If a hospital was being built today to care for seriously ill patients, no one would build it miles from the nearest town and farther from the professional labor pool necessary for staffing. Yet that is what Montana State Hospital is: remote, chronically understaffed, relying on temporary doctors and nurses. Worse yet, patients with serious mental illnesses must travel from all over our vast state, disrupting any connections they have with family, friends and community care providers when they are hospitalized at Warm Springs.
The Montana State Hospital staff members deliver very good care to many patients, but not at the right time or place.
Montana has been sending psychiatric patients to Warm Springs for more than a century — since people came for the supposed therapeutic benefits of the hot springs that still steam on the edge of the hospital campus. It remains the location of the only state-operated psychiatric hospital in Montana.
There is a great need for mental health care in Montana, which has the terrible distinction of having the highest rate of suicide in the nation. But sending people away to an institution isn't the right treatment. Montana must build up its community care and close the gaps that all too often allow ill people to deteriorate to the point that they do need to be hospitalized.
Likewise, there is dire need to provide workable discharge plans for every patient leaving Warm Springs in collaboration with service providers and families in the patient's home community.
Montana now has a better opportunity to upgrade community services because most Montanans with serious mental illnesses are covered by Medicaid. The state pays a share of their community care costs, but the federal government will pay up to 90%. In the aftermath of painful budget cuts the Legislature required in 2017-2018, it's time to figure out a system for sustainably funding community mental health services so that all Montanans can access appropriate care to keep themselves out of the state hospital.
Federal surveyors have repeatedly cited Montana State Hospital for understaffing. As a result, MSH relies heavily on temporary workers. Recently, the hospital had 26.5 full-time equivalent nurses on staff and 25 full-time contract nurses; 2.5 FTE staff psychiatrists and five contract pyschiatrists; along with four advance practice registered nurses and two contract APRNs, according to information from the Montana Department of Public Health and Human Services.
Temporary professionals are extremely expensive, with much higher per hour and per week costs than a full-time staff member. But the state hospital has no choice; the the market is tight for health care professionals and Warm Springs is competing with more desirable locations to live and work.
All told, MSH had 79 staff vacancies when DPHHS replied to The Gazette's request for information last week. Total authorized staff at the hospital is 525 FTE.
In the fall of 2017 when state agencies were required to make a list of spending cuts to help balance the state budget, the Montana Department of Public Health and Human Services proposed numerous cuts to community services, including mental health care. It also sought one spending increase: A raise for psychiatrists. Despite increasing pay for psychiatrists by $9 an hour last year, the highest paid MSH psychiatrist (the medical director) makes $127 an hour in base salary, which is the base for a starting psychiatrist, according to a national survey by Becker's Hospital Review.
The Montanans committed to Warm Springs generally don't stay there more than a couple of weeks, according to DPHHS data on the 676 patient discharges in 2018. Last year, in B Unit, which discharged 363 patients (more than any other unit), half of them stayed less than 14 days. The E Unit discharged 19 patients during the year and half of them stayed more than 125 days.
The patients and data cited in this Gazette opinion involve only civil involuntary commitments. The state operates a separate unit a few miles away for forensic patients held in connection with criminal cases. They may be sent to MSH for a psychiatric evaluation or the court may order them to the hospital rather than prison under certain circumstances.
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Civilly committed patients are involuntarily sent to the hospital because a District Court judge has determined the individual is an eminent danger to herself (suicidal), others or is unable to take care of herself because of mental illness.
The commitment process starts with a recommendation from a psychiatrist or psychiatric nurse practitioner. In Billings, most cases come through Billings Clinic, which has both inpatient and extensive outpatient mental health services. A public defender is appointed to represent the patient. All Yellowstone County District Court judges conduct commitment hearings at the hospital, so patients don't have to go to the courthouse.
"There's a greater spirit of cooperation than ever before," said Deputy County Attorney Kevin Gillen, who has been working on civil commitments for 23 years.
Last year, Yellowstone County judges ordered 121 involuntary commitments to MSH and one to the state nursing home in Lewistown. The commitments involved only 99 patients because some were sent to Warm Springs more than once; one person was committed four times in 2018. A small number of commitments ordered in Yellowstone County involve residents of other counties whose county attorney has requested assistance from court authorities in Billings. The number of civil commitments from Yellowstone County to MSH has varied from 44 in 2011 to 181 in 2016.
While patients are being evaluated at Billings Clinic, the county is responsible for their care costs, Gillen said. The county also must transport patients to Warm Springs, which is both a long trip for the patient (who is handcuffed) and a full day's work for the sheriff's staff. Deputies often must be pulled from patrol duty or paid overtime for the 500-mile roundtrip.
Much better and consistent communication is needed between MSH and community providers, such as the Mental Health Center, its Hub drop-in center, Community Crisis Center and Billings Clinic. Yet patients sometimes arrive back in Billings with a bag of prescription medications and no further plan for living outside the state hospital.
"The more you can keep people in the community, the better off they are," Gillen said.
Although the law allows judges to make a commitment for 90 days, patients from Yellowstone County average 11 days in Warm Springs till they are back in Billings, Gillen said. He recalled a case in which a patient was re-hospitalized at Billings Clinic two days after being released from MSH.
A year ago, MSH reached a patient census low of 189 and has been hovering in the 190's this summer. Yet the gaps in community services and the shortage of MHS staff argue for a much lower patient count at Warm Springs. Rather than continuing efforts to recruit mental health professionals to an outdated, remote hospital, Montana must figure out how to bolster its mental health care in communities statewide.
Budget for change
There may always be a need for psychiatric inpatient care, but it must be delivered in a therapeutic environment that connects the patient to the care she will need after discharge. It must be delivered in a hospital that has sufficient experienced staff. Montana cannot afford to run MSH indefinitely with temps.
Gov. Steve Bullock will soon start developing the executive budget for the 2021-2022 biennium. That budget will be the starting point for the changes his successor and the 2021 Legislature make. The Bullock administration's final budget plan should tell Montanans what's really needed to transform our dysfunctional state mental health system. The plan should show the costs of improving community care and early intervention — and the costs of funding the outdated MSH model we now have.