Full Service Partnerships

Goal/Opportunity

The Commission’s report to the Legislature in January 2023 identified three primary concerns. First, the report noted that missing and inaccurate data limit the Commission’s ability to fully understand how effective FSPs are in preventing homelessness, justice involvement, and hospitalization. Second, despite regulatory requirements, county behavioral health departments did not appear to be allocating the mandatory minimum funding levels for FSP as specified by the law. Third, as of the time of the report, California had not established sufficient technical assistance and support for counties and providers to ensure that FSP programs are meeting the goals of reducing homelessness, hospitalizations, and justice involvement.

Since the Commission’s initial report, the need for high quality FSPs has only grown. An increasing number of unhoused residents, long waiting lists to enter state hospitals, and ongoing reliance on local law enforcement and community hospital care suggest the need for high-quality FSP programs is greater than ever.

• In 2020, approximately 37,000 unhoused Californians were living with mental illness and a similar number were living with chronic substance use disorder.  

• Nearly 80 percent of unhoused individuals in California have a previous incarceration, and approximately 30 percent had been detained during their most recent experience of homelessness. This suggests a strong relationship between living unhoused and being involved in the criminal justice system.  

• Approximately 30 percent of individuals incarcerated at the state and county level were either in need of mental health services or actively receiving psychotropic medication.  

• In 2022, more than 1,700 individuals who were found incompetent to stand trial were being held in jail while on the waitlist for treatment at a state hospital. The cost of treating individuals in jails to restore them to competency was about $172 million. 

• Those who are moved off the waitlist are sent to one of five state hospitals that serve more than 6,200 individuals. The cost to run these five hospitals exceeds $2 billion annually.  

The Commission has done extensive work to better understand what needs to be done to improve FSPs and move the needle on hospitalization, homelessness, and incarceration for Californians with severe mental illness. This includes conducting targeted outreach, community forums, and a statewide survey reaching participants from 45 counties (77 percent of counties).  

In addition to the efforts above, the Commission: 

• Conducted deep dives with Nevada, San Francisco and Orange counties to review current FSP contract practices.
• Conducted case studies in two counties to better understand data collection and reporting practices, and the use of outcome and performance metrics by counties and providers. 
• Is conducting performance management technical assistance and capacity building pilots in Sacramento and Nevada counties. 

Lastly, the Commission hosted two public panels on FSPs including representatives from the Department of Health Care Services, a county behavioral health director, and leading researchers in the field of behavioral health. 

The Commission’s 2024 report has two priorities. The first is to present the required information to the Legislature as directed by Senate Bill 465. The report will cover trends in the characteristics of clients including race and ethnic composition, diagnoses, service utilization, and housing status. The report will also examine how clients have fared prior to and immediately after joining an FSP. The report’s second priority is to examine FSPs as systems of care and illuminate how system-level issues, such State-mandated data collection and reporting policies and practices, impact quality of care and client outcomes.  

Background

California’s investment in FSPs evolved from advocacy efforts in the 1990s to reduce the number of people sent to locked state mental hospitals who could be better served in the community. In 1999, the state passed legislation to establish pilot projects across California, funding comprehensive, integrated care for people with high risk for homelessness, justice involvement, and hospitalization. After signs of success, the program was expanded to more sites across the state. Follow-up evaluations confirmed early findings: Housing is a critical component of recovery, and people with serious mental illness can achieve housing stability with adequate support. 

In the more than two decades since the birth of FSPs, numerous factors have led to advances and changes in how FSPs serve the community and who they serve. 

In September 2022, Governor Newsom signed the Community Assistance, Recovery and Empowerment (CARE) Act. The goal of the CARE Act is to improve access to mental health services for people experiencing schizophrenia or other psychotic disorders and who are either not receiving adequate treatment or who do not have stable housing. Under the CARE Act, mental health consumers and counties negotiate individualized service plans called CARE Plans. CARE Courts oversee these plans and have the authority to compel counties to participate in those plans when necessary. Most CARE Courts were set to roll out in 2024. As more and more counties enact CARE Courts, it is expected that demand on FSPs will increase.

In February of 2024, the Commission allocated $20 million in Mental Health Wellness Act funds towards a technical assistance and capacity building strategy to:

• Advance sustainable funding solutions through the restructuring of current funding models to increase efficiency and impact.
• Strengthen the workforce by identifying innovative, scalable workforce development solutions to increase capacity and reduce turnover.
• Improve accountability by developing metrics of success, identifying key client outcomes, and improving data collection and reporting practices.
• Fortify current infrastructure by strengthening service delivery models connected to the broader continuum of care.

The Commission is currently developing a request for proposals, not to exceed $10 million, for technical assistance and capacity building focused on value-based contracting and performance management and improved service delivery. This substantial investment in technical assistance and capacity building is in direct response to the feedback received from service providers and county staff.

Supplementing the substantial investment of $20 million mentioned above, the Commission has several additional projects underway aimed at improving FSPs. The first is a best practices toolkit for service providers, currently in development in collaboration with Third Sector Capital Partners. This toolkit will bring together recommendations and best practices identified by FSP service providers and county behavioral health staff into a single resource that will be widely available for public use. The toolkit will focus on the following five topics and is expected to be available in summer of 2025:

• Peer and paraprofessional supports in the workforce
• Services and treatment for individuals with substance use disorders
• Collaboration with community and cultural partners
• Step-down levels of support
• Outreach and engagement

Simultaneously, the Commission launched two pilot projects with Healthy Brains Global Initiative to provide performance management capacity building and technical assistance to FSP service providers in Sacramento and Nevada counties. In these pilots, counties and service providers work together to identify performance goals and develop performance monitoring tools to track progress towards these goals. Results from these pilots will also be available in the summer of 2025.

The most recent, and probably most prominent, changes to FSPs come from mandates enacted by Proposition 1. In March 2024, California voters approved Proposition 1, transforming the Mental Health Services Act into the Behavioral Health Services Act (BHSA). With this shift, several fundamental changes through the Welfare and Institutions Code Section 5887 were set in motion that will have substantial impacts on FSPs, including: 

• The expansion of services to individuals with substance use disorders, including assertive, field-based treatment.

• The development of standardized, evidence-based practices for models of treatment including Assertive Community Treatment (ACT) and Forensic Assertive Community Treatment (FACT), Individual Placement and Support model of Supported Employment, high fidelity wraparound, or other evidence-based services and treatment models, as specified by the State Department of Health Care Services (DHCS).

• Establishing levels of care and criteria for stepping down to the least intensive level of care per the guidance of DHCS in consultation with the Commission.

These changes are set to go into effect July 1, 2026. The DHCS has provided an overview of the new Behavioral Health Services Act and how it impacts FSPs.

Lastly, the BHSA mandates the allocation of 30 percent of BHSA funds towards housing for eligible individuals, shifts FSP funding to 35 percent of BHSA revenue, and places a heightened focus on transparency and accountability for financial, performance, and outcomes data.

Project Outcomes

Towards A New Contracting Model for Full Service Partnerships 

This report examines the challenges faced by local behavioral health departments in contracting FSP providers, and makes recommendations about contracting to improve FSP outcomes, data reporting, and program capacity. 

Project Milestones

Next Steps