The role and impact of Milwaukee’s Protective Payee program

Since 2001, three Milwaukee nonprofit agencies have collaborated on a program that provides financial oversight, budget counseling, and supportive case management to more than 200 homeless adults with disabilities each year. A new Forum report released this morning provides an assessment of that program – known as the Protective Payee program – within the context of Milwaukee County’s effort to redesign its adult mental health system.

In addition to describing the Protective Payee program’s design and scope, analyzing its impacts on client housing and health outcomes, and assessing the program’s financing, we provide an in-depth examination of how the program fits into the broader spectrum of case management services available in Milwaukee County for the homeless and persons with mental illness. This analysis offers policymakers a view of how the overall “system” functions, revealing potential opportunities to improve effectiveness and efficiency and assisting in deliberations on the appropriate continuum of case management-type services moving forward.

Key observations emerging from this analysis include the following:

• The Protective Payee program appears to be effective in stabilizing housing for homeless individuals with disabilities. While it is not possible to conclusively determine that the program could be applied successfully to other populations in Milwaukee County in need of case management services, it does suggest an expanded program or similar programs based on the Protective Payee model could be an effective option for the same clientele in other Wisconsin counties.
• Improved coordination between local case management programs could make it possible to increase enrollment in the Protective Payee program and Milwaukee County’s Shelter Plus Care program, potentially alleviating some demand on the County’s Behavioral Health Division (BHD) and serving more clients overall. In order to do so, Milwaukee County and the Protective Payee agencies would need to seek additional funding from HUD or philanthropic sources, or the County would have to identify additional local resources. While the prospect of additional HUD funding may be unlikely, the County may determine that use of additional local resources to provide stable housing for additional BHD clients would pay off in the form of reduced inpatient and crisis care costs.
• In light of concerns that have been raised regarding the limited capacity and flexibility of BHD’s two case management programs (Targeted Case Management and Community Support Program), enhancing capacity at the lower-intensity end of the service spectrum may be a worthwhile strategy to open up space for those in need and better coordinate provision of the most intensive services. A key recommendation of a 2010 report authored by a national consultant and the Forum was to explore providing case management services to a larger population by developing a multi-layered continuum of case management care that is flexible and responsive, moving people to higher and lower levels of care over time, as appropriate. A consistent review of client needs for all case management program clients, along with consideration by BHD of possible expanded partnerships with community agencies to make greater use of lower-intensity support services and case management programs, could help to ensure that individuals are being served by the most appropriate program and that space is available in the County’s highly-intensive CSP program for those with thegreatest needs.
• Positive and stable relationships between clients and case managers are crucial to achieving the primary goal of any case management program: improved client well-being. Local mental health professionals stress the importance of developing and maintaining constructive, stable relationships between clients and case managers regardless of the intensity of support being provided. Improved coordination between programs could also allow those relationships to be maintained, as desired by the client, even if he or she shifts between programs.

We hope that this analysis will assist policymakers in determining the appropriate role for various case management service models in Milwaukee County’s changing mental health system. In addition, we urge BHD and its mental health redesign task force to use this information to consider whether the services analyzed in this report collectively function to provide appropriate levels of community-based services that meet the varied needs of individuals who are seeking them, and/or whether there may be ways to more effectively deploy existing and additional mental health and homelessness prevention resources to establish an even better continuum of care.

Useful strategies but no easy answers in ending homelessness

A new study from the U.S. Housing and Urban Development Department (HUD) examines the costs of serving homeless individuals and families and explores cost-saving possibilities in differentiating services according to individual characteristics.

HUD finds that different types of first-time homeless individuals and families use system resources differently, so some opportunities exist to improve outcomes by developing tailored strategies to meet the needs of each type of individual and family. For example, the report describes how African American families are often homeless primarily due to poverty rather than mental illness or substance abuse, and therefore need permanent housing but not substantial supportive services. Similarly, childless single women have different needs than families.

Despite HUD’s support for tailored services, its cost analysis revealed that there are no loopholes or easy answers when it comes to cost savings. The study found that significant cost reductions are only achievable when targeting the few individuals and families with high levels of involvement in mainstream systems prior to homelessness. Accordingly, while narrowly targeted initiatives aimed at this group will yield the greatest savings-per-person, such initiatives would only be appropriate for a small number of people.

HUD's study was released as Milwaukee is considering its new ten-year plan to end homelessness. The County Board has already endorsed the plan, and so has a Common Council committee. If fully adopted, Milwaukee will join more than 800 cities and counties that have partnered in implementing at least 355 ten-year plans to end homelessness.

Milwaukee’s plan was developed by the Continuum of Care (a conglomeration of social service agencies that address issues facing the homeless) as well as other local participants. Among other things, it calls for both earmarked state funds and reapportioned federal and local expenditures to fund services for the homeless. It targets a number of key issues raised in the HUD study, including prevention, employment, behavioral health, and permanent housing. The plan also calls for revamping methods of discharge planning for those transitioning out of foster care, hospitals, mental health care and jails.

Milwaukee’s plan appears to meet the National Alliance to End Homelessness recommendations for successful planning by possessing four elements: identifying a person or body responsible for implementation; setting numeric outcomes; identifying a funding source; and setting a clear implementation timeline.

According to the U.S. Interagency Council on Homelessness, taking a 10-year plan from “good to great” requires extensive engagement of public officials and community champions, as well as the ability to sustain momentum for implementation through changes in political leadership and priorities. With changes in political leadership likely on the horizon here in Milwaukee, it would appear that momentum-building will need to be a top priority for plan supporters.