Milwaukee County Department of Health & Human Services 2012 Review

The Milwaukee County Department of Health & Human Services is pleased to share our 2012 Review and a message from Director Héctor Colón: 

2012 was a year of change and it was also a year of many triumphs for the Milwaukee County Department of Health & Human Services (DHHS). It is my pleasure to share with you the many accomplishments the department completed in the last year. Our goals were reached by instituting reforms throughout the divisions. We also placed a focus on partnership and collaboration.

I want to thank Milwaukee County Executive Chris Abele for giving me the honor to serve in his Cabinet. His effort to reach across party lines and to provide sustainable and efficient delivery of the best quality service has been exemplary. I also want to thank Mr. Abele and the members of the Milwaukee County Board of Supervisors for their support of DHHS. A big thank you to all of our staff, private hospitals, community-based partners, advocates and consumers who help us carry out our mission. It is our collective pursuit of excellence that helped make 2012 a great year for DHHS.

As director of DHHS, one of my initial objectives was to create a shared workplace culture that defined our values, strengthened teamwork and implemented performance management tools to help us achieve our goals. This shared workplace culture has played an important role in helping our department feel encouraged, engaged and energized. We formed this culture through a process that involved DHHS division administrators and members of their leadership teams. In addition, input was gathered from staff across all divisions in the department. Through this collaboration, we proposed the following values for DHHS:

• We respect the dignity and worth of each individual we serve and with whom we work
• We act with honesty and integrity, adhering to the highest standards of moral and ethical principles through our professional and personal behavior
• We strive for excellence, implementing the best practices and measuring performance toward optimal outcomes
• We work collaboratively, fostering partnerships with others in our service networks and with the community
• We are good stewards of the resources entrusted to us, using them efficiently and effectively to fulfill our mission
• We honor cultural diversity and are culturally competent and sensitive

Employees in every division pledged to uphold these values and are incorporating them into their daily work.

Teamwork has been a high priority for our department. We are working together to help each other fulfill our department and each individual division’s goals. Some examples of great teamwork this year included the collaboration amongst the DHHS divisions contributing to our mental health redesign efforts, responding to emergency fire and threat situations at the Coggs building, and general sharing of best practices that are resulting in better efficiencies across divisions.

Together we put in place performance management tools to help us convert our mission, values and goals into action. All of our department goals have been translated into a format that makes them specific, measurable, achievable, realistic and time-bound. Implementation plans are in place to help us monitor progress. Performance evaluations have been instituted across the department with the goal of ensuring better communication, accountability and success for all employees.

I am pleased to share some of our accomplishments and our plans to continue meeting and exceeding our goals in the future. We are looking forward to leveraging and expanding our public/private partnership, technology and data driven analysis to ensure the long-term sustainability of programs needed to meet the needs of the most vulnerable in this community.

Behavioral Health Division 

The Behavioral Health Division (BHD) is fully committed to reforming mental health care in Milwaukee County and transitioning from institutional care to a community-based system while continuing to provide the best quality of care for clients. Caring for those in need of mental health care services is one of the most critical responsibilities of DHHS. Several key steps required to reach the community care goal were put into place during 2012.

In January, Action Teams presented recommendations from their areas to the Milwaukee County Board of Supervisors Committee on Health & Human Needs. A comprehensive presentation was also made at a public summit in February. The Redesign Task Force resolved to seek technical assistance in implementing affirmed recommendations and that led to a service agreement with ZiaPartners, Inc. and Wilberg Community Planning LLC. The recommendations are also being converted into SMART (specific, measurable, achievable, realistic and time-bound) goals with processes in place to track progress.

Consistent with our redesign efforts, the 2012 BHD budget included $3 Million in community investment funding aimed at improving the community support for residents in need of mental health services. Those funds were used to enter agreements with several organizations that provide community based programs. Those programs include:

•  Community Linkages & Stabilization Program (CLASP)

This program provides extended support and treatment for individuals who are post-hospitalization. Certified Peer Specialists work with clinical coordinators to provide treatment designed to support recovery, increase a client’s ability to function independently in the community and reduce incidents of emergency room contacts and re-hospitalization.

•  Crisis Resource Center (CRC)

The CRC provides a safe, recovery-oriented environment for people in need of stabilization and peer support to prevent hospitalization. This includes adults with mental illness and individuals with co-occurring substance abuse issues who are experiencing psychiatric crises.

•  Stabilization House

Stabilization House is an alternative to psychiatric inpatient hospitalization for individuals with serious and persistent mental illness. The home services adults who are in need of further stabilization after an inpatient hospitalization. It is also used by individuals who require structure and support to ensure a smooth transition into residential placement. Stabilization House may also provide temporary accommodations for people with mental health needs during a crisis or when they need respite from living at home. 

•  Individual Placement & Support (IPS)

IPS is an evidence-based practice of supported employment that helps individuals with severe mental illness or co-occurring disorders obtain employment.

•  Peer Specialists

As part of the Mental Health Redesign, work continues to develop the peer specialist network and to increase consumer participation in BHD activities.

•  Wellness Recovery Action Plan (WRAP)

WRAP allows consumers to make decisions about their own care in advance of any crisis situation.

Upgrades designed to improve patient experiences and care at the BHD Psychiatric Crisis Services (PCS) Admission center were completed in November of 2012. The enhancements are part of the ongoing effort to provide more person-centered and trauma-informed care. Updated features help staff immediately assess patient needs and reduce or eliminate wait times. The new features include a new triage area, an additional workstation and a children’s waiting area. PCS serves about 14,000 people every year. The center is open 24 hours per day, 7 days per week and provides psychiatric emergency services including assessment, crisis intervention and medication.

In the ongoing effort to provide the best patient care, BHD reconfigured its acute care units and bed occupancy. One acute unit was taken out of operation in late 2012. The decision to close one unit was based on several factors including increased community programming, a declining census, fewer emergency visits and increased partnerships with community hospital providers. These improvements are consistent with recommendations from the Mental Health Redesign Task Force.

New treatment units are now available for BHD patients. Female patients now have the option of being in the Women’s Treatment Unit (WTU). WTU offers a combination of effective trauma informed therapies to create an environment that is sensitive and therapeutic for patients. Clients who are the most challenging with behavioral needs are now housed in the Intensive Treatment Unit (ITU). This unit provides a safe place to provide rapid and effective stabilization for patients who are judged to be at high risk for aggressive and disruptive behaviors. The creation of these new units provides more effective care for specialized populations served by BHD. This allows the Acute Treatment Units to offer more specific programming including:

•  Unit community meetings
• Medication & symptom management groups
• Community resource groups
• Music & occupational therapy
• Recovery planning sessions
• Spirituality groups & contacts
• Medication therapy
• Education in managing other medical conditions

Acute units also offer interventions for patients whose needs are best served in a general care environment.

All BHD clinical staff received 16 hours of training to be certified in the Mandt System. Mandt is an advocacy-based curriculum for building healthy relationships through positive behavior support in a trauma sensitive setting. After the training, rates of seclusion and restraint use were reduced significantly at BHD.

BHD launched its new electronic medical records (EMR) system in December of 2012. The improved system will increase the overall efficiency and improve billing and collections processes at BHD. It also helps staff better manage inpatient, outpatient and substance abuse programs effectively.

Emergency Medical Services

Emergency Medical Services (EMS) is an essential part of Milwaukee County’s health care community. EMS is a nationally respected group that has been recognized for high survival rates of cardiac patients among other achievements. The division administers critical emergency medicine in pre-hospital settings. EMS is also responsible for administering the operation and maintenance of county-wide emergency medical services through agreements with county municipalities.

In 2012, four-year contracts were negotiated with nine Milwaukee County Municipalities and the North Shore Fire Department. Those contracts will help assure the future development of the EMS System. The contracts also include improvements that will enhance the EMS system and continue providing high quality out-of-hospital emergency medical care. 

EMS put the following changes in place in 2012:

• Performance Measuring - An updated performance measure program was developed to help monitor system performances of EMS providers from contracting fire departments. The program will also help maintain a high quality EMS system and help strengthen accountability throughout the EMS system.

• EMS Education upgrades - Staff partnered with area fire departments to redesign the model of delivering EMS education. Using a web-conferencing platform helped Milwaukee County EMS save area fire departments more than $100,000 in overtime costs the first semester it was put in place.

• Internet Based Conferences - EMS initiated the use of web-based streaming conferencing to connect with stakeholders. The online meetings will save travel time and thousands of dollars.

• Radio System Redesign - Work is underway to upgrade the emergency medical services radio system. The redesign will result in significant cost savings.

• Funding for Defibrillators - Capital funding was secured to replace aging cardiac monitor defibrillators. New monitors will make better use of wireless technologies and enhance patient care.

• Medication Tracking - A new internet platform database is being used to track federally controlled medications administered by area paramedics. The database allows EMS system administrators to better track medication administration and ensures they are meeting federal guidelines.

• Electronic Records - EMS assisted area fire departments convert patient medical records from paper to electronic formats.

• Cardiac Arrest Research - Pre-hospital research in the area of cardiac arrest and resuscitation of trauma patients was done at EMS. That research was used to help verify medical practices that are scientifically evidence based.

• EMS Progress Reports - Emergency medical services system benchmarks were prepared and results were shared with EMS stakeholders.

EMS is dedicated to efficiently and effectively deploying human resources and providing high quality education to municipal fire department staff. As part of that effort the division began work in 2013 to develop a video conferencing system. Such a system will greatly improve the quality of delivery of EMS education while reducing salary costs.

Disabilities Services Division 

The Disabilities Services Division (DSD) is dedicated to enhancing the quality of life for individuals with physical, sensory and developmental disabilities. Reforms made to the division’s Disability Resource Center (DRC) led to the elimination of a 35-year waiting list. On November 1, 2012, the DRC reached entitlement status. That change eliminated the waiting list of over 3,000 individuals with disabilities and completed implementation of a three-year project to expand Family Care. This significant milestone is a paradigm shift for the service delivery system in Milwaukee County and provides badly needed services to help individuals live independently in the community. Staff worked overtime, reprioritized their duties and rose to the occasion to get this done. The Intake Unit received in excess of 26,000 calls to our call center and we provided disability benefits services to over 1,200 individuals in 2012. 

Over the past two years, DSD has eliminated a 500-person waiting list for children with disabilities and their families.  DSD served 264 families in the Children’s Long Term Support (CLTS) Waiver, 462 families in the Autism Waiver and 749 families in the Family Support Program in 2012. The division continues to respond to the needs of families of children on the Autism Spectrum by helping 88 children to be placed on the waiting list for services and taking 78 children off of the waiting list for Intensive Autism services. 

In 2012 the division embarked on a joint initiative with the Behavioral Health Division to downsize the Center for Independence & Development (formerly known as Hilltop). The planning process has begun with the goal of relocating 12 individuals by April 2013. As part of another related initiative to help support the Center for Independence & Development (CID) project, DSD expanded the Crisis Respite Home program from four to eight beds in 2012. This will allow more individuals to receive services quickly while remaining in the community and avoiding hospitalization.

The Division will be completing a system gap analysis initiative for 2013.  The project design and funding was approved in 2012 and there will be significant review of the gaps in services for persons with intellectual disabilities.

The DSD Birth-to-Three Program is an early intervention program for children with developmental delays and disabilities ages birth to 3 and their families. In 2012 the program maintained nearly 100% compliance with key federal performance indicators while serving more than 3,000 individuals and families. DSD has undergone a significant program financial review of Birth-To-Three contracted agencies and will be moving toward performance based contracts in 2013. The division was able to redirect $150,000 in new funding to the Birth-To-Three program for 2013.

DSD had 100% compliance with timely submittal of WATTS reports to the court system. This is an annual process for individuals who have a protective placement orders in place by the court. DSD staff members perform reviews to ensure those individuals are living in the least restrictive and most integrated settings possible. The Division has over 600 cases that are processed yearly.

DSD established the new 2012 Minority Intern Program and had two wonderful students. Both expressed that they enjoyed their individual experience and learned a lot about the Disabilities Services Division and the Birth-to-Three Program. One student is a sophomore at Knox College in Galesburg, Illinois. She is majoring in Spanish and her minor is social services. She plans to become a bilingual speech pathologist after graduation. The second student is currently enrolled in the Human Services Program at MATC. She is fluent in English and Hmong. She will enroll in a 4-year college for social work after completing courses at MATC. 

Delinquency & Court Services Division

The Milwaukee County Delinquency & Court Services Division (DCSD) continues to move forward with efforts to reduce recidivism in Milwaukee County and to offer viable substitutes to detaining youth. In 2012 DCSD teamed up with the Annie E. Casey foundation to implement new juvenile justice system reforms. The county is one of only three sites in the state of Wisconsin chosen to participate in the foundation’s Juvenile Detention Alternatives Initiative (JDAI). The program has successfully reduced the number of youth in confinement while maintaining or improving public safety in other states across the country.

DCSD received a $725,000 federal grant to develop and implement new tools that will enable officials to make informed decisions about resources and services for youth. The grant was awarded when the Office of Juvenile Justice & Delinquency Prevention (OJJDP) chose Milwaukee as one of the 2012 participants in the Juvenile Justice Reform and Reinvestment Demonstration Program. The program provides funding to states and communities to test an evidence-based juvenile justice reform initiative.

In mid-2012 DCSD commissioned the help of the Public Policy Forum to review its approach to measuring juvenile recidivism and to provide recommendations for improvement and moving toward more evidence based programming. The Forum found that the division had intensified efforts to improve recidivism measures in order to better analyze, improve and disseminate information to justice system leaders and elected officials. The study also concluded “Milwaukee County’s Delinquency and Court Services Division takes its charge to measure recidivism seriously and is committed to improvement.”

The new Milwaukee County Accountability Program (MCAP) was launched in 2012. MCAP is designed to allow qualified youth to stay close to home instead of being sent to a Juvenile Correction Institution four hours away from Milwaukee. Youth in the program are placed in the secure detention center for up to five months and undergo a period of aftercare in the community under probation supervision. Families are also encouraged to become more involved through MCAP. Support and structure from family members are needed to meet the requirements. There are currently 12 youth enrolled in the program. MCAP features several key services including:

• Education – Wauwatosa Public Schools provide classes in reading & English, math, social studies, science, physical education/health and art. Credits earned are transferable to the child’s local school district.

• Juvenile Cognitive Intervention Programming – Running Rebels Community Organization runs daily groups to help youth change their thought process in order to make better choices.

• Family Counseling – All MCAP participants are expected to participate in weekly counseling sessions. These sessions include parents/guardians when possible.

• AODA Education & Counseling - Alcohol & drug abuse counseling is provided to help participants understand the effects of substance abuse.

• Restorative Justice – Groups will be provided to help youth build a sense of community within the program, examine their behavior and learn new skills.

• Targeted Monitoring – Participants will be assigned to a monitor from Running Rebels Community Organization.

• Electronic Monitoring – GPS monitoring will be required during home passes and upon initial release to the community.

• 72-Hour Hold – Youth on aftercare status will be subject to holds in secure detention for investigation of any alleged violations of the rules of their supervision.

Housing Division 

The Housing Division is responsible for coordinating and overseeing federal housing and community development funds awarded to Milwaukee County. During 2012 the division overhauled several programs, making them more efficient and effective. Those reforms received national recognition and the Housing Division was the recipient of the U.S. Department of Housing and Urban Development (HUD) “Turning the Ocean Liner Around” award. The division was acknowledged for having the most improved program and structure for the CDBG and HOME programs.

Enhancements made to the CDBG program include:

• Developing a citizen participation plan
• Improving the application process and providing training sessions for recipients
• Creating an expert panel to make recommendations based on an independent, objective scoring system
• Designing a compliance manual for sub-recipients

HOME program changes include:

• Putting new policy and procedures in place
• Retraining employees on regulations
• Implementing a conflict of interest policy
• Pre-construction meetings with contractors and homeowners
• Increasing public outreach and education efforts

More than 6,000 low income families in Milwaukee County are currently being removed from a Section 8 waiting list. This waiting list has been in place since 2001. A new administrative plan for the program helped the division accomplish this goal. Milwaukee County had been operating on an outdated plan from 1999.

The Division partnered on the creation of 111 new supporting housing units for mental health consumers in 2012. Eighty of the units were located outside the city of Milwaukee and were the first permanent supportive housing units to be located in Milwaukee County suburbs.

Housing was successful in the implementation of several Mental Health Redesign initiatives including:

• Securing additional funds for on-site services at Highland Commons. This step helps meet the redesign goal of increasing permanent supportive housing.
• CDBG funds were used to provide peer support services in permanent supportive housing, meeting the goal of increasing the role of peer support.
• An RFP was completed for Pathways to Permanent Housing, a new housing model designed as an alternative to community based residential facilities. This model will assist consumers with living in a least restrictive setting as they work to secure permanent supportive housing.

Management Services Division

The Contract Administration team of the Management Services Division is responsible for administering funds under the Wisconsin Home Energy Assistance Program (WHEAP). This program helps low-income individuals and families in Milwaukee County pay their home heating and electric bills during the heating season and provides crisis energy assistance during the entire year. WHEAP also funds improvements to homes and apartments to make them more energy efficient. In the 2012 fiscal year $30,423,389 in home energy assistance funds was paid out to nearly 55,000 eligible Milwaukee County households. More than 9,800 households received energy crisis assistance that totaled $3,160,854 for the year.

Contract Administration also administers WHEAP funding under the IMPACT Community Information Line (2-1-1) service - a centralized access point for people in need during times of personal crisis or community disaster. This program is a 24-hour contact and referral service that provides access to a comprehensive database containing more than 5,500 community programs for residents seeking social services in Milwaukee County. In the first six months of 2012, IMPACT 2-1-1 served a total of 84,445 customers, which included 16,791 online database search sessions and 67,654 telephone calls for an average of 14,074 clients served per month.

During the heating season, Milwaukee County residents are directed to call 2-1-1 if they are experiencing a loss of heat after business hours. 2-1-1 tries to determine the reason for loss of heat and determine if there are life-threatening conditions present. Additionally, 2-1-1 helps clients understand eligibility for the WHEAP Emergency Furnace Program. If life threatening conditions exist, an energy assistance agency will contact clients within 18 hours to complete an application and conduct a troubleshooting safety check. 2-1-1 provides referrals to both SDC and Community Advocates for regular energy assistance and the WHEAP crisis program.

To date, through November of 2012, 2-1-1 provided assistance in response to:

• 4,954 utility bill payment assistance requests
• 474 weatherization requests
• 223 furnace repair requests

Contract Administration was the 2012 recipient of the Community Business Development Partners Good Citizens Award. The honor was presented for their outstanding commitment to fulfilling the Disadvantaged Business Enterprise program goals. The unit was also recognized for taking a partnership approach to champion the program creatively and consistently.

Fiscal & Operations 

DHHS staff in the fiscal and operations worked with all divisions throughout the year to help improve systems and boost revenues. Some of their most significant accomplishments include:

• Reduced BHD revenue write-offs with change of services billing process

• Boosted revenue & improved collection results by improving follow-up systems

• Increased nursing home revenue by requiring managed care organizations to pay “actual cost of care”

• Dramatically improved Housing Division fiscal controls to satisfy HUD requirements

• Completed transition of uncollectible data from Housing Division to Department of Administrative Services to maximize Tax Refund Intercept Program (TRIP) collections

• Worked closely with Program, Audit & Contract Management to significantly reduce pharmacy cost and completed an RFP for improved long-term cost efficiencies

These combined efforts led to improved 2012 financial results for DHHS and BHD, as well as sustainable revenue increases and expense reductions moving forward. In 2012, these billing and collection changes will yield between $500,000 and $1million in increased patient revenue. The reforms are anticipated to yield an addition $2 million in 2013.

Looking Ahead

We are looking forward to another exciting and successful year. As we move into 2013 our plan is to continue to improve staff competencies and leadership through professional development. We will also examine program, business and financial practices to ensure we are approaching our operations in the most efficient and effective way possible. Work is underway to continue the movement towards best practices and evidence-based decision making. DHHS is strengthening quality assurance with community based partners by moving towards performance-based contracts which will ensure quality service, accountability and positive outcomes.  We look forward to continuing the work we do to secure human services for individuals and families who need assistance living healthy, independent lives in the community.