Enhanced Role for Nursing in Milwaukee County's Redesigned Mental Health System

Few would dispute the idea that effective mental health care relies on the quality and accessibility of health care professionals, especially nurses. As stakeholders in Milwaukee County work to redesign the county’s mental health system, one of the crucial issues they face is how to build an effective and efficient mental health nursing workforce in light of anticipated changes under the new system.

The Nursing’s Voice project is a collaborative effort of local and national foundations, higher education institutions, and other interested parties to enhance the supply of mental health nurses in Milwaukee.  As part of the project, the Forum surveyed 120 mental health nurses and 34 employers to illuminate the state of the county’s current mental health workforce and to gather insights to inform the redesign planning process and the work of Nursing's Voice.  

Survey responses identified three broad categories of need that an effective redesign effort must address – the need for training and professional development of nurses, specifically in mental health care; the need for a larger mental health nursing workforce today and in the future; and the need for nurses and employers to clarify their respective expectations about what constitutes effective mental health nursing skills and practices. In the research brief that summarizes the survey findings, the Forum describes key policy implications:

• Because of a perceived need for nurses with an interest in mental health both now and in the future, incentives for increasing the mental health workforce might be necessary. The redesign process should also anticipate the need for more nurses. 
• Although employers are satisfied with the mental health nurse applicant pool, very few nurses are nationally certified or advanced practice nurses. This suggests that while schools of nursing provide a basic foundation of mental health training, planners should explore possible reasons for the apparent lack of deeper knowledge and discern how this deficit will affect future service provision.
• Employers envision a larger role for mental health nurses in outpatient/community settings. However, today most nurses work in inpatient settings. Planners should explicitly consider the optimal roles of nurses in community health settings.
• Turnover among mental health nurses is relatively low (less than 10%) with the greatest source of job satisfaction deriving from patient care. Sources of job dissatisfaction are related to pay and advancement. If nurses’ responsibilities become more administrative or policy-oriented under a redesigned system, the reduction in patient contact may cause nurse job satisfaction to suffer (and attrition to rise), particularly if wages do not change.
• Employers and nurses lack consensus about which skills are most important for patients’ recovery. This suggests either a lack of clear communication or differing expectations as to the job objectives. Employers and nurses should work toward greater clarity about these differences if the role of nurses is to change under a redesigned system.
• Employers and nurses find more common ground regarding their views of the specific skills that need strengthening. Planners should therefore focus future professional development resources in these areas.
• Both nurses and employers placed specific importance on the ability of nurses to understand the treatment needs of patients diagnosed with dual/co-occurring disorders in which mental illness coincides with substance abuse. As the county shifts its focus to dual/co-occurring disorder treatment, the need for improved training for nurses will be imperative. 

These findings could serve as guideposts to planners, employers, and nurses themselves as they navigate the uncharted territory of a redesigned mental health care system in Milwaukee County. In addition, Nursing’s Voice will play an active role over the next two years to bring the perspective of mental health nurses to both the redesign and implementation of the new system. To do this, the collaborative partnership will undertake three key activities: 1) conduct research and data collection, such as this survey, to document the current and future need for mental health nurses in the new system; 2) develop strategies to encourage nursing students to pursue a career in mental health service and to provide them with the essential skills to be successful; and 3) provide a platform for the voice of nurses so that the new mental health delivery system can make optimal use of their skills and ideas.

Density and transit in metro Milwaukee

Greater Milwaukee has had a long and contentious debate about public transit, with one common argument against investing in rapid transit being that the region doesn't have the population density to support it. A recent study from the U.S. Census Bureau, however, may be cause for reexamining that contention. It finds Milwaukee among the densest metropolitan areas in the U.S., with greater population density than many of the nation’s most populous metros, including Atlanta, Houston, and Seattle.

In 2010, the Milwaukee metropolitan area – comprised of Milwaukee, Ozaukee, Washington, and Waukesha counties – ranked 15^th in population density among the 102 metro areas in the U.S. with populations over 500,000, with a density of 5,258 persons per square mile. Milwaukee was second only to Chicago among Midwest metros. Notably, the Milwaukee area’s density declined slightly between 2000 and 2010, by 3.6%. This downtick followed a national trend, however, as 33 of the nation’s 50 largest metro areas saw their densities decline during that period. The complete data set can be found here.

Rather than using the traditional method of determining population density, which involves simply dividing total land area by total population, the Census Bureau study used “weighted density,” which averages the densities of each census tract in a metro area while giving each tract a relative weight based on its share of the metro’s total population. Using this methodology, for example, if 75% of a given metro area’s population lives in low-density suburbs, that metro will have a lower weighted density than another metro area of the same size and with the same population where 75% of residents live in medium- or high-density urban neighborhoods.

A frequently-cited example illustrating why researchers are converting to this new method of determining population density is the fact that under the traditional definition, the Los Angeles metro area has a higher density than the New York metro area, which is counterintuitive to anyone who has visited both places. Using weighted density, the New York metro is more than twice as dense as L.A., because the typical New Yorker lives in a denser neighborhood than the typical Angeleno.

While metro Milwaukee is not as dense as New York or Chicago, it is denser than many metro areas considered to have admirable public transit systems, including Seattle and Portland. Milwaukee also is denser than many others that have made recent investments in rapid transit, such as Minneapolis and Phoenix with their relatively new light rail systems, and Cleveland and Kansas City, where bus rapid transit (BRT) systems recently have been developed. 

Rapid transit may come back into Greater Milwaukee’s infrastructure planning at some point in the future. While many factors impact the success of a rapid transit system, we now have a clearer understanding of our population density and how it compares with other metro areas around the country.

City budget manages new fiscal reality, at least for the time being

The main focus of the Public Policy Forum’s annual review of the Mayor’s proposed City of Milwaukee budget – released this morning – is the immense challenge posed by a $59 million pension fund payment in 2013, which marks the beginning of an unprecedented series of pension payments that will impact city budgets for the foreseeable future.  We find that thanks to the foresight exhibited in previous budgets, the impacts in 2013 are manageable.  In fact, the Mayor has proposed a budget that deftly accommodates the remarkable increase in pension payments without fully depleting pension reserves or slashing critical services.

The impact of these new pension payments should not be taken lightly, however.  Pension costs will consume 32% of the city’s property tax levy in 2013, as compared with 15% in 2009. In the next few years, that percentage is likely to continue to grow, as the city’s pension reserves are tapped out and expenditures are cut elsewhere. 

Our 2013 city budget brief also reviews a set of strategic principles proposed by the mayor and his budget team to guide the city through its new budgetary realities.  Those principles emphasize finding new, cost-effective ways of conducting business, with savings reinvested in priority areas while also supporting the sizeable pension payments.  While this concept – labeled “resizing, restructuring and reinvesting” – is both innovative and appropriate, implementing the plan will not be easy.  Indeed, the budget suggests that $65 to $75 million of structural improvements will be needed in the next four years, along with a reduction of 400 to 600 positions.

The 2013 proposed budget also accommodates heightened pension costs with elevated municipal service charges.  The fee increases proposed for 2013 raise the dependency of general fund spending on this revenue source to 19.5%, as compared to 15.9% in 2009.  In fact, in 2013, charges for services become a larger source of support for general departmental spending than the property tax levy, a development that is likely to remain in place for the foreseeable future. 

We conclude by warning that while the 2013 proposed budget largely maintains existing service levels and keeps position reductions at a minimum, it is highly questionable whether enough efficiency can be identified in departmental operations in future years to continue those achievements.  The answer to that question will depend, in part, on the approach the city takes to the revenue side of the equation, as well as how shared revenue fares in future state budgets. 

Our analysis of the 2013 City of Milwaukee proposed budget can be accessed here, and our media release here.

County's finances on the upswing, but big hurdles remain

The Public Policy Forum released its annual review of the Milwaukee County Executive's recommended budget today, and the tone is decidedly more upbeat than in previous years. Because of a smaller (but still substantial) budget gap heading into the year, and thanks to an unexpected $13 million 2011 surplus, this year's county budget is the least difficult in years.  As we point out in our report, multi-year efforts to manage the county's health care benefits and limit long-term borrowing are paying off, though pressing long-term problems remain.

A focus of this year's budget brief is whether the county executive and his budget team seized the opportunity provided by the convergence of these positive circumstances to make continued progress on long-term structural problems, or simply viewed the 2013 budget as a one-year blueprint. We find that, on the whole, the budget responsibly addresses both short-term and long-term issues, though it also leaves the county short on reserves and long on infrastructure repair needs.

Commendable efforts to address immediate fiscal needs include a clean-up of outdated revenue projections in the Behavioral Health Division and Parks budgets; the use of some of the 2011 surplus to cash finance infrastructure repairs; and investments in long-neglected areas of administrative infrastructure, including human resources and information technology.  We also cite the budget's clear priorities when it comes to budget-cutting - which contrasts positively from the across-the-board approach used in many previous years - and the absence of rosy revenue projections and short-term fixes.

The report also cites concerns, however, about the methodologies used to justify big changes to the sheriff's budget, and raises questions about the long-term feasibility of continued cuts in health care benefits and a decision to spend the balance in the county's Debt Service Reserve.

We conclude that, overall, the recommended budget "should be seen as one that proposes several foundational steps that allow the county to continue its path toward financial stability.  Nevertheless, the county's stagnant revenue streams, continued fringe benefits burden, immense infrastructure needs and lack of reserves - combined with the still tenuous legal standing of its recent pension and health care changes - suggest that years of heavy lifting yet will be required before its journey is complete."

The 2013 Milwaukee County Executive Budget Brief can be accessed here.  Our review of the mayor's proposed 2013 budget for the City of Milwaukee will be released early next week.