Section 3: Findings - Gaps in the System
Results from the interviews, focus groups, and surveys were synthesized into four primary themes of gaps in the mental health and substance use services system.
- Gaps in access to care, including workforce issues, lack of services, and inaccessible services
- Lack of integrated systems
- Lack of investment in prevention and early intervention
- Gaps as a result of bureaucracy and regulation of the systems
Supporting data and additional sub-themes are summarized in this section.
Gaps in access to care
Workforce issues
Experts interviewed emphasized the most urgent gaps in the mental health and substance use services system are related to insufficient access to specialists, such as psychiatrists who focus on either children or substance use disorders, and staff with the skills to support people with multiple needs in acute care situations.
Survey participants shared similar sentiments around workforce gaps impacting available services. When asked to identify specific services, all were evenly selected to include: mental health integration with primary care, community treatment services, peer-run supports, co-occurring services, 24/7 crisis intervention, medication management/psychiatric prescription services, and others.
See the Governor's Task Force on Healthcare Workforce Report (PDF) for more data and context on the mental health and substance use services workforce.
Over 75% of survey respondents indicated there are not enough mental health or substance use disorder providers, resulting in waitlists that are too long.
All data sources indicate gaps in services exist statewide, varying by region. Urban areas typically have fewer workforce shortages and gaps in outpatient services, but marginalized groups still face barriers to accessing care due to social factors, such as lack of affordable childcare and transportation issues. One participant shared their experience in Milwaukee County, highlighting that though their area is resource rich and many therapists are available, few are from marginalized communities.
In contrast, rural areas, particularly in the northern, northeastern, and southwestern parts of the state, often lack service and workforce volumes to maintain a comprehensive range of offerings, including substance use and crisis services. Many survey comments identified service providers and services are clustered in population centers, not available in more rural areas.
Similarly, the survey results indicate substance use disorder services facing workforce shortages are distributed across all services: outpatient, day treatment/partial hospitalization, intensive outpatient, inpatient, withdrawal management/intoxication management, adolescent, and residential treatment.
Lack of services and supports
Outpatient and community-based supports
Across interviews and the survey, community-based rehabilitative and support services emerged as a top need that is currently unmet. Support services include case management, supported employment, supported education, housing first, permanent supported housing, skill building, and traditional healing services. Specifically, a top need within the mental health spectrum was community treatment services and recovery residence/sober housing as well as case management within the substance use disorder array.
There are currently no psychiatric residential treatment facilities for youth in the state. Respondents argued that a lack of this facility type forces young people to be placed out-of-state and away from their families. In addition to a lack of outpatient services and community-based supports for specific demographics, key informants and survey participants touched on the broad impact of hospital closures in accessing mental health and substance use services across Wisconsin.
Inaccessible services
Wisconsin is a home rule state, which means counties are responsible for the care and treatment of their residents with mental health and substance use conditions. They provide services related to prevention; diagnosis and evaluation; crisis intervention, outpatient care, and inpatient care. Each county is required to establish its own programs and budgets for these services and may limit services based on available resources. There are currently 67 agencies serving 72 counties.
Tribal nations that share boundaries with the state also manage their own systems of care for their members.
In addition to these public systems of care, many mental health and substance use services are provided by private providers across the state. These providers are usually certified under Wisconsin administrative code and collaborate with Tribal nation and county services.
Most people interviewed mentioned that the availability of mental health and substance use services varies widely by county. They attributed this variability to population size, workforce challenge, and regulation within administrative codes. People interviewed also shared that, with some exceptions, rural areas in the northern, northeastern, and southwestern areas of the state tend to have fewer services available and more challenges sustaining a full array of services. Examples include high intensity outpatient services, substance use services, services to support people more “upstream” to prevent crisis, psychiatry, peer services, crisis services, and more intensive residential services.
Survey comments mirrored comments from the people interviewed, highlighting the service accessibility differences across county lines and describing frustrations about county residency as a barrier.
Additionally, services might exist, but they are not accessible due to language issues, treatment modalities that invalidate cultural beliefs, or patient or client concerns that service providers will judge them if they don’t share cultural identities or experiences. Many survey respondents specifically noted the lack of service providers who are male, religious, Hmong, or Spanish-speaking.
Interviewees and survey respondents also commented on the following challenges of accessing care:
- Language barriers to accessing services and materials
- Language and cultural mismatches with service providers
- Providers that lack understanding of a client’s background and act judgmentally
- Fear of legal, financial, or social consequences of being identified as a person with a mental health or substance use concern
- Fear of being involved in the legal or child welfare system when seeking help
- Communities do not recognize the benefits of investments in universal prevention and early intervention
Despite the various barriers to accessing care, there has been increased telehealth use for mental health and substance use services. Focus groups and survey comments noted the increasing use of telehealth since 2019, specifically with younger individuals due to generational differences in technology-based interactions. At the same time, many commented on additional challenges the service brings. Challenges include: confidentiality and privacy concerns, appropriateness in cases of increasing acuity, as well as technology access. Inconsistent access to broadband in more rural areas renders telehealth less effective at reducing access gaps in these areas.
Additional comments noted that while professional associations have created guidelines, the state has yet to coalesce on appropriateness of telehealth, assessments, referral protocols, and safety planning.
Over 74% of survey respondents indicated an improvement to service gaps with access to telehealth since 2019.
Lack of integrated systems
Survey respondents ranked mental health and substance use care integration into primary care, prescription services, and residential care facilities as the most needed and least available services. Survey respondents mirrored themes heard via interviews: there is a pressing need for behavioral health to be seen as a key aspect of physical health, where primary care providers effectively screen for mental health and substance use needs and serve as the entry point to the system.
Participants also noted the need to improve integration between behavioral health and law enforcement. Changes to mobile crisis benefits have incentivized co-responder models, leading to more team-based crisis response units that include peer support specialists and law enforcement. There remains a desire for more peer support options and more integration of peers at the intersections of mental health and substance use the criminal justice system, across substance use treatment and recovery, and within schools and family support services.
Lack of investment in prevention and early intervention
Repeatedly, respondents emphasized that although acute care is urgent for preserving life, prevention is essential to ensure that fewer people develop acute care needs requiring more intensive resources. Prevention services were described as an afterthought and currently insufficient. Although the provision of prevention services is part of the Wis. Stat. ch. 51 mandate, few respondents considered prevention efforts as part of the system.
One participant described the early intervention barriers between programs and service users as difficult to navigate. From the program side, individuals cannot receive case management or support unless they are in a program. Those seeking services face challenges in entering a program, where they “can’t get over the hump” and “walk away, give up, or stop trying.” Service users access a program, but only after increasing levels of need such as a crisis event or emergency detention. The lack of easily accessible early interventions results in a persistent cycle where service users have already decompensated, resulting in more intense program services.
Currently, primary prevention of substance use disorder focuses mainly on young people in schools, with gaps in efforts to prevent, for example, alcohol use among elderly people and substance use among pregnant people.
Challenges to more robust prevention approach
The challenges listed here are ranked in order of most mentioned in the interviews, focus groups, and survey.
Funding challenges
- The insurance model takes a fail-first approach, so people don’t get help early on before intensive services are necessary.
- A lack of understanding that investment in prevention has a higher return on investment than money spent on intensive treatment.
- Funding is often unavailable for prevention.
System organization challenges
- Ensuring housing is not widely understood as an investment in reducing the community-wide costs associated with substance use disorders and severe mental illness.
- There is no coordinated statewide, cross-agency approach to prevention.
- Data sharing barriers inhibit the ability to get people voluntary treatment when needs are more manageable.
Bureaucracy and regulation of the system
The last theme of gaps relates to regulation, rules, and protocols. The mental health and substance use services system requires a delicate balance between concepts like individual and public safety and autonomy or individual liberties. The system is also influenced by external factors like public versus private insurance policies, federal regulation, and competing interests. Here are some of the ways interviewees and survey respondents said bureaucracy and regulation negatively impacts the system:
- Reimbursement rates that don’t cover the cost of training and operation result in high caseloads, burnout, and turnover.
- Service users face cost and insurance barriers when transferring between public assistance and private coverage that can lead to fragmented continuity of care and financial stressors.
- County-based funding and structure can create different requirements and availability of services between counties.
- Lack of regulation and coordination in the public/private insurance model results in private insurance companies placing limitations and exclusions on services and providing inconsistent coverage.
- Lack of effective collaboration across geographic areas, funding, treatment focuses, types of insurance, and state agencies.
- An eligibility model that requires an individual to decompensate to receive care.
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