System Transformation Under the California Mental Health Services Act: Implementation of Full-Service Partnerships in L.A. County.

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 prospectivemixed-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, teambased, 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.