By Gina Macris
In just the few months she has served as interim director of Rhode Island’s Division of Developmental Disabilities, Jane Gallivan has been instrumental in changing the state’s approach to providing services for individuals with intellectual challenges.
On the most concrete level, she has set plans in motion to adopt an improved version of a controversial assessment – the Supports Intensity Scale (SIS) – to more accurately determine the needs of clients.
With help from the Executive Office of Health and Human Services, Gallivan also has shifted strategies for presenting the division’s budget so that the state Budget Office and the General Assembly better understand what it means to support individuals with developmental disabilities.
The initiatives Gallivan has begun, and the tone she has set, are expected to continue after her role changes Friday, Sept. 30, to that of long-distance consultant.
Gallivan, 68, is taking her 101 year-old mother to Florida for the winter, a commitment she made before Rhode Island officials approached her for short-term help in leading the developmental disabilities division.
She will continue to monitor and guide reforms and will serve on the committee that will screen applicants for the division’s permanent chief.
A former state-level director in Maine and Delaware, Gallivan already has been spreading the word about the director’s job through her nationwide contacts in the field of developmental disabilities.
As she prepared to end her full-time role in Rhode Island, Gallivan shared her perspective on the future of developmental disability services in Rhode Island.
Major Changes Coming to Every State
Gallivan says all state developmental disability service systems are in the midst of a sea change because of sweeping new Medicaid regulations.
The rules say that all services for the elderly and individuals with all types of disabilities must be provided in the least restrictive setting that is therapeutically appropriate, which is presumed to be the community.
After March, 2019, Gallivan said, Medicaid will no longer pay for sheltered workshops or segregated day programs after March, 2019. Sheltered workshops don’t fit the Medicaid’s definition of “community,” she said.
Federal Medicaid dollars pay for half the cost Rhode Island’s developmental disability services.
The federal consent decree requiring Rhode Island to shift to community-based jobs and activities may put the state ahead of the curve, she said.
Both the consent decree in Rhode Island and the changed Medicaid regulations nationwide get their authority from the 1999 Olmstead decision of the U.S. Supreme Court, which is in effect a desegregation order for individuals protected by the Americans with Disabilities Act.
Individuals and families who struggle to find appropriate services may not yet see any change in their lives.
Gallivan says she worries about a caseload ratio that is “way too high” - one social worker to every 205 clients.
Social workers are “really concerned about helping people out,” she said, “but like any other service system, they are often, because of the ratios, dealing more with people in crisis” or those just entering the system, rather than “supporting the people who are not the squeaky wheel.”
“No one wants to expand state government,” but state government must still “figure out how we’re going to put more resources into case management,” Gallivan said.
A New Way to Assess Service Needs
Since taking the interim director’s job in July, Gallivan has been “looking under the hood,” as she put it, to understand the barriers that need to be removed to allow “people to really get out and enjoy activities in the community, to get better connected, to explore new job options and so forth.”
She’s been searching for hindrances in state regulations, the way programs are funded, and the way clients have been assigned individual funding based on “tiers,” or levels of need.
The Supports Intensity Scale, (SIS) is a lengthy questionnaire used since 2011 to determine the individual level of funding according to “tiers” labeled A through E, with E being the costliest.
In the last few years, the SIS been the single most emotional flashpoint for families, many of whom have complained bitterly not only about results that yield insufficient funding, but that interviewers argued with them or recorded answers different than the ones they gave.
In the next several months, Gallivan said, the state will move to what she hopes will be a more accurate version of the assessment, with additional questions focusing on medical and behavioral needs.
SIS Interviewers will be retrained in the new version by representatives of the organization which developed the SIS, the American Association on Intellectual and Developmental Disabilities (AAIDD).
Gallivan said training also will be offered to family members and representatives of service provider agencies, who attend the interviews and help answer questions.
The state will monitor the new approach to determine whether it leads to a reduction of a high number of exceptions now granted to the assessment results.
The exceptions, in which a client may have more funding than warranted by the official level of support, have raised numerous questions in the General Assembly about how the Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH) manages its budget.
Gallivan offered some background on the SIS, which is used in Rhode Island as a basic building block of the developmental disability budget.
On its face, the SIS is a better assessment than some others in use across the country because it frames questions in terms of an individual’s strengths and the supports he or she may need to achieve a particular goal, rather than focusing on deficits, Gallivan said.
But it has its limitations, she readily acknowledged. It is recognized nationwide that the SIS does not address extensive medical needs or behavioral issues, Gallivan said.
“You also have to be sensitive to people who are very independent, but they may get themselves into trouble with the law,” or in some other way, because of their disabilities, she said. For example, some individuals may appear independent, but if they don’t have the proper support and guidance, they may end up at a homeless shelter, or picked up by police for shoplifting.
The SIS was developed as a tool for planning individualized programs of support, not as a funding mechanism, although many states use it for budgeting, Gallivan said..
As a result of the gaps inherent in the original assessment, the state of Oregon developed a number of questions on behavioral and medical support needs that were tried out by other states and ultimately incorporated into a new version of the questionnaire called the SIS-A, Gallivan said.
“Everyone came to the conclusion that these supplemental questions really did add a more robust, accurate assessment,” she said.
AAIDD released the SIS-A in 2015, according to the organization’s website.
Gallivan said arrangements are being made for AAIDD representatives to come to Rhode Island for training in the SIS-A. At the same time, the consultants who developed the formula for turning SIS scores into individual funding levels have been asked to revise that algorithm to correspond to the SIS-A, she said.
Disability Services: a Lifetime Commitment
Meanwhile, Gallivan has tried to set a different tone for presenting the needs of individuals with developmental disabilities to the state Budget Office.
“I’m not saying that people don’t know” what the Division of Developmental Disabilities does, “but a lot of people really don’t know,” she said with a chuckle.
“So I think it’s really important to paint a picture” of the service system and the people in the middle of it, Gallivan said.
Budget officials should know who the division serves, whether they live with their families or elsewhere, the kinds of services they receive, why the services are important to them and their families, the actual costs of providing those services, and the expected outcomes, Gallivan said.
That’s a different approach than seeing the system as a list of line items, she said.
It’s important for the fiscal arm of state government to understand that “we are the long-term care system,” Gallivan said.
“People think of the elderly as being the long-term care system, but they’re only in there for a few years,” she said.
“We’re talking birth to 100” in developmental disabilities, she said.
Legislators must understand that they can’t take money from individuals with developmental disabilities and give it to someone else, Gallivan said.
“In this system, everyone who comes through the door will have a life-long need for some kind of support because of the nature of their disability,” she said.
It’s not analogous to the mental health system, where funds may be shifted because one person is in recovery and another is not, Gallivan said.
A Focus on Families
In any presentation she makes, Gallivan said, she tries to emphasize the need to support families who have a member with developmental disabilities living at home with them.
Many families want their loved one at home, she said. "Ffrom a bureaucratic perspective, it’s (generally) the safest place they’ll be,” she said, “and the cost of services in the family home will be less than they will be anywhere else.”
“So how can we invest in families and recognize them as caregivers? We talk about people as caregivers of those with Alzheimer's, but we have people who are caregivers of people with developmental disabilities who face a lot of challenges” and have their own need for support, Gallivan said.
She suggested families should have access to more respite care and should be able to get financial support for modifications like wheelchair ramps.
Gallivan also indicated technology might help families keep tabs on their loved ones, although options like bedroom cameras might not be universally welcome in some homes.
The full range of supports for families “need to become a very strong focus,” Gallivan said, “and the type of planning we need to do with families is very different.”
“You need to talk about the whole family and what the family needs are,” she said.
Families and individuals who advocate for themselves must be part of the conversation, Gallivan said.