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'A major toll': Effects of state cuts to mental healthcare reverberate in region

Montana Standard - 5/13/2018

May 13--Margie Seccomb, the CEO of the Butte nonprofit Action Inc., cuts right to the point: "This is not a number. This is not a dollar amount. These are human beings."

But that's exactly how it started: as a number, a dollar amount.

$227 million, to be exact.

That was the size of a 2017 state budget shortfall that led to enactment of Senate Bill 261, which included language that slashed funding for mental health targeted case management services and to a special session of the Montana Legislature that resulted in $49 million in cuts to funding for the Montana Department of Public Health and Human Services.

Those cuts have set off a wave of changes to services for some of the most vulnerable populations in the state -- the mentally ill and the developmentally disabled.

That's where the human beings come in.

According to Paul Meyer, the CEO of Western Montana Mental Health Center, case management provides those with mental illnesses and developmental disabilities a predictable, personalized way of navigating complex bureaucracies to develop plans of care and to access the benefits, medical care, and other services that "make life sensible for people with mental illness."

But as budget cuts have reduced the rate at which providers like WMMHC are reimbursed for providing mental health case management by approximately two-thirds, it has become untenable for many of those providers to continue offering the service.

At WMMHC's Butte offices alone, adult case management is no longer offered at all, according to area operations director Kathy Dunks. That means 248 people have stopped receiving case management, and it means an office that once employed 14 case managers now employs only eight people working in different kinds of roles.

"It's been a pretty drastic change for the clients," Dunks says, "as well as the staff."

Pat Noonan, CEO of Anaconda-based AWARE, says the cuts have "taken a major toll," contributing to the nonprofit laying off some 70 employees, the closure of facilities, and even the end of recycling services in Butte.

Todd Hoar, director of Butte-Silver Bow's Developmental Disabilities Office, says cuts at DPHHS have also affected people with developmental disabilities.

"Since HI (Helena Industries) case management went out of business, we lost all of our case management locally," Hoar said. "So every adult with a developmental disability lost their case management locally."

While Hoar says those clients were then "assigned a state caseworker," the clients "didn't know them at all, and they didn't live in this town."

So, while the approximately 200 to 250 case management clients with developmental disabilities in the county were able to continue to receive assistance, Hoar says the disruption created confusion for the vulnerable population and depersonalized a process that works best when people build lasting relationships that can lead to long-term improvements in quality of life.

"They're getting case management, but it's a glorified paper-filler-outer," Hoar says.

In Dillon, the cuts to case management funding have combined with the broader DPHHS budget reductions and other losses of services to create a "heart-wrenching" situation, says Katherine Buckley-Patton, a retired DPHHS administrator who belongs to the Beaverhead County Mental Health Local Advisory Council.

Since late last year, Beaverhead County has lost the local Office of Public Assistance, the local Western Montana Mental Health Center, the local job service office, and the Southwest Montana Chemical Dependency Office.

According to Buckley-Patton, "Elimination of those four offices really left a significant gap for individuals, particularly those with behavioral health."

While DPHHS has attempted to fill that gap by providing people access to a website and an 800 number where they can connect to services, Buckley-Patton says avenues are "not effective for everyone -- and for some folks who are most vulnerable in our community, it's particularly not effective for them."

Buckley-Patton says the abrupt loss of mental health and other public services in Dillon has had a "ripple effect," as the poor, the elderly, and the mentally ill find it difficult to navigate complex public and healthcare systems without help from long-standing local institutions, officials, and caregivers.

"What we've found is people are coming dis-enrolled from their health coverage, from Medicare and Medicaid," Buckley-Patton says.

She says others failed to connect with primary care providers after the closure of WMMHC's Dillon office, which happened "very quickly with very little public notice and with a very challenging transition process."

And as people lose longstanding providers, she says, they have increasingly started to seek care only when it reaches a crisis point by visiting emergency rooms to deal with mental health issues, "which is the most costly way to deliver health care" and which "isn't what an emergency room is for."

In addition to hospital emergency rooms, people with mental health issues are also increasingly finding their way into another setting that's not designed to house them: jails.

"Our jails end up being our mental health facility in Beaverhead County," Buckley-Patton says.

And this is a cycle that's also being felt in Butte.

According to a spokesperson for St. James Healthcare, the Butte hospital saw a 5 percent increase in emergency room visits as of March of this year, compared to the same time last year. While there's no way to determine the connection between that rise and the cuts to mental health services, Butte-Silver Bow Sheriff Ed Lester believes the two are intertwined -- and he thinks law enforcement, too, will be affected.

"The police and the emergency room at the hospital will see increased calls for service because some people who are in acute crisis don't have access to other resources," Lester said via email.

And Dunks says there's another area facility -- along with hospitals and jails -- that has had to deal with ramifications of the cuts to mental health care in the state: the Montana State Hospital in Warm Springs.

While Zoe Barnard, administrator of the addictive and mental disorders division of DPHHS, says she recently reviewed the data and didn't find a statistically significant increase in admissions to the state hospital, Dunks says she says has noticed an "uptick" in admissions since the cuts took effect on Jan. 1.

According to a federal inspection released last year, "chronic, pervasive staff shortages" led to assaults on facility's staff and put the facility at risk of losing its federal certification. That has some observers concerned about what reduced localized case management services in Montana might mean for the state hospital.

"The emergency system is already overloaded," says Seccomb of Action Inc. "Warm Springs is bursting at the seams. The jail is bursting at the seams. When people are in crisis and they act out in some way, they tend to end up in these kinds of places."

Another place they end up, Seccomb says, is the homeless shelter Action Inc. operates in Uptown: "We are the current emergency housing providers in the community."

According to Seccomb, people are sometimes discharged from Warm Springs directly to the shelter.

While Seccomb says her group is working with the state hospital to give the shelter enough lead time to prepare to receive released patients, she says that she wishes there were a better option for providing people with care in the community.

"Shelters are not good environments for people who are trying to stabilize," Seccomb says. "It is not optimal to have people released into homelessness."

As the ramifications of last year's budget cuts take effect in southwest Montana, numerous observers have begun to wonder whether even the financial calculus that led to DPHHS cuts in the first place will pay off.

"I believe that when you make these cuts at these levels to these programs that the net effect doesn't save money," says Montana Senate Minority Leader Jon Sesso of Butte, "because an individual finds that they don't have access to the services that were once provided, then they're put in these jeopardized positions and they have to go to the emergency room. Instead of getting the care they need when they need, there's a gap -- and it leads to a more severe problem down the line. ... That's why the case management has been so useful, in the years leading up to this crisis. That timing is very critical in the delivery of human services."

It's a sentiment echoed by Lester: "Any purported cost savings are not really accurate because costs are simply being pushed to the local taxpayer or medical provider in the form of increased time and resources required to help people in crisis. If case management was still in place, most of these folks would probably never require our services and they would be in a much better situation."

But as the reverberations of the cuts to DPHHS funding spread throughout southwest Montana, people are doing what they can to cope.

Lyn Ankelman, WMMHC's regional clinical director for Butte, Anaconda, and Dillon, set up a team of specialists to serve "some of our sickest folks" who had lost their case management, Dunks says. Currently, there are approximately 55 people being helped with that new program. For other former clients of case management services, WMMHC has started a walk-in service for clients that offers a range of services and support.

And people are working across agencies to lend a hand.

When WMMHC had to stop providing services to kids through the Butte Head Start program earlier this year, for example, the Southwest Montana Community Health Center stepped in to hire counselors and restore those services.

"My philosophy is, if we're helping the community and we're breaking (even), then we're doing good," says the community health center's CEO Jennifer Malone.

While the community health center, which has clinics in both Butte and Dillon, has to remain solvent in order to continue providing care, Malone says she's committed to doing what she can to pitch in when other local organizations have to cut services in response to reduced funding.

"This community is an amazing community," Malone says. "If people can step up, they do."

Evidence of that can be also found in Dillon, where earlier this week the Beaverhead County Mental Health Local Advisory Council held a meeting earlier this week with stakeholders from through the region, including representatives of Action Inc. and the community health center, to find ways to respond to the impact of cuts on residents.

While she acknowledges that "we can't replace what's gone," Buckley-Patton says citizens also can't wait for the Legislature -- or anyone else -- to swoop in and solve the challenges they are facing.

"I think Beaverhead County is doing some unique advocacy and is very strong in this approach to make sure we're not just waiting complaisantly by for the next legislative session," Buckley-Patton says. "We can't. We're losing people every day."


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