In June, the median price for a single-family home in Gallatin County was $702,000, an increase of nearly 54% from the previous year. According to census data from 2019, nearly 21% of the county’s households made between $100,000 and $149,000 in the preceding 12 months, 6.5% higher than the statewide figure. The county’s population is now approaching 120,000 residents, making it one of the fastest-growing regions in the state.
Yet despite the apparent abundance, some local residents, health care providers, law enforcement officials and politicians say the region’s relative wealth has so far failed to create a critical piece of health infrastructure for vulnerable residents: people experiencing mental illness, emotional disturbances and addiction.
“The system is stretched really thin,” said Gallatin County Commissioner Zach Brown. “We’ve got a lot of people that care a lot. And we have had a lot of people in this community over the years that have worked really hard to invest in services and systems that I’m overall very proud of. But the system isn’t healthy at the moment.”
Some of the problems within the county’s fragmented behavioral health system are emblematic of statewide issues, including a severe shortage of licensed psychiatrists and low reimbursement rates for providers who serve Medicaid patients, which compounds staffing shortages.
And still, the dysfunction in the Bozeman area stands out, in part because of the insistence and passion of residents who want to see the system fixed.
Unlike every other highly populated county in Montana, Gallatin County has no inpatient psychiatric hospital beds for people suffering from an acute mental health crisis, signified by severe symptoms that need immediate treatment. There is no formal detox center, leaving much of that responsibility to the local hospital’s emergency department, which saw 818 alcohol-related visits in 2019, alongside an average of nearly three mental health cases per day.
Local law enforcement officials point out there are two beds at the local crisis center for involuntary detention if a person is at risk of harming themself or someone else. If those beds aren’t available, the sheriff’s office drives patients as far as Missoula or Hamilton to be temporarily detained at other facilities until they can appear before a judge and possibly be committed to the state psychiatric hospital in Warm Springs.
In more than two dozen interviews, local stakeholders were blunt about the shortcomings and inefficiencies of behavioral health treatment in Gallatin County. Most zeroed in on the need to fix the piecemeal and inefficient system for helping people in crisis in a state where suicide and substance use rates are routinely above national averages.
“We’re obviously not helping the situation enough right now,” said Dr. Bill Ryan, a psychologist who has practiced in the Bozeman area for more than 30 years. “I think there are plenty of people who really do want to help, but we haven’t found a way … to fully organize ourselves.”
Many of the sources described a sense of urgency about fixing the problems before them. They also expressed their aspiration that, if successful, the county could become a leading example statewide for how to run a high-functioning crisis response system.
However, pinpointing the central problem in the current system, and how it should be fixed, depends on who’s telling the story.
THE LIGHTNING ROD OF INPATIENT CARE
For years, a vocal group of advocates have pressured Bozeman Health, the regional nonprofit hospital, to develop an inpatient psychiatric unit to stabilize and treat patients suffering a mental health crisis.
The group, primarily made up of current and retired medical providers with decades of clinical experience, has used wide-ranging tactics to bring attention to the issue. Advocates have blanketed the editorial pages of the Bozeman Daily Chronicle, held meetings with county officials, sought out the ear of the hospital’s senior staff and board, held marches and, in perhaps their most high-profile appearance, talked about their campaign in a documentary series on mental health co-hosted by Oprah Winfrey and England’s Prince Harry.
In its distilled form, the activists want the hospital to respond to what they see as a clear medical need: creating a safe place for short-term psychiatric care located in the community that’s appropriate for certain dire situations.
“There are always going to be people who need a higher level of care, even if you have every service and preventive service for people with mental illness,” said Dr. Colette Kirchhoff, a retired primary care physician of 25 years and one of the central figures advocating for inpatient services.
“Those things should definitely be done,” she said, “You want to avoid the crisis and avoid hospitalization. Nobody wants to be hospitalized. But the truth is that those crises are going to happen and those people need a place to go.”
In 2019, Bozeman Health saw 1,932 behavioral health visits in its emergency department, according to data collected in a report for Gallatin County’s Crisis Redesign Committee (CRC). The hospital told Montana Free Press that a monthly average of 13 patients from its service area, six adults and seven children, received treatment in 2020 at an inpatient unit somewhere else in Montana. Most of those patients, the hospital said, were initially treated at the hospital’s emergency department before being transferred to another behavioral health unit, such as Billings Clinic or Shodair Children’s Hospital in Helena.
Those transfers are part of the reason local activists insist that Bozeman Health should create a local psychiatric unit. They say treating people in the emergency room, even with the best of care, can’t take the place of the multi-day treatment, de-escalation and medication management that certain patients require, a point echoed by statewide mental health advocates.
“While I agree that it would be wonderful if we were able to, theoretically, treat everyone’s mental health condition before they require inpatient treatment, that isn’t reality,” said Matt Kuntz, director of NAMI Montana, a national policy organization advocating for people with mental illness. “In the same way that we do not catch all kinds of cancer in the earliest stages, or every heart condition, there is a scale. And at one side of the scale, that is inpatient treatment.”
The shortage of inpatient resources has left some families feeling alone and frantic during one of the worst periods of their life.
When Karen Swan’s son Isaac, then a sophomore at Montana State University, began experiencing manic bipolar symptoms in 2007, she said the Bozeman Health emergency department staff concluded his crisis was more than they could handle at that facility.
There was an inpatient facility that could have been a good fit, she remembers hospital staff telling her, but there were no beds available. The last option for the 19-year-old was a temporary placement at the state psychiatric hospital in Warm Springs until a judge could assess him. Isaac was handcuffed and transported there by law enforcement, which Swan said was traumatizing and a disproportionate level of treatment for her son’s needs at the time.
That experience, Swan said, threw her son’s life “upside down.” While he managed his mania after his commitment to Warm Springs, she said he continued to struggle with deep bouts of depression, anxiety and trauma from his memories there.
Swan wonders if another entry to treatment, and more options for a lower level of care, could have set her son on a different course. Isaac died by suicide this January at the age of 32.
“Truthfully, I don’t think Isaac ever forgave me for taking him to the hospital to begin with,” she said. “He did his best to forgive me, and he said he did, but at various times he would say, ‘Mom, what you did caused me untold pain.’”
The behavioral health care options in Bozeman have changed and evolved since 2007, including the creation of a local nonprofit crisis center in 2010. Swan said she is glad that Bozeman Health has added a growing team of behavioral health staff in its emergency department and clinics, including psychiatrists and crisis intervention specialists, in the last few years. She hoped those changes might have a positive effect on current and future patients, and prevent families from feeling any doubt about seeking care for a loved one in crisis.
“As a parent, you always look back and say, well, did we do the right thing … maybe I shouldn’t have taken him to the hospital, but that’s what I thought he needed,” she said. “It’s too late for our family, but if somebody else can be saved from the experience that Isaac had, and our family had, it could be a life saved.”
Local activists and health care providers like Kirchhoff and Ryan maintain that the hospital could still do more for patients by building its own inpatient unit, which would also ease the strain on other providers around the state.
“The community is not getting their needs met,” Ryan said. “We’re not only in need of an inpatient unit, but we’re kind of desperate for it, to be honest.”
‘NOT THE END ALL, BE ALL’
Hospital officials in editorial pages, press releases and interviews with MTFP, expressed a range of concerns and offered caveats about pursuing inpatient psychiatric care.
Citing the recent report conducted for the county’s Crisis Redesign Committee, hospital officials in March said there are not yet “additional support services required to provide quality inpatient care,” and that “current patient volumes would not support a high-quality program” to recruit and retain qualified professionals. Hospital staff leading its approach to behavioral health have also stressed that an inpatient unit isn’t a silver bullet to fix the region’s broader medical needs.
“That’s not the end all, be all,” said Diane Patterson, chief nursing officer for Bozeman Health. “If you don’t have places to refer people, patients and their families end up coming back and back and back through your emergency department or into inpatient services.”
Bozeman Health has also pushed back on the assertion that an inpatient unit is absolutely needed, instead throwing its support behind earlier intervention and other crisis response services before someone reaches the need for a hospital stay.
“How do we, number one, prevent stigma? How do we prevent, as much as possible given the research, any crises,” Patterson said, referencing county-wide discussions about improving mental health education and strengthening crisis responder programs.
Still, inpatient psychiatric care is not off the table. Patterson said the hospital is continuing to consider whether it might eventually add those services in Bozeman.
“We will definitely be providing more services. We just don’t know exactly what that’s going to look like yet, but we’re committed to it,” Patterson said.
She pointed to a steering committee that is exploring more types of behavioral health care, with inpatient services being one of six categories the group is examining.
“Is that on-site? Off-site? How many beds? What’s the scope of services we provide? Do we provide inpatient detox? Do we see adults and pediatrics?” she asked. “How do we make sure we’re not jeopardizing the highly specialized and excellent care that Shodair [Children’s Hospital] provides so we’re not duplicating services but providing what’s needed.”
Bozeman Health is continuing to add specialized staff members housed in its emergency department, where nearly 95% of people experiencing a behavioral health crisis were brought by emergency responders in 2019, according to last year’s report for the CRC.
The hospital is raising money to remodel its old emergency center, which will turn into a less- than-24-hour therapeutic wing for behavioral health patients, separated from the trauma that might be unfolding in the main emergency department. To staff that unit and expand its existing behavioral health team, Bozeman Health has 14 open positions it’s looking to fill.
Sam Nave, a psychiatric nurse practitioner who works in the emergency department at Bozeman Health, has been in the job for about five months. In that time, he says, he’s seen days when, by his estimate, two-thirds of the department’s patients are there because of a behavioral health crisis: mental health, detrimental use of drugs or alcohol, or sometimes both.
Some of those patients, Nave said, may come in more than once if they don’t meet the criteria for inpatient treatment elsewhere and don’t have access to community-level treatment and support.
“Once we do have them seeing an outpatient provider and they get stabilized on medications and get some therapy involved, then all of a sudden they’re not coming back anymore,” he said. “So it just often takes some time to get people fully stabilized.”
While Nave agreed that an inpatient unit at the hospital could be helpful, he said much of its effectiveness would be dependent on what happens outside of the hospital’s walls.
“Honestly, I would love to have inpatient available to us. However, we also have to look at what our goal is for that inpatient,” Nave said. “For however long it is — whether it’s two or three days, whether it’s 30 days — what’s our goal once they leave? If we don’t have, really, follow-up services available right now, we don’t have much for [when] they go home. It’s a big transition going from this 24-hour treatment to going and living independently at home. So how do we make that transition?”
STRETCHED THIN, DESPITE ‘ABUNDANCE’
The community-level treatment that happens outside of a hospital falls to more than two dozen organizations operating in Gallatin County, in addition to individual psychiatrists and therapists. Each group takes responsibility for different services within the health care continuum: crisis hotlines, peer support groups and drop-in centers.
The organization with one of the largest portfolios of services is Western Montana Mental Health Center (WMMHC), one of oldest and best-known community mental health centers working in more than a dozen Montana counties. Its experience and reach also comes with a substantial amount of responsibility.
WMMHC currently receives roughly $564,000 each year from Gallatin County to operate a range of behavioral health crisis services, including conducting mental health evaluations, staffing a co-responder program that partners with law enforcement, and running the Hope House, an eight-bed crisis center for people seeking mental health support.
A bright, modern campus adjacent to Bozeman Health, Hope House is intended to be an accessible and affirming place for people to access crisis services.
“[Crisis facilities] are kind of receiving centers where people can be evaluated for inpatient placement,’” said Michael Faust, area director for WMMHC, who estimated that most patients stay between three and five days.
Hope House was designed as a resource for a person who knows they need mental health support, but is not at the level of needing medical services in a hospital setting, Foust explained. Ideally, he said, the county and the state would be investing more resources in early stage interventions and prevention services in an effort to help people before they need hospital care or commitment to Warm Springs.
Foust said he doesn’t land on one side of the debate over building an inpatient unit in Bozeman. He said his concern is how the reallocation of resources may end up neglecting a large portion of patients.
“Build as much as you want, but 90% of your people are still going to be without the rest of the services,” Foust said. “They don’t even need that level of service.”
To create and run Hope House’s current campus, WMMHC has benefitted from the support and funding of Bozeman Health and Gallatin County. The hospital donated the land for the campus, while the county in 2010 agreed to pay off the $1 million mortgage, plus interest, for the Hope House facility in installments of about $71,000 annually. Last year, the hospital provided seed money to set up a Behavioral Health Urgent Care Center on the same campus.
Foust acknowledges that the main crux for operating all of its services is recruiting and retaining qualified staff. With roughly three people coming into the urgent care center every day between 8 a.m, and 6 p.m., Foust said, WMMHC care coordinators and therapists are busy, sometimes splitting time between Hope House and the urgent care center.
Staffing shortages have created a notable pinch at another unit within the Hope House facility. Across from the private rooms and away from the soothing soundtrack of ocean waves is an emergency detention unit for people who need to be held involuntarily because they pose an immediate risk either to themselves or to others. That two-bed unit has gone through periods where it’s not operable, including a roughly six-month closure last year because of low staffing during the pandemic, despite being a key part of WMMHC’s contract with the county.
WMMHC has repeatedly asked Gallatin County to increase the funding to support its services and boost employee pay when state funding has been low or unreliable. County officials, in turn, have argued against giving WMMHC more money when it hasn’t complied with its current contract.
In his ideal world, Foust said, more state and local funding would support hiring more psychiatric medical staff at Hope House, allowing the facility to serve more people and better meet the needs of some of its patients.
“We need more available psych, medical, more nursing,” Foust said. “Could we use more funding for more staff, just so we could have a better level of care? Could we pay these people better? Absolutely.”
If Bozeman Health and the county decide to invest millions in developing an inpatient care unit and expanding behavioral health services, Foust said, it’s unclear how the services that WMMHC currently provides will be impacted, or whether its programs will be sustainable.
The feeling of an either-or dynamic in a county with growing wealth and resources is incredibly frustrating, Foust said. He points to a long-standing lack of parity for mental health services compared to other public resources and infrastructure. That pattern stings all the more as more affluent residents move into Gallatin County.
“$730,000 for a single-family home? And we don’t have abundance?” Foust said. “That’s what this emergency is about.”
RESPONDING TO A COMMUNITY NEED
Community activists argue that the scarcity of services could be partly relieved by Bozeman Health putting more of its own wealth on the line, even for services that aren’t particularly lucrative. The hospital system reported a 10% revenue margin over expenses, totaling $34 million, on its federal tax forms in 2019. That’s double the national median among nonprofit hospitals for that year, according to an analysis of federal Medicare cost reports.
“The hospital had a very profitable year, generating about $1 profit from every $10 revenue,” said Dr. Ge Bai, professor of accounting and health policy at Johns Hopkins University, who reviewed Bozeman Health’s 2019 tax filings at MTFP’s request.
In a statement, Bozeman Health said it considers its average $20 million operating margin to be a “financially prudent” way to ensure the hospital’s sustainability, particularly when it comes to navigating unforeseen circumstances such as the COVID-19 pandemic.
As a nonprofit, hospital spokeswoman Lauren Brendel said, “any and all revenue is put back into the health system and the community to ensure we can continue providing health and wellness care to all.”
Activists pushing for inpatient care say the hospital’s nonprofit status obligates it to respond to the specific health care needs of the community.
Like all nonprofit hospitals, Bozeman Health is required by the federal government to provide “community benefits” in exchange for its exemption from state and federal taxes. Those benefits, including charity care, can be informed by the results of a Community Health Needs Assessment and implementation plan hospitals must conduct every three years. In 2017 and 2020, residents polled by Bozeman Health put mental health and substance use at the top of their list of concerns, above access to health services and nutrition and physical activity.
Federal law doesn’t specify how much money hospitals must spend on community benefits in order to maintain their nonprofit status. Nationally, health policy analysts debate how to measure community benefits to evaluate whether hospitals are earning their tax exemptions. One metric that receives particular scrutiny is what hospitals record as the cost of their services that are not covered by the reimbursement rates of government insurance. The amount that hospitals absorb is called “Medicaid shortfall,” and can be included in the total amount of community benefit.
In 2019, Bozeman Health calculated that its health system’s total community benefit was roughly $32 million, or 7.7% of its total operating costs. Nearly half of that amount came from the hospital’s “Medicaid shortfall,” or its recorded cost of caring for Medicaid recipients.
Even including the Medicaid shortfall, Bozeman Health’s overall financial community benefits are below the 10% national average for nonprofit hospitals, according to a 2017 survey conducted by the American Hospital Association.
Outside of caring for Medicaid patients, Bozeman Health has said it provides community benefits through various programs meant to prevent stigma around mental health, including suicide prevention education for students in Bozeman and Big Sky and mental health first responder training. Brendel did not provide a specific dollar amount for the hospital’s contribution to those programs, but said investing in stigma reduction is “vitally important” and clearly responsive to the community needs outlined in previous survey responses.
“Often, people avoid or delay seeking treatment due to concerns about being treated differently or fears of losing their jobs and livelihood. That’s because stigma, prejudice and discrimination against people with behavioral health disorders is still very much a problem,” Brendel said.
The Internal Revenue Service outlines that community benefit programs can and should be used to achieve community health objectives, such as easing geographic or financial barriers to care, improving public education and knowledge, or assuming a health care responsibility from the government or another tax-exempt group.
Asked whether an inpatient unit could be seen as meeting the qualifications of a community benefit, as community advocates have suggested, Brendel disagreed.
“Including inpatient behavioral health as a community benefit presumes that an inpatient unit is not sustainable or capable of covering its operational costs,” Brendel said. “It also suggests that the reason for our continued work and significant review of the behavioral health needs present in our community is only focused on financials, which is not the case.”
Brendel added that the hospital is committed to expanding behavioral health care outside of the programs listed as community benefits.
“Bozeman Health has, and continues, to improve access to clinical mental and behavioral health services through programs such as integrated behavioral health, telepsychiatry, behavioral health staffing and expanded crisis response,” she said. “This work and investment is woven into our daily operations in our emergency departments, primary care and pediatric clinics, and our local schools. These early investments and the progress we’ve made serve as good initial steps. Our board and leadership team are actively considering deeper investments toward further expansion of behavioral health services.”
‘WHY WOULD WE DO THAT TO SOMEBODY?’
As negotiations and deliberations continue between the county and health care providers, patients in crisis are struggling to navigate the fractured system every day.
For health care professionals, families and other stakeholders, watching people slip through gaps spawns a feeling some have described as “moral distress.”
Deputy Tom Pallach is one of the members of the Gallatin County Sheriff’s Office responsible for transporting patients to Warm Springs from the hospital, Hope House or other WMMHC facilities. The department estimates it completes about 100 such trips a year, sometimes for the same patients.
Despite the circumstances, Pallach said, he sees his work as an opportunity.
“When we come up, it’s like the worst day of somebody’s life that, at least for me, I get to try to make better,” Pallach said.
That doesn’t come without trying and exhausting circumstances. Pallach said sometimes officers have oversight of a patient at the emergency room for hours until that person can receive a mental health evaluation.
If the involuntary unit at Hope House is not available to hold certain patients in a dangerous crisis, then law enforcement officers transport them to other WMMHC facilities across the state where they are held temporarily.
Pallach said the long-distance trips, during which patients are handcuffed in the back of a patrol car, can be extremely difficult on people in crisis.
“That’s the part that is really frustrating,” he said. “It’s inefficient. And for somebody in crisis, sitting in the back of that car is not comfortable. It’s a three-hour drive from here to Missoula. Why would we do that to somebody?”
The sheriff’s office, along with the Bozeman Police Department, has been among those advocating for a substantially redesigned crisis response system, including developing mobile crisis units that can dispatch trained mental health professionals to respond to emergencies.
Having more beds and units to keep people safe and stabilized in Gallatin County is also an obvious gap to fill, Pallach said, even if it’s not yet clear how that will be accomplished.
In July, Bozeman Health helped draft a plan with the county’s Crisis Redesign Committee that proposes the creation of a more than $9.5-million psychiatric emergency center to receive and stabilize people in crisis, including a five-bed detox wing.
According to the proposal, start-up costs for the facility could come from Gallatin County’s portion of the federal American Rescue Plan Act, of which county commissioners have discussed allocating roughly $8 million to behavioral health services.
The facility would be suitable for voluntary and involuntary treatment, including nine beds for children and adolescents and 12 beds for adults. It would not be designed to keep anyone longer than 24 hours and would not be considered an inpatient psychiatric unit comparable to those at other Montana hospitals.
While county officials stressed that the plan is a draft, multiple stakeholders interviewed for this story said they support the idea of grouping multiple behavioral health crisis services under one roof and expanding the number of available crisis beds to ease the strain on patients, providers and law enforcement. Which medical provider or nonprofit is best positioned to run that facility, or receive the bulk of contracts for those services, has yet to be decided.
“We’re considering the possibility of breaking our services apart and soliciting proposals for pieces of them, or rethinking the whole service continuum that we’re involved in,” said Commissioner Zach Brown. “So everything’s on the table at the moment.”
Brown said he agrees that an inpatient psychiatric unit would be a positive addition to the community, but he doesn’t see the need for better behavioral health care ending there.
“We do very much have an opportunity to rethink and redesign the services that we’re providing in the Gallatin Valley. And we have a historic amount of resources available that are abnormal,” Brown said, referring to federal COVID relief funding. “It’s a really interesting opportunity to kind of reimagine how we do things in Gallatin County and try and get it right this time.”