Ending involuntary commitments would shift burden of dementia care to strapped communities

Reviewed by Emily Henderson, B.Sc.Jan 13 2023

State lawmakers from both parties have shown support for a plan to stop the practice of committing people with Alzheimer's disease, other types of dementia, or traumatic brain injuries without their consent to the troubled Montana State Hospital and instead direct them to treatment in their communities.

But a budget estimate attached to the proposed legislation raises questions about whether Montana communities, many of which are still reeling from past budget cuts and insufficient Medicaid reimbursement rates, will have the capacity to care for them by July 2025, when involuntary commitments would cease under the plan.

Health department officials essentially acknowledged as much in the fiscal note accompanying House Bill 29, sponsored by Republican state Rep. Jennifer Carlson. Health officials wrote in the unsigned fiscal note that 24-hour skilled nursing facilities are often the only appropriate settings for such patients, and that few of those facilities "are willing to take these individuals as an alternative placement to the Montana State Hospital."

As a result, health department officials anticipate having to transfer patients with a diagnosis of Alzheimer's, other dementia, or a traumatic brain injury from the Montana State Hospital to the state Mental Health Nursing Care Center, a long-term, 117-bed residential facility in Lewistown for people with mental health disorders, if the bill passes. The health department says the facility is for people who "require a level of care not available in the community, but who cannot benefit from the intensive psychiatric treatment available at Montana State Hospital."

Department officials expect to move 24 patients from the state hospital to the Lewistown facility between fiscal years 2025 and 2027 if the bill passes. The cost of caring for those patients at the Lewistown facility would start at $181,062 per patient, per year, for a total cost of about $10 million over three years. The beds they vacate at Montana State Hospital would likely be immediately filled by other patients, so there would be no expected cost savings there, according to the fiscal note.

Department of Public Health and Human Services spokesperson Jon Ebelt did not immediately comment on the document outlining the expected transfers.

Carlson said she was surprised health department officials expected to relocate patients to another state-run facility when the point of the bill is to facilitate community treatment.

But, she added, that cost would be lowered if the state raised its Medicaid reimbursement rates. If the state raised its reimbursement rates to nursing homes to $300 per patient, per day, from its current $208 rate, those same 24 patients could end up costing the state a lot less, she said.

Carlson said some dementia patients are committed to the state hospital as a last resort because there are no other options for providing the intensive care they need.

"But that excuse is not good enough for me," Carlson said. "There should be somewhere else for them to go."

Carlson's bill is just one of several measures to overhaul operations at the Montana State Hospital.

The Centers for Medicare & Medicaid Services revoked the hospital's certification after an investigation into a series of deaths and injuries there, leading to the loss of federal funding. The hospital has been strained by high rates of staff vacancies and employee turnover, leading to a reliance on higher-priced temporary staff and contributing to the hospital's waiting list for admissions.

The bill's goal of removing patients with dementia or traumatic brain injuries from the Montana State Hospital and into community care has bipartisan support. The Children, Families, Health, and Human Services interim committee voted unanimously last summer to forward the bill to the full legislature. Carlson's HB 29 was scheduled for its first hearing on Jan. 13 in the House Human Services Committee.

Matt Kuntz, executive director of Montana's chapter of the National Alliance on Mental Illness, said there is broad agreement that the state hospital isn't the place for Alzheimer's patients. The reason the state is in this situation is that community centers don't have the capacity to care for a growing Alzheimer's population, he said.

"The positive thing is at least someone's moving proactively and saying this isn't right," Kuntz said of the bill.

Kuntz said the health department is probably right that some patients would end up at the Mental Health Nursing Care Center in Lewistown if the bill passes. But, he added, the bill is meant to reduce institutionalization, not raise the cost of institutionalization.

"Institutionalization of a patient is incredibly expensive and needs to be avoided whenever possible, and that is the crux of Carlson's bill," Kuntz said.

Democratic House Minority Leader Kim Abbott said the health and safety of the most vulnerable members of the community is a top priority for the Democratic caucus.

"Community-based care that's closer to family makes a lot of sense, but we want to make sure that we're giving it a good vetting," Abbott said.

Carlson said HB 29 does two things: First, it ends the involuntary commitment of people who shouldn't be in a mental institution, she said, unless they are an immediate threat to themselves or others. Second, the measure outlines a plan to provide appropriate care within the patients' communities.

Kuntz said the bill's 2025 deadline for ending involuntary commitments gives room for officials and legislators to figure out ways to improve it.

The bill would create a transition committee made up of legislators, governor appointees, and state employees with expertise in nursing facilities, Alzheimer's and other types of dementia, and traumatic brain injuries. The panel would be tasked with finding answers to some big questions, such as where patients can go for care instead of the hospital and figuring out the logistics of relocating patients already in the state hospital. The panel also would track the progress of developing community-based services until involuntary commitments end in 2025.

Gov. Greg Gianforte's two-year budget proposal, the starting point for legislative budget writers, also includes spending $300 million on behavioral health and improvements to the Montana State Hospital.

Carlson's bill also directs the health department to give geriatric state hospital residents or those with Alzheimer's, other forms of dementia, or traumatic brain injuries priority admission to nursing homes.

"This is a mandate that we improve our community-based systems," Carlson said.

But those nursing homes face problems of their own, with 11 announcing closures last year amid staffing vacancies and Medicaid reimbursement rates too low to cover the cost of care. A study commissioned by the state government recommended raising those rates to $278.75 per patient, per day. But Gianforte's budget proposal includes funding for only a portion of that recommended increase: $238.77 per patient, per day, by 2025.

The Montana Health Care Association represents the state's nursing homes. Executive Director Rose Hughes said nursing homes are probably the places that should be caring for these patients. But there has to be a step between ending involuntary commitment and transitioning all the patients to community centers that can't yet support them, she said.

"For it to be successful, there really has to be an effort made to support the community providers," Hughes said.

She doesn't believe there should be a hard deadline to end involuntary commitments until those community resources are in place. But, she added, there will be another legislative session before the 2025 deadline for lawmakers to extend the process if needed.

"It may not be enough time to solve the problem," Hughes said. "But I don't think the problem is going to be worked on unless there is a deadline."

Keely Larson is the KHN fellow for the UM Legislative News Service, a partnership of the University of Montana School of Journalism, the Montana Newspaper Association, and Kaiser Health News. Larson is a graduate student in environmental and natural resources journalism at the University of Montana.