HomeMy WebLinkAboutfsp-assessment-report-20250707
Alameda County Behavioral Health
Full Service Partnership Assessment
Submitted by:
Roberta Chambers, PsyD
Ardavan Davaran, PhD
Jamie Dorsey, MSPH
Kira Gunther, MSW
Prepared for:
Alameda County Behavioral Health Department
Date:
January 2025 (revised June 2025)
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Table of Contents
Introduction ................................................................................................................................ 1
Background Information ............................................................................................................. 2
Assessment Questions .............................................................................................................. 5
Assessment Question 1 Methodology ........................................................................................ 6
Assessment Question 1 Findings ..............................................................................................12
FSP Referrals ........................................................................................................................12
FSP Service Enrollment ........................................................................................................15
FSP Service Delivery & Service Participation ........................................................................18
Assessment Question 2 Methodology .......................................................................................22
Assessment Question 2 Findings ..............................................................................................30
Estimated Number of Alameda County Residents with an FSP-Level of Need .....................30
Estimated Number of FSP Slots Needed to Meet the Need of Alameda County Residents ...35
Appendix A. Populations who did and did not meet FSP Inclusion Criteria ................................37
Appendix B. FSP and Service Team Clients in FY22-23 with an FSP-Level of Need ................42
Appendix C. Non-FSP/Non-Service Team Clients in FY22-23 with an FSP-Level of Need .......43
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Introduction
In late 2023, Alameda County, Disability Rights California, and the United States
Department of Justice entered into a settlement agreement addressing the provision of
community behavioral health services in the County. The settlement agreement includes
provisions designed to assess the need for Full Service Partnership (FSP) and mobile crisis
services in order to inform the County’s program development and expansion efforts.
Alameda County Behavioral Health Services (ACBH) contracted with the Indigo Project
(Indigo) to conduct the FSP assessment.
ACBH provides a full range of behavioral health services, ranging from crisis services
through outpatient, residential, and inpatient programs to address mental health, substance
use, and co- occurring disorders. Through a partnership with the Office of Homeless Care
and Coordination (OHCC), ACBH also funds a range of housing options for people with
behavioral health issues.
This assessment focuses on the Full Service Partnership program, specifically on the needs
and gaps in FSP services for individuals ages 16 years and older. Full Service Partnerships
are a model set forth by the Behavioral Health Services Act (BHSA) and are the highest
level of outpatient mental health services provided in the community. The purpose of this
assessment is to estimate the number of FSP slots needed to serve individuals ages
16 and older who meet FSP eligibility criteria under 9 C.C.R. § 3620.05. This
assessment also considers an analysis of any demographic or other variables that may
influence participation in FSP programming as well as the challenges and barriers in
identifying, referring, engaging, and serving individuals who need an FSP-level of care. This
assessment is informed by local service utilization data, community and stakeholder input,
and available literature and evidence-based practices and results in an estimate of FSP
slots needed to appropriately serve individuals who meet FSP eligibility criteria.
This assessment does not include any evaluation of existing FSP programs and therefore
does not assess quality and outcomes of existing FSP programs. While this assessment
does use local service utilization data from hospital, crisis system of care, and community-
based behavioral health services within Alameda County’s continuum of services, this
assessment does not include any assessment or evaluation of the capacity or quality of any
other programs that an FSP-eligible individual may access, including crisis, housing, and
other residential and outpatient services.
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Background Information
Full Service Partnerships
The term Full Service Partnership (FSP) was coined during the drafting and passage of the Mental
Health Services Act in the early 2000s. It is a term that is specific to California and is codified in
the Mental Health Services Act, Welfare and Institutions Code, and Title 9 of the California Code
of Regulations. The FSP Service Category is intended to provide a “whatever it takes” approach
to supporting individuals with significant mental health challenges who require an intensive level
of mental health and other supportive services to live safely in the community and reduce the risk
and incidence of crisis, hospitalization, incarceration, and homelessness. The regulations set forth
eligibility criteria for the FSP Service Category1 2 as well as the service expectations.3
FSP-eligible individuals must meet specialty mental health criteria and FSP eligibility criteria.
Specialty mental health criteria include a serious mental disorder that is “severe in degree and
persistent in duration, which may cause behavioral functioning which interferes substantially with
the primary activities of daily living, and which may result in an inability to maintain stable adjustment
and independent functioning without treatment, support, and rehabilitation for a long or indefinite
period of time.”4 FSP criteria includes the following:
Transition Age Youth who are unserved or underserved and homeless or at risk of
homelessness; aging out of the child and youth mental health, child welfare, and/or juvenile
justice systems; involved in the criminal justice system, at risk of involuntary hospitalization or
institutionalization, or have experienced a first episode of serious mental illness.
Adults who are unserved and homeless or at risk of homelessness, involved in the criminal
justice system, and/or frequent users of hospital and/or emergency room services as the
primary resource for mental health treatment; or adults who are underserved and at risk of
homelessness, involvement in the criminal justice system, and/or institutionalization.
Older Adults who are unserved and experiencing a reduction in personal and/or community
functioning; homeless; or at risk of homelessness, becoming institutionalized, out-of-home
care, or becoming frequent users of hospital and/or emergency room services as the primary
resource for mental health treatment; or older adults who are underserved and at risk of
homelessness, institutionalization, nursing home or out-of-home care, frequent users of
hospital and/or emergency room services as the primary resource for mental health treatment,
and/or involvement in the criminal justice system.5
1 California Code, Welfare and Institutions Code - WIC § 5600.3 2 Cal. Code Regs. Tit. 9, § 3620.05 - Criteria for Full Service Partnerships Service Category 3 Cal. Code Regs. Tit. 9, § 3620 - Full Service Partnership Service Category
4 California Code, Welfare and Institutions Code - WIC § 5600.3
5 Cal. Code Regs. Tit. 9, § 3620.05 - Criteria for Full Service Partnerships Service Category
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FSP programs are expected to provide a “full spectrum of community services necessary to attain
the goals identified in the Individual Services and Supports Plan.” This includes mental health
services including mental health treatment, peer support, alternative and culturally specific
treatment, personal service coordination/case management, family education, crisis
intervention/stabilization, and other supportive services regarding housing, employment, and/or
education. FSP services also include non-mental health services, such as food, clothing, housing,
cost of healthcare, cost of co-occurring disorders treatment, and respite.6
FSP programs are associated with improved outcomes for people who participate, including
improved access to and participation in mental health services, reduced crisis and emergency
mental health services,7 8 reduced criminal justice involvement,9 10 and reduced homelessness
and improved housing status.11 12
Placing Full Service Partnerships in Context
Given that FSP is a term specific to California, in order to understand what the existing body of
literature says about “FSP-like” programs outside of California, we must place the FSP Service
Category within the larger continuum of mental health services. Specifically, we must look to
programs across the nation that serve a similar population to those served in FSP—individuals with
serious mental illness who have either experienced or are at risk of crisis, hospitalization,
incarceration, and/or homelessness.
The FSP concept was originally based on a modified version of Assertive Community Treatment
(ACT), which is an evidence-based practice for supporting people with significant mental health
issues to live in the community. FSP may also be considered an intensive case management (ICM)
program, which is a broader term for a collection of programs and services that support individuals
who are affected by and living with serious mental illness to live in the community but may need
the higher level of care.
ACT is a model that arose in the 1970s and is one of the most widely studied mental health models
with consistent outcomes.13 Often referred to as a “hospital without walls,” the ACT model was
designed to support individuals—who would otherwise be confined in a locked psychiatric
setting—to live meaningfully within the community. The ACT model is characterized by a low 1:10
staff-to-client ratio that employs a multi-disciplinary team who practice a team-based approach to
community mental health services.14 The ACT model specifies the positions and ratios to staff the
6 Cal. Code Regs. Tit. 9, § 3620 - Full Service Partnership Service Category 7 https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201100384
8 https://www.ingentaconnect.com/content/wk/mcar/2017/00000055/00000003/art00015
9 https://mhsoac.ca.gov/wp-content/uploads/SB-465-Report-to-the-Legislature_approved_ADA.pdf
10 https://www.sfdph.org/dph/files/CBHSdocs/MHSAdocs/SFMHSA5YearReport-2010.pdf 11 https://jamanetwork.com/journals/jamapsychiatry/article-abstract/210805 12 https://www.sfdph.org/dph/files/CBHSdocs/MHSAdocs/SFMHSA5YearReport-2010.pdf
13 https://ps.psychiatryonline.org/doi/10.1176/appi.ps.51.6.759
14 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4471983/
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team, including psychiatry, nursing, and peer support, as well as a team-based approach. Unlike
case management programs where an individual might work predominantly with a single staff
member, all staff members of an ACT team interact with the individuals that they serve on the team.
The ACT model also prescribes the intensity and frequency of services with multiple face-to-face
contacts expected per week and sets forth that the majority of services should be provided outside
of an office setting.
ACT teams are intended to provide all of the services an individual may need; they serve less of
a case management/brokerage function and provide more direct intervention based on an
individual’s needs and preferences. High fidelity ACT programs are associated with reductions in
psychiatric hospitalization, crisis, and homelessness.15 Forensic ACT, which is a modified ACT
team that specializes in serving individuals who are involved with the criminal justice system, is
associated with reduced arrests and incarcerations.16
Unlike ACT, ICM does not refer to a specific model or intervention. ICM is a term used to describe
a collection of programs that provide more intensive services than a typical outpatient mental health
service; it does not have the same prescriptive staffing or approach as ACT.17 ICM programs are
generally characterized by approximately a 1:20 staff-to-client ratio and operate with an assigned
case manager who serves as the primary point of contact to support the client in receiving needed
services.18 ICM programs may have interdisciplinary staff, but may also operate only with case
management and psychiatry staff with referrals to other services. ICM programs may be
predominantly field-based or office-based. Similar to ACT, ICM programs are associated with
reductions in psychiatric hospitalization, crisis, incarceration, and homelessness.19
ACBH uses the ACT model of care to design and implement their FSP programs. ACBH also provides ICM
programming through their Service Teams. ACBH’s FSP programs and Service Teams are intensive,
community-based mental health programs that are intended to support individuals impacted by
significant mental health challenges to live successfully in the community. In alignment with the
outcomes expected of FSP programs, people enrolled in ACBH FSP programs for at least one
year experience reductions in crisis admissions, psychiatric hospitalizations, and incarcerations.
Among individuals enrolled in ACBH FSP programs during fiscal year 22-23, the proportion of
individuals who experienced crisis admissions dropped from 75% in the year prior to FSP
enrollment to 49% of clients during their most recent year of FSP enrollment. The proportion of
FSP clients who experienced psychiatric hospitalizations in the year prior to enrollment dropped
from 49% to 25% during their most recent year of enrollment, and one third (33%) of FSP clients
15 https://store.samhsa.gov/sites/default/files/sma08-4344-theevidence.pdf
16 https://journals.sagepub.com/doi/full/10.1177/00938548211061489 17 https://ps.psychiatryonline.org/doi/10.1176/ps.2007.58.1.121 18https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6472672/#:~:text=Intensive%20Case%20Management%20(ICM)%20is%20one%2
0such%20intervention.,clients%20(fewer%20than%2020).
19 Ibid.
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were incarcerated at Alameda County Jail in the year prior to FSP enrollment compared to 24%
during their most recent year of enrollment.
Assessment Questions
There are two primary questions that guide this assessment:
1. What are the barriers and challenges to identifying, referring, engaging, and serving
individuals who need an FSP-level of care and what demographic variables influence
participation?
2. How many FSP slots are needed to serve individuals20 who meet FSP eligibility criteria
under 9 C.C.R. § 3620.05?
By answering these two questions, this assessment supports the County to estimate the additional
need for FSP slots, considering any barriers and challenges for eligible individuals to access and
participate in the services.
The assessment includes a mixed methods analysis that leverages: 1) demographic and service
utilization data about individuals who meet FSP inclusion criteria, 2) community and stakeholder
input, and 3) the research and literature regarding ACT and ICM, eligible individuals, and evidence-
based practices for identifying, engaging, and serving eligible individuals in intensive community-
based programming. The assessment culminates in an estimate of FSP capacity, including an
analysis of the barriers and challenges to FSP participation for eligible individuals.
20 The settlement agreement specifies estimating FSP slots for individuals ages 16 and older in order to ensure the assessment
includes transition aged youth (TAY). In Alameda County, TAY FSP programs serve individuals ages 18-24, while individuals under
18 are served in ACBH’s child FSP program. The assessment will include analysis of ACBH Adult and TAY FSP programs, and
therefore will only include individuals ages 18 and older as an analysis of child FSP programs (ages 0-17) would be outside the scope
of the settlement agreement.
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Assessment Question 1 Methodology
The first assessment question seeks to understand: What are the barriers and challenges to
identifying, referring, engaging, and serving individuals who need an FSP-level of care as well as
any demographic variables that may influence participation? The settlement agreement
specifically requires the following to inform the assessment of how many FSP slots are needed
to appropriately serve individuals in the County:
Analysis of numbers and demographics of sub-populations who (a) were not
connected to FSP services despite multiple visits/admissions to PES, John George
inpatient, and/or IMDs, (b) declined to consent to FSP services, or (c) stopped
engaging with FSP services, and analysis of relevant barriers or challenges with
respect to these groups.
The purpose of this assessment question is to explore the demographics and other variables for
individuals who met FSP eligibility criteria but did not receive or maintain participation in FSP
services. This question focuses on exploring the group identified in the first question that are FSP-
eligible but did not receive FSP services, as well as those who were enrolled in an FSP and did
not sustain participation in services.
Figure 1 summarizes the methodology to address Assessment Question 1, where we first use
ACBH administrative data to identify the demographic characteristics and other characteristics of
individuals who were FSP-eligible but did not receive, accept, or sustain participation in services.
The quantitative data findings were used to engage community stakeholders and community
providers in a discussion of barriers and challenges to engagement and participation in FSP
services. This included discussion around barriers and challenges to identifying FSP-eligible
individuals, engaging them in services, and supporting their ongoing participation in services.
Figure 1. Assessment Question 1 Process Flow
Quantitative Methods
Quantitative data were used to:
1) Describe referrals to ACBH FSP programs and identify individuals who met FSP criteria
but were not enrolled in an FSP program;
2) Identify who is and is not enrolling in ACBH FSP programs and how long it takes to get
from referral to enrollment in FSP; and
Analyze Quantitative
Data
Conduct Qualitative
Data Collection Synthesize Findings
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3) Assess FSP service delivery and participation, including differences across sub-
populations.
Indigo worked with the ACBH Data Services Team to identify and obtain aggregate data from the
ACBH electronic health record (EHR) systems, including the ACCESS database, Insyst client
database, and Sheriff’s Office jail booking and incarceration data via the ACBH Data Warehouse.
Analyses included individuals 18 and older referred to or enrolled in ACBH FSP programs.21 The
FSP programs included in the analysis are listed below:
• TAY FSP: BACS PAIGE FSP, Fred Finch Youth & Family Services STAY FSP
• Adult FSP: Abode Greater Hope FSP, BACS HEAT FSP, Telecare Changes FSP,
Telecare Strides FSP
• Older Adult FSP: BACS Circa60 FSP
• Adult Forensic FSP: BACS LIFT FSP, Telecare JAMHR FSP
• Assisted Outpatient Treatment (AOT) & Community Conservatorship (CC) FSP:
Telecare AOT FSP; Telecare CC FSP
Indigo used descriptive statistics to study referral, enrollment, service delivery, and service
participation for FSP services in Alameda County. To the extent possible, Indigo also examined
differences across the following demographic characteristics: age group, race / ethnicity, gender,
language, city, and housing status. Additional information about the specific data utilized and
analyses performed is summarized below.
Referrals to ACBH FSP
Indigo examined all referrals for individuals ages 18 and older to ACBH FSP programs in FY21-
22. Among FSP referrals, we examined: 1) the type of FSP program individuals were referred to
(i.e., TAY, Adult, Older Adult, Adult Forensic, AOT/CC), 2) the referring party, 3) demographic
characteristics of referred individuals, and 4) clinical profile of referred individuals. Clinical profile
included:
• Substance Use Disorder Diagnosis: Number of individuals who had a documented
substance use diagnosis in any ACBH program episode during the 5-year period from
FY18-19 to FY22-23.
• Behavioral Health Diagnoses: Types of behavioral health diagnoses, including
schizophrenia and psychotic disorders, mood disorders (depressive and bipolar
disorders), trauma-related disorders, or other diagnoses.
• Crisis Admissions & Jail Bookings: Number of individuals who were admitted to crisis
receiving centers in Alameda County (Amber House CSU, John George PES, Cherry Hill
21 Referrals to and participation in Berkeley Mental Health FSP programs were excluded.
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Sobering Center) or booked at Santa Rita Jail, as well as the average number of crisis
receiving center admissions and/or jail bookings in the year prior to referral. The number
of jail bookings were included as some people may be arrested and transported to jail
rather than being taken to other crisis receiving centers.
• Psychiatric Hospitalizations: Number of individuals with a psychiatric hospitalization in
the year prior to referral, including average number of psychiatric hospitalizations, average
number of hospital days, and length of stay.
• Incarcerations: Number of individuals incarcerated in the year prior to referral, including
average number of incarcerations, incarcerated days, and length of incarceration.
To determine whether there were individuals met FSP criteria but did not receive an FSP service,
Indigo identified individuals who met FSP inclusion criteria but were not enrolled in and had never
been referred to ACBH FSP services as part of Assessment Question 2. We explored differences
in demographic characteristics between FSP clients and individuals who met FSP inclusion
criteria but were never referred to FSP.
Enrollment in ACBH FSP
After identifying referrals to ACBH programs in FY21-22, Indigo assessed how many referrals
enrolled in FSP services by the end of FY22-23 (June 30, 2023) and how long it took to enroll.
The outreach and engagement process to get individuals to accept FSP services can sometimes
take several months. To account for the outreach and engagement period, we examined
enrollment up to June 30, 2023, allowing at least 1 year for referred individuals to enroll in FSP.
To explore differences in enrollment across sub-populations, we compared demographic
characteristics of individuals who did and did not enroll in FSP by June 30, 2023.
ACBH FSP Service Delivery and Service Participation
Indigo identified how many individuals were enrolled in ACBH FSP programs for at least one day
in FY22-23. Among these individuals, Indigo assessed: 1) program enrollment length at the end
of FY22-23 (June 30, 2023), 2) service frequency (i.e., average number of services per month),
3) service intensity (i.e., average length of services), and 4) level of service participation. We also
examined whether there were differences in service engagement patterns across demographic
characteristics.
Service frequency, intensity, and level of participation analyses examined FSP services during
FY22-23 in order to standardize the time period for assessment. These analyses excluded
individuals with less than one month of FSP enrollment. Service analyses assessed FSP services
directly with the client (excluding collateral contacts, no shows, and cancellations). Service
participation analyses assessed face-to-face FSP services directly with the client and excluded
phone services. Telehealth services were included as face-to-face services. Additionally, service
analyses excluded out-of-community time when individuals were not available for services (e.g.,
incarcerated, hospitalized).
To examine differences in service participation, we created two service participation sub-groups:
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• Active service participation: Individuals who participated in an average of 4 or more
face-to-face FSP services per month.
• Low service participation: Individuals who participated in an average of fewer than 4
face -to-face FSP services per month. Individuals who only participated in phone services
would be included in this group.
As part of the service participation analysis, Indigo explored whether any individuals received no
FSP services during FY22-23. Only one individual, with more than one month of enrollment, did
not participate in any FSP services. This individual is included in the “not active participation”
group. Indigo also explored whether and how many individuals stopped engaging in FSP services
for a period of 90 days or longer; however, this number of individuals was small and are not
reported in the findings.
Qualitative Methods
Survey and Key Informant Interviews
In order to better understand FSP program models, Indigo conducted a short survey followed by
a key informant interview with staff from each FSP provider team. First, we developed and
administered a short online survey to gather information from FSP teams about program capacity.
The goal of this survey was to gather readily available data on contracted and available slots to
inform the subsequent interview and to ensure we were starting each interview with the same
information across providers.
Next, we conducted a one-hour long meeting with a representative or representatives from each
FSP provider. We gathered background information to understand each provider’s program
model, their staffing model and current vacancies, and challenges they are facing in providing
contracted services.
Focus Groups
After Indigo completed and compiled the quantitative analysis, the team conducted four focus
groups with consumers, families, referring parties, and FSP service providers. The goal of the
focus groups was to understand strengths and barriers to FSP services at each step in the
process from identification and outreach to ongoing service delivery.
The referring party focus group included gathering information about how referring parties
become aware of someone who should be referred to an FSP; reasons a referring party decides
to refer or not refer a person; the referral process; and strengths and barriers to referring individuals
who may need these services. Referring parties were also given the opportunity to review and
react to quantitative data on referrals and services to provide additional context about quantitative
findings. The referring party focus group was composed of individuals representing John George,
Santa Rita Jail, Amber House, Cherry Hill, and IHOT.
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The focus group with FSP services providers gathered information on FSP services from
identification to discharge. Indigo asked about reasons a person may engage or not engage in
FSP services, and strengths and challenges to engagement at each step in the process. Similar
to the referring party focus group, FSP providers were given the opportunity to review and react
to quantitative data on referrals and services to provide additional context about quantitative
findings. The focus group was attended by representatives from each of the four agencies that
provide FSP services in the County.
For clients and families, we asked about service experience both prior to and during service
participation. Indigo inquired about how determinations were made around service delivery;
factors that promoted or detracted from service engagement; and strengths and challenges to
FSP service provision.
Data Limitations and Methodology Adjustments
During the assessment process, Indigo made minor methodology adjustments in response to
emerging data trends as well as data limitations or availability. One of the first steps in the
assessment was to confirm that existing FSP programs align more closely with an ACT level of
care, while Service Teams align with an ICM model of care. This was supported by quantitative
data, showing FSP clients had a more acute clinical profile and received more frequent and
intensive services than Service Team clients. If FSP and Service Teams had provided a similar
level of care and served a similar population, we proposed examining referrals, service delivery,
and service participation for both FSP and Service Team programs. However, given the apparent
differences in program model and population, findings are only reported for FSP programs. The
assessment also excludes child and youth programs, and therefore only includes individuals ages
18 and older.22 While all existing TAY FSP programming was included in the analysis, the overall
TAY population may be slightly underrepresented as youth ages 16-17 enrolled in child and youth
FSP programs were not included.
The assessment had initially intended to examine a 2-year period from FY21-22 to FY22-23.
However, program operations were still somewhat impacted by COVID during FY21-22. In order
to assess the most current operations, we adjusted the methodology to focus on clients, service
delivery, and service participation in FY22-23. For the referral analysis, however, we assessed
referrals made in FY21-22. As mentioned, the outreach and engagement process to get
individuals to accept FSP services can take months and clients referred in one fiscal year may
22 Behavioral health services in Alameda County for individuals ages 16-17 are within the children’s system of care. While FSP and
other outpatient services within the Transition Age Youth division provide services from age 18 through 25, crisis, residential, and
hospital programs that serve children and youth stop at age 17, and youth ages 18 and up are served within adult services as required
by state licensing agencies. Services for minors are subject to separate policy and regulatory guidance that differs from the
requirements for programs that serve individuals ages 18+. This assessment does not include services within the children’s system
of care and therefore does not estimate need for 16-17 year olds. Additionally, 16 and 17 year olds who require FSP services would
receive them through the children’s system of care, and this assessment did not include an assessment of the capacity needed for
children’s FSP services as this would fall outside of the scope of the settlement agreement. Services for transition age youth ages
18-25 are included in the assessment.
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not be enrolled until the next fiscal year. FSP program data were incomplete beyond FY22-23
due to a transition in the County’s EHR. As a result, we were unable to examine enrollment for all
referrals made in FY22-23, and instead focused the analysis on FY21-22 referrals.
Some quantitative data was not available or had quality concerns. FSP programs do not track
outreach and engagement contacts in the EHR before the individual has enrolled in FSP. As a
result, it was not possible to explore the associations between outreach and engagement and
FSP enrollment quantitatively, and this was instead assessed through stakeholder interviews.
Housing status is often difficult to assess from administrative datasets because many people
experiencing homelessness use a mailing address, such as a friend or family member or
homeless service provider location. Within the dataset available for the assessment, the housing
status indicator was largely unreported for referred individuals and was unreported for one-third
of FSP episodes, making it difficult to examine trends in referral, enrollment, and service
participation between the housed and unhoused populations. From the data available to this
assessment, it is reasonable to assume that many of the FSP clients experience homelessness.23
Lastly, to comply with HIPAA and protect client anonymity, demographic groups with fewer than
12 clients are either aggregated or are not reported. Lastly, to comply with HIPAA and protect
client anonymity, demographic groups with fewer than 12 clients are either aggregated or are not
reported.
23 It was infeasible to review other data sources that would contain more detailed information regarding housing status, such individual
client charts.
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Assessment Question 1 Findings
What are the barriers and challenges to identifying, referring, engaging, and
serving individuals who need an FSP-level of care and what demographic
variables influence participation?
FSP Referrals
Who is being referred to FSPs?
In Fiscal Year (FY) 21-22 there were a total of 221 referrals made to ACBH FSP programs for
adults (including Transitional Age Youth, Older Adult, and Forensic FSP programs). As shown in
Table 1, among these referrals, nearly 70% were for people diagnosed with schizophrenia
spectrum and other psychotic disorders (55%) or bipolar and related disorders 14%. Seven
percent (7%) of referrals were for people with trauma- and stressor-related disorders, and 6%
were for people with depressive disorders (17% had deferred diagnoses). Over half of referrals
(57%) to FSP programs were for people with co-occurring substance use disorders.
Table 1. Mental Health and Substance Use Disorder Diagnoses of People Referred to
FSP Programs in FY21-22 (N=221 Referrals)
Diagnoses Referrals Percent
Mental Health Diagnosis
Schizophrenia Spectrum and
Other Psychotic Disorders
121 55%
Bipolar and Related Disorders 32 14%
Trauma- and Stressor-Related
Disorders
16 7%
Depressive Disorders 14 6%
Diagnosis Deferred 38 17%
Substance Use Diagnosis
Active SUD Diagnosis 127 57%
No Active SUD Diagnosis 94 43%
Table 2 below shows that nearly half (45%) of referrals to FSP programs in FY21-22 were for
people who identified as Black/African American, while approximately 20% identified as White,
13% identified as Hispanic/Latino, 9% identified as Asian American or Pacific Islander, and 13%
identified as another race or did not report their race. Nearly all referrals were for people who
spoke English as their first language. Over half of referrals were for men (60%) while 40% were
for women. Although approximately 60% of referrals to an adult FSP were between the ages of
25 and 59, a large proportion of referrals were for transitional age youth as well (30%), and
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approximately 10% of referrals were for adults ages 60 and over. Finally, most referrals to FSP
programs were for people whose last known residence was in Oakland (42%), Hayward (15%),
or San Leandro (15%).
Table 2. Demographic Characteristics of People Referred to ACBH FSP Program FY21-22
(N=221 Referrals)
Demographic Characteristic Referrals Percent
Race/Ethnicity
Black / African American 100 45%
White 45 20%
Hispanic / Latino 29 13%
Asian / Pacific Islander 20 9%
Other or Unknown 27 13%
Age Group
18-24 66 30%
25-59 129 58%
60+ 26 12%
Gender
Male 132 60%
Female 89 40%
City
Oakland 92 42%
Hayward 34 15%
San Leandro 33 15%
All Other Cities 62 28%
Overall, the population referred to FSP in FY21-22 appeared to have acute needs, experiencing
significant levels of crisis, hospitalization, and incarceration. Among all referrals:
• Crisis Episodes: 76% experienced at least one crisis episode (CSU, PES, Jail, Sobering
Center) in the year prior to FSP referral, with an average of 7.3 crisis episodes each. Most
crisis episodes resulted in PES admissions. Sixty-eight percent (68%) of referrals to FSP
were for people admitted to PES at least once in the year prior to FSP referral, with an
average of 5.3 PES admissions each.
• Psychiatric Hospitalizations: 54% experienced a psychiatric hospitalization in the year
prior to FSP referral, with an average of 2.2 hospitalizations lasting approximately 20 days
in the year prior to FSP referral.
• Incarceration: 37% were booked into Alameda County Jail at least once in the year prior
to their FSP referral, with an average of 4.7 jail bookings and 128 days spent in jail in the
year prior to FSP referral.
14
Where are referrals to FSP coming from?
Among the 221 referrals made to adult ACBH FSP programs in FY21-22, mental health providers
such as outpatient therapists, psychiatrists, case managers, and other representatives from the
ACBHD systems of care, made 54% of referrals, while 18% of referrals were self-referrals or from
family and friends. Only 12% of referrals were made from law enforcement agencies, 6% were
from John George PES and crisis programs (including but not limited to mobile crisis programs),
5% were from hospitals or another medical professional, and 5% came from other sources such
as CPS and APS, among other community agencies.
Are there people who met FSP eligibility criteria but were not referred to an FSP program?
As described in the proceeding Assessment Question 2 Findings section, there were 1,080 people
who: 1) met FSP inclusion criteria, 2) were not connected to an ACBH FSP or Service Team in
FY22-23, and 3) had never been referred to an ACBH FSP program. Comparing this group with
the 221 referrals to FSP in FY21-22 helps to identify characteristics associated with people who
might have been referred to FSP but were not. To that end, Table 3 demonstrates that the 1,080
individuals who met FSP inclusion criteria but had never been referred to an FSP were more likely
to be criminal justice involved, diagnosed with a trauma-related disorder, adult (as opposed to
TAY and older adults), and male. These individuals were also less likely to have experienced non-
jail crisis episodes and psychiatric hospitalizations. There were no notable differences across
race/ethnicity.
Table 3. Comparison of Characteristics of People Referred to FSP in FY21-22 with People who
Met FSP Inclusion Criteria in FY22-23 and were Never Referred to an FSP
Met FSP inclusion criteria in
FY22-23 & Never Referred to FSP
(n=1,080)
Referrals to FSP in FY21-22
(n=221)
Justice
System
Involvement
55% met FSP criteria through
incarceration in year prior to eligibility
(4+ jail bookings and/or 28+ days in jail)
37% with one or more jail bookings
in year prior to FSP referral
Mental Health
Diagnosis
37% diagnosed with a trauma-related
disorder
9% diagnosed with a trauma-
related disorder
Gender 74% male 60% male
Age Group 85% ages 25-59 58% ages 25-59
What are the barriers to identifying and referring people for ACBH FSP Programs?
Findings from focus groups suggest that there are groups of people who are in need of FSP
services, but do not get a referral for a number of reasons including: 1) a person refusing
services prior to a formal referral, 2) consumers and family members not always having
knowledge about FSP services in the County, and 3) reentry planning challenges resulting
in many individuals who are justice-involved not being referred to FSP upon release from
15
custody. Providers reported that sometimes an individual will be asked if they are interested in
FSP services, and if the person declines, the referral is never made. Data are not available to
determine the extent to which people decline FSP services prior to a referral that is then never
made. Another barrier to getting referred to FSP services appears to be knowledge about FSP
services. In the consumer focus group, there was a large group of people who appeared to have
a high level of need. Most individuals had substantial experience with crisis events, jail,
hospitalization, and homelessness; yet, these people were not aware of what an FSP service was
in the County. Additionally, service providers noted that it appears that many justice-involved
individuals are not being referred to FSP and suggested there may be opportunities to increase
referrals for these individuals.
Another challenge arises when a person is already in a Service Team but needs a higher
level of care. Service Teams provide a lower level of care compared to FSP; however, some
people who likely need FSP remain in Service Teams for a number of reasons. Referring
providers, like those at John George, explained that if a person is already enrolled with a Service
Team, they are unable to refer that person to FSP; instead, the individual must be referred to FSP
through their Service Team provider. Additionally, sometimes a person feels connected to their
Service Team case manager and they do not want to transition to FSP. At other times, the Service
Team is reluctant to refer a client to a FSP for different reasons. Providers shared that in some
cases there may be reluctance to make a referral because there have been instances where
someone referred to FSP did not connect to services and fell out of care. For language-specific
providers, there is an added reluctance because they have had prior experiences when they
referred someone to FSP and there have been language or other cultural barriers that result in
the person not doing as well with the FSP as they were with the Service Team.
FSP Service Enrollment
Once referred to FSP services, who is enrolling?
Of 221 referrals for FSP in FY21-22, 78% (n=172) resulted in FSP enrollment by the end of FY22-
23, while 22% (n=49) did not (Figure 2).
Figure 2. Proportion of FY21-22 FSP Referrals Resulting in FSP Enrollment (N=221)
78%
(n=172)
22%
(n=49)
Enrolled in FSP Not Enrolled in FSP
16
Among the 49 referrals that did not result in an FSP enrollment, 28 were closed by the end of
FY22-23 while 21 referrals remained open (and the person had not yet enrolled in services). Stark
differences suggesting certain demographics groups were significantly more or less likely to enroll
in FSP were not found. However, there were some slight differences in enrollment rates across
demographic characteristics, noted below:
Race: Seventy-five percent (75%) of referrals for Black/African Americans resulted in FSP
enrollment, compared to 78%, 79%, and 80% of referrals for White, Hispanic/Latino, and Asian
American and Pacific Islanders, respectively.
Age: A higher proportion of referrals for transitional age youth (86%) resulted in FSP enrollment
than referrals for adults (75%) and older adults (69%).
Gender: A higher proportion of referrals for females (81%) than male (76%) resulted in FSP
enrollment.
How long, on average, does it take for a person to get from referral to enrollment in an FSP
service?
Figure 3 below shows that among referrals resulting in an FSP enrollment, 61% resulted in
enrollment within 2 months. A much smaller proportion resulted in FSP enrollment within 2 - 6
months (12% in 61-120 days and 3% in 121–180 days). Notably, nearly one-quarter (23%) of
referrals resulting in FSP enrollment took six months or longer to complete.
Figure 3. Number of Days from Referral to Enrollment (N=172)
Overall, there were no notable differences suggesting shorter or longer periods from FSP referral
to enrollment for certain demographic groups, other than age and FSP population. Referrals for
transitional age youth tended to result in enrollment more quickly than referrals for adults and
older adults. Eighty-two percent (82%) of FSP referrals resulting in enrollment for transitional age
youth were completed within 0 to 120 days, compared to 70% of FSP referrals resulting in
enrollment for adults (ages 25-59) and 67% of referrals resulting in enrollment for older adults
(age 60 or older). In addition, enrollment in Adult Forensic FSP programs took longer than other
programs—only 65% of FSP referrals resulting in Adult Forensic FSP enrollment were completed
within 0 to 120 days.
23%
3%
12%
61%
Over 180 Days
121 - 180 Days
61 - 120 Days
0 - 60 Days
Proportion of Referrals Resulting in FSP Enrollment
17
The differences in time periods to enrollment, specifically for those individuals who had an open
referral (i.e., referral not yet closed or enrolled in FSP) for six months or more, likely indicates the
individual was unavailable for enrollment (e.g., incarcerated, hospitalized, etc.) or was unable to
be located and was lost to follow-up, and was then reconnected to the FSP provider when
experiencing an additional crisis, admission, or jail booking because they were in a known
location.
What are the barriers to engaging and enrolling people in ACBH FSP Programs?
When an FSP referral is made, it typically goes through the ACBH ACCESS program. If a person
is not connected to services, providers will connect a person to ACCESS to determine what level
of service they need. Referring parties mentioned that they have experienced the ACCESS line
as being fairly responsive. After the referral has been made, ACCESS staff engage with an
individual and determine the level of care needed. If they determine that the person needs an
FSP, ACCESS staff will assign them to an FSP provider.
Because of the population, people are often hard to find and engage in services after they
have been assigned to an FSP provider. However, liaisons with County staff are often helpful.
Referring parties reported that they work closely with County connections to try to identify where
a person may be located, and mobile outreach is often another source of support in locating a
person. Providers also reported that they try to gather as much collateral information (i.e.,
information from family, friends, or other third parties) about a person to facilitate a smooth
connection.
FSP providers reported they have similar approaches to outreach, but did not have a set
standard of how many attempts at contact they will make in a referral. Some providers
reported attempting outreach contacts three to five times total while others reported focusing on
a timeframe of reaching out three times per week for four to six weeks. In part, this variation in
outreach may be because providers receive referrals from different sources. Some programs, like
those that serve transition age youth, are usually able to get a warm handoff from another provider
and the linkage is often easier. Other providers get most referrals from other system partners
such as the Public Defender or Parole Office.
For all providers, warm handoffs were especially helpful in connecting with the individual
to begin the outreach and enrollment process. Often, providers reach out to the referring party
to connect or meet the person at a specific location. For example, one provider reported having
success with referrals from Parole officers when they can go directly to the Parole office and
connect to the referred individual. Additionally, providers reported that people who are referred
from an IHOT or Crisis Residential program that are being connected to an FSP may be more
likely to engage because they have been stabilized in the prior service. Providers spoke of how
contact with IHOT often facilitates a successful transition to FSP. Providers reported that when
a person is not connected to any other providers or system partners, outreach and
engagement is often very difficult.
18
When people are at John George or Santa Rita Jail, it is often easier to initially engage
them in services but engagement may not last after they are released. Several providers
reported that people often agree to services while hospitalized or incarcerated, but then refuse to
participate when they come back into the community. For example, as one referring party
mentioned, providers at Santa Rita Jail will try to connect a person to an FSP or Service Team
and provide a warm handoff, but the person will not continue with those services post-release. In
part this is because those that have the highest needs for an FSP service are also the ones that
struggle the most to seek help. Another barrier noted by referring parties is service providers’
limited ability to engage with people in-custody and build rapport to facilitate service engagement
post-release. To help address this challenge, staff at Santa Rita Jail are getting tablets to be able
to connect people in custody to providers remotely while also working on getting clearance for
providers to see clients while they are in custody. Several providers mentioned that the ability to
offer a subsidy or access to housing can be a large incentive to participate in FSP services,
especially for individuals being released from jail.
FSP Service Delivery & Service Participation
How many FSP episodes were open during FY22-23 and for how long?
In FY22-23, there were 1,083 FSP episodes open (i.e., individual was enrolled in FSP) for at least
one day during the year, representing 1,055 unique individuals. Of these episodes,
• 50% were open to an Adult FSP program (non-forensic)
• 22% were open to an Adult Forensic FSP program
• 13% were open to a TAY FSP program,
• 8% were open to an Older Adult FSP program, and
• 7% were open to AOT or Community Conservatorship.
At the end of FY22-23, 81% of these episodes remained open and 19% were closed. The average
length of enrollment was 4 years (median 2.7 years, range: 3 days to 27 years), and overall, 29%
of people were enrolled in FSP for less than one year, 30% were enrolled for 1-3 years, 27% were
enrolled 3-5 years, 7% were enrolled 5-10 years, and 6% were enrolled 10+ years.
What level of services do people in FSPs receive, and what kinds of services are they
receiving?
We examined 975 FSP episodes for people who spent at least 30 days in the community (not in
jail, PES, or a hospital) while enrolled in FSP to assess service frequency and intensity and
examine if there were differences across demographic groups. Overall, FSP clients received an
average of 6.5 services per month, including 5.4 face-to-face service contacts and 1.2 phone
contacts (excluding no shows, cancellations, and contacts with collateral), for an average of 9.6
hours per month. Most face-to-face contacts took place in the field (85%) and 15% occurred in an
office setting. Face-to-face contacts lasted an average of 1 hour 45 minutes while phone contacts
19
lasted an average of 40 minutes. There were no notable differences in service frequency and
intensity across demographic groups.
Are there differences in the levels of FSP service participation among different groups?
We examined the same 975 FSP episodes for people who spent at least 30 days in the community
while enrolled in FSP during FY22-23 to assess the level of service participation among FSP
clients.
• Active Service Participation: Clients who, on average, had 4+ face-to-face services with
the FSP provider per month.
• Low Service Participation: Clients who, on average, had less than 4 face-to-face
services with the FSP provider per month.
Based on these criteria, which assume that FSP clients should have at least one face-to-face
contact per week, 60% of FSP clients met active service participation criteria. On average,
individuals with active service participation had 8.3 service contacts (including collateral contacts)
and received 12.6 hours of services per month. These included 5.9 face-to-face services and 1.3
phone contacts per month.
In comparison, 40% of FSP clients met the low service participation criteria. On average, these
individuals had 3.7 service contacts and received 4.8 hours of service per month, including 2.6
face-to-face contacts and 1.1 phone contacts.
Table 4 below shows the level of service participation across demographic characteristics.
Overall, there were some minor differences in level of service participation across gender and
race, however there were more notable differences in participation levels across age groups,
housing status, region of residence, and FSP population types.
Age Group. A higher proportion of older adults (74%) met active service participation criteria than
adults aged 26-59 (58%) and transitional age youth (52%).
Housing Status: A lower proportion of unhoused FSP clients (48%) met active service
participation criteria than those who were housed (62%) or in some other type of housing or
treatment setting (64%). However, it is notable that housing status was unknown or unreported
for 33% of clients, making it difficult to reliably identify trends across housed and unhoused clients.
Region of Residence: Fewer FSP clients live in East and South (n=85) Alameda County
compared to Central (n=370) and North County (n=466) which include the cities of Oakland,
Hayward, and San Leandro. Among FSP clients who do live in East and South County, a lower
proportion met active service participation criteria (45%) compared to Central (68%) and North
County (59%).
FSP Population Types: Not referenced in the Table above, findings also suggested that a much
greater proportion of FSP clients enrolled in AOT or Community Conservatorship (82%), a
20
Forensic FSP (77%), or an Older Adult FSP (72%) met active service participation criteria than
those in Adult (51%) and TAY (52%) FSPs.
Table 4. Service Participation Level, by Demographic Characteristics of FSP Client
(N=975)
Demographic Characteristic Active Service
Participation
Low Service
Participation
Total
Race/Ethnicity N % N % N %
Black / African American 269 60% 183 40% 452 100
White 152 61% 96 39% 248 100
Hispanic / Latino 51 55% 42 45% 93 100
Asian / Pacific Islander 65 66% 33 34% 98 100
Other 21 49% 22 51% 43 100
Unknown 24 59% 17 41% 41 100
Age Group
18-24 78 52% 72 48% 150 100%
25-59 373 58% 275 42% 648 100%
60+ 131 74% 46 26% 177 100%
Gender
Male 380 62% 233 38% 613 100%
Female 202 56% 160 44% 362 100%
Housing Status
Housed 249 62% 151 38% 400 100%
Unhoused 77 48% 84 52% 161 100%
Other Housing/Treatment Setting 56 64% 31 36% 87 100%
Unknown 200 61% 127 39% 327 100%
City
Oakland 246 60% 167 40% 413 100%
Hayward 106 65% 57 35% 163 100%
San Leandro 133 70% 57 30% 190 100%
Other 78 50% 77 50% 155 100%
Region
North 275 59% 191 41% 466 100%
Central 250 68% 120 32% 370 100%
East & South 38 45% 47 55% 85 100%
TOTAL 582 60% 393 40% 975 100%
21
What are the barriers to service engagement?
Individuals with co-occurring SMI and SUD are often difficult to engage in ongoing
services. As service providers mentioned, people often want access to housing or SUD services
to sustain service engagement. However, it is often a challenge to get people connected to SUD
services, and not all FSP programs are able to provide SUD services directly and instead link
FSP clients with SUD services. As one referring party mentioned, these challenges with service
engagement point to the profound impact of addiction and a lack of affordable housing in the Bay
Area, especially for a population with complex needs that may not be successful in many housing
settings.
As mentioned, having an array of housing options to meet someone’s needs supports
engagement. Providers mentioned that the FSP population may struggle more in board and care
type housing where they need to navigate and share space with others. Similarly, consumers also
discussed how getting secure housing that met their needs was a key component to their recovery
process. Family members highlighted challenges getting their loved ones into stable housing and
feeling that there were not enough housing options being provided.
Providers reported that challenges with engaging people on an ongoing basis often comes
from a combination of an inability to locate a person and the person being unwilling to
participate in services. In some cases, assigning a peer mentor is helpful in keeping
engagement levels high. This aligns closely with consumers who expressed the importance of
having peers accompany clinicians. Consumers also suggested that people will engage in
services if the providers are caring and compassionate towards them. Family members spoke of
the importance of service providers being consistent and creative in their approach toward
engagement and providing a ”whatever it takes” approach to services.
Both consumers and providers mentioned that creating a sense of community can facilitate
ongoing service engagement. Several consumers spoke of their connection to the Pool of
Consumer Champions as being important. Others spoke of having goals like growing in recovery
and helping others as supporting them to stay engaged in services.
22
Assessment Question 2 Methodology
Assessment Question 2 aimed to answer the primary question of how many FSP slots are needed
to serve individuals who meet FSP eligibility criteria under 9 C.C.R. § 3620.05. In order to answer
this question, the assessment first needed to identify FSP inclusion criteria that operationalizes
the FSP eligibility criteria established in state regulation. For example, FSP eligibility criteria under 9
C.C.R. § 3620.05 includes imprecise criteria such as being unserved or underserved, involved in
the criminal justice system, and frequent utilization of hospital and/or emergency room services as
the primary resource for mental health treatment. To identify individuals who meet state FSP
eligibility criteria and determine the number of FSP slots needed, the assessment required
specific, quantifiable metrics that define thresholds for imprecise FSP eligibility criteria such as
criminal justice involvement and frequent utilization of hospital and emergency services. To inform
the development of specific, measurable FSP inclusion criteria that align with state regulations,
we conducted a literature review and benchmarking research about inclusion criteria for similar
programs across the country.
We then identified the group of individuals who met FSP inclusion criteria, including examination
of sociodemographic variables, clinical profile, and service utilization history. Within this FSP-
eligible group, some individuals were already participating in an ACBH FSP or Service Team and
some were not. Additionally, there were some individuals who participated in ACBH FSP or
Service Team programs who do not meet the FSP inclusion criteria developed. Once the FSP-
eligible group was identified using the criteria developed from the literature and informed by
relevant regulations, Indigo assembled a group of local subject matter experts who represent the
full spectrum of experiences with FSP programming and FSP-eligible individuals, including
professionals and people with lived experience. This group reviewed data from the initial analysis
about who met preliminary inclusion criteria and provided their guidance and expertise to refine
inclusion criteria to determine what populations have an FSP-level of need. The Indigo team then
re-ran the analyses with the refined inclusion criteria to estimate: 1) the total number of individuals
who require an FSP level of care, and 2) the number of FSP slots needed.
Figure 4 summarizes the methodology to address Assessment Question 2 and identify the number
of FSP slots needed to meet community needs.
23
Figure 4. Assessment Question 2: Methodology Process Flow
To address Assessment Question 1, Indigo utilized several data sources, including:
• Literature review
• Interviews with ACBH FSP and Service Teams
• Quantitative data including ACBH client data and service data
For quantitative data, Indigo worked with the ACBH Data Services Team to identify and obtain
aggregate data from the ACBH electronic health record systems, including the ACCESS
database, Insyst client database, and Sheriff’s Office jail booking and incarceration data via the
ACBH Data Warehouse.
The specific quantitative elements examined include: ACBH FSP and Service Team enrollment,
admissions to crisis facilities, psychiatric hospitalizations, jail bookings and incarcerations,
behavioral health diagnoses, demographic characteristics, and ACBH service and referral history.
The subsequent sections provide greater detail about the specific data sources used, questions
addressed, and methods employed.
•Conduct literature review to identify benchmarks for:
•FSP inclusion criteria
•Expected enrollment length
Inclusion Criteria Literature Review
•Analyze ACBH data to determine:
•How FSP and Service Team populations align with FSP inclusion criteria
•ACBH population not participating in FSP or Service Teams that met FSP inclusion criteria
Preliminary FSP Inclusion Analysis
•Review preliminary eligibility findings with work group of local experts
•Refine FSP inclusion criteria based on stakeholder feedback
Refine FSP Inclusion Criteria
•Analyze ACBH data to determine FSP population based on refined inclusion criteria
•Use analysis findings to estimate number of FSP slots needed to meet community needs
Estimate Number of FSP Slots Needed
24
Literature Review
In order to support the development of the methodology, Indigo conducted a literature review and
benchmarking research to identify: 1) inclusion criteria for FSP services based on the Welfare and
Institutions Code and ACT literature, and 2) expected enrollment length in FSP based on clinical
stability.
FSP Inclusion Criteria
As mentioned, the assessment required the operationalization of FSP eligibility criteria outlined in
state regulations into specific, measurable FSP inclusion criteria in order to estimate the number
of FSP slots needed. Most information about ACT eligibility and service need is derived from
service utilization patterns and cost associated with care. Many studies define ACT eligibility by
the number of hospitalizations or hospital days a person experienced and note the limitation that
jail bookings or length of incarceration are not included. Given the overincarceration of people
with serious mental illness,24 it is recommended to include both psychiatric hospital and
incarceration episodes and/or days in estimates of need, if data are available. For hospitalization,
the literature centers around 2-3 hospitalizations25 and/or incarcerations.26 Other studies define
eligibility or appropriateness by cost and potential cost savings, meaning that the cost of FSP
services should be less than the cost of not providing FSP services (i.e., crisis, hospitalization,
and incarceration).
In Alameda County, the cost of FSP programming varies by provider, but ranges from $24,000-
$40,000 per year per person served.27 Using the midpoint of the range of service costs, the
estimated service costs for an individual enrolled in FSP is approximately $32,000. The rates for
an inpatient psychiatric admission may cost anywhere from $523 - $1,831 per day, or an average
of $1,177.28 Using this average of $1,177 per psychiatric inpatient bed day, the average cost of
FSP services and housing equals about 27 inpatient bed days.29 The average length of stay in a
psychiatric inpatient unit in California for Medi-Cal beneficiaries and indigent individuals ranges
from 5.1- 9.4 days with an average of 7.25 days per stay for publicly funded individuals.30 This
suggests that FSP services that align with the ACT model would be a cost effective approach for
individuals who have experienced 4 or more psychiatric hospitalizations or at least 28 inpatient
bed days in a year. Given the shortage of inpatient beds across the state and the need to triage
available resources to those with the most acute needs, it is reasonable to assume that individuals
24 https://www.americanprogress.org/article/long-term-solutions-to-the-overincarceration-of-people-with-
mental-health-disabilities/#:~:text=Individuals%20with%20mental%20illnesses%20are,to%20be%20killed%20by%20poli
ce.&text=The%20overpolicing%20of%20people%20with,an%20escalating%20mental%20health%20crisis 25 Cuddeback GS, Morissey, JP, Meyer, P. Psychiatric Services , Volume 57 , Issue 12, December, 2006, Pages 1803-1806
26 Cuddeback GS, Morrissey JP, Cusack KJ. How many forensic assertive community treatment teams do we need? Psychiatr Serv.
2008 Feb;59(2):205-8.
27 MHSA 2023-2026 Three-Year Program and Expenditure Plan 28https://www.dhcs.ca.gov/Documents/BHIN-23-038-Regional-Average-Rates-for-Non-Contract-Psych- Inpatient-Hospitals-FY-2023-
24-Enclosure-1.pdf
29 Ibid.
30 https://hcai.ca.gov/facility/santa-barbara-psychiatric-health-facility/
25
who may benefit from a brief inpatient stabilization may not be hospitalized. Similarly, some
individuals may be arrested and booked into jail rather than transported to psychiatric emergency
services. Therefore, the FSP criteria utilized in this assessment is adjusted from 4 psychiatric
hospitalizations to: 4 crisis episodes and/or jail episodes or 28 days in an inpatient psychiatric
hospital and/or jail per year.
Clinical Stability and Expected Duration of FSP Services
While ACT was originally envisioned as a time-unlimited service, its main criticism is that it may
foster dependency because of this time-unlimited expectation.31 While a hallmark of ACT is that
individuals can stay for as long as they need and that there are risks with prematurely discharging
individuals to a lower level of care, the current thinking about length of ACT service participation
is that there should be a year of stability prior to discharge.32 While treatment decisions should be
individualized, it is reasonable to assume that an individual will take 1-2 years to stabilize33 and
then require an additional year to solidify these gains prior to discharge.34 Clinical stability is
evidenced by no more than 1 crisis episode, hospitalization, or incarceration per year. Based on
the literature, clients are likely to be clinically stable and ready to be stepped down to less
intensive services after an average of 3 years of ACT treatment, recognizing some clients may
need a longer or shorter time to stabilize.
Preliminary FSP Inclusion Analysis & Refining Inclusion Criteria
Quantitative Data
Indigo examined how many adults met FSP inclusion criteria among three populations35,:
1) FY22-23 ACBH FSP clients,
2) FY22-23 ACBH Service Team clients, and
3) Individuals not open to ACBH FSP or Service Teams in FY22-23.
31 Finnerty MT, Manuel JI, Tochterman AZ, et al. Clinicians perceptions of challenges and strategies of transition from assertive
community treatment to less intensive services. Community Ment Health
J. 2015;51:85–95.
32 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4636011/
33 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10447266/ 34 Rosenheck R, Kasprow W, Frisman L, Liu-Mares W. Cost-effectiveness of supported housing for homeless persons with mental
illness. Arch Gen Psychiatry. 2003 Sep;60(9):940-51. doi: 10.1001/archpsyc.60.9.940. PMID: 12963676.
35 Individuals enrolled in Berkeley FSP programs and/or Berkeley residents were excluded from analysis as these individuals are
served through Berkeley Mental Health.
Preliminary FSP Criteria
Four or more crisis episodes (CSU, PES, Jail Booking, Sobering Center) or 28 days or
more of psychiatric hospitalization and/or incarceration in a 12-month period.
26
A small number of individuals were enrolled in both FSP and Service Team during FY22-23. For
these individuals, we examined FSP inclusion criteria during their FSP enrollment period (i.e.,
time from FSP admission to FSP discharge).
To determine whether individuals met preliminary FSP inclusion criteria, Indigo examined the
following:
1) Behavioral health crisis admissions (i.e., Amber House Crisis Stabilization Unit, John
George Psychiatric Emergency Services, Cherry Hill Sobering Center)
2) Psychiatric hospitalizations, and
3) Jail bookings and incarcerations at Santa Rita Jail.
For all populations, we first examined whether individuals met preliminary FSP inclusion criteria
on any day FY22-23. Individuals with at least 4 crisis episodes and/or jail bookings OR 28+ days
of psychiatric hospitalization and/or incarceration in the year prior to any day in FY22-23 were
determined to meet preliminary FSP inclusion criteria. To further refine whether individuals
required an FSP level of care, Indigo developed additional criteria specific to each population in
consultation with Subject Matter Expert group.
For FSP clients who did not meet inclusion criteria in FY22-23, we looked at the following
additional factors to determine whether individuals required an FSP level of care:
• Preliminary FSP Inclusion Criteria at program enrollment
• Clinical instability in FY22-23
• FSP service frequency in FY22-23
• Participation in civil court-ordered FSP programs (i.e., Assisted Outpatient Treatment
FSP and Community Conservatorship FSP)
Service Team clients were determined to need an FSP level of care only if they met inclusion
criteria in FY22-23. For ACBH clients not enrolled in FSP or Service Teams in FY22-23, we
additionally examined:
• How individuals met FSP eligibility criteria (i.e., incarcerations and jail bookings only, crisis
admissions and psychiatric hospitalizations only, or a combination of crisis/hospitalization
and incarceration)
• Type of behavioral health diagnosis
• Previous referral to an ACBH Adult or TAY FSP program
• Admission to behavioral health residential treatment (adult residential treatment, crisis
residential treatment, and/or short-term residential therapeutic program) in FY22-23
• Psychiatric hospitalization in FY22-23
• Behavioral health assessments at Santa Rita Jail in FY22-23 indicating need for a high
27
level of behavioral health care36 (i.e., level of care determination score of 3 or 4 indicating
high functional impairment and/or high risk of self-harm, or severe functional impairment
and/or imminent risk of self-harm).
After identifying how many total individuals met inclusion criteria in FY22-23, we also explored
how many individuals met inclusion criteria from each FSP population, including Transition Age
Youth (TAY), Adults, Older Adults, and Forensic FSP populations.
Subject Matter Expert Group
Indigo convened a diverse group of local subject matter experts over two meetings to validate
and refine FSP inclusion criteria. The subject matter expert group included one or more
representatives from the following groups, including ACBH staff and ACBH contract provider staff:
• ACBH Adult and Older Adult Services
• ACBH TAY Services
• ACBH Adult Forensic Behavioral Health
• ACBH FSP programs
• ACBH Service Teams
• ACBH Outpatient Clinics
• ACBH In-Home Outreach Teams (IHOT)
• ACBH ACCESS Line
• Cherry Hill Sobering Center and Detox
• ACBH Crisis System of Care
• ACBH Office of Health Equity
During the first meeting, Indigo shared findings from the initial analysis about who and how many
individuals meet preliminary FSP inclusion criteria and engaged subject matter experts in
discussion to get their guidance on if and how inclusion criteria should be refined to determine
what populations have an FSP level of need. Based on feedback from subject matter experts,
Indigo revised FSP criteria in two ways: (1) by including examination of FSP services frequency
needed to maintain clinical stability and (2) by incorporating behavioral health level of care
determinations at Santa Rita Jail. Indigo then re-ran analyses to estimate the total number of
individuals who require an FSP level of care. During the second meeting, subject matter experts
reviewed and validated the refined FSP inclusion criteria.
36 The level of care determination used at the Santa Rita Jail is an existing measurement used to assess level of behavioral health
risk and need for individuals booked into the facility.
28
Estimate Number of FSP Slots Needed
Quantitative Data
After determining how many individuals met FSP inclusion criteria in FY22-23 and need an FSP
level of care, Indigo estimated the number of FSP slots needed based on the following factors:
• Number of existing ACBH FSP slots
• Number of individuals who need ACBH FSP services in FY22-23 based on refined FSP
inclusion criteria
• The number of FY22-23 FSP clients who did not meet FSP inclusion criteria and could
likely be stepped down
• Average expected duration of FSP services and discharge rate
• Expected length of time to enroll identified individuals
• Expected capacity needed on an ongoing basis
To determine the expected duration of FSP services and discharge rate, Indigo examined 1)
average FSP enrollment length among all FY22-23 FSP clients, and 2) how long it took FY22-23
FSP clients (who met FSP inclusion criteria) to reach clinical stability. To further refine the number
of FSP slots needed, Indigo created several analytic scenarios using different FSP enrollment
lengths and discharge rates to estimate how many additional FSP slots would be needed to enroll
the number of individuals who met FSP inclusion in FY22-23 criteria within 3 to 4 years. The
scenarios also examined when and how many newly eligible individuals (i.e., individuals who meet
FSP inclusion criteria after FY22-23) would be able to enroll in FSP each year.
Survey and Interviews with ACBH FSP & Service Teams
In order to determine the number of existing FSP slots in the County, Indigo conducted a short
survey followed by a key informant interview with staff from each FSP provider to understand
program capacity. Indigo also met with ACBH leadership to understand any planned expansions
in FSP programming that would change FSP capacity.
Data Limitations and Methodology Adjustments
During the assessment process, Indigo made minor methodology adjustments in response to
emerging data trends as well as data limitations or availability. As mentioned in Assessment
Question 1, one of the first steps in the assessment was interviews with FSP and Service Team
providers to understand each program model. Through these interviews, we confirmed that
existing FSP programs align more closely with an ACT level of care, while Service Teams align
with an ICM model of care. This was supported by quantitative data, showing FSP clients
generally had a more acute clinical profile and received more frequent and intensive services than
Service Team clients.
Given these differences in program model and population, the need for an FSP level of care is
assessed differently for FSP and Service Team clients. As FSP clients generally had higher acuity
needs and received a higher level of care, we examined additional factors beyond preliminary
29
inclusion criteria to determine if individuals needed to stay in an FSP level of care. In contrast,
Service Team clients were determined to need FSP only if they showed a need for a higher level
of care, demonstrated by meeting FSP inclusion criteria in FY22-23.
The assessment had also initially intended to examine complexity of risk factors—such as
homelessness, active substance use, and difficulty participating in services—to differentiate
whether individuals who met preliminary FSP inclusion criteria required an FSP level of care.
However, nearly all individuals who met preliminary FSP inclusion criteria in FY22-23 experienced
at least one of these risk factors—including 93% of FSP clients, 85% of Service Team clients,
and 98% of ACBH clients not enrolled in FSP or Service Teams. As a result, we examined other
factors determined in consultation with the subject matter expert group—such as clinical stability,
service frequency, diagnoses, service history, and other factors related to clinical profile.
Information about individuals who did and did not meet FSP inclusion criteria is available in
Appendix A.
The assessment had initially intended to examine a 2-year period from FY21-22 to FY22-23.
However, program operations were still somewhat impacted by COVID during FY21-22. In order
to assess the most current operations, we adjusted the methodology to focus on clients, service
delivery, and outcomes in FY22-23. For the referral analysis, however, we assessed referrals
made in FY21-22. As mentioned, the outreach and engagement process to get individuals to
accept FSP services can sometimes take several months and clients referred in one fiscal year
may not be enrolled until the next fiscal year. FSP program data were incomplete beyond FY22-
23 due to a transition in the County’s EHR. As a result, we were unable to examine enrollment for
all referrals made in FY22-23, and instead focused the analysis on FY21-22 referrals.
Lastly, the settlement agreement specifies estimating FSP slots for individuals ages 16 and older
in order to ensure the assessment considers FSP needs for transition aged youth (TAY). In
Alameda County, TAY FSP programs serve individuals ages 18-24, while individuals under 18
are served in ACBH’s child FSP program.37 The assessment includes analysis of ACBH Adult and
TAY FSP programs (excluding child and youth programs), and therefore only includes individuals
ages 18 and older. While all existing TAY FSP programming was included in the analysis, the
overall TAY population may be slightly underrepresented as youth ages 16-17 enrolled in child
FSP programs were not included as an analysis of child FSP programs (ages 0-17) would be
outside the scope of the settlement agreement.
37 As mentioned, behavioral health services in Alameda County for individuals ages 16-17 are within the children’s system of care.
While FSP and other outpatient services within the Transition Age Youth division provide services from age 18 through 25, crisis,
residential, and hospital programs that serve children and youth stop at age 17, and youth ages 18 and up are served within adult
services as required by state licensing agencies. Services for minors are subject to separate policy and regulatory guidance that differs
from the requirements for programs that serve individuals ages 18+. This assessment does not include services within the children’s
system of care and therefore does not estimate need for 16-17 year olds. Additionally, 16 and 17 year olds who require FSP services
would receive them through the children’s system of care, and this assessment did not include an assessment of the capacity needed
for children’s FSP services as this would fall outside of the scope of the settlement agreement. Services for transition age youth ages
18-25 are included in the assessment.
30
Assessment Question 2 Findings
In the sections below, first we describe the Populations for Analysis and Preliminary FSP Inclusion
Criteria used to identify people who may have an FSP level of need. Then we describe the specific
criteria that were used to identify ACBH FSP Clients with an FSP Level of Need, ACBH Service
Team Clients with an FSP Level of Need, and ACBH Non-FSP/Non-Service Team Clients with
an FSP Level of Need. Finally, we describe the model that incorporates the expected average
duration of services in an FSP program to determine the Estimated Number of FSP Slots Needed
to Meet the Need of Alameda County Residents on an ongoing basis.
Estimated Number of Alameda County Residents with an FSP-Level of Need
Populations for Analysis
To determine the number of FSP slots needed to serve the residents of Alameda County, first we
estimated the number of Alameda County residents with an FSP level of need. There were three
populations we assessed: 1) ACBH FSP Clients, 2) ACBH Service Team Clients, and 3)
Individuals open to any ACBH service (including John George Psychiatric Emergency Services,
Amber House Crisis Stabilization Unit, Cherry Hill Sobering Center, and Adult Forensic Behavioral
Health at the Santa Rita jail) but not enrolled in FSP or Service Teams in FY22-23. These
populations are described in Table 5 below.
Table 5. Populations for Analysis
Population Inclusion Criteria
ACBH FSP Clients Individuals ages 18+ open to ACBH FSP Program for at least one day
in FY22-23
ACBH Service
Team Clients
Individuals ages 18+ open to ACBH Service Team Program for at least
one day in FY22-23
ACBH Non-FSP/
Non-Service Team
Clients
Individuals ages 18+:
• Open to ACBH program / service in FY21-22 or FY22-23
• Alameda County Medi-Cal in FY22-23
• SMI Diagnosis in FY21-22 or FY22-23
• In community when eligibility was assessed
(i.e., not in sub-acute IMD / Facility, jail)
For each population, we examined whether individuals met preliminary FSP inclusion
criteria in FY22-23 (4+ crisis episodes and/or jail bookings AND/OR 28+ days in a
How many FSP slots are needed to serve individuals who meet FSP
eligibility criteria under 9 C.C.R. § 3620.05?
31
psychiatric hospital or incarcerated) as well as additional population-specific criteria.
These criteria are described in greater detail in the sections below.
ACBH FSP or Service Team Clients with an FSP Level of Need
The table above summarizes the FY22-23 ACBH FSP and Service Team client population groups
that were determined to have an FSP level of need based on the following inclusion criteria.
Preliminary FSP Inclusion Criteria in FY22-23. All FSP and Service Team clients who met
preliminary FSP criteria in FY22-23 were determined to need an FSP level of care. Service Team
clients who did not meet FSP inclusion criteria in FY22-23 were determined to not need an FSP
level of care.
Preliminary FSP Inclusion Criteria at FSP program enrollment. Among FSP clients who did
not meet preliminary FSP criteria in FY22-23, we examined whether they met preliminary FSP
criteria at program enrollment. Among clients who met preliminary FSP criteria at enrollment,
those who were not clinically stable in FY22-23 were determined to need an FSP level of care.
Clinical Instability in FY22-23. Individuals were identified as NOT clinically stable if they
experienced any of the following during a 365-day period while enrolled in an FSP during FY22-
23:
• 2+ crisis, incarceration, or psychiatric hospital episodes
• 1 incarceration lasting six days or longer
• 1 psychiatric hospitalization lasting four days or longer
Group 1: ACBH clients participating in FSP during FY22-23 who met FSP criteria in FY22-
23 (n=480)
Group 2: ACBH clients participating in FSP during FY22-23 who did not meet preliminary
FSP criteria in FY22-23, met preliminary FSP criteria at enrollment, and were NOT
clinically stable in FY22-23 OR were clinically stable in FY22-23 but received two or more
face-to-face services per week, indicating a high level of need to maintain their clinical
stability (n=60)
Group 3: ACBH clients participating in an FSP while enrolled in Assisted Outpatient
Treatment or Community Conservatorship in FY22-23 (n=65)
Group 4: Clients participating in a Service Team during FY22-23 who met preliminary
FSP criteria in FY22-23 (n=230)
ACBH FSP or Service Team Clients with an FSP Level of Need (n=835)
32
Individuals who were in an FSP program for at least one year who did not experience this level of
crisis, hospitalization, or incarceration were determined to have reached a level of clinical stability
where an FSP level of care is likely not necessary to maintain ongoing stability.
Level of Service Needed to Maintain Clinical Stability.38 Among FSP clients who were clinically
stable, some needed a high level of service engagement to maintain their stability, suggesting
they still have an FSP level of need. Therefore, individuals who reached clinical stability in FY22-
23 who received an average of 2 or more face-to-face services per week over the most recent 6
months of enrollment were determined to have an FSP level of need.
Enrollment is Assisted Outpatient Treatment or Community Conservatorship. All clients
participating in an FSP while enrolled in Assisted Outpatient Treatment or Community
Conservatorship in FY22-23 were determined to meet an FSP level of need based on their legal
status and the level of care they were assessed for within each program.
Utilizing the criteria outlined above, among the 1,010 ACBH FSP clients in FY22-23, 605 were
identified to have an FSP level of need. Among the 1,534 Service Team clients in FY22-23,
230 were identified to have an FSP level of need. Appendix B includes a detailed map showing
which FSP and Service Team client populations were identified to have an FSP level of need.
38 This analysis was included based on subject matter expert feedback to ensure that people who required an FSP level of service to
maintain clinical stability remained in the FSP grouping.
33
ACBH Non-FSP/Non-Service Team Clients with an FSP Level of Need
The table above summarizes the Non-FSP/Non-Service Team ACBH clients population groups
that were determined to have an FSP level of need.
For the Non-FSP/Non-Service Team ACBH clients39 who met preliminary FSP inclusion criteria
in FY22-23, we examined the following factors to determine whether they met an FSP level of
need.
Preliminary FSP Criteria Group. All individuals who met FSP inclusion criteria through
psychiatric hospitalization and/or behavioral health crisis episodes (i.e., crisis stabilization unit,
psychiatric emergency services, and sobering center) were determined to have an FSP level of
need.
Among Non-FSP/Non-Service Team ACBH clients who met preliminary FSP inclusion criteria
through incarcerations and/or jail bookings only, we examined additional factors described below
to determine whether they met an FSP level of need.
39 In FY22-23 all clients had to be 18 years or older, have a serious mental illness diagnosis, be enrolled in Alameda County Medi-
Cal, open to an ACBH program or service, and be in the community for at least one day during the fiscal year when eligibility was
assessed (i.e., not in jail or a sub-acute IMD / Facility for 365 days during the fiscal year).
ACBH Non-FSP/Non-Service Team clients who met preliminary FSP inclusion criteria AND:
Group 5: Met preliminary FSP Criteria through psychiatric hospitalizations and/or crisis
episodes (n=527)
OR
Group 6: Had a psychotic or mood disorder diagnosis (n=493)
OR
Group 7: Were EVER referred to and ACBH Adult FSP or Service Team (n=53)
OR
Group 8: Were admitted to ACBH Residential MH Treatment in FY22-23 (n=33)
OR
Group 9: Were admitted to Psychiatric Hospital or JGPP PES in FY22-23 (n=18)
OR
Group 10: Were designated at Level of Care 3 or 4 at Santa Rita County Jail in FY22-23 (n=91)
ACBH Non-FSP/Non-Service Team Clients with an FSP Level of Need (N=1,181)
34
Type of Behavioral Health Diagnosis. Among individuals who were only served by ACBH in
jail, we examined their behavioral health diagnoses to better understand whether they would likely
require an FSP level of care in the community. Individuals with psychotic or mood disorders
comprise a majority of people enrolled in FSP (90%), and these diagnoses are likely to be
pervasive regardless of the setting they are documented in. Therefore, individuals with psychotic
or mood disorders were determined to require an FSP level of care. Additional factors described
below were examined for individuals with other diagnoses such as trauma, stress, or anxiety
related disorders, which are more likely to be situational (i.e., symptoms are influenced by the
setting within which they are determined, like a carceral setting), such that individuals who
received these diagnoses in jail may not experience the same symptoms or receive the same
diagnoses in the community.
Previous referral to ACBH Adult FSP or Service Team. If at any time in the past, a clinician
determined that someone who met preliminary FSP inclusion criteria through incarcerations
and/or jail bookings only during FY22-23 needed the highest level of outpatient care (Level 1
service need), it is reasonable to assume that their justice system involvement plus this previous
clinical determination suggests they are likely to need an FSP level of care in the community.
ACBH Mental Health Residential Treatment admission in FY22-23. Similarly, if at any time in
the past year an individual who met preliminary FSP inclusion criteria through incarcerations
and/or jail bookings during FY22-23 was admitted to a residential treatment facility, it is
reasonable to assume that their justice involvement plus this level of mental health treatment need
suggests they are likely to need an FSP level of care in the community.
Psychiatric Hospitalizations in FY22-23. If someone met preliminary FSP inclusion criteria
through incarcerations and/or jail bookings in FY22-23 and was also assessed to require an
involuntary detention at JGPP PES or a psychiatric hospital during the fiscal year, this person
likely requires an FSP level of care in the community.
Santa Rita Jail Level of Care Determinations in FY22-23.40 If a clinician at Santa Rita County
Jail assessed individuals during their most recent level of care determination in FY22-23 (not
conducted at booking or conducted upon release from custody) to have high functional
impairment and/or high risk of self-harm, or severe functional impairment and/or imminent risk of
self-harm, they were determined to require an FSP level of care in the community.
Utilizing the criteria outlined above, among 2,083 ACBH Non-FSP/Non-Service Team clients
who met preliminary FSP criteria in FY22-23, 1,181 were identified to require an FSP level
of care. Appendix C includes a detailed map clearly demonstrating which ACBH Non-FSP/Non-
Service Team clients were determined to have an FSP level of need.
40 This analysis was added based on subject matter expert feedback to support a more thorough understanding of who from the
justice-involved population should be included in the FSP grouping.
35
Total Number of Individuals with an ACBH Level of Need
A total of 2,016 individuals were determined to meet FSP inclusion criteria and a need for
an FSP level of care, including:
• 605 ACBH FSP clients in FY22-23
• 230 ACBH Service Team clients in FY22-23
• 1,181 ACBH clients not open to FSP or Service Teams in FY22-23
Of these individuals, 180 need TAY FSP, 1,615 need Adult FSP, 156 need Older Adult FSP, and
65 were in AOT or Community Conservatorship FSP. Of the TAY, approximately 50 may need
Forensic FSP while approximately 900 of the adults and older adults may need Forensic FSP.
Individuals were determined to need forensic FSP services if they were participating in an ACBH
forensic FSP program in FY22-23 or if they met FSP inclusion criteria through jail bookings and
incarceration only.
Estimated Number of FSP Slots Needed to Meet the Need of Alameda County
Residents
In order to determine how many FSP slots would be needed in order to serve the 2,016 individuals
identified as well as how many slots were likely needed on an ongoing basis, the assessment
considered the following factors.
First, there is likely a backlog of individuals who are in need of FSP services now, but the ongoing
capacity needed is likely lower. The group of 2,016 individuals identified likely reflects needed
capacity over a period of years and is larger than the annual capacity needed.
Second, there are a number of individuals currently enrolled in an FSP program that are likely
ready to step down to a less intensive service as evidenced by meeting the clinical stability
threshold with a lower frequency of service akin to a service team or outpatient program. The
estimate of the number of slots needed assumes that individuals who no longer require an FSP
level of care are given the opportunity to step down into a less intensive service thereby creating
capacity for new enrollments.
Third, understanding the capacity needed requires estimating what the likely length of enrollment
would be for an individual. As stated previously, the expected average length of stay from the
literature is about three years, and the average length of stay among all FY22-23 FSP clients in
Alameda County ranges from 2.7- 4 years. The estimate of needed capacity assumes an average
length of participation of 4 years, recognizing that some individuals may step down sooner and
others may require a longer course of treatment.
Finally, the average number of referrals FSP referrals across FY21-23 (2-year period) was
approximately 200 annually, and the average number of FSP enrollments across FY21-23 (2-year
period) was approximately 250 annually. This number of referrals and enrollments, in part, likely
contributed to the backlog of individuals identified who meet FSP inclusion criteria. We also
36
anticipate that the number of referrals and rate of enrollment is likely to increase in subsequent
years suggesting a need for greater capacity on an ongoing basis than currently exists. As a
result, the likely capacity needed annually is greater than what was available annually in FY21-
22 and FY22-23.
During the assessment period, ACBH had a capacity of 1,000 FSP slots. In December of 2024,
ACBH added an additional 100 FSP slots totaling 1,100 FSP slots. In order to answer the question
of how many slots would be needed, the assessment team ran different scenarios of new FSP
capacity to determine how long it would take to clear the backlog of individuals identified for FSP
services by this assessment and how many slots would be available for new referrals on an
ongoing basis thereafter. The results are presented in Table 6 below.
Table 6. FSP Capacity Scenarios
New Spots Added Time Needed to Serve FSP-
identified Individuals
Average Number of Open
Spots on Ongoing Basis
100 4 Years 300
200 3 Years 325
300 3 Years 350
400 3 Years 375
500 2 Years 400
Based on these results, the actual total FSP capacity needed is approximately 1,400 FSP
slots, this includes an additional 300 slots beyond the existing 1,100 slots. Creating 100
slots would take 4 years to serve everyone identified in this assessment whereas creating 200-
400 new slots would allow for everyone identified to be served within a three year period. While
creating 500 slots would allow for everyone to be served within a two year period, it likely creates
too many slots on an ongoing basis, roughly doubling the referrals expected as compared to the
annual referral rate from FY21-23. Approximately 300 new FSP slots balances enrolling clients in
need quickly, stabilizing enrollment rates over time, and allowing sufficient openings for new
clients on ongoing basis without creating excess capacity in subsequent years.
37
Appendix A. Populations who did and did not meet FSP Inclusion Criteria
Who and how many ACBH clients met preliminary FSP inclusion criteria at baseline?
As a first step to address how many FSP slots are needed, we explored who and how many
individuals met preliminary FSP inclusion criteria at program enrollment for FSP and Service
Team clients, and in FY22-23 for ACBH clients not enrolled in FSP and Service Teams.
For FSP and Service Team clients, we first examined FSP inclusion criteria at program enrollment
to better understand if and what differences existed between clients who were enrolled in FSP
compared to Service Teams. As shown below, over half of FSP clients met preliminary FSP
inclusion criteria at program enrollment compared to only 21% of Service Team clients. Over
2,000 individuals not enrolled in ACBH FSP or Service Teams in FY22-23 met preliminary criteria,
requiring further examination of additional factors to determine need for an FSP level of care.
Table 7. Number of Individuals who met FSP Inclusion criteria, by population group
Eligibility Group
FY22-23
FSP Client
FY22-23 Service
Team Client
Non-FSP / Non-
Service Team Client
Met Preliminary FSP
Inclusion Criteria 551 (55%) 323 (21%) 2,083 (100%)
Did not meet Preliminary
FSP Inclusion Criteria 459 (45%) 1,211 (79%) N/A
TOTAL 1,010 (100%) 1,534 (100%) 2,083 (100%)
What is the clinical profile of ACBH FSP & Service Team clients who did and did not meet
preliminary FSP inclusion criteria at program enrollment?
We examined the clinical profile of FSP and Service Team clients to further explore potential
differences among FSP and Service Team populations who did and did not meet preliminary FSP
inclusion criteria.
As shown below, FSP and Service Team clients who met preliminary FSP inclusion experienced
far more crisis admissions, psychiatric hospitalizations, and incarcerations than clients who did
not meet inclusion criteria.
Notably, FSP clients who met preliminary FSP inclusion had more crisis admissions, had more
hospital days, and were more likely to be incarcerated than Service Team clients who also met
preliminary inclusion criteria. This data suggests FSP clients who meet preliminary inclusion
criteria tend have a more acute clinical profile than Service Team clients.
38
Table 8. Clinical profile of FSP and Service Team clients who did and not meet
preliminary FSP inclusion criteria at program enrollment
Clinical Profile
Characteristics
Met FSP Inclusion Criteria at
Enrollment
Did Not Meet FSP Inclusion
Criteria at Enrollment
FY22-23
FSP Client
(N=551)
FY22-23
Service Team
Client
(N=323)
FY22-23
FSP Client
(N=459)
FY22-23
Service Team
Client
(N=1,211)
Crisis Episodes
% of Clients with Crisis
Episode 95% 98% 46% 34%
Avg # Crisis Episodes 8.2 Episodes 5.8 Episodes 1.9 Episodes 1.6 Episodes
Psychiatric
Hospitalizations
% of Clients with
Hospitalization 72% 72% 30% 24%
Avg # of Hospital Days 33 Days 28 Days 11 Days 11 Days
Incarcerations
% of Clients with
Incarceration 62% 42% 11% 5%
Avg # of Incarcerated Days 108 Days 76 Days 7 Days 8 Days
What is the clinical profile of individuals who met preliminary FSP inclusion criteria and
were not open to FSP and Service Teams in FY22-23?
We also examined the clinical profile of ACBH clients who did not participate in FSP and Service
Teams in FY22-23. As shown below, ACBH clients who met preliminary FSP inclusion criteria in
FY22-23 and who did not participate in FSP and Service Teams were more likely to be
incarcerated, had fewer crisis episodes, and were less likely to be hospitalized than FSP and
Service Team clients who met preliminary FSP inclusion criteria at program enrollment.
39
Table 9. Clinical profile of ACBH clients who met preliminary FSP inclusion criteria in
FY22-23 and were not enrolled in ACBH FSP or Service Teams
Clinical Profile
Characteristics
Met FSP Inclusion Criteria at Baseline
Non-FSP /
Non-Service Team
Client
(N=2,083)
FY22-23
FSP Client
(N=551)
FY22-23
Service Team Client
(N=323)
Crisis Episodes
% of Clients with Crisis
Episode 93% 95% 98%
Avg # Crisis Episodes 3.7 Episodes 8.2 Episodes 5.8 Episodes
Psychiatric
Hospitalizations
% of Clients with
Hospitalization 18% 72% 72%
Avg # of Hospital Days 16 Days 33 Days 28 Days
Incarcerations
% of Clients with
Incarceration 88% 62% 42%
Avg # of Incarcerated Days 105 Days 108 Days 76 Days
Are there differences in how ACBH clients met preliminary FSP inclusion criteria?
To better understand the differences between the population groups who met preliminary FSP
inclusion criteria, we examined how individuals met preliminary inclusion criteria. As shown below,
individuals who were not enrolled in FSP or Service Teams and met preliminary FSP inclusion
criteria in FY22-23 were most likely to meet criteria through jail bookings and incarceration only.
In contrast, FSP and Service Team clients who met preliminary FSP inclusion criteria at
enrollment were most likely to meet criteria through behavioral health crisis admissions and
psychiatric hospitalizations.
40
Table 10. FSP Inclusion Criteria Groups, by Population
Inclusion Criteria Group
Met FSP Inclusion Criteria at Baseline
FY22-23
FSP Client
(N=551)
FY22-23
Service Team
Client (N=323)
Non-FSP / Non-
Service Team
Client (N=2,083)
Jail Bookings & Incarceration Only 145 (26%) 62 (19%) 1,556 (76%)
Crisis Admissions &
Psychiatric Hospitalization Only 285 (52%) 223 (69%) 298 (15%)
Combination of
Jail Booking / Incarceration &
Crisis / Psychiatric Hospitalization
121 (22%) 38 (12%) 229 (11%)
For individuals who met preliminary FSP inclusion criteria and were not open to FSP and
Service Team, are there differences in characteristics based on how individuals met
criteria?
To better understand whether individuals who met preliminary FSP inclusion criteria and were not
open to FSP and Service Team required an FSP level of care, we examined differences in various
characteristics related to clinical profile across FSP inclusion eligibility groups (i.e., jail and
incarceration only, crisis and psychiatric hospitalization only, and a combination of
jail/incarceration and crisis/psychiatric hospitalization). Data are shown below.
Overall, individuals not enrolled in FSP or Service Teams who met FSP inclusion criteria through
jail bookings and incarceration alone—compared to those who met criteria through crisis and
psychiatric hospitalization or combination—were more likely to have trauma, stress, or anxiety
disorders; more likely to have a high level of care determination during a jail booking (score of 3
or 4); and less likely to be referred to FSP or Service Teams, admitted to residential mental health
treatment, or admitted to a psychiatric hospital.
41
Table 11. Characteristics of Non-FSP / Non-Service Team ACBH Clients who met
preliminary FSP inclusion criteria, by FSP Inclusion Criteria Group
Characteristic
Non-FSP / Non-Service Team Clients who Met FSP Inclusion Criteria
Jail Booking &
Incarceration Only
(N=1,556)
Crisis & Psychiatric
Hospitalization Only
(N=298)
Combination
(N=229)
Behavioral Health Diagnosis
Psychotic or Mood Disorder 29% 57% 48%
Trauma, Stress, or Anxiety
Disorder 70% 42% 52%
Referral to FSP or Service
Team
Ever Referred to ACBH Adult
FSP or Service Team 9% 24% 21%
Never Referred to ACBH
Adult FSP or Service Team 91% 76% 79%
Open to Residential
Treatment
Admitted to Residential MH
Treatment in FY22-23 8% 42% 30%
Never Admitted to Residential
MH Treatment in FY22-23 92% 58% 70%
Psychiatric Hospitalization &
JGPP PES Admission
Admitted to Psychiatric
Hospital in FY22-23 4% 48% 34%
Not admitted to Psychiatric
Hospital in FY22-23 96% 25% 28%
Santa Rita Jail LOC
Determination
LOC Determination of 3 or 4
at jail booking in FY22-23 14% 6% 32%
No LOC Determination of 3 or
4 at jail booking in FY22-23 86% 94% 68%
42
Appendix B. FSP and Service Team Clients in FY22-23 with an FSP-Level of Need
43
Appendix C. Non-FSP/Non-Service Team Clients in FY22-23 with an FSP-Level of Need