A 6-year-old girl called 911 from Milwaukee’s lakefront one evening in the fall of 2021. Her mother, standing on the rocks of Lake Michigan’s shore, was inches away from attempting to end her own life.
When law enforcement arrived, Patrice Moore watched from the passenger seat of a squad car as sheriff’s deputies guided the woman to safety and consoled the child. Once the scene was secured, Moore got the OK to approach. That’s when her work as a clinician on Milwaukee County’s Crisis Assessment Response Team began.
Moore ultimately determined involuntary commitment for treatment was the best course of action, and the woman was admitted to the county’s psychiatric emergency department, formerly known as the Psychiatric Crisis Services center and located at the time in Wauwatosa.
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Moore[/caption]
The call was among the first of many Moore would respond to as a county CART clinician, and one that would remain deeply imprinted in her mind.
“We saved a life, but the thing that stuck with me was the exposure of this child and what her future may look like, you know, she will be (a mental health) patient eventually because she saw this whole scene unfold,” she said.
CART works alongside specially trained law enforcement officers in responding to calls involving individuals experiencing mental health and suicide crises to determine the most appropriate level of care. Launched in 2013 as a collaboration between the county’s Behavioral Health Services Division and the Milwaukee Police Department, the service has since expanded to 11 teams serving the entire county.
The expansion of CART and other mobile crisis services is just one of the many steps BHS has taken over the past 12 years to restructure its mental health delivery system.
The mid-2000s brought a wave of controversy related to the treatment of patients under the county’s watch. Overcrowding at its emergency room led to multiple incidents of involuntary psychiatric patients being held for hours in the back of police cars waiting to receive treatment. The scandal led to a 2010 report by Massachusetts-based Human Services Research Institute and the Wisconsin Policy Forum, which deemed the county’s mental health system as overly reliant on crisis intervention and outdated practices, such as institutionalized care.
County officials and health system leaders now describe the system as a “community-based” model. However, the journey from the 2010 report to the latest transformational step, closing the Milwaukee County Mental Health Complex in Wauwatosa, has taken hard work by many people and a willingness to form public-private partnerships that benefit the greater community.
Moore, who has worked as a therapist for 12 years and as a clinician with BHS the past four, sums up her current job description as “meeting people where they’re at,” which applies to both their physical location and level of need.
“I want the person to be the driver in the assessment as far as what do they think they need help with,” said Moore. “Not all people need to go to the hospital, not all people need to be chaptered. … Sometimes when people process what they’re feeling, the crisis is lifted and they can go back, we can follow up, and we create a safety plan.”
In cases in which the individual is an imminent danger to themselves or others, a high level of crisis intervention and care is required. But for others, it may only take a conversation and referral to one of the county’s mental health walk-in clinics or other social services, such as housing or supported employment.
BHS’s redesign includes (but not limited to) the following locations:
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Milwaukee County Mental Health Complex and Psychiatric Crisis Services emergency room (closed September 2022) - 9455 W. Watertown Plank Road
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Mental Health Emergency Center - 1525 N. 12th St.
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Marcia P. Coggs Human Services Center (administrative offices for the county’s Behavioral Health Services Division) - 1220 W. Vliet St.
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Granite Hills Hospital - 1706 S. 68th St.
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BHS Access Clinic South / Sixteenth Street Community Health Centers National Avenue Clinic - 1635 W. National Ave.
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BHS Access Clinic East (in partnership with Outreach Community Health Centers) - 210 W. Capitol Drive
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Milwaukee Center for Independence Behavioral Health Crisis Resource Center – South - 2057 S. 14th St.
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Milwaukee Center for Independence Behavioral Health Crisis Resource Center – North - 5409 W. Villard Ave.
A community-based approach
That philosophy of “meeting people where they’re at” is at the heart of the county’s new and improved model, which shifts resources away from inpatient and institutional care to reinvest in services and programs within communities. In adopting a modernized approach and national best practices – such as holistic and trauma-informed care, stigma reduction, decriminalization and racial equity – the ultimate goal, from a system standpoint, is to reduce the cost of the county’s behavioral health system and prevent hospitalizations, emergency room visits and police detention.
In early September, BHS’s redesign reached its final stage with the permanent closure of the Milwaukee County Mental Health Complex, marking the end of what became known as a controversial chapter in BHS’s 130-year history.
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The Milwaukee County Mental Health Complex at the Regional Medical Center in Wauwatosa.[/caption]
Around the same time, the newly built 12,000-square-foot Mental Health Emergency Center opened its doors at 1525 N. 12th St., just northwest of downtown Milwaukee, strategically placing BHS’s mental health emergency department (previously known as Psychiatric Crisis Services) at the center of greatest need. According to BHS, 93% of patient visits to PCS at the Mental Health Complex in Wauwatosa originated from the city of Milwaukee, with four zip codes on the west and north sides of the city – 53218, 53209, 53206 and 53208 – accounting for 33% of total visits.
What’s equally notable is the new emergency center brings four of Milwaukee’s major health care systems – Advocate Aurora Health, Froedtert Health, Ascension Wisconsin and Children’s Wisconsin – to the forefront of the transformation effort through a historic public-private partnership. A joint venture agreement saw the county cover half the estimated $12 million in construction and startup costs and the health systems divide the other half equally, each covering $1.5 million or 12.5%.
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Lappen[/caption]
About a year before the new emergency center opened, the privately operated Granite Hills Hospital in West Allis, another newly constructed facility where BHS has now outsourced its acute inpatient services, began taking patients.
With the opening of these two mental health facilities, along with ongoing investment in other crisis and outpatient services and partnerships, Milwaukee County’s behavioral health redesign has come full circle.
While long-term patient outcomes and the broader impact on southeastern Wisconsin remain to be seen, there’s no disputing that collaboration has been and will continue to be a key driver of this significant undertaking.
“Now, we’re in it together, and I think that part of the story is a fascinating narrative, that community hospitals, outpatient partners and the county, we are all serving the community for the betterment of the community, and it really aligns with the county’s goal of becoming the healthiest county in Wisconsin,” said Mike Lappen, administrator at Milwaukee County BHS. “… So many folks have been dedicated to make this happen. Something this enormous takes a lot of buy-in.”
Mental Health Emergency Center
1525 N. 12th St., Milwaukee
24/7 crisis mental health services for children, adolescents and adults. Goal is to stabilize patients within four to 23 hours and transfer to the appropriate next level of care.
Exiting the hospital business
The county’s new community-based model counters its old approach of housing the bulk of its acute services at one single location: the now-closed Milwaukee County Mental Health Complex at 9455 W. Watertown Plank Road in Wauwatosa.
The 900,000-square-foot campus was built in the 1960s – during a time when institutionalized or inpatient care was the default – to accommodate thousands of patients in need of acute, long-term and emergency psychiatric care. Today, inpatient care – while necessary in some cases – is considered a last resort.
As mental health best practices and laws evolved, the Milwaukee County Mental Health Complex failed to adapt, and its quality of care was repeatedly called into question by regulatory agencies, namely for the high percentage of patients admitted after being detained by police and heavy reliance on crisis intervention and institutionalized care, which are now considered outdated, expensive and ineffective.
The facility itself, housing both an emergency department and inpatient hospital, also became a drain on the county’s funding.
“When you have something that’s as big of an anchor on your system and your budget, you’re not just paying for those beds, you’re paying for all the legacy costs of this huge facility,” said David Hughes, president of the Human Services Research Institute.
HSRI authored the 2010 report on Milwaukee County’s adult mental health care delivery system. The report recommended several changes, including downsizing and redistributing inpatient capacity and ultimately closing the Mental Health Complex.
At the time of the study, the complex had become “a dumping ground, for lack of a better term,” said Hughes, for the whole community, regardless of patients’ level of need.
That was due in part to BHS’s unique position as a hospital operator. Milwaukee County has a specific requirement under state law to provide the receiving facility and fund care for involuntary psychiatric patients (meaning they are an imminent danger to themselves or others and were detained by law enforcement as a result). And what’s more, under federal law, the county’s psychiatric emergency department – like all emergency departments – was mandated to treat anyone who walked through the door, regardless of an individual’s ability to pay.
Lappen said a stigma developed around so-called “county patients,” or individuals not covered by private health insurance who, as a result, were often turned away by private health systems.
“The four health systems had routinely relied on the ability to, when anybody on their emergency department or inpatient units were having (acute mental health) challenges, it was a relatively simple solution to just ship them over to the specialty hospital,” Hughes explained.
“(The complex) … was the place where just about half of our patients were voluntary who came to us because they knew we would treat them with dignity and respect and give them the help they needed,” Lappen said.
The county had sunk so much of its resources on funding acute, inpatient care that it lacked the ability to invest in the outpatient or community services that are designed to prevent mental health emergencies in the first place, Hughes added.
If the county was going to successfully transform its broken behavioral health system, Lappen said, it had to “get out of the hospital business.”
But to avoid creating a huge gap in the system, the county needed buy-in and support from the private health systems, which had become so reliant on the county’s emergency services that they neglected to build up their own capacity to manage behavioral health patients in their own facilities, said Hughes.
Granite Hills Hospital
1706 S. 68th St., West Allis
24/7 inpatient care for adults and adolescents. Goal for an average seven-day length of stay is to stabilize, treat and work with patients to develop a plan for continued recovery after discharge.
A public-private partnership
It took years of conversations and negotiations to get the four health systems on board with a joint venture to develop a new, psychiatric emergency center, now known as the Mental Health Emergency Center. But the reality all along was that 50% of patients at PCS were there voluntarily, and therefore, not technically the county’s responsibility, so it was clear that joining forces with private providers was the most logical way forward, said Lappen.
From a business perspective, health systems are incentivized to minimize the volume of behavioral health patients in a hospital facility that is not specifically equipped for psychiatric patients.
“There’s a whole thing about milieu in hospitals and having people with more intensive behavioral health needs can really disrupt that, so you can’t fill as many beds,” said Hughes. “The evidence on the treatment side is that (non-psychiatric patients) are going to be better served with better outcomes and fewer costs.”
One major difference between crisis behavioral health care and most other medical emergency care is staff expertise.
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Killoran[/caption]
“We don’t have psychiatrists who routinely staff the emergency departments and are available there 24/7 to see psychiatric patients. We have them available for consultation as needed but that’s not a resource that is universally readily available at every ED in town,” said Carrie Killoran, president of Advocate Aurora Health’s greater Milwaukee patient service area. “It’s highly unlikely that we could recruit enough folks to be able to staff at the level we’d need to have the expertise in a distributed model across every ED. We’d all be competing for the same talent and resources.”
What’s more, psychiatric facilities are constructed with specific requirements geared toward keeping patients safe. For example, spaces and objects must be ligature-resistant, or void of points where cords, ropes, bedsheets or other material could be fastened, resulting in self-harm or suicide.
Not all emergency departments are designed that way, and it would take a major investment to remodel every emergency room across the county. Not to mention a crowded emergency room is not an ideal environment for someone experiencing a psychiatric crisis, said Killoran.
It was those kinds of special considerations that the joint venture made when developing the new Mental Health Emergency Center. And those considerations, among others, are still top of mind for Advocate Aurora as the lead partner and manager of MHEC, overseeing the facility’s day-to-day operations, from staffing to bookkeeping to regulatory compliance.
Leadership is accountable to the joint venture’s eight-director board, including four directors representing the county and four directors representing each of the health systems. MHEC is expected to deliver care with an operating loss of $12 million annually. Operating shortfalls are split equally between the county and the health systems, according to its website.
While staffing remains a challenge for MHEC – and health care providers across the industry – AAH was able to meet the 70-person hiring goal set for the facility ahead of its early September opening.
Killoran, who sits on the joint venture board as AAH’s representative, remembers early discussions in which the idea of a public-private partnership seemed implausible. Now, it’s clear that a high level of collaboration between multiple entities is a necessary piece of a modernized behavioral health care continuum.
“All of our partners are stepping up … If we have patients who need hospitalization, the Mental Health Emergency Center – yes, we are a hospital – but the intention is not to have long-stay psychiatric patients,” she said. “If we have someone who comes through, can get stabilized, but we know is going to need inpatient care, finding the right facility and disposition for those patients (is important). Initially as we work through those initial referral and transfer arrangements, you get a couple hiccups here and there, but all of our partners and the community in general, including other behavioral health resources, have been coming to the table to do their part and meet that need.”
For Children’s Wisconsin, having a stake in the MHEC joint venture goes hand in hand with a five-year plan to invest $150 million in its own mental health services. Earlier this year, Children’s opened the new Craig Yabuki Mental Health Walk-In Clinic on its Wauwatosa campus for children with urgent behavioral health needs.
The clinic was named in honor of a $20 million gift in 2021 from former Fiserv chief executive officer Jeffrey Yabuki’s family foundation. Craig Yabuki was Jeffery Yabuki’s brother who experienced undiagnosed depression during childhood and in 2017 died by suicide. Yabuki's donation - the largest-ever single gift in Children's history - helped the system launch an integrated mental and behavioral health program, which puts licensed therapists in every Children’s primary and urgent care location. The program is expected to expand to 36 full-time master’s degree-prepared therapists by 2023 and could benefit more than a third of the pediatric population in southeastern Wisconsin, Children’s said. Currently, more than 175,000 kids are seen by Children’s Wisconsin pediatricians during routine checkups or at an urgent care visit.
Through the program, therapists and pediatricians will collaborate to address concerns such as anxiety, depression, trauma, suicidal ideation, attention difficulties, sleep challenges and disruptive behaviors. That way, children and their families will have immediate access to expert help, rather than having to wait for referrals and mental health appointments, Children’s said.
Before the COVID-19 pandemic, one in five children in the Wisconsin was living with mental illness, and the state’s suicide rate was higher than most of the U.S. As of March, visits to Children’s emergency department and trauma center for mental and behavioral health concerns had increased by 40% since the pandemic’s onset.
“In our mind, every kid (who visits Children’s) has a mental or behavioral health need and the needs vary, and we want to make sure we’re meeting all of those needs,” said Amanda Quesnell, director of mental and behavioral health at Children’s Wisconsin.
Key to Children’s strategy – especially as it relates to systemic change – is early prevention.
“We know that mental illnesses, a lot of them start earlier than we think, and they often go untreated and unaddressed,” said Quesnell.
Detecting mental illness early and then delivering the appropriate treatment or preventative care through various stages of a patient’s life takes more than just one provider.
“Especially as we want to advance health equity and equitable care, we know that we have a place to partner with the county, partner with the other organizations out there to take a look at our opportunities to enhance system navigation and communication,” she said.
BHS Access Clinic South / Sixteenth Street Community Health Centers National Avenue Clinic
1635 W. National Ave., Milwaukee
Walk-in crisis and non-emergency outpatient services for children, adolescents and adults, with or without insurance coverage. Goal is to bring a wide range of treatment options closer to patients and connect them with other community resources. Similar service model offered at Access Clinic East and at Crisis Resource Centers on the south and north sides.
Ramping up
MHEC’s primary inpatient care partner is the newly built Granite Hills Hospital. Last fall, BHS officially handed over its acute inpatient services for involuntary patients to the private behavioral health hospital, located at 1706 S. 68th St. in West Allis.
Inpatient care represents the highest level of care within the behavioral health continuum, reserved for individuals experiencing the most severe mental health crises such as psychosis and suicidal or homicidal ideation.
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Meyer[/caption]
“The patients that we’re seeing are quite ill … All of our care here is provided in a patient-centric model but all with a really high level of trauma-informed care focus,” said Deanna Meyer, director of business development at Granite Hills. “When we look at it, we really do save lives with the work that we do.”
Delivering a high level of trauma-informed care requires an army of psychiatrists, internal medicine physicians, specialists, certified clinical pharmacists, social workers, psychologists, therapists and other clinical support staff working around the clock. Patients typically stay an average of seven days.
Granite Hills began opening in phases in November 2021, starting with inpatient services for adults and expanding in late October to adolescents. The facility also recently launched intensive outpatient programming for adults. At full capacity, the hospital will service 120 beds, but for now, occupancy is capped at 40%, or up to 24 adult and 10 adolescent inpatients. That’s due in part to staffing levels also lagging at around 40%, or 138 employees.
“Just as any other business is struggling with workforce and staff, that’s truly our greatest challenge right now is staffing. For us to continue to grow and provide services to the community, which are needed, we need to continue to hire staff,” said Meyer.
She pointed to competition within the behavioral health job market. The collective psychological impact of the COVID-19 pandemic drove demand for mental health services, widening the array of employment options within the industry.
“We’re all competing for talented staff to join our team,” said Meyer. “It’s a little bit of a catch-22. We’re here to serve patients, but we need more people to do the work.”
Continuous care
Once a patient is stabilized at Granite Hills, they will be discharged to continue treatment in an outpatient or community setting. Determining that next step starts before a patient is even admitted, said Meyer. Still, social services employees at Granite Hills say it can be “extremely difficult” to connect uninsured or underinsured patients with follow-up care in a timely manner due to funding issues or a lack of providers that take a patient’s insurance.
Those are the kinds of systemic gaps the county is looking to fill by moving services “upstream,” providing services before more intensive and costly interventions are needed.
“The idea was that we would continue to grow our crisis mobile system – and we would use some of the money that we would be saving by not operating a hospital that was overbuilt and cost us $32 million dollars a year – so that the county could really get into the business of prevention and crisis (services),” said Lappen.
While the joint venture with the area’s four health systems – and the contract with Granite Hills’ operator Universal Health Services Inc. – marks a historic milestone in the path to overhaul an outdated system, especially in a region known for a siloed approach to addressing systemic challenges, it’s just one piece of the puzzle, Lappen said.
“Frankly, if this is going to work, it’s gotta be a really small piece because our investments are upstream from there,” he said. “I always say, for instance, once you call 911, our opportunities to provide alternatives really shrink. If we get called by family when they’re concerned about a loved one well before it gets to that level of care, we could provide a lot more opportunities and choices for people, so we have focused our efforts on reducing the barriers to accessing care upstream.”
In anticipation of the transition of emergency and inpatient services from the Mental Health Complex to MHEC and Granite Hills, the county has worked for the past several years to bulk up its presence within the broader community by expanding crisis mobile services and response teams, opening crisis respite centers and placing teams at four federally qualified community health centers in high-risk neighborhoods. Those efforts are already yielding positive results. From 2010 to 2021, psychiatric crisis service visits decreased 53.2% and adult inpatient admissions fell 76%, according to BHS.
For a clear demonstration of what the county’s work within the community actually looks like, look no further than the former Badger Mutual Insurance Co. headquarters building on Milwaukee’s south side. Sixteenth Street Community Health Centers opened its new behavioral health clinic there, at 1635 W. National Ave., last winter, and BHS moved into a 5,000-square-foot leased space soon after.
Enter the building’s shared lobby area through the front door, marked with side-by-side BHS and Sixteenth Street signage: To the left is the county’s crisis services, including psychiatric assessment, medication evaluation, peer support services, counseling and referrals to outpatient clinics; to the right is SSCHC’s outpatient behavioral health services, substance use disorder services and ADHD treatment programs.
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Perez[/caption]
Co-locating these complementary services allows the facility to serve a broader array of patients – who may have otherwise had to trek out to the county’s Mental Health Complex – right in their own community, said Maria Perez, Ph.D., vice president of behavioral health at SSCHC and chair of the Milwaukee County Mental Health Board. She described patient referrals between the two entities as “seamless.”
“County works really well at stabilizing them; they often then get transitioned to us for their outpatient care,” said Perez. “… If (a patient) is a walk-in and they are in distress, that calls for BHS because they can quickly do an assessment and determine, ‘Is this person a danger to themselves, a danger to others? Are they feeling unsafe?’
“Some people are really in distress, and they might say, ‘I feel like I don’t want to live anymore, my life is not worth it.’ But if you sit and talk with them, you learn that they are about to get evicted, their electric just got shut off, they are facing a chronic illness, their child is truant in school, their parents are addicted. Often times in an assessment, it becomes obvious that what they need are resources … that address those social determinants of health,” she added.
That’s not to minimize the seriousness of acute mental illness or suggest there is a quick fix for environmental stressors often faced by underserved communities. Perez, whose career as a psychologist spans three decades, believes the problems are only getting worse, and more complex.
“This is going to get worse because it’s not just mental health. There’s a lot of anger, there’s a lot of rage, there’s a lot of divisiveness in our country. I’ve never in my lifetime seen so many people being divided. School shootings, I never knew that when I was little,” she said.
Still, Perez somehow finds ways to remain optimistic.
“What makes me hopeful are the partnerships, and I think it’s very, very hopeful that we have (organizations) like Aurora, like Froedtert, like BHS, Sixteenth Street. We’ve got (the county’s Department of Health & Human Services) at the table, we have so many loving, caring people cooperating. Private, public partnerships. Who would have thought?”
