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Bozeman Health announced late last month it plans to build an inpatient facility for people struggling with mental health issues, and while the move has been applauded, many say there still aren't enough resources countywide.

The proposed 12-bed inpatient psychiatric unit that the board of directors approved is something advocates have long called for. It's a "good beginning" in addressing Gallatin County's widening need for mental health care, advocates and mental health care professionals said, but more is needed to support people battling issues with mental health in the region.

With a population of a little more than 118,000, Gallatin County has no mental health care beds inside a medical facility, although the county does have a limited number of crisis beds at the Hope House.

For many residents needing care for a mental health emergency, that means being sent to hospitals hours away in Helena, Missoula or Billings — often at the cost of patients and their families.

Advocates, some of whom held rallies in front of Deaconess Hospital this spring, heralded the move from Bozeman Health, but said more is needed to address a broad spectrum — widened by the pandemic — of mental health care needs in Gallatin County.

Last week, Bozeman Health's CEO John Hill said details on the new psychiatric unit are being ironed out, but the renovation and staff recruitment could begin in early 2022.

The new psychiatric unit will be housed in the Madison Wing, which is due for renovations, Hill said 

Remodeling the Madison Wing will cost about $7 million, according to Bozeman Health. That money will come from the health system’s operational budget, Hill said. In 2019, the hospital netted a little more than $330 million in revenue, according to its most recent available public tax filings in 2019.

Renovations in the Madison Wing will displace 21 medical beds, the hospital said in its announcement. Hill said those beds will be moved to the Bridger Tower, which opened in October 2020.

The Bridger Tower has two floors not in use that both can hold 18 to 20 medical beds.

Hill said Bozeman Health opted to renovate the Madison Wing instead of housing the psychiatric unit in another part of the hospital, to ensure it's comfortable and safe and have more control over its design.

“We want this to be safe, not only for the patients that we will care for but also for the teams that will care for those patients,” Hill said. “We also want it to be an environment where we will limit noise and disruption and distraction and do as much as we possibly can to make it a true healing environment.”

When asked whether a 12-bed, adult unit would be sufficient for Gallatin County and its growing population, Hill said Bozeman Health as been “pragmatic” about the county’s growth and pointed toward a comprehensive continuum of care.

“We will continue to monitor the demands and the needs of inpatient psychiatric services, but we also recognize that having effective partnerships in the community to provide crisis services ... all of those services operating at the very highest potential will at least, for what we know today, meet a significant need in the community,” Hill said. 

A national guideline for behavioral health crisis care from the Substance Abuse and Mental Health Services Administration recommends 50 inpatient beds per a 100,000 people, if that is the only mental health care in the community.

Ideally, there are other resources available. With a more rounded access to mental health care including crisis stabilization and mobile mental health teams, the Substance Abuse and Mental Health Services Administration recommended about 15 inpatient beds per 100,000.

Colette Kirchhoff, a community advocate and local hospice and palliative doctor, said she was relieved and grateful to hear that Bozeman Health will open the unit. Kirchhoff, along with a group of advocates and medical professionals, have long called for the unit, including holding rallies in front of the hospital this spring.

“There’s still much work to be done, but this is a critical piece that was needed, I'm glad that it’s going to be happening,” she said.

Bill Ryan, a psychologist and vocal advocate for the inpatient unit, also lauded the move.

“It’s a very good beginning,” Ryan said.

But advocates stressed that the inpatient unit is just a start at addressing the complicated mental health care infrastructure in Bozeman, and that gaps in the continuum of care were still present.

Continuum of care is an integrated system of care for a patient over time, with an array of health services spanning different levels of intensity of care, ranging from education and preventative services to care for the most at-risk people experiencing acute mental health crises.

“The goal is not to get them as an inpatient psychiatric patient,” said Erin Taylor, the statewide coordinator for Montana chapter of the Crisis Intervention Team and a sergeant with the Gallatin County’s Sheriff’s Office.

Taylor, who coordinates statewide with trainings to help law enforcement deal with people in mental health crises, said if a person gets adequate treatment prior to a crisis, or while in crisis, there shouldn’t be a need for inpatient services.

But Gallatin County doesn’t now have adequate resources to meet its need, Taylor said.

Often, law enforcement is the first to respond to someone in a mental health crisis. If they need medical care, officers can be in a bind.

“The problem is we have little to no place to bring them,” Taylor said. “So, our default is the ER.”

Law enforcement should be able to bring someone in crisis to the Hope House, but whether its operational “depends on the day or the week,” said Zach Brown, a county commissioner who also sits on the county’s mental health advisory board.

Since the pandemic began, the Hope House's involuntary unit — which can hold patients in a dangerous crisis —  has often not been open or available.

And, if someone is going through a mental health crisis concurrently with alcohol or substance abuse, “as a default we just end up going to the hospital,” Taylor said. 

"Our responsibility as the sheriff’s office is to handle emergency detention transport. And that is where the inpatient part might be good," Taylor said. Without an inpatient unit in Bozeman, the sheriff's office transports people to hospitals across the state, often at the cost of the patient or family.

Brown said there needed to be more “wraparound services” in the county that provide services prior to an emergency, like case management and a more functional crisis facility.

“Our system is pretty bare bones at the moment and not very functional, there's a lot of different things that we should be doing that we’re not,” Brown said.

Beyond needing more resources of adults in crisis, both Kirchhoff and Ryan added that inpatient care for children or adolescents should be addressed. 

“One of the main important parts of having community inpatient psychiatric care is keeping people in the community,” Ryan said. "Adolescents and children are more vulnerable to that because they need more contact from family members."

The 12 beds in the proposed psychiatric unit are all adult beds. Bozeman Health said it was focusing on adults, citing an expansion at the Shodair Children's Hospital in Helena.

“Bozeman Health is investing in adult inpatient psychiatric care, knowing that Southwest Montana has a provider of child and adolescent inpatient psychiatric care in Shodair Children’s Hospital, who is expanding their care facility,” spokesperson Lauren Brendel wrote in an email.

Shodair Children’s Hospital, a 74-bed hospital in Helena for children and teens in crisis, is planning to open a new building by 2023 that would add more private rooms and group patients by diagnosis and provide an ICU for children, said CEO Craig Aasved. 

Aasved said last year Shodair took patients from 46 of Montana’s 56 counties. With staffing constraints and the level health care fluctuating across the state, Aasved said each county building an inpatient unit for children would “saturate the market.”

“It’s easy to build new beds, but there’s a whole lot more that goes into it,” he said. Staffing challenges and support services are extremely difficult to find, he said.

And for a population size of Gallatin County, building an inpatient psychiatric ward for children and teens likely wouldn’t see enough demand to be sustainable, he said.

Aasved said in 2019 Shodair had 97 patient discharges from the Bozeman area, which included Belgrade, Bozeman, Ennis, Gallatin Gateway, Gardiner, Livingston, Manhattan and Three Forks. In 2020, the children's hospital had 107 discharges for the area.

In September, Shodair opened a small outpatient clinic in Bozeman, with a psychiatric nurse practitioner — part of an effort to bring more services to other parts of the state and limit the amount people have to drive to access care, he said.

“We’re working with Bozeman Health to come up with right service for the needs in that area ... maybe it has inpatient beds, but it's too early to say right now," Aasved said.

This story has been updated to correct Bill Ryan's title. Ryan is a psychologist. 

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