title: System Transformation Under the California Mental Health Services Act: Implementation of Full-Service Partnerships in L.A. County.
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.
authors.affiliation: 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.
authors.forename: Sarah L
authors.initials: SL
authors.lastname: Starks
authors.affiliation: 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.
authors.forename: Paul G
authors.initials: PG
authors.lastname: Arns
authors.affiliation: 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.
authors.forename: Howard
authors.initials: H
authors.lastname: Padwa
authors.affiliation: 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.
authors.forename: Jack R
authors.initials: JR
authors.lastname: Friedman
authors.affiliation: 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.
authors.forename: Jocelyn
authors.initials: J
authors.lastname: Marrow
authors.affiliation: 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.
authors.forename: Marcia L
authors.initials: ML
authors.lastname: Meldrum
authors.affiliation: 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.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Bromley
authors.affiliation: 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.
authors.forename: Erin L
authors.initials: EL
authors.lastname: Kelly
authors.affiliation: 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.
authors.forename: John S
authors.initials: JS
authors.lastname: Brekke
authors.affiliation: 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.
authors.forename: Joel T
authors.initials: JT
authors.lastname: Braslow
mesh_terms: D002140:California; D003156:Community Mental Health Services / Q000191:economics / Q000458:organization & administration*; D003299:Cooperative Behavior; D018166:Health Care Reform / Q000331:legislation & jurisprudence / Q000458:organization & administration*; D006302:Health Services Research; D006801:Humans; D001523:Mental Disorders / Q000534:rehabilitation*; D017146:Models, Organizational; D011446:Prospective Studies
keywords: Community mental health services; Homeless mentally ill; Recovery; Staff relationships/roles; Systems issues in CMI