On a late winter day, a cold gust of wind ruffles the wrinkled pages of a paperback book lying beneath a tree outside one of the recently emptied long-term care units at the Milwaukee County Mental Health Complex.
The Anne Rice horror novel, “Queen of the Damned,” reflects the dreadful image of the Milwaukee County mental health system its new leaders are aiming to overhaul.
Inside the building are bare walls and vacant rooms. Its brown brick exterior overlooks the intersection of Watertown Plank Road and 92nd Street in Wauwatosa on the northeast corner of a sprawling, 900,000 square-foot campus built in the 1960s to accommodate thousands of patients in need of acute, long-term and emergency psychiatric care.
If all goes according to plan, that entire complex could be vacant in four years. Its more than 10,000 patients admitted annually for emergency psychiatric care could be receiving services in a community-based setting at a brand new 60-bed facility paid for and operated by a private provider and located in the City of Milwaukee, where most of the county’s mental health patients actually live. The location of that facility, which will treat most patients on an outpatient basis, is yet to be determined.
Better yet, the number of patients in need of emergency care could diminish as a robust ecosystem of wraparound services, case managers and preventative care programs emerges.
The mental health complex came under increased scrutiny five years ago among a litany of scandals and complaints related to its treatment of patients that went back for decades. Chief among them were the county’s high percentage of patients admitted for care after being detained by police and its heavy reliance on crisis intervention and institutionalized care, which experts see as outdated, expensive and ineffective.
Readmission was high and climbing. Now, it’s still high, but for the first time – possibly ever – it’s falling. The complex’s 30-day readmission rate following acute inpatient care fell more than 20 percent between 2010 and 2015, according to data obtained from the Milwaukee County Behavioral Health Division.
Over the past three years, BHD has gradually phased out long-term care at the complex in preparation for a dramatic shift in the way mental health care is provided in Milwaukee. Simultaneously, it has increased funding to community-based programs, added supportive housing and hired certified peer specialists.
Led by a board of 13 mental health experts appointed in 2014 and fresh administrative faces, the system is being dismantled and rebuilt in the image of a long-established formula followed by most counties around the country – outsourced patient care, aggressive case management and increased community access.
“The commitment to the old system is broken,” said Tom Lutzow, a member of the county’s Mental Health Board and president and chief executive officer of Milwaukee-based Independent Care Health Plan, or iCare. “Nobody’s defending the old ways of doing things anymore. Everybody has agreed that’s history. So what does the new one look like?”
A complex complex
The mental health complex itself is a metaphor for its past – complicated, deceptive and difficult to navigate. It’s easy to get turned around in its building at 9455 W. Watertown Plank Road, which is much larger than it appears.
Near its center is a mock-cobblestone indoor courtyard flooded with natural light. In a conference room, Dr. John Schneider, chief medical officer of the county’s Behavioral Health Division, sits at a table with Lutzow and BHD interim administrator Alicia Modjeska.
They’re discussing the future of the mental health system.
Modjeska, a nurse by training, is bright, energetic and detail-oriented. She joined BHD in January 2015. She spent 22 years at Wheaton Franciscan Healthcare, where she held multiple executive positions, including a two-year stint as president of the former St. Michael Hospital. She has also worked for the West Side Healthcare Association, Community Care, Bryant & Stratton College and Alverno College.
She describes, in detail, plans to implement accountability measures and a software program that gives doctors better access to patients’ mental health and medication histories. She’s asking questions – are patients getting better? Are they satisfied with services? Are they getting to appointments on time?
“We need more access,” she says. “We need access in the evening hours, we need access on the weekends. We have a lot of things going on right now. We’re working with two board task forces to see if we can find a partner to run the acute care. We need to find time in all of this work to start working on prevention. And we need to reach out to families, because otherwise, 20 years from now, we’re still going to be having the same conversations.”
Schneider, a laid-back, silver-haired psychiatrist with years of experience in private and public mental health systems, took over as chief medical officer in 2014. He describes the importance of early intervention.
“If we only fund and create services for the ‘oh-my-god-I’m-going-to-kill-myself moment,’ there is so much lead-up that is missed,” Schneider says. “So how do we change a system that is built around that threshold and get those folks in earlier? The way to do it is to push it into the community; to have a location in the community that becomes part of the neighborhood that people go into. If nothing else, people know: that’s the place to go and they will hook you up.”
Lutzow, wears glasses and a suit. He is the architect of a joint program between Humana and the Milwaukee Center for Independence referred to as iCare. The program serves impoverished people with disabilities, mental health challenges and substantial medical problems. He’s now a leader on the Mental Health Board, and describes what he sees as the board’s role.
“I think it’s creating an expectation,” he says. “Creating expectations to be filled in by staff with real ideas that can work. It’s making sure all voices are heard and those ideas are vetted correctly. Fiduciary responsibilities are part of this, too. It’s a combination of encouraging free thinking and open thinking, and creating a plan that results in a center for excellence.”
As part of the dramatic overhaul of its mental health system, the county has allocated $1.2 million to renovate an existing building on the north side of Milwaukee by the end of this year that will serve as a “community hub” filled with counselors, psychiatrists, nonprofits and health care providers. The facility will have a mix of county employees, private providers and nonprofits. BHD representatives are still scouting locations. Plans are also in the works to open a second $1.2 million hub on the south side by the end of 2017.
The idea is to catch people suffering from mental illness earlier; before their diseases corner them in moments of extreme distress that require intervention from police officers or crisis counselors.
Perhaps the most dramatic planned change — completely closing down the mental health complex — may not happen for four or more years. But the groundwork is being laid.
Last summer, the county began reaching out to behavioral health care providers to see if any were interested in building and operating a 60-bed mental health center on behalf of the county in exchange for reimbursement for uninsured patients.
So far, three have submitted proposals: Bala Cynwyd, Pa.-based Liberty Healthcare Corp.; Nashville, Tenn.-based Correct Care Solutions; and King of Prussia, Pa.-based Universal Health Services Inc.
As of March 9, none of the health care systems currently operating in the Milwaukee area had submitted proposals.
County leaders will choose a provider in June, according to County Executive Chris Abele and Héctor Colón, director of Health and Human Services.
Though the largest and most ambitious pieces of the county’s redesign have yet to be implemented, the small steps it has already taken to consolidate services, increase access and boost wraparound services have already resulted in substantial gains.
The percentage of patients admitted for emergency psychiatric care after being arrested by police decreased by 9 percent from 2010 to 2015, according to data obtained from BHD. In that same time period, the percentage of patients who voluntarily sought emergency treatment increased by more than 13 percent.
The road to change
Abele took office in April 2011. Within the next two years, six patients would die at the mental health complex and a letter would land on Abele’s desk from a psychiatrist hired by Disability Rights Wisconsin to investigate the deaths.
Disability Rights Wisconsin is the state’s federally mandated protection and advocacy agency for people with disabilities.
The psychiatrist concluded inadequate psychiatric and medical care contributed to the patients’ deaths and said the complex should be closed. Decades of studies and plans drew similar conclusions, but nothing had been done. A major reason — rather than the mental health system being run through a board of experts in the field, as is the case with most counties, Milwaukee County’s system was run by the county board itself.
Attempts to close the complex in favor of implementing a dramatic restructuring program were met with political resistance.
Schneider said he feels it’s virtually impossible for a county board to effectively govern a mental health system.
“In some ways, I think it was a potentially no-win situation for a county board,” Schneider said. “Health care in and of itself is such a technical, complex set of issues. I can’t imagine, even with a health and human services sub-committee, how (the board) could actually give it due while worried about all of the other day-to-day county business. You’ve got the airport, you’ve got the zoo, and then you’re supposed to be running an evolving health care entity that is supposed to fit into a broader continuum of care, and modernize it. In some ways, that is unwinnable.”
In 2014, a bill stripping the county board of oversight and establishing a board of medical and psychiatric experts in its place was signed into law by Gov. Scott Walker. Abele was an outspoken supporter of the bill.
“This was an opportunity finally to make a change we should’ve made a long time ago,” Abele said. “The amount of change and the dramatic changes that happened after that in terms of outcomes is pretty significant.”
In recent years, supportive housing units located in nearby communities have replaced the complex’s troubled long-term care units. More than 130 certified peer specialists have been hired to guide patients through the system and the number of people receiving BHD community services has risen by 9 percent, while the number of people seeking emergency psychiatric services has fallen by 24 percent.
“We’re serving more people,” Abele said. “We’re doing a better job. ER visits were going up — they’re going down now. Emergency detentions were going up — they’re going down now. That wasn’t happening before. We have more peer counselors, we finally got out of long-term care. There are just so many stark, inarguable changes. Things were going in the other direction before and are now going in this direction. I have a really hard time imagining anyone getting really worked up over that.”
Colón was hired by Abele to head BHD in 2011.
“This was really, really hard and we had a lot of opposition,” Colón said. “There’s a more effective way of doing this. You’ve got to try and bring in good leaders to execute that change.”
Who it’s helping
Daniel Kane’s curly gray hair peaks out from beneath his baseball cap. Against one wall of his apartment on the south side of Milwaukee is an electric guitar and some recording equipment. He likes to mess around with music in his spare time. He experiments with sounds and tries to piece together songs.
He likes to build things, he said, which makes sense considering his chosen field. For years he worked in real estate investment sales and eventually started a development company that put up large condominium and apartment complexes. But he also battled bipolar disorder, which went undiagnosed for years.
Confused and scared by his symptoms, Kane self-medicated with booze to quiet his racing mind, which led to an alcohol dependency.
“The ups and downs of bipolar; I wouldn’t get really depressed, that wasn’t my speed, I’d get manic,” he said. “And I liked that manic. But when it goes on, and you’re losing sleep, you just can’t function. So then I’d drink to fall asleep. I wasn’t drinking to have fun — that was my medication.”
As his disease spiraled out of control, so did Kane’s career and finances. Between 2004 and 2014, he estimates he was in and out of acute care at the mental health complex a dozen times.
“I was a chronic relapser,” he recalled. “I wasn’t taking my medication and I wasn’t going to the groups. Without the groups and medication, I was not confident enough to get a job … I was in the hospital so many times for detox.”
“The insanity of alcohol addiction,” Kane said, then trailed off. “The things you do because you’re not thinking correctly.”
He became isolated from family and friends as people became wary of his behavior. They were unsure which version of him would show up, he said.
Eventually, he found himself without a home, drifting from shelter to shelter and struggling to stay sober.
But for more than seven months, Kane has been sober, and for the past two, he has had a part-time job at a nearby AutoZone. His coffee table is covered in development projects. He said he’s trying to ease his way back into the field without overwhelming himself.
He has new business cards that read: “Daniel Kane & Associates, Investment Real Estate & Development.”
For the first time, he said, he feels confident his sobriety and his treatment plan will stick.
“I was able to find a path with the wraparound services,” he said. “La Causa was huge. The UCC (United Community Center) was huge. That’s the best place in the city if you don’t have insurance.”
Kane was referred to Milwaukee-based La Causa Inc. through the county’s Comprehensive Community Services team, which connects patients to nonprofit community-based providers that assign case managers and check in with patients a few times a week to make sure they’re going to meetings and taking their medications.
Without access to those services, he said he’s unsure whether he’d have been able start piecing his life back together.
Working in transition
While the county transitions, there is some uncertainty about how the day-to-day roles of nurses, staff workers, emergency clinicians and even police officers will change.
Lauren Hubbard, 27, nurse manager of crisis services, Jeff Munz, 53, nurse manager of child adolescent inpatient services, and Christine Herbert-Fischer, 27, a behavioral health emergency service clinician, exude optimism about the changes and what they feel is an atmosphere of creativity and collaboration within BHD.
“I think these are great programs that we are starting right now with how we approach our patients,” Munz said. “I’m all for it. I think it’s definitely the right thing to move in that direction.”
He said he’s been researching different techniques and strategies employed at mental health facilities in places like Minneapolis and Orlando, Fla.
“I see what they’re doing differently with their patients that might help, and then try to bring that back to my own unit and say, ‘What can we do to bring that forward?’” Munz said.
Neither he, nor Hubbard, nor Herbert-Fischer know precisely how their jobs will change if the county moves operations into community hubs on the city’s north and south sides, or gets a private provider to build a new long-term care facility. But all three agreed they’re in it for the long haul.
“Regardless of where my office is or where I punch in, I think we’re committed to the population we serve no matter what the business model looks like,” Hubbard said.
Milwaukee Police Department assistant chief Carianne Yerkes, a member of the department’s Crisis Intervention Team, is nervous about the transition. As the complex closed long-term care units in preparation for transition, she said officers began encountering mentally ill people more frequently.
“I think the overall concept is great; trying to get more people treated in the community,” she said. “I am, however, concerned that our community is not ready for that. I’m not sure we’re going to have all the resources necessary. In order for that to work, the community has to have resources and has to be engaged in the process. I’m somewhat nervous about whether we’re ready for that.”
Hubbard also said the county’s redesign plan needs to be complemented by increased community engagement to really hum, and she expects the transition into a new system may be difficult. But ultimately, she feels the time is right for change, and that the attitude trickling down through the top ranks of BHD is encouraging.
“It gives young professionals like us, or newer professionals like us, a chance to put our ideas in and to incorporate the patients also, because they’re people,” she said. “They have hopes, wishes and dreams. They have things they’d like to see and do. I think this is the right time in BHD’s history to move forward and to try things a different way; to think outside the box.”