The Successful Recovery-Assisted Community Treatment (SR-AOT) program will provide AOT services in six counties in North Carolina. No less than 300 persons with Serious Mental Illness (SMI), averaging 75/year, that have not been treated and at risk for harm and poor quality of life will be served over the course of the grant. A Care Management Team (CM Team) will ensure a comprehensive evaluation and access to evidence-based practices (EBP). The grantee, Partners Behavioral Health Management (PBHM), will use a comprehensive Theory of Change based evaluation and performance management evaluation model. Persons served will be 18-years or older, have a SMI with emphasis on schizophrenia and schizoaffective disorders, and will found to need services that require judicial support to ensure adherence via referral, evaluation and decision by court judge or magistrate. An integrated and individualized system of care via CM Teams that include licensed professionals, trained Care Managers, Peer Supports and SOAR workers will be offered to each consumer. Assessment will determine which community provider(s) are most likely to be clinically successful and the consumer will be supported by the CM Team to participate in court-mandated, but evaluation determined treatments. At all times
the consumer will be supported, their choices honored whenever possible, and methods to reduce feelings of coercion and stigma used. The SR-AOT will blend several EBPs. The CM Team will provide services consistent with the Critical Time Intervention model, consistently use Motivational Interviewing, and support each SR-AOT consumer to complete a Psychiatric Advanced Directive as a ward against future periods of instability. Other EBPs that PBHM can access via a network of over 500 providers includes, but is not limited to, Assertive Community Treatment Teams (ACTT), Community Support Teams (CST), Psychosocial Rehabilitation, Transitions to Community Living, and the Club House Model. A strength of the SR-AOT is the ability of PBHM as a health plan to match consumers with a breadth of participating providers on an individualized basis. Five overall goals, each with 2-4 objectives, and several evaluation outcomes will be used to determine program impact. The goals of the program are to (1) Lower use of and high cost/ineffective services while engaging with appropriate EBPs to limit harm to self or others; (2) Improve treatment adherence while lowering perceived coercion; (3) Improve disruptive symptoms and community/social engagement; (4) Implement the SR-AOT with fidelity; and, (5) Engage community programs and services in an AOT sustainable network.