All case study states embraced the set-aside policy as a mechanism for developing or expanding services for people with FEP and other ESMI. However, the case studies revealed wide variation among states in how the funds were used. Some states made concerted efforts to establish specific models of FEP programs--developing highly detailed plans and drawing extensively on consultation with outside experts. In other states--notably California, where the funds were divided into relatively small amounts and distributed among many county mental health departments--the funds were used to supplement existing programs serving the target population by providing training in FEP treatment or establishing new referral mechanisms. State-specific factors, such as the extreme decentralization of the administration of MHBG funds in California or the experience with the RAISE program in New York, appear to have had large impacts on decisionmaking across the states. The availability of other public funds, including state general revenue funds (such as the fortuitous infusion of a large amount of state funds into FEP programming in Virginia), also had a large impact.
Most states implemented CSC programs or modified existing programs to become CSC-like, and while many expanded their clinical population focus to disorders beyond FEP, states' main rationale for doing so was to broaden access and enhance sustainability. States also varied in the sophistication and state of implementation of their evaluation plans, but all of them were committed to the goal of assessing program fidelity and outcomes. Although most of the states had not yet developed sustainable models for their ESMI programs and were reliant on continuing MHBG support, all states--even Texas, where only uninsured individuals are currently eligible for services--expressed interest in eventually tapping into third-party reimbursement to cover at least some operational costs. In one case, questions about the reliability of continued support for the ESMI program led to very cautious decisionmaking regarding the use of set-aside funds.
At this early stage, it is possible to conclude that the set-aside policy is improving access to services for individuals experiencing their first episodes of SMI, particularly those experiencing non-affective psychosis. Across the country, states are developing or expanding ESMI services by drawing on existing program models and adapting them to meet local needs. The programs are being designed with an outlook that emphasizes population impact and they include, from their early planning stages, strategies and resources for program evaluation. As more programs become operational over the coming months, a client population whose complex health care needs had been largely unmet is likely to see a large expansion in the availability of services geared to address their needs. Although most states have implemented or are planning to implement programs that closely adhere to CSC or variants, and similarly, all are committed to evaluating their set-aside funded programs, there is a need for ongoing federal guidance on best practices for program implementation and evaluation to ensure success of the policy. Moreover, a declaration of federal commitment to the policy may assuage states' concerns about the sustainability of the policy, and evidence of success could lead to broader dissemination of ESMI programs supported by state or even private funds.