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Two years ago, Rogers Behavioral Health built additional rooms at its hospitals to be able to help more people experiencing mental health crises.
Before the expansion, demand for its services were increasing beyond the behavioral health system’s capacity, and its waitlist of families seeking care was growing. Rogers hoped to open a relief valve when it added 62 residential beds on its wooded lakefront campus in Oconomowoc, 28 beds at its West Allis hospital and multiple new outpatient clinics across the country. Its larger physical footprint meant the system could treat more children, teens and adults seeking help with OCD, anxiety, eating disorders, depression and other mood disorders.
In the two years since, demand hasn’t abated, but a worker shortage has forced the health system to cap its inpatient census, leaving beds that ordinarily would be occupied by those experiencing acute psychiatric crises empty.
“That’s the hardest thing for me to have to say, ‘I’m sorry, we’ll have to cap at this number. I don’t have enough nurses to care for patients safely,’” said Terri Cohn, executive director of nursing. “I’ve been with Rogers (for five years). I’ve never seen us having to do this.”
‘The stakes are high’
Before the pandemic, the mental health treatment gap for children in Wisconsin gave cause for concern. Among the state’s roughly 201,000 youth who needed mental health treatment, 37% had not received any, according to a 2020 Wisconsin Department of Health Services report. The gap was slightly higher in Milwaukee County, at 40%; and in Waukesha and Ozaukee counties, roughly 60% of youth went untreated.
A lag in data obscures the impact of the pandemic, but industry leaders say it has exacerbated those trends. Children’s Wisconsin alone experienced an 80% increase in referrals for mental health services in December 2020 compared to a year earlier.
Providers now face a troubling picture: Demand for mental health services among children has increased dramatically, and the supply of workers to deliver those services has not kept pace with the swelling need.
Though access to care has been particularly scarce in low-income urban areas and rural communities historically, the current workforce issue cuts across demographics and geography. Central city clinics and suburban inpatient facilities alike report challenges recruiting and retaining workers.
“We’re used to having issues finding psychiatry – particularly child psychiatry – providers or psychiatric nurse practitioners or nurses, but the pandemic has really brought with it a shortage of everything else, along with those (positions),” said Dr. Jerry Halverson, chief medical officer for Rogers. “A lot of the programs that we’re looking at expanding and not able to expand is because of a lack of therapists.”
Mental health providers across the region say they are maxed out, leaving children at risk of not receiving the help they need with behavioral health issues, developmental delays, and trauma, which a growing body of research indicates have long-lasting effects on their development and ability to successfully engage in society. When mental health needs go unaddressed and continue into adulthood they only add to the challenges someone faces in participating in the workforce and contributing to the region’s overall economic growth.
Untreated mental health issues among children can also lead to more immediate problems, including increased risk for suicide, homelessness, substance abuse, out-of-home placement, juvenile detention, emergency room visits and in-hospital stays, and a greater burden on taxpayers because of the lack of primary prevention, according to the Wisconsin Office of Children’s Mental Health.
“The stakes are high. You’re talking suicide, you’re talking people relapsing,” Halverson said. “This is at a time of high stress, this is at a time of high need, this is a time where we have to be able to help people or else bad things are going to happen. But we’re struggling like everybody else.”
Wisconsin has historically experienced shortages of mental health providers, which industry leaders attribute to the stigma associated with mental health, lower salaries in those fields compared to physical health providers and limited residency and fellowship opportunities available in the state.
Amy Herbst, vice president for mental and behavioral health at Children’s Wisconsin, describes it as both a front- and back-door problem: Not enough people are entering the field to offset an aging workforce. Those issues are compounded by the taxing nature of the work; burnout rates are high.
“Child and family therapists, they give their all to these kids and families, and sometimes that doesn’t leave much when all is said and done,” Herbst said.
Across the country, clinicians are leaving the field for a host of reasons. “The Great Resignation” has many reevaluating their professional and personal priorities. Some were on the cusp of retirement, and the COVID-19 pandemic was the nudge that closed out their career. Some therapists have been lured away from in-person clinical settings by national telehealth providers that promise more convenience and less taxing caseloads. Some have left their organizations over their opposition to vaccine mandates.
Health systems feel the tension of meeting the needs of their patients without overstretching their employees who are already in short supply.
“We don’t want to (cap our census), and it is a last resort, but we need to be able to keep our staff intact as much as we can,” Halverson said. “… We’re finally at a point of not being able to plug holes with other members of the team.”
That crisis has left few resources for mental health care leaders to focus on other priorities, such as increasing the diversity of their workforce, which experts say leads to better outcomes for patients.
Children’s $150 million plan
Citing a growing mental health crisis among children in the state, Wauwatosa-based Children’s Wisconsin unveiled a sweeping plan in 2019 to increase families’ access to mental and behavioral health services. Its $150 million, multi-pronged strategy includes implementing universal mental health screenings for children, expanding school-based programs, integrating mental and behavioral health services into primary care settings and establishing a dedicated psychiatric assessment team in the hospital’s emergency department.
Leaders knew at the time of the announcement that finding a workforce to execute that vision – which involves roughly doubling the number of behavioral health professionals in its system – would be its biggest challenge, Herbst said.
One of its strategies includes building up a team of 36 master’s degree-prepared behavioral health consultants that will be embedded in all Children’s pediatrician offices and urgent care clinics, with the goal of identifying mental and behavioral health issues earlier on and connecting families more quickly to treatment.
“When a family comes in for, say, a well-child check, one of the things that will happen for that child is they will receive a mental health screen. And if that screen comes back and says ‘there’s some concern here,’ the pediatrician will be able to bring the behavioral health consultant right into the visit in the moment and do a warm introduction of that behavioral health consultant to the family to start engaging in a discussion and likely some ongoing mental health care,” Herbst said. “That is a very different model than bringing your child to an outpatient mental health clinic for an hour and having an hour therapy session.”
Children’s aims to have that program fully staffed by 2023. Herbst said the recruitment process for those positions so far has been successful but has also required a “tremendous amount of work” for its HR team.
“The thing is there are not enough therapists in the state of Wisconsin, let alone child and family therapists in the state of Wisconsin,” she said. “So, we’re all competing with each other to hire the child and family therapists that are available in the state right now.”
A new Children’s fellowship program is aimed at eliminating one of the barriers to master’s-level therapists entering the field: the 3,000 hours of supervised professional practice they are required to clock in after completing their coursework. It takes roughly five years to put in those hours on a part-time basis, and often they are unpaid.
“Typically, people get a full-time job somewhere, they work on those 3,000 hours on the side. … Essentially, they donate their time so they can get the supervision that’s required,” Herbst said.
Through the new program, Children’s hires therapists who have completed their master’s degree, allowing them to work toward the 3,000 hours with a full-time salary and benefits. Fellows can complete their clinical requirement in a year and a half through the program.
“It’s saving us years of time,” Herbst said. “And it takes that risk off the table of somebody leaving the field altogether.”
Children’s hired all the fellows from the first cohort and has another 19 currently enrolled.
The health system is also creating a training program for child psychologists, which it plans to launch in 2022 and leaders hope stems the trend of psychologists leaving the state to complete their training.
Growing financial support
In the Milwaukee area, political and philanthropic support has recently begun coalescing around what advocates have been saying for years: Mental health should be regarded as essential as physical health, and children in particular need more help coping with their mental health struggles and traumatic experiences.
A $20 million gift from the family foundation of former Fiserv chief executive officer Jeff Yabuki to Children’s – the largest donation in its history – is funding the initiative to integrate behavioral and mental health into pediatric visits.
For Jeff, the issue of childhood mental illness hits close to home. His brother, Craig Yabuki, experienced undiagnosed depression during childhood and in 2017 died by suicide. He was married with three children. With the gift, Children’s will be able to intervene sooner, potentially changing the trajectory of other children’s lives, Jeff said.
“We are coming out of the worst crisis of the last 100 years, and we are going to absolutely … transform, redefine the way pediatrics services are delivered, so people like my brother and others don’t end up making the choices that they make,” he said of the Yabuki Family Foundation’s donation during a recent speech at BizTimes Milwaukee’s Nonprofit Excellence Awards event.
Children’s behavioral health initiative is also backed by an anonymous donor’s $15 million gift, a $5 million gift from Kohl’s, and $1 million gifts from both the Rexnord Foundation and Appleton-based The Boldt Co.
Earlier this year, Milwaukee-based human services agency SaintA received $2 million in federal funding to install trauma-informed therapists at Boys & Girls Clubs of Greater Milwaukee sites who will work with children and families dealing with abuse, neglect, violence and other traumas.
Marquette University president Michael Lovell – who with his wife, Amy, has helped push conversations about the adverse effects of trauma on the Milwaukee community in recent years – awarded $250,000 in seed funding through his President’s Challenge grant in 2019 to develop a behavioral health clinic for children in the city’s Metcalfe Park neighborhood who are dealing with adverse experiences, trauma and developmental delays. It’s also designed to be a training ground for future mental health providers.
With additional backing from the Johnson Controls Foundation, Advancing a Healthier Wisconsin Endowment and the Milwaukee Succeeds Funders’ Collaborative, the clinic opened in late 2019.
‘We need to clone ourselves’
Today, Next Step serves over 200 families – more than double what leaders expected when it opened.
“We have more kids than we can handle. … We need to clone ourselves,” said Amy Vaughan Van Hecke, an executive co-director of the clinic and professor of psychology at Marquette.
Located in a repurposed clinic adjacent to Next Door Foundation’s early childhood center at 2545 N. 29th St., the Mental Health America of Wisconsin satellite clinic was designed to address the long wait times families in Milwaukee’s central city have faced after being referred to mental and behavioral health services. Concerns related to COVID have forced the clinic to offer its services virtually since March of last year.
Many of the families it serves are connected to the early childhood center, where about 80% of the children served live in poverty.
“We went into it knowing there was a lot of need. … What we were seeing was that there weren’t places to send people,” Van Hecke said. “… We’d reach these walls we’d run up against, where (we’d have) to send you to Waukesha and there’s a two-year wait. There’s only so much you can do when there’s sort of a box around continuing families through pathways that get them access to mental and developmental health services for their kids that are really going to make a long-term impact.”
Next Step is also designed as a multi-disciplinary training site, meaning students pursuing different clinical roles – from nursing to social work to clinical psychology to school psychology – can complete their practicum requirement there. Last year, it had six student trainees; this year, it has four.
Next Step leaders would like to grow that number, but it faces a bottleneck, Van Hecke said. More trainees would require more licensed clinical supervisors, which is cost-prohibitive for a clinic offering services free of charge to families.
The clinic has drawn from partnering higher education institutions for its clinical supervisor. Faculty are generally able to devote more time to training, compared to private psychologists who rely on billing for their services.
In the future, Next Step leaders envision adding a south side clinic, but they would need to secure funding for another clinical supervisor, Van Hecke said. Meanwhile, many universities – including Marquette – have enacted hiring freezes as they continue to climb out of financial challenges brought on by the pandemic.
“I’m happy to write grants, but ultimately it comes down to this: we need … supervisors overseeing the care. And they don’t come cheap. None of it comes cheap,” she said.
There’s a particular need for clinicians who choose to work in Milwaukee’s under-resourced areas, but retaining trainees proves difficult. Some students go on to take prestigious out-of-state internships, return to their hometowns or go on to work in suburban clinical settings, where jobs often offer better pay, more convenience and less complex caseloads.
“Keeping them here in Milwaukee – that’s hard,” Van Hecke said. “… The best-resourced communities have the most ability to lure people away, but have, to me, the relative least need. … We service kids with trauma, we have kids who lost parents to COVID. It’s hard. But at the same time, you try to instill these values in students that we really need to serve people that have the most barriers. We need to serve the underserved.”
Van Hecke said about 80% of students who get trained through Next Door leave the city after graduation.
Leaders agreed the region needs to grow its own talent if it wants a more diverse pipeline and one that stays in the area after graduation. A concerted effort should be made to expose students to mental health career options in high school, possibly earlier, they said.
Reducing costs for students could also open the possibility of more of them taking jobs in lower-paying clinics. Van Hecke suggested a loan forgiveness program for students who pledge to work in an underserved area for a certain amount of time after graduation as one potential solution.
“Maybe (loan forgiveness) is the only reason someone is able to make that choice to work in a city clinic,” Van Hecke said of a possible program. “Maybe over time they love it and see how impactful that is.”
Meanwhile, Rogers has been forced to develop its own workforce solutions, including makeshift stopgaps to address current needs and training programs focused on more long-term sustainability.
Rogers has asked administrators with clinical backgrounds to pick up shifts on the front line, including nights and weekends. It’s offering sign-on bonuses for new hires and emphasizing the “career ladder” and mentorship opportunities available to new nurses if they stay with Rogers, Cohn said.
Through a partnership with the Milwaukee School of Engineering, the health system is providing nurses the opportunity to receive a full scholarship to continue their training as nurse practitioners. Rogers is hosting Walk-In Wednesdays to make those pitches to prospective hires in person and offer jobs on the spot.
“There’s some interest – not as much as we’d like,” said Cohn of the hiring events.
Employers are left appealing to employees’ sense of mission around the work in an effort to retain them, but that has its limits.
“Our staff is committed to the work, and they’re willing to work harder, and obviously we’re paying them more, and they’re willing to give more to help with our important mission. But especially in a pandemic, people can only give so much,” Halverson said.