Health providers see hope on the horizon with integrated approach

Kate Whipple-Kilmer said when her current job as a licensed clinical psychologist in Sanders County opened up in 2014, it was a “serendipitous” moment.

She had just earned her doctorate degree in Oregon and was searching for a place in Northwest Montana to settle down and start her career at the same time the Clark Fork Valley Hospital and Family Medicine Network was looking to launch its mental-health services.

She is now happily living in Plains, working as one of two traveling therapists for the Network. Whipple-Kilmer and Diana Reetz-Stacey rotate between three clinics that serve patients from Trout Creek to Hot Springs and everywhere in between. For several of these frontier areas, they are the only ones supplying mental-health services.

“I knew I wanted to end up living and working somewhere remote in Montana and I’ve always been aware of how much of a need there was for these types of services in the state. So it was an easy decision,” she said.

Kismet as it was for Whipple-Kilmer, she certainly is a rarity.

Recruiting fresh-out-of-college mental-health providers to live and work in frontier areas has always been a challenge for organizations in Montana. But some health centers are feeling the hiring pressures now more than ever as patient loads push care capacities in the offices and centers that survived massive state budget cuts in 2017. The financial cuts shuttered many vital health centers statewide, discharging hundreds who, in some cases, were tacked onto wait lists 30 patients deep elsewhere. That sting was felt heaviest in more isolated areas, according to providers in Lincoln, Lake and Sanders counties.

But even after nearly $100 million was slashed from Montana’s Department of Public Health and Human Services, stakeholders statewide banded together to fulfill a Montana stereotype that this state is one filled with hardy survivors.

“This is the spirit of what I saw: we all just pulled up our boots, and went out into the trenches to help our people,” said Sindey Filler, practice manager for the office of Randy Guinard LCSW in Libby. “These are our neighbors, these are the people who are with you at the grocery stores, at the gas stations, their kids play with my kids, we go to the same church. They need us.”

Coalitions and committees were formed, initiatives were launched and grants were applied for. And in the months and years that followed the budget cuts, providers say the bulk of their efforts have focused primarily on adopting various integrated behavioral-health models. The transition to a collaborative model, they say, may address many challenges such as the hiring of qualified staff, budgetary limitations and treatment success.

While the concept of integrated behavioral health isn’t necessarily new, it has only recently picked up steam. Also known as “whole-person care,” integrated behavioral health care brings mental health care individuals such as therapists and psychiatrists and together with other medical providers such as primary-care doctors.

A 2016 report on the use of integrated behavioral health care in Montana from the Montana Healthcare Foundation found that “very few primary-care and behavioral-health practices were implementing IBH (integrated behavioral health),” the lack of which can “contribute to escalating health-care costs” and more. But in recent years and through multiple collaborative efforts, that is now starting to change.

The foundation recently launched its integrated behavioral-health initiative with the goal to implement such services in every corner of the state. The initiative aims to have integrated behavioral-health models in eight of 11 of the state’s large hospitals, all 16 community health centers, 26 of the 49 critical-access hospitals, two of the seven tribal health departments and elsewhere. Aaron Wernham, chief executive officer for the foundation, said the initiative and integrated behavioral health care, in general, is about “re-attaching the head to the body.”

“Behavioral health is not just specialty behavior health, you can have the full continuum of care addressed even in a rural area,” said Scott Malloy, program director fr the foundation’s behavioral-health program. “In those more acute rural areas, workforce is an issue, but this system is attractive to a lot of people and brings in nurses, physicians, therapists, counselors, really just about everyone.”

Holly Schleicher, director of the integrated behavioral-health program at the University of Montana in Missoula, said every year for the past several years, the program’s enrollment numbers have increased. And as the program has gained more momentum, the university and other partners, including the Healthcare Foundation, have worked to launch projects that place students into rural clinic settings in an effort to address those hiring concerns.

One such program is the Behavior Health Workforce Education and Training Program. Through the project, 19 Montana graduate students in psychology, social work, counselor education, and psychiatric nurse practitioner programs were placed in rural primary-care settings by way of a grant administered by the Health Research Services Agency and the Montana Healthcare Foundation. The project “connects students with underserved populations that have little access to behavioral-health services, while simultaneously training students in integrated behavioral health,” according to the University’s website.

County health assessments statewide indicate most areas of Montana lack an adequate amount of behavioral health resources. And providers in frontier areas such as Libby, Polson, Ronan and Plains say a major obstacle to addressing that need is the recruiting and retaining of qualified staff. Some people said they have been advertising for mental-health specialists for a year or longer.

“A lot of young professionals coming right out of college don’t want to relocate to a rural area or acutely rural area; they want to be in the more urban areas, which is kind of understandable. Some places such as Eureka, Libby, St. Ignatius are always a challenge for hiring,” said Julie Fleck, executive director of Sunburst Mental Health in Lake County.

But Schleicher and others are hopeful that immersive programs like the ones through UM will help address this issue. Schleicher explained that those in the medical field tend to stay close to where they perform their residencies, or the equivalent of a residency based on his or her chosen specialty. So by trying to better-integrate students into rural Montana, they are more likely to remain in the state after graduating.

“There is a lot of evidence that supports people staying where they are training, which is why residencies in Montana is so important,” said Maria Clemons, executive director of the Northwest Community Health Center in Libby.

PROVIDERS HAVE been working to expand their services as resources and potential staff become available.

Some larger entities such as the Clark Fork Family Medicine Network were able to bring in providers like Whipple-Kilmer to work in tandem with primary-care providers in a total integrated behavioral health setting.

Another integrated behavioral-health system slowly emerging at the Northwest Community Health Center in Libby where officials have been eyeballing a primary care behavioral health (PCBH) model for years. According to Rita Billow, who helped start the center’s behavioral-health program about eight years ago, the specific model they are looking at has been successfully integrated into clinics in Idaho that are similar to the Libby center.

“As an organization we serve about one in three, if not one in two people who live in Lincoln County, and we are able to provide them a comprehensive set of services, which I think is important,” Clemons said.

Clemons said they are excited about the new model, but added the center’s team is moving cautiously, analyzing how patients and providers react to it.

“We want to be thoughtful about the delivery because one of the things I hate and you see a lot in health care, and we try really hard not to do, is delivering something and then taking it away,” Clemons said. “If for some reason we do not succeed with this, then it gives us a foundation to build on.”

While larger hospitals and health centers have been able to incorporate integrated behavioral-health models, other smaller organizations have worked to hire staff that is complementary to their mental-health therapists and counselors, such as licensed addiction counselors.

Kim Harding, one of Lake County’s three dual-licensed mental-health providers, can attest to the importance of having the ability to offer multiple mental health-type services under one roof, or through one person.

“I work with co-occurring clients. Because I am licensed in both areas I am able to work on providing skills training for the client for them to be able to overcome their addiction and work on mental-health concerns that are kind of perpetuating that addiction,” Harding said.

Very seldomly, she added, do the two health-care challenges exist without the other.

According to Abby Harnett, Region 3 director for Western Montana Mental Health Center, the organization’s Thompson Falls location recently hired a new licensed addiction therapist.

“We are now a licensed substance abuse facility,” Harnett said. “This is the first time we (Western) have been able to offer that in Sanders County. Most of our locations now have a substance abuse component and so we are really looking at that integrative approach.”

Western Montana Mental Health was one of the organizations that was hit the hardest in the wake of the cuts, closing locations in Livingston, Ronan and Libby.

But the organization is working to bring resources back into those places — most notably starting with Libby where the center’s closing displaced more than 200 patients and laid off more than a dozen employees.

Harnett said the organization is working on establishing a post acute care (PAC) team in Lincoln County. At the time of the interview in September, she said Western was just waiting for approval from the state before putting out applications for providers.

She said a PAC team is one of the most intensive services that can be provided in hyper rural areas such as Libby. The eventual team of individuals, to hopefully include an out-patient therapist, licensed addiction counselor, care coordinator, psychiatric medication provider and more, will provide 24/7 coverage to the community and will travel to meet patients where they are.

“To my knowledge there is no rural PAC team in Montana right now,” Harnett said. “They are in Kalispell and Missoula, but I’m hoping we will be able to be leaders in the state with regards to building a rural PAC model.”

In the meantime, the organization has moved a prevention specialist back into the once-shuttered Western office in Libby, a small, yet optimistic step forward.

“We believe that keeping people in their community is the best form of treatment and that’s really where the quality comes from,” Harnett said. “On the topic of integrated behavioral health, it’s not a matter of if, it’s a matter of when.”

Reporter Kianna Gardner can be reached at 758-4407 or kgardner@dailyinterlake.com