Montana State Hospital reports stronger discharge planning as emergency detentions surge

Kayla Tamke, director of social services at Montana State Hospital, told the Legislature's health subcommittee on March 1 that the hospital has strengthened its discharge planning operations and filled many clinical vacancies, but a sharp increase in short emergency detentions is creating operational strain.

Tamke said the hospital has 19 full‑time behavioral health care planner positions responsible for discharge documentation and plans, and that ‘‘we've successfully onboarded 7 care planners since April of 2024’’ with three more starting orientation next week — a change that will bring ‘‘17 of 19 positions filled,’’ she said. She told the panel care planners begin discharge conversations at admission and that social assessments are completed within 72 hours to identify needs for community aftercare. "Patient discharges are patient centered driven by the patient and patient preference, and we respect their autonomy," Tamke said.

The staffing gains extend to clinical therapists: Tamke said the hospital has six full‑time therapist positions and has "onboarded 4 licensed clinicians since April of 2024" with another clinician scheduled for orientation on March 3. She and other presenters said those hires let staff reduce caseloads and improve the quality and timeliness of discharge plans, which are sent to receiving community providers 24 to 48 hours before discharge.

Tamke reported operational metrics to the subcommittee: total admissions rose to 765 in fiscal 2024 from 681 in fiscal 2023; the facility's 30‑day psychiatric readmission rate is 9.2%, compared with a national average of 20.9%; and the hospital has begun routine audits and new training tied to CMS regulations and the hospital's discharge criteria and planning policy. She described a formal discharge packet that includes a community reentry plan and a training form used when patients are discharged to shelters or motels.

But the subcommittee focused on a recent increase in emergency detentions. Dr. Flanagan, chief executive officer of Montana State Hospital, and Chad Parker, legal counsel for the Department of Public Health and Human Services (DPHHS), told lawmakers that a rise in county attorney emergency holds and a backlog at the forensic mental health facility (FMHF at Galen) are driving that spike.

"It was a very surprising shift," Dr. Flanagan said, noting that emergency admissions often arrive in crisis and may be at the hospital for only 24 hours, unlike 90‑day involuntary commitments that give staff time for comprehensive treatment and discharge planning. Parker told the committee that county attorneys can order emergency detentions that hold a person without a court order for an initial period (he cited the statutes the department referenced: Montana Code Annotated sections 53‑21‑129 and related provisions) and that to hold someone beyond the initial period requires court orders.

Parker said his review points to navigation around the limited bed capacity at Galen as a contributor: county attorneys, facing a forensic wait list for Galen beds, have sometimes used emergency detention authority to move people into the system. "There may be other complicated reasons behind that, but that seems to be the core issue," Parker said, adding that the department is pursuing legislative changes and stakeholder engagement to address the problem.

Officials and legislators asked for more granular data. Vice Chair Mercer and Representative Cafaro asked the department for a chart breaking fiscal‑year admissions into the commitment subcategories (emergency detention, court‑ordered detention, 90‑day involuntary commitments, tribal commitments, etc.) over recent years; Dr. Flanagan agreed that the total 765 admissions in fiscal 2024 include all commitment types and acknowledged tribal commitments and smaller categories are not shown on the slide the committee reviewed.

The department also described work tied to House Bill 872 commission near‑term initiatives (NTIs). Chad Parker and department staff said the NTI that incentivizes community‑based court‑ordered evaluations has been active: Parker said the program has helped process roughly 40 corridor evaluations in‑house and another ~25 farmed out to community providers since late summer, for "nearly 70" COEs that reduced a backlog at Galen. The subcommittee heard that the NTI funding envelope discussed during prior commission work included up to $7.5 million for court‑ordered evaluations; committee members asked for updated spending and implementation details. A separate NTI — supporting mobile crisis response, crisis receiving and stabilization services — also carries up to $7.5 million in authorizations; committee members noted expenditures on some NTIs remain limited and asked for clearer progress reports.

Lawmakers and hospital leaders repeatedly raised the need for more step‑down or subacute community placements. Dr. Flanagan said such facilities would serve two purposes: provide a less‑restrictive transition for patients leaving acute care and offer placement options for long‑stay patients who are difficult to place. He estimated an ideal statewide capacity of roughly 26 to the mid‑30s beds but said the department has not yet completed a business analysis on location, staffing ratios and costs. Director Brereton said the department is exploring a step‑down subacute facility in Helena as a capital recommendation from the HB 872 commission and is discussing other potential legislation to open at least one additional subacute facility.

Committee members asked for follow‑up materials the department committed to provide: (1) a disaggregated admissions chart by commitment type for FY21–FY24, (2) average length‑of‑stay by commitment category, (3) updated COE and NTI expenditure and placement data, and (4) the alternative settings/partner inventory assembled during the HB 872 work. Dr. Flanagan and department staff said they will supply those materials and that the subcommittee will receive additional follow‑up briefings.

The session underscored an operational tension the department described repeatedly: the hospital must meet federal Conditions of Participation and CMS rules while responding to rapidly changing admission types, and addressing the bottleneck requires coordination across counties, courts, the forensic facility at Galen, and community service providers. Lawmakers urged more cross‑agency coordination and said they want county attorneys and other stakeholders to appear before the committee in future sessions.

The committee did not take any formal votes during the hearing and directed staff to schedule follow‑up briefings on the topics above.