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
Mar 29, 2015
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