Montana nonprofits supportive of state’s recommendations to behavioral health commission

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The Montana State Capitol in Helena on Wednesday, April 26, 2023. (Photo by Mike Clark for the Daily Montanan)

Montana behavioral health nonprofits largely supported recommendations presented Tuesday to the state’s behavioral health commission, which is advising the governor on how to spend $300 million allocated to bolster mental health resources in the state.

Gov. Greg Gianforte has already approved some allocations of the funds like $7.5 million for providers to conduct court-ordered forensic fitness exams to address the backlog in the state, as well as $600,000 in grants for certification and training for professionals working with Montanans with intellectual and developmental disabilities, among other initiatives.

The commission met to give and hear feedback on proposed recommendations presented by the state health department on improving behavioral health case management, expanding services and workforce recruitment and retention. Recommendations also include expanding access to services for the developmentally disabled, for a total of 21 proposed suggestions.

One of the outstanding questions, however, is how to pay for long-term costs associated with keeping the suggested programs going.

Gianforte signed House Bill 872 into law last year, establishing the Behavioral Health System for Future Generations commission made up of legislators from both parties, bill sponsor Rep. Bob Keenan, R- Bigfork, and three Gianforte appointments, including Department of Public Health and Human Services Director Charlie Brereton.

Keenan opened the meeting Tuesday emphasizing the “Future Generations” part of the committee’s name.

“We’re not going to fix everything here today,” Keenan said. “But we’re going to do the best we can.”

The commission has held meetings across the state for months, hearing from stakeholders including nonprofits and advocates, which informed the recommendations. The commission also included input from the state health department and consulting firm Guidehouse, which drafted a report on alternative settings for mental health care outside state run facilities.

Behavioral health care has been a significant concern in Montana as the Montana State Hospital lost federal funding, vacancies persisted, and demand for care has overwhelmed the state.

List of recommendations:

Developmental Disabilities
-Refine and reconfigure the current 208 Comprehensive Waiver services rates
-Expand access to waivered services through a §1915(c) Supports Waiver
-Expand service options for people with dual diagnosis by adding a new 208 Comprehensive Waiver service called Enhanced Community Living
-Redefine and reopen evaluation and diagnostic (E&D) clinics to support families more effectively
-Conduct an in-depth study of the current DDP waitlist management process
Behavioral Health
-Enhance the Targeted Case Management (TCM) program to improve health outcomes for eligible individuals
-Develop a training program for targeted case managers
-Implement a care transitions program
-Enhance 988 call center coordination and support capabilities
-Expand Mobile Crisis Response (MCR) to additional regions in Montana
-Introduce new Crisis Stabilization and Receiving Center Services
-Expand the scope of the Certified Adult Peer Support program by widening eligibility and increasing applicable settings
-Increase support for people with serious mental illness (SMI) and/or substance use disorder (SUD) experiencing homelessness
-Launch a campaign to 1) inform Montanans of new behavioral health services, and 2) raise awareness and reduce stigma around behavioral health
-Reduce barriers to care for non-emergency medical transportation (NEMT)
-Expand the family peer support (FPS) program for parents and caregivers of children with behavioral health issues and/or developmental disabilities
-Redesign rate structure to improve in-state youth residential services
-Invest in school-based behavioral health initiatives
-Incentivize providers to join the behavioral health workforce via tuition reimbursement
-Expand training content available to behavioral health workers
-Assess the feasibility of establishing a Montana community health worker (CHW) program

Developmental disabilities recommendations

There are about 2,500 people with developmental disabilities who use waivers across the state. Developmental Disability Program Director Lindsey Carter with DPHHS said the reimbursement rate for providers servicing the population with disabilities is the same no matter what level of support individuals need – so providers don’t get compensated more if they have patients who require more attention and care. The first recommendation is to base the provider rate on assessments of the disabled individual’s needs.

Adding additional waiver options, like for people who may have families who need help during respite care to help keep them in independent living environments, was another suggestion.

Reopening evaluation and diagnostic (E&D) clinics that would serve as a “front door” to services in the state and reduce wait times for initial assessments, as well as managing the current waitlist of at least 2,100 in the state, are other recommendations.

Behavioral health recommendations

About 10% of Montana’s Medicaid population has a serious mental illness or substance abuse disorder, according to the presentation, and the state currently offers targeted case management to 2,000, or about 2% of the Medicaid population. The state wants to enhance what is already offered and increase provider capacity, as well as create a training program for targeted case managers.

988 and dispatch response

The state is also looking to connect the 988 Suicide and Crisis Lifeline with access to first responders. Historically, only Public Safety Answering Points (like 9-1-1 call centers) can dispatch crisis response, but communication between the lifeline and call centers has been inconsistent. The state is recommending 988 call centers be able to connect with mobile crisis response.

However, eastern Montana doesn’t have any mobile crisis response teams, and the state has six total. DPHHS is suggesting adding crisis responders to more regions in the state through a “hub and spoke model” with a central hub of mental health professionals connecting virtually to spokes – emergency medical technicians or health workers in the community that can help people in crisis.

The department would like to add new crisis stabilization centers that would give mobile crisis responders somewhere to take those needing care. The state has limited access to stabilization centers, with rural areas upwards of four hours from the nearest services. The ideal outcome would be a decreased reliance on emergency room services as well as a decrease in need for psychiatric hospitalization, according to the state health department.

Peer support

The state already offers a Certified Adult Peer Support program, which reduces stigma as well as minimizes the need for emergency treatment, but DPHHS is looking to amend it so the program can include individuals with less severe mental illnesses.

Support for unhoused experiencing mental health crisis

The state is also looking to expand services for people with mental illnesses experiencing homelessness. DPHHS estimates 2,200 Montanans are experiencing homelessness, and about 460 are living with a serious mental illness. But the state said existing housing vouchers are hard to access and don’t go as far in the current rental market.

Recommendations include increasing funding to existing PATH programs (Projects for Assistance in Transition from Homelessness) and awarding grants to new PATH programs.

The state is also looking to increase the purchasing power of housing vouchers by coordinating with housing authorities to develop a Fair Market Rent review.

DPHHS is also looking to increase access to mental health care to youth and increase the number of students screened for mental health needs in schools, in the hope of reducing behavior-related events like bullying.

Workforce recruitment and retention

Bolstering the behavioral health workforce in the state is also a top priority for the state, with recommendations including creating incentives for recruitment and retention.

The state is suggesting developing a tuition reimbursement program as well as expanding training for existing staff to help prevent burnout. The state cites emotional exhaustion as the top reason for turnover in the field.

How to pay for these suggested improvements was one of the big questions at the end of the meeting.

One-time-only costs are slated to be covered in the $300 million, but long-term sustainability of the program will likely need other sources of funding. The DPHHS presentation suggested Medicaid reimbursement, federal grants, state general funds and public-private partnerships as potential options.

A number of organizations largely endorsed the commission’s work and the state’s presentation during public comment, including Montana’s chapter of the National Alliance on Mental Illness and the Montana Medical Association.

“We’re struggling,” said Jamie Palagi, new CEO of Helena-based Intermountain Health. “We’re struggling with workforce retention, recruitment and continuing to provide services and so the recommendations that were discussed today would help my organization tomorrow.”

The commission will accept public comment on the recommendations before drafting its final report, which will be discussed on May 20. The state health department will give a final presentation on the recommendations for adoption on June 28.

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