the
petition, and such other persons as the court may determine to be advised of such date. Upon
such date, or upon such other date to which the proceeding may be adjourned, the court shall
hear testimony and, if it be deemed advisable and the subject of the petition is available,
examine the subject of the petition in or out of court. If the subject of the petition does not
appear at the hearing, and appropriate attempts to elicit the attendance of the subject have
failed, the court may conduct the hearing in the subject's absence. In such case, the court shall
set forth the factual basis for conducting the hearing without the presence of the subject of the
petition.
(2) The court shall not order assisted outpatient treatment unless an examining physician, who
recommends assisted outpatient treatment and has personally examined the subject of the
petition no more than ten days before the filing of the petition, testifies in person at the hearing.
Such physician shall state the facts and clinical determinations which support the allegation that
the subject of the petition meets each of the criteria for assisted outpatient treatment.
(3) If the subject of the petition has refused to be examined by a physician, the court may
request the subject to consent to an examination by a physician appointed by the court. If the
subject of the petition does not consent and the court finds reasonable cause to believe that the
allegations in the petition are true, the court may order peace officers, acting pursuant to their
special duties, or police officers who are members of an authorized police department or force,
or of a sheriff's department to take the subject of the petition into custody and transport him or
her to a hospital for examination by a physician. Retention of the subject of the petition under
such order shall not exceed twenty-four hours. The examination of the subject of the petition
may be performed by the physician whose affirmation or affidavit accompanied the petition
pursuant to paragraph three of subdivision (e) of this section, if such physician is privileged by
such hospital or otherwise authorized by such hospital to do so. If such examination is
performed by another physician, the examining physician may consult with the physician whose
affirmation or affidavit accompanied the petition as to whether the subject meets the criteria for
assisted outpatient treatment.
(4) A physician who testifies pursuant to paragraph two of this subdivision shall state: (i) the
facts which support the allegation that the subject meets each of the criteria for assisted
outpatient treatment, (ii) that the treatment is the least restrictive alternative, (iii) the
recommended assisted outpatient treatment, and (iv) the rationale for the recommended
assisted outpatient treatment. If the recommended assisted outpatient treatment includes
medication, such physician's testimony shall describe the types or classes of medication which
should be authorized, shall describe the beneficial and detrimental physical and mental effects

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85

of such medication, and shall recommend whether such medication should be self-administered
or administered by authorized personnel.
(5) The subject of the petition shall be afforded an opportunity to present evidence, to call
witnesses on his or her behalf, and to cross-examine adverse witnesses.
(i) Written treatment plan. (1) The court shall not order assisted outpatient treatment unless a
physician appointed by the appropriate director, in consultation with such director, develops and
provides to the court a proposed written treatment plan. The written treatment plan shall include
case management services or assertive community treatment team services to provide care
coordination. The written treatment plan also shall include all categories of services, as set forth
in paragraph one of subdivision (a) of this section, which such physician recommends that the
subject of the petition receive. All service providers shall be notified regarding their inclusion in
the written treatment plan. If the written treatment plan includes medication, it shall state
whether such medication should be self-administered or administered by authorized personnel,
and shall specify type and dosage range of medication most likely to provide maximum benefit
for the subject. If the written treatment plan includes alcohol or substance abuse counseling and
treatment, such plan may include a provision requiring relevant testing for either alcohol or
illegal substances provided the physician's clinical basis for recommending such plan provides
sufficient facts for the court to find (i) that such person has a history of alcohol or substance
abuse that is clinically related to the mental illness; and (ii) that such testing is necessary to
prevent a relapse or deterioration which would be likely to result in serious harm to the person
or others. If a director is the petitioner, the written treatment plan shall be provided to the court
no later than the date of the hearing on the petition. If a person other than a director is the
petitioner, such plan shall be provided to the court no later than the date set by the court
pursuant to paragraph three of subdivision (j) of this section.
(2) The physician appointed to develop the written treatment plan shall provide the following
persons with an opportunity to actively participate in the development of such plan: the subject
of the petition; the treating physician, if any; and upon the request of the subject of the petition,
an individual significant to the subject including any relative, close friend or individual otherwise
concerned with the welfare of the subject. If the subject of the petition has executed a health
care proxy, the appointed physician shall consider any directions included in such proxy in
developing the written treatment plan.
(3) The court shall not order assisted outpatient treatment unless a physician appearing on
behalf of a director testifies to explain the written proposed treatment plan. Such physician shall
state the categories of assisted outpatient treatment recommended, the rationale for each such
category, facts which establish that such treatment is the least restrictive alternative, and, if the
recommended assisted outpatient treatment plan includes medication, such physician shall
state the types or classes of medication recommended, the beneficial and detrimental physical
and mental effects of such medication, and whether such medication should be selfadministered or administered by an authorized professional. If the subject of the petition has
executed a health care proxy, such physician shall state the consideration given to any
directions included in such proxy in developing the written treatment plan. If a director is the
petitioner, testimony pursuant to this paragraph shall be given at the hearing on the petition. If a
person other than a director is the petitioner, such testimony shall be given on the date set by
the court pursuant to paragraph three of subdivision (j) of this section.

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(j) Disposition. (1) If after hearing all relevant evidence, the court does not find by clear and
convincing evidence that the subject of the petition meets the criteria for assisted outpatient
treatment, the court shall dismiss the petition.
(2) If after hearing all relevant evidence, the court finds by clear and convincing evidence that
the subject of the petition meets the criteria for assisted outpatient treatment, and there is no
appropriate and feasible less restrictive alternative, the court may order the subject to receive
assisted outpatient treatment for an initial period not to exceed six months. In fashioning the
order, the court shall specifically make findings by clear and convincing evidence that the
proposed treatment is the least restrictive treatment appropriate and feasible for the subject.
The order shall state an assisted outpatient treatment plan, which shall include all categories of
assisted outpatient treatment, as set forth in paragraph one of subdivision (a) of this section,
which the assisted outpatient is to receive, but shall not include any such category that has not
been recommended in both the proposed written treatment plan and the testimony provided to
the court pursuant to subdivision (i) of this section.
(3) If after hearing all relevant evidence presented by a petitioner who is not a director, the court
finds by clear and convincing evidence that the subject of the petition meets the criteria for
assisted outpatient treatment, and the court has yet to be provided with a written proposed
treatment plan and testimony pursuant to subdivision (i) of this section, the court shall order the
appropriate director to provide the court with such plan and testimony no later than the third day,
excluding Saturdays, Sundays and holidays, immediately following the date of such order. Upon
receiving such plan and testimony, the court may order assisted outpatient treatment as
provided in paragraph two of this subdivision.
(4) A court may order the patient to self-administer psychotropic drugs or accept the
administration of such drugs by authorized personnel as part of an assisted outpatient treatment
program. Such order may specify the type and dosage range of such psychotropic drugs and
such order shall be effective for the duration of such assisted outpatient treatment.
(5) If the petitioner is the director of a hospital that operates an assisted outpatient treatment
program, the court order shall direct the hospital director to provide or arrange for all categories
of assisted outpatient treatment for the assisted outpatient throughout the period of the order.
For all other persons, the order shall require the director of community services of the
appropriate local governmental unit to provide or arrange for all categories of assisted outpatient
treatment for the assisted outpatient throughout the period of the order.
(6) The director shall cause a copy of any court order issued pursuant to this section to be
served personally, or by mail, facsimile or electronic means, upon the assisted outpatient, the
mental hygiene legal service or anyone acting on the assisted outpatient's behalf, the original
petitioner, identified service providers, and all others entitled to notice under subdivision (f) of
this section.
(k) Petition for additional periods of treatment. Within thirty days prior to the expiration of an
order of assisted outpatient treatment, the appropriate director or the current petitioner, if the
current petition was filed pursuant to subparagraph (i) or (ii) of paragraph one of subdivision (e)
of this section, and the current petitioner retains his or her original status pursuant to the
applicable subparagraph, may petition the court to order continued assisted outpatient treatment
for a period not to exceed one year from the expiration date of the current order. If the court's
disposition of such petition does not occur prior to the expiration date of the current order, the
current order shall remain in effect until such disposition. The procedures for obtaining any order

New York State Assisted Outpatient Treatment Program Evaluation

87

pursuant to this subdivision shall be in accordance with the provisions of the foregoing
subdivisions of this section; provided that the time restrictions included in paragraph four of
subdivision (c) of this section shall not be applicable. The notice provisions set forth in
paragraph six of subdivision (j) of this section shall be applicable. Any court order requiring
periodic blood tests or urinalysis for the presence of alcohol or illegal drugs shall be subject to
review after six months by the physician who developed the written treatment plan or another
physician designated by the director, and such physician shall be authorized to terminate such
blood tests or urinalysis without further action by the court.
(l) Petition for an order to stay, vacate or modify. (1) In addition to any other right or remedy
available by law with respect to the order for assisted outpatient treatment, the assisted
outpatient, the mental hygiene legal service, or anyone acting on the assisted outpatient's
behalf may petition the court on notice to the director, the original petitioner, and all others
entitled to notice under subdivision (f) of this section to stay, vacate or modify the order.
(2) The appropriate director shall petition the court for approval before instituting a proposed
material change in the assisted outpatient treatment plan, unless such change is authorized by
the order of the court. Such petition shall be filed on notice to all parties entitled to notice under
subdivision (f) of this section. Not later than five days after receiving such petition, excluding
Saturdays, Sundays and holidays, the court shall hold a hearing on the petition; provided that if
the assisted outpatient informs the court that he or she agrees to the proposed material change,
the court may approve such change without a hearing. Non-material changes may be instituted
by the director without court approval. For the purposes of this paragraph, a material change is
an addition or deletion of a category of services to or from a current assisted outpatient
treatment plan, or any deviation without the assisted outpatient's consent from the terms of a
current order relating to the administration of psychotropic drugs.
(m) Appeals. Review of an order issued pursuant to this section shall be had in like manner as
specified in section 9.35 of this article.
(n) Failure to comply with assisted outpatient treatment. Where in the clinical judgment of a
physician, (i) the assisted outpatient, has failed or refused to comply with the assisted outpatient
treatment, (ii) efforts were made to solicit compliance, and (iii) such assisted outpatient may be
in need of involuntary admission to a hospital pursuant to section 9.27 of this article or
immediate observation, care and treatment pursuant to section 9.39 or 9.40 of this article, such
physician may request the director of community services, the director's designee, or any
physician designated by the director of community services pursuant to section 9.37 of this
article, to direct the removal of such assisted outpatient to an appropriate hospital for an
examination to determine if such person has a mental illness for which hospitalization is
necessary pursuant to section 9.27, 9.39 or 9.40 of this article. Furthermore, if such assisted
outpatient refuses to take medications as required by the court order, or he or she refuses to
take, or fails a blood test, urinalysis, or alcohol or drug test as required by the court order, such
physician may consider such refusal or failure when determining whether the assisted outpatient
is in need of an examination to determine whether he or she has a mental illness for which
hospitalization is necessary. Upon the request of such physician, the director, the director's
designee, or any physician designated pursuant to section 9.37 of this article, may direct peace
officers, acting pursuant to their special duties, or police officers who are members of an
authorized police department or force or of a sheriff's department to take the assisted outpatient
into custody and transport him or her to the hospital operating the assisted outpatient treatment
program or to any hospital authorized by the director of community services to receive such
persons. Such law enforcement officials shall carry out such directive. Upon the request of such

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New York State Assisted Outpatient Treatment Program Evaluation

physician, the director, the director's designee, or any physician designated pursuant to section
9.37 of this article, an ambulance service, as defined by subdivision two of section three
thousand one of the public health law, or an approved mobile crisis outreach team as defined in
section 9.58 of this article shall be authorized to take into custody and transport any such
person to the hospital operating the assisted outpatient treatment program, or to any other
hospital authorized by the director of community services to receive such persons. Any director
of community services, or designee, shall be authorized to direct the removal of an assisted
outpatient who is present in his or her county to an appropriate hospital, in accordance with the
provisions of this subdivision, based upon a determination of the appropriate director of
community services directing the removal of such assisted outpatient pursuant to this
subdivision. Such person may be retained for observation, care and treatment and further
examination in the hospital for up to seventy-two hours to permit a physician to determine
whether such person has a mental illness and is in need of involuntary care and treatment in a
hospital pursuant to the provisions of this article. Any continued involuntary retention in such
hospital beyond the initial seventy-two hour period shall be in accordance with the provisions of
this article relating to the involuntary admission and retention of a person. If at any time during
the seventy-two hour period the person is determined not to meet the involuntary admission and
retention provisions of this article, and does not agree to stay in the hospital as a voluntary or
informal patient, he or she must be released. Failure to comply with an order of assisted
outpatient treatment shall not be grounds for involuntary civil commitment or a finding of
contempt of court.
(o) Effect of determination that a person is in need of assisted outpatient treatment. The
determination by a court that a person is in need of assisted outpatient treatment shall not be
construed as or deemed to be a determination that such person is incapacitated pursuant to
article eighty-one of this chapter.
(p) False petition. A person making a false statement or providing false information or false
testimony in a petition or hearing under this section shall be subject to criminal prosecution
pursuant to article one hundred seventy-five or article two hundred ten of the penal law.
(q) Exception. Nothing in this section shall be construed to affect the ability of the director of a
hospital to receive, admit, or retain patients who otherwise meet the provisions of this article
regarding receipt, retention or admission.
(r) Education and training. (1) The office of mental health, in consultation with the office of court
administration, shall prepare educational and training materials on the use of this section, which
shall be made available to local governmental units, providers of services, judges, court
personnel, law enforcement officials and the general public.
(2) The office, in consultation with the office of court administration, shall establish a mental
health training program for supreme and county court judges and court personnel. Such training
shall focus on the use of this section and generally address issues relating to mental illness and
mental health treatment.

New York State Assisted Outpatient Treatment Program Evaluation

89

90

New York State Assisted Outpatient Treatment Program Evaluation

Appendix B
Methods Overview
In this section we provide an overview of methodological and design issues relevant to the
evaluation, including: (1) multiple sources of data; (2) study samples; (3) recruitment and
Institutional Review Board procedures for the 6-county data; (4) measures and instruments; (5)
data structure for repeated measures analysis; (6) analytic approaches; (7) sample weighting
with propensity scores to adjust for comparison group differences; and (8) multiple imputation of
missing data.
1. Multiple Sources of Data

The Assisted Outpatient Treatment (AOT) evaluation research project combined primary data
collection with secondary analysis of several existing data sources. Specifically, we interviewed
key informants throughout the state and conducted structured interviews with AOT recipients
and Enhanced Voluntary Services recipients in six New York counties: Albany, Erie, Monroe,
Nassau, New York, and Queens. We obtained lifetime arrest records for sample members in
these six counties. We conducted secondary analyses of AOT program administrative, tracking,
and evaluation data. We used Medicaid claims and OMH psychiatric facilities’ admissions data
to capture hospitalizations and mental health services encounters. We utilized data from the US
Census, the Mental Health Needs Assessment Project, and the New York Office of Mental
Health (OMH) Patient Characteristics Survey. These various sources of data are represented
schematically in Exhibit B.1 and are briefly described next.
Child and Adult Integrated Reporting System (CAIRS). The CAIRS data contain information
on Assertive Community Treatment (ACT) and AOT service recipients. ACT team members and
AOT case managers complete a standardized assessment for each recipient at the onset of
ACT or AOT services and every six months thereafter for the duration of the ACT and AOT
services. Data are collected on: (1) demographic characteristics; (2) living situation; (3) services
received; (4) engagement in services; (5) adherence to prescribed medications; (6) self-care
and social skills; and (7) the occurrence of significant events, including hospitalization,
homelessness, arrest, incarceration, and harmful behaviors. The CAIRS data were used to
examine a variety of outcomes, including those presented in Chapters 2 and 3.
Tracking for AOT Cases and Treatment (TACT). The TACT database contains information on
each AOT court order, including dates of initiation, expiration, and renewal. The TACT data
were used to create periods of AOT exposure and were then merged with the Medicaid data.
Medicaid. Medicaid claims and eligibility data were used to describe patterns of inpatient and
outpatient services utilization between 1999 and 2007. Only Medicaid-eligible person-months
were included in our multivariable analyses (a more detailed discussion of this can be found in
the Data Structure and Analytic Approaches sections below). Medicaid data were also used to
identify an “intensive treatment” comparison group of non-AOT recipients who had experienced:
(1) two or more hospitalizations; (2) 14 inpatient days in any single year; and (3) had received
ACT or intensive case management (ICM) services in any year since 1999; this comparison
group was used in the analysis of AOT’s impact on the service system (Chapter 6). The same
strategy was used to identify a “usual care” group for the 6-county interview study; however,
there was no ACT/ICM criterion for the 6-county “usual care” group (see Exhibit B.2 and the
Study Samples section below for more information on these two groups). Medicaid analyses are
presented in Chapters 3, 5, and 6.

New York State Assisted Outpatient Treatment Program Evaluation

91

Exhibit B.1. AOT study: Multiple data sources
AOT tracking data
(updated continuously)
People who
received
AOT orders
in New York State
1999 – present:
(N=6,919)

AOT evaluation
forms
(case mgr reports
every 6 months)
OMH hospital
admissions records
(inpatient stays in
OMH-licensed
psychiatric centers)

Medicaid claims
(inpatient and
outpatient mental
health services
utilization)

Arrests
(Dept. of Criminal
Justice Services
records for 6 index
counties)

Key informant
interviews
(qualitative data on
county programs)

County ecological
characteristics and
service capacity
descriptors
(US Census,
synthetic needs
estimates, annual
OMH PCS survey)
Structured
interviews
(AOT, Enhanced
Voluntary Service
recipients, and
Usual Care
recipients)

OMH Hospitalization Data. OMH inpatient hospitalization data were merged with Medicaid
inpatient service claims data to create an overall summary of inpatient days. All inpatient
analyses include both Medicaid and OMH psychiatric facility stays.
County Population Characteristics, AOT Rates, Mental Health Needs, and Services
Utilization Data. We combined multiple sources of data for the “racial disparity” analyses
presented in Chapter 1. Analyses are based on data from: (1) the OMH Patient Characteristics
Survey, a biannual survey that collects information on the population served in the State’s
mental health system and types of services received; (2) OMH hospitalization data; (3) the US
Census, which we used to obtain estimates of county population by race and poverty status;
and (4) synthetic county estimates of the prevalence of severe mental illness (SMI). Estimates
were obtained from Professor Charles E. Holzer III at UTMB Galveston. Holzer’s estimates are
derived from statistical models which apply epidemiological survey data to the demographic
profile of each county (http://psy.utmb.edu/estimation/estimation.htm). These estimates were
obtained for the total number of African Americans and Whites with SMI in each county, whether
or not they were in treatment.
Key Informant Interview Data. Primary data collection included key informant interviews
throughout the State with AOT program directors, service providers, Mental Hygiene Legal
Service attorneys, and others involved with the AOT program. These data were collected
through open-ended qualitative interviews. Data from key informant interviews are interspersed
throughout the Report in the form of direct quotes.

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New York State Assisted Outpatient Treatment Program Evaluation

6-County Interview Data. Primary data collection was conducted in six counties: Albany, Erie,
Monroe, Nassau, New York, and Queens. Data were collected through structured client
interviews. Results from this sample are presented in Chapters 3 and 4.
Department of Criminal Justice Services Arrest Records. We obtained Division of Criminal
Justice Services (DCJS) lifetime arrest records for AOT and Enhanced Voluntary Service
recipients for those in the 6-county sample.
2. Study Samples

Except for the key informant interviews, all participants in the study were mental health service
recipients who had been diagnosed with schizophrenia spectrum or affective disorder. All
participants were aged 18 years or older. There were four main categories of study samples:
AOT, Enhanced Voluntary Service, Intensive Treatment, and Usual Care. Exhibit B.2
summarizes key features of these samples, comparison groups, and methods of analysis. An
overview of primary data collection activities in the 6 counties is presented next.
6-County Primary Data Collection
Interviews were conducted with individuals who had been on AOT or who were receiving
Enhanced Voluntary Service. (There were a total of 211 unique individuals who completed a
total of 277 interviews. Chapter 4 describes how we allocated the 277 interviews across nonduplicative sample groups and the characteristics of those samples.) Our original sampling plan
included a usual care group in addition to the AOT and Enhanced Voluntary Service groups.
Participants from the usual care group consisted of individuals matched to the AOT and
Enhanced Voluntary Service groups on a number of characteristics, including diagnosis,
hospitalization history, and region. However, given difficulties in obtaining appropriate matched
samples from the Medicaid data, sampling for the usual care group was discontinued after 12
subjects had been interviewed. All subjects were re-classified into three groups: (1) no current
or recent AOT, which included individuals who never had an AOT order and those who had not
had an AOT order for at least the past 7 months; (2) current AOT, which included individuals on
an AOT order at the time of the interview; and (3) recent AOT, which included individuals who
had an AOT order in the past 6 months but who were not on an AOT order at the time of the
interview.

New York State Assisted Outpatient Treatment Program Evaluation

93

Exhibit B.2: AOT evaluation project summary of data sources and comparison group operational definitions

AOT sample

Enhanced
Voluntary Services
Sample

94

Medicaid data

CAIRS data

6-county data2

6-county arrest data2

Medicaid claims 1999-2007 for
mental health services for all
OMH service recipients with
AOT orders since 1999 (n= 2.7M
claims); AOT order dates merged
from TACT data

All AOT Evaluation1 Baseline
Assessment Forms and Follow-up
Assessments Forms for AOT
periods, filled out by case
managers every 6 months
(n=5,025; usable analytic sample
n=3,692 )

AOT clients sampled from county
AOT program rosters. Sample
stratified into 3 cohorts: AOT
current, AOT recent past, no
current or recent AOT (see below
for description of final samples)

AOT clients sampled from county
AOT program rosters (arrest data
are then avaliable for 100
months). Sample stratified into 3
cohorts: Pre-AOT, Current AOT,
and Post AOT (see below for
description of final samples)

Counts of AOT orders recorded
in OMH TACT data 2000 to
2006 (n=372 county-years) and
AOT investigations (duplicated
annual counts 2000 to 2002;
unduplicated counts after 2003)

None (no enhanced voluntary
services sample for this analysis).

Enhanced Voluntary Services
participants were sampled from
county active AOT program
rosters. Sample stratified into 3
cohorts: Pre-EVS, Current EVS,
and Post EVS (see below for
description of final samples)

Enhanced Voluntary Services
participants were sampled from
county active AOT program
rosters. Sample stratified into 3
cohorts: Pre-EVS, Current EVS,
and Post EVS (see below for
description of final samples)

Counts of voluntary service
enhancements

None (no enhanced voluntary
services sample for this analysis).

County aggregate data

New York State Assisted Outpatient Treatment Program Evaluation

Exhibit B.2 (Continued): AOT evaluation project summary of data sources and comparison group operational definitions
Medicaid data

CAIRS data

6-county data2

6-county arrest data2

County aggregate data

Medicaid claims 1999-2007 for
mental health services for all
OMH service recipients meeting
the following criteria (n=4.0M
claims)

A. Current service user: OMH
certified outpatient service with a
date of service of July 1, 2006 to
present

Intensive
treatment sample3

B. Diagnosis: schizophrenia or
affective disorder as billing
diagnosis for inpatient admission.

C. Hospital recidivism: 2 or more
psychiatric admissions in any year
since 1999

All CAIRS Baseline Assessment
Forms and Follow-up
Assessments Forms for ACT (nonAOT) periods; filled out by case
managers every 6 months;
matched to AOT sample on
hospitalization history, diagnosis,
gender, race (usable analytic
matched sample n=744 unique
invididuals who never had AOT)

D. Intensive inpatient treatment:
total of 14 or more inpatient days
in a year

Counts of voluntarily and
involuntarily hospitalized patients
admitted to OMH psychiatric
centers by county 2000 - 2006
None (no intensive treatment
sample for this analysis).

None (no intensive treatment
sample for this analysis).

Counts of ACT and ICM
recipients by county from the
Patient Characteristics Surveys4
1999, 2001, 2003, 2005; data for
intervening (non-surveyed) years
are interpolated.

E. Intensive outpatient services:
OMH recipient of ACT or ICM
services at any time since 1999

New York State Assisted Outpatient Treatment Program Evaluation

95

Exhibit B.2 (Continued): AOT evaluation project summary of data sources and comparison group operational definitions
Medicaid data

CAIRS data

6-county data2

6-county arrest data2

County aggregate data

Sample from Medicaid usual-care
group matched to AOT sample
distributions on race, gender, and
diagnosis. Sample stratified into 3
cohorts by time from hosp d/c:
recent hosp; 6 mos; 12 mos after
hosp (see below for description of
final samples)

A. Current service user: OMH
certified outpatient service with a
date of service of July 1, 2006 to
present
Usual care sample

None (no usual care sample for
this analysis).

None (no usual care sample for
this analysis).

None (no usual care sample for
this analysis).
B. Diagnosis: schizophrenia or
affective disorder as billing
diagnosis for inpatient admission.

Counts of OMH service recipients
with SMI NOT receiving
inpatient or Assertive Community
Treatment (ACT) and Intensive
Case Management (ICM) by
county from the Patient
Characteristics Surveys 1999,
2001, 2003, 2005; data for
intervening (non-surveyed) years
are interpolated.

C. Hospital recidivism: 2 or more
psychiatric admissions in any year
since 1999
D. Intensive inpatient treatment:
total of 14 or more inpatient days
in a year

E. Intensive outpatient services:
No criterion for inclusion

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New York State Assisted Outpatient Treatment Program Evaluation

Exhibit B.2 (Continued): AOT evaluation project summary of data sources and comparison group operational definitions
6-county data2

6-county arrest data2

County aggregate data

Analyses included those with 6 or
more months of treatment and
those with 12 or more months of
treatment.
Person-periods: 6 month
observations: ACT alone
(n=1493); AOT+ICM (n=3518);
AOT+ACT (n=2600). 12 month
observations: ACT alone (n=952);
AOT+ICM (n=1734);
AOT+ACT (n=852)

AOT current (n=115), AOT
recent past (n=28), no current or
recent AOT (n=134)5

Individuals: AOT group (n=144);
EVS group (n=42). Personperiods: Pre AOT/EVS
(n=16,709); Current AOT
(n=2,083); Post AOT (n=838);
Current EVS (n=952); Post EVS
(n=518)

NY counties aggregated by region:
NY City, Central, Hudson, Long
Island, Western

Repeated measures, multivariable
logistic regression; statistical
controls for underlying differences
across individuals within different
comparison groups

Mean values calculated for
outcomes of interest across
comparison groups

Repeated measures, multivariable
logistic regression; statistical
controls for underlying differences
across individuals within different
comparison groups

Repeated measures, multivariable
logistic regression analyses by
region; statistical controls for
underlying differences across
individuals within different
comparison groups

Medicaid data

CAIRS data

Comparison
groups for analysis

The analytic samples for the AOT
Medicaid analyses vary by
outcome. However, as an
example, the number of personperiods available for the various
AOT conditions (and subsequent
predicted probabilities) when
evaluating admission to a hospital
were: pre-AOT (n=117,889);
AOT 1-6 months (n=26,949);
AOT 7-12 months (n=14,916)

Methods of
statistical analysis

Repeated measures, multivariable
logistic regression; statistical
controls for underlying differences
across individuals within different
comparison groups

1

AOT Evaluation Database is a combination of data from the CAIRS and TACT databses.

2

Albany, Erie, Monroe, New York, Nassau, Queens. Other data collection in these counties includes case manager informant interviews (1 time at AOT exit) and key informant interviews.

3

The Medicaid intensive treatment sample was used for the analyses that examined the "Impact of Assisted Outpatient Treatment on the New York Service System", which was reviewed in Chapter 6.

4

The Patient Characteristics Survey (PCS) collects demographic, clinical, and service-related information for each person who receives a mental health service during a specified one-week period. All programs licensed or
funded (directly or indirectly) by the NYS Office of Mental Health are required to complete the survey. The PCS is conducted biennially and receives data from over 4,000 programs serving approximately 170,000 people
during the week.

5
For the 6-county sample there were 12 "intensive treatment" (i.e., ACT or ICM)/"usual care" (i.e., no ACT or ICM) participants. Nine of those 12 had received ACT or ICM and the remaining 3 had received "other case
management" in the 6 months prior to their interview. These 12 individuals were folded into the "no/never AOT" group for the analyses described in Chapter 4 ("Participants’ perceptions of Assisted Outpatient Treatment
(AOT) and related treatment experience and attitudes"). The specific breakdown for all 9 original "groups" was: New AOT (n=39); 6 month AOT (n=41); 12 month AOT (n=34); New EVS (n=22); 6 month EVS (n=45); 12
month EVS (n=15); recent post-AOT (n=42); 6 months post-AOT (n=27); Intensive treatment/Usual care (n=12). These 9 groups were reconstituted as AOT current (n=115); AOT recent past (n=28); and no current or
recent AOT (n=134).

New York State Assisted Outpatient Treatment Program Evaluation

97

3. Recruitment and IRB Procedures for the 6-County Data
Recruitment
Eligible clients from the 6 counties were drawn from a list of current AOT and Enhanced
Voluntary Service clients provided by the regional AOT Coordinator. The AOT Coordinator or
program staff used a standard script to introduce the research study to the client and obtain
permission for our research staff to directly contact the client. Clients interested in learning more
about the research signed a screening form and provided contact information. Screening forms
were then faxed or mailed to the research coordinator at PRA, who then confirmed eligibility and
contacted clients to explain the research project and to schedule a meeting with a research
interviewer.

The informed consent document was read aloud to each client by the research interviewer.
Interviewers administered a brief assessment as part of the consent process to determine if the
client understood the basic elements of the research (e.g., that they were free to refuse to
participate or to stop at any time) and was able to communicate clearly. In the event the client
failed the assessment (i.e., was not competent to complete the interview), the interviewer
informed the client that he/she was not eligible to participate and provided them with a copy of
the informed consent plus contact information for the research team. Eligible and competent
clients signed, and were provided a copy of, the consent form prior to beginning the interview.
The interview took approximately 90 minutes and participants were paid $25.
Institutional Review Board Procedures
This research was reviewed annually by several Institutional Review Boards (IRBs), including
those at Duke University Medical Center, Policy Research Associates, Inc., New York’s OMH,
and Biomedical Review Association of New York (BRANY) which served as the IRB of record
for the NYC Health and Hospitals Corporation and the NYC Department of Health and Human
Services. This research was also subjected to individual facility reviews at Bellevue Hospital,
Elmhurst Hospital, and Queens Hospital.
4. Measures and Instruments

We compared recipient groups on multiple outcomes. Descriptions of outcome variables and
other variables of interest are listed below, along with their respective measures and data
sources (Exhibit B.3).

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New York State Assisted Outpatient Treatment Program Evaluation

Exhibit B.3. New York AOT Evaluation
Instrument Table
Construct
Service
engagement

Appointment
adherence or
receipt of services

Measure

NY OMH
ACT/AOT/CM
Assessmentciii

AOT Evaluation
Client Interviewcv

Service billing
Medication
adherence or
receipt

NY OMH
ACT/AOT/CM
Assessmenti

AOT Evaluation
Client Interviewiii

Scale
One item rated on a 5-point scale (not engaged [no contact with providers,
does not participate in services at all] to excellent [independently and
appropriately uses services]).

Individuals were rated as “high engagement=1” if they were rated as 4 or 5.

Data
Source

AOT
Evaluation
Datasetciv

One item rated on a 5-point scale (never missed an appointment to avoided
keeping appointments altogether).
Individuals were rated as “appointment adherent=1” is they were rated as 1 or
2.
A paid case management service claim reported for a given month is rated as
“1” for that person-month observation.
One item rated on a 5-point scale (rarely or never takes medication as
prescribed to takes medication exactly as prescribed). “Medication not
prescribed” coded as “missing.”
Individuals were rated as “high medication adherence=1” if they were rated as
4 or 5.
One item rated on a 6-point scale (never missed taking medication to never
took medication).
Individuals were rated as “medication adherent=1” is they were rated as 1 or 2.

New York State Assisted Outpatient Treatment Program Evaluation

Interview

Medicaid
and OMH
records
AOT
Evaluation
Datasetii

Interview

99

Prescription filled

Attitudes about
medications

Modified Drug
Attitude
Inventory (DAI)cvi

NY OMH
ACT/AOT/CM
Assessmenti
Hospitalization

Harm to others

100

Monthly
psychiatric
hospital
admissions
NY OMH
ACT/AOT/CM
Assessmenti

Medication prescription fills were assessed by examining Medicaid claims and
OMH service data. Only medications appropriate for the individual’s psychiatric
condition, which had to be diagnosed by a psychiatrist or while in an inpatient
hospital stay, were counted.
Individuals were rated as “positive for medication possession=1” if they have a
sufficient medication supply for that month, as indicated by duration of
prescriptions and defined as > 80% days of a given month.

Medicaid
and OMH
records

Eight true/false statements. Item response reflects positive attitude toward
medication, than=1. Example item: “Medications make me feel more relaxed.”
Mean scores calculated, with higher scores reflecting more positive medication
attitudes.
Total number of psychiatric hospitalizations in the previous 6 months.
Individuals were rated as “positive for hospitalization=1” if they had > 1
hospitalizations in previous 6 months.
Monthly psychiatric hospital admissions were assessed by examining Medicaid
claims and OMH service data. An individual admitted in a given month was
rated as “positive for hospitalization admission=1” for that person-month
observation (an individual with multiple hospital admissions in a month is rated
as “1”).
One item assessed the recentness of harm to others (never to this week).
Individual rated as “positive for harm to others=1” if an incident was reported
within the past 6 months.

Interview

AOT
Evaluation
Datasetii

Medicaid
and OMH
records

AOT
Evaluation
Datasetii

New York State Assisted Outpatient Treatment Program Evaluation

Modified
MacArthur
Community
Violence
Interviewcvii

A semi-structured interview was used to gather information from the 6-county
service recipient sample on whether they engaged in 12 violent/aggressive
behaviors, varying in degree of seriousness, in the previous 6 months. Each
act is coded as 1=endorsed by recipient and 1=someone, other than
interviewee, was physically harmed as a result of incident. Example: “In those
six months, did you hit anyone with a fist or beat anyone up? Where did this
happen and who else was involved? Was anyone physically hurt (besides
you)? [If no, probe--] Not even bruises or cuts?”

Interview

The instrument yields a measure of any violence (yes/no).

Harm to self

Arrests

Illness
Characteristics

Alcohol and drug
use

NY OMH
ACT/AOT/CM
Assessmenti

Arrest records

Modified
Colorado
Symptom
Inventorycix
NY OMH
ACT/AOT/CM
Assessmenti

One item assessed the recency of an incident of self-harm (never to this
week).
Individual rated as “positive for self-harm=1” if an incident was reported within
the past 6 months.
Arrest records of service recipients who participated in the 6-county interview
(n=211) were obtained. Individual was rated as positive or negative for arrest
(arrest=1, no arrest=0) for a given month, and the data were structured as
person-month observations). Arrests included both misdemeanors and
felonies.

AOT
Evaluation
Datasetii

DCJS
recordscviii

Fifteen items assessing psychiatric symptoms experienced in the past month,
endorsed on 5-point scale (at least every day to not at all).
Mean scores were calculated, with lower scores reflecting more prominent
psychiatric symptoms.
Recent alcohol and drug use was assessed across 12 substances.
Individual was rated as a “substance user=1” if reported used any substance in
past 6 months (nicotine is not included in scale).

New York State Assisted Outpatient Treatment Program Evaluation

Interview

AOT
Evaluation
Datasetii

101

Global
Assessment of
Functioningcx

Functional
impairment

NY OMH
ACT/AOT/CM
Assessmenti:
Self-care and
community living
NY OMH
ACT/AOT/CM
Assessmenti:
Social,
interpersonal,
and family
functioning

Empowerment

Life satisfaction

102

CMHEI
Empowerment
Scalecxi

AOT Evaluation
Client Interviewiii

Ranked on a scale of 1 – 100, with high scores representing high functioning.
Ten behavioral or symptom descriptors are used to guide the ranking. Example
descriptor: 41 - 50 Serious symptoms (e.g., suicidal ideation, severe
obsessional rituals, frequent shoplifting) OR any serious impairment in social,
occupational, or school functioning (e.g., no friends, unable to keep a job).

Interview

Individual was rated as having a “significant functional impairment=1” if rated <
50.
Thirteen items rated on 5-point scale (acts independently to totally dependent).
Example: “How much support does the consumer typically need to make and
keep necessary appointments?”
Individual was rated as being “impaired in self-care and community living=1” if
rated as a 4 or 5 on any of the 11 items.
Nine items rated on 5-point scale (highly typical to highly atypical). Example:
“How typical is it for the consumer to effectively handle conflict?”
Individual was rated as being “impaired in social functioning=1” if rated as a 4
or 5 on any of the 9 items.
Sixteen items rated on a 5-point agreement scale (strongly agree to strongly
disagree). Example: “People have a right to make their own decisions, even if
they are bad ones.”
Mean scores were calculated, with higher scores reflecting greater
empowerment.

AOT
Evaluation
Datasetii

AOT
Evaluation
Datasetii

Interview

One item rated on a 7-point scale (terrible to delighted).
Mean score calculated with high scores reflecting greater satisfaction.

Interview

New York State Assisted Outpatient Treatment Program Evaluation

Treatment
satisfaction

Working alliance

AOT
understanding

Perceived AOT
stigma

AOT perceived
benefits

Modified MHSIP
Consumer
Surveycxii
Working Alliance
Inventory (WAI)
Short Formcxiii

AOT Evaluation
Client Interviewiii

AOT Evaluation
Client Interviewiii

AOT Evaluation
Client Interviewiii

Nine items rated on a 5-point scale (strongly agree to strongly disagree).
Example: “I was able to get all of the services I thought I needed.”
Mean scores were calculated, with higher scores reflecting greater satisfaction.

Interview

Eight items rated on a 5-point scale (strongly agree to strongly disagree).
Example: “The goals of my work with (provider name) are important to me.”
Mean scores were calculated; higher scores reflected stronger working
alliance.
Twelve true/false statements. Example: “When they have an AOT order,
people are required to go to mental health treatment appointments that are part
of the treatment plan.” (True).
Mean scores were calculated, with higher scores reflecting greater
understanding.
One yes/no item: “When people are under AOT, do you think that most other
people think less of them?”
Individual rated as “perceives AOT stigma=1”.
Three yes/no items. Item response positive for benefit=1. Example: “When
people are under AOT, do you think they are more likely to keep their mental
health or substance abuse appointments?”
Mean scores were calculated, with higher scores reflecting greater perceived
benefits.

New York State Assisted Outpatient Treatment Program Evaluation

Interview

Interview

Interview

Interview

103

Barriers to
treatment

AOT Evaluation
Client Interviewiii

Six true/false items reflecting both mandate- and non-mandate-related barriers.
Item response positive for barrier=1. Example mandate-related barrier: “Did
you delay getting help because you think that going to treatment might get you
in trouble with the law?” Example non-mandate related barrier: “Did you delay
getting help because you think that going for help probably wouldn’t do any
good?”

Interview

Mean scores were calculated, with higher scores reflecting more barriers.
Fear of involuntary
commitment

AOT Evaluation
Client Interviewiii

Perceived coercion

Modified
MacArthur
Admission
Experience
Scalecxiv

Procedural justice

Modified
MacArthur
Admission
Experience
Scalexii

104

One yes/no item, “Has fear of being involuntarily committed ever caused you to
avoid treatment for mental health?”
Individual rated as “positive for fear=1”.
Five items rated on a 5-point scale (strongly agree to strongly disagree)
assessing experiences in the previous 6 months. Example: “It was my idea to
get treatment.”
Mean scores were calculated, with higher scores reflecting greater perceived
coercion.

Interview

Interview

Six items rated on a 3-point scale (not at all, somewhat, or definitely). Example:
“When you received your court order did they treat you respectfully?”
Mean scores were calculated, with higher scores reflecting greater procedural
justice.

Interview

New York State Assisted Outpatient Treatment Program Evaluation

General pressures
to adhere to
treatment

Pressure benefits

AOT Evaluation
Client Interviewiii

Thirty-three yes/no items constituting 4 subscales (warnings, sanctions,
medication oversight, commitment pressure) assessing experiences in the
previous 6 months. Item response positive for pressure=1. Example (warnings
subscale): “Did anyone tell you that you may lose your housing if you don’t
follow your treatment plan?”

Interview

Mean scores were calculated for the total scale and each subscale, with higher
scores reflecting greater pressure.

AOT Evaluation
Client Interviewiii

Nine items rated on a 5-point scale (strongly agree to strongly disagree). Lower
scores reflect greater perceived benefits from pressures to adhere to
treatment. Example: “Overall, the pressures or things people have done were
for my own good.”

Interview

Mean scores were calculated, with higher scores reflecting fewer perceived
benefits of pressure to adhere to treatment.

New York State Assisted Outpatient Treatment Program Evaluation

105

5. Data Structure

For all analyses that used the Medicaid and AOT Evaluation Data (i.e., CAIRS/TACT) we
created analytic files that contained multiple observations per person, or repeated measures
over time. The analytic files created from the Medicaid and AOT Evaluation Data were similar in
form; the only differences were related to timeframe in the source data (i.e., the Medicaid data
could be grouped into one month intervals, while the AOT Evaluation Data were only available
in six month intervals). Because of the overall similarity between the two sets of analytic files,
we will provide a brief overview of how we constructed the Medicaid data only.
Our study period for the Medicaid data consisted of 88 months (i.e., between November 1999
and February 2007). Utilizing these 88 months, we created a vertical data shell or “long file”
where each individual had 88 rows of data. In this data structure, each month became a
separate record and each type of service event or status, such as being on AOT or not, became
a separate variable. Specifically, each individual’s Medicaid claims history was examined for
receipt of any Medicaid-reimbursed mental health services (e.g., ACT, ICM, inpatient days,
other case management, pharmacy fills; OMH hospital days were also merged with the
Medicaid data) that occurred in a given month between November 1999 and February 2007.
Separate variables for each type of service were created and populated with values from the
individual’s Medicaid-reimbursed services. Each of these variables spanned 88 months. We
then merged in dates of each individual’s AOT order, which allowed us to evaluate the
association between receiving AOT and a variety of outcomes, using repeated measures
regression techniques.
6. Analytic Approaches

We used multivariable regression techniques (e.g., logistic regression for dichotomous
outcomes, Poisson or negative binomial regression for count outcomes depending on the
underlying distribution of the data) to estimate the relationship between AOT and various
outcomes. We controlled for time and a wide array of available covariates. We also made
appropriate statistical adjustments to account for the non-independence of observations that is
present when estimating effects in a repeated measures model. In addition to using all available
information to control for differences between subjects, we also created propensity scores that
were used to weight the Medicaid data.
7. Propensity Scoring

We calculated propensity scores that were used to weight the longitudinal Medicaid data. This
approach, inverse probability of treatment weighting115, “predicts” the propensity of an individual
receiving the treatment they actually received; the propensity scores are then used to weight the
data. The goal of using propensity scores is to make the sample similar to a randomized
experiment. We created two sets of propensity scores. The first set of scores modeled the
likelihood of each person receiving an initial AOT order and the second set of scores modeled
the likelihood of each person being renewed on AOT. Propensity scores from each of these
models were output and used to weight the longitudinal Medicaid data to account for baseline
differences in the likelihood of receiving AOT. Our propensity regression models included all
available demographic and clinical variables. Additionally, the propensity models included
information on medication possession ratio and prior inpatient hospitalization.

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8. Multiple Imputation of Missing Data

Because the CAIRS data had a substantial amount of missing data, we used multiple imputation
techniques to provide complete data for subjects. Data were imputed using SAS PROC MI with
imputations set to the default of 5. Imputing data in this manner provides less biased parameter
estimates than other missing data strategies such as listwise or pairwise deletion116. Most of our
analyses had fewer than 5% missing data.

i

New York State OMH ACT, AOT, and Case Management Assessment Form is completed by case managers or ACT team staff
and is collected at baseline and every six months.

ii

AOT Evaluation Dataset consists of the CAIRS database (ACT recipient data), the AOT Evaluation database (AOT recipient
data), and select TACT variables.

iii

AOT Evaluation Client Interview Instrument was used by PRA staff to interview a subsample of current and past AOT
recipients. This instrument consisted of standardized measures, as well as measures created for the purpose of this study.

iv

Hogan TP, Awad AG, Eastwood R. (1983). A self-report scale predictive of drug compliance in schizophrenics: reliability and
discriminative ability. Psychological Medicine,13, 177-183.

v

Steadman, H., Mulvey, E., Monahan, J., Robbins, P., Appelbaum, P., Grisso, T., Roth, L., & Silver, E. (1998). Violence by
people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods. Archives of General
Psychiatry, 55, 393-401.

vi

Division of Criminal Justice Services records included lifetime arrest data (i.e., both pending and disposed charges) for the 6county AOT and EVS groups

vii

Ciarlo JA, Edwards DW, Kiresuk TJ, et al (1981). The Assessment of Client/Patient Outcome Techniques for Use in Mental
Health. Contract 278-80-0005. Washington, DC, National Institute of Mental Health; Conrad KJ, Matters MD, Yagelka J, et al
(2001). Reliability and validity of a Modified Colorado Symptom Index in a national homeless sample. Mental Health Services
Research, 3, 141-153.

viii

Endicott, J, Spitzer, RL, Fleiss, JL, & Cohen, J (1976). The Global Assessment Scale: A procedure for measuring overall
severity of psychiatric disturbances. Archives of General Psychiatry, 33, 766-771.

ix

Rogers, ES, Chamberlain, J, Ellison, ML, & Crean, T (1997). A consumer-constructed scale to measure empowerment among
users of mental health services. Psychiatric Services, 48, 1042-1047.

x

Mental Health Statistics Improvement Program (MHSIP) Consumer Survey. Ganju, V (1999). The Mental Health Statistics
Improvement Program Consumer Survey. Austin, TX: Department of Mental Health and Mental Retardation.

xi

Neale, MS, & Rosenheck, RA (1995). Therapeutic alliance and outcome in a VA intensive case management program.
Psychiatric Services, 46, 719-721.

xii

Gardner, W, Hoge, SK, Bennett, N, Roth, LH, Lidz, C, Monahan, J, & Mulvey, E (1993). Two scales for measuring patients’
perceptions of coercion during mental hospital admission. Behavioral Sciences and the Law, 11, 307-322; Swartz, MS, Hiday,
VA, Wagner, HR, Swanson, JW, Borum, WR, & Burns, BJ (1999). Measuring coercion under involuntary outpatient
commitment: Initial findings from a randomized clinical trial. Research in Community and Mental Health, 10, 57-77.

xiii

Robins, J.M., Hernan, M.A., & Brumback, B. (2000). Marginal structural models and causal inference in epidemiology.
Epidemiology, 11, 550 -560.

xiv

Schafer, J.L. & Olsen, M.K. (1999). Multiple imputation for multivariate missing-data problems: A data analyst's perspective.
Multivariate Behavioral Research, 33, 545-571.

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