For decades Monday’s mentally ill and people with disabilities have been able to find care in their own communities. But ever since the state’s revenue woes led to budget cuts in the Department of Public Health and Human Services, organizations that care for those people have warned that model may be disappearing.

AWARE, Inc., a long-term provider of services for people with developmental disabilities, will soon close all of its services east of Billings. That includes offices in Glendive and Miles City that provided mental health services, case management, outpatient therapy and early childhood services.

“That’s all closing down,” said Matt Bugni, chief information officer for AWARE. “We don’t have the rates to afford it. We’re seeing a dismantling of that community-based system and we think a lot of clients are going to go into higher levels of care, including institutions.”

It's a decision many providers of services for those with developmental disabilities and mental health issues across the state are considering, to varying degrees of severity.

DPHHS is facing a multitude of cuts and reductions, touching a broad range of services from dental care to in-home services for the elderly and disabled, to closing public assistance offices and homes for at-risk pregnant women.

Some of the most vocal groups affected by the cuts are those who provided targeted case management for the developmentally disabled and mentally ill.

Funding for mental health targeted case management for adults and children will decrease by just shy of $1 million each year of the two-year budget. For targeted case management for people with developmental disabilities, the state is ending contracts with service providers. The state plans to that work itself, with significantly higher caseloads.

Two weeks ago the organizations and workers that provide those services again pleaded with an interim legislative committee, though it is likely too late for anything to change. The providers said cuts will move the state away from community-based care and back toward institutionalization, and put more of a burden on other services such as emergency rooms and law enforcement.

Barbara Walsh, head of Helena Industries, said the loss of her organization's targeted case management contract for people with developmental disabilities, which accounted for a third of its operational funds, may cause the nonprofit to shut down.

"I don't know how we can survive at this point," she told the legislative committee. Helena Industries runs a career development services and work program for people who are developmentally disabled, including businesses such as textile and wood products, janitorial serves, electronic recycling and a retail thrift store.

Barb Mettler, with South Central Montana Regional Mental Health Center, said at the end of last year that her organization started making changes in August when it first heard about the reductions in funding to mental health case management and a reduction of 2.99 percent to the Medicaid reimbursement rate.

Several years ago the organization had 20 full-time targeted case managers. By mid-December it was down to two.

“We have already started not refilling positions as people change jobs or left,” Mettler said. “We eventually also ended up having to lay off two.”

The organization has a total of 95 staff members, down from 140 five years ago. It serves 11 counties and has state  satellite offices in Hardin, Red Lodge, Roundup, Big Timber, Columbus and Lewistown. It serves about 2,400 people a month over an area of 2,500 square miles.

“We have had concerns from our clients about cutbacks,” Mettler said. “The two (case managers) that are covering are doing a really excellent job of covering, but we don’t know how much longer we can do that.”

Targeted case management

Community mental health centers came about in the late 1970s, Mettler said, and have made a huge difference in allowing people to remain in their communities, especially in a rural state like Montana. Targeted case management has played a large role in that.

“Case management is one of the things that keeps people in the community and out of the hospital,” Mettler said. “This is taking away the most valuable service of keeping people in their communities. They will end up in hospitals and those are the most expensive places for care."

Bugni said cuts to youth mental health case management amount to about a 65 percent reduction in reimbursement rates. He said that could mean some providers stop doing that type of case management altogether.

“But the people that receive that service don’t disappear. They bubble up and will find services in other areas, like the emergency room,” Bugni said. “Maybe even if things go really bad, they get picked up by the correctional facilities. What doesn’t hit the state budget will hit local taxpayers. ...

"I think some of those people, not all of them, but if they’re adults they’ll go into the state hospital. If they’re children they’ll be finding services in the foster care system, with child protective services, which is also pressured. They’ll be finding services in therapeutic group homes, which is way more costly than in-home care, and in psychiatric residential treatment facilities like Shodair, Yellowstone Boys and Girls Ranch, Acadia, and then — heaven forbid — out-of-state placements.

“It’s a nightmare,” Bugni said.

AWARE may shift its business model to adapt and stay in operation, he said, but that means departing from the organization's mission.

“Sadly, the relief is we see ourselves probably shifting more to accommodate what the state wants, and that is the higher levels of care,” Bugni said. “We make more money per kid at those higher levels of care, but our mission is helping people live independently. We want to follow our mission of doing that, but also trying to stay in business.”

Increases in demand

At the end of last year, Julie Fleck, director of Sunburst Community Service Foundation, said she didn’t believe that the reduction will amount to a budget cut so much as a budget shift.

“I think emergency rooms and jails and things like foster care, those will see increases in demand," Fleck said. "Those are the outcomes of not having a solid system of care in communities. There could be increased hospitalization, increased residential placement of children, increased numbers of people with mental illness in the criminal justice system.”

Sunburst, which as part of its operations provides mental health services in northwest Montana, has not had to lay off any employees because of the cuts, but has implemented a selective hiring freeze.

To make up for the loss, Fleck said, the remaining workers have increased their productivity and the organization has trimmed some administration costs and is looking at reducing its training budget and overhead costs.

“We’re hopeful but it’s a work in progress,” Fleck said.

Sunburst has seen increased referrals in Libby and Missoula, as well as in Kalispell, as other providers have ended services there. Western Montana Mental Health, which served people in the region, announced layoffs late last year and AWARE has reduced services in the area as well, leaving Sunburst to step in.

Sheriff's perspective

Gallatin County Sheriff Brian Gootkin said that while he’s still waiting to see what the full impact of the cuts will be, some of the changes at Western Montana Mental Health Center have caused anxiety.

“I’ve had conversations with my county attorney and my county commissioners just warning them that if those impacts create severe cuts for Western (Montana Mental Health Center), it’s not like we can just stop what we do. We have to still respond and take care of people and get them where they can be taken care of.”

For his department, that has increasingly meant having to transfer patients who are in crisis to secure beds, which can mean driving them to Butte, Hamilton or Polson.

The travel time ties up deputies, who also have to transport people back to Gallatin County for court hearings.

We’re right back to where we were over a decade ago with the state hospital,” he said, referring to when deputies had to transport people in crisis to the Montana State Hospital in Warm Springs because community facilities didn’t exist or weren’t sufficient. “We did the right thing through the Legislature and got everything to be community-based and now because of these cuts and what’s happening, we’re going right back to where we were before.”

Gootkin said he’s spoken with his county attorney and county commissioners about a worst-case scenario where his department and the county would take over crisis services, which is something he’s not eager to do. 

More institutionalization

Sydney Blair, chief executive officer at the Center for Mental Health in Great Falls, told the committee to pay close attention to what happens as the changes are implemented, something she called “extreme model changes we haven’t seen for a number of years.”

“I have a lot of concerns about the unintended consequences of this plan,” she said.

Sandie Dearman, at Montana Independent Living Project, said she also expects more people to be institutionalized.

“Without these services, they are at risk of being institutionalized, whether that be a group home, whether that be a nursing home. Without these services they cannot be at home,” Dearman said. “These cuts can and will be devastating to these people. You could be looking at institutionalization of quite a few people, from what I’m hearing on my caseload.”