AOT: What’s the Conversation We Should Have?

Berger Symposium

November, 2009

Dr. Mike Hogan, Commissioner, OMH

A Conceptual Model for Discussing AOT

The Context: Where Are the Gaps in Care?

• “Mental illness” has high incidence and prevalence, is the leading illness related cause of disability

• It is complex and variable in etiology, course, personal experience, impact, response to treatment

• Getting good care is akin to running the steeplechase…long, hard, lots of hurdles:

• Recognizing that a problem exists

• Recognizing that treatment is available

• Overcoming stigma, inertia to seek care

• Finding the right caregiver

• Arranging payment for care

• Achieving relief through—or without—treatment

• What is the contribution of AOT in this context?

Model: What Facilitates Treatment Engagement?

Accessible, Acceptable, Competent Care

A Navigable, User-Friendly System

Special Enhancements for

Engagement

Use of Leverage

Applies to Few

Applies to Many

More Intrusive

Less Intrusive

A Navigable, User-Friendly System?

“Shambles” “Opaque”

“Is there no place on earth for me?”

“Who’s the bastard out there?”

Mega-city complexity

Continuity of Caregivers?

NYS “System” Resists Order—Change Here is Hard

Accessible, Acceptable, Competent Care: Much Can be Done by Every Provider

0

5

10

15

20

25

30

35

40

45

AnyTreatment

AnyTreatment -

Disorder

AnyTreatment -

SMI

1990-1992

2001-2003

• Dimensions of Good Care– Good access: geographic,

temporal, cultural– Affordability– “Welcoming” – Person-centered care– Family is welcome– Competency: clinical,

interpersonal, cultural– Treatment effective– Convenience high/side

effects are low

Trends: MH Service Utilization

Special Enhancements for Engagement: Our Priority

• Earlier intervention, especially in normative settings e.g. PCP’s• Steps to overcome general stigma, fear, uncertainty

– E.g. Outreach and Engagement enhances clinic care

• To overcome “learned” stigma, fear, uncertainty– Affirmative employment with supports; Peers on staff, Peer

conducted outreach– Peer operated alternatives; “recovery centers”– WRAP plans, Advance Directives/crisis plans

• Intensive Outreach, ACT • Care Monitoring Project to re-connect people to care• What families do, that we should support:

– Care giving, monitoring, advocacy– “Interventions”– Family leverage– Use of courts– Representative Payee arrangements

Use of Leverage by Mental Health Professionals, Agencies, System

• Court-related arrangements• Housing contingencies• Representative payee arrangements• Involuntary commitment

– Inpatient– Outpatient– Both/either

Concluding thoughts

• Do the most good• Do the least harm

• Thank you