Analysis of Adult Bed Capacity for Milwaukee

County Behavioral Health System

September 2014

Human Services Research InstituteTechnical 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

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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

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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)

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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

Findings

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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

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

2006 2007 2008 2009 2010 2011 2012 20130

20

40

60

80

100

120

Num

ber o

f Bed

s

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Psychiatric Inpatient Bed Capacity in Milwaukee County

Hospital Adult Beds Budgeted 2014

Projected Adult Beds FY2015

BHD 66 60Private Psychiatric Hospitals

Rogers Memorial 50 76 Aurora Psychiatric Hospital 40 40

Aurora St. Luke’s South Shore (SLSS) 23 23

Wheaton-St. Francis 22 26 Columbia St. Mary’s 0 0

TOTAL 201 225

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BHD Psychiatric Crisis Services Waitlist Status: Jan-July 2014

Month Number of Days on Waitlist

BHD Actual Operating Capacity

January 0 66February 1 66March 0 60April 6 60*May 14 54June 4 54**July 4 66

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Average Monthly Observation Admissions: 2010-Q1 2014

2010 2011 2012 2013 20140

20

40

60

80

100

120

140

160

180

200

Aver

age

Mon

thly

Adm

issi

ons

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Inpatient Behavioral Health Admissions by Hospital: 2011-2013

2011 2012 2013

BHD 3,244 (20.9%) 2,793 (18.1%) 2,285 (14.9%)

Aurora Psychiatric Hospital 3,186 (20.6%) 3,205 (20.7%) 3,470 (22.6%)

Aurora SLSS 1,110 (7.2%) 1,167 (7.5%) 1,255 (8.2%)

Columbia St. Mary’s 1,789 (11.6%) 1,975 (12.8%) 1,894 (12.4%)

Rogers Memorial 5,197 (33.6%) 5,341 (34.6%) 5,406 (35.2%)

Wheaton-St. Francis 959 (6.1%) 977 (6.3%) 1,029 (6.7%)

Private Hospitals Total 12,241 (79.1%) 12,665 (81.9%) 13,054 (85.1%)

TOTAL 15,485 15,458 15,339

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Inpatient Behavioral Health Admissions: 2011-2013

Jan-11

Mar-11

May-11

Jul-11

Sep-11

Nov-11Jan

-12

Mar-12

May-12

Jul-12

Sep-12

Nov-12Jan

-13

Mar-13

May-13

Jul-13

Sep-13

Nov-13

100

300

500

700

900

1100

1300

Private Hospitals Total BHD

Num

ber o

f Adm

issi

ons

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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.

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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

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Average Open Low- to Moderate-Acuity Beds by Hospital: 2013

Month RogersAurora Psych.

Hospital

Columbia St. Mary’s

Wheaton- St. Francis

Aurora SLSS TOTAL

Jan 6 6 2 2 -- 16Feb 5 6 3 2 -- 16Mar 3 6 1 2 4 16Apr 3 4 1 1 2 11May 4 5 4 1 4 18Jun 3 6 2 2 4 16Jul 2 3 2 0 3 10Aug 2 4 1 1 1 9Sep 5 5 1 1 1 13Oct 6 5 3 3 3 20

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Average Open High-Acuity Beds: 2013

Month

Aurora Psychiatric

HospitalAdult Unit 4

43A Intensive Treatment

Unit

43B Acute

Treatment Unit

43C Women’s Treatment

UnitTOTAL

Jan 4 1 1 1 7Feb 5 1 1 2 9Mar 4 5 3 2 14Apr 3 2 4 3 12May 4 1 2 8 15Jun 4 2 1 2 9Jul 4 2 3 8 17Aug 3 2 2 4 11Sep 3 2 2 2 9Oct 4 2 2 2 10

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Inpatient Admissions by Payer Source, by Hospital: 2013

BHDAurora

Psychiatric Hospital

Rogers Private Non-IMDs

Private Insurance 9% 44% 57% 21%Medicaid HMO 32% 32% 20% 19%Medicaid (Straight T19) 22% 4% 10% 19%Medicare 21% 17% 11% 30%Uninsured/Self-Pay 15% 2% 2% 10%Other or Unknown 2% 0% 0% 2%

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Milwaukee County Psychiatric Crisis Services Average Monthly Admissions: 2010-Q1 2014

2010 2011 2012 2013 20140

200

400

600

800

1000

1200

23% Reduction

Aver

age

Mon

thly

Adm

issi

ons

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Psychiatric Crisis Services Average Monthly Emergency Detentions:

2010-Q1 2014

2010 2011 2012 2013 20140

100

200

300

400

500

600

700

800

32% Reduction

Aver

age

Mon

thly

Adm

issi

ons

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Milwaukee County Mobile Contacts Diverted From Inpatient:

2011-Q1 2014

Jan-11 Jan-12 Jan-13 Jan-140

20406080

100120140160180200

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Milwaukee County Access Clinic Admissions: 2011-Q1 2014

Jan-11 Jan-12 Jan-13 Jan-140

100

200

300

400

500

600

700

800

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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

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Influence of Other Factors on Inpatient Admissions & Demand

• Closure of Rehab Hilltop and Rehab Central• Workforce• Seasonality

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

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec0

500

1000

1500

2000

2500

3000

2011 2012 2013

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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.

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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.

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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.

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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.

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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.

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Four Scenarios

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

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Four Scenarios

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

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Four Scenarios

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

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Four Scenarios

Scenario #4BHD operates a regionalized facility.