A longtime provider of comprehensive in-school mental health services for hundreds of Montana students closed its operations last month, a development that other providers and professionals attribute to broader forces placing stress on the state’s already fragile mental health infrastructure.
Altacare of Montana, a for-profit provider of Comprehensive School and Community Treatment (CSCT) programs owned by Tennessee-based Acadia Healthcare, announced its intent to close its Butte facility and halt its CSCT services in a May 13 letter to the Montana Department of Public Health and Human Services. The letter, shared with Montana Free Press by the Office of Public Instruction, stated Altacare’s plan to “keep staff and resources in place” and “preserve operational integrity” until the end of the 2021-22 school year, and to cease operations no later than June 30. Attempts to contact Altacare and Acadia for comment went unanswered.
“While Altacare of Montana will be discontinuing its operations, we are very proud of the work we have accomplished together,” Altacare Operations Group Chief Financial Officer Marty Garcia wrote in the letter. “During our history, many patients and their families have seen their lives dramatically improved through the hard work of our dedicated staff.”
Altacare had been providing CSCT services in Montana for 15 years.
According to OPI spokesperson Autumn Frey, 307 public school students in Montana were receiving CSCT services through Altacare the month prior to the closure. As of January 2022, Frey added, 15 school districts in the state had contracts with Altacare for CSCT services: Arlee, Boulder, Butte, Deer Lodge, Missoula’s DeSmet School District, Eureka School District #13, Eureka School District #CO, Kalispell’s Evergreen and West Valley school districts, Malta, Noxon, Plains, Powell County High School, Seeley Lake and Sheridan.
MTFP is the first to report on the closure, which has been mentioned in recent meetings regarding changes to state education regulations but was not widely publicized.
In recent months, a change in how Montana handles funding for in-school mental health services has generated debate. That new process went live this week, but for some districts, there’s lingering confusion about what’s expected of them and whether they face added financial risk.
The Comprehensive School and Community Treatment program, which places mental health workers in schools, is beset by an ongoing shortage of therapeutic staff, funding changes, and bureaucratic confusion. How are Montana schools muddling through?
Altacare’s departure comes as mental health service providers across the state report increasing difficulty with workforce recruitment and funding challenges related to state-determined Medicaid reimbursement rates, as well as a significant change in the funding structure for CSCT services specifically. Those services, which station teams of mental health professionals in schools to support children diagnosed with serious emotional disturbances, now require districts to provide the state with a cash payment in order to receive Medicaid dollars they can then use to pay third-party CSCT providers. Prior to the change — passed by the Legislature in 2021 and implemented in February — schools were able to cover that match payment using in-kind services such as office space and equipment. The new system also tasks OPI with collecting those payments and submitting them to DPHHS before the latter agency releases Medicaid funds to the schools.
Mary Windecker, executive director of the Montana Behavioral Health Alliance, said Altacare had been clear with others in the industry about its struggles in the new environment. As a result, she “wasn’t surprised” by the company’s closure.
“I’d be surprised if anybody was surprised,” Windecker said. “We had a change in the [CSCT] model and there was all the confusion when they transferred it to OPI. It’s just been a very difficult year for CSCT.”
Windecker added that it’s become “a fact of life” to see mental health providers cut certain services or even close entirely, which is why her organization and other providers in the field are “constantly bobbing and weaving and trying to fill in the gaps.”
That’s exactly what’s happened in Malta in the wake of Altacare’s closure. When Fallon Handley, the counselor at Malta Elementary School for the past eight years, first heard the news, she said she began to feel “overwhelmed” by the prospect of taking on an increased student caseload. She was already seeing 31 students on an individual basis this spring, in addition to her multi-student and classroom counseling duties. Altacare’s CSCT team was providing one-on-one services to an additional 22 students, Handley said, and she wasn’t sure how she’d be able to continue offering quality care if the job fell solely to her.
“I don’t think I could have,” said Handley, who worked on Altacare’s CSCT team in Malta for five years prior to becoming the school counselor. “I think I would have been on a road to burnout to try to see that many kids every day, and to provide a quality care service for them would be really difficult.”
But the same day the Miles City-based Eastern Montana Community Mental Health Center heard about Altacare’s departure, it reached out to Handley’s district to inquire about continuing CSCT services there. The center already operates 10 CSCT teams in schools throughout eastern Montana, and CEO Brenda Kneeland said her organization desperately wants to keep services operating in its 17-county region. To that end, she said, the center hired Altacare therapist Megan Davis to continue in her CSCT role in Malta.
For Davis, that swift resolution was critical not just for her, but for the students she’s served in Malta through Altacare over the past 12 years. One of her central roles was to help students with serious emotional disturbances develop the social and behavioral skills they needed to interact with their peers and successfully navigate the school environment, through one-on-one sessions and regular classroom monitoring. David said she was unaware of the closure prior to its announcement, and she briefly contemplated sticking around town to offer outpatient services on her own. The more she thought about the prospect, though, the more she realized that the students she’d been serving through the CSCT program were the students least likely to be able to access or afford private treatment — and the ones who are at higher risk for mental health crises and emergencies in the absence of daily in-school services.
“Those are the kids that CSCT programs get to help, those kids that need daily check-ins and support so they don’t have to go to a higher level of care,” Davis said.
Michelle Mitchell chronicled a similar series of events at Evergreen Public Schools near Kalispell, where she’s worked as the elementary school counselor for the past eight years and, prior to that, as a fourth-grade teacher for 12 years. Mitchell said her school has had CSCT services for more than a decade, and she was “blown away” when she heard that Altacare would be halting those services in February, months ahead to the company’s actual closure. The district was “devastated,” she continued, and Mitchell’s caseload was “out of control” as she absorbed responsibility for more students with higher-level behavioral health needs.
“I’m not a therapist, so I’m just going to try to keep plugging along and seeing those kiddos, doing those daily check-ins that I need to do, talking with families, just being in the loop so that if something does happen, I’m going to be able to help as much as I can,” Mitchell said.
According to Mitchell, the nonprofit provider Intermountain ultimately stepped in to help, hiring the former Altacare therapist who was working at Evergreen Elementary and offering once-a-week therapy services for students through the latter half of the spring semester. Retaining that position was an important move for the school, Mitchell said, and one that wasn’t financially feasible without Intermountain’s intervention. But the level of service doesn’t come close to the regular, comprehensive support students had under the old CSCT model, she added, and while she hopes to see a return to that level of service, it remains unclear whether that will happen.
“It was such a great resource and intervention for these kids, because they didn’t have to go anywhere,” Mitchell said. “They had their daily meeting with the therapist and it just, it was … I loved the model that we had.”
The circumstances surrounding Altacare’s closure underscore a host of ongoing statewide conversations in public health and public education circles. Public health professionals are anxiously awaiting the results of a DPHHS-commissioned study of Medicaid services in Montana that could inform changes to existing provider rates next session. In the public education space, the caseload concerns voiced by Handley and Mitchell speak directly to Montana School Counselor Association Executive Director Renee’ Schoening’s staunch opposition to a recent push by Superintendent Elsie Arntzen to eliminate a state-mandated school counselor ratio. If anything, Schoening told MTFP this week, the loss of Altacare highlights the importance of preserving and enhancing mental health services in public schools.
“Without those services, school counselors end up taking responsibility for a lot of those kids because either there isn’t a place in the community they can refer them to, or parents aren’t able to get those kids to therapy,” Schoening said.
At Aware, a nonprofit delivering CSCT and other community-based mental health services across the state, CEO Matthew Bugni said his organization is currently evaluating whether it can take on any of the programs left behind by Altacare. The kind of preventative support offered by CSCT and other services is critical, he said, in addressing individual behavioral and mental health issues before they lead to costly and resource-intensive crises. Ultimately, though, the question comes down to funding, and Bugni questioned whether Altacare’s inability to continue operating is a “canary in the coalmine” for other mental health services in the state.
Bugni isn’t the only one concerned about the broader financial pressures that Altacare’s closure has brought into sharper focus.
“The fact that Altacare was not able to hold on is not surprising,” Kneeland said. “If we look statewide, you see group homes closing, you see limited access to psychiatric beds for youth and adults. You can’t run a program if you can’t staff it, and you can’t staff it if you can’t hire competitively and keep people employed.”
The investigation comes after Save Holland Lake — a group organized last year against a proposed expansion of the nearby Holland Lake Lodge — filed a complaint alleging the federal agency has been ignoring its concerns about the wastewater system near Condon.
In Montana, fall means flannels, comfort foods and foliage. The return of the school year marks a more regular schedule, football season, hunting season, and sausage season. You read that right: sausage season.
PLUS: Some tribal members want school choice too.