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Published Online: 1 February 2017

System Transformation Under the California Mental Health Services Act: Implementation of Full-Service Partnerships in L.A. County

Sarah L. Starks, Ph.D., Paul G. Arns, Ph.D., Howard Padwa, Ph.D., Jack R. Friedman, Ph.D., Jocelyn Marrow, Ph.D., Marcia L. Meldrum, Ph.D., Elizabeth Bromley, M.D., Ph.D., Erin L. Kelly, Ph.D., John S. Brekke, Ph.D., and Joel T. Braslow, M.D., Ph.D. [email protected]Authors Info & Affiliations
Publication: Psychiatric Services
Volume 68, Number 6
https://doi.org/10.1176/appi.ps.201500390
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Abstract

Objective:

The study evaluated the effect of California’s Mental Health Services Act (MHSA) on the structure, volume, location, and patient centeredness of Los Angeles County public mental health services.

Methods:

This prospective mixed-methods study (2006–2013) was based in five Los Angeles County public mental health clinics, all with usual care and three with full-service partnerships (FSPs). FSPs are MHSA-funded programs designed to “do whatever it takes” to provide intensive, recovery-oriented, team-based, integrated services for clients with severe mental illness. FSPs were compared with usual care on outpatient services received (claims data) and on organizational climate, recovery orientation, and provider-client working alliance (surveys and semistructured interviews), with regression adjustment for client and provider characteristics.

Results:

In the first year after admission, FSP clients (N=174) received significantly more outpatient services than did usual care clients (N=298) (5,238 versus 1,643 minutes, p<.001), and a larger proportion of these services were field based (22% versus 2%, p<.001). Compared with usual care clients, FSP clients reported more recovery-oriented services (p<.001) and a better provider-client working alliance (p=.01). Compared with usual care providers (N=130), FSP providers (N=42) reported more stress (p<.001) and lower morale (p<.001).

Conclusions:

Los Angeles County’s public mental health system was able to transform service delivery in response to well-funded policy mandates. For providers, a structure emphasizing accountability and patient centeredness was associated with greater stress, despite smaller caseloads. For clients, service structure and volume created opportunities to build stronger provider-client relationships and address their needs and goals.

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Information & Authors

Information

Published In

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Cover: Ripening Pears, by Joseph Decker, circa 1884. Oil on canvas. Gift of Ann and Mark Kington/The Kington Foundation Avalon Fund. National Gallery of Art, Washington, D.C.

Psychiatric Services
Volume 68 • Number 6 • June 01, 2017
Pages: 587 - 595
PubMed: 28142386

History

Received: 9 September 2015
Revision received: 29 February 2016
Accepted: 18 November 2016
Published online: 1 February 2017
Published in print: June 01, 2017

Keywords

  1. Community mental health services
  2. Recovery
  3. Staff relationships/roles
  4. Systems issues in CMI
  5. Homeless mentally ill

Authors

Affiliations

Sarah L. Starks, Ph.D.
Dr. Starks, Dr. Padwa, Dr. Meldrum, and Dr. Kelly are with the Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles (UCLA). Dr. Meldrum is also with the Department of History, UCLA, where Dr. Braslow is affiliated. Dr. Kelly is also with the School of Social Work, University of Southern California, Los Angeles, where Dr. Brekke is affiliated. Dr. Braslow is also with the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, where Dr. Arns and Dr. Bromley are affiliated. Dr. Arns is also with the Los Angeles County Department of Mental Health. Dr. Bromley is also with the Desert Pacific Mental Illness Research, Education and Clinical Center, Greater Los Angeles Veterans Affairs Healthcare System. Dr. Friedman is with the Center for Applied Social Research, University of Oklahoma, Norman. Dr. Marrow is with Health Studies, Westat, Rockville, Maryland.
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Paul G. Arns, Ph.D.
Dr. Starks, Dr. Padwa, Dr. Meldrum, and Dr. Kelly are with the Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles (UCLA). Dr. Meldrum is also with the Department of History, UCLA, where Dr. Braslow is affiliated. Dr. Kelly is also with the School of Social Work, University of Southern California, Los Angeles, where Dr. Brekke is affiliated. Dr. Braslow is also with the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, where Dr. Arns and Dr. Bromley are affiliated. Dr. Arns is also with the Los Angeles County Department of Mental Health. Dr. Bromley is also with the Desert Pacific Mental Illness Research, Education and Clinical Center, Greater Los Angeles Veterans Affairs Healthcare System. Dr. Friedman is with the Center for Applied Social Research, University of Oklahoma, Norman. Dr. Marrow is with Health Studies, Westat, Rockville, Maryland.
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Howard Padwa, Ph.D.
Dr. Starks, Dr. Padwa, Dr. Meldrum, and Dr. Kelly are with the Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles (UCLA). Dr. Meldrum is also with the Department of History, UCLA, where Dr. Braslow is affiliated. Dr. Kelly is also with the School of Social Work, University of Southern California, Los Angeles, where Dr. Brekke is affiliated. Dr. Braslow is also with the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, where Dr. Arns and Dr. Bromley are affiliated. Dr. Arns is also with the Los Angeles County Department of Mental Health. Dr. Bromley is also with the Desert Pacific Mental Illness Research, Education and Clinical Center, Greater Los Angeles Veterans Affairs Healthcare System. Dr. Friedman is with the Center for Applied Social Research, University of Oklahoma, Norman. Dr. Marrow is with Health Studies, Westat, Rockville, Maryland.
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Jack R. Friedman, Ph.D.
Dr. Starks, Dr. Padwa, Dr. Meldrum, and Dr. Kelly are with the Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles (UCLA). Dr. Meldrum is also with the Department of History, UCLA, where Dr. Braslow is affiliated. Dr. Kelly is also with the School of Social Work, University of Southern California, Los Angeles, where Dr. Brekke is affiliated. Dr. Braslow is also with the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, where Dr. Arns and Dr. Bromley are affiliated. Dr. Arns is also with the Los Angeles County Department of Mental Health. Dr. Bromley is also with the Desert Pacific Mental Illness Research, Education and Clinical Center, Greater Los Angeles Veterans Affairs Healthcare System. Dr. Friedman is with the Center for Applied Social Research, University of Oklahoma, Norman. Dr. Marrow is with Health Studies, Westat, Rockville, Maryland.
View all articles by this author
Jocelyn Marrow, Ph.D.
Dr. Starks, Dr. Padwa, Dr. Meldrum, and Dr. Kelly are with the Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles (UCLA). Dr. Meldrum is also with the Department of History, UCLA, where Dr. Braslow is affiliated. Dr. Kelly is also with the School of Social Work, University of Southern California, Los Angeles, where Dr. Brekke is affiliated. Dr. Braslow is also with the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, where Dr. Arns and Dr. Bromley are affiliated. Dr. Arns is also with the Los Angeles County Department of Mental Health. Dr. Bromley is also with the Desert Pacific Mental Illness Research, Education and Clinical Center, Greater Los Angeles Veterans Affairs Healthcare System. Dr. Friedman is with the Center for Applied Social Research, University of Oklahoma, Norman. Dr. Marrow is with Health Studies, Westat, Rockville, Maryland.
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Marcia L. Meldrum, Ph.D.
Dr. Starks, Dr. Padwa, Dr. Meldrum, and Dr. Kelly are with the Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles (UCLA). Dr. Meldrum is also with the Department of History, UCLA, where Dr. Braslow is affiliated. Dr. Kelly is also with the School of Social Work, University of Southern California, Los Angeles, where Dr. Brekke is affiliated. Dr. Braslow is also with the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, where Dr. Arns and Dr. Bromley are affiliated. Dr. Arns is also with the Los Angeles County Department of Mental Health. Dr. Bromley is also with the Desert Pacific Mental Illness Research, Education and Clinical Center, Greater Los Angeles Veterans Affairs Healthcare System. Dr. Friedman is with the Center for Applied Social Research, University of Oklahoma, Norman. Dr. Marrow is with Health Studies, Westat, Rockville, Maryland.
View all articles by this author
Elizabeth Bromley, M.D., Ph.D.
Dr. Starks, Dr. Padwa, Dr. Meldrum, and Dr. Kelly are with the Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles (UCLA). Dr. Meldrum is also with the Department of History, UCLA, where Dr. Braslow is affiliated. Dr. Kelly is also with the School of Social Work, University of Southern California, Los Angeles, where Dr. Brekke is affiliated. Dr. Braslow is also with the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, where Dr. Arns and Dr. Bromley are affiliated. Dr. Arns is also with the Los Angeles County Department of Mental Health. Dr. Bromley is also with the Desert Pacific Mental Illness Research, Education and Clinical Center, Greater Los Angeles Veterans Affairs Healthcare System. Dr. Friedman is with the Center for Applied Social Research, University of Oklahoma, Norman. Dr. Marrow is with Health Studies, Westat, Rockville, Maryland.
View all articles by this author
Erin L. Kelly, Ph.D.
Dr. Starks, Dr. Padwa, Dr. Meldrum, and Dr. Kelly are with the Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles (UCLA). Dr. Meldrum is also with the Department of History, UCLA, where Dr. Braslow is affiliated. Dr. Kelly is also with the School of Social Work, University of Southern California, Los Angeles, where Dr. Brekke is affiliated. Dr. Braslow is also with the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, where Dr. Arns and Dr. Bromley are affiliated. Dr. Arns is also with the Los Angeles County Department of Mental Health. Dr. Bromley is also with the Desert Pacific Mental Illness Research, Education and Clinical Center, Greater Los Angeles Veterans Affairs Healthcare System. Dr. Friedman is with the Center for Applied Social Research, University of Oklahoma, Norman. Dr. Marrow is with Health Studies, Westat, Rockville, Maryland.
View all articles by this author
John S. Brekke, Ph.D.
Dr. Starks, Dr. Padwa, Dr. Meldrum, and Dr. Kelly are with the Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles (UCLA). Dr. Meldrum is also with the Department of History, UCLA, where Dr. Braslow is affiliated. Dr. Kelly is also with the School of Social Work, University of Southern California, Los Angeles, where Dr. Brekke is affiliated. Dr. Braslow is also with the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, where Dr. Arns and Dr. Bromley are affiliated. Dr. Arns is also with the Los Angeles County Department of Mental Health. Dr. Bromley is also with the Desert Pacific Mental Illness Research, Education and Clinical Center, Greater Los Angeles Veterans Affairs Healthcare System. Dr. Friedman is with the Center for Applied Social Research, University of Oklahoma, Norman. Dr. Marrow is with Health Studies, Westat, Rockville, Maryland.
View all articles by this author
Joel T. Braslow, M.D., Ph.D. [email protected]
Dr. Starks, Dr. Padwa, Dr. Meldrum, and Dr. Kelly are with the Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles (UCLA). Dr. Meldrum is also with the Department of History, UCLA, where Dr. Braslow is affiliated. Dr. Kelly is also with the School of Social Work, University of Southern California, Los Angeles, where Dr. Brekke is affiliated. Dr. Braslow is also with the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, where Dr. Arns and Dr. Bromley are affiliated. Dr. Arns is also with the Los Angeles County Department of Mental Health. Dr. Bromley is also with the Desert Pacific Mental Illness Research, Education and Clinical Center, Greater Los Angeles Veterans Affairs Healthcare System. Dr. Friedman is with the Center for Applied Social Research, University of Oklahoma, Norman. Dr. Marrow is with Health Studies, Westat, Rockville, Maryland.
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Notes

Send correspondence to Dr. Braslow (e-mail: [email protected]).

Competing Interests

Dr. Starks, Dr. Meldrum, Dr. Kelly, Dr. Brekke, and Dr. Braslow report receiving funding (2016–2019) from the Los Angeles County Department of Mental Health to evaluate the county's new assisted outpatient treatment program. The other authors report no financial relationships with commercial interests.

Funding Information

Los Angeles County Department of Mental Health:
National Institutes of Health10.13039/100000002: UL1TR000124
National Institute of Mental Health10.13039/100000025: F-31 MH 085394, P30 MH082760, R-01 MH 080671
Robert Wood Johnson Foundation10.13039/100000867:

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