fidelity and outcomes: lessons from the implementation of california's full service...
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Fidelity and Outcomes:Lessons from the Implementation of California's Full Service Partnerships
Todd Gilmer, PhDDepartment of Family and Preventive Medicine
University of California, San Diego
AHRQ R01 HS01986
Mental Health Services Act
• 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 (eg stigma, suicide)
– Innovations (integrated mental and physical health)
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
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
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
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
Participating Counties
Fidelity Survey Results
Living Situations for FSP Clients in One Year Pre and Post Enrollment
81 1160%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
64
115
61
48
32
3377
22239
27 17
Series7
Other/unk.
Justice
Homeless
Emergency/shel-ters
Parents/family
Congregate
Perc
en
t of
Days
Difference in One Year Standardized Costs for FSP vs. non-FSP clients
Outpatient Inpatient/ Emergency Residential / Locked Fac.
Housing Total
-4000
-2000
0
2000
4000
6000
8000
10000
12000
9363
-2932
-1583
2065.66666666667
5230.66666666667
Effect of Fidelity to Housing First on Residential Status
Apartment/SRO
Congregate
Parents/family
Emergency/shelters
Homeless
Justice
-100 -50 0 50 100 150
120
-51
-13
-25
-64
46
35
-2
-17
-18
-21
16
Service Array / Team Structure Housing / Service Philosophy
Difference in Days between Highest and Lowest Fidelity Programs
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
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