The Behavioral Health System for Future Generations (BHSFG) Commission presented a draft of its final report on Monday. The document proposes a roadmap for how to spend the roughly $300 million budget devoted to overhauling the hobbled system.

“Today is a momentous day for our commission,” said Charlie Brereton, director of the Montana Department of Public Health and Human Services and a member of the commission. “It started very conceptual, and here we are today with a work product.”

Proposed by Gianforte and established by the Legislature in House Bill 872 last year, the nine-member commission is responsible for crafting the comprehensive plan. DPHHS will implement the initiatives that come out of this process. 

The draft report features 21 total recommendations. Most aim to improve the behavioral health infrastructure in a state where 34% of adults report symptoms of anxiety or depressive disorder, higher than the national average. Others look to streamline the Developmental Disabilities Program. There’s currently a waitlist of roughly 2,100 people, many of whom will remain there for many years.

Commissioners repeatedly brought Monday’s discussion back to the central purpose of their convening.

“My personal hope is that we can rebuild community access in a modern and well-funded way,” said Rep. Bob Keenan, R-Bigfork, who chairs the group.

Addressing workforce shortages, lackluster case management and reduced system capacity

Roughly 85,000 Montanans access behavioral health services or developmental disabilities programs every year. Increasingly, they seek community-based options. The report’s focus is on better meeting the needs of these populations with a focus on three themes: workforce development, case management and continuum capacity, or the amount of people the state’s infrastructure can provide care for.

Each of the 21 recommendations ties back to at least one of these cornerstones.

For example, three of the five recommendations relating to development disabilities programs are intended to enhance continuum capacity. Under the draft plan, the health department would create and adopt a standardized assessment tool to better determine the kind of care individuals with disabilities need and how providers would be reimbursed; expand access to more services at a lower cost through waivers; and launch a pilot program to deliver a three-pronged support model for people with the most complex developmental disabilities. 

On the behavioral health side of things, the report suggests expanding mobile crisis response teams. Right now, there are only six statewide, with none located in the eastern part of the state, it says. With that, the report recommends introducing new crisis stabilization centers for children and teenagers. Other recommendations include expanding the peer support model, increasing funding for people experiencing homelessness who also suffer from mental illness and expanding school-based mental health initiatives.

More people receiving care through state programs necessitates a more functional case management system. Already, Montana’s health care programs run with long waitlists and cumbersome delays. Ultimately, this leads to costlier services and poorer patient outcomes. 

The report is rife with ideas for how to make sure people get the support they need to experience improved health without getting stuck in the system: modernize technology so providers know more about who is sitting on the waitlist; create a new training program for targeted case managers with a focus on best practices for specific populations; and create a care transitions program that helps people as they move from hospitals and long-term care facilities back into communities.

Of course, all these strategies would require people to work in the jobs they’d create.

Montana’s severe health workforce shortage has long strained the existing system. Providers can’t provide enough services. Current workers in the field struggle with burnout. A workforce survey conducted by the University of Montana found a turnover rate of 25% among behavioral health workers, with most who left citing emotional exhaustion as the main driver.

The commission’s report seeks to tackle this challenge by creating a tuition reimbursement program to attract behavioral health workers to Montana; bring training content directly to behavioral health workers so they can more easily progress; and piloting a community health worker program.

Josh Kendrick, the CEO of Opportunity Resources, a Missoula-based disability services organization, said during public comment at Monday’s meeting that he was heartened by the conversation. He felt it captured a new shade of collaboration he hadn’t heard in “years and years” of similar meetings.

“I just think we’re entering a new era,” Kendrick said.

How much will it cost?

Step one to overhauling these health care systems is one-time spending. DPHHS estimates it will cost $47 million to launch the recommendations. The report projects another $40 million to operate the programs early on as they get off the ground.

All told, that means $87 million of the commission’s $300 million will be devoted to these 21 recommendations, designed to play out over years, not months. HB 872 also allocates $75 million for capital projects. The draft plan proposes setting aside the remaining $94 million in case costs run over.

More immediate impact will be left to “near-term initiatives” at a cost of about $44 million. These plans, forwarded by the commission and approved by the governor, can be effectuated by DPHHS on a much quicker turnaround.

While the BHSFG Commission’s funding is meant to develop and implement the recommendations, a longer-term funding source to make them sustainable will be needed. While the report notes that a state budget should be able to account for these investments, Brereton did acknowledge that the Legislature’s appetite for recurring funding over time is the biggest unknown looking forward.

What’s next?

HB 872 requires a lot of steps between now and the point when these recommendations will be felt by people within communities.

The commission must submit a final version of the report to the governor’s budget office by July 1 and present its recommendations to a joint meeting of four legislative interim committees. HB 872 also requires a public comment period. DPHHS will have to determine whether it needs additional and specialized staffing, identify statute or administrative rule that might need amending, address infrastructure gaps and more. All the while, the commission will roll out “near-term initiatives,” such as efforts to provide naloxone and fentanyl testing strips to community-based sites and efforts to boost the number of available residential beds, and monitor their impact. 

Only in the months and years that follow will it be possible to discern what this project achieves. Keenan reminded fellow commissioners they were playing the long game for future generations.

“This isn’t going to be fixed in two years,” he said.

The commission’s full draft report can be found here.