By Gina Macris

Rhode Island’s developmental disabilities agency seeks to raise the pay of direct care workers to $18 an hour beginning July 1, 2022, a 14 percent hike over the current hourly rate of $15.75.

The raise would be covered by a $44.5 million increase in federal-state Medicaid funding for the privately operated developmental disability service system, according to a budget request submitted to Governor Dan McKee for Fiscal Year 2023 by the state Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH).

Within an overall agency budget of $585.9 million, representing a 12 percent increase, the Division of Developmental Disabilities would get nearly $380 million. That sum would cover both the privately-operated system of services and a state-run network of group homes. Private providers would get a total of about $352 million in federal-state Medicaid funding, about $44.5 million more than the current budget of $307.9 million. The budget for the state-run group homes would remain relatively flat, at about $28 million.

In an Oct. 1 budget letter to the governor, BHDDH Director Richard Charest wrote, “The Division of Developmental Disabilities (DDD) continues its commitment in complying with the terms of the 2014 federal consent decree and providing integrated employment and day services.”

On Oct. 1, BHDDH was facing the prospect of a contempt hearing in U.S. District Court that was to start today, Oct. 18, over continued failure to comply with the 2014 civil rights agreement. But at the same time, the department was negotiating with an independent court monitor to reach a settlement that would avoid hefty fines proposed by the U.S. Department of Justice. On Oct. 13, five days before the hearing was to start,Chief Judge John J. McConnell, Jr. canceled it without explanation. Any settlement has yet to be announced.

The pace of job placements required by the consent decree has slowed, from 78 percent of the target number spelled out in the agreement for January 1, 2019 to 67 percent of the target for January 1, 2021. A lack of services in general, and employment-related support in particular, has been attributed to an acute shortage of direct care workers.

For years, all sectors of the human services have been affected by a workforce shortage, which has been exacerbated by the COVID-19 pandemic. But only programs serving people with developmental disabilities operate with federal oversight in Rhode Island. Chief Judge John J. McConnell Jr. of the U.S. District Court has ordered Rhode Island to raise direct care worker wages to $20 an hour by 2024 to attract new staff.

In its budget request, BHDDH is also asking for a one-time investment of $119.3 million in federal coronavirus relief funds from the American Rescue Plan Act (ARPA) for the developmental disabilities system. That figure represents more than 10 percent of of the $1.13 billion in ARPA funding available to Rhode Island, the only state in New England which has not yet spent any of its allocation.

The $119.3 million total includes capital expenses of nearly $74.5 million for repair and construction of residential and therapeutic facilities and about $44.9 for operational and program changes over the next few years. All the money would be spent by the end of 2025. The proposal acknowledges chronic underfunding of the developmental disabilities system.

The investments are intended to shore up existing services and facilities to achieve a “more holistic, individualized, and community-based system of supports” to comply not only with the consent decree but with the separate Medicaid Home and Community Based Services (HCBS) Final Rule, which requires integration for all Medicaid and Medicare-funded services, including residential programs.

Both the consent decree and the HCBS Final Rule draw their authority from the Olmstead decision of the U.S. Supreme Court, which has ruled that people with disabilities have the right to receive services in the least restrictive environment that is therapeutically appropriate.

The portion of the ARPA request aimed at programmatic and operational changes assumes that there will be a shift from the current fee-for-service reimbursement method for private providers to a “value-based” reimbursement model, although that change has yet to be defined. BHDDH is expected to award a contract in the next two weeks for a consultant’s study to examine rates and methods of reimbursement. The successful bidder would have six months to complete the work.

Within the $44.9 million ARPA request for operations and programs, BHDDH is seeking:

• $25 million for supported employment services, including efforts to bring more services to “BIPOC communities,” a reference to Black and Indigenous peoples and other people of color.

• $17,350,000 to help private providers arrange more integrated housing options, staff training, assistance in tracking the providers’ own performance according to certain measures, and technologies for shifting from fee-for-service to “alternative based payment models.” This segment of the request assumes each of 34 service providers in Rhode Island will get $500,000. It also would pay for a contractor to manage the program.

• $1,150,000 for a community-based mental health intervention response team for people who have both intellectual or developmental disabilities and behavioral issues that put them at risk of hospitalization. Plans for the model program, called START (Systemic, Therapeutic, Assessment, Resource, Treatment) have already been developed. It has been identified as a best practice by the National Academy of Sciences Institute of Medicine.

• $1 million for information and education for service recipients for and their families to ensure better access to services, particularly for people of color, who have been underrepresented in the service caseload.

The $75 million in capital investments would include:

• $60,350,000 in repairs to state-owned provider facilities. Deferred maintenance in group homes “is a drain on state and provider resources (and) a barrier to individuals aging in place,” the proposal said. The condition of some facilities is “not conducive to making individuals feel safe and valued in their homes and part of the larger community,” it said.

• $8,130,000 to build facilities to house 30 young people with developmental disabilities who are making a transition to the adult service system. Currently, these youngsters, particularly those who also have emotional or behavioral issues, languish in facilities for children or in hospitals, creating a backlog in the youth system.

• $6 million for a 24-hour community residential program for people with developmental disabilities being discharged from a hospital or other institution who still need more specialized care than is offered by a regular group home. Such a program would ensure that services are provided in the least restrictive setting as required by HCBS, the proposal said.

Taken together, “these investments will lay the foundation for a DD system that focuses on supporting participants in a way that promotes community integration and development of personal networks and circles of supports,” the proposal said.

It will require a “major shift in thinking and business models” to move from “caretaking” and programs developed by providers to “a focus on what individualized supports people need to be as independent as possible.”

To read the entire BHDDH ARPA proposal for developmental disabilities, click here.