Behavioral health conditions (including both mental illness and substance use disorders) are common and serious problems throughout Montana. In 2014, Montana had the highest suicide rate in the United States for all age groups, and it has been among the five states with the highest suicide rate in the nation for more than forty years. Community health assessments from Montana’s fifty-six counties consistently ranked behavioral health as one of the leading community concerns.
The Montana Healthcare Foundation (MHCF) was formed in 2013 and is Montana’s largest health-focused philanthropy. Behavioral health is one of the foundation’s three major focus areas.
To develop our approach and understanding of behavioral health challenges in Montana, MHCF commissioned a report titled Integrated Behavioral Health in Montana: A Baseline Assessment of Benefits, Challenges, and Opportunities and met extensively with staff at community mental health centers, substance use treatment centers, hospitals, federally qualified health centers (FQHCs), tribal health departments, and advocacy groups, and with policy leaders and others. Two key findings have driven the foundation’s strategy on behavioral health and, specifically, substance use disorder (SUD).
SUD As A Chronic Health Condition
Whereas mental health is struggling to be recognized as an essential part of the health system, SUD is struggling to be in the health system conversation at all. Mental health has been gradually brought back into the health system, but the recognition that SUD is a chronic health condition is only recently beginning to emerge. As health professionals, we must be honest that both mental health disorders and SUD are still highly stigmatized in the United States and that negative attitudes persist among health care professionals.
As a former behavioral health clinician and administrator, I can safely say that even within the behavioral health field, SUDs are not universally viewed as a chronic health condition. This is despite behavioral health conditions being a leading cause of disease burden in the United States. State authorities have historically separated medical conditions, mental illness, and SUDs through licensing, administrative, regulatory, and financing structures. We are finding that it is much more difficult to reincorporate behavioral health systems into the overall health system.
MHCF believes that improving outcomes for SUD can be catalyzed by a combination of grantmaking to support innovations in SUD service delivery and policy changes that help expand access to treatment and shift the delivery system toward the chronic disease model.
Through grant making, MHCF has highlighted SUD treatment and prevention as part of a continuum of care. This emphasis has resulted in rural health clinics, FQHCs, mental health centers, and hospitals adding SUD to the scope of care, creating new health partnerships, and bringing more awareness of the importance of SUD.
On the policy front, MHCF collaborated on policy analysis with the Montana Department of Public Health and Human Services to explore the opportunities created for the SUD treatment system by Montana’s 2016 expansion of Medicaid. Of great importance for SUD providers were new coverage for SUD and reimbursement for SUD treatment under the state’s Medicaid expansion. Medicaid expansion provided a new avenue to pay for SUD services and is radically shifting the business and clinical models for SUD providers.
Finally, MHCF is partnering with the Montana Department of Public Health and Human Services and the Conrad N. Hilton Foundation to conduct a landscape analysis of Screening, Brief Intervention, and Referral to Treatment (SBIRT). This collaboration will result in a greater understanding of current SBIRT use in Montana and provide recommendations for supporting widespread implementation. MHCF views SBIRT as a practical tool to support more routine efforts by primary care providers to screen for, identify and initiate treatment for, SUD—a key to shifting toward a chronic disease model of care.
To support the transformation of the delivery system, MHCF launched an integrated behavioral health initiative in 2016. Integrated behavioral health is a team-based approach to care that uses a systematic, cost-effective, and population health-driven approach to treatment. Integrated behavioral health involves a medical and behavioral health team (it preferably includes professionals knowledgeable about mental health and SUD). MHCF’s Integrated Behavioral Health Initiative allows organizations to apply for grants (planning and/or implementation grants). The foundation’s two-pronged approach to integrated behavioral health allows organizations to either dip their toe into the water (planning) or jump in head first (implementation). One of our required elements for such grants is for organizations to develop a plan for how they would use SBIRT. This requirement has resulted in increased awareness and understanding of SUD in health settings. Organizations have found that including SUD in the integrated behavioral health approach is quite challenging.
As part of this initiative, MHCF partners with the Montana Department of Public Health and Human Services to jointly fund training and technical assistance, learning communities, and webinars. This co-investment and collaboration demonstrates a shared vision and strategy for an integrated system, as well as alignment of valuable and limited resources.
Strengthening The Behavioral Health Provider Network
Behavioral health providers are competing for scarce resources and are often not aware of key policy and regulatory opportunities. These providers face economic, regulatory, and workforce challenges in a rapidly evolving health care environment, and they struggle continuously to provide services to a group of people who are among the most vulnerable and demanding. These providers have few opportunities to meet; learn from each other; and collaborate on programs, health systems reform, strategic planning, or policy and advocacy.
Historical fragmentation of the federal and state behavioral health systems has resulted in a fragmented delivery system in communities across Montana for adult mental health, youth mental health, and SUDs in the adult, youth, and American Indian populations.
Historically, Montana has had formal and informal state associations that reflect regulatory and oversight divisions of the Montana Department of Public Health and Human Services—that is, mental health and SUD associations for each of the populations (children, adults, and tribes) served, but these organizations have no consistent staffing and few resources with which to support cohesive efforts to strengthen the state’s behavioral health system. A strong state behavioral health association can provide a powerful tool for strengthening behavioral health services. A behavioral health association that includes SUD would inherently elevate SUD as a valued and important health issue as well.
In June 2016, MHCF brought together executives from SUD, mental health, and tribal behavioral health organizations to discuss the formation of a state association for behavioral health. Meeting participants observed that this was the first time the diverse group of behavioral health leaders had met! The leaders realized that to meaningfully integrate behavioral health into the greater health system, the behavioral health leaders themselves must be aligned and united—no small task for their behavioral health provider groups that have functioned separately for decades.
Over several meetings, this group of leaders decided to pursue the creation of a state behavioral health association and solidify their commitment to unite as behavioral health providers and reinforce behavioral health as a foundational component in the state’s health care system.
MHCF has provided convening funds, strategic leadership, and facilitation for this group. The group has developed a vision, a mission statement, and a values statement and is committed to developing a business plan and achieving sustainability within three years.
Despite the numerous behavioral health challenges that exist in Montana, MHCF has found providers, policy makers, stakeholders, and health care leaders willing to partner on creating a more integrated system. Through intentional grantmaking, convening, nonpartisan analysis, and emphasizing SUD as a chronic health condition, MHCF sees practical and transformative work underway in the state’s behavioral health system.
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Scott Malloy, Substance Use Disorders: A Foundation Sees New Opportunities and Continuing Challenges, Health Affairs Blog, August 9, 2017, http://healthaffairs.org/blog/2017/08/09/substance-use-disorders-a-foundation-sees-new-opportunities-and-continuing-challenges/, Copyright ©2017 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.