The entrance to the Bozeman Health Deaconess Emergency Department. Credit: Mara Silvers / MTFP

Gallatin County officials, community advocates and medical providers have arrived at another crossroads in their efforts to overhaul local mental health services: figuring out where the first-stop destination should be for people experiencing an emergency mental health or substance use crisis. 

This latest debate is part of Gallatin County’s protracted struggle to create a reliable system for people with acute mental health and addiction needs. For years, local activists have pressured the local hospital and elected officials to fill out a broad spectrum of psychiatric and therapeutic services. Unlike other major Montana urban areas, the southwest Montana county that includes Bozeman currently has no inpatient psychiatric beds and no designated crisis center where law enforcement can take people who are at risk of harming themselves or others.

“It is absolutely true that our community lacks critical services to meet the behavioral health needs of our children, our families, our friends and our neighbors and ourselves,” said Ellie Martin, a behavioral health consultant representing Gallatin United Way, at a county commission meeting July 12. “The system needs repair and stabilization across the continuum.”

The issue of emergency crisis beds, a temporary setting for people who are involuntarily detained by law enforcement, was at the forefront of the July meeting. 

For years, Gallatin County had a nearly $30,000 per month contract with the nonprofit provider Western Montana Mental Health Center for a variety of mental health services, including two emergency crisis beds at the Hope House facility. The county ended that contract in February, citing the organization’s struggle to provide reliable services due to staffing shortages and rising expenses. 

“It is absolutely true that our community lacks critical services to meet the behavioral health needs of our children, our families, our friends and our neighbors and ourselves.”

Ellie Martin, a behavioral health consultant representing Gallatin United Way

Since that contract was discontinued, the emergency department at Bozeman Health Deaconess Hospital has fielded most acute mental health emergencies, including the temporary detention of patients before they are discharged, transferred to another town’s inpatient psychiatric unit, or committed by a judge to the state psychiatric hospital in Warm Springs. 

Earlier this year, Gallatin County commissioners and County Attorney Marty Lambert made clear that they wanted the arrangement with Bozeman Health to continue. In a letter to hospital leadership in May, county officials stressed the importance of stabilizing those services as soon as possible.

“In consultation with the Commission, the County’s clear desire is to contract directly with BH as an established community entity and partner to guarantee appropriate provision of mental health services in this community,” the letter said.

The county’s appeal did not convince the hospital. While representatives of Bozeman Health have said the hospital plans to expand its emergency behavioral health services and eventually open a 12-bed inpatient adult psychiatric unit, its leadership has maintained that the hospital is not currently the appropriate provider for stabilizing emergency mental health patients or providing involuntary detention for at-risk patients.

“A specialty crisis provider is needed now, in addition to what Bozeman Health is doing, at an appropriate facility,” Bozeman Health’s chief nursing officer Diane Patterson said at the July meeting. “And it must be available to address the deficiencies that we’ve had in our community over the years.”

Hospitals in other Montana towns — including Providence St. Patrick Hospital in Missoula, St. Peter’s Health in Helena and Billings Clinic in Billings — have incorporated specialized behavioral health crisis care into their emergency departments. Patients who arrive at those hospitals are assessed by behavioral health teams in a distinct part of the emergency department before being discharged, admitted to the local inpatient unit, or transferred to Warm Springs. 

Bozeman Health has said it plans to open a new psychiatric unit within its emergency department by the end of the year and will have its inpatient unit up and running by 2024, a later timeline than it originally promised when it announced the unit last October. 

On Tuesday, the hospital announced other financial challenges in a sweeping round of layoffs. CEO John Hill said in an internal email that 28 full-time leadership jobs were terminated and another 25 open positions put on a hiring hold due to economic strain in the health care industry. He told staff the hospital had lost nearly $15 million in the first half of 2022.

In an interview Wednesday, Hill attributed some of the hospital’s financial hardship to workforce shortages and an increased reliance on contract staff. He said the hospital’s plans for increased behavioral health emergency services and a 12-bed inpatient unit have a difficult road ahead, but are still on track. 

“Those two projects, as we are currently speaking, are still a go. And I think the caution that we have with opening those two units is the availability of behavioral health professional staff,” Hill said. “We’re clearly in a staffing crisis for medical professionals … It is a difficult place right now to bring those folks into Bozeman with the cost of living, and frankly just the challenges that we have here in our community.”

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The absence of immediate and robust services from the hospital has created a void for other mental health and crisis service providers to fill. In a strategy supported by Bozeman Health at the July public meeting, Gallatin County commissioners voted to open bidding for an assortment of emergency services previously covered by the contract with Western Montana Mental Health Center, a mobile crisis response unit, and a crisis center that can receive voluntary patients and provide temporary involuntary beds. A vendor could receive up to $568,000 in public funds annually for all services — a sum that includes budget allocations from the county, the city of Bozeman and a federal grant — according to a copy of the county’s request for proposals reviewed by Montana Free Press. The proposal stipulates that the crisis receiving center would need to be operational by March 2023.

One provider expected to submit a proposal before the deadline later this month is Connections Health Solutions, an Arizona-based for-profit crisis service provider that has been recommended to the county by Bozeman Health. 

In an interview with MTFP, Connections staff stressed the company’s ability to provide services that are not currently offered in Gallatin County, including temporary emergency detention beds. Dr. Chris Carson, the company’s co-founder and chief medical officer, said that while Connections believes in a full spectrum of outpatient and rehabilitative mental health care, the county’s lack of inpatient acute psychiatric beds is a “glaring deficit.” 

“There’s clearly gaps, and we are willing to move into any gaps that it makes sense for us to move into,” Carson said. “We are not coming in with, ‘Here is our model in a box, and we can place that box in Gallatin County.’”

“What I see is a big poker game being played right now between Bozeman Health and Gallatin County.”

Gary Popeil, a longtime community mental health advocate

Local activists who have long pressured Bozeman Health to provide inpatient psychiatric services expressed strong opposition in July to the county’s plan to contract with another vendor for behavioral health emergencies. Those medical treatments, they argued, sit squarely with the community’s nonprofit hospital and should not be subsidized with public dollars.

“What I see is a big poker game being played right now between Bozeman Health and Gallatin County,” said Gary Popeil, a longtime community mental health advocate, at the July public meeting. Referencing Connections, he said Bozeman Health is “inviting someone from out of state” to operate emergency and acute psychiatric care on the taxpayer’s dime.

“It’s a game,” he said. “The whole object of it is so they don’t have to do it … Bozeman Health needs to step up, and they’re avoiding it.”

In an interview after the July meeting, Gallatin County Commissioner Zach Brown said the County Commission does not view the situation with Bozeman Health as a game. More important, he said, is figuring out how to build a system with the resources that are immediately available, rather than waiting for Bozeman Health to expedite or change its approach.

“The ‘game-of-chicken’ outcome where we just choose to do nothing has dangerous outcomes for vulnerable people,” Brown said. “Should we be investing in other services and take Bozeman Health at their word that they’re still focused on inpatient [services]? That seems like the most likely course of action for the county.”

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Mara writes about health and human services stories happening in local communities, the Montana statehouse and the court system. She also produces the Shared State podcast in collaboration with MTPR and YPR. Before joining Montana Free Press, Mara worked in podcast and radio production at Slate and WNYC. She was born and raised in Helena, MT and graduated from Seattle University in 2016.