Moving from ‘Whatever it Takes’ to ‘What it Takes’: Examining a Policy-Driven Program for Engaging Underserved Children and Families into Mental Health Services

This dissertation examines the children’s public mental health Full Service Partnership (FSP) program established by the California’s Mental Health Services Act of 2004 in order to provide mental health and social services and supports not otherwise available to the underserved. Utilizing a California statewide dataset of all public county mental health system provisions linked from two sources of data, including FSP program exposure data (Data Collection and Report dataset) and mental health service data (Client Services Information dataset) from the California Department of Health Care Services (CDHCS), analyses compare the FSP program to usual care within county mental health systems. Synthesizing records summarizing each month a child was served, the final dataset encompasses 36 counties (61%) inclusive of 623,031 (70%) children (ages 6<18) served within county mental health systems over 102 months between July 1, 2004 and December 31, 2012, reflecting 15,723 children served by the FSP program. To evaluate whether the FSP program was meeting its goals as established in statute and guidelines, three research questions were addressed: 1) Do FSP programs reach underserved children, as intended? 2) Do FSP programs provide a different array of services as compared to usual care, as intended? 3) Does participation in the FSP program result in positive outcomes as intended, measured by a decrease in the use of mental health emergency service? Adjusting for demographics, indicators of clinical severity, and county of residence, three respective analytical models were developed to compare FSP served children to those in usual care including: 1) hierarchical logistic regression modeling for the odds of a child enrolling into an FSP versus remaining in the pool of those served by usual care in each county, 2) t-tests contrasting service provision arrays for FSP served children as compared to those in intensive (service on >= four days per month) usual care, and 3) longitudinal hierarchical Poisson regression modeling the pre-post matched change in incidence rate of mental health emergency services use before, after and without FSP enrollment.As intended by policy, results indicate that FSPs reach the underserved, provide a different array of service intensity and result in reductions of crisis care for the children and families it served. Compared to others concomitantly served in usual care, FSP enrollees had more clinical indicators of severe disorder and had encountered the mental health system at younger ages (OR=.94, P<.001), but had received fewer total lifetime months of services before enrolling into FSP (OR=.99, P<.001), especially in the six months before beginning an FSP program (OR=.19, P<.001). FSP served children also received an array of services generally more intensive than usual care, even when considering only those children served at least four days per month in usual care. The comparison of service types suggested that the FSP program followed policy guidelines which direct FSPs to offer a heightened focus on linkages to community resources (+80%, P<.001) and to support needs of caregivers and other family members (+60%, P<.001). Improved outcomes were evidenced by changes in emergency service use rates for FSP served children, given that before enrolling in the FSP program, these children showed increasing rates of mental health emergency service use over time which were then reduced or reversed after enrolling in FSP programming and throughout the remainder of the study period – a pattern unlike what was experienced by similar children in usual care. After enrollment, the older groups of FSP served children showed significant improvement in contrast to their mental health emergency service use rates before treatment and to rates of all other comparable children in usual care (ages 11<15 IRR=.83 , P<.001; and 15<18 IRR=.79, P<.001).FSPs are customized programs which address, at least in part, two significant challenges in children’s mental health: (1) outreach and engagement of underserved populations and (2) provision of community-based stabilizing care for children at high risk for psychiatric crises. There is evidence that FSP programs might have benefits for children by (a) more effectively enrolling into care some of the 2/3 of the population with need who are unserved or underserved; (b) providing an intensive array of services inclusive of family care and linkages to external resources; and (c) resulting in improved crisis-related outcomes for children and families. FSP programs incorporate a variety of innovate components, any of which could contribute to increased success in identifying, enrolling and engaging underserved children; improving the availability of an appropriate intensity of services; or delivering positive outcomes across a lasting developmental trajectory. Left unserved and underserved, children with severe mental disorders and their families may lack the appropriate tools to manage or improve symptoms of the disorder leading toward a progression into mental illness in adulthood. A key aspect of FSP programs is their ability to provide a combination of social and mental health services, likely helping underserved families living in poverty to overcome prior barriers to treatment. Supported by the existing infrastructure built around the FSP program, research in California is poised to make a significant contribution toward evidencing methods which increase successful treatment of undertreated children’s mental disorders potentially altering their progression. Results from this dissertation provide justification for putting effort forth toward further evaluation to identify the FSP program components which result in these program successes