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Assisted Outpatient Treatment (AOT)

Assisted Outpatient Treatment team picture.

(left to right: Charles Houston, Angelica Almeida, Veronica Aburto)

Introduction to AOT

This webpage is designed to provide additional information about Assisted Outpatient Treatment (AOT). This program, which is often referred to as Laura’s Law, is a new intervention tool that allows a clinical team to outreach and engage individuals with known mental illness, who are not engaged in care, and are on a downward spiral. San Francisco’s implementation of this program has a particular focus on community-based services that allow multiple opportunities for an individual to engage in voluntary treatment. The ultimate goal of this program is to provide intensive outpatient services to these individuals in an effort to improve their quality of life, as well as prevent decompensation and cycling through acute services (e.g., psychiatric hospitalization) and incarceration. 

If this is a psychiatric or medical emergency, dial 9-1-1

History of Assisted Outpatient Treatment (AOT)?

Assisted Outpatient Treatment, also known as "Laura's Law," was passed by the California Legislature in 2002 as AB1421. This law allows for court ordered outpatient treatment for individuals with a mental illness who meet strict legal criteria (More information about the law).

What will Assisted Outpatient Treatment look like in San Francisco?

In July 2014 the San Francisco Board of Supervisors adopted AOT with added conditions to make sure that the law is used to engage individuals in voluntary treatment (More information about the Health Code). This includes having individuals work with a "Care Team," of:

  1. a forensic psychologist,
  2. a peer specialist, and
  3. a family liasion.

The San Francisco AOT Program will start on November 2, 2015.

How many people will meet criteria for Assisted Outpatient Treatment?

Based on national data, it is expected that less than 100 individuals in San Francisco will meet criteria for the program.

What is the goal of Assisted Outpatient Treatment?

The goal of this program is to provide intensive outpatient services to referred individuals to improve their quality of life, as well as prevent mental health crises and cycling through emergency services or incarceration.

If you have any questions, feel free to contact Angelica Almeida, Ph.D. (Director of Assisted Outpatient Treatment) at (415) 255-3722.

Please see the Assisted Outpatient Treatment Fact Sheet (English | Chinese | Russian | Spanish | Tagalog | Vietnamese) for additional details on the referral and engagement process as well as frequently asked questions (FAQ's).

Who is eligible?

Generally, Assisted Outpatient Treatment (AOT) is a program that is designed to outreach individuals with a known mental illness, who are not engaged in care, and are on a downward spiral.

If you are unsure if an individual qualifies for the program, please contact the AOT Care Team at (415) 255-3936 or the toll free number (844) 255-4097 to discuss the case with a team member.

The law requires that an individual must meet all of the following criteria to qualify for Assisted Outpatient Treatment (AOT):

  1. 18 years of age or older;
  2. Suffering from a mental illness (Welfare and Institutions Code §5600.3 (b)(2) and (3));
  3. Clinical determination that the person is unlikely to survive safely in the community without supervision, per clinical determination;
  4. History of lack of compliance with treatment for his or her mental illness, in that at least one of the following is true:
    a) The person's mental illness has, at least twice within the last 36 months, been a substantial factor in necessitating hospitalization or receipt of services in a forensic or other mental health unit of a state correctional facility or local correctional facility, not including any period during which the person was hospitalized or incarcerated immediately preceding the filing of the petition; or
    b) The person's mental illness has resulted in one or more acts of serious and violent behavior toward himself or herself or another within the last 48 months not including any period during which the person was hospitalized or incarcerated immediately preceding the filing of the petition;
  5. Been offered an opportunity to participate in treatment and continues to fail to engage in treatment;
  6. Substantially deteriorating;
  7. Participation in AOT would be the least restrictive placement needed to ensure the person's recovery and stability;
  8. In need of AOT in order to prevent a relapse or deterioration that would be likely to result in grave disability or serious harm to himself or herself, or to others; and
  9. Likely to benefit from AOT

Who can refer?

A request for Assisted Outpatient Treatment can be made by the following adults (age 18+):

  1. Any adult who lives with the individual with mental illness;
  2. A parent, spouse, sibling, or adult child of the individual with mental illness;
  3. The director of a mental health institution in which the individual with mental illness lives;
  4. The director of a hospital where the individual with mental illness is hospitalized;
  5. A licensed mental health provider supervising the treatment of the individual; or
  6. A peace, parole, or probation officer assigned to supervise the individual.

How do I refer?

If you would like to refer an individual to the Assisted Outpatient Treatment (AOT) program, please:

  1. Complete the referral form (English | Chinese | Russian | Spanish | Tagalog | Vietnamese) and fax it to (415) 255-3798 or email it to AOT-SF@sfdph.org

  2. OR

  3. Call (415) 255-3936, the toll free number (844) 255-4097, or the TDD at (888) 484-7200 and leave a clear message and number where you can be reached.

Please note that email is not a secure form of communication. If you choose to email the referral form, your information will be reviewed and a member of the AOT Care Team will contact you via phone to discuss the case further.

A member of the AOT Care Team will contact you within one business day of receiving the referral. The AOT Care Team works standard business hours Monday through Friday; however, may not be available to answer incoming phone calls.

Please see the Intake Flow Chart (English | Chinese | Russian | Spanish | Tagalog | Vietnamese) for an overview of the process.


Care Team

Angelica Almeida
Angelica Almeida, Ph.D. (Director)

Dr. Almeida is excited to be heading the Assisted Outpatient Treatment (AOT) Care Team. She joins the Department of Public Health with a wealth of information and experience working with individuals with severe mental illness. In her previous role as the Deputy Director of Jail Health Reentry Services in the San Francisco County Jail, Dr. Almeida worked closely with the community and courts (including Behavioral Health Court) to ensure continuity of care between the forensic and community systems of care. Additionally, she has experience working with families and is an adjunct professor at a local university.


Charles Houston

Charles Houston (Team Member)

Charles Houston enthusiastically joins the AOT Care Team with a great deal of experience working at a local outpatient mental health center as a peer educator, systems navigator, and health and safety associate. He is well versed in working with drug treatment programs and has participated in committees to promote recovery and wellness within the San Francisco Department of Public Health. Mr. Houston is passionate about supporting families and working with community programs to ensure that individuals are receiving the support needed.




Veronica Aburto

Veronica Aburto (Team Member)

Veronica Aburto eagerly joins the AOT Care Team with a wide range of experience working at different mental health clinics as a peer counselor, peer navigator, and HIV test counselor. She received her B.S. in Health Education with a Minor in Holistic Health from San Francisco State University. Ms. Aburto has also received a Community Health Worker Certificate, Community Mental Health Worker Certificate, and HIV/STI Prevention Studies Facilitation and Case Management Skill Specialty Certificate from City College of San Francisco. Ms. Aburto is deeply passionate about working with people who face mental illness and supporting their families, particularly in the Latino community. Mindfulness is an important practice to her and she applies it in her daily life and her interaction with others.



Additional Information

Between April and October of this year Dr. Almeida provided numerous trainings on San Francisco's Implementation of Assisted Outpatient Treatment to interested stakeholders. Please review the PowerPoint presentation for additional information.

Annual Report

The Department of Public Health is required to provide an annual report to the Board of Supervisors and the State of California on the effectiveness and cost of the Assisted Outpatient Treatment program. This report will be provided by an external evaluator and will provide quantitative (e.g., numbers of people served, demographics of population) and qualitative (e.g., family and participant satisfaction with services provided). The Board of Supervisors have also required a more in depth analysis (including cost analysis) to be provided by an external evaluator after a three year period.

San Francisco Annual AOT Full Report 2015-2016
San Francisco Annual AOT Full Report 2016-2017

Executive Summary

On November 2, 2015, San Francisco Department of Public Health’s (SFDPH) Behavioral Health Services (BHS) Division launched the Assisted Outpatient Treatment (AOT) program (www.sfdph.org/aot). The program seeks to:

  • improve the quality of life of participants and support them on their path to recovery and wellness,
  • prevent decompensation, and
  • prevent cycling through acute services (e.g., psychiatric hospitalization) and incarceration.

The program, authorized by San Francisco’s Board of Supervisors in 2014, is one of a handful of County-led programs in California to support the primary intent and purpose of the Assisted Outpatient Treatment (AOT) Demonstration Project Act of 2002 (Welfare and Institutions Code (WIC) §§5345-5349.5)—otherwise known as “Laura’s Law”—to (a) identify persons with serious mental illness who are not engaged in treatment, (b) assess if there is substantial risk for deterioration and/or involuntary detention (under WIC §5150) which could be mitigated by provision of appropriate services, and (c) petition the court to order participation in such services if the individual is not able to be successfully engaged by other means.

The San Francisco AOT Model is utilized as an intervention and engagement tool designed to assist and support individuals with serious mental illness. San Francisco’s AOT program places an emphasis on promoting voluntary engagement by utilizing a strength-based and client-centered approach, as well as accessing an individual’s natural support system (i.e., family and friends). The program has been constructed to employ principles of recovery and wellness, and has a particular focus on community-based services and multiple opportunities for an individual to engage in voluntary treatment before a court order is requested. This is the second annual report for the AOT program in San Francisco and covers the first full year of implementation.

The AOT Care Team

Primary program services are provided by the AOT Care Team, in accordance with San Francisco Health Code §§4111-4119, which is comprised of the AOT Director, a Clinician, and two Team Members to provide peer and family support. The AOT Care Team conducts extensive outreach to:

  • assess appropriateness of a referral and eligibility for the program,
  • locate and engage Referred Individuals with local mental health resources
  • encourage voluntary participation in treatment and engagement among Referred Individuals, and
  • petition the court to order individuals into outpatient treatment when indicated.

The Care Team works with Zuckerberg San Francisco General Hospital’s Division of Citywide Case Management (“Citywide”) to coordinate treatment for individuals that are court ordered into treatment and support individuals who have voluntarily agreed to services in linking to long term care.

Calls to the AOT Care Team

Between November 2, 2015 and February 9, 2017 the San Francisco AOT program:

  • Received 268 calls: 135 calls for referrals—predominantly from family members—and 133 requests for information.
  • Of the 135 incoming referrals during the evaluation period, 60 unduplicated referred individuals were considered eligible for AOT participation and successfully contacted.

Snapshot of All AOT Participants

Individuals served by the AOT Care Team are at heightened risk of psychiatric hospitalization, incarceration, homelessness, and contact with Psychiatric Emergency Services (PES). In the 36 months (3-years) prior to being referred to the program:

  • 78% had at least one known inpatient psychiatric hospitalization in San Francisco.
  • 60% had at least one known incarceration in San Francisco.
  • 54% experienced at least one period of homelessness.
  • 82% had at least one known PES contact in San Francisco.

Progress Toward Outcomes for all AOT Participants

Individuals in contact with AOT during the evaluation period showed overall reductions in PES contacts, psychiatric hospitalization, and incarceration. During the evaluation period:

  • 87% of AOT participants were successful in reducing or avoiding PES contact.
  • 65% were successful in reducing or avoiding time spent in inpatient psychiatric hospitalization.
  • 74% were successful in reducing or avoiding time spent incarcerated.

Well-Being, Social Functioning, and Independent Living Skills

AOT Participants were surveyed, and respondents overwhelmingly reported a positive outlook on their future.

  • 89% of respondents feel confident that they can reach their treatment goals.
  • 90% of respondents feel hopeful about their future.

Benefits of AOT engagement and case management were also reflected in the survey responses of program participants.

  • 63% of respondents believed that regularly meeting with a case manager will help them to find or maintain stable housing.
  • 67% of respondents believed that regularly meeting with a case manager will help them to maintain good physical health.
  • 63% of respondents believed that regularly meeting with a case manager will help them live the kind of life they want.

Engagement and Treatment Promotion

As of February 9th, 2017, Citywide has provided clinical case management services to 23 individuals who have voluntarily agreed to treatment. Of these, 10 are still in care with Citywide and receiving services that are designed to stabilize them in preparation for linkage to long term services, and 12 have been successfully linked to long term care.

AOT Care Team members and Citywide staff support clients in identifying their own treatment goals and plans for the future, and then building a treatment plan to support those goals. When asked about their interactions with AOT staff in the participant survey:

  • 89% of respondents reported that the AOT staff always treated them with respect.
  • 79% reported that the AOT staff always listened to their concerns about treatment.
  • 78% reported that AOT staff encouraged them to accept treatment voluntarily.

Current Status and Disposition

More than half (59%) of individuals in contact with AOT during the evaluation period have achieved positive status outcomes—defined as actively engaging in treatment or being successfully connected to care and discharged—through their participation in the program.

  • 45 participants that had contact with AOT remain linked to care.
  • 18 are actively and voluntarily engaged in treatment.
  • 17 have been successfully connected to care and discharged from AOT—one of whom was participating under a court order.
  • 5 are currently participating under a court petition.
  • 4 are subject to ongoing outreach by AOT staff.
  • 1 was found to not meet the criteria for AOT participation upon assessment, but was offered support to access voluntary services.

Snapshot of Court Ordered AOT Participants

Among the 6 court ordered AOT Participants this evaluation period (11/2/15-2/9/17):

  • 5 individuals experienced at least one PES contact in the 36 months prior to AOT contact.
  • 5 individuals experienced at least one inpatient psychiatric hospitalization in the 36 months prior to AOT contact.
  • 2 individuals were incarcerated at least once in the 36 months prior to AOT contact.
  • 2 individuals had experienced homelessness in the 36 months prior to AOT contact.

Progress Toward Outcomes for Court Ordered AOT Participants

The mixed methods evaluation detailed in this report is intended to fully address the regulatory program evaluation requirements of California Welfare and Institutions Code §5348(d). Findings in each of the fourteen mandated evaluation areas are summarized below.

  • At the time of data collection, four of the six individuals where a court petition was filed received housing assistance through the program, and four individuals are currently in independent or supportive housing situations. One participant resides in a hospital setting, and one currently resides with family (§5348(d)(1)).

  • Since engaging in AOT through the court process, five of six individuals have successfully reduced or avoided time spent incarcerated (§5348(d)(2)).

  • Three of six individuals in the court process have successfully reduced or avoided time spent in inpatient psychiatric hospitalization since engagement in AOT (§5348(d)(4)).

  • One court ordered individual was successfully supported and participated in employment activities during the evaluation period (§5348(d)(3)).

  • The overall percentage of weeks in which participants involved in the court process were in compliance with their treatment plans ranged from 36-100% (§5348(d)(5)).

  • During the evaluation period, three individuals voluntarily accepted treatment services after their court petition was filed resulting in a Settlement Agreement (§5348(d)(6)).

  • No one in the court ordered group was a victim of violence during the evaluation period (§5348(d)(7)).

  • Three of six court ordered individuals perpetrated a total of five acts of violence during the evaluation period—all occurring in the early stages of court order and none leading to injury (§5348(d)(8)).

  • Two of six individuals had instances of confirmed substance use over the course of the court process, and five had instances of suspected use (§5348(d)(9)).

  • Throughout their participation in AOT, court ordered individuals had consistent contact with peer, clinical, and medical staff. Staff made at least one contact or attempted contact per week (§5348(d)(10)).

  • At times during the evaluation period, AOT participants were supported via increased frequency of court contact. There were no other enforcement mechanisms employed by staff to encourage compliance (§5348(d)(11)).

  • As a result of participation in AOT, individuals involved in the court process demonstrated an improved ability to function in their communities and build positive relationships with family members and others (§5348(d)(12)).

  • With support from AOT staff, individuals involved in the court process are able to successfully access community-based services vital to maintaining stable and independent living situations (§5348(d)(13)).

  • The majority of participants and family members reported positive perspectives on the approach to engagement by the AOT Care Team, and felt supported by program staff (§5348(d)(14)).

Looking Ahead

As the AOT program progresses in its second full year of implementation, evaluation components moving forward will be expanded to include the following:

  • Input and perspective from additional stakeholder groups.
  • Analysis of the program’s cost and financial impact.

Treatment Resources

If this is a psychiatric or medical emergency, dial 9-1-1

San Francisco Suicide Prevention, 415-781-0500

Resources in a Mental Health Crisis

Treatment Access Programs:

Mental Health and Substance Abuse Treatment
Behavioral Health Access Center (BHAC) and Treatment Access Program (TAP)
1380 Howard Street, 1st Floor
415-255-3737
8:00 am- 5:00 pm (Monday – Friday)
* provides assessment for treatment
* 24 hour hotline available at 415-255-3737 or 888-246-3333 (TDD: 888-484-7200)

Community Behavioral Health Provider List

Call 2-1-1 or visit 211.org for additional local resources.


Family and Peer Support:

National Alliance on Mental Illness (NAMI)
415-905-6264
www.namisf.org

Warm Line
855-845-7415
11:00 AM - 11:00 PM Monday - Friday;
11:00 AM - 7:00 PM Saturday


Printable Resource List (English | Chinese | Russian | Spanish | Tagalog | Vietnamese)

Mental Health Board of San Francisco