Fidelity and Outcomes: Lessons from the Implementation of California's Full Service Partnerships Todd Gilmer, PhD Department of Family and Preventive Medicine.

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