Public Policy Forum Blog

Finding the right balance between inpatient and community-based mental health care

For the past four years, public and private sector stakeholders in Milwaukee County have been working to redesign the county’s adult mental health system.  Those efforts were prompted, in part, by a report produced by national mental health consultants and the Forum in October 2010, which quantified concerns raised in several previous studies that the county system was too reliant on inpatient and emergency care, while failing to provide an appropriate array of community-based care and treatment options.  The concerns were amplified by a recent series of investigative reports in the Milwaukee Journal Sentinel.

There is little question that leaders in Milwaukee County government and the private health systems have made substantial progress so far.  The County’s Behavioral Health Division (BHD) proudly points to millions of dollars of new investment to expand crisis residential beds, peer support services, supported housing assistance, and mobile crisis response services, as well as the phase-in of intensive community-based supports.  Meanwhile, the County and several private hospitals have reached agreement on procedures that determine where in the system patients should receive their inpatient care.

Yet, despite this progress, a persistent question remains: Has the County – in its justifiable  efforts to transfer more care and treatment into community-based settings – moved too quickly to reduce its inpatient bed capacity, and have private health systems picked up enough of the slack? 

A report released by the Forum today finds that for the immediate future, current adult psychiatric inpatient bed capacity in Milwaukee County is appropriate and should not be reduced further as part of mental health redesign efforts.  Over the longer term, however, additional reductions in bed capacity should be possible, though that will depend on the ability of public and private stakeholders to better coordinate service delivery and expand community-based services that decrease the need for hospitalization.

The report was commissioned by BHD per a provision in the 2014 Milwaukee County budget.  As with the October 2010 report, the lead researchers were the Massachusetts-based Human Services Research Institute and Technical Assistance Collaborative, while the Forum served as local researcher and coordinator.    

The report’s key recommendations include the following:

  • Based on the current capacity and composition of the overall adult mental health system in Milwaukee, adult inpatient bed capacity should be in the range of 167 to 188 beds.  Given that there are approximately 201 public and private adult psychiatric beds in the system (of which 150 are utilized), there is enough total capacity to meet current demand.   However, the analysis also finds that a “tipping point” has been reached whereby additional near-term bed reductions could place an unacceptable strain on system capacity.
  • 54 to 60 adult inpatient beds should be maintained to serve high-acuity and/or indigent patients and roughly 128 to 134 beds should be maintained to serve low– to moderate-acuity patients.  54 to 60 beds is the needed capacity for high-acuity and indigent patients who historically have been served by BHD, while 128 to 134 adult beds should be available for patients with low/moderate acuity who historically have been served in the private hospitals. 
  • BHD should expand community-based services that have been shown to promote recovery and decrease the need for hospitalization, and future decreases in bed capacity should be based on metrics that demonstrate a sustainable decrease in demand for inpatient beds.  The report praises BHD for its recent expansion of community-based services, but suggests that  further decreases in bed capacity will require additional investment  in community-based services targeted to those most likely to utilize crisis and inpatient services. 
  • The private hospitals should continue to increase their role in meeting the psychiatric inpatient needs of Milwaukee County residents, and BHD should collaborate with and assist the private hospitals to successfully treat individuals with complex situations and seamlessly facilitate their discharge back into the community.   The report suggests that much of the inpatient care provided at BHD can be provided by the private hospitals, especially if community-based services are increased and providers are equipped to work with consumers who have more challenging behaviors. 

The full report – which can be accessed here – will be presented to the new Milwaukee County Mental Health Board on September 23. 

Rob Henken