Services for Persons with Mental Illness

Informational Paper

Wisconsin Legislative Fiscal Bureau January, 2005

Prepared by

Yvonne M. Onsager, Jessica Stoller, and Rachel Carabell

Wisconsin Legislative Fiscal Bureau One East Main, Suite 301 Madison, WI 53703

Services for Persons with Mental Illness

Introduction diminished level of functioning in the primary aspects of daily living and an inability to cope with The National Institute of Mental Health esti- the ordinary demands of life, which may lead to an mates that 22% of American adults have a diag- inability to maintain stable adjustment and inde- nosable mental disorder. Four of the ten leading pendent functioning without long-term treatment causes of disability in the United States and other and support and which may be of lifelong dura- developed countries are mental disorders -- major tion." This definition includes schizophrenia, as depression, bipolar disorder, schizophrenia, and well as psychotic and other severely disabling psy- obsessive-compulsive disorder. Some individuals chiatric diagnostic categories, but does not include may have more than one mental disorder. infirmities of aging or a primary diagnosis of mental retardation or of alcohol or drug dependence. This paper describes public mental health These definitions are used to determine eligibility services available to people in Wisconsin. The first for services provided under Chapter 51 of the stat- section briefly describes common types of mental utes. disorders and the factors that are believed to cause these disorders. The second section describes the Under federal law, adults with serious mental provision of community-based services to persons illness are people 18 years of age or older who with mental disorders and the programs that currently have, or at any time during the past year provide these services. The final section describes had, a diagnosable mental behavior or emotional the institutional services that provide care and disorder of sufficient criteria specified in the treatment for persons with mental disorders, Diagnostic and Statistical Manual of Mental except services provided for persons committed as Disorders (DSM-IV), published by the American sexually violent persons, which are described in a Psychiatric Association, that has resulted in separate Legislative Fiscal Bureau informational functional impairments, which substantially paper entitled "Civil Commitment of Sexually interferes with or limits one or more major life Violent Persons," and services provided to activities. People with serious mental illness incarcerated individuals. include individuals who have a twelve-month DSM-IV diagnosis and one or more of the following:

Mental Illness • Non-affective psychosis or mania, major depression or panic disorder with evidence of severity indicated either by hospitalization or use Wisconsin statutes define mental illness as a of major psychotropic medications; "mental disease to such extent that a person so af- flicted requires care and treatment for his or her • A planned or attempted suicide at some own welfare, or the welfare of others, or of the time during the last 12 months; community." Chronic mental illness is defined as "a mental illness which is severe in degree and per- • The lack of a legitimate productive role; sistent in duration, which causes a substantially

1 • A serious role impairment in their main inability to concentrate, remember things, or make productive role; and decisions; (g) fatigue or loss of energy; (h) restless- ness or decreased activity noticed by others; and (i) • A serious interpersonal impairment, as thoughts of suicide or death. A diagnosis of major defined through the client's self-report of isolation depression can be made if an individual has one or and loss of capacity to interact with others. more episodes of depression, characterized by at least two weeks of depressed mood (sadness, The clinical definition of a mental disorder, as hopelessness, or feeling discouraged) or loss of in- defined in the DSM-IV, is "a clinically significant terest in nearly all activities accompanied by at behavioral or psychological syndrome or pattern least four other symptoms of depression. Indivi- that occurs in an individual and is associated with duals between 24 and 44 years of age are most present distress or disability or with a significantly likely to have depression. Annually, nearly twice increased risk of suffering death, pain, disability, or as many women (6.5%) as men (3.3%) have major an important loss of freedom. In addition, this depressive disorder. syndrome or pattern must not be merely an expectable and culturally sanctioned response to a Bipolar disorder is another mood disorder, particular event." characterized by severe mood changes that shift between mania and major depression. It is Mental Disorders Affecting Adults. The estimated that 1% of adults have bipolar disorder. Department of Health and Family Services (DHFS) Bipolar disorder has two phases – manic and estimates that approximately 5.7% of non- depressive. Symptoms of the manic phase include: institutionalized adults in Wisconsin have a severe (a) extreme happiness, optimism, or self- mental illness. There are many types of mental confidence; (b) distractibility; (c) rapid, disorders. Anxiety disorders, major depression, uncontrollable ideas and speech pattern; (d) bipolar disorder, and schizophrenia are among the decreased need for sleep; (e) poor judgment; and most common mental disorders affecting adults. (g) sudden irritability, rage, or paranoia. Without treatment, the manic phase could last up to three Anxiety disorders are disorders that are months. The individual may experience a period of characterized by overwhelming anxiety and fear. normal mood and behavior before the depressive They include panic disorder, obsessive-compulsive stage begins with the "normal" period lasting disorder, post-traumatic stress disorder, social between hours and months, depending on the phobia, specific phobias, and generalized anxiety individual. The symptoms of the depressive stage disorder. The common theme among these are the same as those listed previously for major disorders is "excessive, irrational fear and dread." depression. Men and women are equally likely to Depending on the anxiety disorder, men or women be affected by this disease. may be more often affected. Schizophrenia involves dysfunction in one or Depression is a mood disorder, of which the more major areas of functioning, such as most common is major or unipolar depression. An interpersonal relations, self-care, or work or estimated 10% of American adults between the education, with the dysfunction lasting at least six ages of 18 and 54 have major depression. The months and including at least two of the following symptoms of major depression include: (a) feelings symptoms: (a) delusions; (b) hallucinations; (c) of sadness or irritability; (b) loss of interest in ac- disorganized speech; (d) grossly disorganized or tivities that were once enjoyed; (c) changes in catatonic behavior; or (e) restrictions in the range weight or appetite; (d) changes in sleeping pat- and intensity of emotional expression, in the terns; (e) feeling guilty, hopeless, or worthless; (f) fluency and productivity of thought and speech,

2 and in the initiation of goal-directed behavior. In a birth to 18 months of age, were ill, experienced given year, approximately 1% of the adults in the forced separations, emotional, sexual, or physical United States have schizophrenia. Symptoms abuse or neglect, or were at least two years old usually first appear between the ages of 15 and 25 when an adoptive/foster placement occurred are and men usually experience symptoms earlier than more likely to experience attachment disorder. women. There are many symptoms of an attachment disorder, including, but not limited to: (a) being Mental Disorders Affecting Children. The an- superficially engaging or charming; (b) avoiding nual prevalence of mental disorder in children and eye contact with parents; (c) being indiscriminately adolescents is not as well documented as that for affectionate with strangers; (d) being destructive to adults. About 20% of children are estimated to themselves, others, and material things; (e) being have mental disorders with at least mild functional cruel to animals and other people; (f) being unable impairment. While many mental disorders that to connect cause and effect, action and affect adults can also affect children, there are cer- consequence; (g) demonstrating a lack of tain mental disorders that tend to be associated conscience; (h) lying obviously; (i) failing to form most often with children, including attention-defi- deep relationships; (j) having learning disabilities cit/hyperactivity disorder, attachment disorder, or disorders; and (k) having trouble recognizing and conduct disorder. and expressing feelings.

Attention-deficit/hyperactivity disorder (AD- An estimated 10% of children and adolescents HD) occurs in up to 5% of children. Boys are al- have conduct, or disruptive behavior, disorder. most three times as likely to have ADHD as girls. These children repeatedly violate the personal or There are three types of ADHD: (a) inattentive; (b) property rights of others and the basic expectations hyperactive-impulsive; and (c) combined attention- of society. The symptoms of conduct disorder deficit/hyperactive disorder. Children with inat- include: (a) aggressive behavior that harms or tentive ADHD have short attention spans, are eas- threatens to harm other people or animals; (b) ily distracted, do not pay attention to details, make destructive behavior that damages or destroys lots of mistakes, fail to finish tasks, are forgetful, property; (c) lying or theft; and (d) skipping school don't seem to listen, and cannot stay organized. or other serious violations of rules. These Children with the hyperactive-impulsive type of symptoms must persist for six months or longer for ADHD fidget and squirm, are unable to stay seated a diagnosis of conduct disorder. or play quietly, run or climb too much, talk too much, blurt out answers before questions are com- Causes of Mental Illness. The causes of mental pleted, have trouble taking turns, and interrupt illnesses are not definitively known. However, others. The third type, combined attention- researchers have indicated that a number of factors deficit/hyperactive disorder, is the most common play a role in causing or helping to facilitate the type and the symptoms are a combination of both development of many mental illnesses, including the inattentive and hyperactive-impulsive types. biological, cognitive, genetic, and situational For a diagnosis of ADHD, symptoms must begin factors. For example, an individual with relatives before the age of seven, last six months, and be with depression are two to three times more likely evident in at least two different settings, such as to experience depression than an individual school and home. without a relative with depression. In addition, life events may trigger a depressive episode. Finally, Attachment disorder may affect children who the existence of certain medical illnesses, such as a were unable to establish secure and permanent stroke, heart disease, or cancer, appears to increase relationships early in their life. Children who, from the occurrence of mental disorders.

3 Co-Occurring Mental Illness and Substance recommend: (a) model mental health delivery Abuse Disorders. Attention at the national and systems that are effective in an environment that state level is beginning to focus on the prevalence emphasized managed care, client outcomes, and of co-occurring substance abuse and mental performance contracting; (b) ways federal, state, disorders. Approximately 15% of all adults who and county governments can cooperate to gain have a mental disorder in a given year also fiscal efficiencies and greater service capacity; (c) a experience a substance abuse disorder. Some service system targeted at prevention, early studies have found that, in the general population intervention, treatment, recovery, and positive of individuals 18 years or age and older, any past consumer outcomes; and (d) ways to reduce stigma history of mental disorder was associated with in the state's mental health policies and programs. more that twice the risk of having an alcohol disorder. In addition, the studies found that those In its April, 1997, report, the Commission with a mental disorder were more than four times recommended changes to the mental health system at risk of having another substance abuse disorder. that focus on consumer outcomes, the concept of recovery, prevention, and early intervention services, reducing stigma associated with mental disorders, the DHFS role in the mental health History of the Provision of system, and financing and organizational Mental Health Services in Wisconsin structures of the mental health system. Specifically, the Commission recommended pooling federal, state, and county funding for human services During the last 50 years, there has been a shift through a managed care approach to services. in the provision of mental health services from inpatient, institutional care to community-based The Blue Ribbon Commission adopted the care. This shift reflected many changes, including concept of recovery, defined as the successful an increased understanding of the cause and integration of a mental disorder into a consumer's treatment of mental illnesses and a philosophy life, as the key tenet of the redesigned mental change from viewing individuals with mental health system. In a recovery-oriented system, illness as "passive service users" to proactive mental health consumers participate in services consumers who can direct their own care and live that enable them to recover and decrease their and work within the community. During this time, dependence on the mental health system, rather it was realized that mental disorders are not than become long-term users of the system. necessarily lifelong and progressive. With appropriate supports, persons with mental The Commission identified five target disorders or severe emotional disturbance can populations, based on the level of a person's maintain school performance, jobs, friendships, service needs, for which to plan mental health and family networks. Further, it is recognized that services. The first three populations included: (a) mental health services must be flexible and persons who need ongoing, low-intensity, responsive to highly individual needs and comprehensive services; (b) persons who need environments and people with mental disorders ongoing, high-intensity, comprehensive services; value independence and productivity. and (c) persons who need short-term, situational services. The commission recommended that these Blue Ribbon Commission on Mental Health. people receive treatment and recovery services, In May, 1996, under an Executive Order, Governor including: (1) core mental health services Thompson appointed a Blue Ribbon Commission (assessment, crisis intervention, case management); on Mental Health. The Commission was directed to (2) self-help, peer support, and natural supports;

4 (3) community supportive services; and (4) in- administered health plans; (b) reducing residence services. discrimination against individuals with mental illness; (c) providing mental health services in a The other populations include persons who are culturally competent manner; and (d) increasing at risk of developing a mental disorder at some the number of people with a mental health need point in their lives and persons at an acceptable who have access to evidence-based treatment. level of mental health. The Commission recommended that these groups receive prevention and early intervention services. By providing these services, many of the conditions of mental illness The Provision of Mental Health Services can be reduced in absolute number, delayed in onset, or lessened in severity if specific risk factors are reduced, certain protective factors enhanced, The Department of Health and Family and early warning signs treated promptly. Services. The DHFS Bureau of Mental Health and Substance Abuse Services in the Division of The Commission recommended that the Disabilities and Elder Services is the state mental redesigned mental health system emphasize health authority for community mental health flexibility and creativity with the objective to services in Wisconsin. DHFS has a number of empower consumers, families, and mental health statutory requirements that the Bureau implements professionals to be creative as they seek to achieve on behalf of the state. Under s. 51.03 of the statutes, mutually agreed upon outcomes. To meet these DHFS may, within the limits of available state and goals, the Commission recommended that all federal funds, do the following: persons that receive health services: (a) participate in comprehensive assessments; (b) receive highly • Promote the creation of coalitions among individualized services based on that assessment the state, counties, providers of mental health and the consumer's chosen way of life; (c) have a services, consumers of the services and their plan of services designed to achieve positive families, and advocates for persons with mental consumer outcomes, including self-sufficiency; (d) illness to develop, coordinate, and provide a full are served with dignity, respect, and receive the range of resources to advance prevention, early least restrictive interventions necessary to achieve intervention, treatment, recovery, safe and consumer outcomes; and (e) receive services that affordable housing, opportunities for education, meet applicable standards of care. employment and recreation, family and peer support, self-help, and the safety and well-being of The Commission's report outlined a recovery- communities; oriented mental health system that promotes self- determination and quality of life, rather than • In cooperation with counties, providers of dependence, for persons of all ages with mental mental health services, consumers of these services, disorders and emphasizes prevention and early interested community members and advocates for intervention of targeted mental disorders. persons with mental illness, develop and implement a comprehensive strategy to reduce Healthy Wisconsin 2010. The state's public stigma of and discrimination against persons with health plan for 2000 through 2010 includes goals mental illness; for the provision of mental health services in Wisconsin by 2010. These include: (a) incorporating • Develop and implement a comprehensive questions relating to mental health problems in the strategy to involve counties, providers of mental screening and referral process for state- health services, consumers of these services and

5 their families, interested community members and the primary responsibility for the well-being, advocates for persons with mental illness as equal treatment, and care of persons with mental dis- participants in service system planning and abilities (persons with mental illness, developmen- delivery; tal disabilities, and alcoholic and other drug dependent persons) who reside in the county and for • Promote responsible stewardship of human ensuring that persons in need of emergency ser- and fiscal resources in the provision of mental vices who are in the county receive immediate health services; emergency services.

• Develop and implement methods to Under standards established by rule, each identify and measure outcomes for consumers of county establishes its own program and budget for mental health services; these services. The statutes specify that each county is responsible for the program needs of persons • Promote access to appropriate mental with mental illness only within the limits of health services regardless of a person's geographic available state and federal funds and county funds location, age, degree of mental illness, or required to match these funds. Thus, counties limit availability of personal financial resources; service levels and establish waiting lists to ensure that expenditures for services do not exceed • Promote consumer decision making to available resources. For this reason, the type and enable persons with mental illness to be more self- amount of community-based services that are sufficient; and available to persons with mental illness varies among counties in the state. • Promote use of individualized service planning by providers of mental health services, The mental health services available in Wiscon- under which the providers develop written sin range from community-based care to inpatient individualized service plans that promote and psychotherapy services. Counties are directed treatment and recovery, together with service to provide services to individuals in the least re- consumers, families of service consumers who are strictive environment that is appropriate for their children, and advocates chosen by consumers. needs. Counties are required within the limits of available state and federal funds and of required Finally, DHFS is required to ensure that county matching funds, to provide for the needs of providers of mental health services who use persons with mental disabilities, including mental individualized service plans: (a) establish illness, developmental disabilities, and substance meaningful and measurable goals for the abuse by offering the following services: (a) col- consumer; (b) base the plan on a comprehensive laborative and cooperative services with public assessment of the consumer's strengths, abilities, health and other groups for programs of preven- needs, and preferences; (c) keep the plan current; tion; (b) comprehensive diagnostic and evaluation and (d) modify the plan as necessary. services; (c) inpatient and outpatient care and treatment, residential facilities, partial hospitaliza- DHFS also administers state and federal tion, emergency care, and supportive transitional funding for mental health services to counties or services; (d) related research and staff in-service agencies for the provision of these services, which training; and (e) continuous planning, develop- are described elsewhere in this paper. ment, and evaluation of programs and services for all population groups. Counties. In Wisconsin, each county is assigned

6 Under federal law, the state is required to Funding of Mental Health establish and maintain a council on mental health Services in Wisconsin in order to receive CMHBG funds. The Council on Mental Health is an institutional advocacy and advisory council for individuals with mental illness There are four primary funding sources for and is attached to DHFS for administrative public mental health services in Wisconsin: (a) the purposes. The Council is statutorily required to federal community mental health block grant advise DHFS, the Legislature, and the Governor on (CMHBG); (b) state and local funding; (c) medical the use of state and federal resources and on the assistance (MA); and (d) private insurance and provision and administration of programs for individual copayments. The first three funding persons who are mentally ill or who have other sources are discussed in this paper. mental health problems, for groups who are not adequately served by the mental health system, for Community Mental Health Block Grant. In the prevention of mental health problems, and for federal fiscal year 2003-04, Wisconsin received other mental health-related purposes. In addition, $6,864,500 in CMHBG funds. States may use these the Council is required to: (a) provide funds to provide comprehensive community recommendations to DHFS on the expenditure of mental health services to adults with a serious CMHBG funds; (b) participate in the development mental illness and to children with a serious of the CMHBG plan and monitor and evaluate the emotional disturbance and to monitor the progress implementation of the plan; (c) review and monitor in implementing a comprehensive community all DHFS plans and programs affecting persons based mental health system. The federal fiscal year with mental illness; (d) annually submit a report on 2003-04 Wisconsin state mental health plan recommended policy changes in the area of mental identifies six priority program areas for the use of health to the Governor and Legislature; and (e) these funds: (1) wraparound programs for children promote the development and administration of a with serious emotional disorders (SED); (2) delivery system for community mental health consumer and family self-help and peer support services that is sensitive to the needs of consumers services; (3) prevention and early intervention; (4) of the services. DHFS is required to submit all its recovery and other training for consumers and plans affecting persons with mental illness to the providers; (5) protection and advocacy services; council for its review. and (6) program development for the behavioral mental health managed care demonstration Community Aids. Under the state's community projects. aids program, DHFS distributes state and federal funds to counties for community-based social, Of the $6,873,000 FED available in state fiscal mental health, developmental disabilities, and year 2004-05 from the CMHBG, $2,513,400 is substance abuse services. DHFS allocates allocated to counties through community aids, community aids funding to counties on a calendar $1,330,500 is distributed to integrated service year basis and in a single amount that includes projects for children throughout the state, $496,000 federal and state revenue sources. Counties receive is allocated for the coordinated services team both a basic county allocation, which may be initiative, $2,114,800 is allocated for a variety of expended for any of these eligible services, and grant programs distributed to counties and categorical allocations, which are earmarked funds agencies, and $418,300 is budgeted to support for specific services and programs. For 2005, the DHFS operations costs. These programs are estimated basic county allocation totals described in greater detail later in this paper. $186,483,500 (all funds), representing 90% of all funds allocated to counties in that year

7 ($206,154,900). From the remaining portion, of the block grant to pay for administrative costs. counties receive funding earmarked for selected Block grant funding may not be used to provide programs and specific services, including mental inpatient services or to make cash payments to health services. intended recipients of health services.

Services Supported by the Basic County Allocation. Medical Assistance. Wisconsin's MA program Counties may use funding they receive under the provides outpatient and day treatment mental community aids basic county allocation for a wide health services if prescribed by a physician and range of services for specified populations, certain other conditions are met. Health including persons with mental disorders. maintenance organizations (HMOs) serving MA Annually, counties report the funding, including recipients are required to provide all of the same community aids, required county matching funds, services available to recipients receiving services and local funds contributed that are in excess of the on a fee-for-service basis, including mental health required matching funds ("overmatch funds") used services. HMOs do not report their costs of to support services to individuals with mental providing mental health services to MA recipients. disorders. In 2003, counties reported spending The payment information included in this section approximately $330.4 million on mental health only reflects services provided to individuals on a services provided to approximately 86,700 fee-for-service basis, meaning the provider directly individuals. bills the MA program, rather than providing the service through an HMO. Categorical Allocations. One of the five categorical allocations in community aids is the Outpatient Psychotherapy. Outpatient psycho- community mental health block grant. For 2004-05, therapy services are available to any MA recipient an estimated $2.5 million will be distributed from if the service is prescribed by a physician and a the CMHBG to counties to provide comprehensive diagnostic examination is performed by a certified community mental health services to adults with psychotherapy provider. Prior authorization is serious mental illness and to children with a required for outpatient services provided in excess serious emotional disturbance, evaluate programs of $500 or after 15 hours of services are provided to and services, and conduct planning, admini- a recipient in a calendar year. MA payments for stration, and educational activities related to outpatient psychotherapy services totaled providing services. There are eight priority approximately $18.9 million (all funds) in 2003-04. program areas where these funds should be used: Approximately 16,300 recipients received these (1) supported housing for people with serious services in an outpatient hospital setting and mental illness; (2) integrated service projects (ISPs) approximately 56,000 recipients received these for children with serious emotional disturbances; services in a non-hospital setting, such as clinics or (3) jail diversion programs; (4) community support therapists' offices. programs; (5) crisis intervention services; (6) family and consumer peer support services; (7) programs Day Treatment. Day treatment services are for people with co-occurring mental illness and reimbursed for up to five hours per day or 120 substance abuse problems; and (8) community hours per month and require prior authorization mental health data-set development. Counties are after 90 hours are provided in a calendar year. Day required to submit a plan to DHFS annually treatment services are only covered for MA identifying how the county plans to use its recipients with serious and persistent mental allocation in one or more of these priority areas. illness or acute mental illness with a need for day treatment and an ability to benefit from the service, Federal guidelines allow states to use up to 5% as measured by a functional assessment scale

8 provided by DHFS. Payments for day treatment Comprehensive Community Services. Beginning in services totaled approximately $1.3 million in 2003- 2004-05, a new benefit, comprehensive community 04 for services provided to approximately 720 MA services, is available for persons with mental health recipients. or substance abuse conditions, as a county-funded service. Counties must elect to provide the service County-Funded Services. In addition to and provide the state's share of the costs of the outpatient psychotherapy and day treatment benefit. Recipients must have impairment in major services, MA covers several mental health services areas of community living as evidenced by the targeted to individuals with severe, serious, and need for ongoing and comprehensive services of persistent or acute mental illness, but for which either high-intensity or low-intensity nature. local governments pay the state's share of the MA Services can include medical and rehabilitative payment. By claiming federal MA-matching funds services and supportive activities intended to for these services, local governments, particularly provide for a maximum reduction of the effects of counties, are able to supplement local funding for the individual's mental health or substance abuse services provided to MA-eligible individuals. condition and restoration to the best possible level These services include community support of functioning and to facilitate the individual's program (CSP), crisis intervention, and case recovery. A physicians' prescription is required for management services. an individual to receive comprehensive community services and services provided must be Community support program services include consistent with needs identified through a assessments, treatment, case management, and comprehensive assessment, which is completed by psychological rehabilitation services, including a recovery team made up of the individual, a employment-related services, social and licensed mental health professional, the recreational skill training, and assistance with individual's family, and others as appropriate. activities of daily living and other support services. These services are available when prescribed by a Prescription Drugs. In addition to therapy physician and provided by providers that meet the services, treatment for individuals with severe conditions for community support programs mental illness can frequently involve the use of administered by counties. In 2003-04, federal funds medication. In 2003-04, MA paid approximately claimed for CSP services totaled approximately $100.9 million (all funds) on behalf of $23.6 million for services provided to approximately 46,000 MA recipients for anti- approximately 5,000 recipients. psychotic medications. Of all the drugs covered under MA, atypical anti-psychotic medications (a Crisis intervention services are services type of anti-psychotic medication) was the highest provided by a mental health crisis intervention expenditure category in 2003-04, representing program operated by, or under contract with, a approximately 17 percent of all drug purchases in county. In 2003-04, federal funds claimed for crisis that year. The average cost per person was intervention services totaled approximately $7.4 approximately $2,530. million for services provided to approximately 4,600 MA recipients Additionally, MA paid an estimated $49.8 million in 2003-04 for anti-anxiety and anti- Federal claims totaled approximately $3.3 depressant medications. However, not all MA million in 2003-04 for case management services recipients who use these drugs have a severe provided to approximately 5,200 MA recipients mental illness. These medications can be prescribed with serious and persistent mental illness. to any MA recipient who receives services on a fee- for-service basis for a variety of medical reasons.

9 For example, individuals receiving chemotherapy result of an emotional disturbance. for treatment of cancer can be prescribed anti- anxiety medications to address some of the side Functional Impairment. The individual must ex- effects associated with that treatment. MA hibit functional impairment in two of the following payment for drugs used by individuals enrolled in capacities (compared with expected developmental HMOs are included in the capitation payments level): (a) self care; (b) community; (c) social rela- made to those organizations and are not included tionships; (d) family; or (e) school or work. in this data. 4. The individual is receiving services from two or more of the following service systems: (a) mental health; (b) social services; (c) child Programs for Children with protective services; (d) juvenile justice; (e) special Serious Emotional Disturbances education; or (f) substance abuse.

In Wisconsin, DHFS estimates that there are Children with serious emotional disturbances approximately 62,000 children between the ages of (SED) are defined in Wisconsin as individuals nine and 15 with SED and about one-half will, at under the age of 21 who require acute treatment one point, need public services. and may lead to institutional care. In addition, the disability must be evidenced by the following: Integrated Service Projects for Children with SED. Integrated service projects (ISPs) provide 1. The disability must have persisted for six integrated services, also referred to as months and be expected to persist for a year or "wraparound services," which focus on the longer; strengths and needs of the child and family and "wrapping" services around them to treat and 2. A mental or emotional disturbance listed in support families in the community. The program the DSM-IV diagnostic categories appropriate for serves children under 18 years old who: (a) have a children and adolescents and disorders usually serious emotional disturbance; (b) have minimal first evident in infancy, childhood, and coping skills to meet the ordinary demands of adolescence. These could include schizophrenia family life, school, and the community; and (c) are and other psychotic disorders, anxiety disorders, involved in two or more service systems, including attention deficit and disruptive behavior disorders, mental health, child welfare, or juvenile justice. and feeding and eating disorders; Priority is given to children with severe disabilities who are at risk of placement outside of the home, 3. Functional symptoms and impairments. who are in institutions and are not receiving The individual must have either symptoms or integrated community-based services, or who functional impairment, as described below: would be able to return to community placement or their home from an institutional placement if Symptoms. The individual must exhibit one of such services were provided. the following: There are currently 18 counties in Wisconsin • A serious mental illness that is with ISP programs. In 2003-04, DHFS distri- characterized by defective or lost contact with buted $1,440,000 ($133,300 general purpose reality, often with hallucinations or delusions; or revenue (GPR) and $1,306,700 FED from the CMHBG) for grants to these counties for their ISP • Danger to self, others, or property as a programs. Table 1 lists these counties and their

10 annual grant award for 2004. health organization, to provide services for eligible children. In addition to the programs listed in Table 1, eight other Wisconsin counties operate programs Services are supported with combined MA and for children with SED. The Children Come First county funds. In 2003, the program served 251 Program in Dane County and Wraparound children . Milwaukee in Milwaukee County are managed care programs that are funded with MA and Wraparound Milwaukee. Wraparound Mil- county funds. Forest, Oneida, Vilas, Marathon, waukee served 905 children and families in 2003. Langlade, and Lincoln Counties participate in the Of these children, 59% were diagnosed with con- Northwoods Alliance for Children and Families duct disorder or oppositional defiant disorder, 50% and were supported with a federal grant, MA, and with depression, and 46% with ADHD. Nine lead county funds. agencies provided care coordination services in 2003: (a) AJA Enterprises; (b) Alternatives in Psy- chological Consultation; (c) Aurora Family Ser- Table 1: Integrated Service Projects vices; (d) Children's Service Society; (e) La Causa, Calendar Year 2004 Awards Inc.; (f) My Home Your Home; (g) St. Aemilian – Total Lakeside; (h) St. Charles Youth and Family Ser- Counties GPR FED Award vices; and (i) Willowglen Community Care Center.

Ashland $7,500 $72,500 $80,000 The network of service providers had 230 agencies Chippewa 7,400 72,600 80,000 offering 80 different services to families served Door 7,400 72,600 80,000 through Wraparound Milwaukee. The most fre- Dunn 7,400 72,600 80,000 quently utilized community services include in- Eau Claire 7,400 72,600 80,000 Fond du Lac 7,400 72,600 80,000 home family therapy, foster care services, in-home Kenosha 7,400 72,600 80,000 therapy, and crisis stabilization. La Crosse 7,400 72,600 80,000 Marinette 7,400 72,600 80,000 Marquette 7,400 72,600 80,000 The Wraparound Milwaukee program is Portage 7,400 72,600 80,000 operated by the Milwaukee County's Behavioral Racine 7,400 72,600 80,000 Health Division. Wraparound Milwaukee is Rock 7,400 72,600 80,000 supported by combining funding from Milwaukee Sheboygan 7,400 72,600 80,000 Washburn 7,400 72,600 80,000 County, the DHFS Bureau of Milwaukee Child Washington 7,400 72,600 80,000 Welfare, and MA. Waukesha 7,400 72,600 80,000 Waushara 7,400 72,600 80,000 Northwoods Alliance for Children and Families. Total $133,300 $1,306,700 $1,440,000 Forest, Oneida, Vilas, Marathon, Langlade, and Lincoln Counties participate in the Northwoods Alliance for Children and Families. The Alliance is Children Come First of Dane County. Children in supported by a federal grant from the Substance Dane County with SED who are eligible for either Abuse and Mental Health Services Administration MA or BadgerCare, are at imminent risk of an out- (SAMHSA) and the Center for Mental Health of-home placement (including to a psychiatric Services (CMHS). The goal of the Alliance is to hospital), and are not residents of a nursing home create and sustain a regional, integrated system of or a psychiatric hospital are eligible for services care that will successfully meet the complex needs through the Children Come First program. Under of SED children and their families. In 2003, 107 the program, Dane County contracts with children were served by the Alliance, including 55 Community Partnerships, Inc., a limited service in Marathon County. Referrals come from four

11 systems – child welfare, mental health, education, of the Social Security Act, which is funding to and juvenile justice, as well as caregivers and support child welfare activities. health care providers. At the time of enrollment, 42% of the children were diagnosed with a Counties may use this funding: (a) for systems behavior disorder, 37% with ADHD, 21% with change activities; (b) to promote and enable affective disorder or depression, and 1% with a consumer involvement; and (c) to provide direct psychotic disorder. The program is supported with services. No more than 10% of a county's allocation a combination of federal funds, county funds, and can be used for direct services. Instead, the services MA matching funds. Federal funding for this must be provided by the programs already program ended August, 2004. established in the county and the CST grant allocation allows the county to implement the CST Coordinated Service Team Initiative. The approach to serving those families. coordinated service team (CST) initiative combines mental health, substance abuse, and child welfare In FFY 2003-04, $524,700 was allocated to the funding to award grants to support programs in pilot counties for CST activities, $49,300 was ten counties. These projects are implementing a allocated to counties for training, and $67,000 was systems change by coordinating services for budgeted for DHFS administrative costs. In FFY children and families who are involved in multiple 2003-04, $496,000 FED was available from the systems, which may include mental health, child CMHBG, $35,000 FED was available from the welfare, substance abuse, juvenile or adult justice, SAPT block grant, and $110,000 FED was available special education, W-2, domestic violence, and under Title IV-B. developmental disabilities. Projects use a strength- based, family centered, coordinated service Table 2 identifies the funding allocated to approach (wraparound) to improve outcomes for counties in both FFY 2002-03 and 2003-04. Bayfield, children and families. The CST projects use a team Marquette, Portage, and Sauk Counties began approach across agencies, involve parents in all receiving funding for CST later in FFY 2002-03, aspects of the process, build on natural supports, which explains the lower amount of funding respect individual differences and preferences, and allocated to these counties in that year. require collaborative funding.

This initiative began in December, 2002. DHFS Table 2: Coordinated Service Team Grants allocates funding to 10 counties, which were FFY 2002-03 and FFY 2003-04 chosen through a competitive RFP process. These County FFY 2002-03 FFY 2003-04* counties will receive grants for between three to five years, depending on available funding. DHFS Bayfield $4,197 $40,576 Calumet 60,000 63,500 allocates funding to the counties on a federal fiscal Green Lake 36,252 58,500 year (FFY) basis. In FFY 2002-03, $462,000 FED was Iron 43,000 53,770 provided for the initiative. Of this amount, Jefferson 47,000 53,500 Manitowoc 36,588 63,500 $296,000 was allocated to counties, $66,000 was Marquette 8,333 57,000 budgeted for administrative costs, and $100,000 Portage 4,615 62,385 was budgeted for training and consultation with Sauk 7,870 57,769 Waupaca 48,145 63,500 the pilot counties. Of the total funding, $496,000 is from CMHBG, $35,000 was from the substance Total $296,000 $574,000 abuse prevention and treatment (SAPT) block *Includes $49,276 for training. grant, and $131,000 was available under Title IV-B

12 disorders or documentation in the client record Community Support Program that shows that there have been consistent and extensive efforts to treat the client and these efforts have persisted for more than a year, except in Community support programs, or CSPs, pro- unusual circumstances such as a serious and vide treatment, rehabilitation, and support services sudden onset of dysfunction, causing the client's for persons with serious and persistent mental ill- condition to move beyond basic outpatient clinical ness. There are 78 certified CSPs in 61 counties and standards of practice; at least 18 case management programs in Wiscon- sin, as shown in Appendix I. A case management • The individual exhibits persistent danger- program is not MA certified and thus, the county ousness to self or others; cannot claim MA-matching funds for services. • A significant risk of either continuing in a As specified in s. 51.421 of the statutes, in order pattern of institutionalization or living in a to provide the least restrictive and most severely dysfunctional way if CSP services are not appropriate care and treatment for persons with provided; and serious and persistent mental illness, every county must provide community support services, if the • Impairment in one or more of the following funds are provided and within the limits of functional areas: (a) vocational, educational, or available funds under community aids. Each CSP homemaker functioning; (b) social interpersonal or has a coordinated case management system and community functioning; or (c) self care or provides or ensures access to services for persons independent living. with a serious and persistent mental illness who Each individual in a CSP is assigned a case reside within the community. The services manager who maintains a clinical treatment provided or coordinated through a CSP include relationship with the client on a continuing basis, assessment, diagnosis, identification of persons in whether the individual is in the hospital, in the need of services, case management, crisis community, or involved with other agencies. The intervention, psychiatric treatment, activities of case manager works with the client, other CSP daily living, and psychosocial rehabilitation. These staff, and agencies to coordinate the assessment services are provided on an individual basis, and diagnosis of the individual, develop and according to the treatment and psychosocial implement a treatment plan for the individual, and rehabilitation needs of the individual. directly provide care or coordinate treatment and An individual is eligible for services in a CSP if services. he or she has a serious and persistent mental illness which, by history or prognosis, requires repeated Certified CSPs are funded with local and MA acute treatment or prolonged periods of matching funds, and $1.0 million GPR annually. As institutional care and exhibits persistent disability shown in Appendix II, DHFS allocates the GPR or impairment in major areas of community living funding to 23 counties with certified CSP programs as evidenced by: on a calendar year basis. The funding was initially allocated to counties in the 2001-03 biennium to • A condition of serious and persistent serve MA-eligible individuals who met the mental illness; eligibility requirements for CSP, but were on a waiting list for services. In 2003, counties reported • A diagnosis of schizophrenia, affective spending $56.7 million for community support disorders, delusional disorder, or other psychotic mental health programs, including $1.27 million of

13 CMHBG funds. This funding supported services affairs coordinator; (b) developed a consumer self- for 9,156 individuals. help program; (c) developed a recovery training package; (d) in collaboration with DHFS, If a county has insufficient funds to provide developed a functional screen to target the group services to all individuals who qualify for the of people that will be enrolled into the managed program, it may place eligible individuals on care program and developed consumer outcome waiting lists for services or provide less intensive tools; and (e) established a system to collect services to these individuals. individual client expenditure data. In addition, DHFS is developing a web-based functional screen and training materials have been developed for screeners statewide. Finally, analysis of client data Behavioral Health Managed collected from the four projects in 2001 and 2002 Care Demonstration Projects has begun.

Each project received a grant of $125,000 FED in In January, 2001, DHFS began funding four both 2003-04 and 2004-05. The federal funds were mental health/substance abuse demonstration pi- available under the federal CMHBG. lot programs that provide services to persons with mental illness and/or alcohol or other drug de- pendency on a fee-for-service basis. The original four mental health/substance abuse demonstration Services for Homeless Individuals projects were in Milwaukee, Dane, Kenosha, and Forest/Vilas/Oneida Counties. Milwaukee County has since withdrawn from the project and La DHFS estimates that 7,300 people in Wisconsin Crosse County has joined. The projects are in- are homeless and have a serious mental illness. tended to implement the Governor's Blue Ribbon DHFS allocates federal funds the state receives for Commission's recommendations by changing men- projects for assistance in transition from tal health service delivery in these counties from a homelessness (PATH) to public, nonprofit agencies maintenance system (maintaining an individual to provide mental health services to persons who with a mental illness in a humane environment) to are in need of such services and who are also an individualized system, focused on the individ- homeless. These funds, combined with state GPR ual consumer's goals and life. matching funds, are distributed to 11 counties that were identified as having the greatest number of The demonstration projects provide the county the state's homeless population. In 2004-05, DHFS with flexibility in funding. The projects are distributed $45,000 GPR and $557,574 FED to serve working towards an MA-capitation system to fund homeless individuals. These allocations are shown services for those individuals enrolled in the new in Table 3. There is a 25% match requirement on system. Under this change, the participating the PATH funds. The state GPR funding provides a counties agree to provide community aids and portion of this match requirement and counties county funds at current levels for mental health provide the remaining funds. services. Under this managed care approach, the money follows the mental health service consumer. DHFS allocated this funding to support outreach, screening and diagnostic treatment, The demonstration projects receive grants habilitation and rehabilitation, community mental supported with federal CMHBG funds. With this health services, substance abuse treatment services, funding, each project has: (a) hired a consumer staff training, case management, supportive and

14 Table 3: PATH Grants -- 2004-05 Other Grant Programs Federal State Total County Funds Funds Award

Brown $47,298 $2,702 $50,000 In addition to the programs already described, Dane 58,515 6,485 65,000 DHFS allocates federal CMHBG funding for a vari- Douglas 15,974 0 15,974 ety of different consumer support and education Eau Claire 17,838 2,162 20,000 Fond du Lac 17,379 1,621 19,000 opportunities and system change activities. These Kenosha 21,298 2,702 24,000 grants are described below. La Crosse 24,879 1,621 26,500 Milwaukee 180,729 18,870 199,600 Outagamie 30,879 1,621 32,500 Consumer and Family Support Grants. DHFS Racine 22,298 2,702 25,000 allocates $874,000 FED annually for consumer and Rock 120,487 4,513 125,000 family support grants to increase support for

Total $557,574 $45,000 $602,574 mental health family support projects, employment projects operated by consumers of mental health services, mental health crisis intervention and supervisory services in residential setting, referrals drop-in projects, and public mental health for health services, housing, and other allowable information activities. Three organizations receive services. these grants: the National Association of the Mentally Ill, Wisconsin Family Ties, and the Shelter Plus Care Program. The shelter plus care Grassroots Empowerment Project. program provides permanent housing for persons with a serious and persistent mental illness who The National Association of the Mentally Ill are homeless. Funding from the federal Housing receives $210,000 FED annually on a calendar-year and Urban Development (HUD) agency provides basis to support consumer and family projects, the rental subsidy for apartments and PATH funds including consumer education, information referral provide the required match of equal or greater resources, advocacy, a toll-free help line available funding for treatment services. Through a request in English and Spanish, and a bi-monthly for proposal (RFP) process in 1999, DHFS awarded newsletter for consumers and families. All of these $37,500 FED in PATH funds to both Rock and activities are intended to increase public Kenosha Counties to support this program. In understanding and support of mental health and addition, HUD provided $100,000 FED per year for related issues. five years to pay for an apartment rental for homeless individuals with a serious mental illness. Wisconsin Family Ties also receives $210,000 The 25% match requirement for the PATH funds is FED annually on a calendar-year basis. Wisconsin fully supported by the counties. Due to ongoing Family Ties serves children with SED and their problems with the implementation of Shelter Plus families to help them access services, provides Care in Kenosha, DHFS will award all of the PATH advocacy services for these children, distributes a funding for the Shelter Plus Care program to Rock statewide newsletter, and provides training to County in 2004-05. Milwaukee, Dane, and Racine county workers and family members to better Counties receive funding directly from HUD to advocate for individuals who have mental support similar shelter plus care programs. disorders.

Grassroots Empowerment Project is a consumer run organization and receives $454,000 FED annually on a calendar-year basis to fund local

15 consumer organizations for individuals with initiative, and has provided presentations and mental illness. The agency funds seven clubhouse materials for the media and for the Bureau of projects around the state, which provide a number Community Mental Health conferences. of opportunities and supports, including vocational training and job opportunities, for Additionally, from this grant, MHA has individuals with mental illness. allocated $5,000 grants to six agencies to serve specified populations: (a) Interfaith Community Prevention, Early Intervention, and Recovery Volunteers and Heart to Heart, which targets Grants. Under s. 51.03 (1g) of the statutes, isolated, low-income, rural older adults; (b) Mental "prevention" is defined as actions to reduce the Health Association of Sheboygan County, which instance, delay the onset, or lessen the severity of a targets rural farming families; (c) Our Space, which mental disorder, before the disorder may progress targets older urban, low-income Native Americans; to mental illness, by reducing risk factors by (d) Parent Education Project, which targets enhancing protection against and promptly children with disabilities in both urban and rural treating early warning signs of a mental disorder. communities; (e) Waukesha County Human "Early intervention" is defined as actions to hinder Services Department, which targets older adults or alter a person's mental disorder in order to with a support system and multiple risk factors, reduce the duration of early symptoms or to primarily in a rural setting; and (f) Waukesha reduce the duration or severity of mental illness County Health and Human Services Department that may result. "Recovery" is defined as the and Wisconsin Family Ties, which targets youth in process of a person's growth and improvement, foster or kinship care, primarily in an urban despite a history of mental illness in attitudes, setting. feelings, values, goals, skills, and behavior and is measured by a decrease in dysfunctional In 2003-04, $33,000 FED was allocated to Movin' symptoms and an increase in maintaining the Out, a housing counseling agency that provides person's highest level of health, wellness, stability, direct services to households where at least one self-determination, and self-sufficiency. member has a permanent disability and the household's income is 80% or less of the county's DHFS allocates $95,000 FED annually to the median income. The grant supported National Association of the Mentally Ill (NAMI) to individualized housing counseling for individuals provide recovery training for the behavioral health with mental illnesses to assist them in moving demonstration sites on recovery, risk, and choice. towards self-sufficiency.

An annual grant of $95,000 FED was initially System Change Grants. Under s. 46.52 of the awarded to the Mental Health Association (MHA) statutes, system change grants support the initial in Milwaukee in September, 2000. The grant is a phasing in of recovery-oriented system changes, three-year grant, which was renewed annually. prevention and early intervention strategies, and The RFP for the grant stated that the expected consumer and family involvement for individuals outcome is "to implement statewide prevention with mental illness. Counties must use at least 10% and early intervention activities or services for of the funds for services to children with mental mental health." MHA provides technical assistance illness. Counties must continue providing the to the behavioral health managed care community-based services that are developed demonstration projects and to local communities under the system change grant after the three-year within those counties, has developed a MHA grant expires by use of savings made available to resource center and website, has helped to develop the county from incorporating recovery, the Wisconsin Prevention Network, the anti-stigma prevention, and early intervention strategies, and

16 consumer and family involvement in the services. services.

In FFY 2003-04, $275,900 is budgeted for system The Wisconsin Council on Children and change grants. Some of these funds were combined Families receives $45,000 FED annually to support with funding for the behavioral health managed the annual Children Come First conference, a care demonstration projects and allocated as grants family-based conference, and a crisis conference. In to the projects. addition, this funding supports statewide training and technical assistance to counties. The Mental Health Association received a three-year, annually-renewable systems change DHFS distributes $87,000 FED annually to the grant of $245,100 FED from DHFS in October, 2002, University of Wisconsin, Department of for project management services. The Association Psychiatry, for bi-weekly teleconferences for direct works with the demonstration sites to ensure that service providers on a variety of topics, including the projects are delivering recovery services and medications, substance abuse, mental health and provide technical assistance to the projects. The the elderly, vocational rehabilitation, and Association will collect outcome data from 300 consumer dental care needs. consumers to evaluate the performance of the projects. The Grassroots Empowerment Project receives $20,000 FED annually to reimburse consumers who The Mental Health Association also received a participate in and attend state conferences, groups, grant in 2003-04 of $30,845 FED for training on council meetings, and other events. trauma services for women, which it subcontracts to New Partnerships for Women. Under this DHFS allocates $5,000 FED annually to the contract, New Partnerships for Women has Green Bay Area Agency on Aging, which sponsors developed a training curriculum that promotes the aging and substance abuse coalition for the wellness for women who have experienced trauma elderly that includes long-term support programs, and have either mental health or substance abuse the aging network, and the substance abuse problems, or both. Three trainings were held in services system. The agency provides training to 2003-04 for women between the ages of 20 and 60 case management and nursing staff. years old. In addition, $9,200 FED is used for other mental Protection and Advocacy. DHFS distributes health conferences, including $3,000 for the infant $65,000 FED annually to the Wisconsin Coalition mental health initiative which focuses on early for Advocacy, as a supplemental award to federal identification of mental health problems in funds that the Coalition receives independently. children, and $6,200 to support a statewide The Wisconsin Coalition on Advocacy is the community support program (CSP) conference. designated protection and advocacy agency in Wisconsin for people with mental illnesses. The Coalition uses this funding to advocate for individuals with mental illness, training, and Inpatient Services developing training materials.

Training. DHFS distributes $172,800 FED Institutions for Mental Diseases. Federal law annually for training for mental health treatment defines an institution for mental diseases (IMD) as professionals on mental health standards, best a hospital, nursing facility or other institution with practice, recovery principles, and emergency crisis more than 16 beds that is primarily engaged in

17 providing diagnosis, treatment or care of persons Institute (MMHI), located in the City of Madison, with mental diseases, including medical attention, opened in 1860, while the Winnebago Mental nursing care and related services. There is one Health Institute (WMHI), located near the City of nursing home and 10 hospitals in the state that Oshkosh, began operating in 1873. Both facilities operate as IMDs, including two state-operated are licensed and accredited hospitals that provide psychiatric hospitals. The nursing home and six of training and research opportunities, in addition to the hospitals are county-owned and operated. psychiatric services.

Under federal law, residents of IMDs who are MMHI offers a total of 13 different inpatient 22 years of age or older but have not reached the treatment units, including forensic psychiatry, age of 65 are ineligible for MA-supported inpatient child, adolescent, adult, and geropsychiatric psychiatric services, except that an MA-eligible programs. These treatment units include: two child person under the age of 22 who has been receiving units, three adult units and eight forensic units inpatient psychiatric services under the direction of that, in total, have the capacity to serve 249 a physician and provided by an accredited patients. MMHI also operates the Program of psychiatric hospital or facility, remains eligible for Assertive Community Treatment (PACT), a MA until that person is unconditionally released or community support program for individuals with reaches the age of 22. However, the state provides serious mental illness. In addition to these services, a GPR supplement of $9 per person per day to MMHI operates two units at the Mendota Juvenile support the care of individuals who receive Treatment Center (MJTC) that have the capacity to specialized mental health services in an serve 29 adolescent males from Wisconsin's institutional setting. In 2004-05, $10,914,700 GPR is juvenile correctional facilities whose behavioral also budgeted to assist counties in supporting and treatment needs exceed the resources at the residents of IMDs and individuals relocated from correctional facilities. an IMD, or a MA-certified nursing facility, to a community-based treatment program. Another WMHI includes 13 units targeted to different $830,000 annually is budgeted to support adult and youth populations, including five relocation services for individuals who have a forensic units, four adult units, and four child and mental illness, are otherwise eligible for MA, and adolescent units. The Activities Within a Regulated are in need of active treatment but whose needs Environment (AWARE) program assists adults can be met in the community. Counties are who are dually diagnosed with mental illness and required to supply a match of 9.89% of the cost of developmental disabilities, while Service for community service in order to receive these Multiply-Impaired Children (SMIC) treats youth relocation funds. with severe emotional or behavioral problems, in addition to cognitive disabilities. WMHI's Gemini unit provides substance abuse programs for mentally ill and chemically dependent adults, and State Mental Health Institutes the Anchorage unit provides specialized services for chemically dependent adolescents between the ages of 14 and 18. Patients receive a variety of The DHFS Division of Disability and Elder services, including psychiatry, psychology, Services operates two mental health institutes that nursing, education, social, nutritional, and provide psychiatric services to adults, adolescents, chaplaincy. and children who are either civilly-committed or who are forensic patients committed as a result of a Both facilities offer occupational, physical, criminal proceeding. The Mendota Mental Health musical, pre-vocational, recreational, speech, and

18 language therapy. involuntary commitments and, in general, these admissions must be approved by the county of the Table 4 provides information on the average patient's residence. A voluntary admission occurs number of patients, by type, at the institutes in when an adult applies for admission to an fiscal year 2003-04, and the percentage of the total inpatient treatment facility and receives approval each patient population represents. from the director of the facility. In order to be admitted to an inpatient facility, an evaluation Table 4: Average Daily Populations (ADP) at the must confirm that the applicant is mentally ill, Mental Health Institutes (by Type) -- 2003-04 developmentally disabled, or is alcohol or drug dependent and would benefit from inpatient care, Mendota Winnebago treatment, or therapy. Minors may generally be ADP Percent ADP Percent admitted under the same criteria, with the consent Child/Adolescent 22.5 8.9% 52.7 19.8% of a parent or legal guardian. Forensic 157.7 62.4 132.6 49.8 Adult 43.7 17.3 46.2 17.4 Involuntary civil commitments are sought in MJTC 28.9 11.4 0.0 0.0 Substance Abuse 0.0 0.0 34.5 13.0 cases where a patient is considered to be mentally ill and dangerous to either themselves or others. In Totals 252.8 100.0% 266.0 100.0% order to start the involuntary commitment process,

an emergency detention by a law enforcement officer must be made or a petition for examination Annually, DHFS staff establish rates the must be submitted alleging that the individual is: Department charges to provide services to the (a) mentally ill, drug dependent, or developmen- different populations served by the institutes. For tally disabled; and (b) dangerous to themselves or the period between October 1, 2004, through others, based on one of five statutory standards. September 30, 2005, the rates for residents ranged The court reviews each petition to determine if an from $589 per day to $682 per day. Table 5 shows order of detention should be issued. An initial the daily rates DHFS established for each patient hearing to review the allegations is then held population group during that period. within 72 hours. If probably cause is found, a hearing must be held within 14 to 21 days of the individual's detention. If a patient is admitted to a facil-

Table 5: Mental Health Institutes Inpatient Daily ity, the facility is required to provide a copy of the Rates -- October 1, 2004, thru September 30, 2005 patient's and resident's rights to the individual at the time of entry. Mendota Winnebago Criminal commitments of individuals are made Adult Psychiatric Services $651 $608 when a licensed physician or psychologist of a cor- Geropsychiatric 682 Child/Adolescent 665 589 rectional facility reports in writing to the officer in Forensic-Maximum Security 651 charge of the institution that a prisoner is mentally Other Security 595 608 ill, drug dependent, developmentally disabled, or Aware/STEP/Gemini/Anchorage 608 Emergency Detention* 150 150 is an alcoholic and is in need of psychiatric or psychological treatment. If the prisoner voluntarily *For first three days of service consents to a transfer to a state institute for treatment, a transfer application may be submitted to Patients at the institutes are admitted as either the Department of Corrections and DHFS. If a vol- civil commitments or criminal commitments. Civil untary application is not made, the Department of commitments may be either voluntary or Corrections may file a petition for an involuntary

19 commitment. In either case, the state institutes Counties are responsible for supporting the must obtain approval from the county in which the care costs of civil commitments, while the state is jail is located before admitting an individual who is responsible for supporting the care costs of forensic being transferred from a county jail. patients. Charges to counties for civil commitments are represented as "county 51 boards" program Forensic patients are those patients referred revenues in Table 6. from the criminal court system. Forensic services provided by the MHIs include assessment of com- The institutes are funded by a combination of petency to stand trial, treatment to competency, general purpose revenue (GPR) and program reve- and treatment upon a finding of not guilty by rea- nue (PR). Program revenues are comprised of son of mental disease or defect. Individuals found charges to counties for civil commitments, MA not guilty by reason of mental disease or defect are payments for children and elderly patients, Medi- committed to DHFS for the same period of time care payments, and insurance payments from pri- that they would have been incarcerated had they vate payers. Table 6 identifies the amount, by been found guilty. These individuals can initially source, of program revenues for the mental health be placed directly in the community on conditional institutes in 2003-04. release or be committed to either MMHI or WMHI.

Table 6: Mental Health Institutes Program Revenues, by Source Fiscal Year 2003-04

Winnebago Mendota Percent Percent Program Revenues Amount of Total Amount of Total

Medical Assistance $14,833,400 67.5% $6,669,700 38.3% County 51 Boards 5,203,100 23.7 6,892,100 39.6 Private/Commercial 1,433,100 6.5 1,445,300 8.3 Medicare 507.300 2.3 2,407,600 13.8

Total $21,976,900 100.0% $17,414,700 100.0%

20 APPENDIX I

Wisconsin Mental Health Certified Community Support Programs (CSPs)

Bayfield Douglas

(1) (1) Iron (1)

Washburn Vilas Burnett Sawyer Ashland

Price Forest Florence (1) (1) Oneida Polk (1)* (1)*** Marinette Barron Rusk (2) Lincoln (1) (1) Langlade (1) Taylor (1) (1) Oconto St. Croix Chippewa Dunn (1) (1) Marathon Menomi- Clark (1) (1) (1) (2) (1) Pierce (1) Eau Claire (1) Shawano Door (1) (1) Pepin Wood Portage Waupaca Kewaunee Buffalo Outagamie Trem- (2) (1) (2) Brown (1) (1) (1) Jackson Juneau Waushara Winnebago (1) Manitowoc Monroe Adams (1) (1) Calumet (1) La Crosse (2 (1) (1) (1) Marquette (1) Fond du Lac Sheboygan Green Vernon (1) Lake (1) Sauk Columbia Dodge Richland Washington (1) (1) (1) (1) Case Management Programs Crawford (1) (1) Ozaukee (1) Dane Iowa Jefferson Waukesha Milwaukee Grant Certified CSPs (5) (1) (1) (11) (1)** (1) La Fayette Green Rock Walworth Racine

(1) (1) (2) Kenosha (1)

Counties with both CSPs and case management programs are: Chippewa, Dodge, Door, Milwaukee, Outa- gamie, Sheboygan, and Washington Counties. * 1 certified between Washburn and Barron Counties. ** 1 certified between Grant and Iowa Counties. *** 1 certified between Vilas, Oneida, and Forest Counties. 21 APPENDIX II

Allocation of Annual State Funding for Community Support Programs

Estimated Number of County Individuals Served Amount

Ashland 11 $15,858 Brown 42 89,015 Chippewa 47 57,500 Columbia 12 32,616 Dane 31 117,524 Eau Claire 23 11,405 Green 9 12,250 Jefferson 47 61,500 Kenosha 39 41,275 La Crosse 46 61,500 Manitowoc 27 34,650 Milwaukee 38 93,910 Monroe 15 22,497 Forest/Vilas/Oneida 32 61,500 Rock 34 61,500 St. Croix 29 48,211 Sheboygan 35 33,720 Vernon 8 5,380 Washington 24 49,365 Waukesha 30 64,529 Waushara 19 24,295

Total 600 $1,000,000