What is the Strategy?

Previously: In Part 1, the story of a mentally ill Livingston woman, "Sarah," underscored the challenges Montana's mental health system faces as community-level providers are rocked by political battles over public spending. In Part 2, we looked at how two of Montana's most recent budget fights have swung the state toward more health spending - and away from it again. Now: Given budget realities, does Montana have a plan for getting mentally ill citizens the care they need?

Montana Department of Public Health and Human Services Director Sheila Hogan took to the road in February, traveling the state to hold a series of listening sessions with mental health workers and advocates in the wake of budget cuts that had left many service providers reeling.

At a stop in Bozeman, Gallatin Mental Health director Michael Foust welcomed her to the "lion's den" - then asked her to explain the logic behind the way the department had made the cuts.

"What is the strategy going forward and where can we get our hands on that so we can get behind it and partner with you?" he asked.

Foust said a plan has the potential to create a culture that connects scattered Montana towns and people to what's coming from the capitol - something that he said is missing today.

Even with the moment's budget crisis, the state is obligated to plan for prevention. That's according to the national President of Mental Health America Paul Gionfriddo.

"People can point all they want to the demands placed on state budgets, but you still make choices of what you're going to fund," Gionfriddo said. "We should not be letting so many people get to crisis. If they don't do prevention, the state will continue to overspend relative to the services it gets."

Gionfriddo said states that Mental Health America holds up as examples passed early versions of Medicaid expansions, created options for care for people outside of "poor houses," jails and institutions and also have a history of mental health screenings woven into primary doctor appointments and school checkups.

A number of Montana's neighbors, including punch-above-its-spending North Dakota, have invested in comprehensive studies of their mental health systems, projects geared toward identifying what's working and what's not. Idaho, for example - which spent almost four decades in litigation over the conditions in its kids' mental health system - released a major assessment of its efforts this year, recommending more investment in preventative care.

In North Dakota, a 249-page "Behavioral Health System Study" released in April discusses what an optimal state mental health system would look like while cataloguing the strengths and weakness of the status quo. For example, the study discusses how limited options for mental health treatment sometimes mean North Dakotans can't get care unless they're convicted of a crime that gives them access to services in prison. It also points out that a number of entities in North Dakota are working on screening initiatives to identify and help people in the early stages of mental illness - and suggests the state do more to encourage those efforts.

"(S)takeholders emphasized a need for a system that incentivizes wellness rather than focusing only on sickness," the study authors wrote.

Montana officials like DPHHS mental health administrator Zoe Barnard talk about similar ideas, but say they haven't had the time to articulate that big-picture thinking in a formal document and add they want to help individual communities do local planning in any case. They also point to the unclear future of the Medicaid expansion, saying a legislative refusal to renew the program would devastate their ability to focus on prevention with any degree of strategy, forcing them back to the days of spending limited funding on crisis care.

"Trying to improve the system is a continual goal. It's not something that we ever reach the end point of," Barnard said. "The department is committed to continuing to look at the services that we provide for all Medicaid members."

Nationally, the way people expect states and providers to deliver mental health treatment is changing.

"People are looking for help that goes out beyond the doors of a center or mental health hub, out into a community," Gionfriddo said. "The system is going to transform and that's never easy."

When Sarah landed in the emergency room, a social worker and former Livingston center employee showed up at her bedside. The new role is part of the hospital's growing integrated behavioral health system, which weaves mental health professionals and support into primary care. Sarah learned another adult treatment program, L'esprit, opened in Livingston in her months of isolation.

"I was so scared about what would happen before I found this place," Sarah said on a recent afternoon, sitting alongside people she calls her family at L'esprit. "This feels more steady, like it won't go away, which puts my mind at ease."

L'esprit founder Chantelle Plauché said she's able to combine graduate interns and full-time staff to build on the services the center already offered children, even with the cuts. For what they can't cover, the building is a few doors down from Community Health Partners, one of several local groups they're working with more.

"Everybody got knocked to their knees when the budget cuts came, but you had to approach it like, 'The work is still very important - how can we still provide this work and move forward?'" she said.

L'esprit employees say the small community is the exception. Many Montana towns that lost services weren't able to fill in the gaps. Others didn't have services to lose in the first place. Plauché said what's happening in Livingston takes time, community investment and, ideally, continued buy-in in funding and time from the state.

"We all have to look at being more efficient," she said.