BHSOAC
Eval FSP CostOffsetReport Ucla 103112
Read the report at Behavioral Health Services Oversight & Accountability Commission ↗
Full Service Partnerships:
California’s Investment to Support
Children and Transition-Age Youth with
Serious Emotional Disturbance and
Adults and Older Adults with
Severe Mental Illness
UCLA Center for Healthier Children, Youth and Families
The following report was funded by the
Mental Health Services Oversight and Accountability Commission
October 31, 2012
Table of Contents
Executive Summary ............................................................................................................................ i
I. Introduction ....................................................................................................................................1
II. Involvement of Key Stakeholders ...................................................................................................3
1. Presentations to Client & Family Groups/Organizations Representing Unserved/
Underserved Groups .............................................................................................................. 3
2. Key Stakeholder Interviews with Individuals Representing Client & Family Groups/
Organizations Representing Unserved/Underserved Groups ............................................... 4
3. Presentations to Associations/Service Provider Agencies ..................................................... 5
4. Interviews with Representatives from Associations/Service Provider Agencies ................... 5
5. Evaluation Advisory Group ..................................................................................................... 7
6. Interviews with Peer Advocates & Parent Partners ............................................................... 9
7. Involvement of Key Stakeholders: Summary ....................................................................... 12
III. Expenditures on Full Service Partnership Programs ...................................................................... 13
a. Methodology ................................................................................................................................ 13
1. Program Costs ...................................................................................................................... 17
2. Age Groups ........................................................................................................................... 17
3. Housing ................................................................................................................................ 18
4. Outreach .............................................................................................................................. 19
5. Operational Definitions ........................................................................................................ 19
6. Cost Components ................................................................................................................. 20
7. Standardized Client Years .................................................................................................... 21
b. Per-Person Annualized Cost Average by Age Group .................................................................... 25
c. Contextual Factors – Impact on Cost ........................................................................................... 29
d. FSP Expenditures by Funding Source ........................................................................................... 29
e. Summary ...................................................................................................................................... 30
IV. Cost Offsets for Full Service Partnership Programs ...................................................................... 31
a. Methodology ................................................................................................................................ 31
1. New Enrollees ...................................................................................................................... 32
2. Pre-Intake Period – 12 Months Prior to Enrolling in FSP: Annual per-Client Offset-Category
Cost ...................................................................................................................................... 34
3. Post-Intake Period – 12 Months Post-Enrollment into FSP: Annualized per-Client Offset-
Category Cost ....................................................................................................................... 34
b. Physical Health Services ............................................................................................................... 36
1. Acute Care Inpatient Hospitalization (Physical Health) ....................................................... 36
2. Skilled Nursing (Non-Psychiatric) ......................................................................................... 45
3. Emergency Room Visits ........................................................................................................ 51
c. Psychiatric Care ............................................................................................................................ 58
Full Service Partnerships: California’s Investment to Support Children and Transition-Age Youth with
Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
1. Inpatient Psychiatric Hospitalization .................................................................................... 58
2. Long-Term Care (Psychiatric) ............................................................................................... 66
3. Skilled Nursing (Psychiatric) ................................................................................................. 72
d. Criminal Justice Involvement ....................................................................................................... 78
1. Arrests .................................................................................................................................. 79
2. Incarceration ........................................................................................................................ 85
e. Racial/Ethnic Background of FSP Clients with Offset Data ........................................................ 106
f. Summary .................................................................................................................................... 107
Appendix A Key Stakeholder Contacts ............................................................................................ 121
Appendix B Statewide Evaluation Conceptual Framework ............................................................... 123
Appendix C Technical Appendix ...................................................................................................... 126
Appendix D County Participants ..................................................................................................... 147
Appendix E Revenue & Expenditure Reports ................................................................................... 150
Appendix F Key Stakeholder Feedback ............................................................................................ 156
a. Process for Stakeholder Input .................................................................................................... 157
1. Full Service Partnership Cost-Offset Report ...................................................................... 157
Full Service Partnerships: California’s Investment to Support Children and Transition-Age Youth with
Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
Executive Summary
Proposition 63 (2004) provides increased funding through the Mental Health Services Act (MHSA) to support mental
health services and promote innovative services and best practices for individuals with mental illness and inadequate
access to the traditional public mental health system. Prop 63 funds are distributed to county departments of mental
health to implement MHSA components. Components are: Prevention and Early Intervention (PEI); Workforce
Education and Training (WET); Capital Facilities and Technological Needs (CF/TN); Innovation (INN); and Community
Services and Supports (CSS), which includes the Full Service Partnership (FSP). CSS is designed to serve individuals with
severe mental illness (SMI) or serious emotional disturbance (SED). 1
The focus of this report is the Full Service Partnership (FSP), which is designed to serve Californians in all phases of life
who experience the most severe mental health challenges because of illness or circumstance. This population has been
historically underserved and has substantial opportunity for benefits from improved access and participation in quality
mental health treatment and support.
FSP is grounded in earlier efforts, namely Assembly Bill 2034 (AB 2034) 2 and its predecessors. AB 2034 was unique in 1)
its focus on serving homeless persons with serious mental illness; 2) the “housing first” mandate; 3) flexible funding;
and 4) collection and reporting of client and system outcomes in “real time.” The final analysis of AB 2034 reported a
percentage of costs offset of 49.8 percent. 3
FSP programs are a large portion of the Community Services and Supports (CSS) funding allocation from MHSA. CSS was
designed to move the public mental health system beyond “business as usual” in order to improve access to more-
effective services. CSS (particularly FSP) was intended to initiate significant changes, including: 4
Increases in the array of community service options for individuals diagnosed with serious mental
illness and children/youth diagnosed with serious emotional disorders, and their families, that will
allow them to avoid unnecessary institutionalization and out-of-home placements. (p. 3)
There is a requirement that most of the CSS budget be allocated to FSP, and that clients be served with “whatever it
takes.” The remaining portions of CSS (up to 49 percent of county MHSA budgets can be devoted to CSS) are used to
cover gaps in systems of care related to needs for supportive services, such as transportation or vocational training
(which are typically unfunded), crisis intervention and treatment.
The focus of this report is twofold, and critically important.
First, this report identifies the average statewide annual and per-day cost 5 of providing FSP services to clients
in California. The costs of FSP services are calculated in two categories: program services – which include
activities required under the Mental Health Services Act, as well as any evidence-based models and/or
practices offered – and housing costs. 6 While FSP clients may be represented in marginal additional costs
(e.g., outreach), there is not a feasible way of parsing these expenditures, and impacts on cost estimates
would be minor.
Second, this report identifies the cost savings 7 that society realizes because these services have been
provided. Of course, these savings are not the sole justification of expenditures; the primary purpose of the
law is to improve services to citizens with mental illness most in need of assistance. However, it is a primary
purpose of accountable and transparent public service to demonstrate the impacts of this needed and
individually tailored service on public concerns. Therefore, this analysis summarizes the savings that are
incurred in a limited number of public services for the recipients of FSP services. To state this differently, this
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analysis assesses the costs to society with respect to behavioral and physical health services that are incurred
by persons facing severe mental health challenges and public costs incurred because of criminal justice system
involvement attributable to these challenges.
It is important to note that the estimates of cost are conservative. 8 Costs that are not clearly attributable to FSP clients
have not been included, and cost savings estimates have been indexed to conservative estimates of cost. As is widely
recognized, estimating the costs of savings attributable to service is complex – from both a cost estimate and a savings
estimate point of view. At each step in these estimation processes, we have consciously adopted a conservative
approach.
In order to include a county in the FSP Costs and Cost Offsets Report, we needed Full Service Partnership costs broken
out by age group. Per the MHSA Community Services and Supports Three-Year Program and Expenditure Plan
Requirements, “Each county must plan for each age group in their populations to be served.” (p. 13) 9 Age groups are
defined as follows:
Children, Youth and Families (CYF): Birth to 18 years, and special-education pupils from birth to age 21 (p. 21)
Transition-Age Youth (TAY): 16 to 25 years (p. 21)
Adults: 18 to 59 years 10
Older Adults: 60 years and older (p. 21) 11
The only way to reliably and accurately obtain this information was to ask the counties directly. A web survey was
launched in order to collect FSP Costs by Age Group. Almost all of the counties responded – 47 (81.0%). 12 In addition,
calculations were successfully completed for three (3) additional counties that did not complete the web survey. These
three counties aligned their CSS Plans, Annual Updates, and Revenue and Expenditure Reports (RER) in a consistent
manner and broke out FSP programs into discrete age groups. Inclusion of the three (3) additional counties brings the
total number of participants to 50 (86.2%). FSP Costs and Cost Offsets by Age Group for almost all of the counties are
included in this report.
Cost of FSP Services
FSP services are intensive to meet the needs of FSP-targeted clients. This is driven primarily by the policy objective to
meet the serious needs of the hardest-to-serve clients – those with severe mental illness. This policy objective includes
meeting both the service and the quality-of-life needs of FSP clients and the social outcomes and services needs of
California. To address this complex balance between policy objective and client needs, this study has assessed a broad
range of costs to citizens of California that are a consequence of service delivery to mental health clients most in need.
As previously noted, almost all of the counties are included in this report (N = 50; 86.2%). 13 The populations of
counties (numbers of persons residing in the counties according to census data) represented in this report comprise
almost all of the State of California (95.0%). 14
More specifically,
Fiscal years included in the study period are Fiscal Year 2008-09 (FY 08-09) and FY 09-10. The two fiscal years
were selected because:
o Outcome data are most robust and complete in these two fiscal years, and
o Revenue and Expenditure Reports in these two fiscal years are broken out by FSP program, allowing a
drill-down (with county input) to cost by age group.
Costs of service are program and housing costs for all clients in FY 08-09 and FY 09-10 as discussed above.
Separate tables are provided for each fiscal year. Age groups are displayed on separate rows within each table.
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FSP clients represented in Tables 1 through 4 are people who received FSP services during the fiscal year. 15
The calculations shown in Tables 1 and 3 use annualized cost per FSP client year as a standard metric for
service costs across counties. 16
Table 1. Full Service Partnership Services: Annualized Cost per-Client by Age Group
(Fiscal Year 08-09)
Number of Annualized Cost Daily Cost per- % of Total
Number Served Sum of Days Client Years per-FSP Client FSP Client FSP Costs Total FSP Costs
CYF 4,296 983,187 2,693.7 $ 21,931.29 $ 60.09 $ 59,076,305.79 19.0%
TAY 4,593 1,064,015 2,915.1 $ 18,553.96 $ 50.83 $ 54,086,655.41 17.4%
Adults 9,640 2,404,022 6,586.4 $ 26,737.23 $ 73.25 $ 176,102,066.30 56.7%
Older Adults 1,388 344,979 945.1 $ 22,303.26 $ 61.10 $ 21,078,807.79 6.8%
Total 19,917 4,796,203 13,140.3 $ 310,343,835.29 100.0%
Annualized cost is the total cost for an FSP client over a year (12 months).
The average annualized cost (across all age groups) for Fiscal Year 08-09 is $23,617.71.
The average daily cost (across all age groups) for Fiscal Year 08-09 is $60.31.
Table 2 shows overall Full Service Partnership program costs by age group for FY 08-09.
Table 2. Full Service Partnership Services: Percent of Core Cost Components Devoted to FSP Clients,
by Age Group
(Fiscal Year 08-09)
CYF TAY Adults Older Adults
Amount Percent Amount Percent Amount Percent Amount Percent
Housing $ 2,600,274.29 4.4% $ 3,421,055.77 6.3% $ 20,137,423.03 11.4% $ 1,020,646.55 4.8%
Program Services $ 56,476,031.50 95.6% $ 50,665,599.64 93.7% $ 155,964,643.27 88.6% $ 20,058,161.24 95.2%
Total $ 59,076,305.79 100.0% $ 54,086,655.41 100.0% $ 176,102,066.30 100.0% $21,078,807.79 100.0%
Table 3 displays the same type of cost information as in Table 1, but for Fiscal Year 09-10.
Table 3. Full Service Partnership Services: Annualized Cost per-Client by Age Group
(Fiscal Year 09-10)
Number of Annualized Cost Daily Cost per- % of Total
Number Served Sum of Days Client Years per-FSP Client FSP Client FSP Costs Total FSP Costs
CYF 6,348 1,444,331 3,957.1 $ 17,481.79 $ 47.90 $ 69,177,192.53 18.3%
TAY 6,623 1,619,816 4,437.9 $ 13,741.40 $ 37.65 $ 60,982,974.12 16.1%
Adults 12,733 3,456,407 9,469.6 $ 23,626.13 $ 64.73 $ 223,729,986.45 59.1%
Older Adults 1,764 480,383 1,316.1 $ 18,785.22 $ 51.47 $ 24,723,227.99 6.5%
Total 27,468 7,000,937 19,180.7 $ 378,613,381.09 100.0%
The average annualized cost (across all age groups) for Fiscal Year 09-10 is $19,739.29.
The average daily cost (across all age groups) for Fiscal Year 09-10 is $50.55.
Table 4 shows overall Full Service Partnership program costs by age group for FY 09-10.
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Table 4. Full Service Partnership Services: Percent of Core Cost Components Devoted to FSP Clients,
by Age Group
(Fiscal Year 09-10)
CYF TAY Adults Older Adults
Amount Percent Amount Percent Amount Percent Amount Percent
Housing $ 1,686,344.99 2.4% $ 3,675,433.65 6.0% $ 22,691,038.11 10.1% $ 1,385,451.08 10.0%
Program Services $ 67,490,847.54 97.6% $ 57,307,540.47 94.0% $ 201,038,948.34 89.9% $23,337,776.91 90.0%
Total $ 69,177,192.53 100.0% $ 60,982,974.12 100.0% $ 223,729,986.45 100.0% $24,723,227.99 100.0%
The age breakouts reveal that FSP services for Adults account for most of the expenditures in both fiscal years.
The expenditures for components authorized under the Mental Health Services Act comprise:
Mental Health Services Act,
State General Fund,
Other State Funds,
Medi-Cal Federal Financial Participation,
Medicare,
Other Federal Funds,
Realignment,
County Funds, and
Other Funds.
Breakout by age group is not possible due to the limitations of the RER, discussed in the Full Report (see Chapter III and
Appendix E).
Figure 1 displays FSP expenditures from all counties and municipalities that submitted a Revenue and Expenditure
Report in FY 08-09 and/or FY 09-10. Therefore, the pool of counties/municipalities included in the analysis of
proportion of FSP expenditures by funding source is slightly larger than the participant pool for the FSP Costs and Cost
Offsets study (see Appendix E of the full Report).
Figure 1. Proportion of FSP Expenditures by Funding Source
(FY 08-09 & FY 09-10)
$1.00 $0.03 $0.03
$0.90
$0.80
$0.70
$0.66 $0.62 Other*
$0.60
Proposition 63 Funds (MHSA)
$0.50
Federal Financial Participation (FFP)
$0.40
Realignment
$0.30
State General Fund (SGF)
$0.20 $0.26 $0.30
$0.10
<$0.00 <$0.00
$- $0.05 $0.05
FY 08-09 FY 09-10
*Other Funds: Medicare, Other State, County, Other, Other Federal
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MHSA expenditures on Medi-Cal increased in FY 09-10 compared with FY 08-09. The increase in MHSA expenditures on
leveraged resources suggests that counties and municipalities are successfully leveraging MHSA in order to bring in
additional federal dollars.
Cost Offsets of Full Service Partnership Services
Tables 5 and 6 represent costs of service and costs saved as a result of service for FY 08-09 (Table 5) and FY 09-10
(Table 6) new enrollees in FSP. Cost-offset analysis is limited to new enrollees for the following reasons:
The baseline intake assessment (documented on the Partnership Assessment Form) contains questions about
service use in offset categories of interest in the 12 months prior to FSP enrollment.
The post-FSP period, therefore, should be equivalent to the pre-intake period (no more than 12 months), in
order to compare the proverbial “apples to apples.”
Given that the two fiscal years of focus are 08-09 and 09-10, the logical groups for inclusion in analyses were
new enrollees in FY 08-09 and new enrollees in FY 09-10.
Cost offsets are calculated for each individual FSP client (e.g., number of inpatient psychiatric hospitalization
days in the 12 months prior to FSP and the 12 months post-FSP enrollment). 17
More specifically,
Costs of service are program and housing costs for new clients in a given fiscal year as discussed above; and
Cost offsets are the total differential between the cost of mental and physical health services, and criminal
justice involvement costs, in the year prior to entry into FSP services and the average 12-month cost after
entry into services. 18 This is the amount of public money in these areas that was saved after these clients had
access to service. 19
Full Service Partnership Cost Offsets by Age Group include: 20
Physical Health
Acute Care Inpatient Hospitalization (number of days)
Skilled Nursing (Non-Psychiatric) (number of days)
Emergency Room Visits (number of times)
Psychiatric Care
Inpatient Psychiatric Hospitalization (number of days)
Long-Term Care (number of days) 21
Skilled Nursing (Psychiatric) (number of days)
Criminal Justice Involvement
Arrests (number of times)
Division of Juvenile Justice (number of days)
Juvenile Hall/Camp (number of days)
Jail (number of days)
Prison (number of days)
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Table 5. Total Full Service Partnership Services – Costs & Cost Offsets
(Fiscal Year 08-09 New Enrollees ONLY)
Number of New Total Cost for FY 08- Total Cost Offset Percent Offset FY 08-
Enrollees FY 08-09 Sum of Days 09 New Enrollees FY 08-09 09
CYF 2,164 340,323 $ 20,450,009.07 $ 2,428,313.16 11.9%
TAY 2,327 371,250 $ 18,870,637.50 $ 22,437,417.44 118.9%
Adults 4,315 690,298 $ 50,564,328.50 $ 41,509,329.01 82.1%
Older Adults 582 91,220 $ 5,573,542.00 $ 5,421,665.55 97.3%
Total 9,388 1,493,091 $ 95,458,517.07 $71,796,725.16 75.2%
Table 6 displays comparable results for new enrollees in FY 09-10.
Table 6. Total Full Service Partnership Services – Costs & Cost Offsets
(Fiscal Year 09-10 New Enrollees ONLY)
Number of New Total Cost for FY 09- Total Cost Offset Percent Offset FY
Enrollees FY 09-10 Sum of Days 10 New Enrollees FY 09-10 09-10
CYF 3,101 454,605 $ 21,775,579.50 $ 2,262,842.11 10.4%
TAY 2,977 496,190 $ 18,681,553.50 $ 27,501,007.94 147.2%
Adults 4,702 868,415 $ 56,212,502.95 $ 56,120,875.82 99.8%
Older Adults 645 103,459 $ 5,325,034.73 $ 3,857,684.17 72.4%
Total 11,425 1,922,669 $ 101,994,670.68 $ 89,742,410.04 88.0%
These findings support several important conclusions:
Cost savings over the two-year period are consistent in relative magnitude across age groups. In particular,
TAY consumers experienced the greatest cost-related benefits of service. Transition-Age Youth are at high risk
for criminal justice and crisis management services, and FSP participation apparently has a significant impact
on consequences for this age group.
Cost offsets are dramatically lower for the CYF age group. This may reflect the more preventive orientation of
services for children, which is not as clearly reflected in the short time line of the measured offsets. Savings for
children may appear over a much longer period of time, outside the currently funded study period. In
addition, the “consequence” nature of the offset categories examined (e.g., criminal justice involvement) is
more relevant to older age cohorts. 22 Effects of service are sensitive to life maturation, indicators of service
success and the time horizon of measured effects.
Overall, across all age groups, 75 and 88 percent of FSP program costs for new enrollees in FY 08-09 and FY 09-
10 (respectively) are offset by savings to the public mental health, health and justice systems. Although the
argument of cost savings should never be advanced as the primary reason for providing public mental health
services, results of this magnitude make a strong case for the wisdom of investing public resources in
programs such as the Full Service Partnership.
In summary, this analysis of cost offsets in larger social costs attributable to participation in the FSP program
documents positive results. Results for the TAY and Adult age groups, which account for the great majority of clients,
are particularly positive. This reflects the greater risk for hospitalization and incarceration that exists in these age
groups. These results are quite favorable when compared with those of AB 2034, a program charged with serving
homeless (or at risk of being homeless) TAY and adults with severe mental illness – the final analysis reported a
percentage of costs offset of 49.8 percent. 23 Overall, these results suggest a very positive treatment outcome, and
return on investment, for FSP clients.
Table 7 illustrates cost offsets by age and offset category for new Full Service Partnership enrollees in Fiscal Year 08-09.
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Table 7. Full Service Partnership Cost Offsets by Age & Offset Category
(Fiscal Year 08-09 New Enrollees ONLY)
Psychiatric Physical Health Criminal Justice
Percent of Percent of Percent of
Total Offset Amount of Total Offset Total Offset
Amount of Offset for Age Group Offset for Age Group Amount of Offset for Age Group
CYF $ 425,079.62 17.5% $ 908,053.24 37.4% $ 1,095,180.30 45.1%
TAY $ 8,426,402.27 37.6% $ 482,463.53 2.2% $ 13,528,551.64 60.3%
Adults $29,718,862.23 71.6% $ 964,209.28 2.3% $ 10,826,257.50 26.1%
Older Adults $ 3,845,911.36 70.9% $ 1,095,025.10 20.2% $ 480,729.09 8.9%
Total $42,416,255.48 59.1% $3,449,751.15 4.8% $ 25,930,718.53 36.1%
Table 8 illustrates cost offsets by age and offset category for new Full Service Partnership (FSP) enrollees in Fiscal Year
09-10. 24
Table 8. Full Service Partnership Cost Offsets by Age & Offset Category
(Fiscal Year 09-10 New Enrollees ONLY)
Psychiatric Physical Health Criminal Justice
Percent of Percent of Percent of
Total Offset for Total Offset Total Offset for
Amount of Offset Age Group Amount of Offset for Age Group Amount of Offset Age Group
CYF $ 1,104,612.24 38.4% $ (611,869.83) - $ 1,770,099.70 61.6%
TAY $ 9,500,199.91 34.5% $ 3,658,331.16 13.3% $ 14,342,476.87 52.2%
Adults $ 39,688,364.64 70.7% $ 6,195,607.45 11.0% $ 10,236,903.73 18.2%
Older Adults $ 4,290,539.63 92.9% $ (761,785.95) - $ 328,930.49 7.1%
Total $ 54,583,716.42 59.9% $ 8,480,282.83 9.3% $ 26,678,410.79 29.3%
Findings as displayed in Tables 7 and 8 support the following conclusions:
For Adults and Older Adults, the greatest proportion of offsets each fiscal year is accounted for by savings in
psychiatric care (largely due to reductions in inpatient psychiatric hospitalization).
Among TAY and CYF, the greatest proportion of offsets in each fiscal year is accounted for by criminal justice
(incarceration and arrests, although largely due to reduction in the number of days incarcerated).
Physical health (acute care inpatient hospitalization, skilled nursing – non-psychiatric, and emergency room
visits) offsets increased substantially as a percentage of overall offsets between FY 08-09 and FY 09-10.
Current primary care-mental health integration efforts underway will examine the medical needs of FSP clients
in more depth and shed further light on how MHSA meets their myriad needs.
Exhibits 1 through 4 summarize the offset amounts for each age group and the areas examined (psychiatric care,
physical health and criminal justice). Exhibit 1 displays how CYF combined offsets from FY 08-09 and FY 09-10 are
broken out proportionally among psychiatric care, physical health and criminal justice. Results for CYF FSP clients
whose data are displayed in Tables 5 through 8 (in the rows labeled CYF) are now summarized in Exhibit 1.
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Exhibit 1. Full Service Partnership Amount of Cost Offsets for CYF
(FY 08-09 & FY 09-10 New Enrollees ONLY)
$1,529,691.86
$2,865,280.00
$296,183.41
Psychiatric Physical Health Criminal Justice
In FY 08-09 and FY 09-10, the total amount of costs to the public system that were offset for CYF in the three major
categories analyzed (psychiatric care, physical health and criminal justice) was $4,691,155.27 – $4.7 million. Most of
the savings were due to reductions in days incarcerated.
Exhibit 2 displays how TAY combined offsets from FY 08-09 and FY 09-10 are broken out proportionally among
psychiatric care, physical health and criminal justice. Results for TAY FSP clients whose data are displayed in Tables 5
through 8 (in the rows labeled TAY) are now summarized in Exhibit 2.
Exhibit 2. Full Service Partnership Amount of Cost Offsets for TAY
(FY 08-09 & FY 09-10 New Enrollees ONLY)
$17,926,602.18
$27,871,028.51
$4,140,794.69
Psychiatric Physical Health Criminal Justice
In FY 08-09 and FY 09-10, the total amount of costs to the public system that were offset for TAY in the three major
categories analyzed (psychiatric care, physical health and criminal justice) was $49,938,425.38 – $49.9 million. As with
their CYF counterparts, most of the savings for TAY were due to reductions in days incarcerated.
Exhibit 3 displays how Adult combined offsets from FY 08-09 and FY 09-10 are broken out proportionally among
psychiatric care, physical health and criminal justice. Results for Adult FSP clients whose data are displayed in Tables 5
through 8 (in the rows labeled Adult) are now summarized in Exhibit 3.
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Exhibit 3. Full Service Partnership Amount of Cost Offsets for Adults
(FY 08-09 & FY 09-10 New Enrollees ONLY)
$21,063,161.23
$7,159,816.73
$69,407,226.87
Psychiatric Physical Health Criminal Justice
In FY 08-09 and FY 09-10, the total amount of costs to the public system that were offset for Adults in the three major
categories analyzed (psychiatric care, physical health and criminal justice) was $97,630,204.83 – $97.6 million. Most of
the savings were due to reductions in days spent in inpatient psychiatric hospitalization.
Exhibit 4 displays how Older Adult combined offsets from FY 08-09 and FY 09-10 are broken out proportionally among
psychiatric care, physical health and criminal justice. Results for Older Adult FSP clients whose data are displayed in
Tables 5 through 8 (in the rows labeled Older Adult) are now summarized in Exhibit 4.
Exhibit 4. Full Service Partnership Amount of Cost Offsets for Older Adults
(FY 08-09 & FY 09-10 New Enrollees ONLY)
$809,659.58
$333,239.15
$8,136,450.99
Psychiatric Physical Health Criminal Justice
In FY 08-09 and FY 09-10, the total amount of costs to the public system that were offset for Older Adults in the three
major categories analyzed (psychiatric care, physical health and criminal justice) was $9,279,349.72 – $9.3 million.
Most of the savings were due to reductions in days spent in inpatient psychiatric hospitalization.
Exhibits 5 through 7 summarize the offset amounts across the age groups and the areas examined (psychiatric care,
physical health and criminal justice).
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Exhibit 5 displays how all offsets from FY 08-09 are broken out proportionally by age group to show the total amount of
offset. Results for all FSP clients whose data are displayed in Tables 5 and 7 are now summarized in Exhibit 5.
Exhibit 5. Full Service Partnership Amount of Cost Offsets by Age Group
(FY 08-09 New Enrollees ONLY)
$5,421,665.55
$2,428,313.16
$22,437,417.44
$41,509,329.01
CYF TAY Adults Older Adults
In FY 08-09, the total amount of costs to the public system that were offset across all age groups in the three major
categories analyzed (psychiatric care, physical health and criminal justice) was $71,796,725.16 – $71.8 million. Most of
the savings were due to reductions in inpatient psychiatric hospitalization and incarceration among Adult FSP clients,
followed by fewer days of incarceration among TAY FSP clients.
Exhibit 6 displays how all offsets from FY 09-10 are broken out proportionally by age group to show the total amount of
offset. Results for all FSP clients whose data are displayed in Tables 6 and 8 are now summarized in Exhibit 6.
Exhibit 6. Full Service Partnership Amount of Cost Offsets by Age Group
(FY 09-10 New Enrollees ONLY)
$3,857,684.17 $2,262,842.11
$27,501,007.94
$56,120,875.82
CYF TAY Adults Older Adults
In FY 09-10, the total amount of costs to the public system that were offset across all age groups in the three major
categories analyzed (psychiatric care, physical health and criminal justice) was $89,742,410.04 – $89.7 million. As was
observed with the previous fiscal year, most of the savings were due to reductions in inpatient psychiatric
hospitalization and incarceration among Adult FSP clients, followed by fewer days of incarceration among TAY FSP
clients.
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Exhibit 7 displays all offsets from FY 08-09 and FY 09-10 broken out proportionally by age group to show the total
amount of offset. Results for all FSP clients whose data are displayed in Tables 5 through 8 are now summarized in
Exhibit 7.
Exhibit 7. Full Service Partnership Amount of Cost Offsets by Age Group
(FY 08-09 & 09-10 New Enrollees ONLY)
$9,279,349.72 $4,691,155.27
$49,938,425.38
$97,630,204.83
CYF TAY Adults Older Adults
When the fiscal year totals are combined (above exhibit), the total amount of costs to the public system that were
offset across all age groups in the three major categories analyzed (psychiatric care, physical health and criminal
justice) is $161,539,135.20 – $161.5 million. In summary, most of the savings were due to reductions in inpatient
psychiatric hospitalization and incarceration among Adult FSP clients, followed by fewer days of incarceration among
TAY FSP clients.
When the total cost for new enrollees across both fiscal years ($197,453,187.75) is compared with the total amount
offset, the percentage of costs offset is 81.8 percent.
Stakeholder Feedback Process
The Request for Proposal for the Expanded Statewide Evaluation of the Mental Health Services Act specifies:
For Deliverable 1 – Full Service Partnerships, establish and maintain stakeholder engagement in the evaluation that is
representative of a wide scope of expertise, including:
A process for input from individuals living with mental illness, family members/personal caregivers and
representatives of culturally diverse unserved and underserved groups of all ages, and
A process for input from researchers, data analysts and programmers who are responsible for local data
evaluation efforts.
Our stakeholder engagement process involved seven key strategies:
1. Presentations to client and family groups/organizations representing unserved/underserved groups
2. Key stakeholder interviews with individuals representing client/family groups and organizations representing
unserved/underserved groups
3. Presentations to associations/service provider agencies
4. Key stakeholder interviews with individuals representing associations/service provider agencies
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5. Formation of an Evaluation Advisory Group
6. Key stakeholder interviews with peer advocates and parent partners
7. (ongoing) Product review/feedback: Stakeholder input was sought for two key deliverables:
o The draft Executive Summary and the accompanying draft report
o County-specific tables illustrating FSP costs and cost offsets25
The draft of this report 26 was released publicly at the Mental Health Services Oversight and Accountability Commission
meeting on July 26, 2012.
As was previously noted, almost all of the counties are included in this report (N = 50; 86.2%). 27 The populations of
counties (numbers of persons residing in the counties according to census data) represented in this report comprise
almost all of the State of California (95.0%). 28
County-specific matrices that replicate the tables in the draft report were distributed to participating counties on July
27, 2012. Counties were provided a 30-day review and comment period. Feedback was due to EMT Associates by
August 27, 2012. The deadline was set in order to provide EMT with sufficient time to a) make necessary revisions and
b) conduct cross-county analyses for the Final Report, due September 30, 2012. 29
Counties with complete web survey data were analyzed and provided with a county-specific matrix, following the
procedures described in the paragraph above. 30 Input from the counties through the web survey was essential in
determining the breakout of Full Service Partnership expenditures by age group due to limitations in the Revenue and
Expenditure Report data. In particular, the Revenue and Expenditure Reports were not designed with the requirement
that expenditures be reported by age group:
Children, Youth and Families
Transition-Age Youth
Adults
Older Adults
A compendium of feedback submitted and the disposition of each stakeholder’s comments is contained in Appendix F
of the report. Feedback related to future studies, data collection efforts and/or reports is summarized below.
Future Considerations
Feedback included additional areas of focus for MHSOAC consideration when funding future Requests for Proposals
(RFPs), ways in which existing data related to the current report can be analyzed to further answer questions of
importance and suggestions for improvements to the data collection and reporting system.
New Study Areas
Three new studies emerged through the feedback process. The first emerged through feedback from peer partners and
parent advocates, the second from the Evaluation Advisory Group and the third from county mental health
associations/service providers.
Study #1: We recommend that the Mental Health Services Oversight and Accountability Commission consider funding a
participatory evaluation to formally study the potential cost offsets as a result of peer networks. Such a study would
provide a necessary balance to the preponderance of consequence-focused data currently gathered through the state’s
data collection and reporting system, and provide the needed peer and recovery perspectives. Indeed, in a recent
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presentation to the Client and Family Leadership Committee about results from the 2011 Community Forum series, one
key “Finding prompting additional CFLC attention” was:
Forum participants reported terrific success when clients and family members were employed in the mental
health system and significant success resulting from peer provider programs. 31
Previous efforts to engage clients and families in meaningful ways have met with mixed success. Participatory
evaluation stands alone in the following ways:
1. Clients and families are engaged in meaningful ways throughout all aspects of the study;
2. Client and family engagement is a project deliverable, thereby ensuring that the objective is met; and
3. Sufficient funding is provided to support meaningful involvement.
Consistent with these recommendations was a recommendation made by the Client and Family Leadership Committee,
when summarizing the findings of the 2011 Community Forum series:
Trends and findings identified in annual reports on the community forums should be considered when
developing the Commission’s Annual Work Plan. 32
Two recent efforts include UC Davis’ Community Engagement Study, which examined the ways in which unserved and
underserved communities were involved in the planning and execution of MHSA, and the Statewide Participatory
Evaluation, 33 which examined the impact of client and family involvement on the public mental health system.
Although the latter study is contracted to examine the impact of Peer Support Services on 1) perception of access to
services, 2) appropriateness of care, 3) continuity of care, 4) recovery orientation of services, 5) employment, 6)
housing situation, and 7) consumer recovery/resilience and wellness, costs and potential cost offsets are not included
as part of the evaluation.
In order for such a study as the one recommended to receive adequate funding and priority, it is recommended that it
be issued as a stand-alone RFP, rather than as a component of a larger RFP or as an “add-on.” By funding a
participatory evaluation to investigate the potential cost offsets as a direct result of Peer Support Services, client and
family engagement in evaluation will continue to move from an articulated value into action.
Study #2: The real costs incurred by clients and families in meeting their treatment needs and goals have not been
addressed. For example, money spent on transportation. The burden is believed to be particularly heavy on parents
and caregivers, for whom the true cost of care is probably much higher than has been documented through the process
described in this Report. Their contributions to the care of their children and dependents bear further exploration.
Study #3: There is a great deal of interest in comparison of costs and offsets between county and contract providers.
However, the current data systems readily available through the current Statewide Evaluation contract do not support
analyses to shed light on the question. MHSOAC may determine that the question, “Do county contractors (e.g.,
community mental health providers) provide MHSA services in a more cost-effective manner than the county?” posed
by community mental health associations/service provider agencies merits investigation, and may develop a Request
for Proposal in order to thoroughly study the issue, keeping in mind the data requirements outlined in the full Report,
Chapter II. 34
However, increasing impetus to facilitate direct access to county cost data comes from the change in the Revenue and
Expenditure Report (RER). The revised RER is a summary format that will make future cost-offset analyses of FSP
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programs (or any other MHSA program, for that matter) extremely difficult without direct data collection from the
counties.
Use of Existing Data
A number of interesting questions were posed related to the current deliverable, all of which can be answered using
existing data. However, submission of new data by counties that had not previously participated in the study, up until
two weeks before delivery of the draft report to MHSOAC, prevented any additional analyses from inclusion in this
Report.
Future reports could answer key questions (most posed by Commissioners). Suggestions include:
Impact of FSP Activities on Costs and Cost Offsets. Full Service Partnership service profiles have been
developed for each county. The results present a fascinating description of FSP services across the state. Of
additional interest is the potential impact on costs and cost offsets. For example, do certain types of service
packages produce certain types of results? Such questions merit further investigation in a stand-alone report.
Impact of FSP Completion and Length of Treatment on Cost Offsets. This brief could address these core
questions posed by MHSOAC members.
Impact of Substance Abuse and Substance Abuse Treatment on FSP Costs and Cost Offsets. This brief could
address these core questions posed by a parent/family stakeholder. 35
Data Collection and Reporting System
Challenges related to ease of using the statewide data collection and reporting system, particularly with the Key Event
Tracking data and inconsistent/illogical values, represented but a few of the barriers encountered during the course of
analysis and reporting (see Chapter III of the full Report).
Ongoing efforts sponsored by MHSOAC to promote data use (through the contract with California State University,
Sacramento) and current efforts to examine data quality are therefore timely. To further the goal of improving both
data quality and the timeliness with which data are accessible in a usable format to counties and constituents, we
make the following recommendation:
Conduct a thorough review of the Data Collection and Reporting System (DCR) in partnership with the
Department of Health Care Services, the California Mental Health Directors Association and other relevant
stakeholders and experts. This review should focus on a) clearly identifying the pattern of occurrence of
specific data quality problems (e.g., missing demographic data); b) understanding the reasons that this occurs,
including those that are specific to particular county contexts; c) identifying feasible solutions to address these
reasons, and d) identifying a method that will enable all counties to easily upload data into the DCR (see
Appendix D, which lists counties that are currently not in the state’s DCR system). 36
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Definition of Terms
DEFINITION OF TERMS
3M Quarterly Assessment
AB Assembly Bill
CF Capital Facilities
CFTN Capital Facilities and Technological Needs
CMHDA California Mental Health Directors Association
CSA Corrections Standards Authority
CSI Client Services Information System
CSS Community Services and Supports
CYF Children, Youth and Families
DCR Data Collection and Reporting System for MHSA FSP
DJJ Division of Juvenile Justice
DMH Department of Mental Health
DNR Agency did not report costs
DOF Department of Finance
EAG Evaluation Advisory Group
ER Emergency Room
FFP Federal Financial Participation
FSP Full Service Partner or Full Service Partnership
FY Fiscal Year
GSD General System Development
IMD Institution for Mental Diseases
INN Innovation
IMPACT Improving Mood – Promoting Access to Collaborative Treatment
JHC Juvenile Halls and/or Camps
KET Key Event Tracking
LAO Legislative Analyst’s Office
LGBTQ Lesbian, Gay, Bisexual, Transsexual/Transgendered and Questioning
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DEFINITION OF TERMS
MH Mental Health
MHRC Mental Health Rehabilitation Centers
MHSA Mental Health Services Act
MHSOAC Mental Health Services Oversight and Accountability Commission (also OAC)
NC No Camp
NJH No Juvenile Hall
NJHC No Juvenile Hall or Camp
OA Older Adults
OSHPD Office of Statewide Health Planning and Development
PAF Partnership Assessment Form
PEI Prevention and Early Intervention
POQI Performance Outcomes & Quality Improvement
RER Revenue and Expenditure Reports
RFA Request for Applications
RFP Request for Proposal
SAMHSA Substance Abuse and Mental Health Services Administration
SB Senate Bill
SED Serious Emotional Disturbance
SGF State General Fund
SMA Statewide Maximum Allowance
SMI Severe Mental Illness
SMHA State Mental Health Authority
SPSS Statistical Package for the Social Sciences
TAY Transition-Age Youth
TN Technological Needs
WET Workforce Education and Training
WIC Welfare and Institutions Code
YSS Youth Services Survey
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DEFINITION OF TERMS
YSS-F Youth Services Survey for Families
1 Per California’s Welfare and Institutions Code, Part 4.5, Mental Health Services Fund. Specifically, Section 5850, Part 4, and 5800, Part 3.
Requirements were also summarized in California Department of Mental Health (DMH) Letter 05-05, Three-Year Program and Expenditure Plan
Requirements: Mental Health Services Act, Community Services and Supports, p. 1.
CSS requirements are further outlined in Section 5892, (a) (5).
2 Per the Corporation for Supportive Housing (undated report), AB 2034 Program experiences in housing homeless people with serious mental illness:
The state legislature started laying the foundation for MHSA back in 1999 when it passed AB 34, which provided $10 million for pilot programs
through the mental health departments in Los Angeles, Sacramento and Stanislaus counties. Based on the success of that effort, funding increased
dramatically in FY 00-01 under AB 2034. AB 2304 provided the resources necessary to expand existing pilots and create additional programs
statewide. (p. 1)
In summary, there are many predecessors to Prop 63. Others include AB 334 and AB 3777.
3 California Department of Mental Health (2007). (unpublished) Report to the Legislature on the effectiveness of integrated services for homeless
adults with serious mental illness. Sacramento, CA: Author. (p. 3)
Data collected from November 1, 1999 – January 31, 2007. $55 million in costs, $27.4 million in offsets (psychiatric hospitalization, incarceration
and emergency room use for psychiatric episodes).
4 DMH Letter 05-05, Three-Year Program and Expenditure Plan Requirements: Mental Health Services Act, Community Services and Supports.
5 Although the technically accurate term is expenditure based on the data sources analyzed, this term is cumbersome, and not user-friendly to the lay
reader. Therefore, the term cost may be used in place of expenditure throughout this Executive Summary.
6 Housing is defined as housing support, operating support and housing placement. It does not include the Governor’s Housing Initiative. Housing
support is the cost of housing subsidies for permanent, transitional and temporary housing; master leases; motel and other housing vouchers; rental
security deposits; first- and last-month rental payments; and other fiscal housing supports. The operating costs of providing housing supports to
clients include building repair and maintenance, utilities, housing agency management fees, insurance, property taxes and assessments, and credit
reporting fees. Housing placement is assistance in securing housing, including supportive housing – permanent affordable housing with combined
supports for independent living.
7 The terms cost savings and cost offsets are used interchangeably throughout this Executive Summary. Depending upon the age group, savings were
indeed identified when compared with cost. For Transition-Age Youth in particular, the savings exceeded the cost of providing services. For other age
groups, cost benefit was identified – meaning that the dollar amount offset did not “zero out” the cost of providing service, but a benefit to society is
provided, nonetheless, by reductions in hospitalization, incarceration, etc.
8 The most conservative estimate of cost offsets would involve accessing consequence data directly from providers – jails, prisons, etc. However, this
was not feasible from either a time or a study-cost perspective. Therefore, self-report data were relied upon in order to estimate days in jail, prison,
etc. See Chapter II of the full Report for a suggested study option to more closely examine inpatient hospitalization costs by analyzing direct billing
data from counties.
9 http://www.dmh.ca.gov/dmhdocs/docs/letters05/05-05CSS.pdf
Children and adolescents identified as seriously emotionally disturbed (SED) are eligible for FSPs if they meet the criteria set forth in Welfare and
Institutions Code Section 5600.3, Subdivision (a). Adults and older adults identified to have a serious mental disorder are eligible for FSPs if they meet
the criteria set forth in Subdivision (b) of Section 5600.3.
http://www.leginfo.ca.gov/cgi-bin/displaycode?section=wic&group=05001-06000&file=5600-5623.5
California’s Welfare and Institutions Code is posted in its entirety on the website cited above, absent page numbers. Click on the link and the section
cited will appear on screen, verbatim, as quoted.
10 Although the age range for Adults was not included in DMH Letter 05-05, it is defined in the California Code of Regulations, Title 9. Rehabilitative
and Development Services, Division 1. Department of Mental Health, Chapter 14. Mental Health Services Act, Article 2: Definitions, Section 3200.010.
Adult.
11 http://www.dmh.ca.gov/dmhdocs/docs/letters05/05-05CSS.pdf
12 Alignment of plan, update, RER, plus breakout of discrete FSP programs into distinct age groups was a rarity among the counties, but this should
not be viewed as a “negative” on the part of the counties, because the original intent of the RER had nothing to do with breakouts by age group.
Note that one unique partnership of three municipalities was in start-up during the entire study period, and was therefore removed from the
total N for purpose of calculation. This study site is one of two municipalities that optionally decided to apply for MHSA funds to better help serve
their constituents. Therefore, the N = 58 (rather than 59). According to statute, county departments of mental health are required to deliver public
mental health services.
13 See the footnote above. The link to census data is:
http://www.census.gov/popest/research/eval-estimates/eval-est2010.html
14 See Appendix D of the full Report for a list of county participants.
15 Calculation of FSP participants is complex and the methodology too detailed for inclusion in an Executive Summary. In order to explain the process,
a step-by-step procedural breakdown is provided in the Report, with examples to aid understanding. Previous iterations of the Report (with attempts
at shorter, truncated explanations) were insufficient in terms of providing full understanding and comprehension of the methodology for the lay
reader. Therefore, an abbreviated summary is not provided in this Executive Summary due to concerns that the methodology will be misunderstood
or its application misinterpreted. Please refer to Chapter III of the full Report for details.
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16 Calculation of annualized cost per FSP client is complex and the methodology too detailed for inclusion in an Executive Summary. See above for
the challenges encountered when earlier drafts of the Report were reviewed by key stakeholders. Please refer to Chapter III of the full Report for a
detailed explanation of the methodology.
17 For more details on methods related to the cost-offset study, see Chapter IV of the full Report.
18 Annualization of the service period is the same methodology used by the California Department of Mental Health when evaluating and reporting
on AB 2034 outcomes.
California Department of Mental Health (2007). (unpublished) Report to the Legislature on the effectiveness of integrated services for homeless
adults with serious mental illness. Sacramento, CA: Author.
19 Of course, cost savings in individual counties could be attributable to many plausible alternative influences other than FSP enrollment, particularly
additional services from other programs in that county. However, these influences would not adequately explain aggregate state-level savings. This
issue of diversity in county savings, and in county environments, will be addressed in greater detail in an upcoming analysis.
20 Cost Offsets can be developed only for counties that submit data to the State Department of Mental Health’s Full Service Partnership (FSP) Data
Collection and Reporting System (DCR). All of the variables used in the FSP Cost Offset analysis are contained in the DCR. EMT does not have access
to non-DCR data from counties.
The areas analyzed for savings are very similar to those analyzed in the evaluation of AB 2034 efforts, which included inpatient psychiatric
hospitalization and incarceration. Emergency room use was also evaluated but was limited to psychiatric rather than physical health.
California Department of Mental Health (2007). (unpublished) Report to the Legislature on the effectiveness of integrated services for homeless
adults with serious mental illness. Sacramento, CA: Author.
21 Institution for Mental Diseases facilities/Mental Health Rehabilitation Centers. Key Event Tracking data do not distinguish between the two.
Therefore, an average of the IMD and MHRC rates for the facilities contracted by each county was used as the basis for calculating the cost applied to
the number of days in long-term care.
22 Although indicators such as education are logical choices for Children and Youth, challenges inherent in the statewide data collection system
related to floor effects and missing data made this variable unsuitable for analysis. See Phase II Deliverable 2.E – Priority Indicators Report.
23 California Department of Mental Health (2007). (unpublished) Report to the Legislature on the effectiveness of integrated services for homeless
adults with serious mental illness. Sacramento, CA: Author.
Data collected from November 1, 1999 to January 31, 2007. $55 million in costs, $27.4 million in offsets (psychiatric hospitalization, incarceration
and emergency room use for psychiatric episodes).
24 Physical Health amounts in FY 09-10 for CYF and Older Adults actually show a loss, or no cost offset. This means that there were more days of acute
care hospitalization, etc., for physical health reasons among Children, Youth and Older Adults during their tenure as Full Service Partners than in the
12 months prior to intake into the program.
25 The data contained in the county-specific tables form the basis for creation of the statewide data set, summarized and reported here.
26 Phase III Deliverable 1.C. Initial written report that specifies the financial impact of outcomes achieved in comparison with expenditures for FSPs
for each of the four age groups. Stakeholders were asked to submit comments in writing no later than August 26, in order to allow EMT sufficient
time for revision to the Final Report due September 30, 2012.
27 Calculations were successfully completed for three additional counties that did not complete the web survey. These three counties aligned their
CSS Plans, Annual Updates, and Revenue and Expenditure Reports in a consistent manner and broke out FSP programs into discrete age groups.
Alignment of plan, update, RER, plus breakout of discrete FSP programs into distinct age groups was a rarity among the counties, but this should not
be viewed as a “negative” on the part of the counties, because the original intent of the RER had nothing to do with breakouts by age group.
Inclusion of the three additional counties brings the total number of participants to 50 (86.2%).The link to census data is:
http://www.census.gov/popest/research/eval-estimates/eval-est2010.html
28 See Appendix D of the full Report for a list of county participants.
29 Phase III Deliverable 1.B – Revised Deliverable 1.A in response to stakeholder input, and Phase III Deliverable 1.D – Revised Deliverable 1.C in
response to stakeholder input.
30 See footnote 27.
31 Presentation dated July 25, 2012, slide printout p. 4.
32 Ibid.
33 Report forthcoming.
34 For those wishing to seriously explore this question, it is critical that Chapter II receive a thorough review. There is a general misunderstanding that
the County Cost Reports have the ability to answer these questions. However, the Cost Reports do not track individuals served. Only county cost
records at the individual client level provide that level of granularity.
35 The merits of analyzing the impact of substance abuse are also supported by Dr. Brian Yates, expert consultant in the area of cost-benefit analysis,
American University.
36 The California Association of Social Rehabilitation Agencies also recommends reviewing/revisiting the data collection and reporting arrangements
for AB 34/2034. This task should focus on identifying components that prevented delays and enhanced data quality and on identifying solutions
applicable to the current system.
In addition, a number of counties are advocating that the current “event-driven” system be replaced with a quarterly outcome-reporting
system.
A particular question of interest is why any FSP has missing/unknown values for race/ethnicity. Due to the high percentage of cases with
missing/unknown racial/ethnic data, analyses were not conducted for this study. The study of FSP Costs and Cost Offsets examined only those FSP
clients with outcome data in the offset categories of interest. Therefore, the FSP client population of interest for the study is a much smaller group
out of the larger population of FSPs. The sample was first narrowed down by:
1. Selecting only new enrollees in FY 08-09 and FY 09-10.
The sample was secondly narrowed down by
2. Examining offsets in the following categories:
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a. Physical Health
b. Psychiatric Care
c. Criminal Justice
Racial/ethnic analyses were further hampered for the FSP Costs and Cost Offsets study by small sample size for FSP clients showing outcomes in
many of the offset categories. Small sample size impacts the percentage of missing/unknown disproportionately. Again, note that in order to be
considered for the racial/ethnic analysis, an FSP client had to show an outcome in the cost-offset area and have a valid ethnic/racial value in at least
one of the fields for racial/ethnic background.
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I. Introduction
Proposition 63 (2004) provides increased funding through the Mental Health Services Act (MHSA) to support
mental health services and promote innovative services and best practices for individuals with mental illness and
inadequate access to the traditional public mental health system. Prop 63 funds are distributed to county
departments of mental health to implement MHSA components. The focus of this report is the Full Service
Partnership (FSP), which is designed to serve Californians in all phases of life who experience the most severe
mental health challenges because of illness or circumstance. This population has been historically underserved and
has substantial opportunity for benefits from improved access and participation in quality mental health treatment
and support. FSP programs are a large portion of the Community Services and Supports (CSS) funding allocation
from MHSA. There is a requirement that most of the CSS budget be allocated to FSP, and that clients be served
with “whatever it takes.” The remaining portions of CSS (can be up to 49 percent of county MHSA budgets) are
used to cover gaps in systems of care related to needs for supportive services, such as transportation or vocational
training (which are typically unfunded), crisis intervention and treatment. 1
The Statewide Evaluation
UCLA’s Center for Healthier Children, Youth and Families and EMT Associates, Inc., have been contracted by the
Mental Health Services Oversight and Accountability Commission to conduct a statewide evaluation of the Mental
Health Services Act. This evaluation is designed to be consistent with the intent of the Act “to ensure that all funds
are expended in the most cost-effective manner and services are provided in accordance with recommended best
practices subject to local and state oversight to ensure accountability to taxpayers and to the public.”
The UCLA/EMT Evaluation will produce deliverables in several priority areas. The purpose of this report is twofold,
to specify the: 2
Statewide and county-specific per-person annual cost 3 average for FSP Adults, Older Adults, Children and
Transition-Age Youth and proportion of funding by revenue source. In plain language, the cost of providing
FSP program services per person by age group, and
Financial impact of outcomes achieved in comparison with expenditures for FSP clients for at least one of the
four age groups. In the context of FSP impact, this report documents how FSP program costs are offset by
savings 4 in actual dollar amounts as a result of reductions in inpatient hospitalization days (psychiatric and
physical health) and number of days incarcerated.
1 For a more detailed discussion about CSS component expenditures, see:
http://mhsoac.ca.gov/Announcements/docs/Evaluation_Deliverable1A_Brief1_CSS.pdf
2 This report represents the combination of two Phase III contract deliverables: Phase III Deliverable 1.A – FSP Cost Report, which specifies the
statewide and county-specific per-person annual cost average for FSP Adults, Older Adults, Children and Transition-Age Youth and proportion of
funding by revenue source; and Phase III Deliverable 1.B – FSP Cost Offset Report, the Initial written report that specifies the financial impact of
outcomes achieved in comparison with expenditures for FSP clients for at least one of the four age groups.
3 Although the technically accurate term is expenditure based on the data sources analyzed, this term is cumbersome and not user-friendly to
the lay reader. Therefore, the term cost may be used in place of expenditure throughout this Report.
4 The terms cost savings and cost offsets are used interchangeably throughout this Report.
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Report Overview
This report, Full Service Partnerships: California’s Investment to Support Children and Transition-Age Youth with
Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness, contains four (4) chapters. A
brief synopsis of each chapter follows.
Chapter I, Introduction, provides a brief introduction to the report and a short orientation for the reader to the
contents of each chapter.
Chapter II, Involvement of Key Stakeholders, describes the process for obtaining input from expert evaluation
advisors and people with lived experience, and recommendations for next steps in terms of a participatory
evaluation of costs and cost offsets due to the impact of formal and informal peer networks.
Expenditures on Full Service Partnership Programs are presented in Chapter III. In plain language – this chapter
contains the FSP cost per person by age group. There is a brief discussion of the methodology used to produce FSP
cost per person, including the elements that went into compiling FSP cost. The calculation for participant service
years is also presented. The statewide per-person annual cost average by age group is shown in a table.
Chapter IV focuses on Cost Offsets for Full Service Partnership Programs. In this chapter, findings from outcome
analysis of psychiatric services, physical health services and criminal justice involvement are presented that
illustrate how the savings due to reduction in number of days help pay for FSP programs.
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II. Involvement of Key Stakeholders
The Expanded Statewide Evaluation of the Mental Health Services Act specifies that the evaluation team:
Establish and maintain stakeholder engagement in the evaluation that is representative of a wide scope of
expertise. Engagement will include:
A process for input from individuals living with mental illness, family members/personal caregivers and
representatives of culturally diverse unserved and underserved groups of all ages, and
A process for input from researchers, data analysts and programmers who are responsible for local data
evaluation efforts.
The focus of this chapter is to describe the process and contribution of engagement of stakeholders through seven
key strategies:
1. Presentations to client and family groups/organizations representing unserved/underserved groups
2. Key stakeholder interviews with individuals representing client/family groups and organizations
representing unserved/underserved groups
3. Presentations to associations/service provider agencies
4. Key stakeholder interviews with individuals representing associations/service provider agencies
5. Formation of an Evaluation Advisory Group
6. Key stakeholder interviews with peer advocates and parent partners
7. Product review/feedback (further elaborated on in Appendix F, Key Stakeholder Feedback)
1. Presentations to Client & Family Groups/Organizations Representing Unserved/
Underserved Groups
Outreach to client and family groups and organizations representing unserved and underserved groups was
conducted early in the evaluation process. 5 An offer was made to stakeholder groups for presentation about the
Statewide Evaluation of the Mental Health Services Act in person, through conference calls or through webinars. 6
A total of six (6) presentations were made during the spring/summer of 2011, during which feedback on the FSP
Costs and Cost Offsets studies was actively sought. 7
With respect to the FSP Costs and Cost Offsets studies, the following themes emerged:
Client and family groups wanted to review the draft report and needed adequate time to do so: 8
o Reviewers want to know the disposition of their review comments (e.g., were they used in
producing the Final Report, and if not, why not?).
An emphasis on recovery and resilience is sorely needed:
o Most of the data collected through the statewide Department of Mental Health system (the
Data Collection and Reporting System, known as the DCR) are consequence-focused. In lay
5 Late March-July 2011.
6 The study as a whole was presented and feedback sought with the following considerations: a) reduce stakeholder burden (to avoid returning
for every deliverable and thereby requiring multiple presentations/feedback sessions), b) budgetary constraints.
7 See Appendix A for a list of organizations.
8 Commitment was made by EMT Project Director Dr. Elizabeth Harris to each group of stakeholders that they would be sent a copy of the draft
report for review and input.
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terms, most of what is collected about FSP clients is negative (e.g., incarceration,
hospitalization).
o Clients and families would like to see positive outcomes documented and somehow tied to
savings to the system. 9
A key stakeholder group representing underserved and unserved individuals was very concerned that:
Communities of color are not served in proportion to their actual numbers by the Full Service Partnership
program.
The degree to which communities of color are being served by Full Service Partnerships merits investigation, and is
a key question to be addressed in a separate MHSA Statewide Evaluation Deliverable. 10
2. Key Stakeholder Interviews with Individuals Representing Client & Family Groups/
Organizations Representing Unserved/Underserved Groups
Stakeholder groups were contacted and offered participation in a presentation about the Statewide Evaluation of
the MHSA, with an opportunity for comment and recommendation. The evaluation team met with four (4)
organizations that requested in-person meetings to gain a better understanding of the study. Two agencies for
Older Adults opted not to participate in presentations but made the following input:
The needs of Older Adults are not addressed by every county:
o A cost-offset study, therefore, may incorrectly assume that Older Adults do not have positive
outcomes, when the real problem is that there are not programs in place to a) recruit them and
b) to specifically address their needs.11
o Among counties that do address the needs of Older Adults through Full Service Partnerships,
some are implementing evidence-based practices (such as IMPACT). However, IMPACT is also
being implemented by some counties under the Prevention and Early Intervention component. 12
This fragmentation of funding even under MHSA may make it difficult to determine the true cost
offsets for Older Adults.
The evaluation team took these concerns into consideration when conducting analyses of FSP costs and cost
offsets by age group, as the calculation of numbers served was critical to determining cost per client. In addition,
see the discussion in this chapter under the Evaluation Advisory Group for the process developed for documenting
and summarizing FSP services and strategies.
The potential positive impact of evidence-based practices on both costs and cost offsets should not be under-
estimated. The following assumptions may be tested: 13
9 Examples include measuring indicators of recovery, and quality adjusted life years (QALYs).
10 Phase II Deliverable 2.E – Priority Indicator Report planned for release on September 30, 2012. Subsequent reports are planned for December
31, 2012, and March 31, 2013.
11 A thorough, systematic review of CSS Plans was conducted expressly for the purpose of identifying services for Older Adults, using a
structured review tool, by one interviewee. She has given her permission to make the results available, on request.
12 Specifically, under Early Intervention.
13 Due to the review and feedback schedule, there was insufficient time to test these hypotheses in order to determine the potential impact on
cost. Therefore, we propose exploration via an upcoming MHSA Cost Deliverable, in order to make full use of the data collected.
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Implementing an evidence-based best practice may be more expensive because of additional staff
training and ongoing supervision requirements (costs), and
Implementing a proven practice that has previously shown demonstrable outcomes is likely to produce
the same positive outcomes with FSP participants (cost offsets).
3. Presentations to Associations/Service Provider Agencies
Outreach to service provider agencies and community mental health associations/agencies was also conducted
early in the Phase III evaluation.14 A total of six (6) presentations were made during the spring/summer of 2011,
during which feedback on the FSP Costs and Cost Offsets studies was actively sought.15 This was the area that
generated the most interest and enthusiasm among community mental health associations. 16
With respect to the FSP Costs and Cost Offsets studies, the following themes emerged:
Service provider agencies/community mental health associations were interested in reviewing the draft
report. 17
County contractors (e.g., community mental health providers) may provide MHSA services in a more cost-
effective manner than the county. This hypothesis should be tested.
The latter concern has clear implications for conduct of the cost and cost-offset analyses. Accordingly, feasibility
testing is discussed in the following section.
4. Interviews with Representatives from Associations/Service Provider Agencies
When the initial offer was extended to stakeholder groups for a presentation about the Statewide Evaluation of
the MHSA, seven (7) organizations instead opted to meet in person or via conference call to gain a better
understanding of the study. 18
The California Mental Health Planning Council, which recommended the original MHSA performance indicators,
was one. The focus of its meeting was on Phase II Deliverable 2 (Statewide and County Indicator Report).
The remaining organizational representatives were interested in the FSP Costs and Cost Offsets Report. The
themes that emerged during the interviews echoed those discovered during presentations made to
agencies/associations.
In the summer of 2011, the only available data source was the Revenue and Expenditure Reports. A link to the
worksheet provided by the Department of Mental Health for documenting FSP expenditures by program is
provided in Appendix E (Revenue & Expenditure Reports). The worksheet breaks out expenditures under FSP into
county and contractor. Based on this initial information, we determined that the question posed by associations
and service provider agencies merited feasibility testing:
14 Late March-July 2011.
15 See Appendix A for a list of organizations.
16 MHSA coordinators were interested in the Statewide Evaluation as a whole. The main theme was informing them well in advance of any
expectations involving data collection.
17 Commitment was made by Dr. Harris to each group of stakeholders that they would be sent a copy of the draft report for review and input.
18 The plan was that interviewees would report items of interest back to their constituency, given the busy agendas that most association
meetings entailed. However, a subsequent presentation was scheduled for the California Mental Health Planning Council, following the initial
interview.
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Do the available data support our ability to answer the question, “Do county contractors (e.g., community
mental health providers) provide MHSA services in a more cost-effective manner than the county?”
We laid out several questions to be answered during our exploratory process:
1. Are contractors identified by a unique identification number in the Revenue and Expenditure Report?
a. If yes, can this be tracked to individual client (services received) in the DCR?
2. Are contractors identified by name in the Revenue and Expenditure Report?
a. If yes, can this be tracked to individual client (services received) in the DCR?
The answers to #1 and #2 were no. In addition, we learned that although individual client service records in the
DCR may specify the FSP “program” each person participated in, this “program” may have been implemented by
any one of a number of contractors as well as the county itself. The DCR was not designed to capture detailed
service-exposure level data.
The next step was to examine County Cost Reports, with the goal of answering the following questions:
1. Can FSP expenditures be disentangled out of the larger MHSA costs contained in the Cost Report?
a. If yes, can individual contractor FSP billing be traced through the Cost Report (thereby bypassing
the Revenue and Expenditure Reports altogether)?
After an exhaustive review of the Cost Report worksheets and consultation with a county fiscal expert (who
completes the Cost Report worksheets annually), the answers were determined to be no.
In summary, we learned the following:
Individual FSP client data in the DCR contain the general “program” an individual person participated in,
but not the individual contractor that delivered the services nor the number of contacts, amount of time
of each contact, etc.
Individual contractors are not identified in any systematic way in the Revenue and Expenditure Report
(RER). There is no way to link RER expenditure data by contractor to either the DCR or the Cost Report.
Counties would need to turn over individual-level cost data to UCLA/EMT in order to answer the question as to
whether contractors deliver FSP services in a more efficient manner compared with the county. We determined
that requesting this level of participation from counties is not feasible for the following reasons:
Burden on county mental health departments
Confidentiality concerns
Budget/time constraints
In sum, MHSOAC may determine that the question, “Do county contractors (e.g., community mental health
providers) provide MHSA services in a more cost-effective manner than the county?” posed by community mental
health associations/service provider agencies merits investigation and may develop a Request for Proposal in order
to thoroughly study the issue, keeping in mind the data requirements outlined above.
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5. Evaluation Advisory Group
The Evaluation Advisory Group (see Appendix C) explicitly advises on FSP costs and cost offsets. It is composed of
nationally recognized evaluators and evaluation and fiscal staff from county mental health departments.
The group initially convened for an all-day meeting on November 3, 2011, in Anaheim. A follow-up meeting was
held on February 6, 2012, in Encino. Each participant received a binder with PowerPoint slides that organized the
meeting presentations and discussion, and backup materials for reference. The meeting produced two kinds of
decisions:
1. Recommended actions. After presentation of a required step in the cost estimation process and a
recommended action or alternatives, the group offered comment and deliberated. If consensus was
reached, a recommendation for a preferred action was made.
When consensus was not reached because of a need for further assessment, actions were recommended
contingent on this assessment. Criteria for a final decision were typically identified.
2. Recommendations for further information from counties. In some instances it was necessary to get
clarification on county data, fill gaps where information was missing in a county or gain clarification on
critical points of information. The Advisory Group determined that it was appropriate to contact counties
through e-mail to ask for clarifications or information specific to their county, as long as inquiries were
brief and focused. When appropriate, the Advisory Group recommended queries to be made to selected
counties. These Internet queries formed the basis of a web survey that was developed for county
participation.
Evaluation Advisory Group input in the area of cost and cost-offset methodology is best understood in the context
of chapters devoted to these topics. Refer directly to Chapters III and IV for further discussion.
Full Service Partnership Services Description
For the purpose of this report and recognizing the need to be responsive to key stakeholder feedback, the
UCLA/EMT team faced an immediate need to systematically categorize services across counties/municipalities in
order to subsequently link specific services to specific age groups. This is important for the following reasons:
FSP costs vary by county and age group. One reason may be the depth and breadth of services offered
under the Full Service Partnership Program.
FSP cost offsets vary by county and age group. One reason may be the depth and breadth of services
offered under the Full Service Partnership Program.
A report about FSP costs and cost offsets in the absence of information about FSP services and activities by age
group is to present the proverbial black box. In addition, review of the Phase II Deliverable 1 MHSA Cost Report by
county department of mental health stakeholders elicited feedback recommending description of Full Service
Partnership programs, in order to provide the appropriate context within which to interpret findings.
Therefore, the Evaluation Advisory Group recommended documentation of FSP services by county and age group
as an important analysis.
With the primary goal in mind of developing a standardized system of describing planned FSP services, the
Community Services and Supports Plan (CSS Plan) and the attendant updates (Annual Updates through FY 10-11)
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served as the basis for the initial FSP review and summary conducted by EMT Associates. The FSP Service
Assessment for each county/municipality was conducted using a systematic review and summary tool developed
by a consultant formerly employed with a large county department of mental health and directly involved in the
evaluation of that county’s MHSA program. The focus of the tool was straightforward – with instructions to trained
reviewers to indicate whether planned services were present or absent in the CSS Plan and/or Annual Updates.
The rating of “present” or “absent” avoided any judgment about quality, adequacy, etc., as such judgments are
inappropriate absent on-site observation.
The strategy of document review and summary was selected following discussion with the FSP Evaluation Advisory
Group, 19 due to budget limitations and concerns about county/municipal burden inherent in a site visit/on-site
service observation. The draft FSP Service Summary tool was reviewed at a FSP Evaluation Advisory Group
meeting, and refined following that meeting.
Following the FSP Service Summary, counties/municipalities had the opportunity to review their individualized FSP
Services Assessment, and to provide supplementary documentation for consideration in the event that critical
services were not documented in the CSS Plan or Annual Updates. For example, one county submitted its FSP
Implementation Manual for inclusion in its FSP Service Summary. When supplementary documentation was
provided by a county or municipality, its specific, individualized FSP Service Summary was updated to reflect new
information. The FSP Service Summary includes documentation of the source material, for county/municipal
reference.
We have reviewed every county’s Full Service Partnership Plan and Annual Updates in order to generate a county-
specific FSP Service Summary. 20 The FSP Service Summary indicates whether a planned service/activity was
present or absent for each age group.
The FSP Service Summary tool was first developed by an expert consultant and pilot tested on one county. The tool
was then reviewed by the Evaluation Advisory Group. 21 Revisions were made to the tool based on feedback from
the advisory group.
FSP Service Summaries were sent back to each county, along with the source location (basis for the present/absent
rating). 22 Counties were provided the opportunity for review/feedback, which included submission of
documentary evidence to support FSP activities/practices in place. 23
County feedback was incorporated, and the FSP Assessments updated accordingly. However, due to the length of
this report, and the importance of the topic as it relates to cost (and potentially to cost offsets), we propose that a
summary of FSP Services and the potential impact on FSP Costs and Cost Offsets be explored in a stand-alone
report.
19 See Appendix C for a list of Evaluation Advisory Group members.
20 The decision was made to use available data (rather than conduct site visits to each county) in order to avoid burden to the counties and due
to budgetary considerations.
21 Our consultant had worked as a Full Service Partnership Coordinator for a large county. The county reviewed was the one she had worked
for, with its permission. Counties were provided the opportunity to provide additional documentary evidence because services may have
changed following plan submission or a service may have inadvertently been left out of the plan – in short, the Evaluation Advisory Group noted
that the Plans and Updates were not designed to capture everything offered through the Full Service Partnership, and therefore the
opportunity to augment with additional data must be offered to counties.
22 For example, the page number in the original FSP Plan. We provided the source location to make it easier for counties to follow the logic for
our ratings of whether a given service (e.g., wraparound) was present or absent.
23 One county requested a site visit in order to update its FSP Assessment. The FSP Assessment matrix accompanied the site visitor and was
updated following the visit based on qualitative survey results (interview data with FSP staff).
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6. Interviews with Peer Advocates & Parent Partners
Following the series of presentations and interviews, the MHSA Statewide Evaluation team launched a
participatory evaluation (Phase III Deliverable 2). In order to avoid burden on clients and families (and not work at
cross-purposes with the participatory evaluation), the Phase III Deliverable 1 process focused on methodology and
input from the Evaluation Advisory Group during the period of intensive data collection for the participatory
evaluation.
By June 2012, the participatory evaluation survey data collection period was winding down. A brief presentation
was made to the Participatory Evaluation Consumer Advisory Board via conference call on June 5, 2012. The
request was simple:
How can we learn more about the positive ways that FSP clients and families are contributing to
their care, as they progress in their recovery (i.e., offsetting costs)?
We chose an exploratory approach for a number of reasons:
1. The Costs and Cost Offsets Deliverable had ample opportunities for review and feedback from all
stakeholder groups, throughout all phases of development.
2. Clients and families clearly expressed the need (this speaks to the type of data currently collected under
the DCR) to focus on positive outcomes. 24
3. Clients and families are in the best position to inform us about what to look for in terms of potential offset
areas.
4. Budget limitations and time constraints due to the nature of the deliverable and contract prevented us
from launching a second participatory evaluation in which primary (new) data collection from clients and
families could be the focus.
Therefore, the parameters of an exploratory approach required that no more than nine (9) peer advocates/parent
partners be interviewed, and that one general question be posed (What are some of the ways you have seen
people contribute to their care as they progress through recovery?), to be answered in no more than 15 minutes. A
$25 gift certificate would be provided in appreciation for participation in the telephone interview. Peer advocates
and parent partners were deemed excellent sources of information, given both their lived experience and the
numbers of individuals and families mentored through the Full Service Partnership program.
Many wonderful examples of success emerged during the interviews, including a budding entrepreneur who had
formerly been homeless. However, an unanticipated theme surfaced across the interviews. The potential for cost
offsets to the system is great, but it is not being documented due to deficits in the DCR (see the graphic below):
Peer networks (informal and formal): A recurring theme was the power of peers. Connection to others
with lived experience was cited as the reason individuals:
o Became engaged in mental health services (where previous efforts had failed)
o Were no longer homeless (able to maintain independent living)
o Could “step down” in service intensity (presumably resulting in savings of county staff time, or
opening a slot for a new client)
24 Previous research by an Evaluation Advisory Group member on a subset of counties (representing the majority of the state’s population)
using DCR data revealed that there is little change in employment and education outcomes, at least in the manner in which they are currently
collected under the DCR paradigm. Therefore, it did not seem a worthwhile use of our resources to reinvent this particular wheel. There is no
reason to expect that we would have found different results.
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o Stayed out of the hospital (thanks to informal intervention by peers)
o Transported their SED children to enrichment activities (thanks to peer carpooling)
These were but a few examples cited by the peers (employed by county mental health departments and county
contractors).
The Key Event Tracking Form within the DCR requests that FSP clients be queried about time spent in volunteer
activities. It fails to ask what volunteer activity they are engaged in. Therefore, time spent by FSP clients acting
as informal peers/mentors for others is not documented.
Peer advocates indicated that many FSP clients do not engage in paid employment during their first year of
recovery. Nonetheless, the time spent volunteering as a peer advocate provides a critical service on two fronts:
An informal peer network is established within the county, providing a needed support system.
Costs to the formal mental health system presumably are offset by the informal (and formal) peer support
systems.
Time spent working in a formal peer support system is likewise not documented. The Key Event Tracking Form
within the DCR requests that FSP clients be queried about time spent employed. It fails to ask about the nature of
the employment the FSP clients are engaged in.
We recommend that the Mental Health Services Oversight and Accountability Commission consider funding a
participatory evaluation to formally study the positive impact of peer networks. Such a study would provide a
necessary balance to the preponderance of consequence-focused data currently collected through the state’s DCR
system.
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Exhibit II.1
Full Service Partnership Program – Hypothesized Relationship between Peer Networks and Cost Offsets
(Potential ways that
peers provide support Reduced
– not an exhaustive
reliance on staff
list): Peers make
positive
connections with
each other.
Informal &
Greater
Clubhouse or Formal Peer
Support independence
Wellness Center
Networks
Positive outlook
fostered by seeing
success stories on Reduced
weekly basis.
program costs
Modeling via peer
advocates and
parent partners.
Participatory Evaluation
Possibilities (this is not an
exhaustive list):
Determine ways in which peers
provide support; assess and
document cost of peer advocate
and parent partner time;
determine areas of recovery to
be studied for potential offsets
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7. Involvement of Key Stakeholders: Summary
In all, 23 presentations, interviews and conference calls were held with key stakeholders representing clients and
families, service providers and community mental health associations from the end of March through July 2011.
An Evaluation Advisory Group was established, representing nationally recognized experts in cost evaluation and
county department of mental health evaluators and fiscal staff. The group held two formal meetings and continues
to deliberate via e-mail.
Peer advocates and parent partners were interviewed in order to gain the perspective of individuals with lived
experience on potential offsets that FSP participants contribute as they progress in recovery. Their input revealed
a remarkable and unmeasured resource represented by peer networks. A recommendation has been advanced to
formally study the impact of peer networks on the mental health system.
All stakeholders were provided the opportunity to review and comment on this report. The process for doing so is
described in Appendix F, Key Stakeholder Feedback.
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III. Expenditures on Full Service Partnership Programs
Full Service Partnership expenditures 25 are the focus of this chapter. 26 Translated into plain language – what was
spent on Full Service Partnership programs?
This deliverable is defined simply as follows:
Initial written report that specifies:
1) The statewide and county-specific per-person annual cost average and range for FSP Adults, Older
Adults, Children and Transition-Age Youth, and
2) The proportion of revenue by funding source.
The chapter opens with a description of our methodology – how we went about calculating the cost of Full Service
Partnership programs. The chapter closes with statewide Full Service Partnership costs by age group.
a. Methodology
Expenditures on Full Service Partnerships (FSP) were analyzed and reported (through Fiscal Year 08-09) as part of
the Phase II Statewide Evaluation of the Mental Health Services Act, Deliverable 1. 27 The primary data source for
determining FSP cost was the Revenue and Expenditure Reports. 28 Revenue and Expenditure Reports are
completed by each county mental health department, and they document all monies spent and were available to
be spent on mental health services through the Mental Health Services Act.
In the process of completing Phase II Deliverable 1, the UCLA/EMT Team summarized all public mental health
expenditures on Full Service Partnerships documented in the Revenue and Expenditure Reports (RER). 29
Therefore, the RERs were deemed a logical data source to start with.
The initial question to be answered, in order for the analysis to proceed, relates directly back to the deliverable
language (above):
Can FSP costs by age group be calculated using the RERs?
Without the ability to determine age-group-specific expenditures, the county-specific and statewide cost average
and range for FSP Adults, Older Adults, Children and Transition-Age Youth cannot be determined.
25 Although the technically accurate term is expenditure based on the data sources analyzed, this term is cumbersome, and not user-friendly to
the lay reader. Therefore, the term cost may be used in place of expenditure throughout this Report.
26 Phase III Deliverable 1.A. Initial written report that specifies 1) the statewide and county-specific per-person annual cost average and range
for FSP Adults, Older Adults, Children and Transition-Age Youth and 2) the proportion of revenue by funding source.
27 http://mhsoac.ca.gov/Announcements/docs/Evaluation_Deliverable1A_Brief2_FSP.pdf
California’s Investment in the Public Mental Health System: Proposition 63; Brief 2 of 7: Providing Community Services and Supports through
Full Service Partnerships.
28 FY 2006-07 was the earliest fiscal year for which Revenue and Expenditure Reports were submitted by counties. No counties submitted
Revenue and Expenditure Reports (according to the Department of Mental Health) prior to FY 06-07.
29 The expenditures for components authorized under the Mental Health Services Act and reported in the Phase II Deliverable 1 brief include:
Mental Health Services Act, State General Fund, Other State Funds, Medi-Cal FFP, Medicare, Other Federal Funds, Realignment, County Funds,
Other Funds. Breakout by age group is not possible due to the limitations of the RER, discussed in this report. It is not included in this report
due to challenges inherent in merging in the full RER data set (see Appendix E).
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Therefore, it was imperative for the team to quickly identify a reliable and valid means of determining FSP costs
by age group. 30
Recall the discussion of the Revenue and Expenditure Report limitations in Chapter II. A link to the worksheet
provided by the Department of Mental Health for documenting FSP expenditures by program for FY 08-09 is
provided in Appendix E. There was no change to the original FY 09-10 RER form issued to counties. The revised
version, however, requires only a summary total for each FSP program and does not ask for breakout costs. 31
The initial questions posed about the FSP program worksheets (summarized in Chapter II) laid the groundwork for
similar questions about the FSP programs:
1. Are FSP programs identified by a unique identification number in the Revenue and Expenditure Report?
a. If yes, can this be tracked to individual client (services received) in the DCR?
2. Are FSP programs identified by name in the Revenue and Expenditure Report?
a. If yes, can this be tracked to individual client (services received) in the DCR?
b. If yes, can this be tracked to the CSS Plan and Annual Updates?
The answer to #1 was determined to be no. This posed obvious problems – the most troubling being:
How can we reliably link a particular FSP worksheet with expenditures to a particular age group in the
DCR?
An alternative was considered – perhaps FSP programs as identified in the RER worksheets could be tracked to the
CSS Plan and Annual Updates. The team therefore embarked upon an exhaustive review process of attempting to
match up every RER worksheet back to a named FSP program in the original CSS Plan, and then to subsequent
fiscal year Annual Updates.
The results were problematic for a number of reasons:
Names of programs change from year to year in some counties but do not always change on the RER (or
vice versa);
Programs may be combined in a given fiscal year when they were broken out by age the previous year.
For example, all small counties combined FSP breakout programs by age group into one omnibus FSP
program in FY 09-10;
Programs disappear out of the RER but are not documented as to why they disappear in the Annual
Update;
New programs appear in the RER, but they are not documented in the original CSS Plan or the Annual
Update;
Programs are identified as FSP in the original CSS Plan/Annual Update, but no FSP expenditures appear in
the RER;
30 Revenue and Expenditure Reports reviewed were those submitted by counties and municipalities to DMH as of October 1, 2011. Dr. Harris
traveled to Sacramento and personally picked up an encrypted hard drive containing DCR data, Annual Updates and FY 08-09 and FY 09-10 RERs
(EMT already had FY 08-09 RERs from the Phase II Deliverable 1 analysis).
31 Revised instructions were issued to counties on December 27, 2011, with a due date of January 31, 2012, for counties that had not yet
submitted FY 08-09 and FY 09-10 RERs. FY 09-10 is provided in the report, but the revised forms are identical to FY 08-09.
http://www.dmh.ca.gov/dmhdocs/docs/notices11/11-16.pdf
Although the revised instructions did not impact EMT’s time line (FY 09-10 RERs provided by DMH were provided prior to the revised
instructions issuance), the Evaluation Advisory Group will need to carefully consider whether this RER data can be used, given how different the
instructions are from those of previous years.
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Not all age groups that had been planned to be served by a program may, in actuality, be served (when
DCR data is compared with planned budgets); and
Target age groups may change from year to year.
The answer to the question, “Are FSP programs identified by name in the Revenue and Expenditure Report, and can
they be tracked to individual FSPs in the DCR, and to the CSS Plan and Annual Updates?” is:
“It depends entirely on the county, the fiscal year and even the program in question.”
In addition, the answer to the question changes even within a given county, and within a single fiscal year.
However, barriers to extracting FSP cost by age group should not be seen as a poor reflection of county
documentation. Indeed, the Revenue and Expenditure Reports were not designed for this purpose. Counties
reported during the web survey process (additional data collection used for this deliverable, described later in this
chapter) that they complied as best they could with the RER instructions provided, but that the RERs are not a
reflection of county mental health accounting practices. Indeed, the prevailing sentiment among county fiscal staff
may be summarized in one quote received:
“We simply don’t track our mental health spending this way.”
After spending 60 days of investigation, thoroughly exhausting these possibilities as potential data sources, the
Evaluation Advisory Group was convened in order to seek expert guidance and input into resolution of the critical
challenge of breaking out FSP costs into age groups in a reliable and valid manner.
The objectives of the first Evaluation Advisory Group meeting (held November 3, 2011 – see Chapter II for an
introduction to the EAG) were:
a) To define the product necessary to meet the requirements of the deliverable;
b) To identify feasible ways in which the deliverable may be improved (e.g., be made more informative and
useful in understanding what drives cost per client and cost differences across counties);
c) To identify issues and solutions to the issues that need to be resolved to:
1) identify the data elements necessary to the desired products;
2) identify the data sources most suitable to producing these data elements;
3) identify issues and solutions concerning the exact configuration of data elements (e.g., the exact
definition of what FSP costs should include) appropriate to developing the products;
4) conduct the analysis; and
5) display findings; and
d) To suggest an organized set of steps to systematically resolve issues identified under c).
The results of the RER analysis were presented to the Evaluation Advisory Group, along with other potential data
sources. Challenges associated with each potential data source are summarized in Exhibit III.1.
The EAG determined, during the deliberation process, that the critical question of FSP expenditures by age group
would be difficult for EMT to answer using the available data sources. Although the total cost of Full Service
Partnerships each fiscal year can be obtained from the RER (and indeed, was obtained and reported in Phase II
Deliverable 1 for FY 08-09), the RER falls short on its own in terms of providing a reliable and valid mechanism for
breaking out the total cost by age group.
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Exhibit III.1
Available FSP Cost Data Sources & Limitations
COST DATA SOURCE USE CHALLENGES PROPOSED SOLUTION(S)
ELEMENT
Unit of Revenue and FSP 1) Expenditures at the program level, rather than 1) Estimate per-person cost
Analysis Expenditure program- individual per-person FSP client costs (i.e., that
Report, FSP level would be tracked in Medi-Cal data). Because of
Program expenditures budgetary considerations, establishing a study in
Worksheets which we obtain individual-level Medi-Cal data
across all counties and set up a comparison group
in each county is not an option.
a. Our budget for this deliverable is about
20% of the UCSD budget (in which Dr.
Gilmer’s group set up such a study, with a
sampling of counties – EMT is charged
with studying all counties).
b. Not all FSP clients and/or services are
Medi-Cal eligible, so a study limited to
Medi-Cal data doesn’t provide an exact
estimate of FSP costs.
Average Revenue and Proxy for 1) Expenditures are not final, reconciled payments to 1) Adjust FSP total expenditure
Annual Expenditure cost county and therefore may be higher than true proportionate to Cost
County Report, FSP cost; inclusion of “other sources” in total may also Report Total 33 (difference
Cost Programs inflate true cost 32 between MHSA line item on
Grand Total 2) Cannot link FSP Program expenditures clearly to form 1995 and total MHSA
individual FSP participants expenditures on Revenue
3) Role of Outreach & Engagement and General and Expenditure Report);
System Development expenditures for programs Cost Report is not an option
with blended funding because we have no way to
link Vendor ID to FSP
program, and no way to
disentangle FSP costs from
the total MHSA costs
reported on form 1995.
2) Use DCR data for number of
participants.
3) Query on web survey about
the proportion of O&E and
GSD spent on FSP clients.
Age Groups CSS Plan & FSP age 1) Non-standardized data source (narrative) 1) Survey counties about
Annual group(s) 2) Programs that serve multiple age groups proportion of FSP costs per
Updates served by age group.
program
Estimation CSS Plan & Annual Aggregate rather than individual-level data 1) Use DCR data.
of Person Annual caseload (FY) 2) In addition, new challenges
Year for Per Updates – program are introduced, such as how
Capita Cost capacity to count persons who carry
over from year to year, and
persons who enter the
program late in the year
(compared with those who
enter early).
3) Tracking service exposure is
problematic, given the
available data sources.
32 Reporting on the proportion of funding by other sources is a base requirement for this deliverable.
33 The latest Cost Report received is for FY 08-09. There is no FY 09-10 Cost Report against which to reconcile MHSA expenditures.
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Therefore, the absolute necessity of breaking out FSP expenditures by age group formed the basis for launching a
county web survey. The Evaluation Advisory Group determined that only county department of mental health staff
(preferably, fiscal staff) have the information needed to make determinations about how the total FSP cost for
their county should be broken out by age group. Although a county survey represented a data collection burden,
county-informed breakouts were deemed to be far preferable to any educated guess on the part of the UCLA/EMT
team.
Estimating cost for comparable services provides the foundation for assessing the return on the FSP service
investment. The assessment of cost offset is accomplished through identifying how service costs result in
substantial savings to the system (e.g., reduced hospitalization costs, reduced incarceration costs). The web survey
was necessary to augment data already gathered from RERs; to ensure that all counties are adequately
represented in the analysis; and to ensure the most accurate and feasible estimate of appropriate service costs.
1. Program Costs
The total amount expended on Full Service Partnerships in FY 08-09 and FY 09-10 (as reported by each county in its
RER) served as the basis for the total Program Cost. 34 Total Program Cost was only a starting point, however, given
the need to break out cost by age group.
2. Age Groups
Per the MHSA Community Services and Supports Three-Year Program and Expenditure Plan Requirements, “Each
county must plan for each age group in their populations to be served.” (p. 13) 35 Age groups are defined as follows:
Children, Youth and Families (CYF): Birth to 18 years, and special-education pupils from birth to age 21
Transition-Age Youth (TAY): 16 to 25 years
Adults: 18 to 59 years 36
Older Adults: 60 years and older 37
The county web survey contained questions about the proportion of spending on Full Service Partnership services
for each age group, for each fiscal year. 38
34 Only one county, Del Norte, did not submit an FY 09-10 RER. Therefore, expenditures as reported in its web survey served as the sole source
for FSP FY 09-10 expenditures.
35 http://www.dmh.ca.gov/dmhdocs/docs/letters05/05-05CSS.pdf
p. 21. Children and adolescents identified as seriously emotionally disturbed (SED) are eligible for FSPs if they meet the criteria set forth in
Welfare and Institutions Code Section 5600.3, Subdivision (a).
http://www.leginfo.ca.gov/cgi-bin/displaycode?section=wic&group=05001-06000&file=5600-5623.5
California’s Welfare and Institutions Code is posted in its entirety on the website cited above, absent page numbers. Click on the link and
the section cited will appear on screen, verbatim, as quoted.
36 California Code of Regulations, Title 9. Rehabilitative and Development Services, Division 1. Department of Mental Health, Chapter 14. Mental
Health Services Act, Article 2: Definitions, Section 3200.010. Adult. (p. 1).
37 http://www.dmh.ca.gov/dmhdocs/docs/letters05/05-05CSS.pdf
p. 21. Adults and older adults identified to have a serious mental disorder are eligible for FSPs if they meet the criteria set forth in
Subdivision (b) of Section 5600.3.
http://www.leginfo.ca.gov/cgi-bin/displaycode?section=wic&group=05001-06000&file=5600-5623.5
38 Assignment of FSPs into age group categories is done at the county level. This categorization is reflected in the DCR. The UCLA/EMT team
does not make any assignment of individual FSPs to age group category.
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3. Housing
There was consensus among Evaluation Advisory Group members that housing is a critical aspect of FSP services,
and an expensive service. 39 Housing was therefore included as an FSP cost even though it is reported somewhat
differently in some counties. There is a specific line item for housing (General System Development Housing line
item), but it does not contain complete FSP housing expenditures in some counties. For counties that show no
expenditures under the General System Development (GSD) Housing line item:
One-time-only costs may be under the CSS “Administration” line item.
Ongoing costs may be under the FSP “Operating” line item.
Housing is defined in the table below.
Exhibit III.2
Housing Definition (included in the County Web Survey)
Housing Support DMH Letter 06-07
The cost of providing housing supports, including housing subsidies for permanent, transitional and
temporary housing; master leases; motel and other housing vouchers; rental security deposits; first- and
last-month rental payments; and other fiscal housing supports. This does not include the capital costs used
to purchase, build or rehab housing or the salaries and benefits of staff used to provide client housing
supports.
Operating Support DMH Letter 06-07
The operating costs of providing housing supports to clients, including building repair and maintenance,
utilities, housing agency management fees, insurance, property taxes and assessments and credit reporting
fees. This does not include the capital costs used to purchase, build or rehab housing or the salaries and
benefits of staff used to provide client housing supports.
Housing Placement DMH Letter 05-05 Age-specific strategies:
CYF – Permanent supportive housing for homeless families and families reunifying after a child or parent
has been in an institution (e.g., jail, juvenile hall or hospital) or other out-of-home placement.
TAY, Adults, Older Adults: Supportive housing – permanent affordable housing with combined supports for
independent living, including projects that meet the following criteria: (1) housing is permanent, meaning
that each tenant may stay as long as he or she pays his or her share of rent and complies with the terms of
a lease or rental agreement, (2) housing is affordable, meaning that each tenant pays no more than 30% to
50% of household income, and (3) tenants have access to an array of support services that are intended to
support housing stability, recovery and resiliency, but participation in support services is not a requirement
for tenancy. Supportive housing may be site-based (all or a portion of the units in a building are designated
for people with special needs, and supportive services are available on site) or scattered site (tenants have
or rent houses at various locations in the community).
Housing options are available for Transition-Age Youth, Adults and Older Adults who are single and those
who choose to share housing, as well as families with children.
Breakout Reporting of Housing Costs
Since housing is a core service for stabilizing clients, and is a major cost item, the EAG recommended that housing
costs be broken out, presented and discussed as a key expenditure.
39 This does not include the MHSA Housing Program (Governor’s Housing Initiative). There was consensus among EAG members that this cost
would be excluded from the analysis.
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Counties were explicitly queried about the line item in which housing was reported on the RER. If it was reported
on an FSP line item, the housing amount reported for the relevant age group (i.e., the age group for which housing
is documented on an FSP line item) was subtracted from the FSP program cost total for that age group. 40 FSP cost
by age-group calculations using RER and web survey data were included as a worksheet in each county’s FSP Costs
and Cost Offsets Excel file, provided to counties for initial review in May 2012.
4. Outreach
The EAG agreed that outreach in order to recruit individuals and families into FSP programs is another critical
aspect that should be represented in cost, though it may be reported outside the FSP RER worksheet.
There is a specific line item for Outreach in the CSS Program Worksheet, and counties may show outreach
expenditures there (see Appendix E). For counties that show no expenditures under the outreach line item on their
FSP program expenditure worksheets, these expenditures may be reported elsewhere. The web survey therefore
contained specific questions about the cost of outreach for each fiscal year (specific to bringing potential FSP
clients into service) and the proportion spent on each age group.
Counties that participated in the web survey were provided the opportunity to review the initial draft of FSP Costs
and Cost Offsets in a county-specific Excel file, distributed in May 2012.
The initial round of survey participants included a majority of the counties (N = 37; 63.8%).41 The populations of
counties represented in the draft report for FY 09-10 comprised most of the State of California (67.3%).42 The
majority was also represented for FY 08-09 (66.9%).
Although the original intent to include outreach costs represented the desire to document all that Full Service
Partnership participants may receive, when counties reviewed the figures, consensus was that inclusion of
outreach expenditures overinflated the cost of Full Service Partnership programs. In addition, counties indicated
that drilling down on the exact outlay of outreach expenditures for FSP clients was difficult, when outreach is
provided to a much broader population.
Given concerns about inexactitude and over-inflation of cost, outreach expenditures were removed from the
calculations based on county feedback.
5. Operational Definitions
Through the process described in this chapter, counties were queried directly about the proportion of
expenditures provided to each age group for Fiscal Years 08-09 and 09-10. The proportion 43 by age group was
40 Without this adjustment, we would be counting housing costs twice – they are already included in the RER total, and then we would be
counting them again from the county web survey (for those counties that document housing costs on a line item within FSP).
41 Note that one unique consortium of three municipalities applied to provide MHSA services to their constituents. As public mental health
services are not required to be provided by municipalities, this entity was in start-up during the entire study period and was consequently
removed from the total N for purpose of calculation. Therefore, the N = 58 (rather than 59).
42 See Appendix D for a list of county participants. Population data were extracted by county and for the state, for 2008 (corresponding to FY
08-09) and 2009 (corresponding to FY 09-10), from census data:
http://www.census.gov/popest/research/eval-estimates/eval-est2010.html
43 A small number of counties did not answer all questions, or did not answer for all age groups. For these counties, discrepancies were noted
on the county-specific matrix (e.g., no expenditure data for a specific age group, but there are data for that age group in the DCR). For counties
that did not answer the question about the age breakout for supportive services, the original budget/Annual Update age breakouts were used
to estimate the proportion of expenditures by age group (applied to the Revenue and Expenditure Report data). If the original budget/Annual
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then applied to expenditure data 44 in order to arrive at Full Service Partnership cost per age group. 45 This process
was followed for all counties in order to maintain uniformity and in order to rely upon county-informed breakouts.
46
The definition of annual cost average for each age group, in each fiscal year, in each county is:
Aggregated Program Cost
per Age Group
Standardized Client Years
per Age Group
“Program” refers to the summary of all programs operating within a county for each particular age group. This is
the manner in which expenditures are rolled up and reported on the CSS “Program” worksheet.
“Cost” for a given fiscal year is defined as the aggregate cost of all programs for an age group, determined using
the most recent revision of the Revenue and Expenditure (RER) report for a given fiscal year that has been
prepared by the county, in combination with information from that county via web survey that provides a
determination as to how program costs should be broken out into age groups.
Program costs may be adjusted by housing that may be reported outside the FSP program expenditure sheets in
some counties (e.g., on the CSS General System Development worksheet).
“Standardized Client Years” is defined as the number of full FSP client years of service provided across all programs
regardless of numbers of clients entering or exiting, or the individual duration of services. This particular aspect of
the calculation is discussed in more detail below (see 7. Standardized Client Years for further discussion).
6. Cost Components
The proposed data sources and procedures to meet the basic requirement of calculating the annualized number of
clients and FSP program cost per age group are described in this section.
Numerator
The numerator is the Aggregated Program Cost per Age Group. The data source was the Revenue and Expenditure
Report, cumulative across FSP programs. Costs were limited to those reported for FSP clients, using funding
sources identified in the RER program summaries combined with information provided by counties via the web
survey.
Update numbers were unclear/not specific, the actual numbers served by age group in each fiscal year were used as the basis for developing
proportions by age group. The county’s FSP costs by age group were then submitted to the county for review and input.
44 Counties were asked to report on the amount spent per age group on supportive services provided to Full Service Partnership participants by
age group. Some counties accounted for all of their FSP expenditures using this method (verified by matching back to their Revenue and
Expenditure Report). Other counties accounted for only a proportion. For counties that did not account for all Full Service Partnership line-item
expenditures in the web survey, the expenditures used for cost calculations defaulted to the Full Service Partnership line items in the county’s
Revenue and Expenditure Report.
45 Not all counties serve all age groups, but the calculation for these counties was simple. For example, County X indicates that nothing was
spent on Older Adults during FY 08-09. Zero proportion of cost is multiplied by the total FSP expenditure amount, for a total cost of $0. The
value $0 is reflected on County X’s FSP Costs and Cost Offsets Excel spreadsheet.
46 There are a few anomalies – counties that show no expenditures on a certain age group yet show DCR data for this age group. In cases such
as these, the anomaly is noted on the county worksheet, and counties were provided another opportunity for review and feedback following
distribution of revised FSP Costs and Cost Offsets Excel worksheets on July 27, 2012.
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Denominator
The denominator is the Standardized Client Years per Age Group. The data source was FSP clients as identified in
the State Department of Mental Health’s Data Collection and Reporting System (DCR). The DCR was briefly
introduced in Chapter II, Involvement of Key Stakeholders. The following description comes from Phase II
Deliverable 2.E (draft, p. 8):
The DCR system houses data for clients who are served through Full Service Partnership
programs. Data from assessments – the Partnership Assessment Form (PAF), Key Event Tracking
(KET) and Quarterly Assessment (3M) – are collected for clients in specific age categories.
The PAF reflects client history and baseline information, including client education
and/or employment, housing situation, legal issues, health status and substance use.
The KET reflects any important changes in the client’s life such as housing, education
and/or employment and legal issues during Full Service Partnership.
The 3M is used to collect information quarterly on key areas such as education, health
status, substance use and legal issues.
See Standardized Client Years for further discussion.
Fiscal Years Analyzed
The two fiscal years (FY) selected for analysis were FY 08-09 and FY 09-10. These two years were selected as a
result of available data in the DCR. Without DCR data for most of the counties, Standardized Client Years per Age
Group cannot be calculated (see Exhibit III.1 for a summary of the available data sources and their limitations).
Data from earlier fiscal years are incomplete across California counties. 47 The rationale for the focus on later
implementation years is that no statewide assumptions can be made in earlier fiscal years.
Start-up costs 48 are not included in the formula. 49
FY 07-08 is not included in the formula, or in this report, because DCR data are not available for most of the
counties.
7. Standardized Client Years
Standardized Client Years represent a numeric value in the denominator of our annual cost-per-FSP-client rate
calculation. Calculations are completed separately for each fiscal year and for each age group. The definition of this
numeric value, and the rationale for this definition, are provided in this chapter.
Standardized Client Years are calculated through the following process (again, note that this process is run
separately for each fiscal year and for each age group):
Identified all clients who were enrolled in FSP during the target fiscal year;
47 See Phase II Deliverable 2.E –Priority Indicator Report.
48 In addition, external shocks to system (realignment and the end of AB 2034) occurred in earlier fiscal years, calling into question the ability to
replicate the cost calculation into other fiscal years had earlier years been included in the analysis. Counties also provided evidence that RER
instructions changed significantly from FY 06-07 to FY 07-08. Documentation may be provided, upon request.
49 Start-up for each individual county is defined as the first two years of FSP expenditures. Therefore, the actual fiscal years vary, depending
upon the county.
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Calculated the number of days that each was enrolled during the target fiscal year (see the discussion
below, as there are nuances to this particular calculation);
Summed number of days enrolled across all enrollees;
Divided by 365 (the number of days in a year).
Enrollment is defined as the period of time that an individual is enrolled in and eligible for services in FSP. This
definition is not dependent on being enrolled in any specific service or on receiving any specific support. The main
assumption is that enrolled participants are receiving FSP services to meet their varying needs at a level that will
help them achieve individualized service plan goals. These targets and the services received by individual
participants will appropriately vary. Enrollment appropriate to this definition was initially defined by the
partnership start and partnership status change dates entered in the Partnership Assessment Form (PAF).50
As has been the case with most MHSA data, however, realities of the data resulted in alternative strategies,
described below under Challenges.
The primary concept that we measured was the number of persons served during each fiscal year (by age group).
Of course, not everyone is enrolled continuously over an entire year. There are four different participation
patterns that needed to be accounted for in our analysis (refer back to the second bullet point, above). We present
them in each fiscal year, in order to avoid any confusion that calculations may have somehow been different for
different fiscal years:
Fiscal Year 08-09:
Start date in FY 08-09 and end date in FY 08-09 51
Start date before FY 08-09 and end date in FY 08-09
Start date in FY 08-09 and no end date (still enrolled)
Start date before FY 08-09 and no end date (still enrolled)
Fiscal Year 09-10:
Start date in FY 09-10 and end date in FY 09-10 52
Start date before FY 09-10 and end date in FY 09-10
Start date in FY 09-10 and no end date (still enrolled)
Start date before FY 09-10 and no end date (still enrolled)
Examples are provided on the following page to illustrate the number of days calculated in each of the four
categories.
50 The Partnership Status Change date on the PAF is updated automatically when there is a change in status on the KET or 3M.
51 We account for FSP clients with multiple start and stop dates within the same fiscal year.
52 For consistency’s sake, we account for FSP clients with multiple start and stop dates within the same fiscal year.
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Here are some examples to illustrate start and end dates within the same fiscal year (FY 08-09):
Sample Client Start Date in FY 08-09 End Date in FY 08-09 # of Days
001 7/3/2008 1/30/2009 211
002 7/17/2008 5/1/2009 288
003 8/26/2008 12/15/2008 111
Here are some examples that show start dates before the fiscal year and end dates within the fiscal year (FY 08-
09):
Sample Client Start Date before FY 08-09 End Date in FY 08-09 # of Days
066 7/3/2007 7/15/2008 576
067 7/17/2007 7/15/2008 653
068 8/26/2007 8/22/2008 476
Below is an example of a start date within the fiscal year but no end date. (FY 09-10). When there is no end date,
the end date defaults to the end of the most recent fiscal year (June 30, 2012).
Sample Client Start Date in FY 09-10 No End Date # of Days
100 7/1/2009 6/30/2012 1,094
Below is one example of a start date before the fiscal year, but no end date (FY 09-10). When there is no end date,
the end date defaults to the end of the most recent fiscal year (June 30, 2012).
Sample Client Start Date before FY 09-10 No End Date # of Days
045 7/1/2008 6/30/2012 1,459
The examples above (number of days) are building blocks used in calculation of Standardized Client Years. 53
However, they do not represent the completion of the calculations, because they have not yet been tallied across
all FSP clients in the age group in the fiscal year of interest, nor has the divisor of 365 been applied. The tables
merely illustrate how calculations as described under the bolded bullet point are completed:
Identified all clients who were enrolled in FSP during the target fiscal year;
Calculated the number of days that each was enrolled during the target fiscal year;
Summed number of days enrolled across all enrollees;
Divided by 365 (the number of days in a year).
For the purpose of discussing FSP cost by age group, we are interested in the number of FSP clients within each age
group who received services from the FSP program in each fiscal year. It doesn’t matter if some of these people
53 Keep in mind that the primary concept is to measure the number of persons served by FSP in each fiscal year. This is very different from the
number of new enrollees each fiscal year. In Chapter IV, we explain why this difference is so important when we discuss cost offsets.
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are the same people in FY 08-09 and FY 09-10. The important consideration is, Did they receive FSP services in that
fiscal year? If the answer is yes, then we counted them. How we counted and arrived at our final calculations is
described below.
Challenges
Through discussion with several counties following review of their draft FSP Costs and Cost Offsets Excel
worksheets, one issue that came to the fore was the variation across counties in number of FSP clients served in
each fiscal year. This feedback prompted further investigation of FSP clients identified as being served in each FY.
In reviewing DCR data for FY 08-09 and 09-10, we found cases with (the terms in quotation marks represent actual
DCR variable names):
Identical start (“PartnershipDate”) and change (“DatePartnershipStatusChange”) dates
o Many cases are enrollees prior to FY 09-10 – which suggests that this anomaly is not due to
clients recently entered into the system,
A “PartnershipStatus” of “1” (indicating an active partner), and
KET assessment dates subsequent to their “DatePartnershipStatusChange” – meaning that KET data were
entered after the date of partnership status change, and somehow the DCR did not recognize that KET
data were entered and update the DatePartnershipStatusChange variable (see example case below).
Subsequent KET assessments (KETs occurring after the original PAF) suggest that a change date equal to the start
date (“DatePartnershipStatusChange”) for such cases is not accurate. The inaccuracy of these end dates prevented
them from being included in our initial counts.54
The names across the table headers represent DCR variable names. The data shown below were extracted from an
actual case out of the DCR to provide an example. The global identification number has been removed to protect
confidentiality.
GlobalID PartnershipStatus PartnershipDate DatePartnershipStatusChange AssessmentDate_KET AssessmentDate_KET AssessmentDate_KET
xxxxxx 1 16-Mar-2007 16-Mar-2007 01-Oct-2009 16-Oct-2009 03-Dec-2009
In brief, the example above suggests that an FSP participant was discharged on the same day he or she was
enrolled, yet the KET date clearly tells us that this is clearly not the case. This problem with the DCR system
prevented cases such as these from being identified initially, given that our initial assumption was to use:
“PartnershipDate” for the date of enrollment; and
“DatePartnershipStatusChange” for the date of FSP conclusion
Other, related, problems were identified in the DCR data:
Start (“PartnershipDate”) and change (“DatePartnershipStatusChange”) dates prior to the FY being
considered,
“PartnershipStatus” of “1” (indicating an active partner) or “3” (indicating a re-enrollee), and
54 A separate issue that should be followed up with DMH is why DatePartnershipStatusChange is not automatically updated when KET is
entered for these cases. This system glitch is troubling.
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Subsequent KET assessments (in the current fiscal year – yet the CHANGE date is in a fiscal year prior to
the fiscal years we are analyzing)
Again, these subsequent KET assessments (dates in the fiscal years we are interested in analyzing) suggest that
change dates (“DatePartnershipStatusChange”) in prior fiscal years, outside of our analysis range, are not accurate.
Thus, the inaccuracy of these change dates prevented them from being included in our initial counts.
The intricacies of the DCR system identified above also impact calculations of days of service. Given the anomalies
uncovered, we came to the determination that the “PartnershipDate,” “DatePartnershipStatusChange” and
“PartnershipStatus” fields are required for accurate estimation of the number of service days each partner
received during a given FY. Decision rules regarding interpretation of the values contained in these data fields are
required so that days of service can be consistently calculated for all FSP clients served in a given FY. Decision rules
for FSP clients based upon their partnership status are outlined below:
For active partners (i.e., “PartnershipStatus” = 1 or 3), days of service were counted from FSP start date
(“PartnershipDate”) or the beginning of the given FY (July 1 for Partnership Dates prior to the FY) to the
end of the FY (June 30).
o Some active partners show identical “PartnershipDate” and “DatePartnershipStatusChange” and
have KET assessments on the same date, within a given FY. For such cases, days of service were
counted from “PartnershipDate” to the end of the given FY, as there is no indication of service
end.
o Active partners with “PartnershipDate” and “DatePartnershipStatusChange” prior to the FY,
some with subsequent KET assessments, other without subsequent assessments. Such cases
were credited with a full FY of service (365 days), as these partners are active and have no
indication of service end.
For non-active partners (i.e., PartnershipStatus = 0) with “DatePartnershipStatusChange” within the FY or
subsequent to the end of the given FY, days of service were counted from start date (“PartnershipDate”)
or the beginning of the given FY (July 1 for partnership dates prior to the FY) to a
“DatePartnershipStatusChange” within the FY or the end of the FY (June 30).
o Some non-active partners also show identical “PartnershipDate” and
“DatePartnershipStatusChange,” and have KET assessments on the same date, within a given FY.
These cases were defaulted to a single day of service.
Specific decision rules regarding the values (i.e., dates and partnership status) contained in these data files were
required to produce accurate counts of service days for all FSP clients served in a given FY. These decision rules
were outlined in order to provide the most conservative counts of service days per FSP client.
b. Per-Person Annualized Cost Average by Age Group
Almost all of the counties are included in this Final Report (N = 50; 86.2%). 55 The populations of counties (numbers
of persons residing in the counties according to census data) represented in this report comprise almost all of the
State of California (95.0%). 56
55 Calculations were successfully completed for three additional counties that did not complete the web survey. These three counties aligned
their CSS Plans, Annual Updates, and Revenue and Expenditure Reports in a consistent manner and broke out FSP programs into discrete age
groups. Alignment of plan, update, RER, plus breakout of discrete FSP programs into distinct age groups was a rarity among the counties, but
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The calculations shown in Tables III.1 and III.3 below use annualized cost per FSP client year as a standard metric
for service costs across counties. The calculation of annualized cost per FSP client involved the following steps
(recall from earlier in the chapter):
Identified all clients who were enrolled in FSP during the target fiscal year;
Calculated the number of days that each was enrolled during the target fiscal year;
Summed number of days enrolled across all enrollees;
Divided by 365.
This calculation produces the number of FSP client years of service for the year. Service costs for the year divided
by FSP client years of service for the year equals the Annualized cost per FSP client year for that fiscal year. Here is
the formula for annualized cost per FSP:
FSP Costs Total
Number of Client Years
This quotient was calculated within client age categories, for each fiscal year (FY 08-09 and FY 09-10).
Table III.1
Full Service Partnership Services: Annualized Cost per-Client by Age Group
(Fiscal Year 08-09)
Number of Annualized Cost Daily Cost per- % of Total
Number Served Sum of Days Client Years per-FSP Client FSP Client FSP Costs Total FSP Costs
CYF 4,296 983,187 2,693.7 $ 21,931.29 $ 60.09 $ 59,076,305.79 19.0%
TAY 4,593 1,064,015 2,915.1 $ 18,553.96 $ 50.83 $ 54,086,655.41 17.4%
Adults 9,640 2,404,022 6,586.4 $ 26,737.23 $ 73.25 $ 176,102,066.30 56.7%
Older Adults 1,388 344,979 945.1 $ 22,303.26 $ 61.10 $ 21,078,807.79 6.8%
Total 19,917 4,796,203 13,140.3 $ 310,343,835.29 100.0%
Annualized cost is the total cost for an FSP client over a year (12 months).
$ 23,617.71
The average annualized cost (across all age groups) for Fiscal Year 08-09 is
$ 60.31
The average daily cost (across all age groups) for Fiscal Year 08-09 is
Table III.2 shows overall Full Service Partnership program costs by age group for FY 08-09, using the methodology
we described previously.
this should not be viewed as a “negative” on the part of the counties, because the original intent of the RER had nothing to do with breakouts
by age group. Inclusion of the three additional counties brings the total number of participants to 50 (86.2%).
Note that one county was in start-up during the entire study period, and was therefore removed from the total N for purpose of calculation.
Therefore, the N = 58 (rather than 59). The link to census data is:
http://www.census.gov/popest/research/eval-estimates/eval-est2010.html
56 See Appendix D of the full Report for a list of county participants.
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Table III.2
Full Service Partnership Services: Percent of Core Cost Components Devoted to FSP Clients, by Age Group
(Fiscal Year 08-09)
CYF TAY Adults Older Adults
Amount Percent Amount Percent Amount Percent Amount Percent
Housing $ 2,600,274.29 4.4% $ 3,421,055.77 6.3% $ 20,137,423.03 11.4% $ 1,020,646.55 4.8%
Program Services $ 56,476,031.50 95.6% $ 50,665,599.64 93.7% $ 155,964,643.27 88.6% $ 20,058,161.24 95.2%
Total $ 59,076,305.79 100.0% $ 54,086,655.41 100.0% $ 176,102,066.30 100.0% $21,078,807.79 100.0%
Table III.3 displays the same type of cost information as in Table III.2 but for Fiscal Year 09-10.
Table III.3
Full Service Partnership Services: Annualized Cost per-Client by Age Group
(Fiscal Year 09-10)
Number of Annualized Cost Daily Cost per- % of Total
Number Served Sum of Days Client Years per-FSP Client FSP Client FSP Costs Total FSP Costs
CYF 6,348 1,444,331 3,957.1 $ 17,481.79 $ 47.90 $ 69,177,192.53 18.3%
TAY 6,623 1,619,816 4,437.9 $ 13,741.40 $ 37.65 $ 60,982,974.12 16.1%
Adults 12,733 3,456,407 9,469.6 $ 23,626.13 $ 64.73 $ 223,729,986.45 59.1%
Older Adults 1,764 480,383 1,316.1 $ 18,785.22 $ 51.47 $ 24,723,227.99 6.5%
Total 27,468 7,000,937 19,180.7 $ 378,613,381.09 100.0%
$ 19,739.29
The average annualized cost (across all age groups) for Fiscal Year 09-10 is
$ 50.55
The average daily cost (across all age groups) for Fiscal Year 09-10 is
Table III.4 shows overall Full Service Partnership program costs by age group for FY 09-10, using the methodology
described previously.
Table III.4
Full Service Partnership Services: Percent of Core Cost Components Devoted to FSP Clients, by Age Group
(Fiscal Year 09-10)
CYF TAY Adults Older Adults
Amount Percent Amount Percent Amount Percent Amount Percent
Housing $ 1,686,344.99 2.4% $ 3,675,433.65 6.0% $ 22,691,038.11 10.1% $ 1,385,451.08 10.0%
Program Services $ 67,490,847.54 97.6% $ 57,307,540.47 94.0% $ 201,038,948.34 89.9% $23,337,776.91 90.0%
Total $ 69,177,192.53 100.0% $ 60,982,974.12 100.0% $ 223,729,986.45 100.0% $24,723,227.99 100.0%
The age breakouts reveal that FSP services for Adults comprise most of the expenditures in both fiscal years.
Exhibits III.3 and III.4 display (for each age group) a comparison of the percentage of numbers served, sum of days
and percent of total FSP costs. FSP data from Table III.1 are used in Exhibit III.3. Numbers served in FY 08-09, days
of service and total FSP costs are shown for each age group, as a percentage of the overall total in the fiscal year.
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Exhibit III.3
Age Breakout Cost Comparisons: Percentages in FY 08-09
56.7%
60.0%
50.1%
48.4%
50.0%
40.0%
30.0%
21.6% 23.1%
20.5% 22.2%
19.0% 17.4%
20.0%
7.2%
7.0% 6.8%
10.0%
0.0%
CYF TAY Adults Older Adults
% of # Served % of Sum of Days % of Total FSP Costs
FSP data from Table III.3 are used in Exhibit III.4. Numbers served in FY 09-10, days of service and total FSP costs
are shown for each age group, as a percentage of the overall total in the fiscal year.
Exhibit III.4
Age Breakout Cost Comparisons: Percentages in FY 09-10
70.0%
59.1%
60.0%
49.4%
50.0% 46.4%
40.0%
23.1% 24.1%
30.0%
20.6% 23.1%
18.3%
20.0% 16.1%
6.9%
10.0% 6.4% 6.5%
0.0%
CYF TAY Adults Older Adults
% of # Served % of Sum of Days % of Total FSP Costs
In both fiscal years, Older Adults are represented nearly equally in terms of:
percentage of overall FSP participants,
percentage of overall number of days, and
proportion (percentage) of overall FSP dollars spent.
They are the only age group that exhibits this characteristic. Adults, as previously noted (Tables III.1 through III.4),
represent the group on which the most FSP funds are spent. Among the age groups, most of the expenditures are
for Adult FSP clients. Among the age groups, they represent approximately half of all FSP participants, and half of
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the overall number of days of service. The argument may be advanced that the serious needs of Adults with
mental illness require greater investment of resources. 57
Children, Youth and Families and Transition-Age Youth display the opposite pattern – the amounts spent on these
two groups as a percentage of the overall age group total is less than their proportional numbers and days of
service. This expenditure pattern may be indicative of the early-intervention nature of FSP services with these age
groups.
c. Contextual Factors – Impact on Cost
Some small counties received additional time to fully implement Full Service Partnership programs. 58 As a result,
not all small counties were fully operational by FY 08-09, and FSP costs varied widely in comparison with FY 09-10.
Although FSP funds were spent during FY 08-09 by these small counties, FSP was not considered to be fully
implemented. Due to major instability in FSP costs from FY 08-09 and FY 09-10, FY 08-09 was set aside for these
counties and not included for statewide analyses. See Appendix D, which lists the small counties for which FY 08-09
was not included in the FY 08-09 analysis.
Note that setting aside a number of small counties should not be viewed as a poor reflection of FSP
implementation by these counties. As noted above (and in the footnotes), the California Department of Mental
Health fully recognized that small counties required additional time to fully ramp up and roll out Full Service
Partnership services, and provided an exception in order to allow small counties additional time.
d. FSP Expenditures by Funding Source
The expenditures for components authorized under the Mental Health Services Act include:
Mental Health Services Act,
State General Fund,
Other State Funds,
Medi-Cal Federal Financial Participation,
Medicare,
Other Federal Funds,
Realignment,
County Funds, and
Other Funds.
Breakout by age group is not possible due to the limitations of the RER, discussed in earlier in this chapter (see also
Appendix E).
Exhibit III.5 displays FSP expenditures from all counties and municipalities that submitted a Revenue and
Expenditure Report in FY 08-09 and/or FY 09-10. Therefore, the pool of counties/municipalities included in the
57 See Chapter II of the full Report for hypotheses to be tested in future reports related to implementation of evidence-based practices and
potential impact on cost.
58 http://www.dmh.ca.gov/DMHDocs/docs/notices08/08-02.pdf
http://www.dmh.ca.gov/DMHDocs/docs/notices08/08-19.pdf
http://www.dmh.ca.gov/DMHDocs/docs/notices08/08-36.pdf
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analysis of proportion of FSP expenditures by funding source is slightly larger than the participant pool for the FSP
Costs and Cost Offsets study (see Appendix E).
Exhibit III.5
Proportion of FSP Expenditures by Funding Source
(FY 08-09 & FY 09-10)
$1.00 $0.03 $0.03
$0.90
$0.80
$0.70
$0.62 Other*
$0.66
$0.60
Proposition 63 Funds (MHSA)
$0.50
Federal Financial Participation (FFP)
$0.40
Realignment
$0.30
State General Fund (SGF)
$0.20 $0.30
$0.26
$0.10
<$0.00 <$0.00
$0.05 $0.05
$-
FY 08-09 FY 09-10
*Other Funds: Medicare, Other State, County, Other, Other Federal
MHSA expenditures on Medi-Cal increased in FY 09-10 compared with FY 08-09. The increase in MHSA
expenditures on leveraged resources suggests that counties and municipalities are successfully leveraging MHSA
in order to bring in additional federal dollars.
e. Summary
This report identifies the average statewide annual and per-day cost of providing FSP services to clients in
California. The costs of FSP services are calculated in two categories: program services 59 – which includes activities
required under the Mental Health Services Act, as well as any evidence-based models and/or practices offered –
and housing costs. 60 While FSP clients may be represented in marginal additional costs (e.g., outreach) there is not
a feasible way of parsing these expenditures, and impacts on cost estimates would be minor.
59 In addition, FSP program services costs may include administrative costs related to operating the FSP program, overhead, and other costs
typically considered “other direct costs” that support FSP program operations. For example, it would be unrealistic to expect that contractors
do not include ODC and administrative costs when submitting FSP budgets to counties for approval. ODC and administrative costs are standard
operating costs necessary to support programs and program staff, and typically included in any program budget (FSP or otherwise).
60 Housing is defined as housing support, operating support and housing placement. It does not include the Governor’s Housing Initiative.
Housing support is the cost of housing subsidies for permanent, transitional and temporary housing; master leases; motel and other housing
vouchers; rental security deposits; first- and last-month rental payments; and other fiscal housing supports. The operating costs of providing
housing supports to clients include building repair and maintenance, utilities, housing agency management fees, insurance, property taxes and
assessments, and credit reporting fees. Housing placement is assistance in securing housing, including supportive housing – permanent
affordable housing with combined supports for independent living.
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IV. Cost Offsets for Full Service Partnership Programs
One focus of this chapter is “whether costs incurred in providing mental health services … are offset by reduced
costs elsewhere in the health care system.” 61 By virtue of the data collected at the time of intake and follow-up, we
have been able to expand exploration of cost reduction beyond the health care system, to include incarceration.
Specifically, we explore whether the costs of providing the Full Service Partnership are offset by reduced costs in: 62
Physical Health Services
Acute Care Inpatient Hospitalization (number of days) 63
Skilled Nursing (Non-Psychiatric) (number of days)
Emergency Room Visits (number of times)
Psychiatric Care
Inpatient Psychiatric Hospitalization (number of days)
Long-Term Care (number of days) 64
Skilled Nursing (Psychiatric) (number of days)
Criminal Justice Involvement
Arrests (number of times)
Division of Juvenile Justice (number of days)
Juvenile Hall/Camp (number of days)
Jail (number of days)
Prison (number of days)
Results are presented for each age group.
a. Methodology
There are four formulas that are completed when calculating cost offsets (regardless of whether we are calculating
offsets for physical health, psychiatric care or criminal justice). In this section (methodology), each calculation is
61 Fells, T. (1999). Is there a cost offset to psychotherapy? Journal of Psychotherapy Practice and Research, 8, 243, 247. Quote taken from p.
243.
62 Cost Offsets can be developed only for counties that submit data to the State Department of Mental Health’s Full Service Partnership (FSP)
Data Collection and Reporting System (DCR). All of the variables used in the FSP Cost Offset analysis are contained in the DCR. EMT does not
have access to non-DCR data from counties.
The areas analyzed for savings are very similar to those analyzed in the evaluation of AB 2034 efforts, which included inpatient psychiatric
hospitalization and incarceration. Emergency room use was also evaluated but was limited to psychiatric rather than physical health.
California Department of Mental Health (2007). (unpublished) Report to the Legislature on the effectiveness of integrated services for
homeless adults with serious mental illness. Sacramento, CA: Author.
We recognize that there are fixed costs associated with each of the offset categories analyzed. The important point is that participants in the
Full Service Partnership program are less likely to be the ones occupying the inpatient psychiatric bed, jail cell, etc. as a result of intervention.
Obviously, the hospital bed and jail cell are still available for someone else’s use, as it were.
63 As defined in response to physical health needs – we examine psychiatric hospitalization as a separate category of offsets.
64 Institution for Mental Diseases/Mental Health Rehabilitation Centers. The KET does not distinguish between whether an FSP client’s long-
term care was reimbursed at the MHRC rate or the IMD rate. Therefore, an average of the IMD and MHRC rates for the facilities contracted by
each county was used as the basis for calculating the cost applied to the number of days in long-term care.
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introduced and briefly described below. 65 This section is followed by a subsection devoted to each calculation, in
which an in-depth, step-by-step explanation is provided. Please refer to the numbered section (corresponding to
the steps as outlined below) for further explanation of the calculations.
The four calculations are:
1. Out of the larger group of FSP clients new enrollees (FY 08-09 and FY 09-10) are selected.
2. For the pre-intake period (the 12 months prior to enrolling in the FSP), in each of the offset categories –
o Per client:
Number of days per year/number of events per year (annual)
o Annual per-client number of days/events is different from annualized per-client number of
days/events, below, under #3.
3. For the post-enrollment period (the 12 months after intake in the FSP), in each of the offset categories –
o Per client:
Annualized number of days/number of events
o Annualized per-client number of days/number of events is different from annual per-client
number of days/events, above, under #2.
o Annualized per-client number of days/number of events involves application of an annualization
multiplier, in order to arrive at the annualized number of days/number of events per client. The
annualization multiplier is very different from a statewide rate (which is a dollar amount and is
described under #4).
4. A statewide rate (e.g., cost of incarcerating an individual for one day) is applied to arrive at cost offset
(and then applied to number of days of acute hospitalization, etc.)
o After the number of days is multiplied by the rate:
For the pre-intake period (the 12 months prior to enrolling in the FSP), the annual per-
client cost offset is produced.
For the post-enrollment period (the 12 months after intake in the FSP), the annualized
per-client cost offset is produced.
The methodology for each of these new calculations is described in this section.
1. New Enrollees
All cost-offset analyses were limited to new enrollees in each fiscal year. First we explain what a new enrollee is,
and then we will justify why limiting the cost analysis to new enrollees was imperative.
This new aspect of methodology for calculating cost offsets is actually part of a calculation introduced in Chapter
III. Our new enrollees are the bolded groups. Recall the following:
Fiscal Year 08-09
Start date in FY 08-09 and end date in FY 08-09 66
Start date before FY 08-09 and end date in FY 08-09
65 This brief, succinct introduction to the Methodology section is provided for organizational purposes only (in order to provide an orientation
for the reader as to the subsections that will follow), and will be insufficient to provide complete understanding of the methodology. Please
refer to each subsection, in which step-by-step instructions are provided.
66 We account for FSP clients with multiple start and stop dates within the same fiscal year.
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Start date in FY 08-09 and no end date (still enrolled)
Start date before FY 08-09 and no end date (still enrolled)
Fiscal Year 09-10
Start date in FY 09-10 and end date in FY 09-10 67
Start date before FY 09-10 and end date in FY 09-10
Start date in FY 09-10 and no end date (still enrolled)
Start date before FY 09-10 and no end date (still enrolled)
A new enrollee is identified thus:
FY 08-09: Enrollment date between July 1, 2008, and June 30, 2009
FY 09-10: Enrollment date between July 1, 2009, and June 30, 2010
Any FSP client who did not meet these enrollment-date criteria was excluded from the cost-offset analysis.
Enrollment date was the sole determining factor as to which fiscal year an FSP client was placed into for
purpose of analysis.
An FSP client appeared in only one data set (no one appeared in both fiscal years, despite the fact that an
FSP client who enrolled in FY 08-09 might still be enrolled in FY 09-10). 68
It was critical to limit the cost-offset analysis to new enrollees in order to compare the proverbial apples to apples.
In brief:
At intake, days of hospitalization and incarceration are queried for the 12 months prior to enrollment.
In order to provide a valid comparison (apples to apples), the post-comparison period had to be limited to
the 12 months following enrollment.
Table IV.1 displays the number of FSP clients (new enrollees only) in FY 08-09. FY 08-09 new enrollees are a subset
of the larger group of clients displayed in Table III.1.
Table IV.1
Full Service Partnership Services: New Enrollees by Age Group
(Fiscal Year 08-09)
Number of New
Enrollees FY 08-09
CYF 2,164
TAY 2,327
Adults 4,315
Older Adults 582
Total 9,388
Table IV.2 displays the number of FSP clients (new enrollees only) in FY 09-10. FY 09-10 new enrollees are a subset
of the larger group of clients displayed in Table III.3.
67 For consistency’s sake, we account for FSP clients with multiple start and stop dates within the same fiscal year.
68 Length of participation is handled through the annualization calculation. Refer back to the discussion of methods in Chapter III.
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Table IV.2
Full Service Partnership Services: New Enrollees by Age Group
(Fiscal Year 09-10)
Number of New
Enrollees FY 09-10
CYF 3,101
TAY 2,977
Adults 4,702
Older Adults 645
Total 11,425
2. Pre-Intake Period – 12 Months Prior to Enrolling in FSP: Annual per-Client Offset-
Category Cost
This concept is actually straightforward. Because the Partnership Assessment Form (PAF) contains questions for
FSP clients about number of days hospitalized, etc., in the 12 months prior to enrollment, there is no need to apply
an annualization formula. The period of time in question is already 12 months.
PAF data are collected by individual counties, and then entered into the State of California Department of Mental
Health’s Data Collection and Reporting System (DCR). EMT received the DCR data (updated through June 30, 2011)
through the contract to conduct the Statewide Evaluation of the Mental Health Services Act.
Therefore, annual per-client offset-category cost is calculated for the baseline (pre-enrollment) through the
following steps:
Identified all clients who enrolled in FSP during the target fiscal year. 69
Through intake interview data (PAF), identified the number of days of hospitalization, incarceration, etc.,
for each client. 70
In the year prior to enrollment, summed across all clients, multiplied by the daily negotiated cost for the
county 71 and divided by the number of clients enrolled in FSP during the target year. 72
This quotient is the annual per-client (offset-category) cost for the baseline, the year prior to enrollment.
3. Post-Intake Period – 12 Months Post-Enrollment into FSP: Annualized per-Client Offset-
Category Cost
The manner in which annualization is calculated has already been described (Chapter III), and the methodology is
no different when applied to cost offsets. 73
Annualized per-client (offset-category) cost is calculated for the period of time each client is in FSP following
enrollment. This post-enrollment offset-category cost is calculated through the following steps:
69 See above for an explanation of how new enrollees were identified.
70 See each cost-offset category in this section for details.
71 See each cost-offset category in this section for details.
72 Total number of new enrollees – see the Summary tables at the end of this chapter.
73 Annualization of the service period is the same methodology used by the California Department of Mental Health when evaluating and
reporting on AB 2034 outcomes.
California Department of Mental Health (2007). (unpublished) Report to the Legislature on the effectiveness of integrated services for
homeless adults with serious mental illness. Sacramento, CA: Author.
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Identified all clients who enrolled in FSP during the target fiscal year (new enrollees), and the number of
those who had been hospitalized, incarcerated, etc. 74
Through Key Event Tracking data, identified: 75
o The number of days enrolled.
o Days Enrolled is then divided into 365 (the number of days in a year), illustrated in the formula
below:
365
Days Enrolled
o This quotient is the annualization multiplier for each new enrollee.
o The annualization multiplier is applied to all new enrollees, whether or not they were
hospitalized, incarcerated, etc. 76
Identified:
o The number of days of hospitalization, incarceration, etc., for each client post-enrollment, and
o Multiplied by each client’s annualization multiplier.
An example annualization multiplier from a randomly selected Adult FSP client = .62
New enrollees with zero (0) days (of hospitalization, for example) drop out of the
analysis at this point, and we are left with those new enrollees with a number of days in
the offset category of interest.
o This product is the annualized number of days of (cost-offset category) for each new enrollee
(e.g., who was hospitalized or incarcerated during the 12-month follow-up period).
The 12-month follow-up period is completely tailored to the individual FSP client, and
entirely based upon the date of intake into the FSP. For example:
Sample Client Intake (Start Date in FY 08-09) 12-Month Follow- # of Days
Up Period
(Follow-Up goes
into FY 09-10)
251 12/1/2008 11/31/2009 365
Note that this particular FSP client is a new enrollee in FY 08-09 based on the intake date of
12/1/2008. This FSP client is not “double-counted” as a new enrollee in FY 09-10 because there is
no intake date in FY 09-10. The data shown in the table above illustrate the following about the
12-month follow-up period:
The 12-month follow-up period is tied to the individual FSP client;
The 12-month clock starts ticking with the individual FSP client’s date of intake; and
The 12-month follow-up period can cross fiscal years for an individual client.
Summed annualized days of (cost-offset category) across all new enrollees. 77
74 See each cost-offset category in this section for the exact DCR variables that were used in the calculations.
75 See Chapter III for an introduction to the KET, variables used when calculating number of days of FSP participation, and each cost-offset
category in this chapter for the specific cost-offset variables used in analysis.
76 See Chapter III for how days of enrollment were calculated.
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o Multiplied by the daily negotiated cost of psychiatric hospitalization, incarceration, etc., for the
county, 78 and
o Divided by the number of new enrollees in FSP during the target year. 79
This quotient is the annualized per-client hospitalization, incarceration, etc., cost for the post-enrollment period.
Again, note that we limited the analyses to new enrollees in order to have a match with the 12-month pre-
enrollment period, in essence, to compare the 12 months following enrollment with the 12-month period prior to
enrollment (PAF question asks about the 12 months prior to enrollment when asking about hospitalization, etc.).
This chapter summarizes the program costs for clients who initially enrolled in FSP during the target fiscal year, the
amount of offsets, and the percentage of one-year program costs that have been saved in annualized physical
health care, psychiatric care and criminal justice through FSP participation by these new enrollees.
b. Physical Health Services
For the purpose of calculating costs and cost offsets, physical health services include:
Acute Care Inpatient Hospitalization (number of days)
Skilled Nursing (Non-Psychiatric) (number of days)
Emergency Room Visits (number of times)
Costs and cost savings in each of these categories for FSP clients are presented in the following sections.
1. Acute Care Inpatient Hospitalization (Physical Health)
According to the Agency for Health Care Research and Quality (2002), the United States spends more money per
person on health care than any other nation in the world. 80 Stanton and Rutherford (2005) reported that physical
health care costs in the U.S. continued to grow from $1,106 per person in 1980 to about $6,280 per person in
2004.81 Cohen and Herbert (1996) reported in their study that emotional stressors, including negative affect, low
social support and clinical depression, also influence immune-system functioning and contribute to a number of
physical problems. 82
The Substance Abuse and Mental Health Services Administration recently released a national study 83 indicating
that adults (age 18 or older) with any mental illness (regardless of whether it was classified as severe mental
illness) were more likely than adults without mental illness to have:
High blood pressure
77 Note that FSP clients who do not have any days of hospitalization, incarceration, etc., have dropped out of the analysis at this point.
78 See each specific offset category in this chapter for where these rates were obtained and the manner in which they were applied.
79 Total number of new enrollees – see the Summary tables at the end of this chapter.
80 As cited by Crane, D. D., & Christenson, J. (2008). The medical offset effect: Patterns in outpatient services reduction for high utilizers of
health care. Contemporary Family Therapy: An International Journal, 30(2), 127-138.
81 Ibid.
82 Ibid.
83 http://www.samhsa.gov/data/2k12/NSDUH103/SR103AdultsAMI2012.pdf
Substance Abuse and Mental Health Services Administration (2012). Physical Health Conditions among Adults with Mental Illnesses.
Washington, DC: Government Printing Office.
Years analyzed included combined 2008 and 2009 National Survey on Drug Use and Health.
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Asthma
Diabetes
Heart disease
Stroke
In addition, adults with mental illness were more likely to have used an emergency room and to have been
hospitalized.84
Several studies have shown that providing mental health therapy to individuals suffering from mental illness
results in a decrease in the use of other health services. In 1999, Chiles et al. performed a comprehensive meta-
analysis of 91 medical cost-offset studies in medical populations published between 1967 and 1997 and concluded
that 90 percent of the studies reported some degree of decreased medical (physical health) utilization following
psychological intervention. The estimated savings were $1,759 (U.S.) per person over all of these studies. 85 The
results showed an average physical health care use decline of 23.6 percent following individual therapy.
Furthermore, the study found that those in no-treatment comparison groups increased physical health care use by
9.16 percent. 86
Another study conducted by the Group Health Association found that patients in Kansas City receiving mental
health interventions decreased their non-psychiatric usage by 30.7 percent. Lab and X-ray costs (for physical health
issues) also decreased by 29.8 percent (Lane, 1998). 87
A Kaiser Permanente study indicated that patients who participated in psychotherapeutic interventions decreased
their average length of hospital stay (for physical health ailments) by 77.9 percent, had a 66.7 percent decrease in
physical health hospitalization frequency, a 47.1 percent decrease in physician office visits, a 45.3 percent decrease
in emergency room visits, and a four (4) percent decrease in the number of prescriptions received (Sobel, 2000). 88
Law and Crane found similar results in 2000 when they studied medical (physical health) offsets among a sample of
participants receiving therapy from marriage and family therapists through a health maintenance organization
(HMO) and found a significant, 21.5 percent decrease in physical health care use following behavioral health
therapy. 89
Statewide Acute Care Inpatient Hospitalization Rate (Physical Health)
The Office of Statewide Health Planning and Development (OSHPD) is the source for the rates applied by county
for acute inpatient care. 90 Among the counties that participated, a “statewide” rate was determined by calculating
an average of the rates for counties that participated in this round of the study. 91 The statewide rate for FY 08-09
is:
Inpatient Hospitalization - Physical
Statewide Average FY 08-09 $2,546.01
84 For non-psychiatric reasons. SAMHSA analyzed psychiatric ER use and hospitalization separately.
85 As cited by Carlson, L. D. (2004). Efficacy and medical cost offset of psychosocial interventions in cancer care: Making the case for economic
analyses. Psycho-Oncology, 13(12), 837-849.
86 Ibid.
87 As cited in Crane, D. D., & Christenson, J. (2008). The medical offset effect: Patterns in outpatient services reduction for high utilizers of
health care. Contemporary Family Therapy: An International Journal, 30(2), 127-138.
88 As cited by Crane, D. D., & Christenson, J. (2008). The medical offset effect: Patterns in outpatient services reduction for high utilizers of
health care. Contemporary Family Therapy: An International Journal, 30(2), 127-138.
89 Ibid.
90 http://www.oshpd.ca.gov/hid/Products/Hospitals/Utilization/Hospital_Utilization.html
91 See Appendix D for a list of counties that participated.
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The statewide rate for FY 09-10 is:
Inpatient Hospitalization - Physical
Statewide Average FY 09-10 $2,676.36
The OSHPD data set 92 includes all hospitals in each county. If a county has more than one hospital providing acute
hospitalization services, an average within the county was first calculated in order to arrive at a rate for each
county. Below is the definition of acute care hospitalization, as provided by OSHPD.
Acute Care Hospitalization
Acute care refers to the daily hospital service cost centers related to the provision of general acute care, such as
Medical/Surgical Acute, Obstetrics Acute, Definitive Observation, Medical/Surgical Intensive Care and Coronary
Care. The specific rate used in calculations was the Total Net Inpatient Revenue per day from all payer sources. 93
DCR Variables Analyzed at Baseline (Intake) and Follow-Up
The Key Event Tracking Form 94 does not indicate the specific facility in which an individual was hospitalized – only
that an inpatient stay occurred for physical health reasons. Below are the exact variables we used out of the PAF
and the KET, and their definitions. 95
PAF (Intake/Baseline) Variable: MedicalHospital_PastTwelveDays 96 – Defined as:
o RESIDENTIAL INFORMATION: Hospital - Acute Medical Hospital;
o Indicates the number of DAYS the partner has been living in this setting during the past 12
months;
o Valid Codes: 0-365
KET (Follow-Up) Variable: Current.1 through Current.155 = 8, which is a categorical variable assigned to
represent Medical Hospital.
o The Current variables represent the residential status of the FSP client at the time of each follow-
up.
o Follow-ups (as documented on the KET) are not conducted according to any predetermined time
frame, but rather are driven by Key Events occurring in the FSP client’s life (e.g., hospitalization,
incarceration).
o The DCR allows for entry of up to 155 KETs.
This information, on its own, is insufficient to calculate the number of days that an FSP client was hospitalized for
medical reasons. 97 What the Current variable (code = 8) tells us is only that an FSP client was hospitalized for
medical (physical health) reasons, not how many days.
So the challenge for the analysis was how to determine the number of days of acute (physical) inpatient
hospitalization, over 155 possible follow-up points. This is the focus of the Calculations section that follows.
92 Available for download from its website, http://www.oshpd.ca.gov/hid/Products/Hospitals/Utilization/Hospital_Utilization.html
93 The OSHPD worksheets are available online. http://www.oshpd.ca.gov/hid/Products/Hospitals/Utilization/Hospital_Utilization.html
94 The Key Event Tracking Form is collected by counties and entered into the DCR. EMT receives the data only for analysis.
95 Courtesy of California State University, Sacramento (Sac State), currently the contractor managing the DCR.
96 Page 79, DCR Data Dictionary Final_20110915. California State University, Sacramento. There have been multiple releases of the DCR, and at
least two in 2011 marked “Final.” This version will be provided upon request.
The variable wording is confusing because it seems to suggest occurrence over the past 12 days. The variable name and description,
however, have been reproduced verbatim from Sac State’s data dictionary. The variable actually refers to the number of days over the past 12
months (prior to FSP intake).
97 This particular analysis does NOT include psychiatric reasons – we examine those separately, later in this chapter.
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Calculations – Follow-Up, 12 Months Post-Intake: Acute Care Inpatient
Hospitalization (Physical Health)
Accompanying each Current variable is a DateResidentialChange variable. This variable tells us on what date the
FSP client’s residential setting changed.
Therefore, we developed programming commands in SPSS that performed the following calculations for each KET
follow-up period:
1. Selected only those FSP clients who were hospitalized for acute medical (physical health): Current = 8.
2. Calculated the number of days hospitalized by taking the subsequent DateResidentialChange and
subtracting the current DateResidentialChange.
You might point out, “But wait! What about those who were still hospitalized at the second follow-up?”
Their Current.2 status would still = 8, and their number of days would be calculated for the second time period.
There are additional steps to these calculations:
3. After this process was completed 155 times, the number of days hospitalized was summed for each FSP
client to arrive at a grand total for each person.
o The sum is necessary in order to account for subsequent stays that cross KET administrations, as
well as intermittent stays by the same person during his or her FSP involvement.
4. Days Enrolled is then divided into 365 (the number of days in a year), illustrated in the formula below:
365
Days Enrolled
o Days Enrolled, when used in this formula, is not annualized. What we are interested in is the total
time period in which an FSP client was enrolled. What we produce is a proportion, which is then
applied against the Number of Days Hospitalized to adjust for the period of time that a person
was at risk for hospitalization. If we do not apply this adjustment, we would unfairly weight the
results for or against people who were in the program for shorter or longer periods of time.
o Days Enrolled is: 98
DatePartnershipStatusChange_KET – PartnershipDate 99
5. The proportion calculated for each FSP client out of Step 4 is then multiplied by the sum of days
hospitalized in Step 3. This is how we arrive at the number of days hospitalized, without a bias for length
of enrollment.
Findings: Acute Care Inpatient Hospitalization (Physical Health)
Tables IV.3 through IV.6 present cost offsets for each of the age groups, in each fiscal year, for inpatient acute
medical (physical health) hospitalization.
Table IV.3 represents FY 08-09, and Table IV.5 FY 09-10:
98 Elements of this formula were explained in Chapter III. The only element missing from what was presented in Chapter III is the annualization
factor (dividing by 365). But it does not apply here – we are developing a proportion to be applied against number of days hospitalized.
99 Applying all of the caveats discussed in Chapter III, section c. Contextual Factors – Impact on Cost.
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12 Months Pre-Intake – The data displayed under any column marked “Pre” correspond to those collected at
baseline. 100 “Pre-Intake” means before the client enrolled in FSP.
For baseline (intake, 12 months prior to enrolling in FSP):
Number of Days per Year
12 Months Pre-
Intake
Number of Days per Year = the actual number of days (total, across all FSP clients) of hospitalization for
acute medical (physical health) reasons.
o This is an annual number because it is the actual number of days in the 12 months prior to
enrolling in FSP. Nothing is done to this number – no changes or adjustments are made to it – it is
exactly as the FSP client reported on the PAF.
Pre-FSP Cost
Pre-FSP Cost = Number of Days (Pre) multiplied by the Statewide Rate for Acute Care Inpatient
Hospitalization (Physical Health).
o This is an annual cost because the Statewide Rate is multiplied by the actual number of days per
year (see the bullet point above).
12 Months Post-Intake – The data displayed under any column marked “Post” correspond to those collected in the
follow-up period. “Post-Intake” means after the client enrolled in FSP.
For follow-up (post-enrollment, 12 months after enrolling in FSP):
Number of Days per Year
12 Months Post-
Intake
Through Key Event Tracking data, identified: 101
o The number of days enrolled.
o Days Enrolled is then divided into 365 (the number of days in a year), illustrated in the formula
below:
365
Days Enrolled
o This quotient is the annualization multiplier for each new enrollee.
o The annualization multiplier is applied to all new enrollees, whether or not they were
hospitalized for acute medical (physical health) reasons. 102
100 Refer back to the discussion earlier in the chapter for the explanation about which variables we analyzed, and why.
101 See Chapter III for an introduction to the KET, variables used when calculating number of days of FSP participation, and each cost-offset
category in this chapter for the specific cost-offset variables used in analysis.
102 See Chapter III for how days of enrollment were calculated.
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Identified:
o The number of days of acute medical (physical health) hospitalization for each FSP client during
the 12-month post-enrollment period, and
o Multiplied by each FSP client’s annualization multiplier.
New enrollees with zero (0) days (of acute care inpatient hospitalization, for physical
health reasons) drop out of the analysis at this point, and we are left with those new
enrollees who spent at least one day in an inpatient acute hospital for physical health
reasons.
o This product is the annualized number of days of acute medical (physical health) hospitalization
for each new enrollee who was hospitalized (inpatient) for acute medical (physical health
reasons) during the 12-month follow-up period.
Post-FSP Cost
Post-FSP Cost = Number of Days (Post) multiplied by the Statewide Rate for Acute Care Inpatient
Hospitalization (Physical Health).
o This is an annualized cost because the Statewide Rate is multiplied by the annualized number of
days (see the bullet point above).
Decrease in
Number of Days
Decrease in Number of Days = Number of Days at Baseline (Pre) minus the Number of Days at Follow-Up
(Post):
Pre – Post = Decrease in Number of Days
Total Cost Offset
Total Cost Offset = Pre-FSP Cost – Post-FSP Cost
Percent of Offset
Percent of Offset =
Total Cost Offset
Pre-FSP Cost
o In other words, the percent of Acute Care Inpatient Hospitalization (Physical Health) offset is
equal to the total cost offset for Acute Care Inpatient Hospitalization (Physical Health) divided by
the pre-FSP cost for Acute Care Inpatient Hospitalization (Physical Health).
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The figures for baseline and follow-up in Table IV.3 are for FSP clients who enrolled in FY 08-09.
Table IV.3
Full Service Partnership Services – Total Annual Cost Offset for Number of Days Hospitalized – Acute Care
Physical Health
(Fiscal Year 08-09 New Enrollees ONLY)
Number of Days per Year Decrease in
12 Months 12 Months Number of Percent of
Pre-Intake Post-Intake Days Pre-FSP Cost Post-FSP Cost Total Cost Offset Offset
CYF 611 282 329 $ 1,555,609.36 $ 717,973.55 $ 837,635.81 53.8%
TAY 1,735 1,625 110 $ 4,417,319.54 $ 4,137,258.93 $ 280,060.61 6.3%
Adults 5,880 5,812 68 $ 14,970,512.32 $ 14,797,383.94 $ 173,128.38 1.2%
Older Adults 1,897 1,696 201 $ 4,829,772.43 $ 4,318,025.32 $ 511,747.11 10.6%
Total 10,123 9,415 708 $ 25,773,213.65 $ 23,970,641.74 $ 1,802,571.91 7.0%
Table IV.4 represents FY 08-09, and Table IV.6 FY 09-10. Each table is divided in half, with the left half labeled:
12 Months Pre-Intake – the data displayed in this half correspond to those collected at baseline. “Pre-
Intake” means before the client enrolled in FSP.
For baseline (intake, 12 months prior to enrolling in FSP):
Number Hospitalized = the actual number of FSP clients who were hospitalized for acute medical (physical
health) reasons.
o An FSP client is counted only one time at baseline (regardless of whether he or she was
hospitalized multiple times during the 12 months prior to intake). 103
o Number Hospitalized is number of persons hospitalized (across all counties participating in the
study), not number of times hospitalized, average number per county or some other metric.
Average Number of Days per Year = the average number of days FSP clients were hospitalized.
o At baseline, it is simply the average number of days as reported on the PAF.
Annual per-Client Cost = Pre-FSP Cost divided by the total number of new enrollees for the fiscal year. 104
Here is an illustration of the calculation, using data from CYF:
Pre-FSP Cost
$ 1,555,609.36
(this figure comes from Table IV.3)
Number of New
Enrollees FY 08-09
CYF 2,164
(this figure comes from Table IV.1)
=
103 This is one example of our conservative approach to estimation of cost offsets.
104 See the discussion above Table IV.3 for calculation of total FSP cost.
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Annual per Client
Cost (Pre-Intake)
$ 718.86
(this figure is shown below, in Table IV.4)
The right half is labeled:
12 Months Post-Intake – the data displayed in this half correspond to those collected in the follow-up
period. “Post-Intake” means after the client enrolled in FSP.
For follow-up (post-enrollment, 12 months after enrolling in FSP):
Number Hospitalized = the actual number of FSP clients who were hospitalized for acute medical (physical
health) reasons.
o An FSP client is counted only one time at follow-up (regardless of whether he or she was
hospitalized multiple times during follow-up). 105
o Number Hospitalized is number of persons hospitalized (across all counties participating in the
study), not number of times hospitalized, average number per county or some other metric.
Average Number of Days per Year = an average of the annualized total number of days FSP clients were
hospitalized. Because the Average Number of Days per Year is an average of an annualized number, it is
also an annualized number.
Annualized per-Client Cost = Post-FSP Total Cost divided by the total number of new enrollees for the
fiscal year. 106 Here is an illustration of the calculation, using data from CYF:
Post-FSP Cost
$ 717,973.55
(this figure comes from Table IV.3)
Number of New
Enrollees FY 08-09
CYF 2,164
(this figure comes from Table IV.1)
=
Annualized per-
Client Cost
$ 331.78
(this figure is shown, below, in Table IV.4)
105 This is one example of our conservative approach to estimation of cost offsets.
106 See the discussion above Table IV.3 for calculation of total FSP cost.
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The figures for baseline and follow-up in Table IV.4 are for FSP clients who enrolled in FY 08-09.
Table IV.4
Full Service Partnership Services – Annualized per-Client Cost for Number of Days Hospitalized – Acute Care
Physical Health
(Fiscal Year 08-09 New Enrollees ONLY)
12 Months Pre-Intake 12 Months Post-Intake
Number Average Number Annual per- Number Average Number Annualized per-
Hospitalized of Days per Year Client Cost Hospitalized of Days per Year Client Cost
CYF 38 3.0 $ 718.86 17 3.7 $ 331.78
TAY 89 7.9 $ 1,898.29 96 9.4 $ 1,777.94
Adults 296 14.9 $ 3,469.41 402 7.4 $ 3,429.29
Older Adults 87 8.6 $ 8,298.58 103 6.5 $ 7,419.29
Total 510 618
The figures for baseline and follow-up in Table IV.5 are for FSP clients who enrolled in FY 09-10.
Table IV.5
Full Service Partnership Services – Total Annual Cost Offset for Number of Days Hospitalized – Acute Care
Physical Health
(Fiscal Year 09-10 New Enrollees ONLY)
Number of Days per Year Decrease in
12 Months 12 Months Number of Percent
Pre-Intake Post-Intake Days Pre-FSP Cost Post-FSP Cost Total Cost Offset of Offset
CYF 419 695 -276 $ 1,121,393.08 $ 1,860,067.27 $ (738,674.19) -65.9%
TAY 2,113 831 1,282 $ 5,655,139.78 $ 2,224,051.66 $ 3,431,088.12 60.7%
Adults 7,763 5,675 2,088 $ 20,776,549.99 $ 15,188,319.11 $ 5,588,230.88 26.9%
Older Adults 1,231 1,605 -374 $ 3,294,593.98 $ 4,295,551.04 $ (1,000,957.06) -30.4%
Total 11,526 8,806 2,720 $30,847,676.83 $ 23,567,989.08 $ 7,279,687.75 23.6%
Studies have shown that initial engagement of individuals with serious mental illness in supported care results in
increased use of medical health services. Prior to enrollment in FSP, physical health needs have been neglected,
and poor health is “exacerbated by years of untreated severe mental illness, habitual substance use and
homelessness” (Iyog-O’Malley, 2012, p. 9). 107
The figures for baseline and follow-up in Table IV.6 are for FSP clients who enrolled in FY 09-10.
Table IV.6
Full Service Partnership Services – Annualized per-Client Cost for Number of Days Hospitalized – Acute Care
Physical Health
(Fiscal Year 09-10 New Enrollees ONLY)
12 Months Pre-Intake 12 Months Post-Intake
Number Average Number Annual per- Number Average Number Annualized per-
Hospitalized of Days per Year Client Cost Hospitalized of Days per Year Client Cost
CYF 57 3.0 $ 361.62 25 10.8 $ 599.83
TAY 153 8.8 $ 1,899.61 75 4.5 $ 747.08
Adults 340 10.9 $ 4,418.66 294 8.7 $ 3,230.18
Older Adults 87 7.2 $ 5,107.90 98 8.7 $ 6,659.77
Total 637 492
107 Iyog-O’Malley, M. (August 2012). Review and analysis of FSP cost data. Report for Community Behavioral Health Services, City and County of
San Francisco.
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2. Skilled Nursing (Non-Psychiatric)
A skilled nursing facility is a state-licensed facility that provides skilled services such as overall management and
evaluation of a patient care plan, ongoing assessment of rehabilitation needs and therapeutic exercises or
activities. 108
There is an important distinction between skilled nursing facilities that attend to physical health needs and skilled
nursing facilities that focus on psychiatric needs. For the purpose of this analysis, we are focusing on only non-
psychiatric skilled nursing.
As you will read below, the DCR instruments also make a distinction between skilled nursing facilities focused on
physical health needs and those focused on psychiatric needs, as does the Office of Statewide Health Planning and
Development (OSHPD). 109
Statewide Skilled Nursing Facility Day Rate (Non-Psychiatric)
The Office of Statewide Health Planning and Development (OSHPD) is the source for the rates applied by county
for use of skilled nursing facilities (non-psychiatric). A “statewide” rate was calculated by averaging the rates for
counties that participated in this round of the study (see Appendix D). The OSHPD data set 110 includes all skilled
nursing facilities in each county.
The Key Event Tracking Form does not indicate the specific facility in which an individual was hospitalized – only
that a stay in a skilled nursing facility occurred. 111
Therefore, if a county has more than one facility providing skilled nursing (non-psychiatric) services, an average
within the county was first calculated to arrive at a rate for each county. 112 An average rate within a county
means:
The rate for each skilled nursing facility identified for that county (per OSHPD) is automatically tabulated
and averaged in the OSHPD pivot table.
OSHPD is able to distinguish between non-psychiatric and psychiatric skilled nursing facility rates, thereby
matching the DCR variable we analyzed (non-psychiatric – please see below).
We therefore downloaded the non-psychiatric skilled nursing facility average rate from OSHPD.
The statewide rate for FY 08-09 is:
Skilled Nursing - Non-Psychiatric
Statewide Average FY 08-09 $213.96
The statewide rate for FY 09-10 is:
108 http://www.medicareadvocacy.org/medicare-info/skilled-nursing-facility-snf-services/
Medicare and Medicaid Certification are required in order to receive federal reimbursement.
109 OSHPD is our “go-to” source for statewide health-related rates (needed to attach a cost to a day spent in a skilled nursing facility, for
example).
110 Available for download from the website.
111 The categorical code assigned tells us whether it was for psychiatric or non-psychiatric reasons – refer back to the earlier sections on
hospitalization for physical health and psychiatric hospitalization for a discussion about the KET and the use of categorical codes at follow-up.
112 The specific cell within the OSHPD Long-Term Care pivot table is the profile tab, Health Care Expenses by Cost Center, Routine Services,
Skilled Nursing, per Patient Day. http://www.oshpd.ca.gov/hid/Products/Hospitals/Utilization/Hospital_Utilization.html
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Skilled Nursing - Non-Psychiatric
Statewide Average FY 09-10 $230.87
DCR Variables Analyzed at Baseline (Intake) and Follow-Up
Below are the exact variables we used out of the PAF and the KET, and their definitions. 113
PAF (Intake/Baseline) Variable: NursingPhysical_PastTwelveDays 114 – Defined as:
o RESIDENTIAL INFORMATION: Skilled nursing facility (physical);
o Indicates the number of DAYS the partner has been living in this setting during the past 12
months;
o Valid Codes: 0-365
KET (Follow-Up) Variable: Current.1 through Current.155 = 23, which is a categorical variable assigned to
represent Skilled Nursing Facility (Physical).
o The Current variables represent the residential status of the FSP client at the time of each follow-
up.
o Follow-ups (as documented on the KET) are not conducted according to any predetermined time
frame, but rather are driven by Key Events occurring in the FSP client’s life (e.g., hospitalization,
incarceration).
o The DCR allows for entry of up to 155 KETs.
This information, on its own, is insufficient to calculate the number of days that an FSP client was in a skilled
nursing facility (physical health-related). What the Current variable (code = 23) tells us is only that an FSP client
was in a skilled nursing facility for physical health reasons, not how many days.
So the challenge for the analysis was how to determine the number of days in a skilled nursing facility for physical
health reasons, over 155 possible follow-up points. This is the focus of the Calculations section that follows.
Calculations – Follow-Up, 12 Months Post-Intake: Skilled Nursing (Physical Health)
Accompanying each Current variable is a DateResidentialChange variable. This variable tells us on what date the
client’s residential setting changed.
Therefore, we developed programming commands in SPSS that performed the following calculations for each KET
follow-up period:
1. Selected only those FSP clients who were in a skilled nursing facility for physical health reasons: Current =
23.
2. Calculated the number of days in skilled nursing for physical health reasons by taking the subsequent
DateResidentialChange and subtracting the current DateResidentialChange.
3. After this process was completed 155 times, the number of days in a skilled nursing facility (physical
health) was summed for each FSP client to arrive at a grand total for each person.
o The sum is necessary in order to account for subsequent stays that cross KET administrations, as
well as intermittent stays by the same person during his or her FSP involvement.
113 Courtesy of California State University, Sacramento, currently the contractor managing the DCR.
114 Page 85, DCR Data Dictionary Final_20110915. California State University, Sacramento. There have been multiple releases of the DCR, and at
least two in 2011 marked “Final.” This version will be provided upon request.
The variable wording is confusing because it seems to suggest occurrence over the past 12 days. The variable name and description,
however, have been reproduced verbatim from Sac State’s data dictionary. The variable actually refers to the number of days over the past 12
months (prior to FSP intake).
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4. We then took Days Enrolled and divided the figure into 365:
365
Days Enrolled
o Days Enrolled, when used in this formula, is not annualized. What we are interested in is the total
period in which an FSP client was enrolled. What we produce is a proportion, which is then
applied against the Number of Days in Skilled Nursing Facility (physical health) in order to adjust
for the period of time that a person was at risk for stay in a skilled nursing facility for physical
health reasons. If we do not apply this adjustment, we would unfairly weight the results for or
against people who were in the program for shorter or longer periods of time.
o Days Enrolled is therefore: 115
DatePartnershipStatusChange_KET – PartnershipDate 116
5. The proportion calculated for each FSP client out of Step 4 is then multiplied by the sum of days in a
skilled nursing facility (physical health reasons) in Step 3. This is how we arrive at the number of days in a
skilled nursing facility (physical health reasons), without a bias for length of enrollment.
Findings: Skilled Nursing (Physical Health)
Tables IV.7 through IV.10 present cost offsets for each of the age groups, in each fiscal year, for inpatient
psychiatric hospitalization.
Table IV.7 represents FY 08-09, and Table IV.9 FY 09-10:
12 Months Pre-Intake – The data displayed under any column marked “Pre” correspond to those collected at
baseline. 117 “Pre-Intake” means before the client enrolled in FSP.
For baseline (intake, 12 months prior to enrolling in FSP):
Number of Days per Year
12 Months Pre-
Intake
Number of Days per Year = the actual number of days (total, across all FSP clients) in a skilled nursing
facility for physical health reasons.
o This is an annual number because it is the actual number of days in the 12 months prior to
enrolling in FSP. Nothing is done to this number – no changes or adjustments are made to it – it is
exactly as the FSP client reported on the PAF.
Pre-FSP Cost
Pre-FSP Cost = Number of Days (Pre) multiplied by the Statewide Skilled Nursing Facility Day Rate (Non-
Psychiatric).
115 Elements of this formula were presented in Chapter III. The only piece missing from what was presented in Chapter III is the annualization
factor (dividing by 365). But it does not apply here – we are developing a proportion to be applied against number of days hospitalized.
116 Applying all of the caveats discussed in Chapter III, section c. Contextual Factors – Impact on Cost.
117 Refer back to the discussion earlier in the chapter for the explanation about which variables we analyzed, and why.
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o This is an annual cost because the Statewide Rate is multiplied by the actual number of days per
year (see the bullet point above).
12 Months Post-Intake – The data displayed under any column marked “Post” correspond to those collected in the
follow-up period. “Post-Intake” means after the client enrolled in FSP.
For follow-up (post-enrollment, 12 months after enrolling in FSP):
Number of Days per Year
12 Months Post-
Intake
Through Key Event Tracking data, identified: 118
o The number of days enrolled.
o Days Enrolled is then divided into 365 (the number of days in a year), illustrated in the formula
below:
365
Days Enrolled
o This quotient is the annualization multiplier for each new enrollee.
o The annualization multiplier is applied to all new enrollees, whether or not they were in a skilled
nursing facility (for physical health reasons). 119
Identified:
o The number of days in a skilled nursing facility (for physical health reasons) for each FSP client
during the 12-month post-enrollment period, and
o Multiplied by each FSP client’s annualization multiplier.
New enrollees with zero (0) days (in a skilled nursing facility) drop out of the analysis at
this point, and we are left with those new enrollees with number of days in a skilled
nursing facility.
o This product is the annualized number of days in a skilled nursing facility (physical health) for
each new enrollee who was in a skilled nursing facility (for physical health reasons) during the 12-
month follow-up period.
Post-FSP Cost
Post-FSP Cost = Number of Days (Post) multiplied by the Statewide Skilled Nursing Facility Day Rate (Non-
Psychiatric).
o This is an annualized cost because the Statewide Rate is multiplied by the annualized number of
days (see the bullet point above).
Decrease in
Number of Days
118 See Chapter III for an introduction to the KET, variables used when calculating number of days of FSP participation, and each cost-offset
category in this chapter for the specific cost-offset variables used in analysis.
119 See Chapter III for how days of enrollment were calculated.
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Decrease in Number of Days = Number of Days at Baseline (Pre) minus the Number of Days at Follow-Up
(Post):
Pre – Post = Decrease in Number of Days
Total Cost Offset
Total Cost Offset = Pre-FSP Cost – Post-FSP Cost
Percent of Offset
Percent of Offset =
Total Cost Offset
Pre-FSP Cost
o In other words, the percent of Skilled Nursing (Physical Health) offset is equal to the total cost
offset for Skilled Nursing (Physical Health) divided by the pre-FSP cost for Skilled Nursing
(Physical Health).
The figures for baseline and follow-up in Table IV.7 are for FSP clients who enrolled in FY 08-09.
Table IV.7
Full Service Partnership Services – Total Annual Cost Offset for Number of Days in Skilled Nursing Facility
Physical Health
(Fiscal Year 08-09 New Enrollees ONLY)
Number of Days per Year Decrease in
12 Months 12 Months Number of Percent of
Pre-Intake Post-Intake Days Pre-FSP Cost Post-FSP Cost Total Cost Offset Offset
CYF 0 0 0 $ - $ - $ - -
TAY 14 36 -22 $ 2,995.46 $ 7,702.62 $ (4,707.16) -157.1%
Adults 2,031 1,521 510 $ 434,556.10 $ 325,392.87 $ 109,163.23 25.1%
Older Adults 3,175 1,048 2,127 $ 679,328.22 $ 224,231.80 $ 455,096.42 67.0%
Total 5,220 2,605 2,615 $1,116,879.78 $ 557,327.29 $ 559,552.49 50.1%
Table IV.8 represents FY 08-09, and Table IV.10 FY 09-10. Each table is divided in half, with the left half labeled:
12 Months Pre-Intake – the data displayed in this half correspond to those collected at baseline. “Pre-
Intake” means before the client enrolled in FSP.
For baseline (intake, 12 months prior to enrolling in FSP):
Number in Facility = the actual number of FSP clients who were in a skilled nursing facility for physical
health reasons.
o An FSP client is counted only one time at baseline (regardless of whether he or she was in a
skilled nursing facility multiple times during the 12 months prior to intake).
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o Number in Facility is the total number of persons in a skilled nursing facility (across all counties
participating in the study), not number of times in a skilled nursing facility, average number per
county or some other metric.
Average Number of Days per Year = the average number of days FSP clients were in a skilled nursing
facility.
o At baseline, it is simply the average number of days as reported on the PAF.
Annual per-Client Cost = Pre-FSP Cost divided by the total number of new enrollees for the fiscal year.
The right half is labeled:
12 Months Post-Intake – the data displayed in this half correspond to those collected in the follow-up
period. “Post-Intake” means after the client enrolled in FSP.
For follow-up (post-enrollment, 12 months after enrolling in FSP):
Number in Facility = the actual number of FSP clients who were in a skilled nursing facility for physical
health reasons.
o An FSP client is counted only one time at follow-up (regardless of whether he or she was in a
skilled nursing facility multiple times during follow-up).
o Number in Facility is the total number of persons in a skilled nursing facility (across all counties
participating in the study), not number of times in a skilled nursing facility, average number per
county or some other metric.
Average Number of Days per Year = an average of the annualized total number of days FSP clients were in
a skilled nursing facility. Because the Average Number of Days per Year is an average of an annualized
number, it is also an annualized number.
Annualized per-Client Cost = Post-FSP Total Cost divided by the total number of new enrollees for the
fiscal year.
The figures for baseline and follow-up in Table IV.8 are for FSP clients who enrolled in FY 08-09.
Table IV.8
Full Service Partnership Services – Annualized per-Client Cost for Number of Days in Skilled Nursing Facility
Physical Health
(Fiscal Year 08-09 New Enrollees ONLY)
12 Months Pre-Intake 12 Months Post-Intake
Number in Average Number Annual per- Number in Average Number Annualized per-
Facility of Days per Year Client Cost Facility of Days per Year Client Cost
CYF 0 0.0 $ - 0 0.0 $ -
TAY 1 0.4 $ 1.29 2 1.1 $ 3.31
Adults 19 16.6 $ 100.71 55 7.8 $ 75.41
Older Adults 36 38.4 $ 1,167.23 28 11.4 $ 385.28
Total 56 85
The figures for baseline and follow-up in Table IV.9 are for FSP clients who enrolled in FY 09-10.
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Table IV.9
Full Service Partnership Services – Total Annual Cost Offset for Number of Days in Skilled Nursing Facility
Physical Health
(Fiscal Year 09-10 New Enrollees ONLY)
Number of Days per Year Decrease in
12 Months 12 Months Number of Percent of
Pre-Intake Post-Intake Days Pre-FSP Cost Post-FSP Cost Total Cost Offset Offset
CYF 0 0 0 $ - $ - $ - -
TAY 10 0 10 $ 2,308.69 $ - $ 2,308.69 100.0%
Adults 2,493 1,762 731 $ 575,556.29 $ 406,791.09 $ 168,765.20 29.3%
Older Adults 1,701 968 733 $ 392,708.08 $ 223,481.14 $ 169,226.94 43.1%
Total 4,204 2,730 1,474 $ 970,573.06 $ 630,272.23 $ 340,300.83 35.1%
The figures for baseline and follow-up in Table IV.10 are for FSP clients who enrolled in FY 09-10.
Table IV.10
Full Service Partnership Services – Annualized per-Client Cost for Number of Days in Skilled Nursing Facility
Physical Health
(Fiscal Year 09-10 New Enrollees ONLY)
12 Months Pre-Intake 12 Months Post-Intake
Number in Average Number Annual per- Number in Average Number Annualized per-
Facility of Days per Year Client Cost Facility of Days per Year Client Cost
CYF 0 0.0 $ - 0 0.0 $ -
TAY 1 0.2 $ 0.78 0 0.0 $ -
Adults 25 35.3 $ 122.41 34 17.5 $ 86.51
Older Adults 24 17.7 $ 608.85 29 9.5 $ 346.48
Total 50 63
3. Emergency Room Visits
Recall the Substance Abuse and Mental Health Services Administration national study 120 presented under the
section discussing inpatient hospitalization for acute care (physical health reasons – non-psychiatric), indicating
that adults (age 18 or older) with mental illness were more likely to have used an emergency room and to have
been hospitalized. 121
Crane and Christenson (2008) found a significant, 47 percent decrease in urgent care visits 122 for those who
participated in marriage and family therapy. 123 Wayne et al. (2003) found that 34 percent of the complaints
120 http://www.samhsa.gov/data/2k12/NSDUH103/SR103AdultsAMI2012.pdf
Substance Abuse and Mental Health Services Administration (2012). Physical Health Conditions among Adults with Mental Illnesses.
Washington, DC: Government Printing Office.
Years analyzed included combined 2008 and 2009 National Survey on Drug Use and Health.
121 For non-psychiatric reasons. SAMHSA analyzed psychiatric ER use and hospitalization separately.
122 Crane, D. D., & Christenson, J. (2008). The medical offset effect: Patterns in outpatient services reduction for high utilizers of health care.
Contemporary Family Therapy: An International Journal, 30(2), 127-138. According to the study, urgent care visits are similar to emergency
room visits in that help is sought for symptoms deemed too urgent to wait for an appointment. However, symptoms that lead to urgent care
visits are not severe enough to necessitate emergency room admittance.
123 As cited in Crane & Christenson (2008). Ibid.
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reported by patients seeking urgent care occurred within a category of concerns that included headaches,
abdominal pain and chest pain as three of the most common problems.124
According to Crane and Christenson’s findings, individuals receiving mental health services were 30 percent less
likely to use emergency services than individuals in a comparison county. The study also found that evidence-
based group therapy reduced urgent care visits by 85 to 88 percent. 125
An emergency room visit was defined, for the purpose of the FSP Costs and Cost Offsets study, as one emergency
room visit for non-psychiatric reasons. The desire to separate psychiatric from non-psychiatric stems from
concerns about potential overlap of psychiatric emergency room visits with inpatient psychiatric hospitalization.
This is an important distinction, because there are different variables in the DCR associated with emergency room
visits for psychiatric versus non-psychiatric reasons (see the discussion under DCR variables analyzed, below). Only
non-psychiatric visits were analyzed for this report.
Statewide Emergency Room Visit Rate
The Office of Statewide Health Planning and Development (OSHPD) is the source for the rates applied by county
for emergency room visits. A “statewide” rate was calculated by averaging the rates for counties that participated
in this round of the study (see Appendix D).
The statewide rate for FY 08-09 is:
Emergency Room Use
Statewide Average FY 08-09 $206.08
The statewide rate for FY 09-10 is:
Emergency Room Use
Statewide Average FY 09-10 $212.40
The OSHPD data set was calculated especially for this study and is not available for download from its website. The
rate was calculated by OSHPD using the following variables: 126
Total Adjusted Emergency Room Expense
Total adjusted emergency room expense is calculated by taking the total direct emergency service expense and
subtracting any adjustment from direct expense for emergency services reported to OSHPD on the Hospital Annual
Financial Disclosure Report. Total Adjusted Emergency Room Expense would represent the emergency service
expense incurred by hospitals to provide emergency service care to patients. This expense would include labor,
supplies, purchased services, depreciation, leases and rentals, and any other expense that is identifiable to
providing emergency service care.
Total Emergency Room Visits Reported
This is the total number of emergency service visits reported to OSHPD on the Hospital Annual Financial Disclosure
report. An emergency service visit is counted for each appearance of a patient in an emergency services unit
(medical or psychiatric) of the hospital. An emergency service visit also includes non-emergency patients who use
the emergency room for care.
124 Ibid.
125 Depending on the specific evidence-based model implemented.
126 Courtesy of Kyle Rowert, OSHPD, July 2012.
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Total Adjusted Emergency Room Expense/Visit
Total adjusted emergency room expense per visit is calculated by taking the total adjusted emergency room
expense and dividing by the total emergency room visits reported. Total adjusted emergency room expense per
visit represents the average expense to the hospital for each emergency room visit.
DCR Variables Analyzed at Baseline (Intake) and Follow-Up
The Key Event Tracking Form (part of the MHSA DCR) does not indicate the specific facility in which an individual
received emergency room services – only that emergency services occurred. 127 Below are the exact variables we
used out of the PAF and the KET, and their definitions. 128
PAF (Intake/Baseline) Variable: PhyRelated 129 – Defined as:
o EMERGENCY INTERVENTION: Physical health-related;
o Indicates the number of physical health-related emergency interventions 130 the partner has had
during the past 12 months;
o Valid Codes: 0-99
KET (Follow-Up) Variable: EmergencyType1 through EmergencyType155 = 1, which is a categorical
variable assigned to represent Physical Health.
o The Emergency Type variables represent the type of emergency intervention received by the FSP
client at the time of each follow-up. 131
o Follow-ups (as documented on the KET) are not conducted according to any predetermined time
frame, but rather are driven by Key Events occurring in the FSP client’s life (e.g., hospitalization,
incarceration).
o The DCR allows for entry of up to 155 KETs.
This information, on its own, is sufficient to calculate the number of times that an FSP client received emergency
room services. The process of arriving at a summary total across all of the KET follow-ups is the focus of the
Calculations section that follows.
Calculations – Follow-Up, 12 Months Post-Intake: Emergency Room Visits (Non-
Psychiatric)
Therefore, we developed programming commands in SPSS that did the following for each KET follow-up period:
1. Selected only those FSP clients who received emergency intervention for physical health reasons (not
psychiatric). EmergencyType = 1.
2. Calculated the number of times emergency intervention was received for physical health reasons.
3. After this process was completed 155 times, the number of times emergency intervention for physical
health reasons occurred was summed for each FSP client to arrive at a grand total for each person.
4. Next, Days Enrolled was divided into 365 (number of days in a year):
127 The categorical code assigned tells us whether it was for psychiatric or non-psychiatric reasons – we analyzed only the non-psychiatric
emergency services due to perceived overlap of psychiatric emergency services with the inpatient psychiatric hospitalization variable.
128 Courtesy of California State University, Sacramento, currently the contractor managing the DCR.
129 Page 126, DCR Data Dictionary Final_20110915. California State University, Sacramento. There have been multiple releases of the DCR, and
at least two in 2011 marked “Final.” This version will be provided upon request.
130 Although “physical-health-related emergency intervention” does not equate to emergency room use per se, it is the closest proxy available in
the DCR for emergency room use. Emergency room intervention is a logical, likely outcome of a physical health emergency.
131 Page 193, DCR Data Dictionary Final_20110915. California State University, Sacramento. There have been multiple releases of the DCR, and
at least two in 2011 marked “Final.” This version will be provided upon request.
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365
Days Enrolled
o Days Enrolled, when used in this formula, is not annualized. What we are interested in is the total
period in which an FSP client was enrolled. What we produce is a proportion, which is then
applied against the Number of ER Visits 132 in order to adjust for the period of time that a person
was at risk for an ER visit for physical health reasons. If we do not apply this adjustment, we
would unfairly weight the results for or against people who were in the program for shorter or
longer periods of time.
o Days Enrolled: 133
DatePartnershipStatusChange_KET – PartnershipDate 134
5. The proportion calculated for each FSP client out of Step 4 is then multiplied by the sum of ER visits
(physical health reasons) in Step 3. This is how we arrive at the number of ER visits (physical health
reasons), without a bias for length of enrollment.
Findings: Emergency Room Visits (Physical Health)
Tables IV.11 through IV.14 present cost offsets for each of the age groups, in each fiscal year, for emergency room
visits for physical health reasons.
Table IV.11 represents FY 08-09, and Table IV.13 FY 09-10:
12 Months Pre-Intake – The data displayed under any column marked “Pre” correspond to those collected at
baseline. 135 “Pre-Intake” means before the client enrolled in FSP.
For baseline (intake, 12 months prior to enrolling in FSP):
Number of Visits per Year
12 Months Pre-
Intake
Number of Visits per Year = the actual number of visits (total, across all FSP clients) to the ER for physical
health reasons.
o This is an annual number because it is the actual number of visits in the 12 months prior to
enrolling in FSP. Nothing is done to this number – no changes or adjustments are made to it – it is
exactly as the FSP client reported on the PAF.
Pre-FSP Cost
Pre-FSP Cost = Number of Visits (Pre) multiplied by the Statewide Emergency Room Visit Rate.
132 We make the assumption that a single ER visit takes place on a single day (1-to-1 comparison).
133 Elements of this formula were described in Chapter III. The only element missing from what was presented in Chapter III is the annualization
factor (dividing by 365). But it does not apply here – we are developing a proportion to be applied against number of days hospitalized.
134 Applying all of the caveats discussed in Chapter III, section c. Contextual Factors – Impact on Cost.
135 Refer back to the discussion earlier in the chapter for the explanation about which variables we analyzed, and why.
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o This is an annual cost because the Statewide Rate is multiplied by the actual number of visits per
year (see the bullet point above).
12 Months Post-Intake – The data displayed under any column marked “Post” correspond to those collected in the
follow-up period. “Post-Intake” means after the client enrolled in FSP.
For follow-up (post-enrollment, 12 months after enrolling in FSP):
Number of Visits per Year
12 Months Post-
Intake
Through Key Event Tracking data, identified: 136
o The number of days enrolled.
o Days Enrolled is then divided into 365 (the number of days in a year), illustrated in the formula
below:
365
Days Enrolled
o This quotient is the annualization multiplier for each new enrollee.
o The annualization multiplier is applied to all new enrollees, whether or not they spent any time in
the emergency room (for physical health reasons). 137
Identified:
o The number of emergency interventions (for physical health reasons) for each FSP client during
the 12-month post-enrollment period, and
o Multiplied by each FSP client’s annualization multiplier.
New enrollees with zero (0) emergency interventions (for physical health reasons) drop
out of the analysis at this point, and we are left with those new enrollees who have
visited the emergency room for a physical health reason.
o This product is the annualized number of visits to the emergency room (physical health) for each
new enrollee who received an emergency intervention (for physical health reasons) during the
12-month follow-up period.
Post-FSP Cost
Post-FSP Cost = Number of Visits (Post) multiplied by the Statewide Emergency Room Visit Rate.
o This is an annualized cost because the Statewide Rate is multiplied by the annualized number of
visits (see the bullet point above).
Decrease in
Number of Visits
136 See Chapter III for an introduction to the KET, variables used when calculating number of days of FSP participation, and each cost-offset
category in this chapter for the specific cost-offset variables used in analysis.
137 See Chapter III for how days of enrollment were calculated.
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Decrease in Number of Visits = Number of Visits at Baseline (Pre) minus the Number of Visits at Follow-Up
(Post):
Pre – Post = Decrease in Number of Visits
Total Cost Offset
Total Cost Offset = Pre-FSP Cost – Post-FSP Cost
Percent of Offset
Percent of Offset =
Total Cost Offset
Pre-FSP Cost
o In other words, the percent of Emergency Room Visits (Physical Health) offset is equal to the
total cost offset for Emergency Room Visits (Physical Health) divided by the pre-FSP cost for
Emergency Room Visits (Physical Health).
The figures for baseline and follow-up in Table IV.11 are for FSP clients who enrolled in FY 08-09.
Table IV.11
Full Service Partnership Services – Total Annual Cost Offset for Number of Emergency Room Visits
Physical Health
(Fiscal Year 08-09 New Enrollees ONLY)
Number of Visits per Year Decrease in
12 Months 12 Months Number of Percent of
Pre-Intake Post-Intake Visits Pre-FSP Cost Post-FSP Cost Total Cost Offset Offset
CYF 377 35 342 $ 77,692.04 $ 7,274.61 $ 70,417.43 90.6%
TAY 1,108 103 1,005 $ 228,336.29 $ 21,226.21 $ 207,110.08 90.7%
Adults 3,628 319 3,309 $ 747,657.09 $ 65,739.42 $ 681,917.67 91.2%
Older Adults 767 145 622 $ 158,063.12 $ 29,881.55 $ 128,181.57 81.1%
Total 5,880 602 5,278 $ 1,211,748.54 $ 124,121.79 $ 1,087,626.75 89.8%
Table IV.12 represents FY 08-09, and Table IV.14 FY 09-10. Each table is divided in half, with the left half labeled:
12 Months Pre-Intake – the data displayed in this half correspond to those collected at baseline. “Pre-
Intake” means before the client enrolled in FSP.
For baseline (intake, 12 months prior to enrolling in FSP):
Number Visiting ER = the actual number of FSP clients who received an emergency intervention for
physical health reasons.
o An FSP client is counted only one time at baseline (regardless of whether he or she received
multiple emergency interventions during the 12 months prior to intake).
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o Number Visiting ER is the number of persons who received an emergency intervention for
physical health reasons (across all counties that participated in the study), not number of times
the ER was visited, average number of ER visits by county or some other metric.
Average Number of Visits per Year = the average number of ER visits (non-psychiatric).
o At baseline, it is simply the average number of emergency interventions (physical health-related)
as reported on the PAF.
Annual per-Client Cost = Pre-FSP Cost divided by the total number of new enrollees for the fiscal year.
The right half is labeled:
12 Months Post-Intake – the data displayed in this half correspond to those collected in the follow-up
period. “Post-Intake” means after the client enrolled in FSP.
For follow-up (post-enrollment, 12 months after enrolling in FSP):
Number Visiting ER = the actual number of FSP clients who received an emergency intervention for
physical health reasons.
o An FSP client is counted only one time at follow-up (regardless of whether he or she received
multiple emergency interventions during follow-up).
o Number Visiting ER is the number of persons who received an emergency intervention for
physical health reasons (across all counties that participated in the study), not number of times
the ER was visited, average number of ER visits by county or some other metric.
Average Number of Visits per Year = an average of the annualized total number of emergency room visits
(physical health) across all FSP clients who visited the emergency room for a physical health reason.
Because the Average Number of Visits per Year is an average of an annualized number, it is also an
annualized number.
Annualized per-Client Cost = Post-FSP Total Cost divided by the total number of new enrollees for the
fiscal year.
The figures for baseline and follow-up in Table IV.12 are for FSP clients who enrolled in FY 08-09.
Table IV.12
Full Service Partnership Services – Annualized per-Client Cost for Number of Emergency Room Visits
Physical Health
(Fiscal Year 08-09 New Enrollees ONLY)
12 Months Pre-Intake 12 Months Post-Intake
Number Average Number Annual per- Number Average Number Annualized per-
Visiting ER of Visits per Year Client Cost Visiting ER of Visits per Year Client Cost
CYF 210 1.2 $ 35.90 32 0.3 $ 3.36
TAY 444 2.3 $ 98.12 97 1.0 $ 9.12
Adults 1,127 2.7 $ 173.27 295 1.3 $ 15.24
Older Adults 204 2.5 $ 271.59 89 1.0 $ 51.34
Total 1,985 513
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The figures for baseline and follow-up in Table IV.13 are for FSP clients who enrolled in FY 09-10.
Table IV.13
Full Service Partnership Services – Total Annual Cost Offset for Number of Emergency Room Visits
Physical Health
(Fiscal Year 09-10 New Enrollees ONLY)
Number of Visits per Year Decrease in
12 Months Pre- 12 Months Number of Percent of
Intake Post-Intake Visits Pre-FSP Cost Post-FSP Cost Total Cost Offset Offset
CYF 645 48 597 $ 136,999.68 $ 10,195.32 $ 126,804.36 92.6%
TAY 1,162 103 1,059 $ 246,811.82 $ 21,877.47 $ 224,934.35 91.1%
Adults 2,906 841 2,065 $ 617,241.96 $ 178,630.59 $ 438,611.37 71.1%
Older Adults 489 160 329 $ 103,864.87 $ 33,920.70 $ 69,944.17 67.3%
Total 5,202 1,152 4,050 $ 1,104,918.33 $ 244,624.08 $ 860,294.25 77.9%
The figures for baseline and follow-up in Table IV.14 are for FSP clients who enrolled in FY 09-10.
Table IV.14
Full Service Partnership Services – Annualized per-Client Cost for Number of Emergency Room Visits
Physical Health
(Fiscal Year 09-10 New Enrollees ONLY)
12 Months Pre-Intake 12 Months Post-Intake
Number Average Number Annual per- Number Average Number of Annualized
Visiting ER of Visits per Year Client Cost Visiting ER Visits per Year per-Client Cost
CYF 294 1.1 $ 44.18 37 0.4 $ 3.29
TAY 522 1.9 $ 82.91 76 0.8 $ 7.35
Adults 1,042 2.8 $ 131.27 285 1.1 $ 37.99
Older Adults 203 1.5 $ 161.03 77 1.0 $ 52.59
Total 2,061 475
c. Psychiatric Care
For the purpose of calculating costs and cost offsets, psychiatric care includes:
Inpatient Psychiatric Hospitalization (number of days)
Long-Term Care (Psychiatric) (number of days) 138
Skilled Nursing (Psychiatric) (number of days)
Costs and cost savings in each of these areas for FSP clients are presented in the following sections.
1. Inpatient Psychiatric Hospitalization
Mental illnesses such as schizophrenia, schizoaffective disorder and bipolar disorder are often episodic, with
exacerbations and remissions superimposed on varying degrees of prolonged disability. Nationally, care for
138 Institution for Mental Diseases facilities/Mental Health Rehabilitation Centers. Key Event Tracking data do not distinguish between the two.
Therefore, an average of the IMD and MHRC rates for the facilities contracted by each county was used as the basis for calculating the cost
applied to the number of days in long-term care.
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patients with these severe disorders accounts for the use of nearly half (43%) of mental health resources, with the
largest proportion of expenditures allocated to hospital inpatient care. 139
Inpatient Psychiatric Hospitalization is defined as services provided in an acute psychiatric hospital or a distinct
acute psychiatric part of a general hospital that is approved by the Department of Health Services to provide
psychiatric services. Those services are medically necessary for diagnosis or treatment of a mental disorder in
accordance with Section 1820.205. 140 Psychiatric Care refers to the daily hospital service cost centers related to
the provision of psychiatric care, including Psychiatric Acute – Adult and Psychiatric Intensive (Isolation) Care.
Statewide Inpatient Psychiatric Hospitalization Rate
The County Cost Report is the source for the rates applied by county for inpatient psychiatric hospitalization
(please see below for the definition of included facilities). The Cost Report is a report submitted to the California
Department of Mental Health every year, documenting everything that the county has spent on mental health.
The Cost Report is used as the basis for the California Department of Mental Health’s reconciliation of all county
mental health costs within a fiscal year. In essence, billing from disparate sources (e.g., MHSA, Medi-Cal) is all
reconciled and comes together in final form in the Cost Report. 141
The form within the County Cost Report from which we extracted each county’s inpatient psychiatric rate is
MH1966_HOSPINPT. Specifically, we used the Cost per Unit row. For the Cost Report, inpatient psychiatric services
are considered Mode 05 – Service Function 10-18:
Mode 05: 24-Hour Mode of Service – Services designed to provide a therapeutic environment of care and
treatment within a residential setting. Depending on the severity of mental disorder and the need for
related medical care, treatment would be provided in one of a variety of settings.
We included only the following types of facilities from Short-Doyle/Medi-Cal Modes, included in Cost Reports and
CSI Mode 05:
05 – Psychiatric Health Facility 142
07 – Inpatient Psychiatric Hospital Services of an acute care general hospital
A “statewide” rate was determined by calculating an average of the rates for counties that participated in this
round of the study. 143
The Key Event Tracking Form does not indicate the specific facility in which an individual was hospitalized for
psychiatric reasons – only that a psychiatric hospitalization occurred. Therefore, if a county has more than one
hospital providing psychiatric hospitalization services, an average within the county was first calculated in order to
arrive at a rate for each county. An average rate within a county means:
The rate for each hospital identified for that county (per the Cost Report – see above for the definition of
what hospitals were included) is entered into a formula, and then the average is calculated.
139 Fenton, W. S., Mosher, L. R., Herrell, J. M., & Blyler, C. R. (1998). Randomized trial of general hospital and residential alternative care for
patients with severe and persistent mental illness. American Journal of Psychiatry, 155(4), 516-522.
140 From County Cost Reports, Service Functions 10-18: Hospital Inpatient.
141 Through negotiation with the California Department of Mental Health, eventually a final, reconciled version of the Cost Report is produced.
142 Although Code 05 also includes Adult Crisis Residential or Adult Residential facilities, we included Psychiatric Health Facilities and Inpatient
Psychiatric Hospital Services of an acute care general hospital only when calculating the statewide inpatient psychiatric rate.
143 See Appendix D for a list of counties that participated. However, if the county rate was higher than the Statewide Maximum Allowance
(SMA), the SMA rate was used.
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However, if the average is higher than the Statewide Maximum Allowance, the rate defaulted to the
Statewide Maximum Allowance.
Not all counties (notably some small, rural counties) have a facility in which to hospitalize individuals for
psychiatric reasons. Absent a written agreement with a neighboring county for said services, the Statewide
Maximum Allowance was applied for such counties.
The statewide rate for FY 08-09 is:
Inpatient Hospitalization - Psychiatric
Statewide Average FY 08-09 $1,007.30
The statewide rate for FY 09-10 is:
Inpatient Hospitalization - Psychiatric
Statewide Average FY 09-10 $1,032.35
DCR Variables Analyzed at Baseline (Intake) and Follow-Up
The Key Event Tracking Form 144 does not indicate the specific facility in which an individual was hospitalized – only
that an inpatient stay occurred for psychiatric reasons. Below are the exact variables we used out of the PAF and
the KET, and their definitions. 145
PAF (Intake/Baseline) Variable: PsychiatricHospital_PastTwelveDays 146 – Defined as:
o RESIDENTIAL INFORMATION: Hospital – Acute Psychiatric Hospital/Psychiatric Health Facility
(PHF);
o Indicates the number of DAYS the partner has been living in this setting during the past 12
months;
o Valid Codes: 0-365
KET (Follow-Up) Variable: Current.1 through Current.155 = 9, which is a categorical variable assigned to
represent Psychiatric Hospital.
o The Current variables represent the residential status of the FSP client at the time of each follow-
up.
o Follow-ups (as documented on the KET) are not conducted according to any predetermined time
frame, but rather are driven by Key Events occurring in the FSP client’s life (e.g., hospitalization,
incarceration).
o The DCR allows for entry of up to 155 KETs.
This information, on its own, is insufficient to calculate the number of days that an FSP client was hospitalized for
psychiatric reasons. 147 What the Current variable (code = 9) tells us is only that an FSP client was hospitalized for
psychiatric reasons, not how many days.
144 The Key Event Tracking Form is collected by counties and entered into the DCR. EMT receives the data only for analysis.
145 Courtesy of California State University, Sacramento, currently the contractor managing the DCR.
146 Page 79, DCR Data Dictionary Final_20110915. California State University, Sacramento (Sac State). There have been multiple releases of the
DCR, and at least two in 2011 marked “Final.” This version will be provided upon request.
The variable wording is confusing because it seems to suggest occurrence over the past 12 days. The variable name and description,
however, have been reproduced verbatim from Sac State’s data dictionary. The variable actually refers to the number of days over the past 12
months (prior to FSP intake).
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So the challenge for the analysis was how to determine the number of days of psychiatric inpatient hospitalization,
over 155 possible follow-up points. This is the focus of the Calculations section that follows.
Calculations – Follow-Up, 12 Months Post-Intake: Inpatient Psychiatric
Hospitalization
Accompanying each Current variable is a DateResidentialChange variable. This variable tells us on what date the
FSP client’s residential setting changed.
Therefore, we developed programming commands in SPSS that calculated the following for each KET follow-up
period:
1. Selected only those FSP clients who were hospitalized for psychiatric reasons: Current = 9.
2. Calculated the number of days hospitalized by taking the subsequent DateResidentialChange and
subtracting the current DateResidentialChange.
3. After this process was completed 155 times, the number of days hospitalized (psychiatric) was summed
for each FSP client to arrive at a grand total for each person.
o The sum is necessary in order to account for subsequent stays that cross KET administrations, as
well as intermittent stays by the same person during FSP involvement.
4. Days Enrolled is then divided into 365 (number of days in a year):
365
Days Enrolled
o Days Enrolled, when used in this formula, is not annualized. What we are interested in is the total
period that an FSP client was enrolled. What we produce is a proportion, which is then applied
against the Number of Days Hospitalized (psychiatric) in order to adjust for the period of time
that a person was at risk for hospitalization. If we do not apply this adjustment, we would
unfairly weight the results for or against people who were in the program for shorter or longer
periods of time.
o Days Enrolled is: 148
DatePartnershipStatusChange_KET – PartnershipDate 149
5. The proportion calculated for each FSP client out of Step 4 is then multiplied by the sum of days
hospitalized (psychiatric) in Step 3. This is how we arrive at the number of days hospitalized (psychiatric),
without a bias for length of enrollment.
Findings: Inpatient Psychiatric Hospitalization
Tables IV.15 through IV.18 present cost offsets for each of the age groups, in each fiscal year, for inpatient
psychiatric hospitalization.
Table IV.15 represents FY 08-09, and Table IV.17 FY 09-10:
147 Not for physical health reasons – we addressed that in a previous section in this chapter.
148 Elements of this formula were presented in Chapter III. The only piece missing from what was presented in Chapter III is the annualization
factor (dividing by 365). But it does not apply here – we are developing a proportion to be applied against number of days hospitalized.
149 Applying all of the caveats discussed in Chapter III, section c. Contextual Factors – Impact on Cost.
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12 Months Pre-Intake – The data displayed under any column marked “Pre” correspond to those collected at
baseline. 150 “Pre-Intake” means before the client enrolled in FSP.
For baseline (intake, 12 months prior to enrolling in FSP):
Number of Days per Year
12 Months Pre-
Intake
Number of Days per Year = the actual number of days (total, across all FSP clients) of inpatient psychiatric
hospitalization.
o This is an annual number because it is the actual number of days in the 12 months prior to
enrolling in FSP. Nothing is done to this number – no changes or adjustments are made to it – it is
exactly as the FSP client reported on the PAF.
Pre-FSP Cost
Pre-FSP Cost = Number of Days (Pre) multiplied by the Statewide Rate for Inpatient Psychiatric
Hospitalization.
o This is an annual cost because the Statewide Rate is multiplied by the actual number of days per
year (see the bullet point above).
12 Months Post-Intake – The data displayed under any column marked “Post” correspond to those collected in the
follow-up period. “Post-Intake” means after the client enrolled in FSP.
For follow-up (post-enrollment, 12 months after enrolling in FSP):
Number of Days per Year
12 Months Post-
Intake
Through Key Event Tracking data, identified: 151
o The number of days enrolled.
o Days Enrolled is then divided into 365 (the number of days in a year), illustrated in the formula
below:
365
Days Enrolled
o This quotient is the annualization multiplier for each new enrollee.
o The annualization multiplier is applied to all new enrollees, whether or not they were
hospitalized (inpatient) for psychiatric reasons. 152
150 Refer back to the discussion earlier in the chapter for the explanation about which variables we analyzed, and why.
151 See Chapter III for an introduction to the KET, variables used when calculating number of days of FSP participation, and each cost-offset
category in this chapter for the specific cost-offset variables used in analysis.
152 See Chapter III for how days of enrollment were calculated.
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Identified:
o The number of days of inpatient psychiatric hospitalization for each FSP client during the 12-
month post-enrollment period, and
o Multiplied by each FSP client’s annualization multiplier.
New enrollees with zero (0) days (of inpatient psychiatric hospitalization) drop out of the
analysis at this point, and we are left with those new enrollees who spent at least one
day hospitalized (inpatient) for psychiatric reasons.
o This product is the annualized number of days of inpatient psychiatric hospitalization for each
new enrollee who was hospitalized (inpatient) for psychiatric reasons during the 12-month
follow-up period.
Post-FSP Cost
Post-FSP Cost = Number of Days (Post) multiplied by the Statewide Rate for Inpatient Psychiatric
Hospitalization.
o This is an annualized cost because the Statewide Rate is multiplied by the annualized number of
days (see the bullet point above).
Decrease in
Number of Days
Decrease in Number of Days = Number of Days at Baseline (Pre) minus the Number of Days at Follow-Up
(Post):
Pre – Post = Decrease in Number of Days
Total Cost Offset
Total Cost Offset = Pre-FSP Cost – Post-FSP Cost
Percent of Offset
Percent of Offset =
Total Cost Offset
Pre-FSP Cost
o In other words, the percent of Inpatient Psychiatric Hospitalization offset is equal to the total
cost offset for Inpatient Psychiatric Hospitalization divided by the pre-FSP cost for Inpatient
Psychiatric Hospitalization.
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The figures for baseline and follow-up in Table IV.15 are for FSP clients who enrolled in FY 08-09.
Table IV.15
Full Service Partnership Services – Total Annual Cost Offset for Number of Days in Inpatient Psychiatric Hospital
(Fiscal Year 08-09 New Enrollees ONLY)
Number of Days per Year Decrease in
12 Months 12 Months Number of Percent of
Pre-Intake Post-Intake Days Pre-FSP Cost Post-FSP Cost Total Cost Offset Offset
CYF 2,427 2,005 422 $ 2,444,711.45 $ 2,019,631.83 $ 425,079.62 17.4%
TAY 14,002 6,334 7,668 $ 14,104,182.02 $ 6,380,223.46 $ 7,723,958.56 54.8%
Adults 41,242 19,406 21,836 $ 41,542,970.63 $ 19,547,618.64 $ 21,995,351.99 52.9%
Older Adults 4,414 1,639 2,775 $ 4,446,211.93 $ 1,650,960.89 $ 2,795,251.04 62.9%
Total 62,085 29,384 32,701 $ 62,538,076.03 $ 29,598,434.82 $ 32,939,641.21 52.7%
Table IV.16 represents FY 08-09, and Table IV.18 FY 09-10. Each table is divided in half, with the left half labeled:
12 Months Pre-Intake – the data displayed in this half correspond to those collected at baseline. “Pre-
Intake” means before the client enrolled in FSP.
For baseline (intake, 12 months prior to enrolling in FSP):
Number Hospitalized = the actual number of FSP clients who were hospitalized (inpatient) for psychiatric
reasons.
o An FSP client is counted only one time at baseline (regardless of whether he or she was
hospitalized multiple times during the 12 months prior to intake).
o Number Hospitalized is number of persons hospitalized (across all counties participating in the
study), not number of times hospitalized, average number per county or some other metric.
Average Number of Days per Year = the average number of days FSP clients were hospitalized.
o At baseline, it is simply the average number of days as reported on the PAF.
Annual per-Client Cost = Pre-FSP Cost divided by the total number of new enrollees for the fiscal year.
The right half is labeled:
12 Months Post-Intake – the data displayed in this half correspond to those collected in the follow-up
period. “Post-Intake” means after the client enrolled in FSP.
For follow-up (post-enrollment, 12 months after enrolling in FSP):
Number Hospitalized = the actual number of FSP clients who were hospitalized (inpatient) for psychiatric
reasons.
o An FSP client is counted only one time at follow-up (regardless of whether he or she was
hospitalized multiple times during follow-up).
o Number Hospitalized is number of persons hospitalized (across all counties participating in the
study), not number of times hospitalized, average number per county or some other metric.
Average Number of Days per Year = an average of the annualized total number of days FSP clients were
hospitalized. Because the Average Number of Days per Year is an average of an annualized number, it is
also an annualized number.
Annualized per-Client Cost = Post-FSP Total Cost divided by the total number of new enrollees for the
fiscal year.
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The figures for baseline and follow-up in Table IV.16 are for FSP clients who enrolled in FY 08-09.
Table IV.16
Full Service Partnership Services – Annualized per-Client Cost for Number of Days in Inpatient Psychiatric Hospital
(Fiscal Year 08-09 New Enrollees ONLY)
12 Months Pre-Intake 12 Months Post-Intake
Number Average Number Annual per- Number Average Number Annualized per-
Hospitalized of Days per Year Client Cost Hospitalized of Days per Year Client Cost
CYF 149 9.0 $ 1,129.72 118 11.6 $ 933.29
TAY 414 24.5 $ 6,061.10 295 16.0 $ 2,741.82
Adults 1,149 27.0 $ 9,627.57 872 23.6 $ 4,530.15
Older Adults 103 19.8 $ 7,639.54 65 11.8 $ 2,836.70
Total 1,815 1,350
These results are extremely encouraging and are consistent with an evaluation of the AB 2034 program – that
evaluation found cost offsets of approximately $24.7 million from reductions in psychiatric inpatient days and
number of days incarcerated. 153
The figures for baseline and follow-up in Table IV.17 are for FSP clients who enrolled in FY 09-10.
Table IV.17
Full Service Partnership Services – Total Annual Cost Offset for Number of Days in Inpatient Psychiatric Hospital
(Fiscal Year 09-10 New Enrollees ONLY)
Number of Days per Year Decrease in
12 Months 12 Months Number of Percent of
Pre-Intake Post-Intake Days Pre-FSP Cost Post-FSP Cost Total Cost Offset Offset
CYF 3,621 2,551 1,070 $ 3,738,131.70 $ 2,633,519.46 $ 1,104,612.24 29.5%
TAY 14,071 6,313 7,758 $14,526,167.11 $ 6,517,212.21 $ 8,008,954.90 55.1%
Adults 51,321 23,705 27,616 $52,981,125.87 $ 24,471,806.64 $ 28,509,319.23 53.8%
Older Adults 5,406 2,537 2,869 $ 5,580,872.67 $ 2,619,066.59 $ 2,961,806.08 53.1%
Total 74,419 35,106 39,313 $76,826,297.35 $ 36,241,604.90 $ 40,584,692.45 52.8%
The figures for baseline and follow-up in Table IV.18 are for FSP clients who enrolled in FY 09-10.
Table IV.18
Full Service Partnership Services – Annualized per-Client Cost for Number of Days in Inpatient Psychiatric Hospital
(Fiscal Year 09-10 New Enrollees ONLY)
12 Months Pre-Intake 12 Months Post-Intake
Number Average Number Annual per- Number Average Number Annualized per-
Hospitalized of Days per Year Client Cost Hospitalized of Days per Year Client Cost
CYF 269 5.6 $ 1,205.46 140 4.0 $ 849.25
TAY 587 16.0 $ 4,879.46 264 18.1 $ 2,189.19
Adults 1,306 26.1 $ 11,267.79 836 18.6 $ 5,204.55
Older Adults 146 19.7 $ 8,652.52 91 10.4 $ 4,060.57
Total 2,308 1,331
153 Review of the report and appendices did not yield a per-person cost offset in either area, or a breakout for inpatient psychiatric offsets
compared with incarceration offsets. Unfortunately, comparisons broken out into psychiatric and incarceration therefore cannot be provided.
California Department of Mental Health (2007). (unpublished) Report to the Legislature on the effectiveness of integrated services for
homeless adults with serious mental illness. Sacramento, CA: Author.
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2. Long-Term Care (Psychiatric)
Mental Health Rehabilitation Centers (MHRCs) provide intensive support and rehabilitation services designed to
assist people with mental disorders, 18 years or older, who would have been placed in a state hospital or another
mental health facility. Services provided in MHRCs help develop a person’s skills to become self-sufficient and
capable of increasing levels of independent functioning. 154
Key Event Tracking data do not distinguish between whether care was reimbursed at the Institution for Mental
Diseases (IMD) rate or the MHRC rate (both are subsumed under a variable entitled Long-Term Care). Therefore,
there was no way to analyze reimbursement at each rate as distinct from one another. When arriving at a
statewide rate for purpose of comparison, an average of the IMD and MHRC rates for the facilities contracted by
each county was used as the basis for calculating the cost applied to the number of days in long-term care.
Statewide Long-Term Care Rate (Psychiatric)
IMD rates for FY 08-09 and FY 09-10 were provided to EMT courtesy of the MHSOAC, and any missing rates from
counties were extracted from the Cost Report, Mode 05 (Service Function 36-39). 155 MHRC rates were extracted
from the Cost Report, Mode 05 (Service Function 90-94). A “statewide” rate was then calculated by averaging the
rates for counties that participated in the study (see Appendix D).
The statewide rate for FY 08-09 is:
Long-Term Care
Statewide Average FY 08-09 $169.00
The statewide rate for FY 09-10 is:
Long-Term Care
Statewide Average FY 09-10 $182.65
DCR Variables Analyzed at Baseline (Intake) and Follow-Up
Below are the exact variables we used out of the PAF and the KET, and their definitions. 156
PAF (Intake/Baseline) Variable: LongTermCare_PastTwelveDays 157 – Defined as:
o RESIDENTIAL INFORMATION: Long-term institutional care [Institution for Mental Diseases
(IMD)/Mental Health Rehabilitation Centers (MHRC)]; 158
o Indicates the number of DAYS the partner has been living in this setting during the past 12
months;
o Valid Codes: 0-365
154 http://www.dmh.ca.gov/services_and_programs/Quality_Oversight/Licensing_and_Certification/default.asp
155 IMD rates taken from the Cost Report included “Patch,” otherwise known as “with Patch.”
156 Courtesy of California State University, Sacramento, currently the contractor managing the DCR.
157 Page 86, DCR Data Dictionary Final_20110915. California State University, Sacramento (Sac State). There have been multiple releases of the
DCR, and at least two in 2011 marked “Final.” This version will be provided upon request.
The variable wording is confusing because it seems to suggest occurrence over the past 12 days. The variable name and description,
however, have been reproduced verbatim from Sac State’s data dictionary. The variable actually refers to the number of days over the past 12
months (prior to FSP intake).
158 Institution for Mental Diseases (IMD) is a Medicaid reimbursement classification, related to long-term care. It is unclear why it is equated
with MHRCs in the DCR. MHRCs may be reimbursed for care under the IMD category, for example.
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KET (Follow-Up) Variable: Current.1 through Current.155 = 25, which is a categorical variable assigned to
represent Long-Term Care. 159
o The Current variables represent the residential status of the FSP client at the time of each follow-
up.
o Follow-ups (as documented on the KET) are not conducted according to any predetermined time
frame, but rather are driven by Key Events occurring in the FSP client’s life (e.g., hospitalization,
incarceration).
o The DCR allows for entry of up to 155 KETs.
This information, on its own, is insufficient to calculate the number of days that an FSP client was in a long-term-
care facility. What the Current variable (code = 25) tells us is only that an FSP client was in a long-term-care facility,
not how many days.
So the challenge for the analysis was how to determine the number of days in a long-term-care facility, over 155
possible follow-up points. This is the focus of the Calculations section that follows.
Calculations – Follow-Up, 12 Months Post-Intake: Long-Term Care (Psychiatric)
Accompanying each Current variable is a DateResidentialChange variable. This variable tells us on what date the
client’s residential setting changed.
Therefore, we developed programming commands in SPSS that systematically generated the following for each
KET follow-up period:
1. Selected only those FSP clients who were in a long-term-care facility: Current = 25.
2. Calculated the number of days in long-term care by taking the subsequent DateResidentialChange and
subtracting the current DateResidentialChange.
3. After this process was completed 155 times, the number of days in a long-term-care facility was summed
for each FSP client to arrive at a grand total for each person.
o The sum is necessary in order to account for subsequent stays that cross KET administrations, as
well as intermittent stays by the same person during his or her FSP involvement.
4. Days Enrolled was divided into 365 (number of days in a year):
365
Days Enrolled
o Days Enrolled, when used in this formula, is not annualized. What we are interested in is the total
period in which an FSP client was enrolled. What we produce is a proportion, which is then
applied against the Number of Days in Long-Term Care in order to adjust for the period of time
that a person was at risk for stay in a long-term-care facility. If we do not apply this adjustment,
we would unfairly weight the results for or against people who were in the program for shorter
or longer periods of time.
o Days Enrolled is: 160
159 Institution for Mental Diseases (IMD) is a Medicaid reimbursement classification, related to long-term care. It is unclear why it is equated
with MHRCs in the DCR. MHRCs may be reimbursed for care under the IMD category, for example.
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DatePartnershipStatusChange_KET – PartnershipDate 161
5. The proportion calculated for each FSP client out of Step 4 is then multiplied by the sum of days in a long-
term care facility in Step 3. This is how we arrive at the number of days in a long-term care facility,
without a bias for length of enrollment.
Findings: – Long-Term Care (Psychiatric)
Tables IV.19 through IV.22 present cost offsets for each of the age groups, in each fiscal year, for long-term care.
Table IV.19 represents FY 08-09, and Table IV.21 FY 09-10:
12 Months Pre-Intake – The data displayed under any column marked “Pre” correspond to those collected at
baseline. 162 “Pre-Intake” means before the client enrolled in FSP.
For baseline (intake, 12 months prior to enrolling in FSP):
Number of Days per Year
12 Months Pre-
Intake
Number of Days per Year = the actual number of days (total, across all FSP clients) spent in long-term
care.
o This is an annual number because it is the actual number of days in the 12 months prior to
enrolling in FSP. Nothing is done to this number – no changes or adjustments are made to it – it is
exactly as the FSP client reported on the PAF.
Pre-FSP Cost
Pre-FSP Cost = Number of Days (Pre) multiplied by the Statewide Long-Term Care Rate (Psychiatric).
o This is an annual cost because the Statewide Rate is multiplied by the actual number of days per
year (see the bullet point above).
12 Months Post-Intake – The data displayed under any column marked “Post” correspond to those collected in the
follow-up period. “Post-Intake” means after the client enrolled in FSP.
For follow-up (post-enrollment, 12 months after enrolling in FSP):
Number of Days per Year
12 Months Post-
Intake
Through Key Event Tracking data, identified: 163
o The number of days enrolled.
160 Elements of this formula were presented in Chapter III. The only element missing from what was presented in Chapter III is the annualization
factor (dividing by 365). But it does not apply here – we are developing a proportion to be applied against number of days hospitalized.
161 Applying all of the caveats discussed in Chapter III, section c. Contextual Factors – Impact on Cost.
162 Refer back to the discussion earlier in the chapter for the explanation about which variables we analyzed, and why.
163 See Chapter III for an introduction to the KET, variables used when calculating number of days of FSP participation, and each cost-offset
category in this chapter for the specific cost-offset variables used in analysis.
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o Days Enrolled is then divided into 365 (the number of days in a year), illustrated in the formula
below:
365
Days Enrolled
o This quotient is the annualization multiplier for each new enrollee.
o The annualization multiplier is applied to all new enrollees, whether or not they were in long-
term care for psychiatric reasons. 164
Identified:
o The number of days spent in long-term care (psychiatric) for each FSP client during the 12-month
post-enrollment period, and
o Multiplied by each FSP client’s annualization multiplier.
New enrollees with zero (0) days (spent in long-term care) drop out of the analysis at
this point, and we are left with those new enrollees who spent at least one day in long-
term care for psychiatric reasons.
o This product is the annualized number of days of long-term care for each new enrollee who was
in long-term care for psychiatric reasons during the 12-month follow-up period.
Post-FSP Cost
Post-FSP Cost = Number of Days (Post) multiplied by the Statewide Long-Term Care Rate (Psychiatric).
o This is an annualized cost because the Statewide Rate is multiplied by the annualized number of
days (see the bullet point above).
Decrease in
Number of Days
Decrease in Number of Days = Number of Days at Baseline (Pre) minus the Number of Days at Follow-Up
(Post):
Pre – Post = Decrease in Number of Days
Total Cost Offset
Total Cost Offset = Pre-FSP Cost – Post-FSP Cost
164 See Chapter III for how days of enrollment were calculated.
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Percent of Offset
Percent of Offset =
Total Cost Offset
Pre-FSP Cost
o In other words, the percent of Long-Term Care (Psychiatric) offset is equal to the total cost offset
for Long-Term Care (Psychiatric) divided by the pre-FSP cost for Long-Term Care (Psychiatric).
The figures for baseline and follow-up in Table IV.19 are for FSP clients who enrolled in FY 08-09.
Table IV.19
Full Service Partnership Services – Total Annual Cost Offset for Number of Days in Long-Term-Care Facility
(Fiscal Year 08-09 New Enrollees ONLY)
Number of Days per Year Decrease in
12 Months 12 Months Number of Percent of
Pre-Intake Post-Intake Days Pre-FSP Cost Post-FSP Cost Total Cost Offset Offset
CYF 0 0 0 $ - $ - $ - -
TAY 4,711 532 4,179 $ 796,165.08 $ 89,939.11 $ 706,225.97 88.7%
Adults 46,781 3,197 43,584 $ 7,906,049.39 $ 540,341.07 $ 7,365,708.32 93.2%
Older Adults 5,158 148 5,010 $ 871,708.66 $ 25,067.96 $ 846,640.70 97.1%
Total 56,650 3,878 52,772 $ 9,573,923.13 $ 655,348.14 $ 8,918,574.99 93.2%
Table IV.20 represents FY 08-09, and Table IV.22 FY 09-10. Each table is divided in half, with the left half labeled:
12 Months Pre-Intake – the data displayed in this half correspond to those collected at baseline. “Pre-
Intake” means before the client enrolled in FSP.
For baseline (intake, 12 months prior to enrolling in FSP):
Number in Long-Term Care = the actual number of FSP clients who were in long-term care for psychiatric
reasons.
o An FSP client is counted only one time at baseline (regardless of whether he or she was in long-
term care multiple times during the 12 months prior to intake).
o Number in Long-Term Care is number of persons in long-term care (across all counties
participating in the study), not number of times in long-term care, average number per county or
some other metric.
Average Number of Days per Year = the average number of days FSP clients were in long-term care.
o At baseline, it is simply the average number of days as reported on the PAF.
Annual per-Client Cost = Pre-FSP Cost divided by the total number of new enrollees for the fiscal year.
The right half is labeled:
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12 Months Post-Intake – the data displayed in this half correspond to those collected in the follow-up
period. “Post-Intake” means after the client enrolled in FSP.
For follow-up (post-enrollment, 12 months after enrolling in FSP):
Number in Long-Term Care = the actual number of FSP clients who were in long-term care for psychiatric
reasons.
o An FSP client is counted only one time at follow-up (regardless of whether he or she was in long-
term care multiple times during follow-up).
o Number in Long-Term Care is number of persons in long-term care (across all counties
participating in the study), not number of times in long-term care, average number per county or
some other metric.
Average Number of Days per Year = an average of the annualized total number of days FSP clients were in
long-term care. Because the Average Number of Days per Year is an average of an annualized number, it is
also an annualized number.
Annualized per-Client Cost = Post-FSP Total Cost divided by the total number of new enrollees for the
fiscal year.
The figures for baseline and follow-up in Table IV.20 are for FSP clients who enrolled in FY 08-09.
Table IV.20
Full Service Partnership Services – Annualized per-Client Cost for Number of Days in Long-Term-Care Facility
(Fiscal Year 08-09 New Enrollees ONLY)
12 Months Pre-Intake 12 Months Post-Intake
Number in Long Average Number Annual per- Number in Long- Average Number Annualized per-
-Term Care of Days per Year Client Cost Term Care of Days per Year Client Cost
CYF 0 0.0 $ - 0 0.0 $ -
TAY 31 44.3 $ 342.14 11 6.8 $ 38.65
Adults 226 112.9 $ 1,832.22 36 34.6 $ 125.22
Older Adults 19 78.4 $ 1,497.78 3 4.5 $ 43.07
Total 276 50
The figures for baseline and follow-up in Table IV.21 are for FSP clients who enrolled in FY 09-10.
Table IV.21
Full Service Partnership Services – Total Annual Cost Offset for Number of Days in Long-Term-Care Facility
(Fiscal Year 09-10 New Enrollees ONLY)
Number of Days per Year Decrease in
12 Months 12 Months Number of Percent
Pre-Intake Post-Intake Days Pre-FSP Cost Post-FSP Cost Total Cost Offset of Offset
CYF 0 0 0 $ - $ - $ - -
TAY 9,022 614 8,408 $ 1,647,825.18 $ 112,144.17 $ 1,535,681.01 93.2%
Adults 60,683 2,937 57,746 $ 11,083,459.95 $ 536,341.34 $ 10,547,118.61 95.2%
Older Adults 6,027 304 5,723 $ 1,100,802.75 $ 55,524.15 $ 1,045,278.60 95.0%
Total 75,732 3,855 71,877 $ 13,832,087.88 $ 704,009.66 $ 13,128,078.22 94.9%
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The figures for baseline and follow-up in Table IV.22 are for FSP clients who enrolled in FY 09-10.
Table IV.22
Full Service Partnership Services – Annualized per-Client Cost for Number of Days in Long-Term-Care Facility
(Fiscal Year 09-10 New Enrollees ONLY)
12 Months Pre-Intake 12 Months Post-Intake
Number in Long- Average Number Annual per- Number in Long- Average Number Annualized per-
Term Care of Days per Year Client Cost Term Care of Days per Year Client Cost
CYF 0 0.0 $ - 0 0.0 $ -
TAY 51 35.7 $ 553.52 6 7.0 $ 37.67
Adults 287 85.3 $ 2,357.18 32 32.6 $ 114.07
Older Adults 27 61.9 $ 1,706.67 6 2.4 $ 86.08
Total 365 44
3. Skilled Nursing (Psychiatric)
A psychiatric skilled nursing facility is a Medicare-certified facility that provides intervention for individuals
requiring mental health treatment in a secured setting. The focus of these facilities is to stabilize psychiatric
symptoms and treat medical conditions. 165
In state-of-the-art skilled nursing facilities, care managers enhance activation using motivational interviewing
techniques and action plans, which set and track short-term achievable goals for medical care or lifestyle change.
Coaching is provided to patients to help them interact more effectively with their providers. With the participant’s
permission, providers are notified about changes in the patient’s medication regimen and medical status. The care
manager works to help clients overcome barriers to attending medical appointments. 166
There is a distinction between the above and skilled nursing facilities that focus on physical health needs. For the
purpose of this analysis, we are focusing on only the above. Skilled nursing costs and cost offsets related to
physical health were addressed earlier in this chapter.
As you will read below, the DCR instruments also distinguish skilled nursing facilities focused on psychiatric needs
from those focused on physical health needs, as does the Office of Statewide Health Planning and Development
(OSHPD) and the Cost Report.
Statewide Skilled Nursing Facility Day Rate (Psychiatric)
The Cost Report (Mode 05, SF 30-34) is the source for the rates applied by county for skilled nursing facilities
(psychiatric).167 A “statewide” rate was calculated by averaging the rates for counties that participated in the study
(see Appendix D). Therefore, if a county has more than one facility providing skilled nursing (psychiatric) services,
an average within the county was first calculated to arrive at a rate for each county.
The statewide rate for FY 08-09 is:
165 http://www.dhhs.saccounty.net/BHS/Pages/Adult-Mental-Health/SP-Psychiatric-Skilled-Nursing-Facilities.aspx
166 Druss, B. G., Von Esenwein, S. A., Compton, M. T., Zhao, L., & Leslie, D. L. (2011). Budget impact and sustainability of medical care
management for persons with serious mental illness. AJP in Advance, 1-8.
167 The Cost Report does NOT provide the Patch distinction for skilled nursing facilities. Therefore, there is no way to select “with Patch” or
“without Patch” because this option is not offered as a selection criterion.
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Skilled Nursing - Psychiatric
Statewide Average FY 08-09 $222.49
The statewide rate for FY 09-10 is:
Skilled Nursing - Psychiatric
Statewide Average FY 09-10 $233.87
DCR Variables Analyzed at Baseline (Intake) and Follow-Up
Below are the exact variables we used out of the PAF and the KET, and their definitions. 168
PAF (Intake/Baseline) Variable: NursingPsychiatric_PastTwelveDays 169 – Defined as:
o RESIDENTIAL INFORMATION: Skilled nursing facility (psychiatric);
o Indicates the number of DAYS the partner has been living in this setting during the past 12
months;
o Valid Codes: 0-365
KET (Follow-Up) Variable: Current.1 through Current.155 = 24, which is a categorical variable assigned to
represent Skilled Nursing Facility (Psychiatric).
o The Current variables represent the residential status of the FSP client at the time of each follow-
up.
o Follow-ups (as documented on the KET) are not conducted according to any predetermined time
frame, but rather are driven by Key Events occurring in the FSP client’s life (e.g., hospitalization,
incarceration).
o The DCR allows for entry of up to 155 KETs.
This information, on its own, is insufficient to calculate the number of days that an FSP client was in a skilled
nursing facility (psychiatric). What the Current variable (code = 24) tells us is only that an FSP client was in a skilled
nursing facility for psychiatric reasons, not how many days.
So the challenge for the analysis was how to determine the number of days in a skilled nursing facility for
psychiatric reasons, over 155 possible follow-up points. This is the focus of the Calculations section that follows.
Calculations – Follow-Up, 12 Months Post-Intake: Skilled Nursing (Psychiatric)
Accompanying each Current variable is a DateResidentialChange variable. This variable tells us on what date the
client’s residential setting changed.
Therefore, we developed programming commands in SPSS that performed the following operations for each KET
follow-up period:
1. Selected only those FSP clients who were in a skilled nursing facility for psychiatric reasons: Current = 24.
2. Calculated the number of days in skilled nursing for psychiatric reasons by taking the subsequent
DateResidentialChange and subtracting the current DateResidentialChange.
168 Courtesy of California State University, Sacramento, currently the contractor managing the DCR.
169 Page 84, DCR Data Dictionary Final_20110915. California State University, Sacramento (Sac State). There have been multiple releases of the
DCR, and at least two in 2011 marked “Final.” This version will be provided upon request.
The variable wording is confusing because it seems to suggest occurrence over the past 12 days. The variable name and description,
however, have been reproduced verbatim from Sac State’s data dictionary. The variable actually refers to the number of days over the past 12
months (prior to FSP intake).
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3. After this process was completed 155 times, the number of days in a skilled nursing facility (psychiatric)
was summed for each FSP client to arrive at a grand total for each person.
o The sum is necessary in order to account for subsequent stays that cross KET administrations, as
well as intermittent stays by the same person during his or her FSP involvement.
4. Days Enrolled was divided into 365 (number of days in a year):
365
Days Enrolled
o Days Enrolled, when used in this formula, is not annualized. What we are interested in is the total
period in which an FSP client was enrolled. What we produce is a proportion, which is then
applied against the Number of Days in Skilled Nursing Facility (psychiatric) in order to adjust for
the period of time that a person was at risk for stay in a skilled nursing facility for psychiatric
reasons. If we do not apply this adjustment, we would unfairly weight the results for or against
people who were in the program for shorter or longer periods of time.
o Days Enrolled is: 170
DatePartnershipStatusChange_KET – PartnershipDate 171
5. The proportion calculated for each FSP client out of Step 4 is then multiplied by the sum of days in a
skilled nursing facility (psychiatric) in Step 3. This is how we arrive at the number of days in a skilled
nursing facility (psychiatric), without a bias for length of enrollment.
Findings: Skilled Nursing Facility (Psychiatric)
Tables IV.23 through IV.26 present cost offsets for each of the age groups, in each fiscal year, for number of days in
a skilled nursing facility (psychiatric).
Table IV.23 represents FY 08-09, and Table IV.25 FY 09-10:
12 Months Pre-Intake – The data displayed under any column marked “Pre” correspond to those collected at
baseline. 172 “Pre-Intake” means before the client enrolled in FSP.
For baseline (intake, 12 months prior to enrolling in FSP):
Number of Days per Year
12 Months Pre-
Intake
Number of Days per Year = the actual number of days (total, across all FSP clients) in a skilled nursing
facility for psychiatric reasons.
o This is an annual number because it is the actual number of days in the 12 months prior to
enrolling in FSP. Nothing is done to this number – no changes or adjustments are made to it – it is
exactly as the FSP client reported on the PAF.
170 Elements of this formula were presented in Chapter III. The only element missing from what was presented in Chapter III is the annualization
factor (dividing by 365). But it does not apply here – we are developing a proportion to be applied against number of days hospitalized.
171 Applying all of the caveats discussed in Chapter III, section c. Contextual Factors – Impact on Cost.
172 Refer back to the discussion earlier in the chapter for the explanation about which variables we analyzed, and why.
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Pre-FSP Cost
Pre-FSP Cost = Number of Days (Pre) multiplied by the Statewide Skilled Nursing Facility Day Rate
(Psychiatric).
o This is an annual cost because the Statewide Rate is multiplied by the actual number of days per
year (see the bullet point above).
12 Months Post-Intake – The data displayed under any column marked “Post” correspond to those collected in the
follow-up period. “Post-Intake” means after the client enrolled in FSP.
For follow-up (post-enrollment, 12 months after enrolling in FSP):
Number of Days per Year
12 Months Post-
Intake
Through Key Event Tracking data, identified: 173
o The number of days enrolled.
o Days Enrolled is then divided into 365 (the number of days in a year), illustrated in the formula
below:
365
Days Enrolled
o This quotient is the annualization multiplier for each new enrollee.
o The annualization multiplier is applied to all new enrollees, whether or not they were in a skilled
nursing facility (for psychiatric reasons). 174
Identified:
o The number of days in a skilled nursing facility (for psychiatric reasons) for each FSP client during
the 12-month post-enrollment period, and
o Multiplied by each FSP client’s annualization multiplier.
New enrollees with zero (0) days (in a skilled nursing facility) drop out of the analysis at
this point, and we are left with those new enrollees with number of days in a skilled
nursing facility.
o This product is the annualized number of days in a skilled nursing facility (psychiatric) for each
new enrollee who was in a skilled nursing facility (for psychiatric reasons) during the 12-month
follow-up period.
Post-FSP Cost
Post-FSP Cost = Number of Days (Post) multiplied by the Statewide Skilled Nursing Facility Day Rate
(Psychiatric).
173 See Chapter III for an introduction to the KET, variables used when calculating number of days of FSP participation, and each cost-offset
category in this chapter for the specific cost-offset variables used in analysis.
174 See Chapter III for how days of enrollment were calculated.
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o This is an annualized cost because the Statewide Rate is multiplied by the annualized number of
days (see the bullet point above).
Decrease in
Number of Days
Decrease in Number of Days = Number of Days at Baseline (Pre) minus the Number of Days at Follow-Up
(Post):
Pre – Post = Decrease in Number of Days
Total Cost Offset
Total Cost Offset = Pre-FSP Cost – Post-FSP Cost
Percent of Offset
Percent of Offset =
Total Cost Offset
Pre-FSP Cost
o In other words, the percent of Skilled Nursing (Psychiatric) offset is equal to the total cost offset
for Skilled Nursing (Psychiatric) divided by the pre-FSP cost for Skilled Nursing (Psychiatric).
The figures for baseline and follow-up in Table IV.23 are for FSP clients who enrolled in FY 08-09.
Table IV.23
Full Service Partnership Services – Total Annual Cost Offset for Number of Days in Skilled Nursing Facility
Psychiatric
(Fiscal Year 08-09 New Enrollees ONLY)
Number of Days per Year Decrease in
12 Months 12 Months Number of Percent of
Pre-Intake Post-Intake Days Pre-FSP Cost Post-FSP Cost Total Cost Offset Offset
CYF 0 0 0 $ - $ - $ - -
TAY 105 122 -17 $ 23,361.03 $ 27,143.29 $ (3,782.26) -16.2%
Adults 2,282 674 1,608 $ 507,712.96 $ 149,911.04 $ 357,801.92 70.5%
Older Adults 1,226 309 917 $ 272,767.78 $ 68,748.16 $ 204,019.62 74.8%
Total 3,613 1,105 2,508 $ 803,841.77 $ 245,802.49 $ 558,039.28 69.4%
Table IV.24 represents FY 08-09, and Table IV.26 FY 09-10. Each table is divided in half, with the left half labeled:
12 Months Pre-Intake – the data displayed in this half correspond to those collected at baseline. “Pre-
Intake” means before the client enrolled in FSP.
For baseline (intake, 12 months prior to enrolling in FSP):
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Number in Facility = the actual number of FSP clients who were in a skilled nursing facility for psychiatric
reasons.
o An FSP client is counted only one time at baseline (regardless of whether he or she was in a
skilled nursing facility multiple times during the 12 months prior to intake).
o Number in Facility is the total number of persons in a skilled nursing facility (across all counties
participating in the study), not number of times in a skilled nursing facility, average number per
county or some other metric.
Average Number of Days per Year = the average number of days FSP clients were in a skilled nursing
facility.
o At baseline, it is simply the average number of days as reported on the PAF.
Annual per-Client Cost = Pre-FSP Cost divided by the total number of new enrollees for the fiscal year.
The right half is labeled:
12 Months Post-Intake – the data displayed in this half correspond to those collected in the follow-up
period. “Post-Intake” means after the client enrolled in FSP.
For follow-up (post-enrollment, 12 months after enrolling in FSP):
Number in Facility = the actual number of FSP clients who were in a skilled nursing facility for psychiatric
reasons.
o An FSP client is counted only one time at follow-up (regardless of whether he or she was in a
skilled nursing facility multiple times during follow-up).
o Number in Facility is the total number of persons in a skilled nursing facility (across all counties
participating in the study), not number of times in a skilled nursing facility, average number per
county or some other metric.
Average Number of Days per Year = an average of the annualized total number of days FSP clients were in
a skilled nursing facility. Because the Average Number of Days per Year is an average of an annualized
number, it is also an annualized number.
Annualized per-Client Cost = Post-FSP Total Cost divided by the total number of new enrollees for the
fiscal year.
The figures for baseline and follow-up in Table IV.24 are for FSP clients who enrolled in FY 08-09.
Table IV.24
Full Service Partnership Services – Annualized per-Client Cost for Number of Days in Skilled Nursing Facility
Psychiatric
(Fiscal Year 08-09 New Enrollees ONLY)
12 Months Pre-Intake 12 Months Post-Intake
Number in Average Number Annual per- Number in Average Number Annualized per-
Facility of Days per Year Client Cost Facility of Days per Year Client Cost
CYF 0 0.0 $ - 0 0.0 $ -
TAY 4 3.2 $ 10.04 5 2.4 $ 11.66
Adults 19 33.2 $ 117.66 31 4.4 $ 34.74
Older Adults 6 27.3 $ 468.67 5 7.2 $ 118.12
Total 29 41
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The figures for baseline and follow-up in Table IV.25 are for FSP clients who enrolled in FY 09-10.
Table IV.25
Full Service Partnership Services – Total Annual Cost Offset for Number of Days in Skilled Nursing Facility
Psychiatric
(Fiscal Year 09-10 New Enrollees ONLY)
Number of Days per Year Decrease in
12 Months 12 Months Number of Percent of
Pre-Intake Post-Intake Days Pre-FSP Cost Post-FSP Cost Total Cost Offset Offset
CYF 0 0 0 $ - $ - $ - -
TAY 69 259 -190 $ 16,137.29 $ 60,573.29 $ (44,436.00) -275.4%
Adults 5,365 2,663 2,702 $ 1,254,732.52 $ 622,805.72 $ 631,926.80 50.4%
Older Adults 1,807 595 1,212 $ 422,609.82 $ 139,154.87 $ 283,454.95 67.1%
Total 7,241 3,517 3,724 $ 1,693,479.63 $ 822,533.88 $ 870,945.75 51.4%
The figures for baseline and follow-up in Table IV.26 are for FSP clients who enrolled in FY 09-10.
Table IV.26
Full Service Partnership Services – Annualized per-Client Cost for Number of Days in Skilled Nursing Facility
Psychiatric
(Fiscal Year 09-10 New Enrollees ONLY)
12 Months Pre-Intake 12 Months Post-Intake
Average Average Annualized
Number in Number of Annual per- Number in Number of Days per-Client
Facility Days per Year Client Cost Facility per Year Cost
CYF 0 0.0 $ - 0 0.0 $ -
TAY 2 1.6 $ 5.42 4 6.2 $ 20.35
Adults 47 50.2 $ 266.85 36 14.8 $ 132.46
Older Adults 10 36.3 $ 655.21 10 4.8 $ 215.74
Total 59 50
d. Criminal Justice Involvement
Criminal justice involvement, for the purpose of this report, is defined as:
Arrests (number of times)
Division of Juvenile Justice (number of days)
Juvenile Hall/Camp (number of days)
Jail (number of days)
Prison (number of days)
In a 2005 study, Wolff, Bjerklie and Maschi calculated cost for nurse care managers over a two-year period. Cost
was calculated using the mean salaries for registered nurses, based on data from the Bureau of Labor Statistics, a
mean fringe rate of 29 percent and training costs. From a health system perspective, the results show that a mean
annual cost of implementing the intervention, including staff salaries, fringe benefits, supplies and equipment, and
overhead, was estimated at $973 per patient for the first year and $915 per patient for the second year, which did
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not include one-time equipment and training costs. 175 For the second year, the mean costs for patients in the
intervention group were $932 less than for those in a comparison group, reflecting a 92.3 percent probability of a
cost offset. 176 The cost profile was highly favorable and led to a trend toward a cost offset by the second year,
suggesting a good value. 177
Results are presented in each of these offset categories, for each age group.
1. Arrests
Cost offsets for arrests are presented separately from those for incarceration due to the inherent difference in the
data (an incidence of arrest versus number of days incarcerated).
Bierie (2009) “drew a cost-benefit method to compare recidivism between two groups of inmates,” those in boot
camp and those in prison. 178 His study estimated a “loss of $78,864 in 2005 for the 186 arrests generated from the
traditional prison.” This translated into an average cost of $424 per arrest and an average of $652 in police
expenses drained by the average traditional prison inmate (p. 386). 179 In comparison, the study found “the boot
camp’s 114 unique arrests drained a total of $39,342 in police spending.” The total cost translated into an “average
of $345 per arrest and an average loss of $375 per inmate served” (p. 386). 180
Statewide Arrest Rates 181
A booking fee is incurred when an arrestee is taken into custody into county jail or another local detention facility.
The purpose of the booking fee is to enable counties to recover costs associated with booking individuals into
county detention facilities from the arresting agencies. Costs can include searching, wrist-banding, fingerprinting
and medical and mental screening of arrestees. 182
Costs were calculated by dividing the booking fee by the total number of reported number of arrests for each
county. 183
The statewide rate for FY 08-09 is:
Arrests
Statewide Average FY 08-09 $21.38
The statewide rate for FY 09-10 is:
175 Wolff, N., Bjerklie, J. R., & Maschi, T. (2005). Reentry planning for mentally disordered inmates: A social investment perspective. Journal of
Offender Rehabilitation, 41(2), 21-42.
176 Ibid.
177 Ibid.
178 Bierie, D. (2009). Cost matters: A randomized experiment comparing recidivism between two styles of prisons. Journal of Experimental
Criminology, 5, 371-397.
179 Ibid.
180 Ibid.
181 FY 2008-2009 and 2009-2010: State of California Department of Justice: Office of the Attorney General:
http://ag.ca.gov/cjsc/publications/profiles/pub.php
Arrests were calculated by using data from Table 3A – Total Felony Arrests by Gender, Offense and Arrest Rate and Table 4A – Total
Misdemeanor Arrests by Gender, Offense and Arrest Rate.
182 http://www.californiacityfinance.com/BkgFeeFacts100215.pdf
183 FY 2008-2009 – California State Controller’s Office: Division of Accounting and Reporting:
http://www.sco.ca.gov/Files-ARD-Payments/booking_bookingfees08.pdf
FY 2009-2010 – California State Controller's Office: Division of Accounting and Reporting:
http://www.sco.ca.gov/Files-ARD-Payments/bookingfees_fy0910.pdf
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Arrests
Statewide Average FY 09-10 $17.84
DCR Variables Analyzed at Baseline (Intake) and Follow-Up
The Key Event Tracking Form (part of the MHSA DCR) does not indicate the specific facility in which an individual
was arrested – only that an arrest occurred. 184Below are the exact variables we used out of the PAF and the KET,
and their definitions. 185
PAF (Intake/Baseline) Variable: ArrestPast12 186 – Defined as:
o LEGAL ISSUES/DESIGNATIONS: Arrest information;
o Indicates the number of times the partner was arrested during the past 12 months;
o Valid Codes: 0-99
KET (Follow-Up) Variable: Date Arrested1 through DateArrested155 187
o Follow-ups (as documented on the KET) are not conducted according to any predetermined time
frame, but rather are driven by Key Events occurring in the FSP client’s life (e.g., hospitalization,
incarceration).
o The DCR allows for entry of up to 155 KETs.
This information, on its own, is sufficient to calculate the number of times that an FSP client was arrested. The
process of arriving at a summary total across all of the KET follow-ups is the focus of the Calculations section that
follows.
Calculations – Follow-Up, 12 Months Post Intake: Arrests
Therefore, we developed programming commands in SPSS that did the following for each KET follow-up period:
1. Converted the date of arrest (for FSP clients with a date of arrest) to a categorical variable indicating that
an arrest had occurred (e.g., Arrest1 = 1).
2. Calculated the number of arrests.
3. After this process was completed 155 times, the number of arrests was summed for each FSP client to
arrive at a grand total for each person.
4. Next, Days Enrolled was divided into 365 (number of days in a year):
365
Days Enrolled
o Days Enrolled, when used in this formula, is not annualized. What we are interested in is the total
period in which an FSP client was enrolled. What we produce is a proportion, which is then
applied against the Number of Arrests in order to adjust for the period of time that a person was
184 We do not have access to actual arrest records for a number of reasons. However, the primary reason is that counties do not release arrest
data by named individual (in certain counties in some states, this information is actually available online). Furthermore, even if there were
some means of determining whether a named individual had been arrested, this would be a clear violation of UCLA’s IRB, which, in order to
protect confidentiality, has solely authorized receipt of the DCR and CSI data for the purpose of this study.
185 Courtesy of California State University, Sacramento, currently the contractor managing the DCR.
186 Page 120, DCR Data Dictionary Final_20110915. California State University, Sacramento. There have been multiple releases of the DCR, and
at least two in 2011 marked “Final.” This version will be provided upon request.
187 Page 190, DCR Data Dictionary Final_20110915. California State University, Sacramento. There have been multiple releases of the DCR, and
at least two in 2011 marked “Final.” This version will be provided upon request.
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at risk for an arrest. If we do not apply this adjustment, we would unfairly weight the results for
or against people who were in the program for shorter or longer periods of time.
o Days Enrolled: 188
DatePartnershipStatusChange_KET – PartnershipDate 189
5. The proportion calculated for each FSP client out of Step 4 is then multiplied by the sum of arrests in Step
3. This is how we arrive at the number of arrests, without a bias for length of enrollment.
Findings: Arrests
Tables IV.27 through IV.30 present arrest cost offsets for each of the age groups, in each fiscal year.
Table IV.27 represents FY 08-09, and Table IV.29 FY 09-10:
12 Months Pre-Intake – The data displayed under any column marked “Pre” correspond to those collected at
baseline. 190 “Pre-Intake” means before the client enrolled in FSP.
For baseline (intake, 12 months prior to enrolling in FSP):
Number of Arrests per Year
12 Months Pre-
Intake
Number of Arrests per Year = the actual number of arrests (total, across all FSP clients).
o This is an annual number because it is the actual number of arrests in the 12 months prior to
enrolling in FSP. Nothing is done to this number – no changes or adjustments are made to it – it is
exactly as the FSP client reported on the PAF.
Pre-FSP Cost
Pre-FSP Cost = Number of Arrests (Pre) multiplied by the Statewide Arrest Rate.
o This is an annual cost because the Statewide Rate is multiplied by the actual number of arrests
per year (see the bullet point above).
12 Months Post-Intake – The data displayed under any column marked “Post” correspond to those collected in the
follow-up period. “Post-Intake” means after the client enrolled in FSP.
For follow-up (post-enrollment, 12 months after enrolling in FSP):
Number of Arrests per Year
12 Months Post-
Intake
Through Key Event Tracking data, identified: 191
o The number of days enrolled.
188 Elements of this formula were described in Chapter III. The only element missing from what was presented in Chapter III is the annualization
factor (dividing by 365). But it does not apply here – we are developing a proportion to be applied against number of days hospitalized.
189 Applying all of the caveats discussed in Chapter III, section c. Contextual Factors – Impact on Cost.
190 Refer back to the discussion earlier in the chapter for the explanation about which variables we analyzed, and why.
191 See Chapter III for an introduction to the KET, variables used when calculating number of days of FSP participation, and each cost-offset
category in this chapter for the specific cost-offset variables used in analysis.
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o Days Enrolled is then divided into 365 (the number of days in a year), illustrated in the formula
below:
365
Days Enrolled
o This quotient is the annualization multiplier for each new enrollee.
o The annualization multiplier is applied to all new enrollees, whether or not they were arrested.
192
Identified:
o The number of arrests for each FSP client during the 12-month post-enrollment period, and
o Multiplied by each FSP client’s annualization multiplier.
New enrollees with zero (0) arrests drop out of the analysis at this point, and we are left
with those new enrollees who have been arrested.
o This product is the annualized number of arrests for each new enrollee who was arrested during
the 12-month follow-up period.
Post-FSP Cost
Post-FSP Cost = Number of Arrests (Post) multiplied by the Statewide Arrest Rate.
o This is an annualized cost because the Statewide Rate is multiplied by the annualized number of
arrests (see the bullet point above).
Decrease in
Number of Arrests
Decrease in Number of Arrests = Number of Arrests at Baseline (Pre) minus the Number of Arrests at
Follow-Up (Post):
Pre – Post = Decrease in Number of Arrests
Total Cost Offset
Total Cost Offset = Pre-FSP Cost – Post-FSP Cost
192 See Chapter III for how days of enrollment were calculated.
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Percent of Offset
Percent of Offset =
Total Cost Offset
Pre-FSP Cost
o In other words, the percent of Arrests offset is equal to the total cost offset for Arrests divided by
the pre-FSP cost for Arrests.
The figures for baseline and follow-up in Table IV.27 are for FSP clients who enrolled in FY 08-09.
Table IV.27
Full Service Partnership Services – Total Annual Cost Offset for Number of Arrests
(Fiscal Year 08-09 New Enrollees ONLY)
Number of Arrests per Year Decrease in
12 Months 12 Months Number of Percent
Pre-Intake Post-Intake Arrests Pre-FSP Cost Post-FSP Cost Total Cost Offset of Offset
CYF 467 135 332 $ 9,984.93 $ 2,892.85 $ 7,092.08 71.0%
TAY 1,432 252 1,180 $ 30,617.59 $ 5,396.56 $ 25,221.03 82.4%
Adults 1,981 340 1,641 $ 42,355.76 $ 7,265.26 $ 35,090.50 82.8%
Older Adults 46 3 44 $ 983.53 $ 53.45 $ 930.08 94.6%
Total 3,926 730 3,196 $ 83,941.81 $ 15,608.12 $ 68,333.69 81.4%
Table IV.28 represents FY 08-09, and Table IV.30 FY 09-10. Each table is divided in half, with the left half labeled:
12 Months Pre-Intake – the data displayed in this half correspond to those collected at baseline. “Pre-
Intake” means before the client enrolled in FSP.
For baseline (intake, 12 months prior to enrolling in FSP):
Number Arrested = the actual number of FSP clients who were arrested.
o An FSP client is counted only one time at baseline (regardless of whether he or she was arrested
multiple times during the 12 months prior to intake).
o Number Arrested is the number of persons who were arrested (across all counties that
participated in the study), not number of times arrested, average number of arrests by county or
some other metric.
Average Number of Arrests per Year = the average number of arrests.
o At baseline, it is simply the average number of arrests as reported on the PAF.
Annual per-Client Cost = Pre-FSP Cost divided by the total number of new enrollees for the fiscal year.
The right half is labeled:
12 Months Post-Intake – the data displayed in this half correspond to those collected in the follow-up
period. “Post-Intake” means after the client enrolled in FSP.
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For follow-up (post-enrollment, 12 months after enrolling in FSP):
Number Arrested = the actual number of FSP clients who were arrested.
o An FSP client is counted only one time at follow-up (regardless of whether he or she was arrested
multiple times during follow-up).
o Number Arrested is the number of persons who were arrested (across all counties that
participated in the study), not number of times arrested, average number of arrests by county or
some other metric.
Average Number of Arrests per Year = an average of the annualized total number of arrests across all FSP
clients who were arrested during the follow-up period. Because the Average Number of Arrests per Year is
an average of an annualized number, it is also an annualized number.
Annualized per-Client Cost = Post-FSP Total Cost divided by the total number of new enrollees for the
fiscal year.
The figures for baseline and follow-up in Table IV.28 are for FSP clients who enrolled in FY 08-09.
Table IV.28
Full Service Partnership Services – Annualized per-Client Cost for Number of Arrests
(Fiscal Year 08-09 New Enrollees ONLY)
12 Months Pre-Intake 12 Months Post-Intake
Number Average Number Annual per- Number Average Number Annualized per-
Arrested of Arrests per Year Client Cost Arrested of Arrests per Year Client Cost
CYF 266 1.4 $ 4.61 71 1.3 $ 1.34
TAY 800 1.9 $ 13.16 207 0.9 $ 2.32
Adults 1,140 1.7 $ 9.82 270 1.1 $ 1.68
Older Adults 38 0.6 $ 1.69 6 0.1 $ 0.09
Total 2,244 554
The figures for baseline and follow-up in Table IV.29 are for FSP clients who enrolled in FY 09-10.
Table IV.29
Full Service Partnership Services – Total Annual Cost Offset for Number of Arrests
(Fiscal Year 09-10 New Enrollees ONLY)
Number of Arrests per Year Decrease in
12 Months Pre- 12 Months Post- Number of Percent of
Intake Intake Arrests Pre-FSP Cost Post-FSP Cost Total Cost Offset Offset
CYF 578 153 425 $ 10,313.81 $ 2,733.70 $ 7,580.11 73.5%
TAY 1,817 292 1,525 $ 32,422.49 $ 5,215.79 $ 27,206.70 83.9%
Adults 1,814 316 1,498 $ 32,368.96 $ 5,636.91 $ 26,732.05 82.6%
Older Adults 78 13 66 $ 1,391.83 $ 223.05 $ 1,168.78 84.0%
Total 4,287 774 3,513 $ 76,497.09 $ 13,809.45 $ 62,687.64 81.9%
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The figures for baseline and follow-up in Table IV.30 are for FSP clients who enrolled in FY 09-10.
Table IV.30
Full Service Partnership Services – Annualized per-Client Cost for Number of Arrests
(Fiscal Year 09-10 New Enrollees ONLY)
12 Months Pre-Intake 12 Months Post-Intake
Number Average Number Annual per- Number Average Number of Annualized per-
Arrested of Arrests per Year Client Cost Arrested Arrests per Year Client Cost
CYF 356 0.9 $ 3.33 79 0.7 $ 0.88
TAY 975 1.9 $ 10.89 157 1.0 $ 1.75
Adults 1,014 1.4 $ 6.88 199 0.9 $ 1.20
Older Adults 44 0.7 $ 2.16 9 0.2 $ 0.35
Total 2,389 444
2. Incarceration
Incarceration in four different types of facilities is presented in this section. Because the methodologies are nearly
identical, we present the discussion of rates, variables and calculations at the beginning of the section, followed by
the findings.
Although we recognize that the methodologies are complex, it is our assumption that, with the calculations having
been explained in the seven previous sections, familiarity allows us to group the incarceration variables together
and thereby avoid needless repetition.
Incarceration comprises these four types of facilities:
Division of Juvenile Justice
Juvenile Hall/Camp
Jail
Prison
Wolff, Bjerklie and Maschi (2005) assert that correctional facilities are under increasing pressure to respond to the
treatment needs of mentally disordered offenders during their incarceration and to arrange for treatment after
release through reentry planning. 193 According to their study, reentry planning, from a social investment
perspective, is a mechanism that protects the health outcomes produced by investments in correctional health
care and, by extension, produces justice outcomes to the extent that the public is protected from future criminal
behavior associated with untreated mental illness. 194
Statewide Incarceration Rates
In this section, we present each of the sources for obtaining incarceration rates for the four facilities:
Division of Juvenile Justice
Juvenile Hall/Camp
County Jail
Prison
193 Wolff, N., Bjerklie, J. R., & Maschi, T. (2005). Reentry planning for mentally disordered inmates: A social investment perspective. Journal of
Offender Rehabilitation, 41(2), 21-42.
194 Ibid.
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Depending upon the source, additional calculations were conducted in order to arrive at a statewide average.
The statewide rates for FY 08-09 are below:
DJJ* JHC Jail Prison*
Statewide Average FY 08-09 $641.18 $296.40 $142.47 $129.05
*Note that this rate was not available by county, so the statewide rate was used for all counties.
The statewide rates for FY 09-10 are below:
DJJ* JHC Jail Prison*
Statewide Average FY 09-10 $641.18 $292.80 $151.43 $129.05
*Note that this rate was not available by county, so the statewide rate was used for all counties.
Division of Juvenile Justice
The Division of Juvenile Justice (DJJ) provides education and treatment to California youth 12 to 25 years of age
who have serious criminal backgrounds and exhibit the need for intensive treatment. Treatment programs can
address such needs as violent and criminal behavior, sex offender behavior, and substance abuse and mental
health issues. 195
The Division of Juvenile Justice (DJJ) costs were divided by 365 to get the cost per day, as costs listed were the
average annual cost per ward. 196 This calculation results in an annualized rate.
Juvenile Halls and Camps
Juvenile Halls and Camps (JHC) 197 provide secure detention and confinement to delinquent youth from 8 to 25
years of age who are awaiting adjudication and disposition. 198 Camps also provide rehabilitative treatment, care
and custody of minors who are wards of Juvenile Court. 199
The average daily cost survey contains the average daily population and average daily cost for Juvenile Halls and
Camps as reported by the Probation Department for each county. Juvenile Hall rates are reported independently
from the Camp rates in the Average Daily Cost Survey. 200 DCR data do not distinguish between Juvenile Halls or
Camps, and so the rates from the Average Daily Cost Survey (completed by the California Department of
Corrections) were averaged to get a combined rate. 201
195 http://www.cdcr.ca.gov/juvenile_justice/index.html
196 FY 2008-2009 – Department of Finance. (2009) Corrections and Rehabilitation. 5225 Department of Corrections and Rehabilitation, California
Budget 2009-10. Sacramento, CA: State of California, Department of Finance
FY 2009-10 – California Correctional Peace Officers Association http://www.ccpoa.org/issues/ccpoa_on_prison_reform#juvenile-justice
197 California Department of Corrections and Rehabilitation – Corrections Standards Authority (CSA): Average Cost per Day – Juvenile Halls and
Camps
http://www.cdcr.ca.gov/csa/FSO/Average_Daily_Cost_Survey.html
198 The upper age limit of “youth” is dependent upon the county (i.e., varies on a county-by-county basis).
199 http://www.laalmanac.com/crime/cr39.htm
200 California Department of Corrections and Rehabilitation – Corrections Standards Authority (CSA): Average Cost per Day – Juvenile Halls and
Camps
http://www.cdcr.ca.gov/csa/FSO/Average_Daily_Cost_Survey.html
201 Not every county has both types of facilities. CSA is exact in its cost calculations, and provides a daily cost for only the exact type of facility in
each county (i.e., daily cost is matched to a specific facility, and the exact number of individuals incarcerated during the year is accounted for).
When creating an average cost per county, we included only the actual facilities operating in each county. For some counties, this will include
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Jail
A Type II facility is a local detention facility that detains persons awaiting arraignment, post-arraignment and
during the trial and sentencing period. A Type III facility is a local facility that detains convicted and sentenced
persons. 202
The California Department of Corrections and Rehabilitation – Corrections Standards Authority (CSA) was the
source for county jail costs. Specifically, the average cost per day was used as the rate. 203
Two counties (Los Angeles and Lake) provided a daily jail rate inclusive of mental health services. They were the
only two counties to provide this rate. The rate for Los Angeles County (see Appendix C) is higher than the daily jail
rates provided for counties from CSA. Therefore, Los Angeles County’s higher rate impacted the average statewide
jail rate. 204
Prison
For FY 08-09, the prison rate was obtained directly from the LAO (Legislative Analyst’s Office) Annual Costs to
Incarcerate an Inmate in Prison for California on the Criminal Justice and Judiciary FAQ page. 205 The total line item
was then divided by 365 to obtain the average cost per day. This calculation results in an annualized rate.
The prison rate for FY 09-10 was taken from the Key Facts section of page 17 in the DOF’s (Department of Finance)
2010-11 Supplementary Budget Summary. 206 Although the document summarizes projected budget solutions for
2010-11, the average cost presented is consistent with other reports/articles from various news outlets.
DCR Variables Analyzed at Baseline (Intake) and Follow-Up
Below are the exact variables we used out of the PAF and the KET, and their definitions. 207
Division of Juvenile Justice
PAF (Intake/Baseline) Variable: DJJ_PastTwelveDays 208 – Defined as:
o RESIDENTIAL INFORMATION: Justice Placement – Division of Juvenile Justice;
o Indicates the number of DAYS the partner has been living in this setting during the past 12
months;
o Valid Codes: 0-365
juvenile halls and camps. For other counties, this will include just juvenile hall or just camp. For details on what type of facility each county
operates, please follow the link below and look up the specific county you are interested in.
California Department of Corrections and Rehabilitation – Corrections Standards Authority (CSA): Average Cost per Day – Juvenile Halls and
Camps
http://www.cdcr.ca.gov/csa/FSO/Average_Daily_Cost_Survey.html
202 http://www.cdcr.ca.gov/CSA/FSO/Docs/6_2008%20Adult_T_24_FINAL_REGULATION_TEXT.pdf
203 Average Cost per Day Type II and III Jails –
http://www.cdcr.ca.gov/csa/FSO/Average_Daily_Cost_Survey.html
204 The rate inclusive of mental health services for Los Angeles County comes from Economic Roundtable (2009). Where we sleep: Costs when
homeless and housed in Los Angeles. “Sheriff’s Department costs for incarceration in medical or mental health jail facilities were … $1,093 per
day in fiscal years 2006-2007 and 2007-2008.”
205 http://www.lao.ca.gov/laoapp/laomenus/sections/crim_justice/6_cj_inmatecost.aspx?catid=3
206 http://www.dof.ca.gov/budget/historical/2010-11/governors/documents/Supplementary_Budget_Summary.pdf
207 Courtesy of California State University, Sacramento (Sac State), currently the contractor managing the DCR.
208 Page 88, DCR Data Dictionary Final_20110915. California State University, Sacramento. There have been multiple releases of the DCR, and at
least two in 2011 marked “Final.” This version will be provided upon request.
The variable wording is confusing because it seems to suggest occurrence over the past 12 days. The variable name and description,
however, have been reproduced verbatim from Sac State’s data dictionary. The variable actually refers to the number of days over the past 12
months (prior to FSP intake).
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KET (Follow-Up) Variable: Current.1 through Current.155 = 16, which is a categorical variable assigned to
represent Division of Juvenile Justice.
o The Current variables represent the residential status of the FSP client at the time of each follow-
up.
o Follow-ups (as documented on the KET) are not conducted according to any predetermined time
frame, but rather are driven by Key Events occurring in the FSP client’s life (e.g., hospitalization,
incarceration).
o The DCR allows for entry of up to 155 KETs.
This information, on its own, is insufficient to calculate the number of days that an FSP client was in a Division of
Juvenile Justice facility. What the Current variable (code = 16) tells us is only that an FSP client was in a Division of
Juvenile Justice facility, not how many days.
Juvenile Halls and Camps
PAF (Intake/Baseline) Variable: JuvenileHall/Camp_PastTwelveDays 209 – Defined as:
o RESIDENTIAL INFORMATION: Justice Placement – Juvenile Hall / Camp / Ranch;
o Indicates the number of DAYS the partner has been living in this setting during the past 12
months;
o Valid Codes: 0-365
KET (Follow-Up) Variable: Current.1 through Current.155 = 15, which is a categorical variable assigned to
represent Juvenile Hall/Camp. 210
o The Current variables represent the residential status of the FSP client at the time of each follow-
up.
o Follow-ups (as documented on the KET) are not conducted according to any predetermined time
frame, but rather are driven by Key Events occurring in the FSP client’s life (e.g., hospitalization,
incarceration).
o The DCR allows for entry of up to 155 KETs.
This information, on its own, is insufficient to calculate the number of days that an FSP client was in a Juvenile Hall
or a Juvenile Camp. What the Current variable (code = 15) tells us is only that an FSP client was in Juvenile
Hall/Camp, not how many days.
Jail
PAF (Intake/Baseline) Variable: Jail_PastTwelveDays 211 – Defined as:
o RESIDENTIAL INFORMATION: Justice Placement – Jail;
o Indicates the number of DAYS the partner has been living in this setting during the past 12
months;
o Valid Codes: 0-365
209 Ibid.
210 California Department of Corrections and Rehabilitation – Corrections Standards Authority (CSA): Average Cost per Day – Juvenile Halls and
Camps
http://www.cdcr.ca.gov/csa/FSO/Average_Daily_Cost_Survey.html
211 Page 89, DCR Data Dictionary Final_20110915. California State University, Sacramento (Sac State). There have been multiple releases of the
DCR, and at least two in 2011 marked “Final.” This version will be provided upon request.
The variable wording is confusing because it seems to suggest occurrence over the past 12 days. The variable name and description,
however, have been reproduced verbatim from Sac State’s data dictionary. The variable actually refers to the number of days over the past 12
months (prior to FSP intake).
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KET (Follow-Up) Variable: Current.1 through Current.155 = 27, which is a categorical variable assigned to
represent Jail. 212
o The Current variables represent the residential status of the FSP client at the time of each follow-
up.
o Follow-ups (as documented on the KET) are not conducted according to any predetermined time
frame, but rather are driven by Key Events occurring in the FSP client’s life (e.g., hospitalization,
incarceration).
o The DCR allows for entry of up to 155 KETs.
This information, on its own, is insufficient to calculate the number of days that an FSP client was in jail. What the
Current variable (code = 27) tells us is only that an FSP client was in jail, not how many days.
Prison
PAF (Intake/Baseline) Variable: Prison_PastTwelveDays 213 – Defined as:
o RESIDENTIAL INFORMATION: Justice Placement – Prison;
o Indicates the number of DAYS the partner has been living in this setting during the past 12
months;
o Valid Codes: 0-365
KET (Follow-Up) Variable: Current.1 through Current.155 = 26, which is a categorical variable assigned to
represent Prison.214
o The Current variables represent the residential status of the FSP client at the time of each follow-
up.
o Follow-ups (as documented on the KET) are not conducted according to any predetermined time
frame, but rather are driven by Key Events occurring in the FSP client’s life (e.g., hospitalization,
incarceration).
o The DCR allows for entry of up to 155 KETs.
This information, on its own, is insufficient to calculate the number of days that an FSP client was in prison. What
the Current variable (code = 26) tells us is only that an FSP client was in prison, not how many days.
Calculations – Follow-Up, 12 Months Post-Intake: Incarceration
Accompanying each Current variable is a DateResidentialChange variable. This variable tells us on what date the
FSP client’s residential setting changed.
Therefore, we developed programming commands in SPSS that performed the following calculations for each KET
follow-up period:
1. Selected only those FSP clients who were incarcerated. As noted previously, these calculations were
conducted separately for each of the incarceration categories.
2. Calculated the number of days in each incarceration category by taking the subsequent
DateResidentialChange and subtracting the current DateResidentialChange.
212 http://www.cdcr.ca.gov/CSA/FSO/Docs/6_2008%20Adult_T_24_FINAL_REGULATION_TEXT.pdf
213 Page 90, DCR Data Dictionary Final_20110915. California State University. Sacramento (Sac State). There have been multiple releases of the
DCR, and at least two in 2011 marked “Final.” This version will be provided upon request.
The variable wording is confusing because it seems to suggest occurrence over the past 12 days. The variable name and description,
however, have been reproduced verbatim from Sac State’s data dictionary. The variable actually refers to the number of days over the past 12
months (prior to FSP intake).
214 http://www.lao.ca.gov/laoapp/laomenus/sections/crim_justice/6_cj_inmatecost.aspx?catid=3
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3. After this process was completed 155 times (again, separately for each incarceration category), the
number of days in each incarceration category was summed for each FSP client to arrive at a grand total
for each person in each of the four categories.
o The sum is necessary in order to account for subsequent stays that cross KET administrations, as
well as intermittent stays by the same person during his or her FSP involvement.
4. Days Enrolled was divided into 365:
365
Days Enrolled
o Days Enrolled, when used in this formula, is not annualized. What we are interested in is the total
period in which an FSP client was enrolled. What we produce is a proportion, which is then
applied against the Number of Days in each incarceration category 215 in order to adjust for the
period of time that a person was at risk for incarceration. If we do not apply this adjustment, we
would unfairly weight the results for or against people who were in the program for shorter or
longer periods of time.
o Days Enrolled is: 216
DatePartnershipStatusChange_KET – PartnershipDate 217
5. The proportion calculated for each FSP client out of Step 4 is then multiplied by the sum of days
incarcerated (separate for each facility) in Step 3. This is how we arrive at the number of days in
incarceration for each facility, without a bias for length of enrollment.
Findings: Incarceration
Division of Juvenile Justice
Tables IV.31 through IV.34 present Cost Offsets for each of the age groups, in each fiscal year, for the Division of
Juvenile Justice.
Table IV.31 represents FY 08-09, and Table IV.33 FY 09-10:
12 Months Pre-Intake – The data displayed under any column marked “Pre” correspond to those collected at
baseline. 218 “Pre-Intake” means before the client enrolled in FSP.
For baseline (intake, 12 months prior to enrolling in FSP):
Number of Days per Year
12 Months Pre-
Intake
Number of Days per Year = the actual number of days (total, across all FSP clients) incarcerated.
215 Each of the steps we are laying out is run separately for each category, as you will see from the separate tables we display later in this
section.
216 Elements of this formula were presented in Chapter III. The only element missing from what was presented in Chapter III is the annualization
factor (dividing by 365). But it does not apply here – we are developing a proportion to be applied against number of days hospitalized.
217 Applying all of the caveats discussed in Chapter III, section c. Contextual Factors – Impact on Cost.
218 Refer back to the discussion earlier in the chapter for the explanation about which variables we analyzed, and why.
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o This is an annual number because it is the actual number of days in the 12 months prior to
enrolling in FSP. Nothing is done to this number – no changes or adjustments are made to it – it is
exactly as the FSP client reported on the PAF.
Pre-FSP Cost
Pre-FSP Cost = Number of Days (Pre) multiplied by the Statewide DJJ Rate.
o This is an annual cost because the Statewide Rate is multiplied by the actual number of days per
year (see the bullet point above).
12 Months Post-Intake – The data displayed under any column marked “Post” correspond to those collected in the
follow-up period. “Post-Intake” means after the client enrolled in FSP.
For follow-up (post-enrollment, 12 months after enrolling in FSP):
Number of Days per Year
12 Months Post-
Intake
Through Key Event Tracking data, identified: 219
o The number of days enrolled.
o Days Enrolled is then divided into 365 (the number of days in a year), illustrated in the formula
below:
365
Days Enrolled
o This quotient is the annualization multiplier for each new enrollee.
o The annualization multiplier is applied to all new enrollees, whether or not they were in a DJJ
facility. 220
Identified:
o The number of days in a DJJ facility for each FSP client during the 12-month post-enrollment
period, and
o Multiplied by each FSP client’s annualization multiplier.
New enrollees with zero (0) days (incarcerated in a DJJ facility) drop out of the analysis
at this point, and we are left with those new enrollees who were incarcerated in a DJJ
facility.
o This product is the annualized number of days incarcerated in a DJJ facility for each new enrollee
who was incarcerated in a DJJ facility during the 12-month follow-up period.
Post-FSP Cost
219 See Chapter III for an introduction to the KET, variables used when calculating number of days of FSP participation, and each cost-offset
category in this chapter for the specific cost-offset variables used in analysis.
220 See Chapter III for how days of enrollment were calculated.
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Post-FSP Cost = Number of Days (Post) multiplied by the Statewide DJJ Rate.
o This is an annualized cost because the Statewide Rate is multiplied by the annualized number of
days (see the bullet point above).
Decrease in
Number of Days
Decrease in Number of Days = Number of Days at Baseline (Pre) minus the Number of Days at Follow-Up
(Post):
Pre – Post = Decrease in Number of Days
Total Cost Offset
Total Cost Offset = Pre-FSP Cost – Post-FSP Cost
Percent of Offset
Percent of Offset =
Total Cost Offset
Pre-FSP Cost
o In other words, the percent of DJJ cost offset is equal to the total cost offset for DJJ divided by
the pre-FSP cost for incarceration in DJJ facilities.
The figures for baseline and follow-up in Table IV.31 are for FSP clients who enrolled in FY 08-09.
Table IV.31
Full Service Partnership Services – Total Annual Cost Offset for Number of Days in Division of Juvenile Justice Facility
(Fiscal Year 08-09 New Enrollees ONLY)
Number of Days per Year Decrease in
12 Months 12 Months Number of Percent
Pre-Intake Post-Intake Days Pre-FSP Cost Post-FSP Cost Total Cost Offset of Offset
CYF 757 126 631 $ 485,373.26 $ 80,788.68 $ 404,584.58 83.4%
TAY 2,615 106 2,509 $ 1,676,685.70 $ 67,965.08 $ 1,608,720.62 95.9%
Adults 0 0 0 $ - $ - $ - -
Older Adults 0 0 0 $ - $ - $ - -
Total 3,372 232 3,140 $2,162,058.96 $148,753.76 $ 2,013,305.20 93.1%
Table IV.32 represents FY 08-09, and Table IV.34 FY 09-10. Each table is divided in half, with the left half labeled:
12 Months Pre-Intake – the data displayed in this half correspond to those collected at baseline. “Pre-
Intake” means before the client enrolled in FSP.
For baseline (intake, 12 months prior to enrolling in FSP):
Number Incarcerated = the actual number of FSP clients who were incarcerated in a DJJ facility.
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o An FSP client is counted only one time at baseline (regardless of whether he or she was
incarcerated in a DJJ facility multiple times during the 12 months prior to intake).
o Number Incarcerated is the total number of persons incarcerated in a DJJ facility (across all
counties participating in the study), not number of times in a DJJ facility, average number per
county or some other metric.
Average Number of Days per Year = the average number of days FSP clients were incarcerated in a DJJ
facility.
o At baseline, it is simply the average number of days as reported on the PAF.
Annual per-Client Cost = Pre-FSP Cost divided by the total number of new enrollees for the fiscal year.
The right half is labeled:
12 Months Post-Intake – the data displayed in this half correspond to those collected in the follow-up
period. “Post-Intake” means after the client enrolled in FSP.
For follow-up (post-enrollment, 12 months after enrolling in FSP):
Number Incarcerated = the actual number of FSP clients who were incarcerated in a DJJ facility.
o An FSP client is counted only one time at follow-up (regardless of whether he or she was
incarcerated in a DJJ facility multiple times during follow-up).
o Number Incarcerated is the total number of persons incarcerated in a DJJ facility (across all
counties participating in the study), not number of times incarcerated in a DJJ facility, average
number per county or some other metric.
Average Number of Days per Year = an average of the annualized total number of days FSP clients were
incarcerated in a DJJ facility. Because the Average Number of Days per Year is an average of an annualized
number, it is also an annualized number.
Annualized per-Client Cost = Post-FSP Total Cost divided by the total number of new enrollees for the
fiscal year.
The figures for baseline and follow-up in Table IV.32 are for FSP clients who enrolled in FY 08-09.
Table IV.32
Full Service Partnership Services – Annualized per-Client Cost for Number of Days in Division of Juvenile Justice Facility
(Fiscal Year 08-09 New Enrollees ONLY)
12 Months Pre-Intake 12 Months Post-Intake
Number Average Number Annual per- Number Average Number Annualized per-
Incarcerated of Days per Year Client Cost Incarcerated of Days per Year Client Cost
CYF 6 14.6 $ 224.29 5 3.8 $ 37.33
TAY 22 27.9 $ 720.54 3 3.2 $ 29.21
Adults 0 0.0 $ - 0 0.0 $ -
Older Adults 0 0.0 $ - 0 0.0 $ -
Total 28 8
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The figures for baseline and follow-up in Table IV.33 are for FSP clients who enrolled in FY 09-10.
Table IV.33
Full Service Partnership Services – Total Annual Cost Offset for Number of Days in Division of Juvenile Justice Facility
(Fiscal Year 09-10 New Enrollees ONLY)
Number of Days per Year Decrease in
12 Months 12 Months Number of Percent
Pre-Intake Post-Intake Days Pre-FSP Cost Post-FSP Cost Total Cost Offset of Offset
CYF 553 20 533 $ 354,572.54 $ 12,823.60 $ 341,748.94 96.4%
TAY 2,662 45 2,617 $ 1,706,821.16 $ 28,853.10 $ 1,677,968.06 98.3%
Adults 0 0 0 $ - $ - $ - -
Older Adults 0 0 0 $ - $ - $ - -
Total 3,215 65 3,150 $ 2,061,393.70 $ 41,676.70 $ 2,019,717.00 98.0%
The figures for baseline and follow-up in Table IV.34 are for FSP clients who enrolled in FY 09-10.
Table IV.34
Full Service Partnership Services – Annualized per-Client Cost for Number of Days in Division of Juvenile Justice Facility
(Fiscal Year 09-10 New Enrollees ONLY)
12 Months Pre-Intake 12 Months Post-Intake
Number Average Number Annual per- Number Average Number of Annualized per-
Incarcerated of Days per Year Client Cost Incarcerated Days per Year Client Cost
CYF 15 9.4 $ 114.34 1 0.5 $ 4.14
TAY 28 19.6 $ 573.34 6 0.8 $ 9.69
Adults 0 0.0 $ - 0 0.0 $ -
Older Adults 0 0.0 $ - 0 0.0 $ -
Total 43 7
Juvenile Halls and Camps
Tables IV.35 through IV.38 present cost offsets for each of the age groups, in each fiscal year, for Juvenile Halls and
Camps.
Table IV.35 represents FY 08-09, and Table IV.37 FY 09-10:
12 Months Pre-Intake – The data displayed under any column marked “Pre” correspond to those collected at
baseline. 221 “Pre-Intake” means before the client enrolled in FSP.
For baseline (intake, 12 months prior to enrolling in FSP):
Number of Days per Year
12 Months Pre-
Intake
Number of Days per Year = the actual number of days (total, across all FSP clients) incarcerated.
o This is an annual number because it is the actual number of days in the 12 months prior to
enrolling in FSP. Nothing is done to this number – no changes or adjustments are made to it – it is
exactly as the FSP client reported on the PAF.
221 Refer back to the discussion earlier in the chapter for the explanation about which variables we analyzed, and why.
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Pre-FSP Cost
Pre-FSP Cost = Number of Days (Pre) multiplied by the Statewide Juvenile Hall/Camp Rate.
o This is an annual cost because the Statewide Rate is multiplied by the actual number of days per
year (see the bullet point above).
12 Months Post-Intake – The data displayed under any column marked “Post” correspond to those collected in the
follow-up period. “Post-Intake” means after the client enrolled in FSP.
For follow-up (post-enrollment, 12 months after enrolling in FSP):
Number of Days per Year
12 Months Post-
Intake
Through Key Event Tracking data, identified: 222
o The number of days enrolled.
o Days Enrolled is then divided into 365 (the number of days in a year), illustrated in the formula
below:
365
Days Enrolled
o This quotient is the annualization multiplier for each new enrollee.
o The annualization multiplier is applied to all new enrollees, whether or not they were in juvenile
hall and/or camp. 223
Identified:
o The number of days in juvenile hall and/or camp for each FSP client during the 12-month post-
enrollment period, and
o Multiplied by each FSP client’s annualization multiplier.
New enrollees with zero (0) days (incarcerated in juvenile hall and/or camp) drop out of
the analysis at this point, and we are left with those new enrollees who were
incarcerated in juvenile hall/camp.
o This product is the annualized number of days incarcerated in juvenile hall and/or camp for each
new enrollee who was incarcerated in juvenile hall/camp during the 12-month follow-up period.
Post-FSP Cost
Post-FSP Cost = Number of Days (Post) multiplied by the Statewide Juvenile Hall/Camp Rate.
o This is an annualized cost because the Statewide Rate is multiplied by the annualized number of
days (see the bullet point above).
222 See Chapter III for an introduction to the KET, variables used when calculating number of days of FSP participation, and each cost-offset
category in this chapter for the specific cost-offset variables used in analysis.
223 See Chapter III for how days of enrollment were calculated.
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Decrease in
Number of Days
Decrease in Number of Days = Number of Days at Baseline (Pre) minus the Number of Days at Follow-Up
(Post):
Pre – Post = Decrease in Number of Days
Total Cost Offset
Total Cost Offset = Pre-FSP Cost – Post-FSP Cost
Percent of Offset
Percent of Offset =
Total Cost Offset
Pre-FSP Cost
o In other words, the percent of Juvenile Hall and/or Camp cost offset is equal to the total cost
offset for Juvenile Hall and/or Camp divided by the pre-FSP cost for incarceration in Juvenile Hall
and/or Camp.
The figures for baseline and follow-up in Table IV.35 are for FSP clients who enrolled in FY 08-09.
Table IV.35
Full Service Partnership Services – Total Annual Cost Offset for Number of Days in Juvenile Hall/Camp
(Fiscal Year 08-09 New Enrollees ONLY)
Number of Days per Year Decrease in
12 Months 12 Months Number of Percent
Pre-Intake Post-Intake Days Pre-FSP Cost Post-FSP Cost Total Cost Offset of Offset
CYF 6,714 4,408 2,306 $ 1,990,044.86 $ 1,306,541.22 $ 683,503.64 34.3%
TAY 33,378 2,905 30,473 $ 9,893,315.06 $ 861,048.60 $ 9,032,266.46 91.3%
Adults 0 0 0 $ - $ - $ - -
Older Adults 0 0 0 $ - $ - $ - -
Total 40,092 7,313 32,779 $ 11,883,359.92 $ 2,167,589.82 $ 9,715,770.10 81.8%
Table IV.36 represents FY 08-09, and Table IV.38 FY 09-10. Each table is divided in half, with the left half labeled:
12 Months Pre-Intake – the data displayed in this half correspond to those collected at baseline. “Pre-
Intake” means before the client enrolled in FSP.
For baseline (intake, 12 months prior to enrolling in FSP):
Number Incarcerated = the actual number of FSP clients who were incarcerated in juvenile hall and/or
camp.
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o An FSP client is counted only one time at baseline (regardless of whether he or she was
incarcerated in juvenile hall and/or camp multiple times during the 12 months prior to intake).
o Number Incarcerated is the total number of persons incarcerated in juvenile hall or camp (across
all counties participating in the study), not number of times in juvenile hall and/or camp, average
number per county or some other metric.
Average Number of Days per Year = the average number of days FSP clients were incarcerated in juvenile
hall and/or camp.
o At baseline, it is simply the average number of days as reported on the PAF.
Annual per-Client Cost = Pre-FSP Cost divided by the total number of new enrollees for the fiscal year.
The right half is labeled:
12 Months Post-Intake – the data displayed in this half correspond to those collected in the follow-up
period. “Post-Intake” means after the client enrolled in FSP.
For follow-up (post-enrollment, 12 months after enrolling in FSP):
Number Incarcerated = the actual number of FSP clients who were incarcerated in juvenile hall and/or
camp.
o An FSP client is counted only one time at follow-up (regardless of whether he or she was
incarcerated in juvenile hall and/or camp multiple times during follow-up).
o Number Incarcerated is the total number of persons incarcerated in juvenile hall and/or camp
(across all counties participating in the study), not number of times incarcerated, average
number per county or some other metric.
Average Number of Days per Year = an average of the annualized total number of days FSP clients were
incarcerated in juvenile hall and/or camp. Because the Average Number of Days per Year is an average of
an annualized number, it is also an annualized number.
Annualized per-Client Cost = Post-FSP Total Cost divided by the total number of new enrollees for the
fiscal year.
The figures for baseline and follow-up in Table IV.36 are for FSP clients who enrolled in FY 08-09.
Table IV.36
Full Service Partnership Services – Annualized per-Client Cost for Number of Days in Juvenile Hall/Camp
(Fiscal Year 08-09 New Enrollees ONLY)
12 Months Pre-Intake 12 Months Post-Intake
Number Average Number Annual per- Number Average Number Annualized per-
Incarcerated of Days per Year Client Cost Incarcerated of Days per Year Client Cost
CYF 122 33.9 $ 919.61 94 28.5 $ 603.76
TAY 273 55.9 $ 4,251.53 71 15.9 $ 370.03
Adults 0 0.0 $ - 0 0.0 $ -
Older Adults 0 0.0 $ - 0 0.0 $ -
Total 395 165
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The figures for baseline and follow-up in Table IV.37 are for FSP clients who enrolled in FY 09-10.
Table IV.37
Full Service Partnership Services – Total Annual Cost Offset for Number of Days in Juvenile Hall/Camp
(Fiscal Year 09-10 New Enrollees ONLY)
Number of Days per Year Decrease in
12 Months 12 Months Number of Percent of
Pre-Intake Post-Intake Days Pre-FSP Cost Post-FSP Cost Total Cost Offset Offset
CYF 10,491 5,636 4,855 $ 3,071,729.83 $ 1,650,202.01 $ 1,421,527.82 46.3%
TAY 38,072 3,972 34,100 $ 11,147,354.69 $ 1,162,988.36 $ 9,984,366.33 89.6%
Adults 0 0 0 $ - $ - $ - -
Older Adults 0 0 0 $ - $ - $ - -
Total 48,563 9,608 38,955 $ 14,219,084.52 $ 2,813,190.37 $ 11,405,894.15 80.2%
The figures for baseline and follow-up in Table IV.38 are for FSP clients who enrolled in FY 09-10.
Table IV.38
Full Service Partnership Services – Annualized per-Client Cost for Number of Days in Juvenile Hall/Camp
(Fiscal Year 09-10 New Enrollees ONLY)
12 Months Pre-Intake 12 Months Post-Intake
Number Average Number Annual per- Number Average Number Annualized per-
Incarcerated of Days per Year Client Cost Incarcerated of Days per Year Client Cost
CYF 229 20.6 $ 990.56 119 21.3 $ 532.15
TAY 393 57.0 $ 3,744.49 87 19.0 $ 390.66
Adults 0 0.0 $ - 0 0.0 $ -
Older Adults 0 0.0 $ - 0 0.0 $ -
Total 622 206
Jail
Tables IV.39 through IV.42 present cost offsets for each of the age groups, in each fiscal year, for County Jail.
Table IV.39 represents FY 08-09, and Table IV.41 FY 09-10:
12 Months Pre-Intake – The data displayed under any column marked “Pre” correspond to those collected at
baseline. 224 “Pre-Intake” means before the client enrolled in FSP.
For baseline (intake, 12 months prior to enrolling in FSP):
Number of Days per Year
12 Months Pre-
Intake
Number of Days per Year = the actual number of days (total, across all FSP clients) incarcerated.
o This is an annual number because it is the actual number of days in the 12 months prior to
enrolling in FSP. Nothing is done to this number – no changes or adjustments are made to it – it is
exactly as the FSP client reported on the PAF.
224 Refer back to the discussion earlier in the chapter for the explanation about which variables we analyzed, and why.
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Pre-FSP Cost
Pre-FSP Cost = Number of Days (Pre) multiplied by the Statewide Jail Rate.
o This is an annual cost because the Statewide Rate is multiplied by the actual number of days per
year (see the bullet point above).
12 Months Post-Intake – The data displayed under any column marked “Post” correspond to those collected in the
follow-up period. “Post-Intake” means after the client enrolled in FSP.
For follow-up (post-enrollment, 12 months after enrolling in FSP):
Number of Days per Year
12 Months Post-
Intake
Through Key Event Tracking data, identified: 225
o The number of days enrolled.
o Days Enrolled is then divided into 365 (the number of days in a year), illustrated in the formula
below:
365
Days Enrolled
o This quotient is the annualization multiplier for each new enrollee.
o The annualization multiplier is applied to all new enrollees, whether or not they were in jail. 226
Identified:
o The number of days in jail for each FSP client during the 12-month post-enrollment period, and
o Multiplied by each FSP client’s annualization multiplier.
New enrollees with zero (0) days (incarcerated) drop out of the analysis at this point,
and we are left with those new enrollees who were incarcerated.
o This product is the annualized number of days incarcerated in jail for each new enrollee who was
incarcerated in jail during the 12-month follow-up period.
Post-FSP Cost
Post-FSP Cost = Number of Days (Post) multiplied by the Statewide Jail Rate.
o This is an annualized cost because the Statewide Rate is multiplied by the annualized number of
days (see the bullet point above).
Decrease in
Number of Days
225 See Chapter III for an introduction to the KET, variables used when calculating number of days of FSP participation, and each cost-offset
category in this chapter for the specific cost-offset variables used in analysis.
226 See Chapter III for how days of enrollment were calculated.
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Decrease in Number of Days = Number of Days at Baseline (Pre) minus the Number of Days at Follow-Up
(Post):
Pre – Post = Decrease in Number of Days
Total Cost Offset
Total Cost Offset = Pre-FSP Cost – Post-FSP Cost
Percent of Offset
Percent of Offset =
Total Cost Offset
Pre-FSP Cost
o In other words, the percent of Jail cost offset is equal to the total cost offset for Jail divided by
the pre-FSP cost for incarceration in Jail.
The figures for baseline and follow-up in Table IV.39 are for FSP clients who enrolled in FY 08-09.
Table IV.39
Full Service Partnership Services – Total Annual Cost Offset for Number of Days in Jail
(Fiscal Year 08-09 New Enrollees ONLY)
Number of Days per Year Decrease in
12 Months 12 Months Number of Percent
Pre-Intake Post-Intake Days Pre-FSP Cost Post-FSP Cost Total Cost Offset of Offset
CYF 0 0 0 $ - $ - $ - -
TAY 24,816 5,829 18,987 $ 3,535,606.42 $ 830,445.79 $ 2,705,160.63 76.5%
Adults 84,754 12,599 72,155 $ 12,075,144.53 $ 1,795,015.53 $ 10,280,129.00 85.1%
Older Adults 2,954 95 2,859 $ 420,864.82 $ 13,591.91 $ 407,272.91 96.8%
Total 112,524 18,523 94,001 $16,031,615.77 $ 2,639,053.23 $13,392,562.54 83.5%
Table IV.40 represents FY 08-09, and Table IV.42 FY 09-10. Each table is divided in half, with the left half labeled:
12 Months Pre-Intake – the data displayed in this half correspond to those collected at baseline. “Pre-
Intake” means before the client enrolled in FSP.
For baseline (intake, 12 months prior to enrolling in FSP):
Number Incarcerated = the actual number of FSP clients who were incarcerated in jail.
o An FSP client is counted only one time at baseline (regardless of whether he or she was
incarcerated in jail multiple times during the 12 months prior to intake).
o Number Incarcerated is the total number of persons incarcerated in jail (across all counties
participating in the study), not number of times in jail, average number per county or some other
metric.
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Average Number of Days per Year = the average number of days FSP clients were incarcerated in jail.
o At baseline, it is simply the average number of days as reported on the PAF.
Annual per-Client Cost = Pre-FSP Cost divided by the total number of new enrollees for the fiscal year.
The right half is labeled:
12 Months Post-Intake – the data displayed in this half correspond to those collected in the follow-up
period. “Post-Intake” means after the client enrolled in FSP.
For follow-up (post-enrollment, 12 months after enrolling in FSP):
Number Incarcerated = the actual number of FSP clients who were incarcerated in jail.
o An FSP client is counted only one time at follow-up (regardless of whether he or she was
incarcerated in jail multiple times during follow-up).
o Number Incarcerated is the total number of persons incarcerated in jail (across all counties
participating in the study), not number of times incarcerated, average number per county or
some other metric.
Average Number of Days per Year = an average of the annualized total number of days FSP clients were
incarcerated in jail. Because the Average Number of Days per Year is an average of an annualized number,
it is also an annualized number.
Annualized per-Client Cost = Post-FSP Total Cost divided by the total number of new enrollees for the
fiscal year.
The figures for baseline and follow-up in Table IV.40 are for FSP clients who enrolled in FY 08-09.
Table IV.40
Full Service Partnership Services – Annualized per-Client Cost for Number of Days in Jail
(Fiscal Year 08-09 New Enrollees ONLY)
12 Months Pre-Intake 12 Months Post-Intake
Number Average Number Annual per- Number Average Number Annualized per-
Incarcerated of Days per Year Client Cost Incarcerated of Days per Year Client Cost
CYF 0 0.0 $ - 0 0.0 $ -
TAY 303 50.3 $ 1,519.38 193 20.3 $ 356.87
Adults 878 68.6 $ 2,798.41 402 27.4 $ 415.99
Older Adults 20 32.8 $ 723.14 8 2.2 $ 23.35
Total 1,201 603
The figures for baseline and follow-up in Table IV.41 are for FSP clients who enrolled in FY 09-10.
Table IV.41
Full Service Partnership Services – Total Annual Cost Offset for Number of Days in Jail
(Fiscal Year 09-10 New Enrollees ONLY)
Number of Days per Year Decrease in
12 Months 12 Months Number of Percent
Pre-Intake Post-Intake Days Pre-FSP Cost Post-FSP Cost Total Cost Offset of Offset
CYF 0 5 -5 $ - $ 757.17 $ (757.17) -
TAY 23,584 6,885 16,699 $ 3,571,410.02 $ 1,042,620.34 $ 2,528,789.68 70.8%
Adults 72,626 11,052 61,574 $ 10,998,016.63 $ 1,673,644.15 $ 9,324,372.48 84.8%
Older Adults 2,334 225 2,109 $ 353,446.02 $ 34,072.56 $ 319,373.46 90.4%
Total 98,544 18,167 80,377 $ 14,922,872.67 $ 2,751,094.22 $ 12,171,778.45 81.6%
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The figures for baseline and follow-up in Table IV.42 are for FSP clients who enrolled in FY 09-10.
Table IV.42
Full Service Partnership Services – Annualized per-Client Cost for Number of Days in Jail
(Fiscal Year 09-10 New Enrollees ONLY)
12 Months Pre-Intake 12 Months Post-Intake
Number Average Number Annual per- Number Average Number Annualized per-
Incarcerated of Days per Year Client Cost Incarcerated of Days per Year Client Cost
CYF 0 0.0 $ - 1 0.1 $ 0.24
TAY 291 42.7 $ 1,199.67 161 27.6 $ 350.23
Adults 793 53.5 $ 2,339.01 323 20.8 $ 355.94
Older Adults 28 25.3 $ 547.98 8 3.4 $ 52.83
Total 1,112 493
The results of the Full Service Partnership Cost Offset analysis – over $25 million in savings from reductions in days
spent in jail alone for FY 08-09 and FY 09-10 – are extremely encouraging and are consistent with an evaluation of
the AB 2034 program; that evaluation found cost offsets of approximately $24.7 million from reductions in
psychiatric inpatient days and number of days incarcerated. 227
Prison
Tables IV.43 through IV.46 present cost offsets for each of the age groups, in each fiscal year, for Prison.
Table IV.43 represents FY 08-09, and Table IV.45 FY 09-10:
12 Months Pre-Intake – The data displayed under any column marked “Pre” correspond to those collected at
baseline. 228 “Pre-Intake” means before the client enrolled in FSP.
For baseline (intake, 12 months prior to enrolling in FSP):
Number of Days per Year
12 Months Pre-
Intake
Number of Days per Year = the actual number of days (total, across all FSP clients) incarcerated.
o This is an annual number because it is the actual number of days in the 12 months prior to
enrolling in FSP. Nothing is done to this number – no changes or adjustments are made to it – it is
exactly as the FSP client reported on the PAF.
Pre-FSP Cost
Pre-FSP Cost = Number of Days (Pre) multiplied by the Statewide Prison Rate.
o This is an annual cost because the Statewide Rate is multiplied by the actual number of days per
year (see the bullet point above).
227 Review of the report and appendices did not yield a per-person cost offset in either area or a breakout for inpatient psychiatric offsets
compared with incarceration offsets. Unfortunately, comparisons broken out into psychiatric and incarceration therefore cannot be provided.
California Department of Mental Health (2007). (unpublished) Report to the Legislature on the effectiveness of integrated services for
homeless adults with serious mental illness. Sacramento, CA: Author.
228 Refer back to the discussion earlier in the chapter for the explanation about which variables we analyzed, and why.
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12 Months Post-Intake – The data displayed under any column marked “Post” correspond to those collected in the
follow-up period. “Post-Intake” means after the client enrolled in FSP.
For follow-up (post-enrollment, 12 months after enrolling in FSP):
Number of Days per Year
12 Months Post-
Intake
Through Key Event Tracking data, identified: 229
o The number of days enrolled.
o Days Enrolled is then divided into 365 (the number of days in a year), illustrated in the formula
below:
365
Days Enrolled
o This quotient is the annualization multiplier for each new enrollee.
o The annualization multiplier is applied to all new enrollees, whether or not they were in prison.
230
Identified:
o The number of days in prison for each FSP client during the 12-month post-enrollment period,
and
o Multiplied by each FSP client’s annualization multiplier.
New enrollees with zero (0) days (incarcerated) drop out of the analysis at this point,
and we are left with those new enrollees who were incarcerated.
o This product is the annualized number of days incarcerated in prison for each new enrollee who
was incarcerated in prison during the 12-month follow-up period.
Post-FSP Cost
Post-FSP Cost = Number of Days (Post) multiplied by the Statewide Prison Rate.
o This is an annualized cost because the Statewide Rate is multiplied by the annualized number of
days (see the bullet point above).
Decrease in
Number of Days
Decrease in Number of Days = Number of Days at Baseline (Pre) minus the Number of Days at Follow-Up
(Post):
Pre – Post = Decrease in Number of Days
229 See Chapter III for an introduction to the KET, variables used when calculating number of days of FSP participation, and each cost-offset
category in this chapter for the specific cost-offset variables used in analysis.
230 See Chapter III for how days of enrollment were calculated.
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Total Cost Offset
Total Cost Offset = Pre-FSP Cost – Post-FSP Cost
Percent of Offset
Percent of Offset =
Total Cost Offset
Pre-FSP Cost
o In other words, the percent of Prison cost offset is equal to the total cost offset for Prison divided
by the pre-FSP cost for Prison.
The figures for baseline and follow-up in Table IV.43 are for FSP clients who enrolled in FY 08-09.
Table IV.43
Full Service Partnership Services – Total Annual Cost Offset for Number of Days in Prison
(Fiscal Year 08-09 New Enrollees ONLY)
Number of Days per Year Decrease in
12 Months 12 Months Number of Percent of
Pre-Intake Post-Intake Days Pre-FSP Cost Post-FSP Cost Total Cost Offset Offset
CYF 0 0 0 $ - $ - $ - -
TAY 1,243 25 1,218 $ 160,409.15 $ 3,226.25 $ 1 57,182.90 98.0%
Adults 3,960 0 3,960 $ 511,038.00 $ - $ 5 11,038.00 100.0%
Older Adults 562 0 562 $ 72,526.10 $ - $ 72,526.10 100.0%
Total 5,765 25 5,740 $ 743,973.25 $ 3,226.25 $ 740,747.00 99.6%
Table IV.44 represents FY 08-09, and Table IV.46 FY 09-10. Each table is divided in half, with the left half labeled:
12 Months Pre-Intake – the data displayed in this half correspond to those collected at baseline. “Pre-
Intake” means before the client enrolled in FSP.
For baseline (intake, 12 months prior to enrolling in FSP):
Number Incarcerated = the actual number of FSP clients who were incarcerated in prison.
o An FSP client is counted only one time at baseline (regardless of whether he or she was
incarcerated in prison multiple times during the 12 months prior to intake).
o Number Incarcerated is the total number of persons incarcerated in prison (across all counties
participating in the study), not number of times in prison, average number per county or some
other metric.
Average Number of Days per Year = the average number of days FSP clients were incarcerated in prison.
o At baseline, it is simply the average number of days as reported on the PAF.
Annual per-Client Cost = Pre-FSP Cost divided by the total number of new enrollees for the fiscal year.
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The right half is labeled:
12 Months Post-Intake – the data displayed in this half correspond to those collected in the follow-up
period. “Post-Intake” means after the client enrolled in FSP.
For follow-up (post-enrollment, 12 months after enrolling in FSP):
Number Incarcerated = the actual number of FSP clients who were incarcerated in prison.
o An FSP client is counted only one time at follow-up (regardless of whether he or she was
incarcerated in prison multiple times during follow-up).
o Number Incarcerated is the total number of persons incarcerated in prison (across all counties
participating in the study), not number of times incarcerated, average number per county or
some other metric.
Average Number of Days per Year = an average of the annualized total number of days FSP clients were
incarcerated in prison. Because the Average Number of Days per Year is an average of an annualized
number, it is also an annualized number.
Annualized per-Client Cost = Post-FSP Total Cost divided by the total number of new enrollees for the
fiscal year.
The figures for baseline and follow-up in Table IV.44 are for FSP clients who enrolled in FY 08-09.
Table IV.44
Full Service Partnership Services – Annualized per-Client Cost for Number of Days in Prison
(Fiscal Year 08-09 New Enrollees ONLY)
12 Months Pre-Intake 12 Months Post-Intake
Number Average Number Annual per- Number Average Number Annualized per-
Incarcerated of Days per Year Client Cost Incarcerated of Days per Year Client Cost
CYF 0 0.0 $ - 0 0.0 $ -
TAY 6 24.4 $ 68.93 1 0.7 $ 1.39
Adults 30 52.5 $ 1 18.43 0 0.0 $ -
Older Adults 3 5.7 $ 1 24.62 0 0.0 $ -
Total 39 1
The figures for baseline and follow-up in Table IV.45 are for FSP clients who enrolled in FY 09-10.
Table IV.45
Full Service Partnership Services – Total Annual Cost Offset for Number of Days in Prison
(Fiscal Year 09-10 New Enrollees ONLY)
Number of Days per Year Decrease in
12 Months 12 Months Number of Percent of
Pre-Intake Post-Intake Days Pre-FSP Cost Post-FSP Cost Total Cost Offset Offset
CYF 0 0 0 $ - $ - $ - -
TAY 1,142 180 962 $ 147,375.10 $ 23,229.00 $ 1 24,146.10 84.2%
Adults 6,864 0 6,864 $ 885,799.20 $ - $ 8 85,799.20 100.0%
Older Adults 65 0 65 $ 8,388.25 $ - $ 8,388.25 100.0%
Total 8,071 180 7,891 $ 1,041,562.55 $ 2 3,229.00 $ 1,018,333.55 97.8%
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The figures for baseline and follow-up in Table IV.46 are for FSP clients who enrolled in FY 09-10.
Table IV.46
Full Service Partnership Services – Annualized per-Client Cost for Number of Days in Prison
(Fiscal Year 09-10 New Enrollees ONLY)
12 Months Pre-Intake 12 Months Post-Intake
Number Average Number Annual Per Client Number Average Number of Annualized Per
Incarcerated of Days Per Year Cost Incarcerated Days Per Year Client Cost
CYF 0 0.0 $ - 0 0.0 $ -
TAY 9 16.7 $ 49.50 1 4.3 $ 7 .80
Adults 44 40.8 $ 188.39 0 0.0 $ -
Older Adults 1 1.5 $ 13.01 0 0.0 $ -
Total 54 1
Stephan (1999) reported that each year prisons across the country are estimated, on average, to spend 12 percent
of their total operating expenditures on health care, with roughly 17 percent of the correctional health care dollar
allocated to mental health services.231 In 2001, Beck and Maruschak reported on federal statistics showing that
while in prison, 61 to 79 percent of inmates with mental health problems receive some type of mental health
treatment, and 50 to 60 percent of these inmates also receive psychotropic medications. 232
Treating individuals with mental illness out in the community instead of in a criminal justice setting of course offers
many more advantages in addition to the obvious cost savings reported above. Cost savings should not be the sole
reason for advocating that treatment take place in a community-based setting. Cost savings do provide a
compelling reason, however, particularly during a period of criminal justice realignment. 233 The Full Service
Partnership should be at the forefront as a meritorious alternative.
e. Racial/Ethnic Background of FSP Clients with Offset Data
Decision rules for data analysis established by the UCLA/EMT team require that no more than 10 percent of the
data for any given variable be missing. The percentage of missing/unknown racial/ethnic background for FSP
clients demonstrating outcomes in the physical health categories ranged from 15 to 70 percent, depending upon
the age group and offset category. As a result, only TAY 234 and Older Adults 235 exhibiting outcomes in the area of
skilled nursing met the requirement necessary to display racial/ethnic findings.
The percentage of missing/unknown racial/ethnic background for FSP clients demonstrating outcomes in the
psychiatric categories ranged from 14 to 63 percent, depending upon the age group and offset category. As a
result, only TAY 236 and Older Adults 237 exhibiting outcomes in the area of long-term care met the requirement
necessary to display racial/ethnic findings.
231 As cited in Wolff, N., Bjerklie, J. R., & Maschi, T. (2005). Reentry planning for mentally disordered inmates: A social investment perspective.
Journal of Offender Rehabilitation, 41(2), 21-42.
232 Ibid.
233 AB 109, most recently.
234 FY 08-09 and FY 09-10.
235 FY 09-10 only.
236 FY 08-09 only.
237 FY 09-10 only.
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The percentage of missing/unknown racial/ethnic background for FSP clients demonstrating outcomes in the
incarceration categories ranged from 14 to 100 percent, depending upon the age group and offset category. As a
result, only CYF 238 and TAY 239 exhibiting outcomes in the area of DJJ incarceration, and Older Adults 240 exhibiting
outcomes in the area of prison incarceration met the requirement necessary to display racial/ethnic findings.
Due to the high percentage of cases with missing/unknown racial/ethnic data, analyses were not conducted for
this study. The study of FSP Costs and Cost Offsets examined only those FSP clients with outcome data in the
offset categories of interest. Therefore, the FSP client population of interest for the study is a much smaller group
from the larger population of FSP clients. The sample was first narrowed down by:
1. Selecting only new enrollees in FY 08-09, and in FY 09-10.
The sample was secondly narrowed down by:
2. Examining offsets in each of the following categories:
a. Physical Health
b. Psychiatric Care
c. Criminal Justice
Racial/ethnic analyses were further hampered for the FSP Costs and Cost Offsets Study by small sample size for FSP
clients showing outcomes in many of the offset categories. Small sample size impacts the percentage of
missing/unknown disproportionately. Again, note that in order to be considered for the racial/ethnic analysis, an
FSP client had to show an outcome in the cost offset area, and have a valid ethnic/racial value in at least one of the
fields for racial/ethnic background. 241
For racial/ethnic analyses on the entire population of FSP clients, please refer to the Initial Statewide Priority
Indicator Report Phase II. 242 The Priority Indicator Report presents an analysis in which race/ethnicity is the only
variable of interest for the entire population of FSP clients. Because there are no qualifying criteria (e.g., did not
need to also show an arrest at baseline), the criteria for missing/unknown are met. Race/ethnicity is presented for
the entire FSP client population in the Priority Indicator Report.
f. Summary
This report identifies the cost savings that society realizes because these services have been provided. Of course,
these savings are not the sole justification of expenditures; the primary purpose of the law is to improve services
to mentally ill citizens most in need of assistance. However, it is a primary purpose of accountable and transparent
public service to demonstrate the impacts of this needed and individually compassionate service on public
concerns. Therefore, this analysis summarizes the savings that are incurred in a limited number of public services
for the recipients of FSP services. To state this differently, this analysis assesses the costs to society with respect to
health services that are incurred by persons facing severe mental health challenges, and public costs incurred
because of criminal justice system involvement attributable to these challenges.
238 FY 09-10 only.
239 FY 08-09 only.
240 FY 09-10 only.
241 Otherwise, our analysis would have simply duplicated the work being done for the Statewide Priority Indicator Report.
242 http://www.mhsoac.ca.gov/Evaluations/docs/InitialStatewidePriorityIndicators_Report2EPhase2.pdf
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It is important to note that this is a conservative analysis. Costs that are not clearly attributable to FSP clients have
not been included, and cost savings estimates have been indexed to conservative estimates of cost. As is widely
recognized, estimating the costs of savings attributable to service is complex – from both a cost estimate and a
benefit estimate point of view. At each step in these estimation processes, we have consciously adopted a
conservative approach.
Per the MHSA Community Services and Supports Three-Year Program and Expenditure Plan Requirements, “Each
county must plan for each age group in their populations to be served.” (p. 13) 243 Age groups are defined as
follows:
Children, Youth and Families (CYF): Birth to 18 years, and special-education pupils from birth to age 21 (p.
21)
Transition-Age Youth (TAY): 16 to 25 years (p. 21)
Adults: 18 to 59 years 244
Older Adults: 60 years and older (p. 21) 245
Almost all of the counties are included in this report (N = 50; 86.2%). 246 The populations of counties (numbers of
persons residing in the counties according to census data) represented in this report comprise almost all of the
State of California (95.0%). 247
FSP services are intensive to meet the needs of FSP-targeted clients. This is driven primarily by the policy objective
to meet the serious needs of the hardest-to-serve clients – those with severe mental illness. This policy objective
includes meeting both the service and the quality-of-life needs of FSP clients and the social outcomes and services
needs of California. To address this complex balance between policy objective and client needs, this study has
assessed a broad range of costs to citizens of California that are a consequence of service delivery to mental health
clients most in need. Table IV.47 below represents costs of service and costs saved as a result of service for Fiscal
Year (FY) 08-09 new enrollees in FSP.
Costs of service are program and housing costs for new clients in a given fiscal year as discussed above;
and
Cost offsets are the total differential between the cost of mental and physical health services, and
criminal justice involvement costs, in the year prior to entry into FSP services and the average 12-month
cost after entry into services. 248 This is the amount of public money in these areas that was saved after
these clients had access to service. 249
243 http://www.dmh.ca.gov/dmhdocs/docs/letters05/05-05CSS.pdf
Children and adolescents identified as seriously emotionally disturbed (SED) are eligible for FSPs if they meet the criteria set forth in Welfare
and Institutions Code Section 5600.3, Subdivision (a). Adults and older adults identified to have a serious mental disorder are eligible for FSPs if
they meet the criteria set forth in Subdivision (b) of Section 5600.3.
http://www.leginfo.ca.gov/cgi-bin/displaycode?section=wic&group=05001-06000&file=5600-5623.5
California’s Welfare and Institutions Code is posted in its entirety on the website cited above, absent page numbers. Click on the link and the
section cited will appear on screen, verbatim, as quoted.
244 Although the age range for Adults was not included in DMH Letter 05-05, it is defined in the California Code of Regulations, Title 9.
Rehabilitative and Development Services, Division 1. Department of Mental Health, Chapter 14. Mental Health Services Act, Article 2:
Definitions, Section 3200.010. Adult.
245 http://www.dmh.ca.gov/dmhdocs/docs/letters05/05-05CSS.pdf
246 See the footnote above. The link to census data is:
http://www.census.gov/popest/research/eval-estimates/eval-est2010.html
247 See Appendix D of the full Report for a list of county participants.
248 Annualization of the service period is the same methodology used by the California Department of Mental Health when evaluating and
reporting on AB 2034 outcomes.
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Full Service Partnership Cost Offsets by Age Group include: 250
Physical Health
Acute Care Inpatient Hospitalization (number of days)
Skilled Nursing (Non-Psychiatric) (number of days)
Emergency Room Visits (number of times)
Psychiatric Care
Inpatient Psychiatric Hospitalization (number of days)
Long-Term Care (number of days) 251
Skilled Nursing (Psychiatric) (number of days)
Criminal Justice Involvement
Arrests (number of times)
Division of Juvenile Justice (number of days)
Juvenile Hall/Camp (number of days)
Jail (number of days)
Prison (number of days)
Table IV.47
Total Full Service Partnership Services – Costs & Cost Offsets
(Fiscal Year 08-09 New Enrollees ONLY)
Number of New Total Cost for FY 08- Total Cost Offset Percent Offset FY 08-
Enrollees FY 08-09 Sum of Days 09 New Enrollees FY 08-09 09
CYF 2,164 340,323 $ 20,450,009.07 $ 2,428,313.16 11.9%
TAY 2,327 371,250 $ 18,870,637.50 $ 22,437,417.44 118.9%
Adults 4,315 690,298 $ 50,564,328.50 $ 41,509,329.01 82.1%
Older Adults 582 91,220 $ 5,573,542.00 $ 5,421,665.55 97.3%
Total 9,388 1,493,091 $ 95,458,517.07 $71,796,725.16 75.2%
Table IV.48 presents the same analysis for new enrollees in FY 09-10.
California Department of Mental Health (2007). (unpublished) Report to the Legislature on the effectiveness of integrated services for
homeless adults with serious mental illness. Sacramento, CA: Author.
249 Of course, cost savings in individual counties could be attributable to many plausible alternative influences other than FSP enrollment,
particularly additional services from other programs in that county. However, these influences would not adequately explain aggregate state
level savings. This issue of diversity in county savings, and in county environments, will be addressed in greater detail in an upcoming analysis.
250 Cost Offsets can be developed only for counties that submit data to the State Department of Mental Health’s Full Service Partnership (FSP)
Data Collection and Reporting System (DCR). All of the variables used in the FSP Cost Offset analysis are contained in the DCR. EMT does not
have access to non-DCR data from counties.
The areas analyzed for savings are very similar to those analyzed in the evaluation of AB 2034 efforts, which included inpatient psychiatric
hospitalization and incarceration. Emergency room use was also evaluated but was limited to psychiatric rather than physical health.
California Department of Mental Health (2007). (unpublished) Report to the Legislature on the effectiveness of integrated services for
homeless adults with serious mental illness. Sacramento, CA: Author.
251 Institution for Mental Diseases facilities/Mental Health Rehabilitation Centers. Key Event Tracking data do not distinguish between the two.
Therefore, an average of the IMD and MHRC rates for the facilities contracted by each county was used as the basis for calculating the cost
applied to the number of days in long-term care.
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Table IV.48
Total Full Service Partnership Services – Costs & Cost Offsets
(Fiscal Year 09-10 New Enrollees ONLY)
Number of New Total Cost for FY 09- Total Cost Offset Percent Offset FY
Enrollees FY 09-10 Sum of Days 10 New Enrollees FY 09-10 09-10
CYF 3,101 454,605 $ 21,775,579.50 $ 2,262,842.11 10.4%
TAY 2,977 496,190 $ 18,681,553.50 $ 27,501,007.94 147.2%
Adults 4,702 868,415 $ 56,212,502.95 $ 56,120,875.82 99.8%
Older Adults 645 103,459 $ 5,325,034.73 $ 3,857,684.17 72.4%
Total 11,425 1,922,669 $ 101,994,670.68 $ 89,742,410.04 88.0%
The findings displayed in Tables IV.47 and IV.48 support a number of conclusions:
Cost savings over the two-year period are consistent in relative magnitude across age groups. In
particular, TAY consumers experienced the greatest cost-related benefits of service. Transition-Age Youth
are at high risk for criminal justice and crisis management services, and FSP participation apparently has a
significant impact on consequences for this age group.
Cost offsets are dramatically lower for the CYF age group. This may reflect the more preventive
orientation of services for children, which is not as clearly reflected in the short time line of the measured
offsets. Savings for children may appear over a much longer period of time, outside the currently funded
study period. In addition, the “consequence” nature of the offset categories examined (e.g., criminal
justice involvement) is more relevant to older age cohorts. 252 Effects of service are sensitive to life
maturation, indicators of service success and the time horizon of measured effects.
Overall, across all age groups, 75 and 88 percent of FSP program costs for new enrollees in FY 08-09 and
FY 09-10 (respectively) are offset by savings to the public mental health, health and justice systems.
Although the argument of cost savings should never be advanced as the primary reason for providing
public mental health services, results of this magnitude make a strong case for the wisdom of investing
public resources in programs such as the Full Service Partnership.
In summary, this analysis of cost offsets in larger social costs attributable to participation in the FSP program
documents positive results. Results for the TAY and Adult age groups, which account for the great majority of
clients, are particularly positive. These results are quite favorable when compared with AB 2034, a program
charged with serving homeless (or at risk of being homeless) TAY and adults with severe mental illness – the final
analysis reported a percentage of costs offset of 49.8 percent. 253
This reflects the greater risk for hospitalization and incarceration that exists in these age groups. Overall, these
results suggest a very positive treatment outcome, and return on investment, for FSP clients.
Table IV.49 illustrates cost offsets by age and offset category for new Full Service Partnership enrollees in Fiscal
Year 08-09.
252 Although indicators such as education are logical choices for Children and Youth, challenges inherent in the statewide data collection system
related to floor effects and missing data made this variable unsuitable for analysis. See Phase II Deliverable 2.E – Priority Indicator Report.
253 California Department of Mental Health (2007). (unpublished) Report to the Legislature on the effectiveness of integrated services for
homeless adults with serious mental illness. Sacramento, CA: Author.
Data collected from November 1, 1999 to January 31, 2007. $55 million in costs, $27.4 million in offsets (psychiatric hospitalization,
incarceration and emergency room use for psychiatric episodes).
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Table IV.49
Full Service Partnership Cost Offsets by Age & Offset Category
(Fiscal Year 08-09 New Enrollees ONLY)
Psychiatric Physical Health Criminal Justice
Percent of Percent of Percent of
Total Offset Total Offset Total Offset
Amount of Offset for Age Group Amount of Offset for Age Group Amount of Offset for Age Group
CYF $ 425,079.62 17.5% $ 908,053.24 37.4% $ 1,095,180.30 45.1%
TAY $ 8,426,402.27 37.6% $ 482,463.53 2.2% $ 13,528,551.64 60.3%
Adults $ 29,718,862.23 71.6% $ 964,209.28 2.3% $ 10,826,257.50 26.1%
Older Adults $ 3,845,911.36 70.9% $ 1,095,025.10 20.2% $ 480,729.09 8.9%
Total $ 42,416,255.48 59.1% $ 3,449,751.15 4.8% $ 25,930,718.53 36.1%
Table IV.50 illustrates cost offsets by age and offset category for new Full Service Partnership enrollees in Fiscal
Year 09-10. 254
Table IV.50
Full Service Partnership Cost Offsets by Age & Offset Category
(Fiscal Year 09-10 New Enrollees ONLY)
Psychiatric Physical Health Criminal Justice
Percent of Percent of Percent of
Total Offset for Total Offset Total Offset for
Amount of Offset Age Group Amount of Offset for Age Group Amount of Offset Age Group
CYF $ 1,104,612.24 38.4% $ (611,869.83) - $ 1,770,099.70 61.6%
TAY $ 9,500,199.91 34.5% $ 3,658,331.16 13.3% $ 14,342,476.87 52.2%
Adults $ 39,688,364.64 70.7% $ 6,195,607.45 11.0% $ 10,236,903.73 18.2%
Older Adults $ 4,290,539.63 92.9% $ (761,785.95) - $ 328,930.49 7.1%
Total $ 54,583,716.42 59.9% $ 8,480,282.83 9.3% $ 26,678,410.79 29.3%
The findings displayed in Tables IV.49 and IV.50 support the following conclusions:
For Adults and Older Adults, the greatest proportion of offsets each fiscal year is accounted for by savings
in psychiatric care (largely due to reductions in inpatient psychiatric hospitalization).
Among TAY and CYF, the greatest proportion of offsets in each fiscal year is accounted for by criminal
justice (incarceration and arrests, although largely due to reduction in the number of days incarcerated).
Physical health (acute care inpatient hospitalization, skilled nursing – non-psychiatric, and emergency
room visits) offsets increased substantially as a percentage of overall offsets between FY 08-09 and FY 09-
10. Current primary care-mental health integration efforts underway will examine the medical needs of
FSP clients in more depth and shed further light on how MHSA meets their myriad needs.
254 Physical Health amounts in FY 09-10 for CYF and Older Adults actually show a loss, or no cost offset. This means that there were more days
of acute care hospitalization, etc., for physical health reasons among Children, Youth and Older Adults during their tenure as Full Service
Partners than in the 12 months prior to intake into the program.
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Percentage of overall offset represented by each age group (new enrollees only) is compared with their proportion
in terms of overall numbers served, days of service and costs in Exhibits IV.1 and IV.2. FSP data from Tables IV.47
and IV.49 are displayed in Exhibit IV.1.
Exhibit IV.1
Full Service Partnership % of Costs & Cost Offsets by Age & Offset Category
(Fiscal Year 08-09 New Enrollees ONLY)
70.0%
57.8%
60.0% 53.0%
46.0%
50.0% 46.2%
40.0%
23.1% 24.9% 31.3%
30.0% 24.8%
22.8% 19.8%
21.4%
20.0%
6.2%
7.6%
6.1%
10.0% 3.4% 5.8%
0.0%
CYF TAY Adults Older Adults
% of # Served % of Sum of Days
% of Total FSP Costs % of Total FSP Cost Offsets
FSP data from Tables IV.48 and IV.50 are used in Exhibit IV.2.
Exhibit IV.2
Full Service Partnership % of Costs & Cost Offsets by Age & Offset Category
(Fiscal Year 09-10 New Enrollees ONLY)
70.0%
62.5%
60.0% 55.1%
45.2%
50.0%
41.2%
40.0%
26.1% 30.6%
27.1%
30.0% 23.6% 25.8%
21.3% 18.3%
20.0%
5.6%
5.4%
10.0%
2.5% 5.2% 4.3%
0.0%
CYF TAY Adults Older Adults
% of # Served % of Sum of Days
% of Total FSP Costs % of Total FSP Cost Offsets
Findings as illustrated in Exhibits IV.1 and IV.2 support the following conclusions:
TAY as an age group show offsets in greater proportion to their costs when compared with other age
groups.
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
Older Adults are represented nearly equally in terms of percentage of overall FSP participants, number of
service days, FSP cost, and cost offsets.
Adults represent the age group with the largest proportion of FSP cost offsets compared with other age
groups. The investment in the serious mental health needs of Adults yields a return on investment.
Children and Youth display the opposite pattern – the amount of offsets as a percentage of the overall age
group total is less than their proportional numbers and days of service. 255
Exhibits IV.3 through IV.10 illustrate the proportion of offset in each category for the age groups.
Exhibit IV.3
. Full Service Partnership % of Cost Offsets for CYF Age Group
(FY 08-09 New Enrollees ONLY)
50.0% 45.1%
45.0%
40.0% 37.4%
35.0%
30.0%
25.0%
20.0% 17.5%
15.0%
10.0%
5.0%
0.0%
Psychiatric Physical Health Criminal Justice
CYF
Exhibit IV.4
. Full Service Partnership % of Cost Offsets for CYF Age Group
(FY 09-10 New Enrollees ONLY)
100.0%
78.2%
80.0%
60.0% 48.8%
40.0%
20.0%
0.0%
Psychiatric Physical Health Criminal Justice
-20.0%
-40.0% -27.0%
CYF
255 CYF savings are more likely in the long term; consequence data may not be the most appropriate for this age group. See Chapter II of the full
Report for limitations re: analysis of the Education variable in the DCR.
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Exhibit IV.5
Full Service Partnership % of Cost Offsets for TAY Age Group
(FY 08-09 New Enrollees ONLY)
70.0%
60.3%
60.0%
50.0%
37.6%
40.0%
30.0%
20.0%
10.0%
2.2%
0.0%
Psychiatric Physical Health Criminal Justice
TAY
Exhibit IV.6
Full Service Partnership % of Cost Offsets for TAY Age Group
(FY 09-10 New Enrollees ONLY)
60.0%
52.2%
50.0%
40.0% 34.5%
30.0%
20.0%
13.3%
10.0%
0.0%
Psychiatric Physical Health Criminal Justice
TAY
Criminal Justice (arrests and incarceration) showed the greatest cost offsets compared with costs for CYF and TAY.
Depending on the age group and fiscal year, from 45.1 to 78.2 percent of criminal justice costs to the public in the
12 months prior to intake were offset in the 12 months following intake due to reductions in numbers of days
incarcerated and number of arrests. 256
The results diverge for health-related offsets (Psychiatric and Physical Health), depending upon age group and
fiscal year. Among TAY, between 34.5 and 37.6 percent (FY 09-10 and FY 08-09, respectively) of Psychiatric costs to
the public in the 12 months prior to intake were offset in the 12 months following intake due to reductions in
256 Mostly related to reductions in incarceration – see the sections on Arrests and Incarceration in this chapter.
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numbers of days hospitalized and in long-term care. 257 For CYF, the percentage of offsets ranges from 17.5 to 48.8
(FY 08-09 and FY 09-10, respectively).
In the area of Physical Health, the percentages of costs offset are not as high – a finding consistent across the older
age groups as well (Adults and Older Adults). However, the argument may be advanced that FSP clients of all ages
are particularly vulnerable to medical problems and are therefore provided with access to necessary physical
health care as a result of program participation. 258
Exhibit IV.7
Full Service Partnership % of Cost Offsets for Adult Age Group
(FY 08-09 New Enrollees ONLY)
80.0%
71.6%
70.0%
60.0%
50.0%
40.0%
26.1%
30.0%
20.0%
10.0% 2.3%
0.0%
Psychiatric Physical Health Criminal Justice
Adults
Exhibit IV.8
Full Service Partnership % of Cost Offsets for Adult Age Group
(FY 09-10 New Enrollees ONLY)
80.0%
70.7%
70.0%
60.0%
50.0%
40.0%
30.0%
18.2%
20.0%
11.0%
10.0%
0.0%
Psychiatric Physical Health Criminal Justice
Adults
257 Mostly related to reductions in inpatient psychiatric hospitalization, as discussed earlier in this chapter.
258 Indeed, research literature supports this hypothesis, as discussed early in this chapter.
Full Service Partnerships: California’s Investment to Support Children and Transition-Age Youth with Page 115
Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
For Adults and Older Adults (illustrated in exhibits above and below), Psychiatric care (inpatient hospitalization,
skilled nursing – psychiatric, and long-term care) showed the greatest cost offsets. Depending on the age group
and fiscal year, from 70.7 to 111.2 percent of publicly funded psychiatric care costs in the 12 months prior to
intake were offset in the 12 months following intake due to reductions in numbers of days of inpatient psychiatric
hospitalization, skilled nursing (psychiatric) care, and long-term care. 259
Exhibit IV.9
Full Service Partnership % of Cost Offsets for Older Adult Age Group
(FY 08-09 New Enrollees ONLY)
80.0%
70.9%
70.0%
60.0%
50.0%
40.0%
30.0%
20.2%
20.0%
8.9%
10.0%
0.0%
Psychiatric Physical Health Criminal Justice
Older Adults
Exhibit IV.10
Full Service Partnership % of Cost Offsets for Older Adult Age Group
(FY 09-10 New Enrollees ONLY)
120.0% 111.2%
100.0%
80.0%
60.0%
40.0%
20.0% 8.5%
0.0%
Psychiatric PPhhyyssiiccaal Hl Heaeltahl th Criminal Justice
-20.0%
-19.7%
-40.0%
Exhibits IV.11 through IV.14 summarize the offset amounts for each age group and the categories examined
(physical health, psychiatric care and criminal justice). Exhibit IV.11 displays how CYF combined offsets from FY 08-
259 Mostly related to reductions in inpatient psychiatric hospitalization, as discussed earlier in this chapter.
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
09 and FY 09-10 are broken out proportionally among psychiatric care, physical health and criminal justice. Results
for CYF FSP clients whose data are displayed in Tables IV.47 through IV.50 (in the rows labeled CYF) are now
summarized in Exhibit IV.11.
Exhibit IV.11
Full Service Partnership Amount of Cost Offsets for CYF
(FY 08-09 & FY 09-10 New Enrollees ONLY)
$1,529,691.86
$2,865,280.00
$296,183.41
Psychiatric Physical Health Criminal Justice
In FY 08-09 and FY 09-10, the total amount of costs to the public system offset for CYF in the three major
categories analyzed (psychiatric care, physical health and criminal justice) was $4,691,155.27 – $4.7 million. Most
of the savings were due to reductions in days incarcerated.
Exhibit IV.12 displays how TAY combined offsets from FY 08-09 and FY 09-10 are broken out proportionally among
psychiatric care, physical health and criminal justice. Results for TAY FSP clients whose data are displayed in Tables
IV.47 through IV.50 (in the rows labeled TAY) are now summarized in Exhibit IV.12.
Exhibit IV.12
Full Service Partnership Amount of Cost Offsets for TAY
(FY 08-09 & FY 09-10 New Enrollees ONLY)
$17,926,602.18
$27,871,028.51
$4,140,794.69
Psychiatric Physical Health Criminal Justice
In FY 08-09 and FY 09-10, the total amount of costs to the public system that were offset for TAY in the three major
categories analyzed (psychiatric care, physical health and criminal justice) was $49,938,425.38 – $49.9 million. As
with their CYF counterparts, most of the savings were due to reductions in days incarcerated.
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
Exhibit IV.13 displays how Adult combined offsets from FY 08-09 and FY 09-10 are broken out proportionally
among psychiatric care, physical health and criminal justice. Results for Adult FSP clients whose data are displayed
in Tables IV.47 through IV.50 (in the rows labeled Adult) are now summarized in Exhibit IV.13.
Exhibit IV.13
Full Service Partnership Amount of Cost Offsets for Adults
(FY 08-09 & FY 09-10 New Enrollees ONLY)
$21,063,161.23
$7,159,816.73
$69,407,226.87
Psychiatric Physical Health Criminal Justice
In FY 08-09 and FY 09-10, the total amount of costs to the public system offset for Adults in the three major
categories analyzed (psychiatric care, physical health and criminal justice) was $97,630,204.83 – $97.6 million.
Most of the savings were due to reductions in days spent in inpatient psychiatric hospitalization.
Exhibit IV.14 displays how Older Adult combined offsets from FY 08-09 and FY 09-10 are broken out proportionally
among psychiatric care, physical health and criminal justice. Results for Older Adult FSP clients whose data are
displayed in Tables IV.47 through IV.50 (in the rows labeled Older Adult) are now summarized in Exhibit IV.14.
Exhibit IV.14
Full Service Partnership Amount of Cost Offsets for Older Adults
(FY 08-09 & FY 09-10 New Enrollees ONLY)
$809,659.58
$333,239.15
$8,136,450.99
Psychiatric Physical Health Criminal Justice
In FY 08-09 and FY 09-10, the total amount of costs to the public system offset for Older Adults in the three major
categories analyzed (psychiatric care, physical health and criminal justice) was $9,279,349.72 – $9.3 million. Most
of the savings were due to reductions in days spent in inpatient psychiatric hospitalization.
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
Exhibits IV.15 through IV.17 summarize the offset amounts across the age groups and the areas examined
(psychiatric care, physical health and criminal justice).
Exhibit IV.15 displays how all offsets from FY 08-09 are broken out proportionally by age group to show the total
amount of offset. Results for all FSP clients whose data are displayed in Tables IV.47 and IV.49 are now
summarized in Exhibit IV.15.
Exhibit IV.15
Full Service Partnership Amount of Cost Offsets by Age Group
(FY 08-09 New Enrollees ONLY)
$5,421,665.55
$2,428,313.16
$22,437,417.44
$41,509,329.01
CYF TAY Adults Older Adults
In FY 08-09, the total amount of costs to the public system offset across all age groups in the three major
categories analyzed (psychiatric care, physical health and criminal justice) was $71,796,725.16 – $71.8 million.
Most of the savings were due to reductions in inpatient psychiatric hospitalization and incarceration among adult
FSP clients, followed by fewer days of incarceration among TAY FSP clients.
Exhibit IV.16 displays how all offsets from FY 09-10 are broken out proportionally by age group to show the total
amount of offset. Results for all FSP clients whose data are displayed in Tables IV.48 and IV.50 are now
summarized in Exhibit IV.16.
Exhibit IV.16
Full Service Partnership Amount of Cost Offsets by Age Group
(FY 09-10 New Enrollees ONLY)
$3,857,684.17 $2,262,842.11
$27,501,007.94
$56,120,875.82
CYF TAY Adults Older Adults
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
In FY 09-10, the total amount of costs to the public system that were offset across all age groups in the three major
categories analyzed (psychiatric care, physical health and criminal justice) was $89,742,410.04 – $89.7 million. As
was observed with the previous fiscal year, most of the savings were due to reductions in inpatient psychiatric
hospitalization and incarceration among Adult FSP clients, followed by fewer days of incarceration among TAY FSP
clients.
Exhibit IV.17 displays all offsets from FY 08-09 and FY 09-10 broken out proportionally by age group to show the
total amount of offset. Results for all FSP clients whose data are displayed in Tables IV.47 through IV.50 are now
summarized in Exhibit IV.17.
Exhibit IV.17
Full Service Partnership Amount of Cost Offsets by Age Group
(FY 08-09 & FY 09-10 New Enrollees ONLY)
$9,279,349.72 $4,691,155.27
$49,938,425.38
$97,630,204.83
CYF TAY Adults Older Adults
When the fiscal year totals are combined (above exhibit), the total amount of costs to the public system that were
offset across all age groups in the three major categories analyzed (psychiatric care, physical health and criminal
justice) was $161,539,135.20 – $161.5 million. In summary, most of the savings were due to reductions in inpatient
psychiatric hospitalization and incarceration among Adult FSP clients, followed by fewer days of incarceration
among TAY FSP clients.
When the total cost for new enrollees across both fiscal years ($197,453,187.75) is compared with the total
amount offset, the percentage of costs offset is 81.8 percent.
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
Appendix A
Key Stakeholder Contacts
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
LIST OF PRESENTATIONS, MEETINGS, INTERVIEWS, CALLS PERSONALLY CONDUCTED BY DR. HARRIS WITH KEY STAKEHOLDERS IN
RE: STATEWIDE MHSA EVALUATION
March 22, 2011 In-person with Southern Regional MHSA Coordinators Service Providers
March 23, 2011 In-person with Bay Area Regional MHSA Coordinators Service Providers
March 29, 2011 In-person with Superior Regional MHSA Coordinators Service Providers
March 30, 2011 In-person with Central Regional MHSA Coordinators Service Providers
April 1, 2011 In-person with LA County DMH Service Providers
April 15, 2011 In-person with FSP Practices Workgroup (Todd Gilmer, UCSD, Service Providers
Jen Clancy, CiMH, and others)
May 9, 2011 In-person with MHSA Partners Service Providers
May 11, 2011 In-person with NAMI CA (Kathleen Derby) Client & Family Agency
June 13, 2011 In-person with California Network of Mental Health Clients Client & Family Agency
(Delphine Brody and client representatives)
June 13, 2011 In-person with California Department of Aging (Lin Benjamin) Agency representing under-served
June 13, 2011 In-person with California Community Colleges - Student Service Providers
Services and Special Programs (Betsy Sheldon)
June 14, 2011 In-person with United Advocates for Children and Families Client & Family Agency
(Oscar Wright)
June 14, 2011 In-person with Client and Family Leadership Committee (Dee Client & Family Agency
Lemonds), Cultural and Linguistic Competence Committee
(Pete Best)
June 14, 2011 Webinar with NAMI CA clients and family representatives, Client & Family Agency
onsite at NAMI CA offices
June 23, 2011 In-person with the California Mental Health Directors Service Providers & Agency representing
Association (Heather Anders, contact) and Mental Health and under-served
Aging Coalition (Vivana Criado)
July 15, 2011 In-person at Nevada County (Michele Violett) Presentation to Clients & Families
July 22, 2011 In-person at Shasta County (Jaime Hannigan) Presentation to Clients & Families
July 22, 2011 Telephone call with Alameda County (Rick Crispino) Service Providers
July 22, 2011 In-person with California Mental Health Planning Council (Ann Association
Arneill-Py)
July 22, 2011 In-person with California Council of Community Mental Health Association
Agencies (Harriett Markell)
July 22, 2011 In-person with Sacramento Association of Mental Health Association
Contractors (John Buck)
July 22, 2011 In-person with CASRA (Joseph Robinson) Association
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
Appendix B
Statewide Evaluation Conceptual
Framework
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
Exhibit 1: MHSA Phase II & III Statewide Evaluation Framework
Monitoring / Reporting
Inputs Services Evaluation Products
Infrastructure (existing)
MHSA Values Cost
Increase client and family involvement Community Services & Supports Co nsumer & Service Information (CSI)
and engagement (CSS) Consumer Demographics
Reporting on MHSA Funding and
Reduce di sparities in access and
General System Development (GSD)
Services Received
Expenditures
outcomes
(Phase II - Deliverable 1)
Increase cultural competency
Promote re covery / wellness / resiliency Outreach & Engagement Data Collection & Reporting System for
orientation FSP (DCR) Cost Analysis of Full Service Partnerships
Increase integration of mental health Full Service Partnerships (FSP) Partnership Assessment Form (PAF) (Phase III - Deliverable 1)
services experience Mental Health Services Key Event Tracking (KET)
Integrate mental health services with Support Services
P
e r
Q
fo
u
r
a
m
rt
a
e
n
rl
c
y
e
Assessment Forms (3M)
substance abuse and primary care
Wrap-around services for Children Per formance Planning
services
Final Report Including Recomme ndations
Establish and foster community
partnerships and systems collaborations Innovation (INN) Performance Outcomes & Quality for Next Steps, Identification of Gaps,
Increase stakeholder involvement Planning & Development Improvement (POQI) Projected Costs, and Transition Plan
(Phase II - Deliverable 4)
throughout public community mental Youth Services Survey (YSS)
health syst em
Youth Services Survey for Families Final Report Including Recommendations
Prevention & Early Intervention (PEI) (YSS-F) for Improved Measurement and Analysis to
County Specific MH System Context Assess Effectiveness
Environment
Universal Prevention Adult Survey
(Phase III - Deliverable 3)
County Population Selected Prevention Older Adults Survey
Availabilit y of Affordable Housing Early Intervention Summary & Synthesis of Existing
Ethnic/Language Variation Evaluations on Impact of MHSA on
Community Socio-economic Stress Workforce Education & Training Consumer Outcomes
Involuntary Services (Phase II - Deliverable 3)
Targ et Population Workforce &
(W
S
E
ta
T
ff
)
i ng Support
Report of Conservatorships
Report of Involuntary Detentions
Children/Y outh (0-15 with SED) Training & Technical Assistance
Transition Age Youth (16-25 with SED) Report in Persons Detained in Jail Performance
MH Career Pathways Program
Adults (26-59 with SMI) Facilities Participatory Research to Determine:
Residency & Internship Programs
Older Adults (60+ with SMI) Impact of GSD on Consumer Outcomes
Financial Incentive Programs
Un-served / Underserved Impact of Consumer involvement on MH System
Cultural Competence Plans
(Phase III - Deliverable 2)
Funding Capital Facilities (CF) & Technological
MHSA Needs (TN) Development and reporting of Priority
County Reports
State General Fund Building/Land Acquisition Performance Indicators (i.e., Consumer and
Revenue & Expenditure Reports
Other State Funds Renovation, Construction, Repair System) at County and Statewide Levels
Annual Updates
Medi-Cal (Phase II - Deliverable 2)
Medicare Housing
Quarterly Progress Reports
Other Federal Funds
Realignment
County Evaluation Reports
County Funds
Other Funds
CCoonnssuummeerr,, FFaammiillyy aanndd ootthheerr SSttaakkeehhoollddeerr PPaarrttiicciippaattiioonn aanndd IInnppuutt
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
Appendix C
Technical Appendix
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
Evaluation Advisory Group Members
1. Maria Iyog-O’Malley, Former FSP Services Manager, San Francisco Department of Mental
Health/EMT Expert Consultant
2. Debbie Innes-Gomberg, Los Angeles County Department of Mental Health
3. Christina Cordova, Orange County Health Authority
4. Keith Erselius, San Bernardino Behavioral Health
5. Ruben Gasco, San Bernardino Behavioral Health
6. Keith Haigh, San Bernardino Behavioral Health
7. Brian Yates, American University, EMT Expert Consultant
8. Todd Gilmer, University of San Diego, EMT Expert Consultant
9. Steve Hahn-Smith, Contra Costa Health Services Department
10. Diane Prentiss, San Francisco Department of Public Health
Full Service Partnerships: California’s Investment to Support Children and Transition-Age Youth with Page 127
Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
County FSP Cost by Age Group Web Survey
RespondentID
Please enter county name: Open-Ended Response
Please enter county code: Open-Ended Response
Where did your county/municipality
document FSP Housing Expenditures on
the FY 08-09 Revenue & Expenditure
Reports: GSD Housing
GSD Operating
FSP Operating
Outreach & Engagement Operating
Administrative: Operating
Outside of the MHSA Housing
Program
None of these – Another line item
If you indicated “None of these –
Another line item”, please specify.
What amount of expenditures in this line
item for FY 08-09 is devoted to FSP
Housing? GSD Housing
GSD Operating
FSP Operating
Outreach & Engagement Operating
Administrative: Operating
None of these – Another line item
What percentage of expenditures in this
line item for FY 08-09 is devoted to FSP
Housing? (Please have total equal 100%) GSD Housing
GSD Operating
FSP Operating
Outreach & Engagement Operating
Administrative: Operating
None of these – Another line item
What % of monies from the “GSD
Housing” source of FSP Housing in FY 08-
09 was expended on each age group:
(Please have total equal 100%) Children
TAY
Adults
Older Adults
What % of monies from the “GSD
Operating” source of FSP Housing in FY
08-09 was expended on each age group:
(Please have total equal 100%) Children
TAY
Adults
Older Adults
Full Service Partnerships: California’s Investment to Support Children and Transition-Age Youth with Page 128
Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
What % of monies from the “FSP
Operating” source of FSP Housing in FY
09-10 was expended on each age group:
(Please have total equal 100%) Children
TAY
Adults
Older Adults
What % of monies from the “Outreach &
Engagement Operating” source of FSP
Housing in FY 08-09 was expended on
each age group: (Please have total equal
100%) Children
TAY
Adults
Older Adults
What % of monies from the
“Administrative - Operating” source of
FSP Housing in FY 08-09 was expended
on each age group: (Please have total
equal 100%) Children
TAY
Adults
Older Adults
What % of monies from the “Other”
source of FSP Housing in FY 08-09 was
expended on each age group: (Please
have total equal 100%) Children
TAY
Adults
Older Adults
Where did your county/municipality
document FSP Housing Expenditures on
the FY 09-10 Revenue & Expenditure
Reports? GSD Housing
GSD Operating
FSP Operating
Outreach & Engagement Operating
Administrative: Operating
Outside of the MHSA Housing
Program
None of these – Another line item
If you indicated “None of these –
Another line item”, please specify.
Full Service Partnerships: California’s Investment to Support Children and Transition-Age Youth with Page 129
Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
What amount of expenditures in this line
item in FY 09-10 is devoted to FSP
Housing? GSD Housing
GSD Operating
FSP Operating
Outreach & Engagement Operating
Administrative: Operating
None of these – Another line item
What percentage of expenditures in this
line item in FY 09-10 is devoted to FSP
Housing? (Please have total equal 100%) GSD Housing
GSD Operating
FSP Operating
Outreach & Engagement Operating
Administrative: Operating
None of these – Another line item
What % of monies from the “GSD
Housing” source of FSP Housing in FY 09-
10 was expended on each age group:
(Please have total equal 100%) Children
TAY
Adults
Older Adults
What % of monies from the “GSD
Operating” source of FSP Housing in FY
09-10 was expended on each age group:
(Please have total equal 100%) Children
TAY
Adults
Older Adults
What % of monies from the “FSP
Operating” source of FSP Housing in FY
09-10 was expended on each age group:
(Please have total equal 100%) Children
TAY
Adults
Older Adults
What % of monies from the “Outreach &
Engagement Operating” source of FSP
Housing in FY 08-09 was expended on
each age group: (Please have total equal
100%) Children
TAY
Adults
Older Adults
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
What % of monies from the
“Administrative - Operating” source of
FSP Housing in FY 08-09 was expended
on each age group: (Please have total
equal 100%) Children
TAY
Adults
Older Adults
What % of monies from the “Other”
source of FSP Housing in FY 08-09 was
expended on each age group: (Please
have total equal 100%) Children
TAY
Adults
Older Adults
How many programs FY 08-09 are
devoted to outreach to FSPs? 0 Programs
1-10 Programs
What amount of expenditures in this
program for FY 08-09 is devoted to
outreach to FSPs? Program 1
Program 2
Program 3
Program 4
Program 5
Program 6
Program 7
Program 8
Program 9
Program 10
What % of monies for outreach in
“Program 1” in FY 08-09 was expended
on FSPs in each age group: (Please have
total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for outreach in
“Program 2” in FY 08-09 was expended
on FSPs in each age group: (Please have
total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for outreach in
“Program 3” in FY 08-09 was expended
on FSPs in each age group: (Please have
total equal 100%) Children, Youth & Families
TAY
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
Adults
Older Adults
What % of monies for outreach in
“Program 4” in FY 08-09 was expended
on FSPs in each age group: (Please have
total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for outreach in
“Program 5” in FY 08-09 was expended
on FSPs in each age group: (Please have
total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for outreach in
“Program 6” in FY 08-09 was expended
on FSPs in each age group: (Please have
total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for outreach in
“Program 7” in FY 08-09 was expended
on FSPs in each age group: (Please have
total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for outreach in
“Program 8” in FY 08-09 was expended
on FSPs in each age group: (Please have
total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for outreach in
“Program 9” in FY 08-09 was expended
on FSPs in each age group: (Please have
total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for outreach in
“Program 10” in FY 08-09 was expended
on FSPs in each age group: (Please have
total equal 100%) Children, Youth & Families
TAY
Adults
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
Older Adults
How many programs FY 09-10 are
devoted to outreach to FSPs? 0 Programs
1-10 Programs
What amount of expenditures in this
program for FY 09-10 is devoted to
outreach to FSPs? Program 1
Program 2
Program 3
Program 4
Program 5
Program 6
Program 7
Program 8
Program 9
Program 10
What % of monies for outreach in
“Program 1” in FY 09-10 was expended
on FSPs in each age group: (Please have
total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for outreach in
“Program 2” in FY 09-10 was expended
on FSPs in each age group: (Please have
total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for outreach in
“Program 3” in FY 09-10 was expended
on FSPs in each age group: (Please have
total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for outreach in
“Program 4” in FY 09-10 was expended
on FSPs in each age group: (Please have
total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for outreach in
“Program 5” in FY 09-10 was expended
on FSPs in each age group: (Please have
total equal 100%) Children, Youth & Families
TAY
Adults
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
Older Adults
What % of monies for outreach in
“Program 6” in FY 09-10 was expended
on FSPs in each age group: (Please have
total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for outreach in
“Program 7” in FY 09-10 was expended
on FSPs in each age group: (Please have
total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for outreach in
“Program 8” in FY 09-10 was expended
on FSPs in each age group: (Please have
total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for outreach in
“Program 9” in FY 09-10 was expended
on FSPs in each age group: (Please have
total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for outreach in
“Program 10” in FY 09-10 was expended
on FSPs in each age group: (Please have
total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
How many programs for FY 08-09 are
devoted to supportive services for FSPs? 0 Programs
1-10 Programs
What amount of expenditures in this
program for FY 08-09 is devoted to
supportive services for FSPs? Program 1
Program 2
Program 3
Program 4
Program 5
Program 6
Program 7
Program 8
Program 9
Program 10
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
What % of monies for supportive
services in “Program 1” in FY 08-09 was
expended on FSPs in each age group:
(Please have total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for supportive
services in “Program 2” in FY 08-09 was
expended on FSPs in each age group:
(Please have total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for supportive
services in “Program 3” in FY 08-09 was
expended on FSPs in each age group:
(Please have total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for supportive
services in “Program 4” in FY 08-09 was
expended on FSPs in each age group:
(Please have total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for supportive
services in “Program 5” in FY 08-09 was
expended on FSPs in each age group:
(Please have total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for supportive
services in “Program 6” in FY 08-09 was
expended on FSPs in each age group:
(Please have total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for supportive
services in “Program 7” in FY 08-09 was
expended on FSPs in each age group:
(Please have total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
What % of monies for supportive
services in “Program 8” in FY 08-09 was
expended on FSPs in each age group:
(Please have total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for supportive
services in “Program 9” in FY 08-09 was
expended on FSPs in each age group:
(Please have total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for supportive
services in “Program 10” in FY 08-09 was
expended on FSPs in each age group:
(Please have total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
How many programs for FY 09-10 are
devoted to supportive services for FSPs? 0 Programs
1-10 Programs
What amount of expenditures in this
program for FY 09-10 is devoted to
supportive services for FSPs? Program 1
Program 2
Program 3
Program 4
Program 5
Program 6
Program 7
Program 8
Program 9
Program 10
What % of monies for supportive
services in “Program 1” in FY 09-10 was
expended on FSPs in each age group:
(Please have total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
What % of monies for supportive
services in “Program 2” in FY 09-10 was
expended on FSPs in each age group:
(Please have total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for supportive
services in “Program 3” in FY 09-10 was
expended on FSPs in each age group:
(Please have total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for supportive
services in “Program 4” in FY 09-10 was
expended on FSPs in each age group:
(Please have total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for supportive
services in “Program 5” in FY 09-10 was
expended on FSPs in each age group:
(Please have total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for supportive
services in “Program 6” in FY 09-10 was
expended on FSPs in each age group:
(Please have total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for supportive
services in “Program 7” in FY 09-10 was
expended on FSPs in each age group:
(Please have total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
What % of monies for supportive
services in “Program 8” in FY 09-10 was
expended on FSPs in each age group:
(Please have total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for supportive
services in “Program 9” in FY 09-10 was
expended on FSPs in each age group:
(Please have total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
What % of monies for supportive
services in “Program 10” in FY 09-10 was
expended on FSPs in each age group:
(Please have total equal 100%) Children, Youth & Families
TAY
Adults
Older Adults
Please provide any comments or notes
you may have for EMT. Open-Ended Response
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
FSP Services Assessment Tool
YES/NO
CYF TAY AD OA
1 Outreach to Underserved and Unserved Communities
2 Priority to Unserved Populations
3 FSP Eligibility (criteria)
3 Needs Assessment
3 Individual Services & Supports Plan
3 Service Delivery based on Needs Assessment & ISSP
4 Low Caseload
4 Consumer/Family Staff
4 24/7 Coverage
4 Services in Community v. in the Clinic
5 Client Centered Care
5 Family Centered Care
5 Culturally Appropriate
5 Collaboration with Community Services
5 Integrated Service Delivery
6 Individual Therapy
6 Group Therapy
6 Medication Support
6 Crisis Intervention
6 Employment Case Management
6 Medical Case Management
6 Social Case Management
6 Rehabilitative Case Management
6 Educational Case Management
6 Community Client Services
7 Case Management Support
7 Housing Case Management
7 Psychoeducation
7 Family Education
8 Instrumental Needs
8 Cost of Health Care Treatment
8 Respite Care
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
HOUSING YES/NO
CYF TAY AD OA
9 Housing Supports
9 Operating Support
9 Housing Placement
YES/NO
CYF TAY AD OA
10 Psychiatrist/NP staff
10 Social Worker staff
10 Team Approach
11 Educational/Employment Supplies
11 Recreational Activities
11 Transportation
12 Education/Employment Case Management
12 Recreational Case Management
12 Parenting Education
12 Intimate Partner Violence Services
13 Substance Abuse Treatment
14 Wellness Recovery Action Plan
14 Cognitive Behavioral Therapy
14 Dialectical Behavior Therapy
14 Social Skills Training
14 Behavior Therapy
14 Modeling
14 Family Psychoeducation
14 Partners in Care
14 IMPACT (Improving Mood--Promoting Access to Collaborative Treatment)
14 Multisystemic Therapy
14 Therapeutic Foster Care
14 Psychoeducational Multi-Family Groups
14 Parent-Child Interaction Therapy
14 Wraparound
15 Alternative Treatment
15 Culturally Specific
16 Coordination w/Hospital
16 Coordination w/Criminal Justice
17 Discharge Planning / Criteria
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
Average Daily Cost – Juvenile Halls & Camps
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
Average Daily Cost - Juvenile Halls and Camps
County County Code Juvenile Halls Camps Total
Alameda 1 $374.61 $181.95 $278.28
Alpine 2 N/A
Amador 3 NJHC
Berkeley City 65 N/A
Butte 4 $265.49 NC $265.49
Calaveras 5 NJHC $0.00
Colusa 6 NJH DNR $0.00
Contra Costa 7 $241.09 $241.09 $241.09
Del Norte 8 $226.39 $226.39 $226.39
El Dorado 9 $240.00 $240.00 $240.00
Fresno 10 $321.09 $321.09 $321.09
Glenn 11 $152.37 NC $152.37
Humboldt 12 $163.54 NC $163.54
Imperial 13 $222.11 NC $222.11
Inyo 14 $282.00 NC $282.00
Kern 15 $174.79 $197.08 $185.94
Kings 16 NC $0.00
Lake 17 $281.69 NC $281.69
Lassen 18 $478.43 NC $478.43
Los Angeles 19 $384.00 $250.12 $317.06
Madera 20 $125.00 $125.00 $125.00
Marin 21 $383.64 NC $383.64
Mariposa 22 NJHC $0.00
Mendocino 23 $221.46 $221.46
Merced 24 $234.69 $234.69 $234.69
Modoc 25 NJHC $0.00
Mono 26 NJHC $0.00
Monterey 27 $208.00 $208.00 $208.00
Napa 28 $332.08 NC $332.08
Nevada 29 $230.76 NC $230.76
Orange 30 $317.47 $317.47 $317.47
Placer 31 $438.36 NC $438.36
Plumas 32 NJHC $0.00
Riverside 33 $220.76 $220.76 $220.76
Sacramento 34 $220.00 $247.00 $233.50
San Benito 35 $282.00 NC $282.00
San Bernardino 36 $439.38 $439.38 $439.38
San Diego 37 $236.17 $172.02 $204.10
San Francisco 38 $315.00 $569.00 $442.00
San Joaquin 39 $225.09 $225.09 $225.09
San Luis Obispo 40 $336.21 NC $336.21
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Average Daily Cost - Juvenile Halls and Camps
San Mateo 41 $429.00 $558.76 $493.88
Santa Barbara 42 $255.95 $220.04 $238.00
Santa Clara 43 $382.00 $382.00 $382.00
Santa Cruz 44 $441.78 NC $441.78
Shasta 45 $285.67 $285.67 $285.67
Sierra 46 NJHC $0.00
Siskiyou 47 DNR NC $0.00
Solano 48 $239.00 $154.00 $196.50
Sonoma 49 $492.00 $492.00 $492.00
Stanislaus 50 $188.75 NC $188.75
Sutter-Yuba 58/63 $186.16 $196.16 $191.16
Tehama 52 $379.00 NC $379.00
Tri-City 66 N/A $0.00
Trinity 53 $182.00 $182.00 $182.00
Tulare 54 $231.16 $231.16 $231.16
Tuolumne 55 NJHC $0.00
Ventura 56 $274.95 $274.95 $274.95
Source
California Department of Corrections and Rehabilitation - Corrections Standards Authority
(CSA)
Average Cost per Day - Juvenile Halls and Camps
http://www.cdcr.ca.gov/csa/FSO/Average_Daily_Cost_Survey.html
DNR = Agency did not report costs
NJH = No Juvenile Hall
NC = No Camp
NJHC = No Juvenile Hall or Camp
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
Average Daily Cost – Type II and III Jails
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
Average Daily Cost - Type II & III Facilities
County County Code ADC
Alameda 1 $103.06
Alpine 2 --
Amador 3 $151.67
Berkeley City 65 --
Butte 4 $93.89
Calaveras 5 $82.38
Colusa 6 --
Contra Costa 7 $148.31
Del Norte 8 $77.17
El Dorado 9 $172.98
Fresno 10 $58.44
Glenn 11 DNR
Humboldt 12 $103.37
Imperial 13 $77.17
Inyo 14 DNR
Kern 15 $99.13
Kings 16 $79.60
Lake 17 $77.17
Lassen 18 DNR
Los Angeles 19 $1,093.00
Madera 20 $82.00
Marin 21 $149.01
Mariposa 22 $105.00
Mendocino 23 $91.15
Merced 24 $157.86
Modoc 25 $138.71
Mono 26 DNR
Monterey 27 $94.56
Napa 28 $120.23
Nevada 29 $118.80
Orange 30 $131.00
Placer 31 $158.00
Plumas 32 $133.95
Riverside 33 $122.10
Sacramento 34 $92.87
San Benito 35 $116.75
San Bernardino 36 $76.91
San Diego 37 $147.90
San Francisco 38 $107.54
San Joaquin 39 $118.04
San Luis Obispo 40 $103.16
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Average Daily Cost - Type II & III Facilities
San Mateo 41 $139.44
Santa Barbara 42 $80.87
Santa Clara 43 $133.62
Santa Cruz 44 $77.17
Shasta 45 $102.87
Sierra 46 DNR
Siskiyou 47 $143.89
Solano 48 $12.00
Sonoma 49 $153.74
Stanislaus 50 $114.10
Sutter-Yuba 58/63 $73.81
Tehama 52 $58.24
Tri-City 66 --
Trinity 53 $101.02
Tulare 54 $64.50
Tuolumne 55 $119.60
Ventura 56 $126.55
Yolo 57 $122.46
Rates from Lake and Los Angeles were obtained directly from the counties themselves.
The rate inclusive of mental health services for Los Angeles County comes from Economic Roundtable (2009). Where we sleep: Costs when
homeless and housed in Los Angeles. “Sheriff’s Department costs for incarceration in medical or mental health jail facilities were…. $1,093 per
day in fiscal years 2006-2007 and 2007-2008.”
Source
California Department of Corrections and Rehabilitation - Corrections Standards Authority
(CSA)
Average Cost per Day Type II and III Jails
http://www.cdcr.ca.gov/csa/FSO/Average_Daily_Cost_Survey.html
DNR = Did Not Report
-- = County was missing from source document
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Appendix D
County Participants
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Study Participants 260
# of FSPs/Days of FSP Cost Offsets by Notes
FSP Costs by Age
Service by Age Age Group
Group
County Group
FY 08-09 excluded from analysis; Not in
Alpine
Statewide Data Collection System
Alameda Not in Statewide Data Collection System
Amador FY 08-09 excluded from analysis
Berkeley Not in Statewide Data Collection System
Butte
Calaveras FY 08-09 excluded from analysis;
Colusa FY 08-09 excluded from analysis;
Contra Costa
Del Norte FY 08-09 excluded from analysis;
El Dorado
Fresno
Glenn
Humboldt FY 08-09 excluded from analysis;
Imperial
Inyo FY 08-09 excluded from analysis;
Kern
Kings
Lake
Lassen FY 08-09 excluded from analysis;
Los Angeles
Madera
Marin Not in Statewide Data Collection System
Mariposa
Mendocino
Merced
Modoc
Mono FY 08-09 excluded from analysis;
Monterey Not in Statewide Data Collection System
Napa
Nevada
Orange
Placer
Plumas
260
Tri City indicated that they were in start-up during the entire study period (FY 08-09 and FY 09-10). Start-up years are not included in the
calculations.
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Study Participants 260
# of FSPs/Days of FSP Cost Offsets by Notes
FSP Costs by Age
Service by Age Age Group
Group
County Group
Riverside Not in Statewide Data Collection System
Sacramento
San Benito
San Bernardino
San Diego
San Francisco
San Joaquin
San Luis Obispo
San Mateo*
Santa Barbara Not in Statewide Data Collection System
Santa Clara
Santa Cruz
Shasta
Sierra
Siskiyou
Solano
Sonoma
Stanislaus
Sutter-Yuba
Tehama FY 08-09 excluded from analysis
Trinity
Tulare
Tuolumne
Ventura
Yolo
TOTAL 50 43 42
*San Mateo County made best efforts to participate in the study, but their data is not in the DCR, and we were unable to conform it to the DCR
format in time for inclusion in this report.
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Appendix E
Revenue & Expenditure Reports
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Exhibit E.1
Full Service Partnership Program Worksheet: Revenue and Expenditure Report
(Fiscal Year 08-09)
http://www.dmh.ca.gov/DMHDocs/docs/notices09/09-22_Enclosure2.xls
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Revenue and Expenditure Reports
Process of Transferring Individual County Excel Files from FY 09-10 into Master Cross-Site File
The MHSA (FY: 06/07, 07/08, 08/09) Database was created in the Spring of 2011 in order to conduct
analyses for Phase II Deliverable 1. It is an aggregated database containing fiscal data from a total of 59
California counties/municipalities spanning three fiscal year periods, covering 25 program data sets, sourced
from 589 distinct file locations, containing a total of 4,498 unique variables, encompassing a grand total of
287,265 distinct data points.
Fiscal Year 2006-2007 contained 1,325 distinct variables provided by 57 counties/municipalities across 6
programs located within 57 separate files containing a total of 72,525 distinct data points.
Fiscal Year 2007-2008 contained 1,265 distinct variables provided by 59 counties/municipalities across 7
programs located within 60 separate files containing a total of 75,900 distinct data points.
Fiscal Year 2008-2009 contained 2,264 distinct variables provided by 59 counties/municipalities across 11
programs located within 472 separate files containing a total of 135,840 distinct data points.
The MHSA Database was constructed through a process of template creation, formula crafting, running
transfer protocols and performing validity checks.
Templates were formed via construction of a list of all variables across each program over all three fiscal
years. Formula were generated to transfer the values of individual cells to the database template and were
compiled to transfer all the relevant data points within a given workbook and, subsequently, entire source-
file.
Formulas were crafted for each of the unique variables contained within each program or workbook. Master
formulae were crafted for each workbook within a file or fiscal year. The master formulae performed the
relocation of each relevant data point, across all programs, within a given file or fiscal year.
Transfer protocols were generated to perform manual and semi-automated opening and closing of files,
updating formula and transferring the relevant data values of each fiscal year to the database. Validity
checks were performed throughout each stage of the process with full checks on each new formula, random
spot checks, specific value checks and redundant report checks.
Challenges/Limitations
Complications in the construction of the database template arose from the systemic variance within a
specific program across multiple fiscal years. Each program contains differing sets of reported variables
across each fiscal year. Such complexity required the database construction and formulae formats to
account for the disparate data formats. This was accomplished through the merger of otherwise identical
variables names that were renamed and through the adjustment of cell-specific spacing references in all
formulae.
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Further complicating the construction of the database was the systemic variance among the three fiscal
years in file sets and data locations. While fiscal years 2006-2007 and 2007-2008 are rather similar the 2008-
2009 fiscal year is provided in an entirely different file set format. Additionally, each fiscal year contains
noteworthy variance in data locations from the other fiscal years. This complexity required the substantial
retooling of the formula sets and numerous additional, unique formula sets to be constructed.
However, the most severe complications came as a result of modifications performed by reporting counties
to the file names, workbook names and, most significantly, workbook formats. Variances which caused
transfer protocols to report incorrect and invalid data points, if not miss the source-data entirely. These
issues necessitated the manual reformatting of all files and workbooks locations found to be employing
deviant standards and the subsequent manual operation of all associated transfer protocols.
EMT hired a contractor to complete the initial extraction and merge. The contractor’s services have been
retained to complete the extraction and merge for the FY 09-10 data.
However, in the interest of expediency, FSP totals were taken from RERs through transcription and input
into county Costs and Cost Offsets worksheets (provided to counties for review). Totals were cross-checked
for accuracy. This initial process was much less costly and time-consuming, and met the immediate
deliverable deadline need.
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Exhibit E.5
Counties/Municipalities that submitted Revenue and Expenditure Reports
(Fiscal Year 08-09 & Fiscal Year 09-10)
Revenue & Expenditure
Report
Counties FY 08/09 FY 09/10
Alameda 1 1
Alpine 1 1
Amador 1 1
Berkeley City 1 1
Butte 1 1
Calaveras 1 1
Colusa 1 1
Contra Costa 1 1
Del Norte 1 0
El Dorado 1 1
Fresno 1 1
Glenn 1 1
Humboldt 1 1
Imperial 1 1
Inyo 1 1
Kern 1 1
Kings 1 1
Lake 1 1
Lassen 1 1
Los Angeles 1 1
Madera 1 1
Marin 1 1
Mariposa 1 1
Mendocino 1 1
Merced 1 1
Modoc 1 1
Mono 1 1
Monterey 1 1
Napa 1 1
Nevada 1 1
Orange 1 1
Placer 1 1
Plumas 1 1
Riverside 1 1
Sacramento 1 1
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Serious Emotional Disturbance and Adults and Older Adults with Severe Mental Illness
Revenue & Expenditure
Report
Counties FY 08/09 FY 09/10
San Benito 1 1
San Bernardino 1 1
San Diego 1 1
San Francisco 1 1
San Joaquin 1 1
San Luis Obispo 1 1
San Mateo 1 1
Santa Barbara 1 1
Santa Clara 1 1
Santa Cruz 1 1
Shasta 1 1
Sierra 1 1
Siskiyou 1 0
Solano 1 1
Sonoma 1 0
Stanislaus 1 1
Sutter-Yuba 1 1
Tehama 1 1
Tri City 1 1
Trinity 1 1
Tulare 1 1
Tuolumne 1 1*
Ventura 1 1
Yolo 1 1
*New summary format
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Appendix F
Key Stakeholder Feedback
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This appendix describes our process for receiving stakeholder input on this report draft, and the manner in which
stakeholder feedback was handled.
a. Process for Stakeholder Input
Stakeholder input was sought for two key deliverables:
o The draft of this report
o County-specific tables depicting FSP costs and cost offsets 261
1. Full Service Partnership Cost-Offset Report
The draft report 262 was released publicly at the Mental Health Services Oversight and Accountability Commission
meeting on July 26, 2012. Stakeholders were asked to submit comments in writing via e-mail to:
eharris@emt.org
Feedback was required to be submitted no later than August 26, in order to allow EMT sufficient time for revision
to the Final Report due September 30, 2012. Feedback received (in order of receipt) and disposition, is summarized
in the following table.
Stakeholder Feedback
Constituent Implemented in Notes
Representative Feedback
Organization Report
MHSOAC Eduardo Vega Include amounts of offsets overall Seven new pie charts have been added
and by age group in pie charts to both the Executive Summary and
the full Report
MHSOAC Eduardo Vega Tie the relevant table data is being Narrative has been added to the
drawn from to the chart using Executive Summary and the full Report
narrative
MHSOAC, San Richard Van Examine costs & cost offsets for Receipt of new data from additional
Mateo County Horn, Patrick those with longer periods of service participating counties up until two
Behavioral Health Miles – the current report annualizes in weeks before submission of the draft
Services order to present results for 12 report prevented any new analyses
months of service. Mr. Van Horn is from being completed. However, we
interested in a comparison of 12 propose re-purposing one of the Phase
and 24 months. Patrick Miles is II Deliverable 1.B briefs (due 11/30/12)
interested in pre-post testing in order to answer Richard Van Horn’s
(regardless of length of service) question. Because a number of
stakeholders requested additional
analyses that could not be completed,
and the upcoming Cost briefs due on
11/30/12 represent the logical vehicle
in which to answer these questions, a
summary of proposed re-purposing of
the Phase II Deliverable 1.B Cost Briefs
is included at the end of this appendix.
261 The data contained in the county-specific tables form the basis for creation of the statewide data set, summarized and reported here.
262 Phase III Deliverable 1.C Initial written report that specifies the financial impact of outcomes achieved in comparison with expenditures for
FSP clients for each of the four age groups.
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Stakeholder Feedback
Constituent Implemented in Notes
Representative Feedback
Organization Report
MHSOAC Ralph Nelson Examine costs & cost offsets for See above.
completers compared with non-
completers – the current report
makes no distinction between
results for FSP graduates compared
with FSP dropouts.
MHSOAC, Los Larry Poaster, CYF savings are not likely until Notation made to Chapter II as to why
Angeles County Deborah Innes- longer-term; consequence data may Education was not a suitable variable
Department of Gomburg not be the most appropriate for this for analysis in a Cost Offset study
Mental Health age group
MHSOAC Commissioner There are fixed costs associated Footnote added under Methods,
Brown with hospitalization & incarceration Chapter IV. However, FSPs are less
that do not change likely to be occupying the beds, etc.
MHSOAC Commissioner AB 109 (criminal justice Noted in report that the change in FY
Brown realignment) will make it difficult to 10-11 to a streamlined summary RER
compare costs & cost offsets to will make it very difficult to conduct
later years this level of cost offset analysis
without direct data collection from
counties
San Joaquin County Raul Sanchez Include web survey in Appendix
Family Member
“ “ “ “ The goal of any publicly funded The study period has concluded, but
program must be 100% we agree with this feedback and will
participation by all the involved state as goal for future reports.
government agencies. Whether the
goal is reached and the reasons why
the goal is not reached are separate
issues. The goal must be 100%
participation.
“ “ “ “ Pie charts should be self-
explanatory – the combination pie
chart because some area offsets
were in arrears was confusing –
suggest bar charts for each fiscal
year instead.
San Joaquin County Raul Sanchez, Substance abuse in adults may be a We suggest an additional report in
Family Member, Brian Yates factor to consider order to examine substance abuse
American University costs and cost offsets among adult
Professor/Expert FSPs
Consultant
CASRA Joseph Robinson Clearly explain whether psychiatric, Only non-psychiatric ER visits were
non-psychiatric, or both types of analyzed due to concerns about the
emergency room visits were psychiatric ER variable and potential
analyzed and reported. overlap with inpatient psychiatric
hospitalization in the DCR
CASRA Joseph Robinson Request that other physical We were limited to variables in the
outcome measures be analyzed, DCR, and of the list requested, only
such as non-psychiatric non-psychiatric hospitalizations and
hospitalizations, attendance at skilled nursing stays for physical health
routine physical health reasons were available in the DCR.
appointments, filling non-psychiatric
meds, etc.
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Stakeholder Feedback
Constituent Implemented in Notes
Representative Feedback
Organization Report
CASRA Joseph Robinson In order to best prepare for See Chapter II for the data limitations,
increased attention on clinical our feasibility assessment, and the
outcomes, effectiveness, and cost of necessity of collecting billing data
services, we respectfully request directly from counties in order to
that two additional reports be comply with this request. MHSOAC will
completed comparing costs & cost need to issue a separate RFP, should
offsets between the county and this become a funding priority.
contracted providers
CASRA Joseph Robinson Recommend that the data collecting After reviewing the last report
& reporting system that supported provided to the legislature, we agree.
AB 2034 be revisited The recommendation is in the
Executive Summary
CMHDA Patricia Ryan Recommend that CSI & DCR be The recommendation is in the
reviewed jointly by CMHDA & DHCS Executive Summary, but limited to the
DCR because that was the dataset we
worked with for this report
Contra Costa Steve Hahn-Smith In order to provide the most See above. In addition, EMT is limited
County Health accurate count of clients, costs and to use of the UCLA-agreed upon
Services cost offsets, EMT should analyze common data set (DCR), and does not
Department county billing data have sufficient funding to process any
data set outside of the DCR. The
intricacies of accommodating differing
data systems from different counties,
and then attempting to reconcile the
varying systems, are well outside the
scope of EMT’s subcontract.
UC San Diego Todd Gilmer See above See above. In addition, Dr. Gilmer
received federal monies from ACYF to
conduct an ongoing study of costs and
cost offsets in a sample of counties,
with a focus on articulating a model of
reducing homelessness. The multi-
year award and amount of funding is
sufficient to the task of
accommodating Medi-Cal billing data,
as well as site visits in order to collect
the necessary fidelity data. CSI & DCR
data are linked to OSHPD and Medi-
Cal Short Doyle via Social Security
number and date of birth (this only
took place following thorough IRB
review and approval of human
subjects protection protocols). Our
sub-task within a larger study was
much more limited in scope (in terms
of both time and subcontracted
amount) – largely confined to existing
data, with a narrow window for
counties to provide additional fiscal
information via web survey. These
constraints influenced our
recommendation (along with CASRA’s
strong call for a comparison study)
that MHSOAC consider funding a study
solely focused on the use of county
billing data, in order that core
questions be answered across all
counties.
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Representative Feedback
Organization Report
Contra Costa Steve Hahn- The key event approach to data See above. Dr. Gilmer has reported,
County Health Smith, Todd collection produces an under- however, through analysis of data
Services Gilmer reporting of hospitalizations. after from participants in the ACYF study
Department , enrollment. If clinicians don’t think that the change in offsets is overstated
University of to fill out a key event, it appears in when DCR data is the sole source of
California at San the DCR as if the event never outcome analysis. However, cost
Diego occurred. This suspicion was offsets are still realized in the areas
validated through a comparison of explored.
KET and claims data.
Napa County Health Felix Bedolla The DMH system is flawed, in that See previous page.
and Human Services CSI excludes some FSP clients from
the DCR. Therefore, FSPs are
accurately represented in the
county MIS, but not in the statewide
DCR.
Los Angeles County Debbie Innes- Housing costs for all age groups are See previous page.
Department of Gomberg likely under-stated due to how they
Mental Health are reported and tracked by each
county.
Lake County Mental Sarah Deng CSI data should be used (i.e., crisis Due to the amount of data
Health /hospitalization services/dates) for manipulation and cleaning necessary
purposes of maximizing the use of (CSI and DCR data provided by DMH
existing data and minimizing were not analysis-ready), EMT was
duplicate entry into the DCR, only able to access the DCR in time for
thereby reducing the potential for report analysis.
inconsistencies due to data entry
errors/omissions
Mental Health Dave Pilon Recommend that the successful After reviewing the AB 2034
Association of Los data collection systems established evaluation reports sent, we agree that
Angeles under AB 2034 be revisited much can be learned from AB 2034.
Contra Costa Steve Hahn-Smith Recommend that outcome data be Recommendation is included in the
County Health collected on a required quarterly executive summary.
Services assessment schedule in order to
Department address the under-reporting
problem
San Benito County Lynda Yoshikawa Actual housing and program Small counties with N of 1 in an age
Behavioral Health services costs are more accurate group, and/or less than one year of
and useful than the annualized cost service – a modified formula was
per client (unfair bias toward small applied involving fractional application
counties with small client N). It of cost, in order to more accurately
appears as if entire budget was represent cost per person.
spent on one person in an age
group, which is not accurate.
Community Maria Iyog- Procedure for calculating housing This is not true in our calculation of
Behavioral Health O’Malley cost “assumes that all clients in housing cost because we take the
Services, City & housing have the same lengths of housing cost as an expenditure sum
County of San housing stays as their treatment for the fiscal year. Just as for other FSP
Francisco services.” costs in our calculation, it is a fiscal
year total expenditure. It is true that
we factor it into an annual (or daily)
cost per client based on the number of
client years. Housing is part of that
average cost regardless of the number
of days it was actually used by
different clients, but that is no
different than any other client cost
paid for out of FSP.
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Constituent Implemented in Notes
Representative Feedback
Organization Report
San Joaquin County Raul Sanchez Executive Summary, Page vi “because” replaced with “after” and a
Family Member “This is the amount of public money caveat footnote added to the
in these areas that was saved Executive Summary
because these clients had access to
service.”
Comment:
This raises the cause and effect
issue.
San Joaquin County Raul Sanchez Full Report, Page 9, Footnote 45 However, we believe the fault lies with
Family Member “Previous research by an Evaluation the DCR itself, primarily in the way in
Advisory Group member on a subset which the Education questions are
of counties (representing the structured (inconsistencies between
majority of the state’s population) intake and follow-up), as well as issues
using DCR data revealed that there with KET data collection discussed
is little change in employment and earlier. Fundamental reform must
education outcomes”… Mr. Sanchez occur at the measurement level in
concluded that a program does not order to ensure that the data
produce significant outcomes on the collection and reporting system is
Education indicator, and that this measuring what it is supposed to
finding should be verified and, if measure with respect to educational
appropriate, resources reallocated outcomes.
to programs that work.
San Joaquin County Raul Sanchez Add costs to the flow chart We support the call for full funding of
Family Member Consider direct costs and a participatory evaluation to
benefits and indirect costs and investigate costs and cost offsets of
benefits this important aspect of the MHSA.
The cost offset of “Greater
Independence” leads me to
think of emotional well being
and the various techniques
developed to measure this
(Global Assessment of
Functioning, the Kennedy
Scale, research results by Rand
Corp. for the evaluation of
Prevention and Early
Intervention Programs under
the Mental Health Services
Act)
Peer support (and family
support) could result in cost
offsets for psychiatric health
care, physical health care, and
incarceration
Reduced reliance on staff and
reduced program costs is a
result of greater independence
and improved emotional well-
being. As a family member, I
keep questioning the
conventional objectives of
greater penetration rates and
retention rates.
Improved medication
compliance could be a result
of positive modeling by peers
“Parent partners” are included
– perform a literature search
on family member supports
and their outcomes.
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