Across America, the alarming increase in youth behavioral health needs is considered a public health crisis.[1] The behavioral health system is challenged to meet the needs of youth, which has resulted in youth seeking treatment and services in emergency departments or institutional settings that inadequately address their needs. Some states are responding to these challenges by establishing youth crisis receiving and stabilization facilities as alternatives to these settings.
Youth crisis receiving and stabilization facilities are one core component of the crisis continuum of care.[2] These facilities are intended to work in conjunction with the other crisis components — crisis call centers, mobile response teams, and post-crisis support — to more effectively meet the needs of individuals experiencing a behavioral health crisis.[3] NASHP’s brief “Leading State Priorities and Considerations for Youth Crisis Receiving and Stabilization Facilities” explores states’ opportunities, challenges, and key considerations for implementing youth crisis receiving and stabilization facilities.
This case study will focus on Wisconsin’s efforts to establish youth crisis stabilization facilities (YCSFs) as a community-based alternative to inpatient hospital and institutional settings to support the state’s youth in receiving timely and appropriate mental health crisis services.
The Youth Mental Health Crisis in Wisconsin
Nationally and in Wisconsin, the need for youth behavioral health services is well-documented. Across the U.S., youth diagnosed with anxiety, depression, and other behavioral health challenges increased over a five-year period from 2016 to 2020.[4] In Wisconsin, over one-third of all students surveyed (33.7 percent) reported feeling sad or hopeless almost every day for more than two weeks in a row, a statistically significant increase of 5.2 percentage points since 2019 and the highest rate since the Youth Risk Behavior Survey was first administered.[5] Additionally, 18.1 percent of all students in the state seriously considered attempting suicide in the past 12 months, the highest rate since 2003.[6]
In Wisconsin, young people up to age 25 were identified as a specific population group falling through the gaps in the behavioral health system.[7] Between 2013 and 2017, suicide was the second leading cause of death among 10- to 19-year-olds.[8] Females ages 15 to 17 had the highest rates of emergency department visits and hospitalization stays for self-harm injuries from 2016 to 2017.[9] In 2019, Wisconsin had an average of 490 individuals served by one mental health provider in a county, if the population were equally distributed across providers.[10] In addition, the psychiatrist supply for the state could only meet 19 percent of the need for services.[11]
Establishing Youth Crisis Stabilization Facilities in Wisconsin
In response to the ongoing mental health crisis, Wisconsin passed legislation in 2017 to establish YCSFs.[12] They were promoted as a new community-based residential treatment option for youth experiencing a mental health crisis.[13] Wisconsin Statute 51.042 establishes YCSFs in the state, defined as “a treatment facility with a maximum of eight beds that admits a minor to prevent or de-escalate the minor’s mental health crisis and avoid admission of the minor to a more restrictive setting.”[14] The impetus for implementing YCSFs in Wisconsin was to provide youth and their families access to crisis stabilization services in the community, within a reasonable distance from their homes, and to avoid high-cost acute care in inpatient hospital settings. In 2018, the Wisconsin Department of Health Services (DHS) Learning Collaborative for Crisis Intervention and Emergency Detention developed a toolkit that provides strategies and approaches, including crisis stabilization facilities, on how to support people experiencing a mental health crisis in the community.[15] A 2019 Wisconsin DHS survey of all counties on crisis intervention services found that 21 counties had no options for crisis stabilization services and 62 percent of counties said the closest option for crisis stabilization services was outside their county.[16]
Youth Crisis Receiving and Stabilization Facilities
Outlining the Certification Process for Youth Crisis Stabilization Facilities and Program Services
Wisconsin Administrative Code § DHS 50 authorizes Wisconsin DHS to certify YCSFs and defines the YCSF requirements for certification of facilities, program components (i.e., policies, personnel, training, services offered, etc.), and the facility’s physical elements.[17] Wisconsin YCSFs can be publicly or privately owned. Applicants wanting to operate a YCSF must complete a two-step certification process, with an initial application submitted to DHS Division of Care and Treatment Services. Following approval of the first step, applicants must complete a second step that entails background checks,[18] an application (form DHS 50),[19] and fee payment[20] to DHS Division of Quality Assurance. Once approved, a YCSF certification does not expire and is valid until it is suspended or revoked.
Wisconsin’s YCSFs are one component of a coordinated continuum of care. They are intended to provide a safe and supervised place to prevent an impending crisis, emergency mental health services during a crisis, and a step-down option from a higher level of care before youth return home.[21] Admission to a YCSF requires written informed consent of youth or a legal representative. In addition, all Wisconsin YCSFs must provide certain services (see box below).
Wisconsin’s Minimally Required Services for All YCSFs [22]
- A structured therapeutic setting supervised by a clinical coordinator
- Therapeutic and skills-building interventions that will help youth avoid future crises
- Care coordination services provided by a qualified care coordinator
- Discharge planning to support the successful reintegration of youth into family, community, and school activities and to prevent recurrence of a crisis
How Wisconsin Is Operating State-Funded Youth Crisis Stabilization Facilities
Wisconsin YCSFs are eight-bed facilities, and youth may stay up to 30 days; however, the average length of stay is only a few days.[23] A team of trained professionals provide counseling and care for youth to help them manage their mental health crisis and divert them from an inpatient hospital admission. YCSF services must be trauma-informed, strengths-based, and culturally responsive, and YCSFs must encourage involvement of families and caregivers.[24],[25] Wisconsin YCSFs currently operate with two qualified licensed staff (e.g., psychiatrist, clinical social worker) per shift at all times, and the programs are supervised by a clinical coordinator in a structured therapeutic environment, which meets regulatory requirements.[26],[27] Staffing to meet the minimal requirements, including ensuring 24/7 and night-shift coverage, can present operational challenges. Staffing challenges may also present a hurdle to opening additional YCSFs to increase access to youth crisis stabilization services in other counties and communities where they are currently nonexistent. Certification waivers or variances may have to be considered to address barriers to this staffing approach and to maintain program operations.[28]
Currently, Wisconsin has two state-funded YCSFs that have been in operation for approximately two years; the populations that are served differ across facilities.[29] Lad Lake Masana is in the southeastern part of the state in Milwaukee County, one of the largest and most populous urban areas in the state. North Central Health Care is in Marathon County, which is also urban and in central Wisconsin. The maximum age for both facilities is 17. Lad Lake Masana serves girls ages 13–17, and North Central Health Care serves both girls and boys ages 17 and younger. Both Wisconsin YCSFs serve youth residents across county lines.
Funding Wisconsin’s Youth Crisis Stabilization Facilities Requires a Multifaceted Approach
The implementation of Wisconsin’s YCSFs has required a multipronged financing strategy of federal and state funds. The state funds YCFSs through the federal Substance Abuse and Mental Health Services Administration’s Community Mental Health Services Block Grant, Bipartisan Safer Communities Act, Consolidated Appropriations Act, state general purpose revenues, and Medicaid. Medicaid covers a percentage of YCSF services, which are reimbursed through a crisis daily per diem reimbursement rate or a crisis hourly professional billing reimbursement rate.
Wisconsin as a Model for Other States
Many states are considering crisis stabilization facilities as a strategy to provide services in a community-based setting to youth experiencing a behavioral health crisis and to address the ongoing youth behavioral health crisis across the country. States interested in designing and implementing a youth crisis stabilization facility may consider using Wisconsin’s approach as a model. New York also provides an innovative state approach, which is described in NASHP’s companion study “Supporting Youth Behavioral Health Through Crisis Receiving and Stabilization Facilities: New York Case Study.”
[1] “Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory,” U.S. Department of Health and Human Services, December 2021. www.hhs.gov/sites/default/files/surgeon-general-youth-mental-health-advisory.pdf.
[2] “National Guidelines for Behavioral Health Crisis Care Best Practices Toolkit,” Substance Abuse and Mental Health Services Administration, February 24, 2020. www.samhsa.gov/sites/default/files/national-guidelines-for-behavioral-health-crisis-care-02242020.pdf.
[3] “National Guidelines for Behavioral Health Crisis Care Best Practices Toolkit,” 2020
[4] U.S. Department of Health and Human Services. “New HHS Study in JAMA Pediatrics Shows Significant Increases in Children Diagnosed with Mental Health Conditions from 2016 to 2020,” press release, March 14, 2022. www.hhs.gov/about/news/2022/03/14/new-hhs-study-jama-pediatrics-shows-significant-increases-children-diagnosed-mental-health-conditions-2016-2020.html.
[5] Wisconsin Department of Public Instruction. “Data Shows Wisconsin Students Face Significant Mental Health and Emotional Challenges,” press release, December 6, 2022 https://dpi.wi.gov/news/releases/2022/youth-risk-behavior-survey-wisconsin-mental-health.
[6] Wisconsin Department of Public Instruction. “Data Shows Wisconsin Students Face Significant Mental Health and Emotional Challenges,” press release, December 6, 2022 https://dpi.wi.gov/news/releases/2022/youth-risk-behavior-survey-wisconsin-mental-health.
[7] Vigna AJ, Connor T. “The 2019 Behavioral Health Gaps Report for the State of Wisconsin,” Madison, Wisconsin: University of Wisconsin Population Health Institute, October 2020. https://uwmadison.app.box.com/s/gbdrrm4ktk2ljwm80kac9rrk3zksyi02.
[8] “Suicide in Wisconsin: Impact and Response,” Prevent Suicide Wisconsin, September 2020. www.dhs.wisconsin.gov/publications/p02657.pdf.
[9] “Suicide in Wisconsin: Impact and Response,” 2020.
[10] “2021 Fact Sheet Addressing Shortages in the Mental Health Workforce,” Wisconsin Office of Children’s Mental Health, February 2021. https://children.wi.gov/
[11] “Wisconsin 2019 Health Care Workforce Report,” Wisconsin Hospital Association, October 2019. www.wha.org/
[12]“Youth Crisis Stabilization Facility,” Wisconsin Legislative Fiscal Bureau, Joint Committee on Finance, May 16, 2017. https://docs.
[13] “Youth Crisis Stabilization Facility and Peer-Run Respite Center for Veterans,” Wisconsin Legislative Fiscal Bureau, Joint Committee on Finance, May 2019. https://docs.legis.wisconsin.gov/
[14] Wisconsin State Statute. Mental Health Act, § 51.042 Youth Crisis Stabilization Facilities (passed 2017). https://docs.legis.wisconsin.gov/statutes/statutes/51/042.
[15] “Toolkit for Improving Crisis Intervention and Emergency Detention Services,” Wisconsin Department of Health Services, Division of Care and Treatment Services, August 2018. www.dhs.wisconsin.gov/publications/p02224.pdf.
[16] “Crisis Intervention Services Survey Summary,” Wisconsin Department of Health Services, Division of Care and Treatment Services, November 2021. www.dhs.wisconsin.gov/publications/p03135.pdf.
[17] Wisconsin Administrative Code. Department of Health Services, § 50 Youth Crisis Stabilization Facilities (effective 2019). https://docs.legis.wisconsin.gov/code/admin_code/dhs/030/50.
[18] “Background Check: Overview.” Wisconsin Department of Health Services, accessed June 22, 2023. www.dhs.wisconsin.gov/misconduct/backgroundchecks.htm.
[19] “Mental Health or Substance Use Treatment Provider: Initial Certification Application DHS 40 and DHS 50,” Wisconsin Department of Health Services, accessed June 22, 2022. www.dhs.wisconsin.gov/library/collection/f-02564.
[20] “Mental Health, Youth Crisis Stabilization Facilities (DHS 50): Initial,” Wisconsin Department of Health Services, accessed June 22, 2023. www.dhs.wisconsin.gov/regulations/mh/youth-crisis-stab-fac.htm
[21] “Crisis Services: Youth Crisis Stabilization Facilities.” Wisconsin Department of Health Services, accessed June 22, 2023. www.dhs.wisconsin.gov/crisis/ycsf.htm.
[22] Wisconsin Administrative Code. Department of Health Services, § 50 Youth Crisis Stabilization Facilities (effective 2019). https://docs.legis.wisconsin.gov/code/admin_code/dhs/030/50/ii/11.
[23] Wisconsin Department of Health Services. “Crisis Services: Youth Crisis Stabilization Facilities.” www.dhs.wisconsin.gov/crisis/ycsf.htm.
[24] Wisconsin Administrative Code. Department of Health Services, § 50 Youth Crisis Stabilization Facilities (effective 2019). https://docs.legis.wisconsin.gov/code/admin_code/dhs/030/50/i/05/4.
[25] Wisconsin Administrative Code. Department of Health Services, § 50 Youth Crisis Stabilization Facilities (effective 2019). https://docs.legis.wisconsin.gov/code/admin_code/dhs/030/50/i/05/5.
[26] Wisconsin Administrative Code. Department of Health Services, § 50 Youth Crisis Stabilization Facilities (effective 2019). https://docs.legis.wisconsin.gov/code/admin_code/dhs/030/50/ii/07.
[27] Wisconsin Administrative Code. Department of Health Services, § 50 Youth Crisis Stabilization Facilities (effective 2019). https://docs.legis.wisconsin.gov/code/admin_code/dhs/030/50/ii/09.
[28] Wisconsin Administrative Code. Department of Health Services, § 50 Youth Crisis Stabilization Facilities (effective 2019). https://docs.legis.wisconsin.gov/code/admin_code/dhs/030/50/i/04.
[29] “Crisis Services: Youth Crisis Stabilization Facilities,” Wisconsin Department of Health Services, accessed June 22, 2023. www.dhs.wisconsin.gov/crisis/ycsf.htm.
Acknowledgements
This case study was written by Robin Buskey. Several NASHP staff contributed to the case study through input, guidance, or draft review, including Karen VanLandeghem, Heather Smith, Zack Gould, and Veronnica Thompson. NASHP extends its thanks and appreciation to Jason Cram and Elizabeth Rudy of the Wisconsin Department of Health Services and the Health Resources and Services Administration, Maternal and Child Health Bureau, for their review.
This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UD3OA22891, National Organizations of State and Local Officials. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by, HRSA, HHS, or the U.S. government.
