Fidelity and Outcomes: Lessons from the Implementation of California's Full Service Partnerships
AHRQ's 2012 Annual Conference Slide Presentation
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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).
- Community Services and Supports:
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.
- Administrative data (N=8,553, 60% schizophrenia):
- 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:
- Housing First in Veterans Affairs.
