More on Milwaukee County mental health services facility crisis

On June 18, 20 the able reporter Ms. Meg Kissinger for the Milwaukee Journal Sentinel newspaper that has been superbly documenting this now 15 year old story, wrote of the latest repair efforts by the County to fashion a feasible plan to resurrect and restructure this facility and its services to its clients. She documents the new effort in her article, “County considers closing Mental Health Complex, privatizing care.” In my distant uninformed opinion they do deserve a lot of credit for toiling under years of stress, failed plans, recurrent crises and scandals. If anything they are to be commended for long term public service efforts, through I am sure, multiple sets of officials.

As it is reported currently, there are a number of short and long term plans to try to create better services. Ms. Kissinger details this in her latest article, “County considers closing Mental Health Complex, privatizing care.”

The major elements of the plan appear to be to get the county government out of the operation of the center and the judgment appears to be that this level of system change is needed to have a chance of success and improvement when the newspaper’s own series, “Chronic Crisis: A System That Doesn’t Heal,” referred to in recent posts has failed in part because of poor political leadership, division and poor follow through as well it appears just poor paltry efforts at reorganization inadequate to the task.

The main elements appear to be: 1) “turning over direct patient care to a private organization as is done in most other counties across the country;” 2) delivering psychiatric services at two separate locations at two different and hopefully dispersing and easing access to services; 3) including multiple services at each “access hub,” including a mental health clinic, peer-run services (where patients having achieved high levels of recovery and stability can help give on the spot support and guidance to new and continuing patients–a very effective mode of service and means of helping sustain compliance and continuing attendance and contact; 4) intensive  outpatient services, 5) a crisis line, 6) care coordination with I expect designated staff specialized in obtaining, scheduling and referring to diversified services, long known as case managers, essential parts of any such outpatient mental health organization that did not exist decades ago; 7) and a medication management clinic. Additionally, and very significantly, the long nationally neglected truly essential component of local inpatient crisis psychiatric care, a 60 bed inpatient unit “for patients that need around-the-clock care will be included. On the face of it, this sounds like a very well thought out plan.

Further the article notes that apparently the plan was put together with extensive consultation with all the needed stakeholders essential to the enterprise, patients, families, advocated, clinicians. Workers and current clinicians are to be afforded apparently every opportunity to retain their jobs and continue to work. In past efforts I have witnessed in a number of states, the private organizations would come in and ape Frank Lorenzo’s original model with bankrupting and reorganizing Continental Airlines in the 1980’s of essentially firing everyone, then making them re-apply for their jobs, and then paying them if they consented to be rehired–at far lower salaries wages, taking cruel advantage of their needs like everyone else not inherently wealthy like big Cheeses like Mr. Lorenzo, to go back to work at any cost to themselves, establishing the model of screwing the working class (I now disavow being a radical, Commie, or goof ball Socialist or any of the other epithets used to discredit anyone who notes the consequences to now depleted “middle working class).”

What I have seen happen over and over in now TWO different states who reorganized their “mental health center” based systems with this costs at any cost rehiring approach and vile treatment of committed clinical staffs, is that many of the staff who face losing up to say 40% of their pay, in many instances, much of their retirement and vestments, is that they quit and move on….Then the private corporate re-organizers happily, as this HAS seemingly been their intended plan, hire new clinicians, like Mr. Lorenzo did, desperate to get jobs in a recession economy, willing to settle for lower pay, but also altering job descriptions and required clinical qualifications to a lower level, from  Master’s levels counselors, social workers and psychologists, to those with 2 or 4 year Associates’ or Bachelors’ degrees, far far less actual patient centered exposure and clinical experience and “rotations,” as those are very expensive for these lower level training programs to provide, and the privatized “behavioral centers,” end up with often very less qualified staff who nonetheless work hard and are happy to be fulfilling their own mental health worker aspirations. Later many of them find they have been locked into near permanent lower pay servitude with not much of a ladder of career and earning power advancement, a cruel but now pervasive employment practice in so many industries. Quality of care suffers.

Other cost cutting measures usually follow. Less well trained “prescribers,” and experienced therapists with less experience than Masters’ level, and PhDs and MDs manage acute and chronically mentally ill patients’ psychotherapeutic and psychopharmcological treatment needs. Patients are seen in medication groups instead of individual as much as possible to further save money, are seen often only on walk in basis in crisis. Patients are smart, and they migrate to the ERs where they can see more skilled practitioners, and get better care and we end up with mess we have now, patients flooding local hospitals’ ERs.

One cautionary note and quote in Ms. Kissinger’s June article is by the County Executive Mr. Chris ABele, who was quoted as stating: “Uncontrollable expenses significantly influence the cost of doing business as a county entity.” This kind of mantra used to be heralded as justifiable and ethical as it was long repeated all over the county in this now overwhelmingly utilized of mental health local system of care delivery, would save costs by ‘getting the meddlesome government out of it.’ What has evolved instead is that clinical services are cut in every manner conceivable in addition to the honest expense saving approach of consulidating administrative services, and unifying the management components into a central cost effective entity. That was done and almost always promotes honest savings, more unified management, better oversight, etc. But the other hack and slash approaches are just too tempting for most organizations to resist and almost universally quality of care has declined in the last two decades dramatically. Just ask patients older than 40 or parents of adult mentally ill, or patients trying to seek more than piecemeal, silo’ed services in which the client/family has to apply separtely for every service they need and processes of delivery take far longer than they did before in the organizations that have followed this kind of recipe. It is repairable and correction and refinement of service delivery organization is finally beginning to evolve in enlightened centers.

But when privatization evolves to equal profits over service expenditures and funding sources, i.e., the local and state government start the Nixon approach of decreasing funding annually, then quality declines in synchrony with those cuts as governemnts handily and happily get out of the “mental health business.” Recently Obamacare has taken the aporach that an interim solution is to expand Medicaid. Right now that is the only visible solution but it should be temporary. And it has rightly generated enormous controversy as it shifts costs to the federal level, WILL result in cuts elsewhere in the Federal budget at time when we need to be rebuilding everywhere, infrastructure and God knows what else, or means the dreaded rabies inducing reaction to “higher revenue streams,” the euphemism for higher taxes. The reality is that the public mental health client cannot fully pay for their mental health services they need and few in the world of economic governmental reality are paying responsible attention to that undeniable reality. And again the powers that be seem to still be forgetting the old American ideal of the “common weal,’ the good of the majority, the ‘help thy neighbor ethos.’

Let us hope the folks, all concerned in Milwaukee learn from the mistakes of the rest of the country’s floundering experiment with “mental health reform,” and do it better and differently. They certainly sound as if they have a sound plan, if only they make it work RIGHT.

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Author: Frank

I am a older child, adult, geriatric teaching psychiatrist with over 30 years' practice experience in North Carolina, first at Duke as clnical teaching faculty, then in Western NC as a primary child psychiatry specialist. I have taught and supervised child psychiatrists and psychiatrists in training and many other mental health professionals and taught at two medical schools. I have served in many public and private practice settings. My primary interest is in observing and documenting the ongoing mental health reform efforts in the State of North Carolina and documenting its sucessess and failures at all levels. My favorite pastime among many others is spoofing my friends and kids with my deadpan sense of humor.

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