This report describes the planning process that the board of trustees and staff of the Montana Healthcare Foundation (MHCF) carried out to guide the Foundation’s first full year of programming. Countless individuals, organizations, and public agencies generously contributed time, insights, and data that are reflected in the pages that follow.
The Montana Healthcare Foundation makes strategic investments to improve the health and well-being of all Montanans. MHCF envisions a measurably healthier State through improving access to quality and affordable health services, evidence-based health education, research and analysis, improving the upstream influences on health and illnesses, and informed public policy. MHCF is committed to upholding this promise to the residents of Montana and being governed by the guiding principle that everyone benefits from better health.
2015 is our first full year of programming. Accordingly, this document is best seen as a snapshot in a continuous process of investigation, collaboration, and learning through which MHCF will continue to evolve our programming to address statewide needs and opportunities for improving Montanans’ health and well-being.
The Montana Healthcare Foundation was created in 2013, and came into existence as result of the sale of Blue Cross/Blue Shield of Montana to a private corporation. In accordance with State law, the assets were transferred to a charitable trust to be managed for public benefit. Currently, MHCF has approximately $80 million in assets. The Foundation is a permanent resource for Montanans. Rather than spending the money in the trust over a few years and then dissolving, the Foundation will spend the income from trust investments (roughly 5 percent of the total value of the trust each year) on grant disbursements and related programs and expenses, and provide a stable, reliable resource supporting health for Montanans. The trust has the potential to grow to as much as $180 million in future years.
The approach that foundations take to improving health is distinct from the more familiar contributions of hospitals, clinics, and health departments. Foundations can make grants that allow organizations to plan and try new ideas—innovations that have the potential to improve health outcomes and lead to a stronger and more efficient health system. Foundations also carry out research, convene meetings that bring stakeholders together to develop solutions to important health issues, and provide data and expertise to support policy decisions that support health.
In developing this plan, MHCF focused on identifying investments that will lead to lasting improvements in Montanans’ health and the health system that serves us. The following pages describe what we have learned through data review and meetings with health experts, hospitals, clinics, health departments, tribal leaders, and community members; the decisions we have reached with regard to our 2015 investment strategy; and finally, our initial objectives for 2015 and future years.
Planning Process
Board Educational Presentations
Beginning with its formation in December, 2013, the Montana Healthcare Foundation’s Board of Trustees has actively sought to learn about the health needs of the state. At each Board meeting, Trustees have invited presentations on a range of important health topics. Below a list of those topics:
- Conflicts of Interest and Self-Dealing; Laura Hoehn
- Native American Health in Montana: Challenges and Opportunities; Kenny Smoker and Duane Jeanotte (Fort Peck Health Promotion/Disease Prevention program)
- Health and Healthcare Issues in Montana; Lindsey Krywaruchka (DPHHS)
- Mental Health Issues in Montana; Gary Mihelish (Montana Health Trust)
- Hospital and Health System Issues in Montana; Dick Brown (MHA)
- Childhood Obesity; Barbara Moore (Shape Up America!)
- Vision, Mission, Goals; Kristen Holway and Mark Sedway (The Giving Practice)
- Public Health Issues; Ellen Leahy, Date Siegrist, Robin Nielson (Missoula City/ County Health Dept.)
- Economics of Health and Healthcare in Montana; Bryce Ward (Bureau of Business & Economic Research, MSU)
- Aging in Montana; Kelly Williams (Senior and Long Term Care), Charlie Rehbein (Aging Services), Claudia Clifford (AARP Montana), and Sarah Cobler Leow (MT Budget & Policy Center)
Review of Programming and Strategy in Other U.S. Health Foundations
To learn about the strategies foundations use to address the needs of their communities, MHCF staff selected a sample of approximately 20 U.S. health foundations, chosen because of their similarities to MHCF in terms of trust size, geography served (i.e. rural versus urban), or programming of particular relevance to Montana. We reviewed material available on foundation websites regarding strategy, program design, and outcomes. We spoke with foundation leaders at several organizations, and attended the annual Grantmakers in Health meeting in March, 2015, at which we had the opportunity to hear presentations and discuss programming with health foundation staff from around the U.S.
Research and Literature Review
To understand what health problems are most common in Montana, how they vary across different parts of the state, and which are most important in terms of suffering and loss of life, we reviewed a large number of local and statewide data sources. To identify opportunities and successful models for addressing these challenges, we also reviewed resources such as peer reviewed literature, cost-benefit analyses, and research reports, and spoke with other health foundations and Montana-based organizations and experts. Examples of the Montana data sources used in MHCF’s planning are listed below.
- State of the State’s Health—Montana State Health Improvement Plan 2013
- Montana Annual Vital Statistics reports
- Montana Behavioral Risk Factor Surveillance Study
- Youth Risk Behavior Survey
- SAMHSA Behavioral Health Barometer
- State Health Rankings
- County Health Rankings
- Kids Count Annual Report
- Hospital Community Health Needs Assessments
- Office of Rural Health Community Health Profiles
- Local Health Department Community Health Assessments
Stakeholder Discussions
Montana is a large state with a rich and varied landscape, history, and culture. From tiny ranching and agricultural towns, to larger cities with cutting-edge healthcare and research facilities, to the eight federally and state-recognized American Indian Tribes, the diversity of culture, economy, and resources among Montana’s communities means that few generalizations can be made and state-level health statistics must be interpreted with caution. A relatively low prevalence of diabetes statewide, for example, belies the very high rates in some rural and American Indian communities.
No amount of data and research can take the place of the insights gained from visiting communities and talking with experts, leaders, and residents about the strengths and character, challenges, needs, and opportunities in the places where they live and work. Since hiring its CEO, Dr. Aaron Wernham, the Foundation has made community outreach and stakeholder engagement its top priorities. The list below provides a partial list of those with whom we have met since October, 2014, and we are committed to continuing to do our work in partnership with communities around the state.
- Healthcare Associations
– Montana Medical Association
– Montana Hospital Association
– Montana Primary Care Association
– Montana Public Health Association
- Hospital and Clinic Leadership
– John Bishop, Madison Valley Medical Center
– Lander Cooney, Community Health Partners
– Kevin Pitzer and Terry Cunningham, Bozeman Deaconess
– Bren Lowe, Scott Coleman MD, Livingston Health
– Glendive Medical Center leadership team
– Sidney Regional Medical Center leadership team
– Mark Zilkoski, MD, Northeast Montana Health Services
- Behavioral Health
– Matt Kuntz, NAMI
– Jodi Daly, WMMHC
– Western Montana Mental Health Center Leadership Team
– Eric Arzubi, MD, Billings Clinic
– Gary Mihelish, NAMI and MT Mental Health Trust
– Dan Aune, Mental Health America
– Bruce Swarney, MD, Glendive Medical Center
– Eastern Montana Mental Health Center leadership team
– Jim Fitzgerald, Intermountain
– Scott Malloy, Gallatin Mental Health
– Erin McGowan, Montana Children’s Initiative
- American Indian Health
– Lesa Evers, DPHHS
– Kevin Howlett and Anna Whiting-Sorrell, CSKT
– Ken Smoker, Fort Peck HP/DP
– Duane Jeanotte
– Prof. Suzanne Christopher, MSU
– Montana-Wyoming Tribal Leaders’ Council
– Montana Tribal Epidemiology Center
– Bonnie Satchatello-Sawyer, Hopa Mountain
– Dorothy Dupree, IHS
– Harry Brown, MD, IHS
– LeeAnn Johnson, Missoula Indian Center
– National Native Children’s Trauma Center, UM
- Government (elected, state and local agency leaders)
– Governor Steve Bullock
– Attorney General Tim Fox
– Monica Lindeen, Insurance Commissioner
– Dorothy Dupree, Director, Billings Area IHS
– Mayor Jeff Krauss, Bozeman
– Councilmember (Sidney)
– Councilmember (Bozeman)
– Richard Opper, DPHHS
– Zoe Barnard, DPHHS Childrens Mental Health Bureau
– Deb Matteucci, DPHHS AMDD
– John Felton, Riverstone Health
– Ellen Leahy, Kate Siegrist, Missoula Health Department
– Matt Kelley, Gallatin Mental Health
– Judy LaPan, Richland County Health Department
– Association of Montana Public Health Officials
– Vicki Bell, Roosevelt County
- Foundations
– Mike Halligan, Dennis and Phyllis Washington Foundation
– Lynda Moss, Northwest Area Foundation
– Crow-Northern Cheyenne Funders gathering (multiple foundations)
– Montana Non-profit Association foundations gathering (multiple foundations)
– Empire Health Foundation
– Grantmakers in Health (gathering of US health foundations)
– Helmsley Charitable Trust
- Other Health Experts
– Kristin Juliar, Office of Rural Health
– John Griffin, MD
– Brad Putnam, Healthshare Montana
– Prof. Bryce Ward, UM
– Dean Reed Humphrey, UM
– President Waded Cruzado, MSU
– Cathy Costaikis, MSU
– Prof. Yiyi Wang, MSU
- Other Stakeholders
– Montana Community Development Corporation
– Neighborworks Montana
– Trust for Public Lands
– Special Olympics, Montana
What We Learned: Montana’s Health Challenges
Overall, Montana can be considered a healthy state. Residents in many regions benefit from unparalleled access to open space and trails (which support an active lifestyle), clean air and water, a strong economy, and excellent healthcare. According to one organization’s rating scale, Montana ranks 22 out of 50 states for overall health. Strengths include relatively low statewide rates of chronic illnesses related to diet and exercise, such as obesity, heart disease, and diabetes.
Certain people in our state, however, face severe barriers to good health. “Health disparities”—defined as the higher rates of illness documented among certain subgroups—are all too common among certain racial and ethnic groups, among those who face social and economic disadvantage, and among children and older adults.
By some measures, Montana consistently ranks poorly. For many years, for example, our state has had one of the highest suicide rates in the nation. Injuries and death related to driving under the influence of alcohol and poor use of seat belts and child safety seats are far more prevalent in Montana than most other states, and these problems are responsible for many years of life lost, particularly among children and young adults. Reflecting these problems and others, in 2014 Montana was ranked 50th out of 50 states for the health of its children by the national organization Kids Count.
Here are some of the specific health challenges we learned about:
Behavioral Health Problems (Mental Illness & Drug and Alcohol Use)
Suicide is often the tragic end result of a far more widespread problem: mental illness. Mental illness and drug and alcohol use cause untold suffering and disability, yet too often these behavioral health problems remain unrecognized and untreated. In the many studies and surveys we reviewed, and in conversations with almost every stakeholder we met, behavioral health issues (mental illness and drug and alcohol abuse) ranked as the leading health concerns. In the annual Behavioral Risk Factor Surveillance Survey conducted by the state, poor mental health, depression, and binge drinking were more common in Montana than the national average.
Montana’s youth are at particularly high risk. A recent national survey documented that Montana ranks among the top three states nationally for exposure to adverse experiences in early childhood (ACES). Robust research shows that ACES create a high risk of health and social problems, both in childhood and later in life. In the Youth Risk Behavior Survey, binge drinking and driving under the influence were more common in Montana than the national average. Students in alternative high school programs (public school programs for students at risk of dropping out) and American Indian students had extraordinarily high rates of symptoms of depression (as high as 50% among some subgroups), alcohol and prescription drug use, and attempted suicide.¹ In surveys of health needs carried out by Montana’s rural hospitals, both hospitals and community members ranked these issues among the most important health challenges in their communities. ² A recent national survey examined both the prevalence of behavioral health problems and access to services to treat these problems in each U.S. state: Montana ranked 44th among 50 states, and 49th for youth.³
In many communities—particularly in reservations and rural Montana—we heard about the lack of funding and access to needed mental health and addiction services, and the challenge of recruiting and retaining mental health and addiction professionals.
Beyond the toll in lives and suffering, untreated mental illness and addiction have profound economic costs. Untreated mental illness is a common cause of poor health outcomes for chronic illnesses as well (such as heart disease, diabetes, asthma, and others). Indeed, among people who require frequent hospitalization and emergency room treatment, many have untreated mental illness or addiction. Police and corrections costs are similarly affected by untreated mental illness, as police are often required to respond to people in mental health crisis, and behavioral health problems are prevalent among prison inmates. Untreated mental illness and addiction, therefore, can create a serious burden on the budgets of rural hospitals, clinics, county corrections departments, and businesses.
In conversations with stakeholders and health experts, we learned that improving behavioral health outcomes in Montana will require solutions to a wide range of challenges. For example:
- A shortage of mental health providers, particularly in rural communities. According to many stakeholders, this relates in part to low reimbursement rates for mental health services, which makes it difficult to adequately compensate, recruit, and retain well-trained providers.
- The need for more facilities that can effectively treat drug and alcohol dependence, people in mental health crisis, and people with co-occurring disorders.
- The lack of affordable housing and supportive services to allow people to transition successfully to outpatient settings, particularly in rural areas and American Indian communities.
- A lack of coordination between the state systems responsible for mental illness and drug and alcohol treatment, and challenges including regulations and financing that make it difficult to serve the needs of people with dual diagnoses.
- Minimal mental health and drug and alcohol treatment services available to at-risk youth in many communities, including those in rural areas, alternative high schools, and urban Indians.
- Poor data regarding the prevalence of drug and alcohol use during pregnancy, despite indications that this problem may be extraordinarily prevalent in some communities.
- Broadly, a lack of a statewide vision and plan to guide the development of a more robust behavioral health system that measurably improves outcomes.
American Indian Health Disparities
In a 2014 report on the health of Montanans, the Montana Department of Public Health and Human Services presented deeply disturbing statistics on the health disparities affecting Montana’s American Indian people. American Indians in Montana die at a median age of 50 years (20 years earlier than white Montanans), and the death rates for serious illnesses including heart disease, cancer, respiratory illnesses, injuries, and suicide were all found to be substantially higher among Montana’s American Indian communities. 4
Montana is home to seven federally recognized Tribes, one state-recognized Tribe, and a large and diverse urban American Indian population. The health disparities documented among Montana’s American Indian people are rooted in longstanding challenges including high poverty and unemployment, racial discrimination and historical trauma, inadequate housing, and food insecurity, among others. Specific issues that we identified through data review and conversations with American Indian community leaders and health professionals include:
- Inadequate funding of health services, including funding for referrals outside the Indian Health Service system and for disease prevention programs.
- High vacancy rates for health and social service positions serving American Indians.
- Minimal funding for programs that serve urban American Indians, who cannot access Indian Health Service facilities.
- Limited availability of treatment for drug and alcohol addiction, even for pregnant women and mothers.
- Adverse childhood experiences and historical trauma, which extensive research now shows have profound consequences for almost all health outcomes throughout a person’s life.
- High rates of traffic injury, with risk factors including DUIs and low rates of seatbelt and child safety seat use.
- High rates of diabetes and obesity (as opposed to the relatively low prevalence in the state population) due, in part, to limited access to healthy foods.
Injury
“Unintentional injury” (often thought of as “accidents”) is the leading cause of death for Montanans age 1 to 49, and a leading reason for Montana’s poor national ranking for child health. Motor vehicle crashes are the most common cause of serious injuries in this category, followed by falls. Driving under the influence, as noted above, is a prevalent problem in Montana, and a major contributor to this problem. Seat belt and child safety seat use are low in Montana as well (only 33% of people who died in car crashes were wearing a seat belt). Based on national studies, the high speed limits on Montana’s rural roads may also contribute.
Children’s Health
A recent national survey ranked Montana 50th among the 50 U.S. states for children’s health.5 Many of the issues discussed above—particularly the high rates of alcohol-related injury and low rates of seat belt and child restraint use, mental illness, suicide, and drug and alcohol abuse—contribute to this ranking. Children living in poverty are at particularly high risk for health disparities. Challenges identified in our review include:
- Children who suffer traumatic experiences in childhood are at markedly elevated risk for behavioral and physical health problems, school failure, incarceration, and other problems in childhood and adulthood. According to one recent estimate, the percentage of Montana children who suffer 3 or more adverse childhood experiences (ACES) is higher than most other states.6
- High rates of injury related to low seatbelt use and driving under the influence.
- Extremely high rates of behavioral health issues including depression, suicidal ideation, and substance abuse among children in Alternative High School programs, and American Indian children.
- Under-immunization: By one composite estimate, Montana ranks 44th among U.S. states for immunization rates.7 Recent interventions by DPHHS have helped improve this problem, but immunization rates in Montana continue to lag behind national targets, and many other states.
Aging
Montana’s population is aging. In 2015, it is estimated that Montana will rank as the 5th leading state in its population of people 65 and older. Many older adults live in frontier counties, with even the most basic health services lying many miles from home. Many stakeholders mentioned the fiercely independent nature of many rural seniors. Many Montanans in their 80’s, 90’s, and even centenarians live alone and independently, and a culture of self-reliance has been reported to contribute to many older adults’ reluctance to ask for help when needed. Challenges for this population that we learned about include, for example:
- Many communities lack the full range of healthcare services that older adults require, and the distances required for accessing primary care as well as specialty services create a serious burden.
- Aging in place is challenging when people live far from each other and from the services they need.
- The financing and staffing for levels of care between home and hospital—such as skilled nursing units, assisted living facilities, supportive housing, and in-home care is complex and challenging, particularly for rural hospitals. We often heard that there were shortages of assisted living beds, little supportive housing available, and inadequate funding for in-home support. At the same time, in some communities there are unoccupied skilled nursing beds because of staffing shortages.
- While there are many successful programs that provide services such as in-home care for Montana’s older adults, too often these programs do not have enough funding to meet needs across the state.
- Evidence-based interventions to improve outcomes and help reduce emergency department and hospitalization rates, such as care navigators, case management, and community health workers, are not yet widely available and may not be reimbursed by public or private insurance.
Health Workforce Shortages
Woven throughout all of our conversations, the issue of recruiting and retaining professional healthcare staff came up as a prominent challenge. Rural hospitals have an aging workforce, with many physicians and nurses nearing retirement. In Richland County, we learned that the high housing prices related to the Bakken oil boom has made it more and more difficult for nurses, doctors, and other healthcare staff to afford to live in the community. Many communities face a severe shortage of dentists, and we often heard that this problem is particularly severe for lower income Montanans. As mentioned above, low rates of reimbursement for mental health services make it hard for Montana to compete with other states. This problem is compounded by the fact that many health professionals train in urban areas and are less likely to want to relocate and stay in remote, rural communities. Indian Health Service facilities face similar challenges. Many reservations have high vacancy rates for healthcare jobs—we heard that in one community nearly 60% of staff positions are unfilled.
Other Issues
Many other challenges have come to our attention over our first year of investigation. Among these:
Funding and staffing for local health departments: Under state law, local boards of health have considerable authority and responsibility for protecting and promoting health at the county level, and county health departments are charged with fulfilling these responsibilities. Yet there is little state funding available for local public health: many local health departments have inadequate funding and some have none, and are therefore not able to realize their potential. Moreover, in many counties there seems to be little collaboration or coordination between hospitals and county health departments, which may create missed opportunities for better health outcomes and more efficient and effective use of resources. For this reason, the Foundation made a major grant in 2014 to the Montana Department of Public Health and Human Services (DPHHS) to provide grants to county and tribal health departments to support their efforts to improve the health of their communities.
Lack of data to guide development of more effective health programs: Although we found many helpful sources of data, large gaps remain, and this makes it more difficult for government public health, healthcare organizations, and private sector entities to plan effective interventions. For example, little data exists regarding differences in patterns of illness between rural, frontier, and urban areas in Montana. Montana is one of 10 states that do not participate in the annual Pregnancy Risk Assessment Monitoring System, and hence there is relatively little information about the health and risks facing pregnancy women and newborns available for Montana communities. In our outreach, for example, we heard from public health experts, hospitals, and administrators in some areas that rates of drug and alcohol use during pregnancy were high: with little data available to evaluate these claims, it is possible that an important health problem is not being fully addressed.
Summary
This strategic plan is our starting point: it is a synthesis and summary of many months of data collection and investigation, not a comprehensive, detailed accounting of the health challenges in Montana. As such, there are undoubtedly many important issues not reflected in the discussion above, and many others about which we have much to learn as a new foundation. This. As stated in the Introduction, our strategic planning process will continue, and will drive the evolution of our programming in the coming months and years. Specifically, over the next two years, we intend to deepen our knowledge of the needs and opportunities in our state in several ways:
- Continuing outreach to healthcare systems, experts, policy makers, and community members across Montana.
- Learning from the grant we provided to DPHHS to make funding available to support health planning to every county and tribal health department in Montana. We anticipate receiving results of this work over the next two to three years.
- Our 2015 Call for Proposals (CFP) will allow eligible organizations around the state to provide us more information about the needs they see, and effective ways to address them.
- Convening meetings to allow stakeholders to discuss key issues in depth.
- Conducting research on issues of particular importance to Montanans’ health but where relatively little information exists to guide the development of effective interventions.
Strategic Plan: Opportunities to Improve Montanans’ Health
In the course of investigating the health challenges facing Montana, we identified many opportunities as well. Agencies, organizations, businesses, and individuals across our state are already bringing an impressive range of skills and expertise to these challenges. In the course of our investigations over the last year, the Foundation has identified many promising models—examples that, if more broadly implemented, have the potential to strengthen the health system and improve health outcomes. The most promising models share two basic features: they are effective, and they create changes that are financially sustainable. Guided by these principles, the Foundation has developed criteria to guide our approach to addressing the needs we have identified, the health issues we will focus on, and our approach to making grants.
Criteria to Guide the Montana Healthcare Foundation’s Investments
With limited resources and no shortage of challenges, we have developed criteria to guide our investments and maximize our impact. These criteria serve as both our internal guideposts in choosing areas of focus, and our general criteria for selecting among potential grant recipients.
- Importance of health issue to be addressed: The proposed project will address an important health issue, as defined by the burden of suffering it creates in terms of prevalence in the population, severity of the outcomes, and costs to families and communities.
- Potential for sustainability and lasting change: A short-term grant investment will catalyze improvements that endure long after the grant funding runs out.
- Creating or strengthening partnerships: The proposed project will create or advance strong partnerships between organizations such as healthcare providers (hospitals, clinics, behavioral health treatment centers), public health (local or tribal health departments), and other organizations (such as community developers, county Sheriffs, or schools).
- Focus on at-risk populations and health disparities: The proposed project will serve a region or population of high need, as measured by the existence of health disparities, poor access to healthcare, health professional staffing shortages, geographic remoteness, or other factors clearly described in the proposal. Health disparities are defined as the higher rates of illness experienced by certain populations, including socially or economically disadvantaged families, racial and ethnic minorities, children, and older adults. In all of our initiatives, MHCF seeks to decrease health disparities—and to improve health and wellbeing among those at greatest risk.
- Solutions exist: Effective, evidence-based interventions exist to address the problem, but are not already being implemented.
- Workable in Montana and culturally appropriate: Infrastructure, community support, and strong partners exist to implement the intervention here; the intervention is tailored to work well within the community(ies) that will be served.
- Feasibility and scale: There is a high probability that this MHCF investment will lead to success. The strongest proposals will also have a high potential for being replicated successfully in other communities.
- Contribution to a diverse grantee portfolio: MHCF seeks to support a range of projects across Montana. We recognize that preparing a high-quality grant application may be more difficult for smaller communities that lack staff and resources. We may, therefore, also give preference to proposals based on their contribution to the overall diversity and balance of our portfolio, and in particular, to proposals from communities with the greatest demonstrated need.
Focus Areas
Applying these criteria to what we have learned over the past year, we have selected the following focus areas for 2015. The 2015 Call for Proposals describes our approach to working in each of these areas—the specific opportunities we have found and our approach to selecting and supporting successful projects. Appendix A (the Case Studies) describes a few of the successful initiatives we have found in Montana—examples of initiatives that appear to meet the criteria above: over the next year, we will continue to focus on learning about examples of what works in Montana.
- Behavioral Health (Mental Illness and Drug and Alcohol Addiction): A leading challenge according to virtually every source we have encountered, this is an area on which we focus considerable effort in 2015 and beyond. Specifically, we will seek to catalyze long-term improvements through encouraging partnerships and innovative use of existing resources, as well as on identifying longer-term opportunities for systems-level change.
- American Indian Health Disparities: The health statistics reviewed above paint a disturbing picture of the challenges confronting American Indians in Montana. These health problems are deeply rooted, and MHCF views this work as a long-term commitment. In 2015, MHCF will focus efforts on working in partnership with American Indian communities and organizations to develop both short- and longer-term strategies to address these health disparities.
- Partnerships for Better Health: This focus area reflects the common challenges in many areas we investigated. Many of the issues discussed in the preceding pages—such as aging, health workforce shortages, the funding of local public health activities, management of chronic illnesses, access to oral health services, and dual diagnosis (behavioral health problems and chronic disease)—would benefit from: better coordination among the organizations serving patients in a given community; the implementation of evidence-based approaches such as care coordination; and more emphasis on upstream approaches to disease prevention. Rather than focusing on a specific illness or population group, this area emphasizes new and innovative partnerships to improve outcomes and use existing resources more efficiently.
- Grant Seeker Assistance Program: Given that our own resources are limited compared with the needs in Montana, one of our strategies to maximize our impact will be to bring new resources to bear on the health challenges facing our state. To do this, we will assist Montana-based organizations in applying for grants available through other foundations and government programs. We will develop this aspect of our programming over the next several months.
As the summary of what we learned illustrates, improving health in Montana is a complex enterprise, and there are many important issues to address. MHCF understands that these focus areas may not cover every important issue facing Montanans. The framework we have created with these focus areas, however, will allow organizations around the state to work on a wide range of innovative, effective, and community-driven approaches to improving some of the state’s most pressing health problems. Through our first full year of grantmaking, we will continue to learn, and in response to what we learn, we will continue to evolve our programs to ensure that our investments fulfill the intent and promise of the Trust.
Summary
This strategic plan is our starting point: it is a synthesis and summary of many months of data collection and investigation, not a comprehensive, detailed accounting of the health challenges in Montana. As such, there are undoubtedly many important issues not reflected in the discussion above, and many others about which we have much to learn as a new foundation. This. As stated in the Introduction, our strategic planning process will continue, and will drive the evolution of our programming in the coming months and years. Specifically, over the next two years, we intend to deepen our knowledge of the needs and opportunities in our state in several ways:
- Continuing outreach to healthcare systems, experts, policy makers, and community members across Montana.
- Learning from the grant we provided to DPHHS to fund health planning in every county and tribal health department in Montana. We anticipate receiving results of this work over the next 2-3 years.
- Our 2015 call for proposals will allow eligible organizations around the state to provide us more information about the needs they see, and effective ways to address them.
- We will convene meetings to allow stakeholders to discuss key issues in depth.
We will conduct research on issues of particular importance to Montanans’ health but where relatively little information exists to guide the development of effective interventions.
Activities Planned for 2015
Grantmaking
In 2015, the Montana Healthcare Foundation will make a grants through an open Call for Proposals, as well as through inviting specific proposals where we see a high potential for impact. In addition to making grants, we will carry out other activities such as supporting meetings, conducting applied research, and a feasibility study for the creation of a public health institute in Montana. We describe each of these areas below.
Open Call for Proposals: Our 2015 Call for Proposals will allow eligible organizations (Montana-based non-profits, government agencies, Tribes, and universities) to apply for grants in each of our three focus areas.
Invited Proposals: In 2015, we will invite several proposals for projects that have a high potential to improve health outcomes, and also appear to be readily adaptable to meet similar needs in other communities. This approach, which we think of as “pilot and scale,” can achieve an impact that goes beyond the pilot project and eventually results in broader systems-level improvements. Proposals we have invited to date are described here: it is not certain whether each of the invited organizations will submit a proposal (discussions are ongoing). We also anticipate identifying and inviting additional projects over the next year:
- Evaluation to support expansion of the Medicaid Health Improvement Program to Montana’s Indian Reservations: We have invited a proposal from a tribal health department that would evaluate the Medicaid Health Improvement Program to support the state’s proposed plan amendment to extend this program to other tribes in Montana.
- Collaborative Approach to Addressing the Needs of medical “super-utilizers” and patients with complex chronic illness and behavioral health issues: We have invited a proposal from a collaborative group including a critical access hospital, community health center, and mental health center to pilot and implement a new program that will improve outcomes and reduce the costs associated with caring for patients who use emergency and hospital services frequently and have complex chronic illnesses and behavioral health issues.
- Collaborative models for implementing care navigation and community health worker programs to address the social, economic, and practical barriers to health among patients with complex medical issues: To support any grantees under our Partnerships for Better Health focus area who choose to implement care management models, we will consider providing a grant or contract to two state-wide organizations focused on Montana’s rural health organizations, to support implementation, evaluation, and dissemination of successful models.
CEO Discretionary Fund: MHCF’s CEO has authority to provide a limited number of small grants (up to $10,000 each). This program is intended to allow MHCF to be more nimble, and respond opportunistically to high-value opportunities that arise throughout the year. Some projects funded under the CEO Discretionary Fund will be identified through the open call for proposals; others will come about as we continue our strategic planning meetings with stakeholders around the state. While most CEO discretionary grants are expected to fall into one of our four focus areas, we anticipate that some may present new topics for consideration. All proposals considered under this program must meet the Foundation’s general selection criteria as described above.
Conference Planning and Support
We will provide a limited amount of support to several conferences and meetings that have a high potential to advance important health improvements. While we have not made final commitments for some of the events listed here, conferences under consideration for limited support include:
First Montana Healthy Communities Meeting: with the Office of Rural Health and the Montana Branch of the Minneapolis Federal Reserve, we are organizing a meeting of health experts, community developers, banks and financial experts focused on economic development in Montana, to discuss opportunities for creating new, innovative partnerships beyond the health sector to address Montana’s health challenges. This meeting will be similar to others hosted by the Federal Reserve and Robert Wood Johnson Foundation nationally, and will focus on identifying specific projects to pilot new collaborations.
Montana Healthcare Forum: this is an annual meeting that brings healthcare organizations, policymakers, and advocates together to discuss current policy issues. We have reserved a small amount of funding to support the meeting, but will not be a primary organizer.
Other potential meeting support in 2015: Many potential topics have come up in our discussions with stakeholders. These include:
- Helping to support the Indian Health Service’s annual Health Director’s summit, through providing scholarships to help Tribal health leaders or invited speakers attend.
- Convening meetings on mental health, addiction, or American Indian health disparities, with a specific topical focus and agenda focused on specific outcomes that can be best achieved through a meeting.
Applied Research
Alternative High Schools: Because of the striking health risks among students in these programs and the dearth of published information regarding the location and nature of alternative high school programs and how they meet the mental health needs of their students, we commissioned a study of these programs and opportunities for health grantmaking. The study was recently completed and a report summary is forthcoming.
Other topics: Over the course of the year, we anticipate identifying other specific research questions within our focus areas. Similar to the Alternative High Schools project, we would choose specific questions that appear to address a topic of significant importance to health, on which little attention has focused to date. Potential topics include, for example:
- Analyzing the policy context and barriers to providing integrated services for mental health and addiction.
- A feasibility study for supporting fiscal and management improvements in the Tribal health system, including, for example, replicating the Fort Peck HP/DP reimbursement structure; improving coding and billing in IHS facilities; assisting Tribes with compacting to assume responsibility for IHS services under Public Law 638.
- A report on methamphetamine and opioid use in pregnancy, which would develop a more complete data set to characterize the extent and distribution of the problem, and identify effective programs and funding streams to address it.
Feasibility Study—Creating a Montana Health Institute
More than 30 states now benefit from having public health institutes, independent non-profit organizations that work in close partnership with local, state, and tribal health agencies, hospitals, and other partners to strengthen state health systems (see www.nnphi.org for more information). These institutes perform a number of important functions, such as:
- Serving as a fiscal intermediary for government health agencies: In some states, public health institutes support stronger and more efficient government health systems by serving as a fiscal agent on grants and contracts and providing grant management and oversight.
- Non-partisan research and analysis to support health-informed public policy: Montana’s ranking as the least healthy state for children is one example of the importance of bringing health and health-related cost data to bear on important policy decisions. Seat belt and child restraint laws, DUI enforcement and treatment programs, immunization policies, and many other policies have the potential to make an impact on child health and many of the other important health challenges discussed above. Public health institutes provide a solid foundation and rigorous, non-partisan analysis to ensure that important legislative and administrative decisions are made with adequate information about the health implications.
- Program evaluation: Public health institutes can play a vital role in ensuring that scarce resources are used most effectively, through leading and coordinating program evaluations.
- Technical assistance: Public health institutes provide technical assistance on a wide range of topics, such as public health accreditation, Medicaid and Medicare pilots and reform initiatives, and others.
Over the next year, the Foundation may investigate the feasibility of developing a Montana Health Institute.
Beyond 2015: A Brief Look at the Future
The Montana Healthcare Foundation is a permanent resource for the people of Montana. Through a continuous process of investigation, collaboration, and learning, MHCF will evolve programming that addresses statewide needs and opportunities for improving Montanans’ health and well-being.
Making improvements on some of the major health issues in the state—challenges such as mental illness, substance abuse, and American Indian health disparities—will require years of investment and a steady hand. We view our first call for proposals as a critically important part of a longer-term strategy. Responses to the CFP will help us understand much more about the needs in the state, and the
organizations and opportunities that exist.
This year, we are offering mainly small, short-term grants. These smaller projects will allow us to begin a multi-year process of developing partnerships and refining our approach. We recognize that some initiatives may require a multi-year period to develop a stable base of funding. As our funding base grows in future years, MHCF will continue to evaluate the most effective investment strategies to support long term sustainability for effective initiatives, such as providing larger grants, longer grant
terms, or opportunities to renew funding.
Objectives — 2015 and Beyond
Improving health is a complex undertaking: health outcomes reflect the sum total of a myriad of factors, including genetic risks, personal choices, and each individual’s exposures to social, economic, and environmental risks and opportunities. As we are learning through recent studies such as those that focus on adverse childhood experiences (the ACE Study), events in early childhood can shape health throughout a person’s life.
For this reason, objectives for a health foundation must balance aspiration with practical realities, and take into account the fact that even though some improvements may occur in the short term, many will require a steady hand and years of patience to achieve. Based on what we have learned about Montanans’ health and the factors that shape health and wellbeing in our state, we have developed the following initial objectives for 2015. This section also outlines the process we envision for further defining our objectives and specific outcomes for future years.
Objectives for 2015-2016
- Long-term planning: Beyond supporting health and systems-level improvements, we intend that our 2014 and 2015 grantmaking will also generate rich information that supports more focused initiatives in the future, and better informed planning over the longer-term. Through this work, we will develop a more complete map of the state’s challenges, effective initiatives that can be scaled, and organizations capable of carrying out successful grant projects.
- Partnerships: These early grants will also begin the work of establishing new partnerships among grantee organizations, and between the Foundation and our grantees and other partners. These partnerships will facilitate successful projects during this grant cycle, and lay a foundation for even greater impact in future years.
- Bringing new resources to the project of improving Montana’s health: Through the Grant Seeker Support Program, through actively pursuing our own partnerships with other Montana-based and national funders, and through targeted research projects such as the Alternative High Schools report, we hope to bring new resources to bear to address the challenges identified in this strategic plan.
- Identifying effective and scalable interventions that can become financially self-sustaining: Because Montana’s mainly rural and frontier communities are often severely constrained by staffing and funding issues, we have chosen to focus particular attention on projects that demonstrate a high potential for becoming self-sustaining through using existing resources more effectively and efficiently. Models such as the Fort Peck Health Promotion/Disease Prevention program which is funded largely through effective billing and reimbursement, the Jail Diversion programs now being adopted by Montana Counties, the Nurse Care Navigator programs being paid for by Critical Access Hospitals, and inter-agency collaborations such as the hospital-mental health center project in Gallatin County are all good examples of programs that are improving health outcomes as well as strengthening their home institutions’ bottom line. Each of these models operates in a unique setting, and over the next two years we will focus on identifying these and similar models and understanding whether and how they can be scaled and adopted to other settings. At the same time, many beneficial programs may not show the same sort of short-term fiscal return on investment yet based on strong evidence, they improve health and reduce costs over the longer term. Evidence-based home visiting programs such as the Nurse Family Partnership may be one example, and one that the Foundation will continue to investigate so as to learn how such programs can be sustainably funded and successfully implemented in smaller communities and Tribes.
- Generate data to create awareness and inform program planning to address specific health challenges: By conducting up to three additional short-term studies of specific issues (similar to the Alternative High School report), we will draw attention to critically important health issues and offer solutions to guide state and local governments, non-profits, and others in developing solutions.
- A sound and practicable plan for a Montana Health Institute: By early 2016, MHCF will complete the feasibility study. If we conclude that such an institute would fill a valuable role in Montana, we will identify funding partners and develop a business plan for launching this institute.
Grant-Specific Objectives
In addition to the Foundation’s general objectives for 2015 and 2016, each grantee will develop measurable outcomes and a strong evaluation plan. Some of these may include specific health outcomes, such as reducing the number of Emergency Department visits among a group of frequent ER utilizers, reducing recidivism rates for mentally ill inmates upon release, or improving measures such as blood pressure or diabetes control. Others may relate to upstream factors, such as creating access to healthful foods, improving housing, or increasing the number of people able to access mental health services. Through these grant-specific evaluations, we will learn about what is achievable under these grant programs, and use this information to develop more structured, targeted programming in future years.
Appendix A: Case Studies
Jail diversion for people with behavioral health problems in the corrections system
Three counties in Montana (Silver Bow, Lewis and Clark, and Gallatin) have recently implemented jail diversion programs. These programs provide treatment for those with mental illnesses pre-arrest, during incarceration, and after release.
The programs are producing impressive results. In Gallatin County, for example, after implementing the program, recidivism rates dropped to 9 percent (for comparison, the statewide rate is 41.9 percent). Although each county’s program was initially funded primarily with grants, diversion is proving so successful that now primary funding of the programs is out of its corrections budget. Referring to Montana as a whole, Representative Margie MacDonald, chair of the legislature’s Law and Justice Interim Committee, said, “If we reduce recidivism rates, we have the potential to save literally tens of millions of dollars. Incarceration is one of the most expensive things the state of Montana does.”
With positive results in each county, the Montana Association of Counties is now planning an initiative to help corrections departments around Montana implement similar programs, in hopes of not only improving mental health outcomes but reducing recidivism and related correction costs as well.
Care Coordination and Case Management
In the past year the critical access hospitals in Ennis and Deer Lodge, Montana have implemented clinical care coordinator programs. The programs are internally funded by the hospitals and are run by experienced nurses who understand the challenges of an increasingly complex healthcare system, the challenges to health that come up in people’s daily lives. These programs seek to improve patient care, reduce hospital readmissions, improve chronic disease outcomes, and provide a consistent point person for patients throughout their treatment.
Even though both programs are still in their first year of implementation, there are already signs of improvement. The Madison Valley Medical Center for example, has seen a reduction of readmission rates from 7.4% to 2.6%, and patients have expressed tremendous appreciation for the follow up calls and additional support during their illness and recovery. Another benefit of these programs is that they help people referred out of the community for specialty care to return home sooner, more safely, and without any breaks in their care. The Deer Lodge Medical Center, for example, observed that patients appear to recover more quickly when they have a consistent point person throughout their treatment, and help transitioning from tertiary hospitals back into their communities.
Evidence from around the U.S. suggests that care coordination via nurse care navigator programs, community health workers, and collaboration between public health departments and hospitals can improve health outcomes and reduce costs. These two programs show that such efforts are feasible in Montana, and can yield substantial rewards for patients and the hospitals and clinics that serve them.
Partnerships & Collaboration: Richland Health Network
In 2000, the Richland County Health Department and the Sidney Health Center partnered to form the Richland Health Network in an effort to improve health and quality of life in the community. This longstanding partnership has achieved notable outcomes that would have been difficult for either organization alone to achieve.
The Network’s initial goal was to decrease hospital re-admissions among older adults by providing outreach, care coordination and assistance with daily needs, such as taking medications correctly and eating well. Together the Health Department and Health Center applied for and received a federal grant for the project. The project was not only successful in reducing re-admissions, but also in enabling the Network members to expand their focus to include the needs of the growing number of people with diabetes in the county.
Over the course of the partnership, the Richland Health Network has implemented a variety of programs, such as training diabetes ambassadors and creating a Senior Health Coalition to provide outreach to vulnerable seniors in their homes. The collaboration also led to the creation of a new diabetes center housed at the Sidney Health Center, which offers patients tools and support for managing their illness; and the Health Department continues to facilitate collaboration between agencies and organizations while identifying and securing resources to address other chronic disease issues.
A County Health Department leads a community-wide coalition focused on improving health
One of the most important roles that county health departments can play is providing strategic leadership and bringing the members and organizations in a community together to address important health issues. As part of the community health improvement process that local health departments carry out periodically, the Richland County Health Department completed a health assessment, in collaboration with stakeholders, to identify the most important health-related issues facing the county. The Health Department then built a steering committee to address these issues, with members from all areas of the county including representatives from the Health Department and other leadership groups such as the City-County Planning Board and the Chamber of Commerce. Some of the other partners include the faith-based community, Transportation Director, County Commissioners, County and City Public Works Director, Park and Recreation board members, the hospital, and the library.
Action groups made up of steering committee members took ownership for implementing various aspects of the strategic plan. Their accomplishments to date are impressive. One action group focused on physical activity to reduce the risks of diabetes and obesity, advocating successfully for a “complete streets” policy and new walking paths to local schools. To provide social support, opportunities for learning, and physical activity for vulnerable kids, another action group created the Richland County Boys and Girls Club, raising approximately $2 million to house the club. Some other notable accomplishments of the steering committee’s working groups include:
- Creating a community foundation.
- Establishing a family resources center, that provides parenting classes and a “Parent Café” for the Sidney Schools.
- Holding trainings on Mental Health First Aid, an evidence-based intervention that helps community members identify, understand, and respond to signs of mental illnesses and substance use disorders in friends, co-workers, and students. Mental Health First Aid has become increasingly widely used in Montana, and the mental health action group in Richland County was the first in the state to do so.
- Assembling a large coalition of local organizations, businesses, and individuals to address emergency response for the RV parks created in Richland County during the recent increase oil production.
Appendix B: Strategic Plans
2015 Strategic Plan PDF
1 Montana Office of Public Instruction. 2014. Youth Risk Behavior Survey. Online at: http://www.opi.mt.gov/pdf/YRBS/13/13FinalRpt.pdf
2 Montana Office of Rural Health. 2014. Addressing Community Health Needs: Health Priorities and Strategies Found in MT Implementation Plans. http://healthinfo.montana.edu/documents/CHSD%20health%20priorities%20strategies.pdf
3 Mental Health America. 2015. Parity or Disparity: The State of Mental Health in America. Online at: http://www.mentalhealthamerica.net/sites/default/files/Parity%20or%20Disparity%202015%20Report.pdf.
4 Montana DPHHS. 2013. The State of the State’s Health. A report on the health of Montanans. http://dphhs.mt.gov/Portals/85/publichealth/documents/Epidemiology/StateOfTheStatesHealth.pdf
5 Annie E. Casey Foundation. 2014. Kids Count Data Book: trends in child wellbeing, 25th Edition. Online at http://www.aecf.org/m/resourcedoc/aecf-2014kidscountdatabook-2014.pdf.
6 Child Trends. 2014. Adverse Childhood Experiences: national and state-level prevalence. Online at http://www.aecf.org/m/resourcedoc/aecf-2014kidscountdatabook-2014.pdf.
7 America’s Health Rankings. 2014. Immunization rates. http://www.americashealthrankings.org/MT/Immunize/2014
