Devils in the details

A nervous Julio Salazar walked into the North Central Health Care facility on a drizzly morning in May to speak in front of a small audience gathered in the facility's theater.

He was flanked by a group of runners wearing shirts with the slogan “Defeat the Stigma.” They arrived at NCHC after running nearly 20 miles from Ringle to Wausau on the Mountain Bay Trail to raise awareness about mental illness.

Salazar, who has battled depression and has attempted suicide, proposed this to audience members: “If I asked you to raise your hand if you ever had a physical injury, most people here would. But if I asked you to raise your hand if you ever had a mental illness, few people here would.”

The presentation was one of several events planned in Marathon County during May to raise awareness about mental health. And it comes at a crucial time in NCHC's history.

Mental health and mental disability affect hundreds, if not thousands, of families and individuals in Marathon County, not to mention the profound impact on law enforcement and the justice system. Much of the treatment for these patients funnels through North Central Health Care.

With more 825 employees, the agency provides addiction, mental health, crisis, and elder care services for Marathon County. For now.

NCHC has been the center of a year-long controversy with county officials who feel the agency has long mishandled its contractual obligations to treat county residents, including those in jail, and mishandled its part in efforts to curb repeat drunk driving offenses.

In September, the county board will vote on dissolving its long-standing relationship with NCHC and replacing it with a new county-run department of human services.

It would be a huge change in local government. The decision has been called one of the most important the county board has faced in years.

Of the county’s $160 million tax levy, $8 million goes to NCHC services (this is just the local taxpayers’ cost; the actual cost of services is much higher, because many fees are reimbursed by Medicaid and Medicare.)

In the meantime, county staff have been tasked with figuring out how difficult such a transition would be and how much it would cost.

And in the meantime, the public needs to assess whether this is a wild goose chase, a needed shakeup, or something in between.

The process of switching to a county department is infinitely more complicated than changing some staff and the sign on the front door. And it could be far more costly than anyone imagined. Some pitfalls that have emerged already:

•   Hundreds of payer contracts—16 for each of the 63 medical professionals currently at the organization—need to be renegotiated.

•   More than 30 programs need to be relicensed; all of the organization’s doctors, counselors, psychologists and other professionals must be credentialed under the new department.

•   That licensing and certification takes time — up to 18 months in some cases, and could delay not only Medicare and Medicaid payments, but also services to patients. The total potential costs are something consultants are being hired to figure out.

•   Thousands upon thousands of patient records would have to be copied and/or transferred. At this point, officials aren’t sure how problematic or costly this will be, but in sheer volume, it’s a huge detail.

•   Grant-funded programs already in place could be at risk. NCHC operates under agreements with Marathon, Langlade and Lincoln counties. For the 2016 budget, NCHC received $5.9 million in grants and state funding, $3.6 million of it designated to Marathon County. It’s uncertain how much grant and state funding would transfer to a county-run model, because some is specific to multi-county operations or may apply only to NCHC. Grant-funded programs include: Intoxicated Driver Program, for which NCHC gets $106,000; a block grant for AODA (alcohol and other drug abuse) of $296,000; and a Mental Health Community Programs grant of $258,000.

Wisconsin has been gearing toward multi-county approaches in healthcare, and dissolving that model here would fly in the face of the state’s goals, says County Board Supervisor John Robinson, who also serves on NCHC’s board. While the county’s decision must consider the best interest of its residents, replacing NCHC with a new department could ultimately cost residents, considering how much state funding is at risk, he warns.

The process of replacing NCHC with a county department is so convoluted that a work group convened to handle the transition plans to pass off the task to a team of consultants.

County Board Supervisor Jeff Zriny doesn’t support the potential transition to a government-run human service model. Zriny, who also serves as chair of the NCHC board, says it doesn’t make business sense to disrupt an agreement affecting three counties because of a problem with what Zriny says is 2% of the NCHC organization.

“In my business experience, I never said let’s cancel a contract without having a strategy for how we’re going to move forward and telling my boss what the financial ramifications are,” says Zriny, who worked at Wausau Insurance and with medical claims.

He’s also worried about the future of the psychiatric residency program, a partnership with Medical College of Wisconsin, which would train new psychiatrists at NCHC with the hope they stay to work full time. Recruiting psychiatrists has been notoriously difficult, NCHC leaders have said, and the program is meant to combat that.

So why go through all this trouble of trying to create another county department?

Because some officials in Marathon County have grown so discontent with NCHC over what they say were failures in treating mentally ill people, including those at the jail.

The final straw seemed to come when County Deputy Administrator Deb Hager and Chief Deputy Sheriff Chad Billeb presented what they called a series of systematic failures on the part of NCHC, citing individual situations in which a mentally ill or drug addicted individual didn’t get the help they needed.

The coup de grace, presented only in closed session, was a case in which a minor allegedly was denied treatment at NCHC, despite what responders considered a desperate need. While details of the closed session have not been released, some board members found the case so egregious they voted to look into severing its relationship with NCHC. The full county board decided to first study the proposed transition before finally voting in September.

With that vote now only four months away, that proposed transition is looking seriously daunting.

One person tapped for their input has been Kim Gochanour, executive director of operations at Mount View Care Center, which is a wing of NCHC. Before coming to Wausau, she held a similar position in Sauk County, where officials considered similar changes that Marathon County is pondering now.

Gochanour says that in 2006 Sauk County explored creating a sort of "super structure" that, like the NCHC proposal, would have transferred human services to county control. A year-long study revealed the transition would be complicated and costly, and the idea was dropped.

“We thought shared resources might be more efficient, but in the end there was no real benefit to changing,” Gochanour says.

NCHC Interim CEO Michael Loy says whatever the county decides, he hopes it’s sooner rather than later. It’s becoming difficult to retain staff and to recruit new staff, he says. Despite assurances that good employees would be retained under a new county department, no one likes working for an organization with an uncertain future.

“What I’ve been saying is that the county can do this," Loy says. "It’s just a matter of how long it will take, how much it will cost and what the impact will be on the populations we serve.”

A lot can happen in a year. A mental health panel convened in early 2015 highlighted a growing discontent with NCHC among some county leaders. Some say that communication with the organization had become strained. That making changes to better serve the county was next to impossible.

     Multiple law enforcement agencies said NCHC often turned away patients who were in need of crisis service. Then officers were left in the precarious position of having someone in custody who needed help, and not having somewhere to take them.

     County officials were furious that people looking to enter a diversion program for repeat drunk drivers weren’t getting the required assessments at NCHC in anything close to a timely fashion. Those delays held up courts, cost attorneys and the county, and held people back from getting much-needed resolutions to their cases.

NCHC this year looks like a different organization. At its head is Loy, a former city of Wausau employee, who acts as a liaison to county leaders.

Another key addition: NCHC in January hired Laura Scudiere, who hopes to do what she did at Bridge Community Clinic—turn around an organization struggling to meet patient needs.

Since then, a number of initiatives are aiming to do that. Under former CEO Gary Bezucha, NCHC started providing mental health services at the jail, including a therapist, tele-psychiatry services and a social worker.

The organization now partners with area school districts to provide mental health counseling as a form of early intervention.

And NCHC is working on setting up its own transport system to reduce the trips law enforcement officers now make to shuttle patients.

NCHC also launched Lakeside Recovery, a 21-day treatment program that gives people with drug addictions the coping skills they need to stay sober. The program is so popular and effective it has a more than 150-person waiting list. Plans are already underway to grow the program, which right now treats six patients at a time. County leaders have been working on setting up a drug court — the judge, prosecutor and infrastructure are all planned out, Hager says. The only thing missing is a big enough treatment program.

With the help of NCHC, local law enforcement are undergoing Crisis Intervention Partner training, and a select few will train to be on the Crisis Intervention Team. The training helps officers and responders work with individuals struggling with mental illness, with the aim of resolving many situations without simply arresting people. Disorderly conduct is the common charge for people doing something socially unacceptable, Billeb says. Training officers to find other ways to deal with those individuals is more humane, and will save money in incarceration and court costs.

Marathon County Administrator Brad Karger convened an administration workgroup shortly after the county board decided in February to pursue a county run health care system.

After a couple of months of sorting through the mess, Karger decided that an outside group needs to give direction.

“We’re trying to figure out who would have the expertise and status, where there wouldn’t be any dispute,” Karger says. “It has to be bulletproof.” He cites the Brokaw study, for which the county paid $50,000, that definitively laid out Brokaw’s dire financial situation and possible solutions. “People were disappointed in it, but no one challenged the expertise.”

The challenge is getting the new county board members—there’s enough to field a baseball team—up to speed on the issue that spanned most of the previous board session.

Not everyone is out of the loop though. New County Board Supervisor Katie Rosenberg, for example, whose district NCHC resides in, has been following the issue since before she was elected. Rosenberg was also appointed to the Health and Human Services board, which NCHC reports to.

“It’s not a black and white issue, there are a lot of different things to take into consideration,” Rosenberg says. “I think there is an opportunity to change and do things different.” 

The fear, both from county administration and from NCHC leaders, is less about what the county board decides, and more about whether it makes a decision at all.

The hiring process has been severely hampered, says Scudiere, the executive in charge of NCHC’s human services operations, and retaining current employees is difficult when no one knows what the outcome will be. The future of NCHC is something that gets asked about over and over during job interviews, Scudiere says. She tells job candidates that no matter what agency’s name is on the door, their professional services will be needed.

And Karger says most NCHC staff members would have a future with the new county department. “We’ll need them,” Karger says. And of course if NCHC remains as an entity, it will need those employees too.

And if the county decides to form its own department, which would take effect after Jan. 1, 2018, a decision sooner rather than later helps the county get started on some of those certification processes, some of which can take up to 18 months.

The most important thing, no matter who is steering the ship, is to make sure people are being served in the manner they need, Loy says. “There are people in this community that desperately need these services,” Loy says. “I won’t let that go backwards for a minute.”