Due to an ongoing therapist shortage aggravated by COVID and changes in funding sources and processes, fewer Montana schools are offering mental health services through an established state program.
The Comprehensive School and Community Treatment program, started in 2003 by the state Department of Public Health and Human Services, offers therapy to students with serious emotional disturbances. School districts enroll in Montana Medicaid and contract with mental health providers, which place therapy teams in schools.
Advocates say the CSCT program offers students immediate and necessary help, and that federal Medicaid dollars pay about 65% of the cost.
“We’re there every day to provide services to kids,” said Calvin Mann, regional clinical supervisor for Altacare, a Butte-based provider of CSCT services in many Montana schools. The in-school presence of a therapist means students don’t have to leave school for appointments, he said. “If something is happening in a child’s life, and the child is in crisis and needs help, they don’t have to wait.”
Mann said many Montana students are dealing with serious issues, including trauma, depression, addiction, bipolar disorder, parental divorce, family instability, homelessness and suicidal thoughts.
“We’re trying to help these kids get past their sadness and hopelessness and see that there’s a light at the end of the tunnel,” Mann said.
According to the 2021 Youth Risk Behavior Survey, 22% of Montana students surveyed had considered suicide in the previous 12 months, 18% had made a plan, and 10% had attempted suicide.
But the number of schools that provide CSCT services has dropped by nearly half from fiscal year 2020 [the 2019-2020 school year] to this fall, from 300 to 155 schools, according to DPHHS. Participating school districts dropped from 87 to 51.
CSCT is being destabilized by an ongoing therapist shortage, which has been worsened by COVID-related uncertainties and the federal government’s change in requirements from a local “soft” match of in-kind services to a “hard” match of cash. The state had paid that hard match since 2020, but the 2021 Legislature discontinued that funding. Various parties are now working to shore up the CSCT program or create other mental health options for students.
NOT ENOUGH THERAPISTS
“We used to be in a lot more schools, but since COVID, it cut down on that,” said Tracy Nash, human resources manager for Altacare, one of 14 CSCT-licensed mental health providers. “Hopefully, we’re building that back up.”
As of Nov. 11, the Altacare of Montana website was advertising 21 open therapy positions.
“It’s a competitive market,” Nash said. “They can do private practice and make a lot more [money],” she said.
CSCT therapists have master’s degrees and are normally licensed clinical professional counselors or licensed clinical social workers. Each therapist is teamed with a behavioral intervention specialist who has at least a high school diploma and two years’ experience in the field. (School district counselors don’t provide behavioral health treatment.)
Superintendents and mental health providers say many therapy positions are vacant, especially in rural areas, which is affecting school CSCT programs like the one at the Wolf Point School District, which ended in May 2020 because the contracted provider couldn’t staff the program with a therapist.
“Most school districts are finding it hard to hire counselors as well as mental health providers,” Wolf Point Superintendent Loverty Erickson said. “A school counselor — we can’t even find that.” She said the district has gotten help from the Fort Peck Tribes’ Health Promotion and Disease Prevention program, which pays for therapists and licensed addiction counselors at various schools.
The situation is similar on the other side of the state. Superior Public Schools lost its three CSCT teams (six people) in 2016-2017 when its provider decided the program was no longer economically viable.
“They really left a huge crater,” Superintendent Scott Kinney said. Students lost their therapists, and teachers lost support and training.
Superior decided to employ one LCPC this year using federal Elementary and Secondary School Emergency Relief COVID dollars. Kinney considers school-based mental health services essential: “I would contend it is probably the most important part of school,” he said.
THE FUNDING FACTOR
The therapist shortage has been exacerbated by a recent change in how the program is funded. Until 2019, 65% of the cost was paid by federal Medicaid money, and 35% was payable with in-kind contributions from participating schools, like office space for CSCT staff.
In 2019 the federal government began requiring more detailed documentation or cash for the local match. DPHHS paid that match starting in 2020 and requested match funding for 2021-2023, but the 2021 Legislature didn’t approve the funding in the state budget bill, House Bill 2.
As chair of the Joint Appropriations Subcommittee for Education, Rep. David Bedey, R-Hamilton, oversaw the debate. In an interview with Montana Free Press, Bedey said, “We were reluctant to put $20 million to a program that no one could show us any metrics that it was effective. We need to make sure that the programs we fund are the best programs for solving the problems we’re trying to solve.”
Bedey said the Legislature did approve $2.2 million in bridge funding to help school districts pay the local match through the first part of the fiscal year and ease the transition to a new funding system. As of Sept. 30, $653,766 of that bridge funding has been used, according to the state Office of Public Instruction, which was directed by Bedey’s House Bill 671 to design and implement a new funding process with DPHHS. (Medicaid funds flow through DPHHS). According to the bill’s fiscal note, implementing the program will require OPI to hire two full-time staffers at an estimated annual cost of $122,500.
Local school districts are grappling with how — or whether — to pay the 35% match and continue CSCT services.
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They are assessing the complexity of the new funding process, searching for funding sources for the new federally required local match, and exploring alternative ways to provide mental health services to students. Different schools are taking different approaches, with some dipping into their budgets to keep CSCT programs afloat, and others reducing or cutting CSCT entirely.
LOSSES AND WORKAROUNDS
Missoula County Public Schools decided to reduce its CSCT services.
“Last year, we were told we had to foot the bill of 35% of the program out of our general fund, which pays for teachers, utilities,” Superintendent Rob Watson said. “We don’t have that kind of money.”
At its pre-COVID height, Missoula had 31 CSCT teams working in the district’s 18 schools. (Each team has two therapeutic workers and serves 12 to 20 students.) The $5 million program cost the district nothing other than a soft match of office space and equipment.
With such soft matches no longer accepted, the district would have to find up to $1.75 million to cover the new hard match, Watson said. That expense, added to therapist attrition caused by the COVID-disrupted school schedule, led to a reduction of the district’s program to 10 teams at 16 schools this year. The number of CSCT employees dropped from 62 to 20.
The remaining 10 teams cost about $1.6 million.
“If we are required to cover 35% of that total cost, that is $565,000 which will need to come from our general fund,” Watson said. “We will have to watch the budget carefully and hope that we have some year-end money to cover this cost.” He expects some of the money to come from the state’s bridge fund, but doesn’t know how the program will be supported going forward.
Adding to the frustration, Watson said, his district received $28 million in federal COVID-relief ESSER funding, but isn’t allowed to use federal money to match other federal money. So Missoula used ESSER funds to hire nine full-time behavioral interventionists, one for each of the district’s elementary schools, and boosted existing middle and high school social workers from half-time to full-time — “a little bit of a replacement for the loss of CSCT,” he said.
Faced with the same dilemma, Belgrade Public Schools discontinued its CSCT program.
“In a traditional sense, we do not [now] have CSCT” because it’s not billed through Medicaid, said Superintendent Godfrey Saunders. He said the district’s provider canceled its services because the CSCT funding model was in flux.
Belgrade hired eight behavioral specialists with ESSER funding, he said. Therapy is taking place outside of school and paid for through private or public health insurance. For kids without family means, the district is footing the bill.
“It’s continuing to evolve. We’re working with [provider] Intermountain to get an in-school model in place,” Saunders said. “Kids are not going without services completely.”
Other districts are trying to maintain CSCT at existing levels.
“We would like to have it fully staffed,” said Laurie Barron, superintendent of Evergreen School District, a pre-K-8 district in Kalispell. “We do not have our funding situation fully worked out. We continue to work with the OPI.”
Barron said the funding uncertainty is making staffing CSCT more difficult. “I do think this change in the funding has made some people unsure of the long-term stability of the Comprehensive School and Community Treatment services program. So, I think it has made it less appealing to some people to choose this as their venue to provide mental health care to youth.”
Helena Public Schools also decided to maintain its CSCT program, which operates in 15 of the district’s 17 schools (the other two are short-staffed) and is using a savings account to cover some costs.
“It’s an extremely valuable resource to students and families,” said Josh McKay, assistant superintendent of grades 6-12. HPS contracts with providers Intermountain, Aware, and Shodair.
DEVIL IN THE DETAILS
OPI and DPHHS continue working to define the new funding process and explain it to districts.
“This is a very complex project which we have done a deep dive into,” OPI Deputy Superintendent Sharyl Allen said. “The OPI has been working diligently to streamline the process.” In emailed comments, DPHHS said, “DPHHS and OPI have collaborated to create the least impact possible to school districts.”
A DPHHS/OPI flow chart of the new “Intergovernmental Transfer Process” conveys the steps:
- Provider submits CSCT Medicaid claim to the state
- Montana Medicaid Management Information Services calculates local match amount
- DPHHS reviews match report and submits it to OPI
- OPI reviews report and notifies school district of match due
- School district sends match check to OPI
- OPI reconciles funds and transfers them to DPHHS
- DPHHS reviews payment information and releases the CSCT claim to Medicaid
- School district receives the federal and local match payments and pays its contracted provider of therapists
“This differs from the historical process because school districts are required to submit, monthly, non-federal funds to OPI/Medicaid Agency for the state share of delivered services,” DPHHS clarified by email.
The flow chart doesn’t mention in-kind matches, but OPI’s “CSCT Accounting Guidance Document” indicates that school expenses like IT support, supplies, space, utilities and “Time and Effort Logs” documenting CSCT-related time spent by clerks, special education directors, principals, teachers, etc., can be used toward the local match.
That process is much more extensive than previously required, according to school money managers.
“The time and effort logs and the extra documentation that is part of this process is extra effort that would probably require a district to need to hire additional staff for paperwork,” said Denise Williams, executive director of the Montana Association of School Business Officials.
The full impact of the funding changes won’t be known until January because schools have not yet experienced the Intergovernmental Transfer Process, said Kim Chouinard, executive director of community-based services for Yellowstone Boys and Girls Ranch, based in Billings. Chouinard facilitates a coalition of Montana CSCT mental health providers.
CSCT advocates say the program provides critical support, not just for participating students, but for school communities at large, including teachers who may otherwise be called on to address mental health crises in class.
“These programs help kids who are struggling to navigate school, which then helps other students. It allows for all students to continue learning. In crisis situations, teachers can then work forward with students who are ready to learn, while [a CSCT therapist] works with the kids who are struggling. The classroom continues on like normal instead of that behavior being in front. When those services work best, no one knows they are there. But when they’re missing, the difficult behaviors, the emotions, the interruptions to learning occur,” McKay said.
Rep. Mary Caferro, D-Helena, describes the program’s struggles as “an example of how children who have disabilities and their families — and their day-to-day struggle — get caught up in politics,” she said.
She believes that inserting OPI into CSCT management “added another layer of bureaucracy” to the program, and that the Gianforte administration should find a way to fund the program for the next two years.
“We have more General Fund than usual for the Medicaid program, thanks to the COVID fiscal relief, and state revenue came in higher than projected,” she said.
Caferro also noted that Gianforte included CSCT funding in his original budget presented to the Legislature.
Bedey said the administration overlooked CSCT because it had not been presented as a new proposal but was “hidden” within ongoing funding.
“The Legislature was not made aware that the soft match was no longer permissible until the Legislature’s fiscal analyst discovered this within the governor’s budget,” Bedey said. “The Legislature was distressed to find out that DPHHS had diverted funds from other Medicaid programs to cover that match starting in 2020.”
Bedey, who was a school board member in Hamilton for nine years, said the Legislative Finance Committee staff will report in December on the feasibility of studying youth mental health programs.
“In order to be prudent stewards of taxpayer dollars and do the best we can to meet mental health needs and suicide prevention, it’s incumbent on us to scrutinize the effectiveness of programs. Maybe there are alternatives,” he said.
“I understand the need to have some type of concrete measuring tool to see if something works or not,” said Altacare’s Mann, “but mental health is the most difficult discipline to come up with measuring success. I think one of the biggest ways of determining whether these programs are effective and successful is that schools want us there.”
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