A state audit of Milwaukee County’s behavioral health services turned up big questions about its services, contracts and oversight.

Auditors found that youth patients in the county’s mental health hospital were spending a higher-than-average time in restraints, the wait list for mental health and substance abuse services grew in the first half of 2016, the county couldn’t provide detailed information about its programs and it wasn’t getting approval for six-figure contracts with vendors.

It’s the first major, independent audit conducted on the county’s Behavioral Health Division since its oversight was taken from the Milwaukee County Board of Supervisors in 2014 and given to the Milwaukee County Mental Health Board (MHB), a panel made up of mental health experts appointed by Milwaukee County Executive Chris Abele. The law that created the Mental Health Board also required the state Legislative Audit Bureau to conduct biannual audits of its operations and oversight.

Since its formation by state legislators in 2014, the MHB has given the green light to privatize the mental health hospital, shut down its long-term care units and is trying to provide more services in the community.

The Behavioral Health Division is part of the county’s Health and Human Services Department, which has been run by Director Héctor Colón since 2011. In a contentious reappointment battle this fall, supervisors gave him a two-year appointment, instead of the typical four-year commitment. Colón named Michael Lappen as the director of Behavioral Health Division in April 2016; much of the data for this audit pre-dates his tenure.

As detailed in a series of Shepherd articles, the new appointed Mental Health Board has struggled with its role overseeing the Behavioral Health Division. Until a few months ago, board members had no staff and were totally dependent on information from the Behavioral Health Division, which it is supposed to oversee, making observers question who was really in charge of the department. The board rarely allows the public to testify before it and struggles with transparency.

As noted by the state Legislative Audit Bureau, through 2016 the board had adopted 27 policies.

“However, BHD has not centrally compiled these policies or made them readily available to board members or the public,” auditors wrote. “We identified two instances in which the board was not following its own bylaws.”

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Since that revelation, the board has amended its bylaws.

Critical Issues Raised

The auditors provided a rare independent, detailed look at the operations and oversight of the county’s behavioral health services and raised critical issues, such as:

• Lack of budget details: Auditors had difficulty digging into the details of the division’s operations because it “does not consistently budget on a program-level basis or maintain expenditure information in sufficient detail to allow for an accurate estimation of program-level expenditures for most of its 26 programs.”

• Big contracts not submitted for board approval: The division is supposed to get Mental Health Board approval for contracts worth more than $100,000. Yet auditors found that fee-for-service contracts, which don’t have a set dollar amount upon signing but can be worth more than $100,000, typically weren’t going to the board. At least 79 fee-for-service contracts signed in 2015 were worth more than $100,000, with an average contract being worth $695,000. The Behavioral Health Division has begun sending fee-for-service contracts to the board.

• Staff shortages: The Behavioral Health Division has long had staffing shortages, part of a national trend that’s made acute in Milwaukee because of the hospital’s uncertain future. Auditors found that 24% of budgeted positions were vacant. Vacancies reach 30% in the hospital, where the county’s most vulnerable residents are treated.

• Use of restraints: Behavioral health division reported using physical restraints on its child and adolescent patients 19.3 times more often than that national average. It uses restraints on adults six times the national average. It has since revised its policies, added more training and reduced the use of restraints, according to an email from Director Lappen to the Shepherd.

• Not tracking patients: Auditors found that the county was not analyzing data on patients discharged from the hospital’s emergency room, so there’s no easy way to track whether these individuals received follow-up care and services as outpatients. The data is only included in individual patient files, making analysis difficult if not impossible.

• Failing to achieve its own goals: The Behavioral Health Division sets broad performance indicators for its services. Its hospital achieved 9 of its 27 indicators in 2015. In addition, it hasn’t developed specific performance indicators for its community-based programs for adults, making evaluation difficult if not impossible.

• Waiting lists grew in 2016: Perhaps due to staff shortages and demand in the community, waiting lists for services grew during the period covered by the audit. A full 801 recipients were placed on the waiting list for the psychiatric emergency room in the first six months of 2016, “which is more than all of 2014 and 2015 combined.” The waiting list for services in the community grew in 2016 as well. For example, the wait list for alcohol and drug abuse residential programs increased from an average of 14 days in the final quarter of 2015 to 23 days in the first quarter of 2016 and 22 days in the second quarter—long waits for those seeking treatment in a crisis. In addition, there was no wait list for community-based mental health programs at the end of 2015. That ballooned to 96 days from January-March 2015 and 138 days in April-June 2016.

“Wait times for community services, in general, have been reduced since June and that capacity has increased substantially,” Lappen emailed.