The Mental Health Services Act in Los Angeles County

In 2004, California voters approved Proposition 63, which was signed into law as the Mental Health Services Act (MHSA). The intent of the act was to address the urgent need for expanding access to community mental health services. The MHSA levied a 1 percent tax on all California personal incomes over $1 million, resulting in a substantial investment in mental health services in the state. Because California has a decentralized behavioral health system, most MHSA funding has been administered by California's counties.

As California's most populous county (with roughly one-quarter of the state's population), Los Angeles County receives the single largest share of MHSA funds. The Los Angeles County Department of Mental Health (LAC DMH) has used MHSA funds to provide a full spectrum of mental health services. One area of focus has been expanding access to Full-Service Partnership (FSP) programs, in which mental health staff partner with clients to do "whatever it takes" to improve residential stability and mental health outcomes for people with serious mental illness. Another focus has been implementing Prevention and Early Intervention (PEI) programs, which aim to prevent onset and negative consequences of mental illness.

To assess progress and inform efforts to improve program quality, LAC DMH commissioned an evaluation of a broad segment of its FSP and PEI programs. The evaluation, conducted by a team of RAND and UCLA researchers, examined the geographic and demographic reach of MHSA-funded activities and assessed their impact on clients. The team used administrative and program data from 2012 to 2016, the most recent five-year period for which data were available, to examine the programs' reach and outcomes. The team supplemented analyses of these data with qualitative interviews on additional topics.

PEI Programs

• The evaluation focused on PEI programs that provide direct services to children (ages 0–15) and transition-age youth (ages 16–25). These programs are one component of a comprehensive range of PEI services.
• The county's PEI programs provided services to almost 130,000 children and transition-age youth between 2012 and 2016. The vast majority of these were members of ethnic minority groups. Almost 65 percent of these clients were new clients, suggesting that PEI programs are successfully reaching children and transition-age youth who have not previously received care.
• Utilization of such treatments as therapy and case management increased with use of PEI programs.
• PEI programs were associated with positive outcomes in the clients they serve (Figure 1).
• Hispanic and Asian youth responded particularly well to PEI services, in comparison with white and black youth. However, all racial/ethnic groups experienced significant improvements in symptoms.

Staying well: Of those receiving care preventively (i.e., those who scored below a widely used threshold for psychological distress at entry into care), almost 9 out of 10 remained below the threshold for clinically significant symptoms over time.

Getting better: Of those who had symptoms at a level at or above a clinical cut point for psychological distress at the start of their PEI service, more than 5 out of 10 no longer had clinically significant symptoms over time.

FSP Programs

• The evaluation focused on LAC DMH's full range of FSP programs for children, transition-age youth, and adults.
• FSP enrollment increased over the five years evaluated. Further, the majority of those enrolled actively engaged in the program. In total, FSP programs served almost 25,000 clients from 2012 through 2016.
• FSP programs provide services to vulnerable and diverse populations. The programs are located throughout the county but primarily in areas with more households in poverty (see Figure 2), where LAC DMH services are likely to be needed the most. The programs predominantly serve racial/ethnic minorities.

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• The individuals served by the program tend to be diagnosed with severe conditions (e.g., psychotic disorders) and have relatively high rates of homelessness. Qualitative interviews also revealed that FSP clients often simultaneously experience problems with mental health, physical health, and social issues.
• FSP clients experienced improvements in life circumstances and health. FSP clients experienced decreased rates of homelessness (Figure 3), decreased rates of criminal justice involvement (Figure 4), and fewer inpatient hospitalizations for mental health. The number of adult clients who reported having a primary care provider increased, suggesting a better connection to physical health care.

Next Steps for Los Angeles County

Continue efforts to reach vulnerable populations across Los Angeles 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. However, not all groups benefit equally from the services received. Consequently, 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.

Facilitate future outcome-monitoring and quality-improvement efforts by retooling the approach to measuring outcomes. This evaluation was limited by the available data, which did not measure all the outcomes of potential interest and sometimes lacked complete follow-up information. 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 measures are needed to understand how clients are doing with respect to whether they have "somewhere to live, someone to love, and something to do" and other indicators of recovery from serious mental illness. However, because many data-collection procedures are state-mandated, 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. Further research should develop key performance indicators and examine how they vary across providers. Knowing whether some providers are performing better than others would be instructive regarding where to focus quality-improvement efforts.

Conduct cost-effectiveness and cost-benefit analyses. Now that the reach and outcomes of key programs 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

MHSA-funded activities in Los Angeles County are reaching a highly vulnerable population with their FSP and youth PEI programs. Furthermore, those reached by these programs experience improvements in their mental health and life circumstances. Refining data collection would enable more-thorough evaluations of processes of care and of whether clients have "somewhere to live, someone to love, and something to do," and this refinement would inform the program's quality-improvement efforts.

CalMHSA

The California Mental Health Services Authority (CalMHSA) is an organization of county governments working to improve mental health outcomes for individuals, families, and communities. Prevention and early intervention programs implemented by CalMHSA are funded by counties through the voter-approved Mental Health Services Act (Prop. 63). Prop. 63 provides the funding and framework needed to expand mental health services to previously underserved populations and all of California's diverse communities.

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Topics

• Child Health
• Health Care Program Evaluation
• Health Interventions
• Homeless Populations
• Los Angeles
• Mental Health Treatment