For Persons With Serious Mental Illness
AHRQ Delivery System Research: Study Snapshot
Authorized by California's Mental Health Services Act (MHSA), full-service partnerships (FSPs) provide integrated, supported housing and treatment to people with severe mental illness (SMI) who are homeless or at risk of becoming homeless. This study assessed variation in implementation of FSPs across California. The goal was to understand whether the MHSA has resulted in the uniform development of FSPs characterized by a "recovery orientation" that emphasizes doing "whatever it takes" to improve residential stability and mental health outcomes.
By Todd P. Gilmer, Marian L. Katz, Ana Stefancic, and Lawrence A. Palinkas.
The study authors compared FSP practices to a benchmark program that shares similar goals, vision, and structure: Housing First. In multiple studies, Housing First has been shown to improve residential outcomes of homeless people with SMI. It has also been designated an evidence-based model. Housing First programs provide access to affordable, permanent, scattered-site housing. They emphasize consumer choice, self-determination, and independence; actively use harm reduction, motivational interviewing, assertive engagement, and person-centered planning; and avoid coercive practices.
The authors used a quantitative survey of 135 FSPs (which generated 93 responses) and qualitative site visits to 20 FSPs. The survey allowed evaluation of the degree of variation across programs in adherence to key components of Housing First, while the site visits allowed identification of key features that distinguish high- and low-fidelity programs.
- Wide variations in adherence to Housing First principles: Adherence was low for components related to housing and service philosophy, but higher for those related to service array and program structure. As detailed below, many FSPs implemented a broad array of services but applied housing readiness requirements and did not offer consumer choice.
- Housing and service philosophy: Only 14 percent of respondents had at least 85 percent of participants living in scattered-site housing; only 43 percent did not have housing readiness requirements (such as mandatory time spent in transitional housing or requiring treatment, sobriety, or medication compliance); and only 30 percent offered standard lease agreements without similar restrictions.
- Service array and program structure: Most FSPs did not impose participation requirements for services (63 percent), pharmacotherapy (67 percent), or substance use treatment (81 percent). Similarly, 76 percent endorsed a harm-reduction approach to substance use, and most adhered to standards related to availability of services and took a team approach to service delivery.
- Distinguishing features of high-fidelity programs: The site visits identified the distinguishing features of programs with high fidelity to the Housing First model. Organized into three categories, these features are described below:
- Role of program directors: Leaders of high-fidelity programs focus unequivocally on client needs and have a recovery orientation. By contrast, their peers in low- fidelity programs tend to emphasize other goals (such as cost savings) and accept or endorse physical settings and behavioral norms that hinder the focus on recovery. Directors of high-fidelity programs have prior experience with similar service models; view clients as equals with valid, authoritative views; prioritize income and housing over medication; understand the therapeutic value of scattered-site housing; and are aware of the local political context and how it affects the FSP.
- Internal culture, staffing, and protocols: High-fidelity programs describe clients as "underserved" and highlight improvement in their quality of life as the primary goal. By contrast, low-fidelity programs tend to describe clients as "high utilizers" of services and make managing utilization the primary goal. High-fidelity programs generally had a pre-existing service philosophy and approach that closely matched the recovery-oriented FSP philosophy. They also tend to hire staff whose personal values and beliefs align with this philosophy (or support staff in moving toward this orientation); commit to client-centered decisionmaking; explicitly refer to the importance of language in implementing recovery-oriented services; and emphasize use of available funds to subsidize permanent housing.
- External environment: High-fidelity programs tend to be part of larger networks of similar programs, thus enabling more frequent and extensive communication with like-minded peers and creating opportunities to influence county policies. Similarly, directors of high-fidelity programs often get support and guidance from the county on how to operate in accordance with the FSP philosophy, or are monitored for adherence to that philosophy.
- Ample opportunity for improvement: FSPs in California have an opportunity to improve adherence toward a focus on recovery for homeless individuals with SMI, rather than imposing upfront restrictions on who can enter supported housing.
- Many features to emulate: This study identified distinguishing features of high-fidelity programs that program directors, county officials, and other stakeholders might consider, such as placing a singular focus on client needs, hiring staff whose personal values and beliefs fit with a recovery orientation, and prioritizing scattered-site housing.
- Critical importance of program director: The program director plays a significant role in creating a culture and environment that promotes recovery. As one FSP executive director noted, "I try to enhance the environment so that it's consistent with recovery values."
- Value of external support: Tapping into external networks and eliciting support from county officials can also be helpful, particularly for programs that do not have a pre-existing recovery-oriented philosophy.
Todd P. Gilmer, Marian L. Katz, Ana Stefancic, and Lawrence A. Palinkas. Variation in the implementation of California's full service partnerships for persons with serious mental illness. Health Serv Res 2013;48:6.2. https://www.hsr.org/node/426386.
For additional information on AHRQ Delivery System Research, visit our Web site at http://www.ahrq.gov/professionals/systems/system/delivery-system-initiative/index.html or contact Michael Harrison at Michael.Harrison@ahrq.hhs.gov.
Based on research funded by ARRA Grant No. R01 HS19986.
The findings and conclusions in this document are those of the authors, who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this brief should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.