Montana Healthcare Foundation: Leveraging Funds, Providing Technical Assistance, and Supporting Public Health

Q&A with Aaron Wernham, MD, CEO of Montana Healthcare Foundation, and Scott Malloy, Program Director

by Allee Mead

The last of four articles in the series During Pandemic, Rural Health Foundations Provide Financial Support, Technical Assistance, and Other Services

 
What is your foundation doing to support rural communities during the pandemic?

Wernham: The Montana Healthcare Foundation is a private nonprofit foundation. We're what's called a conversion foundation: one of a few hundred in the U.S. that are created whenever a hospital or health insurance company changes its tax status from nonprofit to for-profit. We are the state's largest private health-focused foundation. We made our first grant at the end of 2014, so we're pretty new. We have several broad areas of focus. We work on behavioral health, American Indian health, public health, and Medicaid and health policy. We touch on a lot of other areas of the state's health system. The foundation really exists to tackle the state's major health issues, however we can.

…we didn't think we could meet the need just by doing something like accelerating our grant making. We really wanted to figure out how to leverage the staff expertise, relationships, and capital that we have to help the state cope.

One of the first things that we realized is that, dollar for dollar, our budget is minuscule: not a thousandth of what the federal government has already poured into the pandemic, not to say other philanthropies. And so we didn't think we could meet the need just by doing something like accelerating our grant making. We really wanted to figure out how to leverage the staff expertise, relationships, and capital that we have to help the state cope. We gave our grantees flexibility, which I think has been recommended and broadly implemented by most foundations I've talked with, and lightened up on any timeline requirements and grant reporting and whatnot ― just gave them flexibility to use the resources they have for what their most acute needs are.

But most grantees have continued the work they were doing with our grants before the pandemic, just because the projects are so fundamentally important to what they're trying to accomplish in their community. Our work has focused on three broad categories in pandemic response. The first is leveraging our funds to help partners bring in larger sources of funding. We regularly scan and identify large grant opportunities and other types of funding opportunities. We immediately contact partners when something comes up that's relevant to them. We hire grant writers for them, help them put together a strategy, and help them bring in those funds. That's netted around $15 million so far. We also have helped guide some existing sources of funding. The best example is getting some crisis behavioral health funds out to county health departments that are responding to the mental health issues created by COVID.

The second category is direct technical assistance. We have spent a lot of time with tribes, behavioral health providers, other partners that we work with, and county health departments, just helping them figure out how to navigate the landscape of both economic damage and how to continue to serve their population. We hired contractors and helped organizations we work with think about provisions under FEMA for cost recovery and how to help tribes and behavioral health providers implement telehealth under the new rules.

The final area that we spent a lot of time in is just supporting the public health system. Montana has a decentralized public health system, so a lot of the authority and responsibility for implementing rules and regulations and every aspect of pandemic response actually land with the counties, many of which have a tiny staff. We have quite a few counties in the state that, before the pandemic, had one full-time equivalent staff member in the county health department, who is now charged with testing, quarantine and isolation, enforcing orders, interpreting data, putting out press releases, helping school districts figure out whether to reopen, and everything else under the sun. We've been working with them for years to build the public health capacity in the state. We've been creating a new nonprofit public health institute to take that work and build it into a stronger, more effective portfolio. We went ahead and accelerated the Montana Public Health Institute, which is now a freestanding nonprofit that's working with the state, the counties, and the tribes on pandemic response.

Malloy: When this hit ― it seems like it was like five years ago, right? ― and the governor's orders were coming down here and the emergency declaration was occurring and there was a lot of chaos as far as how to interpret the rules of staying open as a provider, there were questions around: Should we be doing things remotely? Should this be in person? And so one of the things that we immediately did when the system was in chaos is we organized webinars and learning opportunities between the department of public health and the healthcare community.

There were specific calls and webinars around the behavioral health providers, primary care providers, and peer support specialists. And those initial focuses were on clarifying the emergency declaration orders and the governor's orders as they relate to the types of services that can be provided and the level of detail that needed to be put into place. So that stabilization in those first two weeks was pretty critical. Once the Montana Department of Public Health and Human Services got their footing, they were able to take those ongoing calls over and they still continue. They're now at bimonthly calls with the behavioral health providers just to speak specifically about COVID-related questions around anything from billing to safety precautions, to quarantine, et cetera. And I think that's been very powerful.

As we know, over the last several months now, there's been a continuation of changes that have occurred. A lot of the focus early on has been on the telehealth component. There was kind of a blanket waiver regarding telehealth. Restrictions were lifted for where telehealth services could be provided and the type of platform being HIPAA-compliant. There was a lot of latitude that the state had to navigate, and clarity had to be provided to the behavioral health and primary care providers. In Montana, most folks were not doing telehealth. Those who were had to pivot toward this new world of: "Well, we can do telehealth, but it doesn't have to fit all of these requirements that it once did. So are we going to do that? Are we going to hold to the requirements?"

There's a lot of shifting that had to occur, but the majority of providers were getting into telehealth for the first time: "Well, what code do we use? Is there a modifier? Do we have an attribution site? Do we have to do this from our home? Does it have to be in the office?" All of those details required a significant amount of trust, if you will, between the department and the providers. And we facilitated those early webinars to clarify very granular things like coding and billing. Even though there was a period where things went back to face-to-face, we now have seen a resurgence that has provided another opportunity to engage in the telehealth discussion.

Telehealth, even when the cases were going down, became baked into the system.

Telehealth, even when the cases were going down, became baked into the system. It'll be really interesting to see how this transitions once the virus gets under control. And I think the state has really been open with the providers to say that we may keep some of these things that were under an emergency declaration because we understand that it really increased access and eliminated a lot of barriers to care. I think that's been a very powerful thing that has happened that I think could have a pretty dramatic long-term impact.

We have initiatives surrounding integrated behavioral health and primary care in obstetrics, as well as initiatives around substance use disorder with a focus on crisis peer support. We have the behavioral health leadership portfolio. That was really the creation of the first behavioral health association in Montana. Those initiatives and the relationships that we had with those partners really went well for us to be able to mobilize those initiatives, to address a lot of what had to occur very quickly. And I think that's still maintained to be true.

When you talk about how the behavioral health community in particular was able to rally together under that new association, it's remarkable what they were able to do because they were a formal group. And when you look at our grant application assistance initiative ― where we will identify federal, state, and private grants; utilize a grant writer; and be the strategic partner ― there were a lot of grants flying out as a result of this, which is wonderful, but people didn't have the time to even look at them, much less read them and apply for them. So that initiative allowed us to very quickly pivot with our partners and provide some resources and time and strategic thinking to bring those dollars into the state.

There was a tremendous amount of resources that came in that were already baked into a strategic framework. One of the early grants that we got from the relief funds was, I think, $2 million that was specific to behavioral health crisis. That's pretty broad. There's a lot that you can do with that. Those funds really advanced the existing work that was in place around communities redesigning their crisis systems.

Behavioral health funds went directly to local health departments for them to help lead and identify how they could, in their rural communities in particular, use funds to address behavioral health issues with a crisis focus, but was set up in a way where it could be used for foundational monies to live on. And I think those things are really exciting because you can see the fruits of that already, and it's going to be really cool to see how that lives on in the future.

Wernham: Those behavioral health crisis funds basically help the state develop a strategy to get them out to the county health departments or tribal health departments to help provide ongoing assistance to guide their youth.

What other services or stories would you like to highlight?

Wernham: Changes in telehealth reimbursement are going to be a potential game changer, because we're talking about these frontier areas where you don't have internet or broadband in some cases. The providers were limited before to not being able to have a phone call to check in on the client, which we would all recognize is very, very powerful, particularly during this time. If you can't get reimbursed for that, you're not going to do it. So now you have a situation where people can have a phone call and do a therapeutic intervention and get reimbursed for it. Part of the discussion is to make sure there's quality control, make sure there's appropriate documentation, but that's very much part of the conversation post-crisis to have this type of telehealth be part of the frontier delivery of care. And I think that's really important. That's much different than your traditional telehealth, where you have to have a compliant software platform or the patient has to go into an office, which isn't really possible in many of the areas of Montana. But being able to have a phone call with the person in their home, that is possible.

Part of the discussion is to make sure there's quality control, make sure there's appropriate documentation, but that's very much part of the conversation post-crisis to have this type of telehealth be part of the frontier delivery of care.

We also hired a contractor to help tribes identify each funding opportunity from the CARES Act and to provide either one-on-one help or even just a website that catalogs each part of the bill that was relevant to tribes and how tribes would go about accessing funds or other resources that Congress was putting out. There were quite a few instances where we were able to quickly alert tribes to something where a deadline was coming up and help them apply, to bring in funds that might have otherwise kept coming down without anyone even knowing they were available.

In addition, the Montana Public Health Institute, even in its first few months of operation, has already begun playing an essential role. They worked with the state health department to carry out a survey of all of the county health departments. They basically had phone interviews with every county and every tribe, to find out what's working well on pandemic response and what could be better. And they're now using that to convene the leadership and other key stakeholders to basically figure out very quickly what else can be done to allow the state to better support an effective county-level public health response. It's a work in progress, but I guess it's already starting to play a pretty important role in helping guide the state response.

What else would you like to share?

Malloy: It's just amazing how the partners we work with have responded to the crisis.

Opinions expressed are those of the interviewees and do not necessarily reflect the views of the Rural Health Information Hub.