1. Analysis of Adult Bed Capacity for Milwaukee County Behavioral Health System September 2014 Human Services Research Institute Technical Assistance Collaborative Public Policy Forum

2. Introduction System that is recovery-oriented and community-focused 2010 HSRI/TAC/PPF Report Changes at BHD since 2011 – Reduction in use of Crisis Services – Decrease in inpatient admissions – Increasing community-based services Determining inpatient bed need 2

3. National Context Decreasing inpatient capacity Olmstead Institutions for Mental Disease (IMD) exclusion and other reimbursement issues Affordable Care Act (ACA) Growth of community-based alternatives 3

4. Methods Data Collection – Monthly inpatient admissions 2011-Q1 2014 requested from BHD and private hospitals – Community-Based Service summaries from BHD – In-person and telephone interviews with key stakeholders – Cross-county data from Wisconsin Hospital Association (WHA) 4

5. Methods Utilization-based formula used to estimate bed need in the system currently: [Adult admissions  Median length of stay]/365 = Number of beds utilized – Applied occupancy rate range of 80% to 90% Future bed need projection: [# of decreased adult admissions  Median length of stay]/365 = Number of fewer beds utilized 5

6. Findings 6

7. Stakeholder Perspectives Mental Health Task Force members Milwaukee Health Care Partnership Behavioral Health Provider workgroup Consumers, family members, providers Area hospital systems Wisconsin Hospital Association 7

8. Adult Inpatient Beds at the Milwaukee Mental Health Complex: 2006-2013 8

9. Psychiatric Inpatient Bed Capacity in Milwaukee County 9 Hospital Adult Beds Budgeted 2014 Projected Adult Beds FY2015 BHD6660 Private Psychiatric Hospitals Rogers Memorial5076 Aurora Psychiatric Hospital40 Aurora St. Luke’s South Shore (SLSS) 23 Wheaton-St. Francis2226 Columbia St. Mary’s00 TOTAL201225

10. BHD Psychiatric Crisis Services Waitlist Status: Jan-July 2014 10 Month Number of Days on Waitlist BHD Actual Operating Capacity January066 February166 March060 April660* May1454 June454** July466

11. Average Monthly Observation Admissions: 2010-Q1 2014 11 Average Monthly Admissions

12. Inpatient Behavioral Health Admissions by Hospital: 2011-2013 12 201120122013 BHD3,244 (20.9%)2,793 (18.1%)2,285 (14.9%) Aurora Psychiatric Hospital3,186 (20.6%)3,205 (20.7%)3,470 (22.6%) Aurora SLSS1,110 (7.2%)1,167 (7.5%)1,255 (8.2%) Columbia St. Mary’s1,789 (11.6%)1,975 (12.8%)1,894 (12.4%) Rogers Memorial5,197 (33.6%)5,341 (34.6%)5,406 (35.2%) Wheaton-St. Francis959 (6.1%)977 (6.3%)1,029 (6.7%) Private Hospitals Total12,241 (79.1%)12,665 (81.9%)13,054 (85.1%) TOTAL15,48515,45815,339

13. Inpatient Behavioral Health Admissions: 2011-2013 13 Number of Admissions

14. Cross-County Data Adjusting for poverty, an estimated 36% of individuals with serious mental illness (SMI) in Milwaukee County had an ER visit in 2013, compared to the state average of 20%. Adjusting for poverty, Milwaukee County ranked in the middle of the 20 counties for individuals with SMI who had an inpatient discharge for mental illness in 2013. 14

15. Factors That Influence Inpatient Admissions & Demand Patient Characteristics – Medical diagnoses – Forensic involvement – Behavioral issues – Co-occurring disorders Medicaid and Other Payer Issues Increased Community-Based Services, Including Crisis Diversion 15

16. Average Open Low- to Moderate-Acuity Beds by Hospital: 2013 16 MonthRogers Aurora Psych. Hospital Columbia St. Mary’s Wheaton- St. Francis Aurora SLSS TOTAL Jan6622--16 Feb5632--16 Mar3612416 Apr3411211 May4541418 Jun3622416 Jul2320310 Aug241119 Sep5511113 Oct6533320

17. Average Open High-Acuity Beds: 2013 17 Month Aurora Psychiatric Hospital Adult Unit 4 43A Intensive Treatment Unit 43B Acute Treatment Unit 43C Women’s Treatment Unit TOTAL Jan41117 Feb51129 Mar453214 Apr324312 May412815 Jun42129 Jul423817 Aug322411 Sep32229 Oct422210

18. Inpatient Admissions by Payer Source, by Hospital: 2013 18 BHD Aurora Psychiatric Hospital Rogers Private Non-IMDs Private Insurance9%44%57%21% Medicaid HMO32% 20%19% Medicaid (Straight T19)22%4%10%19% Medicare21%17%11%30% Uninsured/Self-Pay15%2% 10% Other or Unknown2%0% 2%

19. Milwaukee County Psychiatric Crisis Services Average Monthly Admissions: 2010-Q1 2014 19 23% Reduction Average Monthly Admissions

20. Psychiatric Crisis Services Average Monthly Emergency Detentions: 2010-Q1 2014 20 32% Reduction Average Monthly Admissions

21. Milwaukee County Mobile Contacts Diverted From Inpatient: 2011-Q1 2014 21

22. Milwaukee County Access Clinic Admissions: 2011-Q1 2014 22

23. Access to Community-Based Services Budgeted initiatives since 2011 – Community Recovery Services (CRS) – Comprehensive Community Services (CCS) Community-Based Services – SAIL – CARS – CLASP – Targeted Case Management – Community-Based Residential Facility – Outpatient 23

24. Influence of Other Factors on Inpatient Admissions & Demand Closure of Rehab Hilltop and Rehab Central Workforce Seasonality 24

25. Milwaukee County Adult Monthly Admissions (Age 21+): 2011-2013 25

26. Recommendations 1.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. 26

27. Recommendations 2.Using the upper range of beds needed in the system to meet demand (188 beds), 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. 27

28. Recommendations 3.BHD should expand community-based services that have been shown to promote recovery and decrease the need for hospitalization. Future decreases in bed capacity should be based on inpatient and community-based services metrics that demonstrate a sustainable decrease in demand for inpatient beds. 28

29. Recommendations #3 continued…. – Based on current length of stay, we estimate that for every 225 BHD admissions (median LOS 8 days) that the system can divert and sustain, roughly five fewer high-acuity beds are needed in the system. – For every 450 admissions to the private hospitals (median LOS 4 days) that the system can divert, roughly five fewer low/moderate acuity beds are needed in the system. 29

30. Recommendations 4.The private hospitals should continue to increase their role in meeting the psychiatric inpatient needs of Milwaukee County residents. 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. 30

31. Four Scenarios Scenario #1 BHD continues to operate a smaller number of high-acuity beds at the Mental Health Complex or in a smaller facility. 31

32. Four Scenarios Scenario #2 BHD purchases high-acuity capacity at a private hospital. 32

33. Four Scenarios Scenario #3 Milwaukee County residents with high-acuity, longer term needs are referred to a state- operated hospital. 33

34. Four Scenarios Scenario #4 BHD operates a regionalized facility. 34