Rethinking Step Down: The Next Step in Transforming Mental Health Services

At Third Sector, our mission is to transform our government agencies' ability to serve everyone in our communities, no matter their race, background, or circumstance. And one of the most exciting and challenging things about this work is how trying to solve one set of problems reveals some other challenges we might not have understood in the same way. This is particularly true in the work we've been doing over the last five years in California to transform how nine counties in the state are serving and supporting tens of thousands of people with the most severe mental health challenges. 

On behavioral health, California is leading the way, with a 1% tax on its wealthiest citizens that commits significant funds for mental health services. One service this tax funds is the Full Service Partnership (FSP), which provides community-based programs with the flexibility to serve individuals experiencing severe mental illness in whatever way is most effective for them. The inspiration behind the FSP model, which is similar to the Assertive Community Treatment (ACT) model used across the country, is a belief that giving agencies and service providers flexibility puts them in a better position to make the lives of the people they serve better. Third Sector worked with behavioral health departments in nine counties to refocus their FSPs on several outcomes that we collectively believe will transform people's lives, including housing, reduced justice involvement, social connectedness, and reduced inpatient psychiatric hospitalizations. 

Counties with high-performing FSP programs can help clients achieve positive outcomes through intensive support. But, too frequently, when clients graduate or "step down" from intensive programs like FSP, they lose most of the support services that help them maintain stability. For instance, many people participating in FSP programs receive housing subsidies, but those subsidies depend on continued enrollment in FSP. Or clients who received intensive outpatient services that helped them avoid stays in psychiatric facilities suddenly find themselves limited to case management support just a few times a month. 

The truth is we have not invested the way we should in quality step-down programs to serve individuals who do not need ACT/FSP-level care, but still require moderate outpatient treatment. Without more graduated tapering of services as clients become more stable, two things can happen: people stay in FSP programs indefinitely, which prevents the programs from enrolling new people who desperately need mental health services; or people leave FSP before they are ready to independently manage their mental health challenges, which can lead them into a vicious cycle where they may regress and need services again.

As we continue to support counties transforming their FSP programs, we are eager to collaborate with communities to ask tough questions. Questions like:  If we all rely on government services to play a vital role in maintaining the stability of our most vulnerable community members, how can we rethink the way those agencies serve people so that when it's time to "step down," it is truly a step, not a cliff?

How can we build our government systems to provide support in ways that understand mental health is a lifetime journey while balancing the reality of often-limited funding and more people in need than there are spots in a program? How do we rethink what it means to achieve "stability" and understand that even the most stable people in our communities need support? And how do we reimagine ways our communities might be able to provide some of that support?

There are some promising cases where counties have adopted tiered step-down programs where individuals can retain some continuity of service for stepping down from FSP. For example, one tiered outpatient behavioral health program for adults in rural communities allows individuals to keep seeing the same case manager and clinicians, albeit less frequently, after stepping down from FSP. While these programs help ensure continuity of care for these individuals, this type of continuity can be challenging for programs due to cost, complexity, and limited staff and resources.

Addressing step down is the next big challenge to reshaping our government's mental health systems. When we realize that mental health is more than just treatment and support when a person is in crisis, we'll be better positioned to build the kinds of services that we all need to live our best lives.