Evaluation of the Mental Health Services Act in Los Angeles County

Background

On November 2, 2004, California voters approved Proposition 63, which was signed into law as the Mental Health Services Act (MHSA). The MHSA levied a 1 percent tax on all California personal incomes over $1 million, resulting in a substantial investment in mental health in the state. The intent of the act was to address the urgent need for expanding accessible, recovery-based, community mental health services. California has a decentralized behavioral health system in which treatment services are provided by its 58 counties. As a result, MHSA funding has been largely administered by California's counties.

Key MHSA-funded services include Prevention and Early Intervention (PEI) services, which aim to prevent onset and negative consequences of mental illness, and Full-Service Partnership (FSP) services that take the “Housing First” approach and aim to do “whatever it takes” to improve residential stability and mental health outcomes for people with serious mental illness (Gilmer, Stefancic, et al., 2010).

The current evaluation focuses on Los Angeles County, which used MHSA funds to offer new PEI services and greatly expand access to FSP services. The goal of the evaluation is to understand who is being reached by key MHSA-funded services and what the impact of services has been. The Los Angeles County Department of Mental Health (LAC DMH) is providing PEI services across the life span, but the current evaluation focuses specifically on PEI services for children and transition-age youth (TAY) and FSP programs for children, TAY, and adults.

Approach

The reach and short-term outcomes of the PEI and FSP services were assessed using a range of administrative data, including claims data from all payers and program data shared with the evaluators by LAC DMH. Analyses of these data were supplemented with qualitative interviews designed to collect detailed accounts from clients who had received these MHSA-funded services.

Key Findings

PEI Programs for Children and TAY

• LAC DMH's PEI services provided care to almost 130,000 children and TAY, the vast majority of whom were of racial/ethnic minority backgrounds. Almost 65 percent of these clients were new clients, suggesting that PEI services are successfully reaching children and TAY who have not previously gotten care.
• Utilization of treatments, such as therapy and case management, increased with use of PEI services.
• PEI evidence-based practices are associated with staying well and getting better. Of those receiving preventive care (i.e., those who scored below a widely used threshold for psychological distress at entry into care), almost nine out of ten remained below the threshold for clinically significant symptoms over time. Of those who had symptom levels at or above a clinical cut point for psychological distress at the start of their PEI service, more than half no longer had clinically significant symptoms after care.
• Hispanic and Asian youth responded particularly well to PEI services, in comparison with non-Hispanic white and black youth. However, all racial/ethnic groups experienced significant improvements in symptoms.

FSP Programs for Children, TAY, and Adults

• FSP enrollment increased over the five years evaluated for children, TAY, and adults. Further, the majority of those enrolled actively engaged in the program.
• FSP programs provide services to vulnerable and diverse populations. The programs are located throughout the county, but they are primarily in areas with more households in poverty, where LAC DMH services are likely to be needed the most. The individuals served by the programs tend to have severe diagnoses (e.g., psychotic disorders) and relatively high rates of homelessness. Qualitative interviews also revealed that FSP clients were simultaneously experiencing problems with mental health, physical health, and social issues. The programs predominately serve racial/ethnic minorities.
• FSP clients experienced improvements in their life circumstances and functioning. FSP clients experienced decreased rates of homelessness, decreased rates of detention or incarceration within the justice system, and decreased utilization of inpatient hospitalization for mental health. Adults in particular had increased rates of having a primary care provider, suggesting a better connection to physical health care.

Recommendations

LAC DMH should continue its efforts to reach vulnerable populations across the county and improve outcomes for diverse racial/ethnic groups. There is evidence that LAC DMH programs are already reaching at-risk individuals and members of racial/ethnic minority groups across the county. Future evaluations should focus on understanding the unique PEI needs of different racial/ethnic groups, and LAC DMH should use these evaluation findings to inform quality-improvement efforts for groups not faring as well.

Facilitate future outcome-monitoring and quality-improvement efforts by retooling the approach to measuring outcomes. LAC DMH should consider refining which outcomes it measures, how it measures them, and how often it measures them for both FSP and PEI programs. New data-collection tools are needed to understand how clients are doing with respect to whether they have “somewhere to live, someone to love, and something to do” (the pillars of life satisfaction, according to LAC DMH) and other indicators of recovery from serious mental illness. For evaluations of child PEI programs, such outcomes as school engagement and performance should be considered. Careful attention should be paid to choosing measures that are reliable, valid, and responsive to change, with available benchmarks for measuring progress. Key measures, such as homelessness, should be collected at regular intervals, rather than in response to life changes, to reduce missing data and enhance the interpretability of available data. However, many elements of FSP data are collected at state-mandated intervals, so advocacy may be needed at the state level to adjust data-collection requirements.

Consider measuring processes of care and using these data for quality improvement. LAC DMH should consider evaluating the fidelity with which the most frequently used interventions are implemented. In addition, it might query patients' satisfaction with care and their impressions of providers' cultural competency.

Examine provider-level differences in engagement and outcomes. We recommend the development of key performance indicators and an examination of how they vary across providers.

If some providers are better at engaging clients and getting positive results than are others, this would be instructive regarding where to focus quality-improvement efforts.

Conduct cost-effectiveness and cost-benefits analyses. Now that the reach and outcomes of key programming have been established, a next step could be to examine the resource investments in these programs in relation to the social and economic benefits associated with those investments.

Conclusions

The current evaluation found evidence that LAC DMH is reaching the highly vulnerable populations it seeks to reach with its PEI and FSP programs. Furthermore, those reached by the programs experience improvements in their mental health and life circumstances. Refining data collection will enable more-thorough evaluation of processes of care and whether clients have “somewhere to live, someone to love, and something to do” and would inform the program's quality-improvement efforts.