Objective

To determine whether the Office of Mental Health (OMH) is effectively monitoring Assisted Outpatient Treatment (AOT) to provide reasonable assurance that existing and potential AOT recipients receive their court-ordered treatment. Our audit covered the period from April 2019 to September 2023.

About the Program

On August 9, 1999, Kendra’s Law (Law) was enacted, creating a statutory framework for court-ordered AOT for individuals with severe mental illness who meet criteria outlined in the Law. The Law is reviewed periodically by the Legislature, most recently in 2022.

Implementation of AOT is a joint responsibility and collaboration among OMH, its five regional Field Offices, and local mental health authorities in 57 counties and New York City (we refer to local authorities collectively as local government units or LGUs).

Under the Law, LGUs must timely investigate a referred person’s circumstances to determine if the person meets AOT criteria. If so, LGU staff file a petition for AOT with the appropriate court and a hearing is held to review the case and proposed treatment plan. The Law doesn’t define “timely,” and OMH hasn’t developed guidance to use as a benchmark in determining whether investigations are timely.

OMH requires that AOT recipients be escorted home from a hospital discharge or court and be connected with their treatment services through a face-to-face visit within 1 week of the court order. Generally, providers meet with AOT recipients in person weekly after the initial face-to-face meeting. As part of the intensive monitoring and oversight by care management providers to help recipients comply with the terms of their treatment, providers are required to report significant events to their respective LGU within 24 hours of being made aware of them. Significant events are those that may negatively impact a person’s AOT, such as being accused of or arrested for committing a crime, becoming incarcerated or homeless, or refusing to take court-ordered medications. LGUs, in turn, must report certain serious significant events, such as weapons possession, sex offenses, domestic violence, and inability to locate an AOT recipient, to the appropriate Field Office to be entered in OMH’s Tracking of AOT Cases and Treatments system, or TACT. OMH Central Office and Field Office staff use TACT information to monitor AOT recipients, including identifying circumstances that may affect compliance with their treatment plan and intervening if necessary.

AOT orders generally cover up to 1 year and may be renewed if the LGU determines that the recipient continues to meet AOT criteria after a review that includes an examination by a physician. LGUs must notify their OMH Field Office in writing as to whether they’ll pursue renewal. If warranted, within 30 days prior to an order’s expiration, LGU staff may petition the court to renew an AOT order. If a recipient no longer meets the criteria, the reason for non-renewal must be reported to OMH.

According to OMH’s public statistics on AOT, since the inception of Kendra’s Law in 1999 through August 2023, LGUs have conducted nearly 47,000 investigations. Of the 33,847 AOT petitions filed, 32,324 (96%) were granted. New York City is the largest petitioner, accounting for about 20,000 (62%) of the petitions granted. At any given time between 2019 and 2023, there have been an estimated 3,200 to 3,500 individuals under an AOT order.

Key Findings

OMH needs to improve its oversight in some areas to better ensure that existing and potential AOT recipients receive their court-ordered treatment, as described below.

• We identified instances in which LGUs didn’t investigate AOT referrals timely. Using 6 months as a benchmark, we found that 19 of the 41 investigations we reviewed at three LGUs (46%) were not timely and ranged from taking slightly longer than 6 months to nearly 2½ years (198 days and 879 days, respectively).
• We found that most of the AOT recipients whose records we reviewed received their court-ordered treatment timely and in accordance with their treatment plans, but also that OMH doesn’t receive information that would allow it to proactively identify delays in the onset of treatment. For example:
  • In one case, the recipient’s first face-to-face meeting with their provider was nearly 1 month after their AOT order took effect. The second meeting should have been scheduled for the following week, but wasn’t. On the day that the second meeting should have taken place, the recipient was arrested for homicide. It was not until LGU officials reported this information to the Field Office that OMH became aware of the delay in treatment services, investigated the incident and determined that care management providers did not promptly connect with the recipient, and provided guidance to LGU staff and the care management provider.
• We identified problems with the completeness and usefulness of information about significant events and its communication among the parties involved with AOT services. This information may be used to drive decisions that could impact the care and safety of both recipients and the public and plays an important role in overseeing and assessing AOT. For example:
  • For one recipient, case notes indicated that the recipient received psychiatric emergency room or psychiatric inpatient hospital services for suicidal thoughts on 33 separate dates – equivalent to 33 significant events – during the 19-month period between October 2019 and May 2021. However, these events were unreported and, ultimately, this person died by suicide on the same day they were discharged from a hospital visit.
• There were lapses in AOT services for some recipients because LGUs didn’t complete reviews of their renewal eligibility as required. For 23 of 37 recipients in our sample (62%), a complete review either wasn’t done or potentially wasn’t done prior to expiration of their AOT orders, including 17 who weren’t examined by a physician and six for whom LGUs didn’t document any attempt to examine the recipients before their orders expired. This resulted in expiration of AOT for 11 recipients and temporary lapses for 12 recipients. The lapses in court-ordered services lasted between 34 and 198 days.

Key Recommendations

• Develop guidance to define “timely” that LGUs and Field Offices can use as a benchmark for completing investigations.
• Evaluate the feasibility of collecting data about the time to connect AOT recipients with their initial services.
• Review and – where considered necessary – clarify existing guidance about significant event reporting to improve:
  • The ability to capture and appropriately share the desired information; and
  • The completeness, accuracy, and comparability of the information reported.
• Improve assurance that LGUs take appropriate action to ensure that AOT orders that are due to expire and should be renewed continue without lapses in treatment and monitoring.