Mental Illness

California’s Efforts to Aid the Homeless with SMI

Society often likes to ignore the challenges faced by citizens with serious mental illness (SMI), especially those who are homeless. California, however, has funded an initiative to help this vulnerable population.

On November 2, 2004, California voters approved Proposition 63, which was signed into law as the Mental Health Services Act (MHSA). The MHSA applied a tax of 1 percent on incomes over $1 million to fund public mental health services. The cornerstone of the MHSA was the implementation of Full Services Partnerships (FSPs). FSPs are integrated supported housing and team-based treatment models that do “whatever it takes” to improve residential stability and mental health outcomes among persons with serious mental illness who are homeless or at risk of homelessness.

The FSPs not only provide housing for homeless SMI individuals, but also mental health services, and educational, vocational, financial, and social supports. FSP’s are modeled on the Housing First program. “Housing First programs provide immediate access to affordable, permanent, scattered-site housing with tenancy rights, and team-based services according to a recovery-oriented service philosophy, which draws heavily on the psychosocial rehabilitation model.” A variety of studies have shown that Housing First does improve the housing situation of the previously homeless SMI population.
Housing First emphasizes that clients be placed in scattered site, permanent residences rather than temporary (or emergency) centralized shelters. The program separates the provision of housing and social services to promote client autonomy. Clients do not have to agree to participate in any treatment plans or have their adherence to psychiatric medicines monitored. Client autonomy is paramount.
The authors found that when FSP, upon implementation, did not maintain complete fidelity to the Housing first principles.

We found substantial variation among programs in fidelity to the Housing First model. Fidelity was particularly low along domains related with housing and service philosophy, indicating that many FSPs implemented a rich array of services but applied housing readiness requirements and did not adhere to consumer choice in housing. The infusion of FSP funding may have served to expand existing resources for housing and services, but in many cases this expansion did not necessarily include adoption of a new program model or service philosophy. Rather, the funding enhanced programs’ abilities to utilize existing networks of housing providers, which had most commonly been congregate/residential treatment settings such as room and board or board and care.

The results of this study should not be surprising. There is significant path dependence in providing these services. Although decentralizing housing and separating housing from services may be a laudable goal, completely overhauling existing centralized site or closing down facilities may be difficult politically. Further, it may even be suboptimal if some of these centers have developed expertise in working with SMI in these settings. Retraining social workers and providers to engage the SMI in decentralized facilities may be preferable, but the cost of retraining the staff to operate in this way should not be ignored. In fact, the FSPs with the most Fidelity to housing first were the sites with existing cultures which already emphasized client autonomy.

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