Fidelity and Outcomes: Lessons from the Implementation of California's Full Service Partnerships

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Slide 1

Fidelity and Outcomes: Lessons from the Implementation of California's Full Service Partnerships 

Todd Gilmer, PhD
Department of Family and Preventive Medicine
University of California, San Diego

AHRQ R01 HS01986

Slide 2

Mental Health Services Act (MHSA)

• In 2004, California voters approved proposition 63, which was signed into law as the MHSA:
  • Policy history included AB3777 (1988), AB34 (1999), and AB2034 (2000) which funded integrated models.
• 1% tax on incomes >$ million to fund public mental health services in specific areas:
  • Community Services and Supports:
    • Recovery oriented programs targeting the underserved: homeless, Latinos, Asians, older adults, transitional age youth.
    • 28% of CSS funding to Full Service Partnerships.
  • Prevention and Early Intervention (e.g., stigma, suicide).
  • Innovations (integrated mental and physical health).

Slide 3

Full Service Partnerships

• FSPs provide supported housing and team based services with a focus on rehabilitation and recovery.
• FSPs are client centered and recovery oriented programs that do 'whatever it takes' to improve residential stability and mental health outcomes.
• FSPs were implemented with substantial stakeholder input, and were adapted to local environments, resulting in a wide diversity in approaches to both housing and services.

Slide 4

Housing First

• Developed in New York City by Pathways to Housing.
• Traditional housing model required treatment adherence and sobriety before placement.
• Housing first model emphasized immediate housing in scatter site apartments with tenancy rights.
• Adherence to the Housing First model can be measured using a fidelity scale.
  • Choice/affordability, scatter site housing, separation of housing and treatment, service philosophy, service array, team structure.

Slide 5

Why use a Fidelity Scale to Study FSPs?

• FSPs provide a natural experiment to study various approaches to housing and services.
• Housing First model provides a gold standard.
• Fidelity to Housing First provides a method of mapping FSP practices.
• Opportunity to identify both best practices among FSPs and the important elements of Housing First.

Slide 6

Mixed Methods Study

• Quantitative data:
  • Administrative data (N=8,553, 60% schizophrenia):
    • Provides information on housing, service utilization and costs.
    • Difference-in-difference analysis.
    • Propensity score matched control group.
  • Fidelity to Housing First obtained through a survey of 94 FSP practices:
    • Survey based on the HF Fidelity Scale.
    • Respondents were FSP teams + clients.
    • Allows us to link practices to outcomes.
• Qualitative data:
  • Fidelity to Housing First obtained through 20 site visits.

Slide 7

Participating Counties

Image: A map of California is color-coded to show the participating counties.

Slide 8

Fidelity Survey Results

Image: A graph shows housing compared against services.

Slide 9

Living Situations for FSP Clients in One Year Pre and Post Enrollment

Image: A bar graph shows percentage of days in types of living situations:

FSP Client 81:

• Congregate: 64 days.
• Parents/family: 61 days.
• Emergency/shelters: 32 days.
• Homeless: 77 days.
• Justice: 23 days.
• Other/unknown: 27 days.

FSP Client 116:

• Congregate: 115 days.
• Parents/family: 48 days.
• Emergency/shelters: 33 days.
• Homeless: 22 days.
• Justice: 9 days.
• Other/unknown: 17 days.

Slide 10

Difference in One Year Standardized Costs for FSP vs. non-FSP clients

Image: A bar graph shows the following differences in costs:

• Outpatient: 9363.
• Inpatient/Emergency: -2932.
• Residential/Locked Facility: -1583.
• Housing: 2066.
• Total: 5231.

Slide 11

Effect of Fidelity to Housing First on Residential Status

Image: A bar graph shows difference in days between highest and lowest Fidelity Programs:

Housing/Service Philosophy:

• Apartment/SRO: 120.
• Congregate: -51.
• Parents/family: - 13.
• Emergency/shelters: -25.
• Homeless: -64.
• Justice: 46.

Service Array/Team Structure:

• Apartment/SRO: 35.
• Congregate: -2.
• Parents/family: - 17.
• Emergency/shelters: -18.
• Homeless: -21.
• Justice: 16.

Slide 12

Conclusions (so far)

• FSPs are effective for improving residential and service outcomes.
• Fidelity to Housing First is related to improved residential outcomes.
• Qualitative work will provide a depth of information, and will be used to complement, explore, and expand on findings.

Slide 13

Housing First Implementation

• Pathways to Housing, Inc.
  • http://www.pathwaystohousing.org.
  • Housing First Partners Conference.
  • NYC, Westchester County, DC, Burlington VT, Philadelphia.
• Canadian Demonstration Project:
  • http://www.mentalhealthcommission.ca/English/Pages/homelessness.aspx.
• Housing First in Veterans Affairs.