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.

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.

How does a new mental health facility fit into the county's infrastructure picture?

The decision last week by Milwaukee County's Health and Human Needs Committee to "put the brakes" on planning for a new inpatient mental health facility - as reported in the Milwaukee Journal Sentinel - was welcomed by many mental health advocates, who have been urging the county to prioritize community-based care and substantially shrink its inpatient capacity. That sentiment is largely consistent with the recommendations of a national consultant - the Human Services Research Institute - contained in a 2010 report co-authored by the Public Policy Forum.

But also embedded in the committee's decision - as reflected by comments from the county executive - is the encouraging recognition that any possible new mental health complex must be considered within the context of the county's overall infrastructure needs.

For the past several years, as supervisors and administrators have argued over where and how large to build a new mental health complex, they have done so without the perspective of an overall facilities management and capital financing plan. Such a plan is needed not only to provide a clearer picture of the breadth and cost of the county's total infrastructure challenges, but also to assess how a potential significant investment in a new mental health complex will jive with the county's limited borrowing capacity.

The need for such a plan also was hammered home last week by a new report from the county's parks director, which recommended spending $15 million in each of the next five years to address a significant infrastructure backlog.

To put that request into context, the county currently has a policy that caps annual borrowing for capital needs at a little over $30 million. That means if policymakers heed the recommendation and want it to be part of the county's annual general obligation bonding, then almost half the annual allotment would be used simply for repairs and maintenance in the parks. That, in turn, would leave little room for capital needs related to the Zoo, Courthouse Complex, corrections facilities, information technology, transit, economic development, and county trunk highways.

The good news is that per a recommendation of its Long-Range Strategic Planning Committee, the county has hired a consultant to perform a comprehensive analysis of its existing infrastructure and help develop a master infrastructure plan. It is within the context of that planning process and the ongoing deliberations about the nature of the county's mental health care delivery system that the discussion about a new mental health complex would best proceed.

Framing the issues for the county executive candidates

During the past three years, the Public Policy Forum has churned out more than a half-dozen reports on issues pertaining to Milwaukee County government as part of our mission to educate the public about key policy issues impacting the region's economy and quality of life.

Those include an award-winning report on the county's transit funding crisis; a comprehensive review of the fiscal condition of its parks system and cultural facilities; another award-winning assessment of its overall fiscal condition; a redesign plan for its adult mental health system; and a carefully-researched analysis of potential substantive changes to its governance structure.

Today, we release a 2011 Milwaukee County Executive Election Brief that describes and frames those issues in a manner designed to be comprehensible to voters and helpful to the candidates themselves. The report begins with an overview of Milwaukee County’s budget and finances that provides a broad sense of the county’s budgetary structure and its longstanding fiscal challenges. Then, it summarizes and updates our recent research on the structural deficit, mass transit, mental health, and parks/recreation/culture. Each section concludes with a set of questions and policy considerations that should be foremost in the minds of candidates and voters.

Our goal, as always, is to cut through the politics and boil down these controversial issues to their basics. Doing so shows that in many respects, the issues and problems facing Milwaukee County government are elementary in nature and demand equally elementary, yet politically difficult, responses. Our hope is that the candidates will acknowledge the relatively uncomplicated roots of the county's challenges and candidly discuss their proposed solutions.

The full report can be accessed here. Also, tomorrow's the last day to sign up here for our February 4 county executive candidates forum, at which the report will be discussed.

Some good news from Milwaukee County's mental health complex

While the problems experienced by Milwaukee County's Behavioral Health Division (BHD) justifiably receive considerable attention in the local news media, there also are some shining success stories that seldom are reported.

One obvious example is the division's Wraparound Milwaukee program for children with complex mental health and emotional needs, which received an "innovations" award from Harvard's Kennedy School of Government in September 2009. Another - discussed recently in a report submitted to the county's Health and Human Needs Committee - is its WIser Choice program for individuals suffering from substance abuse.

WIser Choice was created by BHD and the state after they were awarded a three-year, $22 million federal Access to Recovery (ATR) grant in 2004. The grant funds gave BHD the resources to transform its substance abuse program into one that provides a comprehensive blend of recovery-oriented services. Those services extend beyond traditional drug and alcohol treatment to also include pre-employment education/training, transportation, housing, life skills training and other supports. The county and state successfully collaborated on a second three-year ATR award in 2007 and recently received federal approval for a third three-year installment.

The program's success in competing for scarce federal funds is a direct reflection of its impressive client outcomes. In fact, according to BHD, those outcomes - based on national measures established as part of ATR - generally have been the best of any ATR grantee. Also, in the 2002-2004 pre-WIser Choice period, Milwaukee had the highest rate (13.47%) of any urban area in the nation of persons with a past-year substance use disorder. From 2006-2008, however, Milwaukee’s rate dropped to 9.96%, which ranks it only 22nd among urban areas.

Recently released federal data also show the following impressive results:

• Milwaukee dropped from 1st among urban areas to 7th in binge drinking.


• Milwaukee dropped from 2nd to 20th among urban areas in past-year treatment gap for alcohol use disorders.


• Milwaukee’s rate of substance use disorders dropped 20.1% from 2004 to 2008, while the nation’s rate as a whole decreased only 1.8%.

The success of Wraparound and WIser Choice has relevance to efforts to address the serious problems plaguing BHD's adult mental health operations. A report released in October by the Forum and Human Services Research Institute argues for a redesign of those operations, highlighted by a much greater emphasis on community-based services and a gradual downsizing of the county's role in inpatient and long-term care. A few of the encouraging lessons from Wraparound and WIser Choice that might inspire the adult mental health redesign effort:

1. BHD has shown that with sufficient resources and appropriate support from elected officials, it is fully capable of designing and implementing successful models of behavioral health care and treatment.


2. BHD and the Wisconsin Department of Health Services have shown they can put the politics of their elected leaders aside to collaborate effectively and bring additional federal resources to Milwaukee County.


3. BHD has deftly created and managed relationships with community-based providers in both programs to achieve results that benefit both clients and taxpayers.

Good news from Milwaukee County’s mental health complex may be rare, but in this case it should provide hope for the future.

PPF's top research findings of 2010

The Forum recently received a communication from a national research group detailing its top five findings this year. That got us to thinking about our top five research findings of 2010. The competition was stiff, but here they are, in chronological order (drum roll please):

1. Southeast Wisconsin's skilled workforce may be its greatest economic strength. Our March Innovation Index report benchmarked our region with three Midwestern peers and three innovation leaders using several indicators linked to success in building a knowledge-based economy. While the overall assessment was mixed, we found southeast Wisconsin was number one among the group in its percentage of residents working in middle-skill jobs, i.e. those that require specialized training or education beyond a high school diploma, but less than a four-year degree. The finding suggests that while our region may be lacking in college graduates, we still possess the type of workforce that should be very attractive to certain industries.


2. Milwaukee County's structural deficit is really, really daunting. In our July preview of the county's 2011 budget, we used the county's fiscal forecasting tool to determine how its five-year fiscal outlook would change under two relatively dramatic scenarios: 1) the property tax increased at double the projected growth rate, or 6.6% per year, for each of the next five years; or 2) projected growth in salaries and fringe benefits was reduced by 50% and 25% respectively in each of the next five years. We found that in both cases, the projected structural deficit in 2016 still would be in the range of $65 to $70 million. Quite a challenge, indeed, for the next county executive.


3. MATC clearly spends more than its peers. Our September fiscal assessment of the Milwaukee Area Technical College found an institution struggling to accommodate shrinking revenue streams at the very time that demand for its services had reached historic highs. While plummeting property tax capacity and shrinking state revenues certainly hurt, however, it appears there is capacity to make adjustments to the expenditure side of MATC's ledger. Our research compared MATC with 84 other large two-year technical and community colleges nationally with regard to total operating expenses, salary expenditures and fringe benefit expenditures. We found that MATC ranks number one in expenditures per full-time-equivalent student on each of those measures.


4. Milwaukee County's mental health system is out of balance. Our October report on mental health care for adults in Milwaukee County - released jointly with the Human Services Research Institute - found a system that is out of sync with national trends and best practices in light of its emphasis on inpatient care and its lack of comprehensive community-based services. Particularly telling was a finding that the county's 472 public and private acute inpatient beds are nearly triple the number that would be expected in a mature mental health system that contains the appropriate balance of inpatient, crisis and community-based services.


5. The state's expensive child care subsidy program has grown as household incomes have shrunk. When the state created the Wisconsin Shares child care subsidy program in 1996, all low-income families became eligible, not just former welfare recipients. Participation has grown nearly 350% since then, in part because of a decline in household incomes. Whereas the program's eligibility limit of 185% of federal poverty line represented 57% of the state median income in 1999, today it equals 68%. As we point out in a December report, this trend does not bode well for the state’s new child care quality ratings system initiative, as a continued decline in household incomes may mean continued growth in program enrollment. That, in turn, could translate into less money available to offer incentives to providers for quality improvements.

Narrowing the list to five wasn't easy. We were forced to leave out additional key findings from reports on the Milwaukee Parental Choice Program, the region's public schools, regional property values and taxes, the City of Milwaukee's Main Street Milwaukee program, and three People Speak surveys, among others. Each of the 20 reports the Forum has published so far this year can be accessed here.

A new strategic direction for mental health care in Milwaukee County

A recent series of articles in the Milwaukee Journal Sentinel on safety issues at Milwaukee County's Mental Health Complex is the latest to raise questions about the level and quality of mental health care in our community. Unfortunately, while these exposes have ranked high in shock value, they have yet to produce the comprehensive redesign of the public and private mental health systems that many feel is needed.

A report released today may provide the impetus for such change. The report - authored by Massachusetts-based Human Services Research Institute - culminates a two-year project initiated by the Milwaukee Health Care Partnership (a collaboration headed by the five major health systems in Milwaukee County), the Medical Society of Milwaukee County, and the Milwaukee County Behavioral Health Division. The project’s objective was to bring in national expertise to examine gaps in the existing adult mental health care delivery system and devise ways to transform that system into one that more closely mirrors national best practices. The Public Policy Forum has served as local facilitator for the project.

Readers of the report should be forewarned - in many respects, this is a technical document that contains dozens of pages of data findings and analysis and lots of references to mental health policies and practices that may not be familiar to the average citizen.

But that also may be its strength. Indeed, by suggesting a new strategic direction based on data and facts, it is hoped that this report can de-politicize and de-sensationalize a set of complex issues and challenges that must be confronted for the sake of the overall health of our community and the fiscal health of Milwaukee County government.

Some of the report's recommendations may be controversial, and some may require new fiscal resources (though the report emphasizes re-directing existing dollars, as opposed to finding new ones). Implementing those recommendations will not be easy, and will require teamwork and cooperation from several levels of government, law enforcement, consumers, advocates, community-based organizations, and private sector payers and providers. Yet, the diversity of the stakeholders group that has brought the project this far certainly provides hope.

The media release accompanying the report - which provides additional details about the project's history and the stakeholders that have guided it - can be accessed here. The executive summary and full report can be accessed here and here.

Local mental health planning effort can learn from others' mistakes

The need to engage in long-term strategic planning has been a consistent theme from the Public Policy Forum in our analyses of local government budgets, as well as our reports on local government policies in areas like economic development and housing.

It is important to note that our passion for planning does not stem from an idealistic belief that the problems of local government can be solved simply by getting people in a room for a day-long retreat. Rather, it is based on our concern that short-term election cycles discourage effective long-term decision-making; and our strong conviction that an effective and accountable government must establish clear objectives that are tied to measurable indicators and that emanate from a long-term strategic vision.

There are times, however, when government planning can backfire. A recent example comes from our neighboring state of Minnesota, where the Minneapolis Star Tribune reports that a restructuring of state mental health services has come under duress.

The overhaul was designed by the Minnesota Department of Human Services. Its main component was creation of a statewide network of community "mini-hospitals" to replace large institutions in caring for those with severe and persistent mental illness. It was thought that serving individuals close to their community and linking psychiatric care with medical care would provide superior treatment and shorten hospital stays.

An added bonus was the opportunity to receive partial Medicaid reimbursement for the cost of treatment. Under federal law, such reimbursement is not provided for most patients treated in large "institutes of mental disease", but is granted to smaller hospitals with 16 beds or less. {For this very reason, Milwaukee County explored the concept of creating 16-bed mini-hospitals as an alternative to its 96-bed mental health hospital a few years ago, but never moved past the discussion stage}.

In Minnesota, according to the Star Tribune article, this experiment has been a colossal failure. Nine of the 10 hospitals stand "half-empty" and the tenth closed for lack of use. Consequently, the state is now contemplating a new plan that would change the mission of the mini-hospitals and cut $17 million from the program's budget.

The article notes that while few Minnesotans appear to be questioning the need to develop a new plan, advocates are challenging the state's apparent intent to do so largely on its own. They say a fatal flaw in the previous plan was the state's lack of partnerships with local hospitals and community health organizations, and they are calling for inclusion of other key stakeholders.

Reports of the Minnesota planning mess arrive at a time when a planning effort surrounding Milwaukee County's adult mental health system is entering its final stages. The Forum is serving as local facilitator for this effort, which is being led by private and public sector entities that have made a concerted effort to involve all key stakeholders. Those include the major health care systems, the Medical Society of Milwaukee County, the Medical College of Wisconsin, county and state government, advocates, mental health consumers and civic leaders.

The project's objective is to redesign both the public and private systems that provide adult mental health care and treatment in Milwaukee County in a manner that will produce better coordination and better results. It's being led by a national consultant from Massachusetts - Human Services Research Institute - that has led similar efforts in other states. A project summary can be found here.

Stay tuned for the final report, which will be released sometime this summer.