RI Proposes E-Records for DD System That Raise Questions about Consent Decree Compliance

By Gina Macris

For the last five-and-a-half months, Rhode Island has been considering eight proposals for an electronic case management system to keep track of services for adults with developmental disabilities.

In part, the electronic system would satisfy demands for up-to-date information so that federal officials could better gauge the state’s compliance with a 2014 consent decree requiring it to shift to community-based daytime services to comply with provisions of the Americans With Disabilities Act.

But the solicitation also indicates that the design of the electronic case management system could conflict with implementation of other requirements of the consent decree, which call for individualization of services and a more flexible approach to delivering them.

Among the vendors submitting proposals is Deloitte Consulting, the company involved in the chaotic rollout of a statewide public assistance benefits computer system known as the Unified Health Infrastructure Project (UHIP), which went live last September. 

At last count, more than 10,000 individuals, which include those with disabilities, are experiencing difficulties with food stamps and other public assistance and medical benefits, according to state officials. And UHIP has contributed to confusion about caseload estimates, used by policy makers to calculate demands on the budget that begins July 1.

Deloitte and the state are still trying to fix UHIP and are negotiating a financial settlement for the $364 million project, although the company recently gave the state a $27 million credit, primarily to cover the cost of re-hiring workers previously let go to help de-bug the system.

The state is appealing a federal fine of $805,197 over the implementation of the project, and the U.S. Attorney’s Office is investigating separate allegations that the federal-state Medicaid program was billed for services that were not provided in connection with the UHIP rollout.

The language of the 116-page request for proposals concerning  the developmental disability program, issued last fall,  indicates that the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) would conduct business as usual in its funding and delivery of services in two key areas:

  • The use of a mathematical formula to translate the results of a standardized needs assessment called the Supports Intensity Scale (SIS) into one of five levels of funding, which in turn would define the scope of services, or “service packages.”
  • The continuation of a fee-for-service billing system for private providers, which pays out only when a service is provided face-to-face, in 15-minute increments during the day, and in 24-hour segments for residential programs, with rates subject to change on a quarterly basis.

The solicitation remains active even as the Division of Developmental Disabilities has signaled it is gearing up for an overhaul of existing regulations to comply with the consent decree. And in a report filed with the U.S. District Court in April, the state agreed to explore new approaches to funding to follow-up on statistics that showed at least one third of private agencies don’t have the ability to expand the kinds of services the consent decree demands.

The independent federal court monitor who is overseeing implementation of the consent decree, Charles Moseley, has said that funding must respond to the individual’s “goals and preferences” as expressed in an individual support plan.

In other words, the money should follow the person, rather than the other way around, as is currently the case.

During the month of May, the Division of Developmental Disabilities and the Sherlock Center on Disabilities at Rhode Island College have invited the public to attend presentations on the central idea behind personalizing services, or "person-centered" thinking; the notion that individuals with disabilities should have more control over their lives.

The regulatory overhaul will be based on that personalized approach, with families, consumers, and providers participating in the rule-writing, Kerri Zanchi, the division director, said at a recent public forum. 

Asked after the meeting how how changes in practice brought about by the new regulations would be funded, Zanchi said, “When we figure out what it (the service system) would look like, then we need to figure out the funding for it.”

The consent decree, meanwhile, also criticizes the fee-for-service reimbursement model for private providers as insufficiently flexible to accomplish the its goals, which focus on individualized community-based supports for jobs and leisure activities.

In response, BHDDH has established a pilot program for supported employment, which provides bonuses for staff training, job placement, and job retention. It has resulted in 40 new jobs since January, according to a BHDDH official.

But in light of the recent survey indicating gaps in providers’ ability to take on new clients, BHDDH has agreed to take a deeper look at funding.

Through a BHDDH spokeswoman, state officials declined to comment on the solicitation for proposals while bids are under evaluation. The eight bids were opened last Nov. 29, according to the website of the state purchasing office.

The request for proposals appears to respond, at least in part, to complaints about data collection expressed by both Moseley, the consent decree monitor, and the U.S. Department of Justice.

Moseley has said the information was so inadequate that it was impossible to tell whether the state was meeting employment targets and other requirements.  Just a year ago, state officials were struggling to come up with an accurate count of the total number of adults with developmental disabilities who were protected by the agreement.

Since then, the state has adopted a work-around to the existing system that can respond to specific queries from the monitor or the U.S. Department of Justice, but not on a real-time basis. The patchwork approach enlists data collected quarterly by the Sherlock Center on Disabilities at Rhode Island College. 

The budget for the electronic case management system has not been made public. The request for proposals (RFP) anticipated an initial three-year contract period beginning March 1.

Asked about the apparent delay, the BHDDH spokeswoman, Jenna Mackevich, said in an email that “it’s important that the agency take the time necessary to thoroughly evaluate proposals and conduct its due diligence during the purchasing process. “

During the evaluation period, the state also has allowed the expiration of a 120-day ban on vendors changing their proposals, which is spelled out in the RFP. The RFP said the state would consider not only price but various aspects of functionality in the proposals as part of its evaluation.  Vendors would be required to demonstrate their products.

To keep costs down, the state is seeking “off-the-shelf” software with customization not to exceed 15 percent. 

According to the RFP, the new electronic case management system would computerize all record-keeping for the developmental disability service system, allowing access by families, providers, and BHDDH staff for multiple purposes.

Besides Deloitte, the vendors are Consilience Software, of Texas;  Eccovia Solutions, Inc., of Utah; FELCOM, Inc., of Maryland;  FOOTHOLD, Inc. of New York; Mediware, of Virginia; Netsmart Technologies, Inc., of Kansas; and Therap Services, Inc., of Connecticut.

RI Report To Consent Decree Monitor Details Gaps in Community-Based Services for Adults with DD

By Gina Macris                                

Three years after Rhode Island agreed to desegregate its daytime services for adults with developmental disabilities, it does not yet have the staffing or expertise to support community-based work and leisure activities for all who want or need them.   

And while the state pushes shared living arrangements in private homes as a less restrictive and less costly alternative to group homes, nearly two thirds of the private direct service providers cannot help with the back-up supports necessary to make that option workable for additional clients.  

Overall, the private agencies report that inadequate staffing, training and funding are holding them back, according to a new report on “provider capacity” that the state has submitted to an independent federal court monitor on implementation of the 2014 desegregation agreement.

In a survey of 32 private service providers, the state found that 14 agencies (42 percent) cannot accept new clients seeking supported employment and 11 agencies (34 percent) cannot expand staffing for non-work community services.

These two types of community-based supports form the core of service demands mandated by the 2014 consent decree, which requires Rhode Island to comply with the Americans With Disabilities Act (ADA) by moving away from sheltered workshops and segregated day programs.

In addition, 20 agencies (63 percent) cannot take on new clients who may choose shared living arrangements, 16 agencies (50 percent) can’t accept new residents in group homes, and 15 agencies (47 percent) can’t offer supports to additional clients living more independently in apartments.  Finally, 25 agencies, or 78 percent, can’t provide temporary “respite” care to help families or hosts of shared living arrangements who otherwise cannot leave home.  Most adults with developmental disabilities live with their families.

The state included all service categories in a survey of “provider capacity” as part of a quarterly report submitted in mid-April to the consent decree monitor, Charles Moseley, even though he focuses only on daytime services.

The data on residential supports helps flesh out the picture of services that appear to be affected by low reimbursement rates and correspondingly low wages for direct care staff. The numbers also are relevant to an upcoming change in Medicaid regulations, separate from the consent decree, but similar in their emphasis on community-based services of all kinds for adults with disabilities.

As a result of the survey on provider capacity, as well as other data suggesting that about 18 percent of young adults have trouble getting appropriate first-time services, the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) said it would refine its data-gathering to better “evaluate how funding is affecting access to services in order to inform possible funding methodology and mechanism changes.”

BHDDH also said it would explore alternatives to “Project Sustainability,” the current set of funding and service regulations put into place by the General Assembly in 2011.

A spokesman for House Majority Leader Nicholas Mattiello defends “Project Sustainability” for bringing accountability to the developmental disability service system.

 In 2014, however, the U.S. Department of Justice found that Project Sustainability diminished access to integrated, community-based services in violation of the ADA.

Since that time, Rhode Island also has been preparing for a deadline of March, 2019 to comply with a new Home and Community Based (HCBS) rule promulgated by Medicaid which affects residential services for adults with developmental disabilities.  On May 9, however, the Centers for Medicare and Medicaid Services issued a bulletin extending the deadline for three years, until March 17, 2022. A BHDDH  spokeswoman could not say on Friday what effect, if any, the extension would have on the implementation in Rhode Island.  

The new HCBS rule and the consent decree both get their legal authority from the 1999 Olmstead decision of the U.S. Supreme Court. In Olmstead, the nation’s top court re-affirmed a desegregation mandate in Title II of the ADA, which says that all kinds of services for individuals with disabilities must be provided in the least restrictive environment that is therapeutically appropriate.

In Rhode Island, group homes historically have been the first choice of aging parents who find it difficult to provide 24-hour care at home for sons or daughters with complex needs. But BHDDH has a virtual freeze on new group home admissions, except for dire emergencies.

While adults with developmental disabilities are living at home, their family members might need a few hours or days of respite care, but historically, many have found it difficult to arrange that service. 

Among young adults looking for first-time services, those with complex medical needs and those who use sign language have had particular problems making appropriate arrangements, according to the BHDDH quarterly report to Moseley, the monitor.

The monitor’s report also included responses to Moseley’s requests for detailed progress reports for tasks where implementation of the consent decree has fallen short, including information from the Office of Rehabilitation Services (ORS), and the Rhode Island Department of Education (RIDE), as well as BHDDH. All three agencies are involved in implementing the consent decree.

The creation of a career development plan, which takes into account each person’s preferences, strengths, and need for assistance, is a key element in individualizing supports for developmentally disabled clients.  

Moseley had set a deadline of June 30, 2017 for all required career development plans to be in place, noting that Rhode Island didn’t have a policy or implementation strategy in place for career development planning until April, 2016,sixteen months after the deadline of Jan 1., 2015.

But BHDDH was able to obtain an extension of the deadline until Sept. 30 for adults with developmental disabilities who have been in sheltered workshops or segregated day programs. 

In its report to the monitor on career development planning, BHDDH wrote, “The first efforts emphasized compliance and simplicity in the approach to the plan. The next steps are to improve the quality of these initial plans, ensure that individuals have an active and leading role in their career development planning process, and ensure that actions are stated to meet the stated goals.” Read the report here.

Career development planning “has been a new concept to many people,” BHDDH said. 

During the month of May, BHDDH and the Sherlock Center on Disabilities at Rhode Island College are rolling out a series of public presentations on “person-centered planning,”  the concept of individuals having greater control over their lives. That idea is at the heart of career development planning and all other types of services for individuals with disabilities. The presentations are also a precursor to an invitation to families and consumers to assist in an upcoming effort to rewrite developmental disability regulations The schedule for the presentations is here.

The state’s quarterly report to the monitor also covered these topics: 

  • School-to-work "transition" activities for students with intellectual or developmental disabilities aged 14 and older, including at least two trial work experiences in the community, each lasting about 60 days.
  • A RIDE policy emphasizing long-range employment goals for high school special education students.
  • An ORS policy saying the agency will serve students younger than 16.
  • Strategies for increasing the average number of hours worked by adults with developmental disabilities.
  • A plan for increasing staff training at ORS and private provider agencies in various aspects of providing job supports for adults with developmental disabilities.
  • Strategies for increasing the number of  "benefits plans", which are individualized explanations of how - and if -work will affect a client's government assistance, so that job seekers can make well-informed choices about employment.
  •  Plans to further define the role of the Employment First Task Force, a committee representative of various segments of the developmental disabilities community that was created by the consent decree to serve as a bridge between state government and the public.

Moseley’s summary of the state’s various reports is here:

The next round of quarterly reports is due in mid-July. Judge John J. McConnell is scheduled to review the case from the bench in U.S. District Court on July 28.

 

Top Aide To RI Gov. Raimondo To Lead EOHHS; Policy Director For Providence Mayor To Run HHS

By Gina Macris

RI Governor Gina Raimondo has named Eric Beane, the top aide tasked with fixing the UHIP computer disaster, as Executive Secretary of Health and Human Services. 

Courtney Hawkins, chief policy officer for Providence Mayor Jorge Elorza, will become the new Director of the Department of Human Services (DHS). And Zach Sherman, Director of HealthSource RI, will take over the day-to-day management of the UHIP turnaround, according to a statement from Raimondo’s office issued May 12.

“Rhode islanders deserve and demand high-quality public services. I am confident the new leadership for our Health Cabinet will ensure better access to care and better outcomes for Rhode Islanders,” Raimondo said.

There has been a nearly complete turnover in the human services leadership since the start of the year, primarily because of problems with the UHIP computer system and with the management of the Department of Children, Youth and Families.

Beane has been with Raimondo since she took office in 2015, serving first as deputy chief of staff and then as chief operations officer, before the governor put him in charge of running DHS and turning around the $364-million Unified Health Infrastructure Project (UHIP) in January.

Hawkins, a Rhode Island native, “brings more than 15 years of experience working with social service agencies and in public policy” here and elsewhere, Raimondo said.

Hawkins has a bachelor’s degree from the University of Rhode Island and a master’s degree in social work from Columbia University. Before returning to Rhode Island in 2015, she worked as senior vice president at the now-bankrupt FEGS Health and Human Services, one of the largest social service agencies in New York City. The agency closed its doors in 2015.

UHIP, the largest information technology project ever undertaken by the state, has delayed eligibility decisions and healthcare and social service benefits for tens of thousands of Rhode Islanders – including some with developmental disabilities - since it was launched in September, 2016.

The botched rollout also cost the jobs of former EOHHS Secretary Elizabeth Roberts, the state’s chief digital officer, Thom Guertin, and the former DHS director, Melba Depena Affigne. 

In announcing the new appointments, Raimondo’s office said that Anya Radar Wallack, Acting Secretary of EOHHS since February, will return to the Brown University School of Public Health in June.

Beane is to start his new duties June 1 and Hawkins will take office June 12. Both appointments require confirmation by the state Senate.

Jennifer Wood, Leader of RI DD Consent Decree Compliance, To Leave State Government

Photo by Anne Peters

Photo by Anne Peters

By Gina Macris

Jennifer L. Wood, largely responsible for accelerating Rhode Island’s lackluster response to a federal consent decree affecting adults with developmental disabilities, is leaving state government to become director of the Rhode Island Center for Justice.

The non-profit public interest law center works with community groups and the Roger Williams University School of Law to strengthen legal services and advocacy on issues that reflect the most pressing needs of low-income Rhode Islanders, including housing, immigration, and workers’ rights.  

Miriam Weizenbaum, the board chair for the Center for Justice,  announced the appointment Wednesday, May 3, saying that Wood’s legal background in public interest law, combined with her extensive experience in education and health and human servicesin state government, “makes her an ideal leader for the Center for Justice at a time when basic rights are under significant challenge.” 

Wood was deputy secretary and chief legal counsel to Elizabeth Roberts until Roberts resigned in mid-February as head of the Executive Office of Health and Human Services amid fallout from the UHIP fiasco, the botched roll-out of a computerized Medicaid benefits system. Thousands of Rhode Islanders were left without a wide range of benefits, including from food stamps, health coverage, subsidized child care, and even developmental disability services. At the time Roberts left, Wood was demoted to general counsel.

AshleyG. O’Shea, spokeswoman for OHHS, noted in a statement that Wood has devoted two decades of her life to state service and said, “We wish her the best in her new endeavor.” 

In March, the office of the U.S. Attorney in Providence issued a demand for UHIP documents, saying it is investigating the “allegation that false claims and/or payment for services and/or false statements in support of such payments have been submitted to the U.S. government.“

In a statement May 3, Wood indicated that since the November election, she has been considering a change in career to go back to her roots. As a lawyer in the private sector, her work emphasized civil rights and disability rights. She represented inmates at the Rhode Island Training School and special education students, among others who otherwise might have lacked a legal voice.

Wood joined state government in 1998 as chief of staff at the Rhode Island Department of Education, leaving in 2007 to work as Roberts’ second-in-command after the latter was elected Lieutenant Governor. When Governor Gina Raimondo appointed Roberts as Secretary of Health and Human Services in 2015, Wood followed as deputy secretary and chief legal counsel.

At the end of 2015, when U.S. District Court Judge John J. McConnell, Jr. signaled that he would personally oversee enforcement of the consent decree affecting daytime services for adults with developmental disabilities, Wood took charge of moving the implementation forward.

At that point, the agreement had brought virtually no change to the lives of adults with developmental disabilities since it was signed in April, 2014. By all accounts, Wood moved the implementation into high gear. 

O’Shea, the OHHS spokeswoman, said Wood is turning over her responsibilities in developmental disabilities to other officials, including Dianne Curran, a lawyer who is consent decree coordinator, and Kerri Zanchi, the new director of developmental disabilities. They are in touch with the federal court monitor and the U.S. Department of Justice weekly, according to O’Shea.

The consent decree requires the state replace sheltered workshops and segregated day programs with community-based supports so that adults with developmental disabilities may seek regular jobs and enjoy non-work activities in a more integrated way. The desegregation of services for everyone with disabilities was ordered by the U.S. Supreme Court in the Olmstead decision of 1999, which re-affirmed Title II of the Americans With Disabilities Act. 

 

 

Rebecca Boss Named Director of RI BHDDH

By Gina Macris

Rebecca Boss, who has more than 20 years’ experience in behavioral healthcare and the treatment of substance abuse disorders, has been named Director of the Rhode Island Department of Behavioral  Healthcare, Developmental Disabilities and Hospitals (BHDDH), the state agency she has run in an interim capacity during the last ten months.

Governor Gina Raimondo and Acting Health and Human Services Secretary Anya Radar Wallack announced the appointment Wednesday, May 3. Boss’ appointment must be confirmed by the Senate.

In a statement, Raimondo said that Boss’ “commitment, leadership and vision over the last 13 years” at BHDDH "have been instrumental in moving a diverse department forward to meet the needs of our residents in a constantly changing service environment. I am pleased to have a strong leader with her depth of knowledge and respect from the community serving as the director at BHDDH.”

Boss, 53, previously deputy director of BHDDH, became acting director when the former department chief,  Maria Montanaro, left in June, 2016 after a 17-month tenure.

Boss began her career in residential care for youth and then moved to CODAC Behavioral Healthcare, Inc., where she provided clinical services and served in various managerial positions.  Boss joined BHDDH in 2004 as administrator for behavioral healthcare and was named deputy director in 2014.  

While at BHDDH, she has been recognized locally and nationally for creating innovative programs, including peer support services for emergency room patients who have overdosed.

Boss said she was honored by the appointment. "The Governor and her administration are committed to the populations served by the department,” Boss said. 

RI DD Director Invites Families to Help Overhaul Design of Services With Individual Needs in Mind

Photos by Anne Peters

Photos by Anne Peters

Kerri Zanchi, center, Director of the RI Division of Developmental Disabilities, is flanked by administrators Heather Mincey, left, and Anne LeClerc, right, as she addresses the audience at a public forum in Newport May 2. 

By Gina Macris

Beginning May 10, Rhode Island’s Division of Developmental Disabilities plans to involve the adults it serves, their families, service providers and advocates in a step-by-step process to overhaul the way it does business .

Kerri Zanchi, the new director of the division, told Aquidneck Island residents who attended a public forum May 2 at the Community College of Rhode Island that the initial discussions will inform an effort to re-write the regulations governing developmental disability services to put the needs and wants of its clients front and center. 

The changes have two drivers:

  • A 2014 consent decree requiring the state to correct violations of the Americans With Disabilities Act by providing employment supports and access to non-work supports in the community.
  • A compliance deadline of March, 2019 for implementation of a Medicaid rule on Home and Community Based Services (HCBS), which requires an individualized approach to care, treating individuals with disabilities as full-fledged members of their communities.  

Both the consent decree and the HCBS rule draw their authority from the 1999 Olmstead decision of the U.S. Supreme Court, which amounted to a desegregation order affecting all services for all individuals with disabilities.

 Zanchi used the term “person-centered” to sum up the kind of planning and practices that go into the new inclusive approach.  A. Anthony Antosh, director of the Sherlock Center on Disabilities at Rhode Island College, elaborated.

A. Anthony Antosh

A. Anthony Antosh

“The way the system has worked forever is that someone else controls what people get. We want people with disabilities to get more control of their own lives,” he said. “Resources support part of their lives but not all of their lives,” he said.

He said that in several states, including Texas, Kentucky and North Carolina, faith-based support networks in various communities have resulted in a “dramatically broader network” of personal relationships for individuals with disabilities. “And 80 percent of them have jobs,” Antosh said.

To flesh out the concepts of individualization and integration and how they might work in Rhode Island,  Antosh and Zanchi will co-host a series of discussions to explore the idea and solicit comments throughout the month of May.

The first two sessions will be held in the morning and evening of Wednesday, May 10 at the Sherlock Center. (Details at end of article.)

 “It’s a lot of change. It’s a pivotal time,” Zanchi said. But “if you don’t have a strong person-centered practice, it’s really hard to move the system forward and comply with the consent decree and HCBS.”

Zanchi said she and her staff will pull together comments from all the public sessions and present the results to the public in the early summer, setting the stage for regulatory reform.

Howard Cohen

Howard Cohen

Howard Cohen, whose adult son has developmental disabilities, took a dim view of the current regulations.  While the goal was to “even up the playing field among the agencies” by establishing uniform rates of reimbursement, he said, the regulations resulted in “a lot of resources toward book keeping rather than managing care.” 

And “the last time, the regulations got ramrodded through,” Cohen said, an allusion to the regulatory changes adopted by the General Assembly in 2011 as part of “Project Sustainability.”

Kevin Savage, director of licensing for developmental disability services, said all those with a stake in the regulations – including families – will be invited to participate in writing new ones.

The new regulations will not be aimed at “correcting past mistakes” but will try to conform to the law reflected in the consent decree and in HCBS, he said. The process also is expected to result in 20 percent fewer regulations than there are now, Savage said.

Zanchi emphasized that compliance with HCBS will mean a change in case management, or the formal approval process for allocating resources to each person’s program of services.

Currently social workers, who have an average caseload of 205 clients per person, share the case management responsibilities with provider agencies, she said. But HCBS sees an inherent conflict of interest in providers making decisions about the services they themselves furnish, to the possible detriment of the individualized goals of the client.

Zanchi said some states use third-party case management and others have state employees do the job, with a “firewall” between them and the fiscal arm of state government.  In Rhode Island, changes in case management won’t come until 2018, she said.

She also told family members that the state would explore expanding the options for residential care, an issue of particular concern to older parents in light of a virtual freeze on group home admissions. HCBS expects states will move away from group home residential care.

After the meeting, Zanchi was asked how changes in practice brought about by the new regulations would be funded.

“When we figure out what it (the service system) would look like, then we need to figure out the funding for it,” she said.

During the forum, Dottie Darcy, the mother of an adult with developmental disabilities, wondered aloud how officials would “develop a system, without money, to account for the needs of all the people. At some point funding has to be addressed,” she said.

“I think it’s outrageous” that service providers “can’t keep workers” because they can’t pay enough, Darcy said.

She lamented a lack of organized advocacy with members of the General Assembly on behalf of individuals with developmental disabilities.

Claire Rosenbaum, a member of the Rhode Island Developmental Disabilities Council, said it is in the process of trying to revive its family organization to do exactly the kind of work Darcy described, “but it’s not there yet.”

The first two sessions on “Person-Centered Thinking and Planning” will be Wednesday, May 10, from 10 a.m. to noon and from 6 p.m. to 8 p.m., at the Sherlock Center on Disabilities on the campus of Rhode Island College, 600 Mount Pleasant Ave., Providence. These meetings will be of particular interest to families who direct their own programs of services for family members, but all sessions in the series are open to the public.

Those wishing to attend should RSVP with Claire Rosenbaum by May 8 at 401-456-4732 or crosenbaum@ric.edu

Quarterly RI DD Forum In Newport Tuesday

The quarterly Developmental Disability Community Forum, sponsored by the Rhode Island Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH), will be Tuesday, May 2, from 4 to 6 p.m. in the auditorium of the Newport campus of the Community College of Rhode Island, 1 John Chafee Blvd.

Kerri Zanchi, Director of Developmental Disabilities, and other developmental disabilities administrators host the meeting, according to a BHDDH spokeswoman.  The campus can be reached from Coddington Highway, which is off Route 114.  

 

RI DD Service Providers Could Do Same Job for 13 Percent Less Money, Said 2011 Memo To Assembly

By Gina Macris

This article has been updated.

In a single day in 2011, the Rhode Island General Assembly slashed about $26.5 million, or 12.7 percent, from payments to private agencies which care for adults with developmental disabilities, some of the state’s most vulnerable citizens.

The massive cutback sent the privately-run developmental disability service system into a tailspin from which it has not yet recovered, even though the dollar amount has been restored.

Documents obtained by Developmental Disability News through public records requests indicate that the budget cutback was based on an unsupported assumption that the private agencies could uniformly deliver the same level of service with far less money.

Moreover, the records show how Project Sustainability, a set of regulations designed to assess the needs of persons with developmental disabilities and assign them a dollar value for services, seemed to function instead as an attempt to control spending – albeit with questionable success.

Today the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) spends more than $21 million a year to “supplement” funding authorizations for individual clients made through Project Sustainability. The supplemental payments amount to about ten percent of all the reimbursements the state makes to the private agencies. Much of the supplemental funding occurs when families and providers appeal the funding determinations successfully, making the case that the original authorizations were inadequate to provide needed services.

A spokesman for House Speaker Nicholas Mattiello defends Project Sustainability, saying that it’s brought accountability to disabilities spending.

Larry Berman said that “Project Sustainability changed a system that did not have a consistent payment model, could not provide information about what services were being provided or in what setting, and if any services were actually provided. It created a new billing system that could account for that.”

“All providers are paid uniform rates for the same services,” he said. Previously, each agency negotiated with the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH.) a monthly stipend for a bundle of services for each client.

Since 2011, the General Assembly has added $47 million to services for adults with developmental disabilities, Berman said.

Berman rejected the notion that the General Assembly contributed to conditions which led to a 2014 consent decree with the U.S. Department of Justice and ten years of federal oversight of the state’s developmental disability system, which ends in 2024. 

Findings of the U.S. Department of Justice

In findings that led to the consent decree between the state and federal government, however, the DOJ linked Project Sustainability with violations of the Americans With Disabilities Act (ADA).

It said Project Sustainability restricted individuals’ access to regular jobs and non-work activities in the community – opportunities for choice that are guaranteed under Title II of the ADA.  The U.S. Supreme Court re-affirmed Title II in its 1999 Olmstead decision, saying that individuals with all types of disabilities are entitled to receive services in the least restrictive environment that is therapeutically appropriate. And that environment is presumed to be the community.

In its findings, the DOJ noted that the “precipitous state budget cuts in 2011” exacerbated the problem of retaining qualified staff – a problem that today is described by providers as a “crisis”, despite an incremental pay raise to direct-care workers adopted in the current budget. Workers would get a second small raise in the next fiscal year, according to the budget proposal of Governor Gina Raimondo.

RI Allowed Less Money Than Provider Costs

To understand how the BHDDH budgeting process got more than $20 million off course, a history of Project Sustainability is in order.

In 2011, then-Governor Lincoln Chafee recommended $10 million to $12 million in cuts to developmental disability services, but the leadership of the General Assembly wanted bigger reductions. It first sought to limit eligibility, but backed off when an outside healthcare consultant under contract to BHDDH advised against it, according to a memo obtained through a public records request.

The consultant, Burns & Associates, said restricting eligibility would probably violate the federal “maintenance of effort” requirement for federal Medicaid funding and would not be approved by the Centers for Medicaid and Medicare Services.  All developmental disability services are funded through the federal-state Medicaid program.

Five days after that opinion, dated May 26, 2011, BHDDH sent the General Assembly a memo describing a “methodology” for steep cuts to dozens of reimbursement rates, most of them between 17 and 19 percent below a target rate that was established after a year’s research that included data from the providers themselves on their costs. In undercutting that “target” rate, BHDDH said that the state could not afford to spend more, the memo said.

“We did not reduce our assumption for the level of staffing hours required to serve individuals,” the memo said.

“In other words, we are forcing the providers to stretch their dollars without compromising the level of services to individuals,” said the memo.

Craig Stenning, who was BHDDH director at the time, recently declined all comment for this article and ended a phone conversation with a reporter before any questions could be asked.

The General Assembly doubled Chafee’s recommended reductions in reimbursements on the basis of a  last-minute floor amendment in the House, after the public had been cleared from the gallery of the chamber, early the morning of July 1, the final day of the General Assembly’s regular session that year. The budgeted reduction was $24.5 million, but the actual cut eventually totaled $26.5 million, according to the state’s figures on actual spending.

The vote also established Project Sustainability, the bureaucratic process - still largely in place today – that the DOJ later found violated the civil rights of clients of BHDDH. The primary elements:

  • The Supports Intensity Scale (SIS), a standardized assessment designed to determine needed for an individual to accomplish his or her goalls.
  •  A formula or algorithm developed by Burns & Associates to assign funding to individuals according to one of five different levels or tiers, designated by letters A through E. 
  • A billing system that requires providers to document face-to-face time with clients in 15-minute increments in order for them to be reimbursed for day services.  

Since 2010,  BHDDH and the Executive Office of Human Services (EOHHS) have paid Burns & Associates about $1.4 million to introduce Project Sustainability, develop the equation, or algorithm, and monitor its use.

DOJ Cited "Seeming Conflict of Interest"

In challenging the state’s treatment of persons with disabilities in 2014, the Department of Justice found, at a minimum, “a seeming conflict of interest” in the way Rhode Island used the SIS as a “resource allocation tool”, because BHDDH both administered the assessment and determined the budgets.

The DOJ findings continued:

“The need to keep consumers’ resource allocations within budget may influence staff to administer the SIS in a way that reaches the pre-determined budgetary result.”

“Numerous persons stated that this lack of neutrality, and apparent tension between the need to assess the full spectrum of an individual’s support needs and state efforts to cut costs, has negatively. impacted the resources individually allocated to people with I/DD (intellectual or developmental disabilities “Further,” the DOJ said, “we received considerable feedback from parents, family members, advocates, direct support staff, and providers that the individuals administering the SIS lack the training, qualification, or experience working with individuals with I/DD necessary to make resource allocation decisions on behalf of individuals with I/DD.”  

The DOJ also said that “we find that several formative practical and procedural barriers exist under Project Sustainability that contribute to individuals’ inability to access the resources, including funding allocations, that they need to purchase services like supported employment and integrated day planning.”

And the department found inflexibility in the requirement that workers be “face to face” with clients for their employers to receive reimbursement for services. Through the consent decree, the “face to face” provision has been eliminated in a pilot program to help adults with developmental disabilities seek regular jobs in the community.

Families and service providers routinely appealed adverse funding allocations, and many of them were successful, resulting in supplemental payments for a year. But the following year, they received notice that the supplemental payments would be withdrawn, and the appeal process began all over again.

Until Stenning left office in 2015, parents and service providers were denied copies of the actual SIS scores. Some parents have said BHDDH officials told them the questionnaires, developed by the American Association on Intellectual and Developmental Disabilities (AAIDD), could not be released because they contained private propriety information.

That’s changed. Today developmental disability officials have acknowledged that the completed questionnaires are personal health care records that must be made available to patients or their guardians, according to federal law. BHDDH has never released the funding formula. 

Parents also have complained publicly that social workers administering the interviews either argued with them and with providers about their responses or that they wrote down scores different from the ones offered by family members and providers.

AAIDD Defends SIS

Margaret Nygren, executive director of AAIDD,  which created the SIS, said it is a “well-established, scientifically valid, replicable tool” designed to measure support needs, and those who administer it must complete a “very rigorous training program” that includes an “annual recheck to make sure they are not drifting what we are training them to do.”

“It is certainly possible someone could get through the training and not apply what they’ve learned,” she said. “It’s not the kind of thing we’d like to see happen,” Nygren said. But she suggested it would be the rare exception rather than the rule.

In December, 2015, Wayne Hannon, then Deputy Secretary of EOHHS for Administration, tried to get a handle on the amount of money that BHDDH spent on supplemental payments outside the regular funding authorization process. These supplemental payments are not reflected as a separate line item in the budget.

Hannon asked Burns & Associates to figure out how much money the state could save if all the supplemental payments were eliminated. In a nine-page memo, the consultants concluded that the state could save a total of $13 million if all the supplemental payments were curtailed, but they stopped short of recommending such a move, saying they did not have enough information to know if the supplements were in fact warranted or used.

In the analysis that led to the conclusion, Burns & Associates' figures suggested there was a great deal of variability in SIS scores, even though the needs of particular individuals usually can be expected to remain fairly constant over time. For example, about 40 percent of those who had been assessed twice over a three-year period, or 726 of 1,798 individuals, had a change in funding levels the second time around, according to the consultants. In a smaller sample of 599 individuals, Burns & Associates said about 54 percent of funding authorizations decreased and the remainder increased.

AAIDD’s Nygren, who saw the memo, said the changes have to do with the funding algorithm created by the state, not the SIS itself. A small change in SIS scores could result in a change in funding, depending on how the formula is constructed, she said. BHDDH has not responded to requests for the formula. 

SIS And Funding Formula Updated    

The extent to which re-assessments generated changes in funding authorizations, whether up or down, raised eyebrows when they came to the attention of state developmental disability officials in the summer of 2016. 

At the time, the state had just promulgated a new policy declaring that the SIS would be administered solely on the basis of an individual’s need for support, in response to a federal court order that had been issued to enforce the consent decree.

 Meanwhile, Jane Gallivan, an experienced administrator of developmental disability services, had just been hired as a consultant and interim director of developmental disabilities. 

 Gallivan later recommended the state switch to an updated version of the SIS, which she said she believed would be more accurate in capturing clients’ needs, particularly for those requiring behavioral and medical supports. Burns & Associates also was re-hired to re-tool the funding formula.

The conversion to the so-called SIS-A included the retraining of all the interviewers and was launched in November, 2016, in the hope that the number of appeals – and supplemental payments – will come down.  Initial reports on the results of the SIS-A indicate that overall, they result in higher funding authorizations, according to developmental disability officials.

In the meantime, the current BHDDH budget allows for $18.5 million for supplemental payments, but in the first three quarters of the fiscal year the department went $3 million over that authorization, according to a recent House fiscal presentation. And Governor Raimondo seeks $22 million in supplemental payments in the fiscal year beginning July 1.

Taking in these numbers on overruns in the supplemental payments at a recent Senate Finance Committee hearing, Sen. Louis DiPalma told BHDDH officials to “look at the equation” that assigns funding authorizations to adults with developmental disabilities.

DiPalma and Rep. Teresa A. Tanzi, D-Narragansett and South Kingstown, have sponsored companion legislation that would make developmental disability caseload part of the semi-annual caseload estimating conference, used by both the executive and legislative branches of government to gauge expenses for Medicaid and public assistance.

DiPalma also has sponsored a separate bill that would require the SIS to be administered by an independent third party to avoid even the appearance of a conflict of interest.

AAIDD recommends that states take steps to ensure “conflict-free” administration of the SIS, a point noted by the DOJ in its 2014 findings.

Court Monitor Has A Say

The independent court monitor in the implementation of the consent decree would go a step further and uncouple the SIS from the funding mechanism altogether.

The monitor’s reports to the U.S. District Court say the SIS should be used for “person-centered planning,” a bedrock principle of the consent decree, which puts the focus on the needs and preferences of individuals, rather than trying to fit their services into a pre-determined menu of choices, as is now the case.

The monitor, Charles Moseley has said the SIS should be used as a guide for developing an individualized program of services, and then funding should be applied to deliver those services. Currently, the funding defines the scope of the services.

Moseley has put the state on a quarterly schedule of progress reports toward implementing “person-centered planning.”                

The changes have as-yet undefined budget implications for the state in the future.

Tom Kane, CEO of AccessPoint RI, a provider, explained to a subcommittee of the House Finance Committee in a recent hearing that it will be inherently more expensive to provide services in the community than it has been historically to have one person working with ten clients in a room in a sheltered workshop or day program.

There is now only slightly more in the private developmental disability system than there was in 2010, he said.  (The General Assembly has approved $218.3 million in reimbursements to private providers for the current budget cycle, or $10.2 million more than was spent in the fiscal year that ended June 30, 2010, according to state budget figures.)

“There are more people in the system” and “the requirements of the consent decree are far more extensive than the kind of supports we were providing,”  Kane said.

He said he’s “definitely in favor” of Governor Gina Raimondo’s budget proposal, which would add $10 million to the system over the next 15 months, but he believes the available funding is only half of what is needed to stabilize private provider agencies and ensuring their clients get the “services they deserve and require.”

 

 

RI Legislation Aims For Greater Accuracy And Transparency In Budgeting BHDDH, DCYF Costs

By Gina Macris

Companion bills in the General Assembly would require cost estimates for services to adults with developmental disabilities and children in state custody to become part of Rhode Island’s semi-annual Caseload Estimating Conference, a key budgeting guide. 

The bills, sponsored by Sen. Louis DiPalma, D-Middletown; and Rep. Teresa A. Tanzi, D-Narragansett and South Kingstown; specify that the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) and the Department of Children, Youth, and Families. (DCYF) would submit all their service costs, funded through Medicaid, to the Caseload Estimating Conference. 

Both BHDDH and DCYF have been plagued by chronic deficits. At BHDDH, a 2014 federal consent decree enforcing the 1999 Olmstead decision of the U.S. Supreme Court is putting additional demands on the developmental disabilities budget.

The executive branch prepares BHDDH budgets on the basis of “target” figures set by the Office of Management and Budget. In the past, BHDDH officials have said that the targets are not enough to cover actual service costs. This year, Governor Gina Raimondo accepted BHDDH figures in submitting her budget proposal to the General Assembly.

In a statement, DiPalma said, “The legislation is about honest and transparent budgeting. We need an accurate accounting of how many individuals we are serving in these vital programs, so that our budget reflects the associated costs, or makes program adjustments, or both.” 

He said about 3,000 children and teenagers are in DCYF care and roughly 4,000 adults with developmental disabilities depend on services from BHDDH.

Tanzi said, “Accurate caseloads will ensure the General Assembly is able to fully understand and appreciate the budgetary requirements of the agency to meet their obligations to our state’s vulnerable children and families. This legislation is about caring for our most vulnerable citizens but doing so in the most responsible way for the taxpayers.”

Medicaid accounts for about 31 percent of the state’s budget, according to the House Fiscal Office. That is roughly $3 billion in expenses annually, with each state dollar matched by slightly more than one federal dollar. Of all Medicaid funds, BHDDH spends 12.3 percent of and DCYF accounts for 1.4 percent.

In addition to adding BHDDH and DCYF to the Caseload Estimating Conference, DiPalma’s and Tanzi’s bills spell out the managed care reporting requirements of EOHHS in greater detail.

Current law allows agencies other than DHS and EOHHS to participate in the Caseload Estimating Conference but does not require them to contribute data.  It is not clear why DCYF and BHDDH have not been included in the Caseload Estimating Conference in the past.

The Caseload Estimating Conference runs back-to-back with the Revenue Estimating Conference in November and May. There are three principals; the House and Senate fiscal advisors and the state budget officer, who reach agreement through consensus on the latest estimates for revenue and for expenses in the human services, including Medicaid and a general public assistance program of about $1.5 million.

The governor relies, in part, on the November conference report to prepare the budget that is submitted to the General Assembly in January. The House and Senate use the results of the May conference as a basis for finalizing budget negotiations. 

The bills: S 0266 and H 5841

 

Budget Testimony: Need For DD Raises Critical, Stable Services Demand Double Current Funding

tom Kane                         RI capitol tv Image

tom Kane                         RI capitol tv Image

By Gina Macris 

This article has been updated. 

As others had done before him, Tom Kane told members of the House Finance Committee that he “could not stress enough” the importance of the General Assembly approving an additional $6.1 million to lift the poverty-level pay of some 4,000 front-line employees of private agencies under contract with the state to care for adults with developmental disabilities.  

At the same time, Kane, CEO of AccessPoint RI, one of those private agencies, said in a hearing April 11 that the overall funding for developmental disabilities is only about 50 percent of what is needed for service providers to regain the financial stability they once had and help their clients receive the supports they need and deserve. 

All together Governor Gina Raimondo seeks General Assembly approval for raising the currently enacted developmental disability budget of $246.2 million by $10.5 million over the next 14 months, with $4.4 million of the increase applied before June 30. Another $6.1 million would be added for the fiscal year beginning July 1, for a total of $256.7 in the fiscal year ending June 30, 2018.

Kane explained to members of the Finance Committee’s Human Services Subcommittee, led by Rep. Teresa A. Tanzi, D-South Kingstown and Narragansett), the different kinds of pitfalls he saw in Raimondo’s attempts to offset the cost of the raises by cutting expenses in other areas – or not covering some necessary spending at all.  

For example, Kane said, AccessPoint had a $107,000 increase in health insurance rates this year. ”There is no money” to cover that cost, he said. “We spend almost $1.2 million in health insurance for 158 people,” he said.  Kane said he could not expect his employees, many of whom make less than $11 an hour, to contribute more to health insurance, so other adjustments were made. He did not elaborate. 

“But at some point there’s going to be a collision between all these additional costs” and direct care workers, Kane said. In written remarks, he said the “cost of other insurances, building maintenance, rent, vehicles, fuel and office supplies continue to increase, adding to the financial strain on organizations. These costs should not be seen as extraneous. They directly relate to our ability to focus our full attention on good quality service provision,” Kane said.

He also zeroed in on some line-item savings that Raimondo has budgeted to offset the cost of the second consecutive raise for direct care workers, particularly the plan to reduce group home costs by $2.1 million in state funds. That ongoing effort, driven by economic and policy considerations, aims to move group home residents to less costly shared living arrangements in private homes - a process that requires clients to actively agree to the change. 

During the transition, there must be a consideration for maintaining the living arrangements of the individuals left behind in the group homes, Kane said, recalling a case in which two of four people in one AccessPoint home opted for shared living. Because the agency could not afford to keep the house operating with only two residents, it sought supplemental funds from the Division of Developmental Disabilities for a few months to cover outstanding expenses while it figured out its long-range plan, Kane said. The home finally closed, he said.

The example illustrates how, during a transition, “you are balancing two systems at the same time, “ Kane said.

“If you don’t pay attention to the current system with the same amount of zeal as the new system, people will get lost,” he said.

In fact, the state so far has been unable to realize much savings from the emphasis on shared living, only $100,000 of a target of $2.6 million in state funds in the current fiscal year, according to officials of the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH).

Since last July, a total of 48 group home residents have committed to shared living. That figure is 18 shy of a target of 66 individuals for the fiscal year ending June 30.

Kerri Zanchi, Director of the Division of Developmental Disabilities, said that of the 48, 28 have moved since December, when the division began addressing issues that were barriers to shared living arrangements, like a need for physical modifications to some houses to make them more easily accessible, as well as extra medical and behavioral supports needed in the host homes. She said the division is also considering a range of other alternatives to group home living.

Ultimately, Kane said, a budget is a “representation of the values of our state.”  The care for people with disabilities and the salaries paid to caregivers either will reflect the dignity and respect afforded valuable members of society, or they won’t, Kane said.

 “I understand you have a lot of very difficult decisions to make,” he told the legislators, “and the numbers (revenues) aren’t looking great this year, which are going to make all those decisions even tougher.”

But Kane asked them to look at historical spending for developmental disability services, which he said are now only $9 million more than they were in 2010. In the meantime the demands of a 2014 federal consent decree with the U.S. Department of Justice, as well as new Medicaid rules for Home and Community Based Services (HCBS), make the job of supporting individuals with disabilities much more complex and expensive, he said. 

Traditionally, he said, support has been provided in “congregate” settings, or facilities “where you have groups of ten people with one staff person. “

“Under the consent decree they have to be either at a job or in the community,” he said. Those settings demand ratios of one staffer for each client, or no more than three clients, depending on the circumstances, Kane said.  In addition, the consent decree requires job coaches to be trained to a specific certification. and trained workers will demand higher pay, Kane said.t

The latest statistics indicate the current average pay for direct care workers is $11.14 an hour, before taxes, a figure that reflects a raise of about 32 cents effective last July 1, according to Donna Martin, executive director of the Community Provider Network of Rhode Island (CPNRI), a trade association which represents 25 of some three dozen private providers of developmental disability services.

The hourly reimbursement rate the state pays the employers for direct care workers is $11.91, which includes both wages and most – but not all – of employers’ actual costs for overhead and fringe benefits. That figure is still lower than the hourly reimbursement rate of $12.03 the General Assembly authorized in July, 2011  at the same time it cut a total of $24 million for private provider services, according to a chart prepared by James Parisi of the Rhode Island Federation of Teachers and Health Professionals.

In October, 2011, three months after the General Assembly acted, BHDDH reduced the actual reimbursement rate to $10.66 an hour, according to Parisi’s calculations.  Since then, the rate has been climbing incrementally to its current level of $11.91.

Parisi represents workers at the Trudeau Center in Warwick, where the starting salary is now $10.71 an hour.

Tori Flis, a service coordinator at one agency, which she did not name, said that even though there has been a slight increase in wages in the last year, the turnover is “just as high.”

Martin, of CPNRI, put the average turnover at one out of three workers a year, or 33 percent, although it varies from one agency to another.  Employers are unable to fill one out of six vacancies, and it costs an agency an average of $4900 every time it must search for a replacement and train a new hire, Martin said.  

Markella Carnavalle, who works at Trudeau, described the impact that turnover can have on individuals with developmental disabilities.

One client, who had grown attached to a worker who had to leave, was “crying for weeks,” she said.

That person had behavioral issues and didn’t want to work or eat, Carnavalle said. The client believed the worker left because “they didn’t want to be with me,” Carnavalle said, but “you can’t say the person needed more money. They don’t look at it that way.”

“You become a part of their lives and they become a part of yours” over time, Carnavalle said.

Flis, meanwhile, said the workers she supervises all have two and three jobs to make ends meet. Some work as many as three consecutive 12-hour shifts at different agencies – a total of 48 hours straight.

Those kinds of conditions lead to burnout, abuse and neglect, Flis said. The only reason she can afford to work one job at Trudeau is that she is married to a teacher who has a good salary and fringe benefits, including a pension, Flis said.

In another part of the current budget,  BHDDH officials and the legislators disagreed on whether there is funding for a developmental disabilities ombudsman, a position approved by the General Assembly last year after a woman died in a state-run group home. The state-run residential system is separate from the private system. 

The legislators and a member of the House fiscal advisory staff, Linda Haley,  said a total of $170,000 had been included in the BHDDH budget for the position.

Representing BHDDH, Christopher Feisthamel, the chief financial officer, and Zanchi, the developmental disabilities director, both said they understood it was an “unfunded mandate.”  Haley and BHDDH officials spoke informally after the hearing but reached no agreement on the status of the position.

(This article has been updated to correct the total cost of health insurance for AccessPoint RI, which is $1.2 million, not $12 million, according to CEO Tom Kane.)

 

RI Senate Finance Hearing Highlights Cost Overruns, Challenges, in DD Budgets

By Gina Macris 

Cost overruns are a recurring theme for Rhode Island’s Division of Developmental Disabilities, with expenses for mandated services running  about $4.4 million over budget in the current fiscal year, while $6 million in projected savings group home-related costs  are proving elusive. 

Overall, Governor Gina Raimondo seeks to close out the current fiscal year with a total of $250.6 million in developmental disabilities funding and requests $256.7 million for the fiscal year beginning July 1. Taken together, the $4.4 million increase she has requested in current spending and the proposed increase of nearly $6.1 million for the next fiscal year run almost $10.5 million more than the existing budget authorized by the General Assembly - $246.2 million.   

At a budget hearing April 4, members of the Senate Finance Committee seemed to understand the challenges faced by the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH), but Sen. Louis DiPalma, D-Middletown, still asked officials for more realistic budget figures in the future.

One case in point was $100,000 in actual savings in costs related to group homes, rather than the $2.6 million cut in state revenue that originally had been projected during the current fiscal year. 

The savings are associated with a shift in residential care from group homes to less costly shared living arrangements in private homes scattered throughout the state, a change that is driven both by budgetary constraints and federal Medicaid rules.

In April of 2016, BHDDH said it would move a total of 100 individuals with developmental disabilities from group homes to shared living by the end of the fiscal year June 30, but it achieved only 27 transfers, DiPalma said. 

For the current fiscal year, the goal is 66 moves. Noting the $2.5 million gap between projected and actual savings, DiPalma said he would have recommended a target of 45 transfers. 

But “the budget is what it is,” he said.

“If you want to move someone, they have to say yes,” DiPalma said. “If they say no, they stay where they are.”

Rebecca Boss, the acting BHDDH director, said, “you are right about the challenges.”

But she added that BHDDH already has 45 commitments from group home residents who have agreed to go into shared living.  

A year ago, the Division of Developmental Disabilities had not yet done a “deep dive” into the shared living program to understand what needed to be done to make it more attractive to consumers, Boss said.  She suggested that since then, officials have identified some issues that have prevented more rapid expansion of the program, but Boss was not specific.

Pressed for more details, she said they would be forthcoming in a month – May 5.  At last count in December, there were 333 residents in shared living arrangements and 1,283 in state or privately-run group homes, according to a Senate fiscal analysis. 

In the next budget, beginning July 1, BHDDH has proposed saving $3.9 million in state revenue related to movement out of group homes, but Boss said she could not guarantee that the department would meet its future budget targets. 

DiPalma also warned Boss that a similar transition away from group home care for children in state custody has shown that, for a time, residential costs actually increase because the state must maintain group housing while it builds its community-based network of home care.

A big part of the savings plan in the next fiscal year is to close a total of five group homes run directly by the state through Rhode Island Community Living and Supports (RICLAS), a division of BHDDH, including two in July, one in October, and two in January, 2018. 

Jim Cenerini, legislative affairs and political action coordinator for the American Federation of State, County and Municipal Employees, Council 94, (AFSCME) expressed concern about the closures, which would move 30 residents, or 20 percent of the 150 people in the state-run system, into private care.

He said BHDDH officials have not talked about the closings with the union, which represents several hundred workers staffing the homes. 

Boss said BHDDH officials would be “more than happy” to sit down with the union.

Cenerini said, “We believe RICLAS provides a very vital service as a provider of last resort.”  He maintained that RICLAS residents are not ready to go to shared living arrangements. 

Two years ago, the union negotiated many cost-saving concessions with BHDDH that gave the department much more flexibility in staffing, but BHDDH hasn’t implemented any of the reforms except to hire seasonal workers who are ineligible for benefits, Cenerini said.

RICLAS workers are state employees, many of whom make at least double the poverty-level wages of workers in a parallel system of private agencies under contract with the state to provide most of the developmental disability services.

DiPalma told Cenerini that the “train has left the station” on the shift from congregate care to settings that are more like home. 

The change in Medicaid rules have been influenced by the 1999 Olmstead decision of the U.S. Supreme Court, which ruled that the Americans With Disabilities Act requires services for all people with disabilities to be available in the least restrictive environment that is therapeutically appropriate. That environment is presumed to be the community for both daytime and residential services.

“It’s up to us to figure out how to move those people into the community,” DiPalma said, and “how to facilitate the  workers at RICLAS to do other things.”  The conversation should not be about residents remaining in RICLAS homes “because this is what we have,” DiPalma said.

Cenerini emphasized that RICLAS offers continuity of care, something the private system lacks because of low wages and high turnover. “I don’t want to see the destruction of my union,” he said.

About 20 RICLAS workers also host adults with developmental disabilities in their homes as shared living providers, Cenerini said.

One reason BHDDH has a hard time meeting budget targets, Cenerini said, is that “they are asked to do so much with so little.”

Testimony at the hearing reiterated support for a $6 million wage increase in the fiscal year beginning July 1 for private-sector direct care workers, who now earn an average of about $11.14 an hour, according to the latest figures provided by Donna Martin, executive director of the Community Provider Network of Rhode Island. 

The current hourly average of $11.14 is only slightly higher than the federal poverty level of $9.82 an hour for a single parent household with two children, a profile that represents the typical direct care worker in developmental disability services, she said.

About one in three workers a year leave private agencies, many of them for slightly higher pay in a local market or to work at RICLAS, where they are paid an additional $5 an hour to do the same work, Martin said in written testimony she submitted to the committee.

The budget now in effect gave private-sector workers their first increase in a decade, putting an additional 36 cents an hour in their pockets, before taxes.  

DiPalma has sponsored a resolution that would increase the pay of these workers to $15 an hour in five years – the fiscal year beginning July 1, 2021. (In the House, State Rep. Teresa A. Tanzi has sponsored a similar resolution, which would achieve a $15 hourly rate in three years – by July 1, 2019.)

DiPalma’s and Tanzi’s resolutions also urge the legislature to link future annual raises to the consumer price index so that pay stays ahead of the minimum wage, currently $9.60 an hour. Governor Raimondo has proposed increasing the minimum wage to $10.50 on July 1.   The Senate Finance Committee held a separate hearing on wage increases May 21. (Click here to read related article.)

DiPalma highlighted another feature of the budget that seeks to add a total of $500,000, or $250,000 in state funds, to a supplemental allocation for developmental disability services that he said runs about $20 million to $22 million annually.

These supplemental funds are used when those receiving developmental disability services believe their individual budgets are inadequate and make a successful argument for more money, or when they need a short term boost in care triggered by events like a discharge from a hospital, according to Kerri Zanchi, Director of the Division of Developmental Disabilities.

DiPalma said he concurred with the use of funds to cover short-term extra needs, but he believed $22 million a year, or 10 percent of all service appropriations -  was too high for supplemental appropriations. 

 He called on BHDDH to change the equation that assigns individual funding.

Zanchi said the individual budgets are assigned on the basis of a standardized assessment of an individual’s need called the Supports Intensity Scale. In November, Rhode Island moved to an updated version of the assessment believed to be more accurate and began tracking the results to see if the number of appeals decline in the long run.

DiPalma noted that the current arrangement favors those who have the strongest advocates on their behalf.

Another hearing on budget is scheduled before a subcommittee of the House Finance Committee on Tuesday, April 11, in Room 35 of the State House at the conclusion of that day’s full House session. 

 

 

RI Advocates In Action To Host Information Session

Rhode Island’s Advocates in Action, a non-profit educational organization aimed at empowering adults with disabilities to advocate for themselves, will sponsor a free informational session Thursday, March 30,  on “Frequently Asked Questions” about federal and state-funded Medicaid services offered through the Division of Developmental Disabilities.

Members of the organization’s current leadership class have surveyed recipients of developmental disability services on their primary concerns and will share the top questions and answers during the session, from 7 to 9 pm. at the Crowne Plaza Hotel in Warwick, according to a spokeswoman. The leadership class includes recipients of developmental disability services and individuals who support them. 

Topics on the agenda include applying for services, finding a place to live, looking for a job, planning for supports, appealing decisions made by the state, and living in the community.

Pre-registration is not required, but those planning to attend are asked to RSVP by phone to 877-532-5543 (toll free) or by email to aina@advocatesinaction.org

 

Low Wages Create Labor Shortage in RI DD Services; Advocates Testify for Higher Pay

By Gina Macris

Low wages for workers who provide direct care for adults with disabilities in Rhode Island have led to such a crisis that some agencies lose 80 percent of their front-line staff within six months, although the average annual turnover rate is 33 percent.

To fill the gap, their employers spend millions of dollars in overtime and in training new hires, only to lose them again.

Advocates for the developmental disability service system spelled out the consequences of poverty-level wages for direct care workers during a hearing before the Senate Finance Committee March 21.

A Rhode Island College expert submitted written testimony which said that an underpaid workforce results in instability, anxiety, and a diminished quality of life in the people it serves. 

The new developmental disabilities director, Kerri Zanchi, also linked the stability of the workforce to the quality of services and outcomes for the people it serves. 

Governor Gina Raimondo has proposed adding $6.1 million for raises to direct care workers in the budget beginning July 1. If it passes, it would provide the second annual raise –albeit a modest one – for some 4,000 part-time and full-time caregivers.

The first raise was enacted under pressure from federal enforcement of a 2014 consent decree. The $5-million line item added about 36 cents an hour for front-line caregivers, giving them an average of $11.18 an hour retroactive to July 1, 2016, according to Sen. Louis DiPalma, D-Middletown, the first vice-chairman of the Senate Finance Committee.

DiPalma is leading a drive to increase the average wage for direct care workers and home health care workers to $15 an hour by July 1, 2021. Testimony during the hearing indicated that Massachusetts is on track to reach that goal in 2018.

DiPalma also noted that Rhode Island’s minimum wage rose 30 percent between 2012 and 2016, from $7.40 an hour to the current $9.60 an hour, while the average pay for direct care workers increased 1.6 percent during the same period.

Governor Raimondo is seeking a 90-cent increase in the minimum wage, or $10.50 an hour, for the fiscal year that begins July 1.  

The interstate disparity in wages, compounded by the fact that many Rhode Island residents can just as easily work in Massachusetts as in their home state, puts the developmental disability system at a distinct disadvantage in competing for employees.

Rhode Island’s system is “economically inefficient,” said Jim Parisi, spokesman for the Rhode Island Federation of Teachers and Health Professionals, who represents workers at Trudeau Memorial Center, one of about three dozen private developmental disability service providers in the state.

Donna Martin, director of the Community Provider Network of Rhode Island (CPNRI), said that an average of about 16 percent of jobs go unfilled, forcing employers to use overtime to fill vacant shifts, particularly in situations where safety requires a certain minimum level of staffing.

In some agencies the job vacancy rate is as high as 25 percent, according to Rebecca Boss, the acting director of the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals.

Martin, meanwhile, said reports from 18 of the 25 CPNRI member organizations indicate they spend a $2 million a year on overtime, suggesting that the total statewide could be higher. Turnover, which includes training new hires, costs an average of about $4900 per person, she said.

A raise this year is expected to be slightly bigger than the average of about 36 cents an hour enacted in the current year. The exact amount is difficult to calculate in advance because the rate the state pays providers reflects wages and some, but not all, overhead costs, Martin said. And overhead costs vary from one provider to another.

The workforce crisis is the biggest single issue her membership faces, Martin noted.  Data she submitted to the committee indicated that the demand for staffers who provide direct support of adults with developmental disabilities is expected to grow 38 percent by 2022.

In written testimony, A. Anthony Antosh, director of the Sherlock Center on Disabilities at Rhode Island College, linked the labor shortage to a diminished quality of service for individuals with disabilities – an issue which is at the center of ongoing enforcement efforts of the 2014 federal consent decree.

With some agencies losing more than 80 percent of new hires within six months, Antosh said, workers cite low pay and the complexity of the work as the chief reasons they leave. They must work two or three jobs simply to make ends meet, he said.

A growing body of research documents that a stable, high quality direct support staff produces positive results in the population it supports. Those benefits include “increased personal competence, increased employment, increased social networks and social capital and increased satisfaction with life,” Antosh wrote.

“A direct support workforce destabilized by low wages, limited opportunities for professional development and a lack of a career ladder results in instability and anxiety in the lives of the people they support,” Antosh said.

Those who depend on services have “decreased opportunities for community connection, decreased employment, and a general decrease in quality of service,” Antosh said.

Quality service, with access to community-based employment and non-work activities, are a key goal of the 2014 consent decree and a subsequent court order, which aim to enforce the 1999 Olmstead decision of the U.S. Supreme Court.

That ruling re-affirmed Title II of the Americans With Disabilities Act, which says that individuals with disabilities are entitled to receive services in the least restrictive environment that is therapeutically appropriate.The decision presumes that the community is the least restrictive environment. 

RI DSP Graphic 1 3-22-17

At right are submitted to the the Senate Finance Committee March 22 by the Community Provider Network of Rhode Island, a trade association of 25 private agencies that provide services to adults with developmental disabilities. In the graphic, DSP stands for "Direct Support Professional," the title given to front-line workers. The average hourly wage does not include raises enacted  that took effect July 1, 2016.  

Judge McConnell: Consent Decree Progress Should Not Distract State From Long Road Ahead

By Gina Macris

U.S. District Court Judge John J. McConnell, Jr. says Rhode Island has made considerable progress in laying the groundwork to comply with a three year-old consent decree aimed at improving the lives of adults with developmental disabilities.

But that progress should not distract all concerned from “how far we have to go,” McConnell said.

In a quarterly review of the case on March 10, McConnell called attention to the remarks of the U.S. Department of Justice (DOJ), Nicole Kovite Zeitler, who spoke of the state’s progress and the unrealized potential of the consent decree to transform lives for a generation. 

“From where we were a year ago the work the state has done is commendable,” Zeitler said, “but the ultimate goal of the 2014 agreement is the transformation of services” for adults with developmental disabilities.

“These people have goals, just like anyone else,” Zeitler said.

Yet, a recent review of the day services typically offered adults with disabilities conveys a lack of purpose.  “There’s a feeling that attending a day program is just something people do,” she said.

The DOJ is committed to ultimate compliance with the consent decree, Zeitler said, but the decree means more than financing plans for services.  

Rather, the effort must put individuals’ goals and dreams at the center of the process and incorporate ongoing quality assurance practices to ensure continued compliance with the consent decree, she said.

Zeitler referred to a review of the day services of 21 adults by consultant William H. Ashe that was incorporated into a recent report to the court by the independent monitor in the case, Charles Moseley.

In many cases, Ashe found the signposts of individualized or “person-centered’” planning absent.  The service planning process required by the state  ”feels rigid and automatic,” Ashe noted. ”The ISP (individual service plan) for a person this year may often look remarkably similar to the one that was done last year. The funding that agencies receive is based on assessed ‘functioning level’ and not based upon what people may want or actually need,” Ashe said.

”Agencies are often in a situation where their staffing levels prohibit them from individualizing supports to the extent that is necessary to really implement services that are based upon real choice,” he said.

The monitor, Moseley, has given the state notice in a recent report to the court that he wants changes in the funding and planning process that meet the “person-centered” requirements of the consent decree. The state must give him progress reports quarterly, beginning April 1.

McConnell asked why the percentage of young adults finding employment was so low – only 22 percent. Moseley said the percentage dipped as the state complied with a request he made last fall to fully identify all eligible individuals who have left school since 2013.

The count of the so-called “youth exit” group initially stood at 151 young adults with developmental disabilities. By November the figure had jumped to 501, and, now is 516, Mary Madden, the state’s consent decree coordinator, told the court.  

The number of young adults with jobs is 109, according to the latest reports of the state to the monitor.

Referring to a provision of the consent decree decree which requires “all” young people to have jobs the same year they leave school,  McConnell asked why the employmentbenchmark for young adults is so “aggressive”.

Zeitler said the goals were designed that way because the generation going through school now is learning the skills necessary to prepare for adult life.

These young people have the most to gain from the consent decree and the most to lose without it, Zeitler said. They know their own potential, but under the old system they would spend years in isolation from the larger community, she said.

The 2014 consent decree settled findings of the DOJ that the state relied on sheltered workshops and segregated day programs in violation of Title II of the Americans With Disabilities Act, which was reaffirmed in the Olmstead decision of the U.S. Supreme Court in 1999. The Olmstead decision said that individuals with disabilities have a right to receive services in the least restrictive environment that is therapeutically appropriate, which is presumed to be the community.

The Rhode Island decree is not the first Olmstead enforcement action in the country, but the first one that addresses daytime programs that segregate adults with disabilities. Because they ard the DOJ.

A year ago, the state had made virtually no effort to implement the consent decree and lacked the financing, data, and staff to respond to requests made by the monitor. After an evidentiary hearing in April, McConnell issued a multi-faceted order which put the state on short deadlines for responding to discrete tasks – or face contempt proceedings.

So far, the order has brought results:  $11 million more in federal-state Medicaid funding, a larger staff to work on policy changes, and better cooperation and communication among the agencies responsible for implementing the agreement – the Department of Behavioral Healthcare, Developmental Disabilities, the Office of Rehabilitation Services, and the Rhode Island Department of Education.

One part of McConnell’s order has led to an incentive program for service providers to find jobs for their clients and help them stay employed. That program has placed 20 new hires since January, although Zeitler said the state needs to have “frank discussions” with service providers about continued gaps in job placement targets in two of three segmentsof the population represented by the consent decree.    

Moseley, the monitor, has followed McConnell’s lead in adopting short-term deadlines for specific tasks he has assigned the state. One such inquiry led to the identification in November of young adults with autism or multiple disabilities who hadn’t previously been counted as part of the consent decree population. That’s what boosted the so-called “youth exit” population to more than 500.

More recently, Moseley has enumerated dozens of tasks relating to the individualization of services, better internal quality improvement efforts, methods of funding, employment, and other consent-decree issues, along with short-term deadlines for responses.

Jennifer Wood, General Counsel to the Secretary of Health and Human Services, the head of the state’s response to the consent decree, said Rhode Island now has the bureaucratic “infrastructure” to delve into the actual service delivery system.  “Person-centered planning is at the heart of that,” she said.

The next court review will be scheduled for mid-July, but McConnell said he wants to receive interim progress reports from Moseley.  McConnell also noted that from time to time, he receives letters from parents and makes them part of the case file, which is a public record. 

Related articles: 

"RI Still Lags in DD Consent Decree Compliance, But Shows Progress in Number of Job Placements"

"Monitor Seeks Changes In BHDDH Funding Methods to Satisfy Consent Decree"

"Monitor Wants Mountains of Details to Push Compliance With RI Olmstead Consent Decree"

RI Still Lags in DD Consent Decree Compliance, But Shows Progress In Number of Job Placements

By Gina Macris

Rhode Island appears to be meeting almost 60 percent of court-mandated goals in placing adults with developmental disabilities in jobs paying at least minimum wage, according to newly-released figures which track the state’s progress through Sept. 30 of 2016.

The state had found jobs for 363 individuals, or 58.8 percent of the 651 placements required at that time, according to compliance figures the state submitted to an independent court monitor in accordance with a 2014 federal consent decree that requires community-based day services to correct violations of the Americans with Disabilities Act.

For one group of individuals protected by the consent decree- those in segregated day programs – the state has made triple the number of required placements. But for other groups, the going has been slower. Only about 22 percent of special education students "exiting" high school got jobs, far short of the 100 percent employment goal. The figures for a third group - adults who had been in so-called sheltered workshops – show 87 percent compliance with the benchmark for job placement at the end of September.

Source: State of Rhode Island 

Source: State of Rhode Island 

Figures at the bottom of the table, set against a pale blue background, allow comparisons among the latest available job placement numbers Sept. 30 and those at the end of the first and second quarters of 2016.

It’s not surprising that the state does not meet overall compliance with the consent decree, Rhode Island began focusing on compliance only in the last 12 months – two years after the agreement went into effect,

In May, 2016, Judge John J. McConnell, Jr. of U.S. District Court reinforced the consent decree with an order addressing numerous shortcomings, including an inability to even get an accurate count of the number of individuals protected by the agreement.

McConnell required the state to create a “live” database, always up-to-date, on the population protected by the consent decree – at latest count 3,456 teenagers and adults – that the monitor and the U.S. Department of Justice could use to gauge compliance.

Such an up-to-the-minute database is in the works but has not yet been completed. In the interim, the  Executive Office of Health and Human Services has coordinated a cooperative effort involving three state agencies and the Sherlock Center on Disabilities at Rhode Island College to connect different sources of data so that the state can make detailed reports to the court, albeit with a time lag. The three state state agencies participating in the combined data effort are the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals; the Department of Education, and the Office of Rehabilitation Services.

The ten-year consent decree has progressively stiffer requirements, with the latest deadlines occurring Jan. 1. It is not yet known how well the state has done against these most recent benchmarks.

 Charles Moseley, the monitor,  has concluded that the state has “significantly improved its ability and capacity to gather, aggregate and analyze” data required by the consent decree.

Moseley submitted the state’s figures to McConnell March 3, supplementing two earlier reports. One made recommendations on stepping up job placements and other aspects of compliance. .The other made sweeping recommendations that would put emphasis on the needs of of individuals in the funding process for developmental disability services and would reorganize operations of the state Division of Developmental Disabilities to incorporate a seamless and continual quality improvement effort. Both reports have implications for greater costs.

All of Moseley’s recent reports are likely to come up during the next open-court hearing on the consent decree, now scheduled for 10 a.m. March 10 before McConnell. (Two hearings in January and February had been cancelled.)

The progress the state reported as of Sept. 30 reflect the efforts of privately-run service providers who for years have been working under significant financial and bureaucratic constraints that make it difficult for them to hunt for jobs for clients and support them once they find employment. 

Front-line workers make poverty-level wages, despite a pay increase approved by the General Assembly in 2016. The legislature also set aside $6.8 million to pay bonuses for new job placements and job retention and for specialized training completed by direct care workers. But that program was still on the drawing boards when the latest data was collected.

In his report on data, Moseley noted that the state did not reach goals for career development plans and benefits counseling. Benefits counseling is necessary to ensure individuals make informed choices about the way particular jobs would affect their government benefits, like supplemental security income (SSI.) Career development plans consider long-range goals, and the intermediate steps necessary to achieve them, in a way that aligns activities with individuals’ needs and interests.

Overall, about 43 percent of the entire consent decree population had career development plans. In one of the earlier reports to McConnell, Moseley was critical of the quality of those career development plans. 

Source: Charles Moseley, U.S. District Court Monitor

Source: Charles Moseley, U.S. District Court Monitor

In the table above, "youth transition" refers to high school special education students likely to qualify for adult services, and "youth exit"refers to adults who have left school since 2013. Other categories refer to older adults who historically have been in segregated day programs or sheltered workshops. The letters CDP are an acronym for career development plan. 

Another table, below, shows that the state had complied with a requirement to provide benefits counseling to young adults with jobs but had failed to similarly advise more than half of older adults who had obtained jobs after 2012. The letters BP are an acronym for benefit plan.

Source: Charles Moseley, U.S. District Court Monitor

Source: Charles Moseley, U.S. District Court Monitor

The state reported that those who had jobs worked an average of nearly 12 hours a week and made an average of about $10.00 an hour. The consent decree says the average work week should be 20 hours.  

The consent decree requires the state to integrate adults with developmental disabilities in their communities to comply with the 1999 Olmstead decision of the U.S. Supreme Court, which reaffirmed the rights of citizens with disabilities to receive services in the least restrictive environment that is therapeutically appropriate under provisions of the Americans With Disabilities Act. In Rhode Island in 2014, the U.S. Department of Justice found an over-reliance on sheltered workshops paying sub-minimum wages and on isolated day programs that did not offer their clients purposeful activities.

Click here for the monitor's data report.

Click here for the data the state submitted to the monitor.

 

 

Madden to Leave RI Consent Decree Post; Lawyer Dianne Curran Named New Coordinator

By Gina Macris

Mary Madden, the coordinator of Rhode Island’s efforts to comply with a federal consent decree mandating a transformation of developmental disability services, will step down from that post at the end of March.

Mary Madden                          File Photo

Mary Madden                          File Photo

In her place will be Dianne Curran, a longtime disability rights lawyer who has worked both in Rhode Island and Massachusetts, most recently as a consultant to the Massachusetts Department of Elementary and Secondary Education.

The announcement was part of a public community forum at the North Providence Senior Center Feb. 23 that also catalogued a series of system-wide changes undertaken in recent months, even though developmental disability services still fall short of the funding parents said is necessary to individualize supports for their sons and daughters.

And the audience was reminded that family stories are the ones that make the biggest impact with members of the General Assembly, who in the next several months will consider increases in the current budget and one for the fiscal year which begins July 1.

Curran, al awyer for both Rhode Island Legal Services and the RI Protection and Advocacy System (now the Disability Law Center) during the 1980s, also has served Massachusetts state government in various legal positions in education, human services and developmental disabilities departments. Her lengthy experience in that state includes a brief stint coordinating activities in response to consent decrees affecting adults with developmental disabilities and mental illness.

Madden, a veteran developmental disabilities professional in the private sector, became consent decree coordinator for Rhode Island in January, 2016, at a time when the state was just beginning to craft a response to the 2014 federal consent decree.

 On Thursday, Madden said that continuing as consent decree coordinator “was not in the long-term plan.”  Madden said she would not have returned to graduate studies in disabilitiesand public policy at Rhode Island College if she were not satisfied that that the state had gained momentum in responding to the consent decree. 

Most recently, Rhode Island recruited Kerri Zanchi as director of developmental disabilities after a six-month vacancy in that post.

Zanchi is a career administrator in developmental disability services, who, like Curran, has extensive experience in Massachusetts. She told the audience at Thursday’s forum that she was drawn to the Rhode Island job because of the state’s commitment to community-based services and the opportunity to make lasting change as the state shifts away from isolated day programs and sheltered workshops to comply with the consent decree. The decree requires the state to comply with the 1999 Olmstead decision of the U.S. Supreme Court, which ruled that services for all persons with disabilities must be desegregated in accordance with the Americans With Disabilities Act.

Thursday’s session, attended by about 30 people, was notable for its low-key, conversational tone, a sharp departure from the angry complaints that dominated such meetings during 2016.

In the last six months, developmental disability officials reported, they have made several improvements, including the following:

  • speeded up the application process for adult services for individuals with developmental disabilities and adopted a policy to determine eligibility for adult services by the time special education students turn 17

• named a full time transition coordinator,  Carolee Leach, to work with high schools and the families of their special education students in preparing for adult life

• implemented a modest raise of about 36 cents an hour for direct care workers, as directed by the General Assembly

• introduced revisions to an assessment process used in determining individual funding allocations

• rolled out a supported employment incentive program for private service providers whohave placed 20 adults with developmental disabilities in jobs in the community since January

An independent court monitor in the consent decree case, however, has said in a recent report that the state must do much more to comply with the consent decree. (Click here for article on monitor’s latest report.)

At the meeting,  Zanchi, Madden and several other officials, including Jennifer Wood, General Counsel to the Office of Health and Human Services, heard from parents who said their adult children are lacking individualized community-based services.

Pat Abbate

Pat Abbate

Pat Abbate, who has a 46 year-old son with significant challenges, said the agency which serves him has good intentions but does not have enough financial resources to individualize services in the community

Tammy Russo, who has a 21 year-old son with disabilities, said he gets “no community services except for me.”

Greg Mroczek said 70 percent of his daughter’s program is in a day center isolated from the community.

Earlier in February, the same developmental disability officials heard a similar theme – a lack of adequate funding - from a mother who said she was forced into managing her daughter’s services because no agency would take her. Mary Genco said she asked 19 agencies, and each one said it had no nurse who wanted to deal with her daughter’s medical needs.

Genco, who is home with her daughter nearly all the time, said she represents growing minority of aging parents who are being “worn out” by adult children with extensive medical or behavioral support needs.

On Thursday, Pat Abbate put numbers on the funding gap. She said – and a check of the state’s Office of Management and Budget (OMB) website confirms – that funding for developmental disabilities lags behind the high of $260 million enacted by the General Assembly for the fiscal year between July 1, 2007 and June 30, 2008. At this time last year, the enacted budget was just shy of $231 million, according to OMB documents.

In response to a federal court order which said the state did not allocate enough money to implement the consent decree, Governor Gina Raimondo later pushed for increases, approved by the General Assembly, which boosted the bottom line to $246.2 million in the current fiscal year.

In her most recent budget proposal in January, Raimondo seeks an additional $4.4 million to finish the current fiscal year, for a total of $250.6 million. For the next fiscal year, beginning July 1, Raimondo has asked the General Assembly for $256.7 million.

Heather Mincey, a developmental disabilities administrator, said, “With our budget we try to advocate for as much money as we can.”

Brian Gosselin, chief strategic officer at OHHS, explained that the various departments of state government are active in their own advocacy, working with OMB and the Governor’s office, from July through December. But the state agencies don’t control the allocations, he said.

With the governor’s budget proposal now in the hands of the General Assembly, Gosselin and Mincey agreed, it’s vital that the community speak up.

“It’s important for families and advocates to be out there to speak to their representatives and let them know what your needs are,” Mincey said. 

A member of the audience, who said he works for a developmental disability service agency in Massachusetts, drove home Mincey's and Gosselin’s message.

The voice of families and advocates for developmental disability services is much stronger in Massachusetts than it is in Rhode Island, he said.

“When a family member calls up and gives them (legislators) a story, it makes such an impact,” he said. “I don’t think enough people get that point” in Rhode Island.

 

 

RI Gov Appoints Wallack HHS Secretary; Wood To Continue to Lead DD Effort; UHIP Woes Continue

By Gina Macris

The Rhode Island Department of Human Services has begun re-hiring - months after it laid off about 70 workers in conjunction with the roll-out of a dysfunctional automated benefits system – to help Rhode Islanders who face hardships from delays and denials caused by the broken computer system.

That is but one step going forward that Governor Raimondo announced at a media briefing Wednesday, Feb. 15, when she released a scathing report on the Unified Healthcare Infrastructure Project, or UHIP, compiled by Eric Beane, the acting director of the DHS and her chief operating officer.

Blaming the vendor, Deloitte, for delivering a “defective system,” Raimondo also warned that it will take 60 to 70 days to stop the backlog in applications from growing and about a year to fix the system.  Beane’s report, completed over the last thirty days, showed the problem was much worse than she had previously believed, the Governor said. 

She apologized to Rhode Islanders for a situation she said was “unacceptable, inexcusable, and intolerable.”  

She introduced Anya Radar Wallack as the new Secretary of Health and Human Services  (HHS). Wallack formerly served as Medicaid director and the director of the state’s health insurance exchange under the Affordable Care Act.

Elizabeth Roberts, who had made a career of health care reform as a state senator, lieutenant governor and HHS secretary, submitted her resignation Wednesday. Raimondo accepted it, she said, because she agreed with Roberts that the problem needed a “fresh set of eyes.”

 Roberts had taken the stance that the system could be fixed quickly, despite the glitches, but Beane’sunvarnished analysis showed that not to be the case, Raimondo said. 

As Roberts’ long-time deputy, Jennifer Wood had been heavily involved in trying to fix the troubled UHIP rollout. Wood, who has served both as Deputy Secretary and General Counsel of HHS, will continue as General Counsel and will remain in charge of the state’s efforts to comply with the 2014 federal consent decree mandating integration of daytime services for adults with developmental disabilities, according to Beane.

Among thousands who have suffered hardships from the UHIP fiasco are individuals with developmental disabilities applying for adult services from the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH).

Last September, just as BHDDH solved an eligibility backlog in applications, many of them from young adults leaving high school, the introduction of UHIP caused months-long delays in the release of the money necessary to actually pay for approved services. In December, there were an estimated 100 young adults who had services delayed or expected services to be delayed as a result of the UHIP snafu, according to one informal report from the Rhode Island Parent Information Network.

Timely service is an issue of concern to an independent court monitor in the enforcement of a 2014 federal consent decree requiring community-based developmental disability services.

At the press conference, Beane said the backlog in all types of applications will continue to grow unless there is a “staffing surge to address the timelines.”

Beane’s report said Deloitte assured the state the computer system was ready to go live when it was not.

Raimondo said the state continues to withhold tens of millions of dollars (about $68 million of a $364 million project)  and is re-negotiating its contract with Deloitte. “It’s tense,” she said.  But she emphasized that UHIP can be fixed.

Raimondo said she has come to realize that the state needs to have more high-level officials with the technical expertise to analyze a vendor's claims and call out mistakes. In general, the public sector has been lacking in that regard, she said.

There had been warnings from federal officials that the computer system was not ready for a state-wide roll out, but human services officials decided against a try-out period.

Former DHS director Melba Depena Affigne and her chief digital officer Thom Guertin resigned in January under pressure from Raimondo. 

Click here to read Beane's report

Roberts Resigns as RI Health and Human Services Secretary; Wood's Future Role Unclear

By Gina Macris 

Rhode Island’s Secretary of Health and Human Services, Elizabeth Roberts, resigned late Tuesday, Feb. 14, over the quagmire created by UHIP, the state’s computerized human services benefits system.

Governor Gina Raimondo, in a press conference outside her office, said she met with Roberts “and she presented me with her resignation, which I accepted.”

“It was her choice, and I commend her for it. I think she realized, as I realized, that the challenges we’re having with UHIP require a new set of eyes, and a fresh set of eyes. “

Roberts’ top aide for many years, Jennifer Wood, who is Deputy Secretary of Health and Human Services, has been involved closely with the roll-out of the UHIP computer system and also has directed the state’s compliance effort with a 2014 federal consent decree affecting adults with developmental disabilities.

Asked whether Wood’s position is at all affected by the problems of the UHIP rollout, Raimondo’s spokesman, David Ortiz, said in an email that the Governor would give a “full update” on Wednesday.

The resignation came on the eve of a briefing Raimondo has scheduled for the media on Wednesday, Feb. 15, to discuss an analysis of UHIP conducted during the last month by her chief operating officer, Eric Beane, and steps that will be taken going forward.

“Secretary Roberts has been in public service for decades and has done so many good things for the people of Rhode Island,” Raimondo said.

In a statement, Raimondo said Roberts has “fought her entire career to expand access to affordable healthcare for more people. As my Secretary of Health and Human Services, Elizabeth played a key role in our successful efforts to drive Rhode Island’s uninsured rate to one of the lowest in the nation while reducing costs.”

Roberts was criticized by Nicholas A. Oliver of the Rhode Island Partnership for Home Care.

In a statement, he said that “Roberts’ rigid view of the state healthcare system blinded her from understanding the realities of operating healthcare practices and agencies in Rhode Island.”

“Because Roberts was a visionary stemming from her healthcare public policy interest as a state senator and a lieutenant governor without practical operational experience as a healthcare provider, her naivete and inexperience led to her ineffectiveness in the role of Secretary,” Oliver said.

Roberts’ is the third resignation connected to the $364 million computer fiasco. Melba Depena Affigne, director of the Department of Human Services, and her chief digital officer, Thom Guertin, resigned in January under pressure from Raimondo. 

Monitor Seeks Changes in BHDDH Funding Methods To Satisfy RI Consent Decree

By Gina Macris

Rhode Island’s method of allocating funding to adults with developmental disabilities does not meet the requirements of a 2014 consent decree in that it does not take into sufficient account the needs and goals of the individuals involved, according to a new report from an independent court monitor.

The monitor, Charles Moseley, wants the state to review and modify its methods of assigning funding to make sure that “service dollars are targeted to meet the individual’s personal goals and preferences.”

That’s not all. In a report submitted to the U.S. District Court Feb. 10, Moseley incorporated recommendations from outside experts that would bring sweeping changes to the organization of the state Division of Developmental Disabilities (DDD).  (A court hearing scheduled for Feb. 14 has been postponed.) 

The report focuses on the degree to which community-based non-work services are individualized, concluding that Rhode Island has a way to go to achieve compliance.

It also incorporates recommendations from a quality improvement expert who suggested a merger of fragmented licensing, investigative, and program improvement functions at DDD, clearer regulatory standards, and a more precise definition of the future role of the social worker in light of burdensome caseloads (last reported by the state at 205 clients per worker.)

The consultant, Gail Grossman, a former Massachusetts state official, envisioned a unified and continual quality improvement initiative encompassing both DDD and the Office of Rehabilitation Services at the state Department of Human Services.  Both agencies oversee employment-related  services for adults with disabilities.

Grossman said there should be enough staff to review the performance of 38 service providers every two years. ORS now has only enough staff to make the circuit every nine years,  which Grossman found “totally insufficient.” 

The court monitor asked the state for quarterly progress reports, beginning April 1, on its progress in meeting a number of goals. They include specific quality improvement recommendations made by Grossman as well as modifications in funding methods and other changes necessary to personalize the planning and delivery of services according to the needs and preferences of individuals entitled to them.

Recommendations concerning the funding of individualized services resulted from a review undertaken in November by Moseley, A. Anthony Antosh, director of the Sherlock Center on Disabilities at Rhode Island College, and a Vermont-based independent consultant, William Ashe. They examined the non-work community-based services provided to a sample of 21 adults with developmental disabilities who had widely varying profiles.

From Ashe’s report on the study of 21 individuals and from other data, Moseley concluded that so-called “person-centered” planning and community-based services do not meet the requirements of the consent decree.

The consent decree defines “person-centered planning” as a “formal process that organizes services and supports around a self-directed, self-determined and goal-directed future.”  It gives additional detail on how such a plan is to be written.

Ashe and Moseley emphasized that the person-centered plan should drive services, not a funding formula based on a person’s ability to function independently, as is currently the case.

“The funding that agencies receive is based on assessed ‘functioning level’ and not based upon what people may want or really need,” Ashe wrote.

Moseley put it this way: there should be a connection between a “person-centered planning process” and funding methods so that “service dollars are targeted to meet the individuals personal goals and preferences.”

Moseley also wants the state to strengthen its oversight and the capacity of private providers to deliver “truly person-centered plans and services based on clear standards and expectations.” 

Ashe said the annual plans written for the 21 individuals in the study were too similar. The state’s planning process “feels rigid and automatic,” and an individual’s current plan “may often look remarkably similar to the one that was done last year.”

“Agencies are often in a situation where their staffing levels prohibit them from individualizing supports to the extent that is necessary to really implement services that are based upon real choice, ” Ashe wrote.  

What appears to be lost in the allocation process is an idea of the outcomes that are important for the persons involved, Ashe said.

Ashe said the consent decree recognizes that the state uses the Supports Intensity Scale, a standardized assessment tool, to determine an individual’s need for support.

The current funding method connects the results of the assessment to one of five allocation levels, based on an algorithm developed by a healthcare management consultant for the state. Planning for services occurs only after funding limits have been established.

In some of the case records reviewed by Ashe, Moseley, and Antosh, it was “exceedingly difficult to see how the service to be delivered could ever be realized to the standard expected by the consent decree,” the report said.

For most of the individuals whose services were reviewed, the choice of activities was limited..

Ashe placed a high priority on training for everyone involved in developmental disability services -  private providers as well as state workers, services recipients, their families, and advocates - on the meaning of purposeful activities in integrated, community settings and how to provide them.

Click here to read the monitor's report. 

One In Six DD Jobs in RI Goes Unfilled; Raises Would Ease Crisis and Improve Service Quality

image by capitol tv 

image by capitol tv 

Kevin Nerney of the Rhode Island Developmental Disabilities Council, left, and Maureen Gaynor, second from right, share pleasantries just before their testimony before the House Finance Committee on Feb. 8. Looking on are Gaynor's support worker, Melanie Monti, and Emmanuel Falck of the Service Employees International Union State Council.  Image by RI Capitol TV. 

By Gina Macris

Raising the pay of Rhode Islanders who serve adults with developmental disabilities is not only about helping these poverty-level workers pay their bills, according to testimony before the House Finance Committee Feb. 8.

The proposed raises also will reduce staff turnover and, in turn, improve the quality of life for some of the state’s most vulnerable citizens, Donna Martin, executive director of the Community Provider Network of Rhode Island (CPNRI), told the legislators. 

Kerri Zanchi, the new director of the Division of Developmental Disabilities, agrees with Martin’s assessment. Zanchi says the pay hike is not only an “investment in the direct service professional, but an investment in our community" and in high quality services.  

She estimates that the wage increase will amount to an average of 42 cents an hour, and says that provider agencies are now experiencing a staff turnover rate of about 33 percent.

Carol Dorros, the mother of a 21-year-old man with behavioral issues and other complex problems, knows firsthand the value of support staff retention. When her son was still in high school and receiving some adult services from a private agency, his support worker changed four times during a single academic year. As a result, he made “no progress” from September to June, Dorros said.

 Maureen Gaynor rolled up to the speakers’ table in a power chair and used a computerized voice to speak the text she had written with a “headstick,” a pointer attached to a band around her head.

These people deserve higher pay, Gaynor said, explaining that support staff sometimes must help with the most intimate care, such as bathing, dressing and using the toilet.

And she reminded the legislators that she would not have been able to attend the hearing without an aide willing to drive her to the State House and get her to the basement hearing room.

After she spoke, Kevin Nerney of the Rhode Island Developmental Disabilities Council reinforced her remarks:  “When you help someone eat, drink or bathe, you need to have a really good relationship with that person. We’re not talking about folding shirts at the Gap or flipping burgers at McDonald's,” said Nerney.

At AccessPoint RI, a service provider, the starting salary is $10 an hour, or $22,000 a year, said the agency’s executive director, Tom Kane. The average pay was $10.82 an hour until the current fiscal year, when the General Assembly set aside $5 million for raises for developmental disability workers – the first pay increases since 2006, Kane said.

The added funding resulted in a 36-cent hourly increase, raising the average to $11.18, according to calculations made by service providers and others.

When Kane reviewed the the roster of employees at the time his agency processed the raises last fall, he said he was heartbroken to find a 30-year employee who was to receive a total of $13.10, with the pay bump.

Kane and others indicated they believe that a “15 in 5” campaign to raise the pay of direct care workers to $15 in five years (by July 1, 2021), is simply not enough.

Kane alluded to a drive launched by State Sen. Louis DiPalma, D-Middletown, last fall when he asked Governor Raimondo to include a raise for direct care workers in her budget proposal for the next fiscal year.. While she has done so, her $6.2 million set-aside for wages is about $$600,000 shy of what DiPalma requested.

Kane said raises should not only be based on a percentage increase.

 “A four or five percent increase on an insufficient wage is an insufficient increase,” he said.

If the minimum wage increases to $10.50 an hour, as Governor Raimondo has proposed, “and we give 5 percent” raises, Kane said, “we’re paying minimum wage again.”

Kane took issue with figures presented by Linda Haley of the House Fiscal Staff that the raises in the current budget also bumped up pay for supervisory personnel.

He said the raises all went to direct care workers, (as stipulated in current state budget.)  Some agencies, including AccessPoint, used other funding sources to provide raises or bonuses to supervisory employees.

At AccessPoint, Kane said, front-line supervisors spend half their time doing direct care anyway.

“It is incredibly important that this bill passes, hopefully with more money in it,” to support not only those providing direct care but people who perform other important tasks, like writing clients’ state-mandated individual support plans, which are akin to road maps for services that are specific to each client. Most of these employees “have not had a raise in 11 years,” he said. “I don’t know why they stay.”

Emmanuel Falck of the Service Employees International Union (SEIU) State Council represents 270 workers at the Arc of Blackstone Valley. One of them, a 52- year-old woman with 20 years’ experience in the field, used to be able to make ends meet by working 60 to 65 hours a week, he said.

But after an 18-month bout with cancer, the most she can now work is 20 hours a week. And the last vacation she had was three days in Washington, D.C., in 2000, Falck said.

He said the proposed 42-cent increase to the hourly rate would be much appreciated, but the state needs to move faster to raise workers’ pay to a living wage.

“I urge this committee to bump it up as fast as possible,” he said, proposing a $15 hourly wage by 2019 instead of 2021. As it is, direct support workers living in Rhode Island will be able to cross the state line to neighboring Massachusetts and do the same work for $15 an hour on July 1, 2018, Falck said.

Donna Martin, the CPNRI director, said that developmental disability service providers face a “tremendous crisis” in competing for the same pool of workers who serve elderly clients, thanks to a growing number of aging baby-boomers.

On average, the 27 providers belonging to CPNRI cannot fill one in six job openings, creating a vacancy rate of about 16 percent, she said. During exit interviews, workers say that they love their jobs but can’t feed their families with what they are paid, according to Martin.

As a result of the vacancies, employers are forced to spend money on overtime that they would rather put into worker pay and training, Martin said.

“I appreciate your sensitivity to the struggles of our staff,” Martin told the finance committee members.  “They are where the rubber meets the road when it comes to quality.”

Chris Semonelli of Middletown, the father of a 14-year-old girl with autism, put some historical context around the discussion of the wage proposal.

From 2006 through 2011, the budget for developmental disability services was reduced 20 percent, Semonelli said, quoting a profile of the system written by the Sherlock Center on Disabilities at Rhode Island College in 2013. And the services are not designed with an eye toward results. In the current design, more money gives more of the same service, he said.

That said, Semonelli said he strongly supports Governor Raimondo’s proposed wage increase in the next budget, as well as the “15 in 5” campaign. The governor’s plan for the next fiscal year “is a start,” said Semonelli, who also is co-director of an advocacy group called Friends of the Disabled on Aquidneck Island.

Although Wednesday’s hearing sounded like a budget discussion, it focused only on Article 23 – one of 24 chapters in the overall fiscal package Raimondo has submitted to the General Assembly.

The provision would require a one-time increase in the base pay of direct care workers, “in an amount to be determined by the appropriations process” and also require the Office of Management and Budget to perform an audit to ensure that the raises go only to those workers.