Table 3.

Qualitative Themes and Their Related Consolidated Framework for Implementation Research Domains

Implementation Domains	Theme	High Fidelity	Low Fidelity
Characteristics of individuals (Program Director)
Knowledge and beliefsabout intervention	Value orientation to full service partnership (FSP) goals	“As executive director…[I] try to enhance the environment so that it's consistent with recovery values.”	“…it's a crisis oriented team because we're always putting out fires.”
Knowledge and beliefs about intervention	Prior experience with programs similar to high fidelity FSPs	“…as part of my fourth year elective [as a Psych resident], I worked half time for the whole year at The Village…and I completely became converted to the cause of psychosocial rehab…”	“…my background has been in corrections…and I've only been at this position for the last 8 months. And so it's a huge transition for me, because in jail it was predominantly a medical model, and coming here it was completely different.”
Knowledge and beliefs about intervention	Value orientation to client	“I spend a lot of time helping people [staff] look at the perspective of the member [client], and then helping them move that way instead of what we think is the best thing for them…”	“…what we're really saying is, ‘How do I see something from their perspective to get their buy-in and reframe it?’ That's all it is is reframing it in a way that's digestible and palatable for them. And so, yeah it's manipulation, yes, but we believe that we're doing it with the best intentions.”
Knowledge and beliefs about intervention	Medication philosophy	“I believe that if we help them get on SSI and help them get housing that their mental health will improve dramatically. Forget the medications, because there's no meds for poverty, and there's no meds for homelessness, and there's no meds for childhood trauma either, which we have a lot of.”	“…we've saved a tremendous amount of money [on] client medications and client housing because we have a lot of other options…we try to come up with really sustainable resources for folks, and so we don't spend nearly what our budget amount is.”
Knowledge and beliefs about the intervention	Housing philosophy	“I lean more toward the scattered site…when people start talking about site-based services, what the hell is normalizing about that?”	“…there are plenty of people that don't really want any kind of housing. They'd rather just bounce around in hotels, and that's easier and better for them.”
Other personal attributes	Political awareness	“…they [city leaders] said, ‘Well, this is an older section of ((city))…And property values have dropped in this area … so we'll create this containment area. And it conjures up for me old Europe and Jewish ghettos…yet at the same time you have people running programs down here in the area [saying] ‘Well, let's build another hotel down there.’”
Inner setting
Culture	Program goals	“…people are people. We're here to help them in their quality of life and to be what they want to be.”	“Our main goal is really to keep them from going to jail and from getting back in the hospital.”
Culture; compatibility	Continuity or change in approach to housing and services	“…the agency has always been very focused on the emerging best practices for folks with co-occurring disorders, the evidence-based practices for folks with severe and persistent mental illness…we've operated housing now for over thirty years as an organization…”	“We didn't really have any structure for how to use them [flex funds], and we were hearing this ‘whatever it takes’ and ‘housing first’ and not really knowing how to do that…”
Compatibility (also related to Characteristics of individuals, Knowledge and Beliefs about the Intervention; and Process, Engaging)	Staffing	“…it's constant in this agency, the trainings on it [recovery],…and when you hire people you look for it, you know, ‘what is your position on it? Can the guy who is using crack have a job? What do you think?’ ‘Absolutely not; you've got to be abstinent.’ Cool, you don't need to work here.”	“…I think that we have to work with the staff that we have in terms of their comfort level…their capacity and their skills… And it really is generally kind of hard with their days that are so full of delivering direct services…I mean people have to do what they feel confident with, so if there's not gonna be some intensive kind of training, then the changes, I think, have to be more gradual.”
Culture	Control of decision making	“…there are so many issues around where in the county somebody feels comfortable to be. What neighborhood, the size of the building. Some people do better when there is a gate out front…”	“The team first starts to decide where we think clients might do well [re: housing]… So we kind of made the decision for her to put her in an ILF [Independent Living Facility].”
Networks and communication; culture	Language/usage	“…language is the primary way we communicate with people…and knowing that you convey a different level of respect…ultimately gaining a different level of effectiveness by the language you use, by the way you conceptualize, through your language, a cooperative effort in terms of services. So, it becomes services done with somebody not to somebody…”	“I think writing that way [writing for Medi-Cal using recovery language] really helps you…start to think that way, you know, cognitively… and like I said I'm trying—I mean, we're getting there. But I think that that would help not being so rigid and do this medical model.”
Readiness for implementation	Distribution of housing funds to clients	“We have money for housing…so anybody who needs it…we pay for their housing until we can help them establish that.”	“I have maybe eleven or twelve clients that we pay for, otherwise they are with family or they are with SSI and/or we're just paying a supplemental rate because they are at a high level of Board and Care. And so SSI will cover them to a point and then we just have to pay the little supplemental rate.”
Outer setting
Patient needs and resources	Target population	“We do outreach, and we find people in the community that are unserved because part of our population is- you are supposed to be unserved by the mental health system. So there's no list that the county has of who those folks are because [they are] the folks that the county hasn't served.”	“Here in [County Name] the greatest need has been high utilizers of hospitals and jails, so I would say at least 85 percent of our referrals are coming from those settings.”
Cosmopolitanism	FSP networks and social capital	“They [the Village] refer to us a lot. like [name of Village ED] will call up and say “Hey, I've got some older adults for you…so he'll actually refer people to us and try to get people into our program because he knows that we're good…and our administrator's been around for a very long time and he knows the president over there [at the Village], so we're just constantly in contact…”	“…it's also a county thing is they're really rigid in terms of billing to Medi-Cal standards, which is more a traditional medical model. And so it's gonna be hard when you're reading our charts to really pick up on us being strength based or being stage based… And I've heard, at these FSP network meetings, other agencies say that they've been able to kind of get around that and been able to document more to that style. I'm not sure how they do it or how they go about it.”
External policy and incentives	County policies affecting FSP implementation	“…we had a lot of guidance from the county…there were trainings for how to do an ACT [Assertive Community Treatment] model, how to do an FSP model, and we continue to get trainings from the county frequently.”	“They [the county] don't want any of the programs to have a wait list…So that creates a challenge for us because on the one hand we have to make sure we're providing service to our clients, and with the level of functioning in a lot of our clients it can get challenging to determine who we move on so we can make room for other clients coming into the program.”