RI Rate Cuts To DD Providers Or Wait Lists For Services Loom Without More Funding For BHDDH

By Gina Macris   

Rhode Islanders with developmental disabilities would face “drastic measures” such as waitlists for services or reductions in the amounts the state pays private organizations providing these supports if their funding agency must resolve a sizeable budget deficit by the end of the fiscal year June 30.

Rebecca Boss                       Photo By Anne Peters

Rebecca Boss, director of the agency, the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH), reached that conclusion in a Nov. 30  letter to the director of the state budget office and the finance committee chairmen of the House and Senate.

She pledged to keep working  “to minimize the anticipated disruptions and destabilization that would result from such measures on our vulnerable populations.”  In the last several years, the General Assembly has covered BHDDH deficits with supplemental funding.

The letter outlined a corrective action plan for reducing the deficit, an estimated $15.9 million in in state spending, including about $12 million from developmental disabilities programs and nearly $4 million from the Eleanor Slater Hospital. Without a state match, roughly the same amount in federal Medicaid dollars also would evaporate.

The corrective action plan described a variety of cost-cutting initiatives that at best, would address less than half the overall shortfall, but Boss’s letter did not add up the total savings. BHDDH officials were not able to respond immediately to several detailed questions about the corrective action plan. 

Corrective action plans are required whenever a state agency runs a deficit. But the BHDDH plan raises questions about its future ability to comply with a 2014 federal consent decree that requires Rhode Island to integrate adults with developmental disabilities in the community to comply with the Americans With Disabilities Act (ADA).

Integrated services, which require small staff-to-client ratios, are inherently more costly than the segregated, facility-based programming Rhode Island has used in the past, in which one person can keep an eye on larger groups of people gathered in one room.  An over-reliance on sheltered workshops and day centers put Rhode Island in violation of the ADA's integration mandate, which is spelled out in the Olmstead decision of the U.S. Supreme Court, according to findings of the U.S.Department of Justice.

Rhode Island has never been in complete compliance with the incremental integration goals of the consent decree and in the spring of 2016 came close to being held in contempt of court over lack of funding, among other issues. Since then, as long as the state has put additional money and professional expertise into efforts to improve services, it has avoided sanctions.

Most recently, during a U.S. District Court hearing Nov. 30 – the same day Boss turned over her corrective action plan – the judge in the consent decree case  repeatedly brought up his concerns about money to fund the services required by the consent decree. John J. McConnell, Jr. said he would be keeping an eye on the budget process, both at the state and federal levels.

The BHDDH plan proposes returning to the state a $2 million balance in funds that had been allocated to a performance –based supported employment program that responded to a court order to help more adults with developmental disabilities find jobs. In the plan, Boss said that BHDDH would continue to provide funding for supported employment. Anecdotal information from providers and families has indicated that, even with the performance-based program, employment services have not been available to all who wanted them.  

Boss, meanwhile, outlined other cost savings. She said correcting errors in the needs assessments of 46 adults with developmental disabilities will result in $400,000 in savings, once the individual funding authorizations for those persons are reduced.

Because of widespread complaints that the original assessment shortchanged individual needs, resulting in routine awards of supplemental funds, BHDDH adopted an updated version of the standardized interview about a year ago that was said to be more accurate.

The newer assessment contributed to higher per-person costs that are reflected in much of the $12 million projected deficit in developmental disabilities, Boss said. The 46 errors in assessment occurred because interviewers did not correctly utilize a certain group of questions in the new interview process, she said.  

At the start of the current fiscal year in July, with rising costs from the new assessment already apparent, BHDDH imposed stringent health and safety standards for awarding supplemental funds on appeal.

Of the $12 million projected deficit in developmental disabilities, $4 million is related to “various” cost-cutting initiatives in the current fiscal year which BHDDH does not expect to achieve, Boss said.

She did not describe these unachieved savings in any detail, except to attribute $500,000 to the department’s inability to move residents out of three of five state-run group homes that had been scheduled to close. The remaining two homes are special care facilities that are being consolidated and will close, Boss said. She has said such special care facilities do not comply with a new Medicaid Final Rule on Home and Community-Based Services.

In the last quarter of the fiscal year, beginning April 1,  BHDDH plans to cut the daily reimbursement rates for residents of group homes with relatively mild developmental disabilities, those assigned to the lowest two levels ( labeled A and B) of a five-tier funding scale. This measure is expected to save $200,000.

Additionally, BHDDH has a “continuing commitment” to reducing the population of group homes by 110 during the current fiscal year, which would bring an estimated savings of $900,000, Boss said. She did not elaborate.

In Rhode Island, the primary alternative to group homes is shared living, in which a person with a developmental disability lives with a family in a private home.

During the 27 months between July 1, 2015 and Sept. 20, 2017 the number of individuals in shared living increased by 92, according to BHDDH figures, from 268 to 360. The breakdown includes 40 in the fiscal year that ended July 1, 2016 38 in the fiscal year that ended July 1, 2017, and 14 in the first three months of the current budget cycle.

At the Eleanor Slater Hospital, all but $900,000 of the nearly $4 million shortfall can be attributed to salaries and benefits, including $2.1 million in overtime, Boss said.

The hospital has faced numerous problems, most critically a preliminary report from the Joint Commission in September that signaled Eleanor Slater would be denied accreditation because of unsafe facilities. The report prompted an increase in staffing so that patients are checked every five minutes.

BHDDH plans to move patients out of the substandard facilities, but that consolidation is behind schedule.

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

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.)

Friends of the Disabled to Hold Forum in Newport on DD Services in Rhode Island

By Gina Macris

Friends of the Disabled, organized by Newport County families who have members with intellectual or developmental disabilities, will host a forum on the future of Rhode Island’s disability service system Wednesday, Oct. 5, from 5 to 8 p.m. at the Newport campus of the Community College of RI. 

Candidates for the General Assembly have been invited to attend and address several questions about adult services that are provided by the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH), according to Chris Semonelli of Middletown, co-director of the group.  

Most of the issues of concern to the parents are related to a history of declining funding.  The General Assembly, under pressure from the U.S. Department of Justice, the U.S. District Court, and Governor Gina Raimondo, added about $11 million to developmental disabilities for the current fiscal year to comply with a federal consent decree requiring community-based employment and day services. 

Wednesday's program will cover current and future options for both daytime and residential services. 

The consent decree does not apply to residential services, although parents have expressed concern about the future availability of group home placements, which have been hard to come by in recent years. 

Since January, BHDDH has been emphasizing shared living arrangements, in which adults with developmental disabilities live in private homes. BHDDH should provide better supports to families providing shared living, according to Jane Gallivan, who until Sept. 30 served as Interim Director of Developmental Disabilities. 

Gallivan's Short Stint in RI Brings Plenty of Change, Starting with Plans for Better DD Assessment

Jane Gallivan   Photo by Anne Peters

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.

Despite Missed Deadlines, Consent Decree Monitor Says Rhode Island Moving in the Right Direction

By Gina Macris

Rhode Island has not met all the deadlines so far in shifting toward integrated, community-based services for adults with developmental disabilities as required in a 2014 federal consent decree, according to the independent court monitor in the case.

But because the state has taken important steps in the right direction in the last few months, the monitor, Charles Moseley, says he believes it is appropriate to delay evaluating the state’s performance on the deadlines.

Even one missed deadline gives Moseley the option of asking U.S. District Court Judge John J. McConnell, Jr. to conduct a show cause hearing as to why the state should not be held in contempt, according to an order McConnell issued in May.

The order says that the state must comply with every deadline contained in it and in the consent decree from May 18 forward or face possible contempt proceedings and fines. The consent decree contains deadlines running until 2024.

McConnell’s highly prescriptive order came after the state made little progress in complying with the consent decree in the two years since it had been put into effect. The judicial order lit a fire under a team of state administrators led by Jennifer Wood, Deputy Secretary of Health and Human Services.

Moseley submitted his latest assessment to McConnell Sept. 9, in anticipation of a status conference on the case Sept. 16. Typically, lawyers for the U.S. Department of Justice also submit statements to the judge before a hearing, but any submissions from the DOJ have not yet surfaced in the case file.

Moseley, meanwhile, said in his report that the state missed job placement deadlines.  The most recent was a July 1 deadline for finding employment for all young adults with developmental disabilities who left high school during the 2015-2016 academic year. That class is estimated at a minimum of 74 individuals, according to the Rhode Island Department of Education (RIDE). Many of them would be seeking part-time jobs.  

Eligibility specialists at the state Division of Disabilities have been working intensely to try to eliminate a backlog of applications from more than 200 individuals – most of them young adults – who seek developmental disability services.

In his report, Moseley said the state “is implementing substantive changes across the array of day and employment services furnished to individuals with I/DD (intellectual or developmental disabilities).”

He said continued refinements are needed in the data system that enables him and the DOJ to track compliance, and additional policies and practices must be implemented to expand the availability of high quality integrated and individualized day services.

“While challenges remain,” he said, “the foundational steps taken by the state to address key areas related to funding, administrative oversight, training and documentation” are moving Rhode Island “on a path toward achieving the requirements of the consent decree.”

Among the steps forward, Moseley cited the General Assembly’s approval of slightly more than $11 million in added revenue to increase salaries to underpaid direct service workers and implement performance-based contracts with financial incentives for private providers who help their clients find jobs.  

With that funding, the state has agreed to raise pay for direct service workers and job coaches to a minimum of $11.55 an hour, an average of 3.1 percent, Moseley said. The workers are still waiting for that increase to kick in. Wood, the Deputy Secretary of Health and Human Services, has promised the pay increase, retroactive to July 1, would be processed by Oct. 1.

Moseley said the pay raise plan submitted to him by the state needs to be more specific to ensure that the added funding will be used to “increase salaries, benefits, training and supervision”  as required by McConnell’s May 18 order.                                                                                                                                                                                                         

Summarizing what he describes as other“substantive efforts” to comply with the consent decree, Moseley cited the development of performance-based contracts intended to give providers incentives to help clients find and retain jobs, as well as training for professionals and parents in career development planning that will guide individuals’ job searches.

He said funding for start-up costs – a total of $800,000 – has been distributed to nine private service providerswhich are planning to shift from segregated to community-based programs, and the Sherlock Center on Disabilities at Rhode Island College is working closely with private service agencies  to help them make that change.

In addition, Moseley said, the state has provided heightened technical assistance and hired key staff, including an employment specialist and a program improvement officer, to beef up the leadership at the state Division of Disabilities.

Click here to read the monitor's report. 

Click here to read related article

RI Official Describes How Nearly $12 Million in DD Budget Responds to Consent Decree

By Gina Macris

Rhode Island is poised to offer financial rewards to agencies that meet certain performance goals in delivering supported employment services to adults with intellectual and developmental disabilities, according to the Deputy Secretary of Health and Human Services.

At a meeting of the Employment First Task Force on Aug. 9, Jennifer Wood explained how the state will use a total of nearly $12 million in funding authorized by the General Assembly in the current budget to implement the two year-old federal consent decree which mandates that adults with developmental disabilities have access to regular jobs in their communities.

A total of $6.8 million will be set aside for the supported employment bonuses –an estimated average of $15,750 after a client has been employed for six months. An additional $5.1 million has been earmarked for modest wage increases to about 4,000 agency staff who work directly with clients.

Ultimately, it is up to Judge John J. McConnell, Jr. of U.S. District Court to say whether these measures conform with a detailed order he issued in May requiring Rhode Island to lay the groundwork for long-term compliance with the consent decree, which remains in effect until Jan. 1, 2024.

At some point, the independent court monitor in the case, Charles Moseley, is expected to report to the court on whether he believes that state’s latest compliance efforts meet the requirements of the court order.

The May 18 order said that by Aug. 1, the state had to:

• implement performance-based contracts for supported employment services

• implement a flexible reimbursement model that pays service providers for the actual cost of providing services

• implement individual financial authorizations for clients receiving services that include specific allocations for supported employment services 

• increase salaries, benefits, training, and supervision for direct service workers and job coaches.s

The Task Force, made up of representatives of individuals with developmental disabilities, their families, and community organizations, was created by the consent decree as a bridge between government and the community. It met in the offices of the Community Provider Network of Rhode Island on Jefferson Boulevard in Warwick, 

Wood told Task Force members that the private agencies employing the workers will get lump sums for raises retroactive to July 1, but she could not say exactly when that will happen. Figuring out the payments has been a huge mathematical exercise, she said, and still requires changing the programming on state computers.

Based on current average pay of $11.55 an hour, the raises would be an average of $.30 an hour, Wood said, although actual salaries vary from one agency to another.

In a report to the court on July 29, the state said that it will require service providers to show that the money went to workers who have direct contact with clients, as the General Assembly intended.

Wood told Task Force members that state officials have been working with private service providers on the incentive program.

The July 29 report to the court said the incentive program will be implemented from August through next June, although the state has not yet begun taking applications from service providers. The program will serve a minimum of 200 clients with developmental disabilities. according to the filing with the court.

These clients will receive specific allocations for supported employment services as part of their individual financial authorizations from the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH), Wood said in a brief interview after Tuesday’s meeting.

Others served by BHDDH who are not part of the supported employment incentive program will not be affected. That means that if they want supported employment services, they must continue to trade in hours from another category of daytime support.

The bonuses will be paid in stages; when a client gets a job and after three months and six months on the job respectively, according to the report to the court. It also said the dollar amounts and numbers of incentives may be adjusted.

Wood told the Task Force that the experience of the first six months of the program would be used to make improvements for the second half of the fiscal year.

After the meeting, she said the incentive program would be an added “layer” over the current reimbursement model, which requires agencies to document clients’ face-to-face interaction with direct service workers in 15-minute increments during the day. 

That “unit service model” will remain in place, she said.

Because the reimbursement system does not pay an agency when a client is absent, for whatever reason, the provider cannot collect the full amount of the client’s authorization for daytime activities.

The consent decree found fault with this method of payment. It required the following change:

“The State will ensure that its reimbursement model for day activity services is sufficiently flexible to allow providers to be reimbursed for costs (e.g. transportation to the job site, employer negotiation, counseling clients by telephone) that are: (1) directly related to providing Supported Employment Services to individuals in the Target Populations, and (2) provided when service provider staff is not face-to-face with a client. “

Monitor Gives RI Mostly Passing Grades, Except for Failure to Pay Bills

By Gina Macris

Update: At the close of business July 26, all nine developmental disability service providers owed money for start-up costs in converting from sheltered workshops to supported employment had received payment in full, according to a spokeswoman for the Rhode Island Executive Office of Health and Human Services. A list of the agencies and the amounts appear at the end of this post.

With one exception, the state of Rhode Island largely has met the latest deadlines of a federal court order which spells out how it must lay the groundwork for long overdue compliance with a 2014 consent decree meant to desegregate adults with intellectual and developmental disabilities.

The state has until Friday, July 29, to pay up to $800,000 in start-up costs, as specified in the consent decree, for nine private service providers converting to community-based services from sheltered workshops, according to the court monitor in the case, Charles Moseley.

If that deadline is not met, Mosely said in a new report to U.S. District Court Judge John J. McConnell, Jr., the judge should impose fines of $5,000 a day, with an additional $100 per day for each person protected by the consent decree whose employment or integrated day services are delayed or interrupted as a result of the violation.

Those fines, with a maximum of $1 million per year, were set forth in the order McConnell issued May 18.  It is the second time in three months that the state has faced the prospect of fines for failing to pay its bills in relation to implementing the consent decree.

Moseley said he had received assurances from Jennifer Wood,  the Deputy Secretary for Health and Human Services, Jennifer Wood, that the Friday deadline will be met.

The plans for converting sheltered workshop operations to integrated employment services had been approved by the state and the bills for start-up costs had been submitted by the agencies at least three months ago.

The start-up activities are necessary to enable the service providers to meet employment targets in the consent decree. Moseley noted, adding that this point was made during April 8 evidentiary hearing, which McConnell used as the basis for his order, issued May 18.

According to an investigation of the U.S. Department of Justice, the sheltered workshops violate Title II of the Americans with Disabilities Act, which says, in effect, that individuals with intellectual or developmental disabilities cannot be relegated to segregated settings simply because they are disabled.

In the 2014 consent decree, the state agreed to change its services to emphasize integrated employment paying minimum wage or higher and other community-based activities over a ten-year period.

Moseley’s most recent status report was submitted to the court last Friday, July 22.

In it, he said that the budget enacted by the General Assembly, a total of $246.2 million for developmental disabilities, will provide sufficient funding to meet requirements of the consent decree during the current fiscal year, which ends June 30, 2017.

The budget is still a little more than $11 million more than Raimondo had originally requested.

Budget provisions specifically related to the consent decree include:  

• A total of $9.1 million for wage increases and performance-based contracts for providers offering integrated employment supports.

• Funding for four state (staff) positions focused on consent decree implementation, including chief transformation officer, consent decree coordinator, employment specialist, and program development director.

Although the General Assembly did not approve Raimondo’s request for $5.8 million for a caseload increase, citing flat enrollment, Moseley noted that the legislature left the door open to reconsider if the numbers changed.

The monitor said 125 new cases had been approved during the fiscal year which ended June 30, although most of them were still in high school and were not expected to need a full array of adult services during the coming fiscal year. (According to the state's report, these cases encompassed ages 17 to 24.) 

Mosely did ask the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) to report to him on any individuals protected by the consent decree “whose acceptance into the adult DD system is delayed or deferred due to lack of funding.”

McConnell’s order required the state to develop a management plan for accomplishing consent decree goals and tasks, and while Moseley said the plan met basic criteria, he found it lacking in detail on organizational strategies within BHDDH  and on interagency cooperation.

The lack of specificity is “understandable,” he said, given that three key positions at BHDDH are vacant. They are the department director, the director of the division of developmental disabilities and the chief transformation officer.

Moseley recommended that the state have until December 1 to expand and strengthen the management plan.

Other comments in Moseley’s status report focused on high school students with developmental disabilities who are 14 years and older and of particular concern to federal officials because they are at risk for segregation as adults if they are not afforded transitional services.

He secured a commitment that state employees from BHDDH or from the state Office of Rehabilitation Services in the Department of Human Services would be available to attend all Individual Education Plan meetings for special education students with developmental disabilities who are at least 14 years old.

Moseley noted that BHDDH has developed a protocol for timely communications with individuals having developmental disabilities and their families concerning applications for adult services.

He also recommended that BHDDH develop and distribute a description of the process for determining eligibility that is “clear, easy to access, user-friendly and written in plain language,” including contact information for BHDDH employees who would be able to answer additional questions.

“It is important to note that the eligibility determination process frequently is associated with a great deal of anxiety and concern among individuals with disabilities and their families,” Moseley said.

“By its nature, the process is technical, complicated, and difficult for a lay person to understand. Direct contact with an eligibility determination staff member offers an important opportunity for famelies to learn about the process and have their questions answered,” he said. 

Click here to read the monitor's full report

Service providers that received start-up costs for supported employment, as required by the monitor 

ri executive office of health and human services

Montanaro Says Rhode Island DD Services Have a Long Way to Go; She Won't Miss the Politics

Photo by Anne Peters 

By Gina Macris

When she became director of Rhode Island’s developmental disability agency in February,  2015,  Maria Montanaro inherited a budget with no relation to actual costs that was destined to run a deficit.

 She had to work with a state­-run system of group homes resistant to change, which she said exists to preserve jobs and not to serve clients.

And she had virtually no high-­level staff to form the leadership team necessary to move forward on compliance with the 2014 federal consent decree that requires Rhode Island to transform its services for adults with disabilities from segregated programs to integrated, community­-based supports.

A little more than a year into the job, as she was trying to reduce costs to hit a budget target that seemed plucked out of thin air, Montanaro realized that working in state government was not for her.

She said Governor Gina Raimondo and the Secretary of Health and Human Services, Elizabeth Roberts, have been very supportive. After favorable state revenue estimates in May, Raimondo added to her budget request for developmental disabilities, and the General Assembly gave her most of what she wanted.

Nevertheless, the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) needed everything the governor asked for - a total of $16.9 million in new Medicaid funding, Montanaro said.

In March, Raimondo had asked her to stay on until the budget process was complete, Montanaro said, and she agreed.

In the end, the political aspect of running  BHDDH proved to be ‘very draining,” said Montanaro. Her last day at BHDDH is June 24.

“It takes an enormous amount of effort to move the levers” of state government, she said in a recent interview. Formerly CEO of Magellan Behavioral Healthcare in Iowa and the Thundermist Health Center in Rhode Island, Montanaro had never worked in state government before she came to BHDDH.

In public statements in recent weeks, Montanaro has helped start a new conversation about splitting up BHDDH – a change that could not come without legislation enacted by the General Assembly.

Accustomed to dealing with budgets as professional challenges, Montanaro said she found that trying to get funding in the right places is also a political issue in state government. That was “very difficult for me,” she said.

It was “enormously frustrating,” she said, to inherit a system of fragmented services and balance sheets always running millions of dollars in the red. (The deficit has averaged about $4.6 or $4.7 million for the past eight years.)

 She offered a frank analysis of what’s wrong at BHDDH, and the reasons the Division of Developmental Disabilities should be a separate entity, with its own commissioner, working hand in hand with the state’s Medicaid administrator.

 “Politics aside, there is a responsibility to adequately fund the system,” Montanaro said.

Actually, there are two systems of care in Rhode Island for adults with developmental disabilities, and Montanaro indicated that is one of the problems.

One division of BHDDH operates a network of 25 group homes serving roughly 150 adults with a staff of less than 400 employees. The division is known as Rhode Island Community Living and Supports (RICLAS).

BHDDH also contracts with about two dozen private agencies which, in turn, hire some 4000 workers to serve roughly  3,600 clients day and night, including some 1,120 adults with intellectual challenges who live in about 250 group homes.

Montanaro said the one good thing about the state­-run homes is that employees are paid adequately. Their pay ranges from $15 to $25 an hour. Direct support workers in the private sector make minimum wage or a little higher -  an average of about $11.50 an hour. Burnout is high, and turnover runs an average of about 35 percent, according to testimony presented to the House Finance Committee last month.

 “RICLAS as a provider system needs to make changes, and it’s very hard to enact change with a unionized workforce with very rigid views on change,” she said. “We have a lot of limitations in negotiating those changes. Do we need a state-­run residential system?” Montanaro says she thinks not.

“Why not do that in the private sector; use contracts and incentives in the private sector to make sure we get people what they need,” Montanaro said.

“We should not be running a system to employ people. We should be running a system to serve clients,” Montanaro said.

Services for adults with developmental disabilities are all funded by Medicaid, Montanaro said, and the future costs can be projected fairly accurately by looking at the state’s costs for the past three years.

Montanaro contends that the social support services funded by Medicaid through the Division of Disabilities probably avoid medical costs in the long run. The social supports, like job coaching and other services, “allow them to live their best life, doing meaningful work and having a meaningful personal life,” Montanaro said. People who are more active and engaged in their communities are not as sick, using fewer medical services, Montanaro said.

“That is why I am arguing to change the structure,” she said, She envisioned a separate unit run by a commissioner of developmental disabilities – someone like Charles Moseley, a developmental disability career professional who formerly served as commissioner in Vermont.

Moseley is now the federal court monitor for compliance with the 2014 consent decree which requires Rhode Island to transform its segregated system into an integrated one over a 10-year period in accordance with the 1999 Olmstead decision of the U.S. Supreme Court. That decision clarified the integration mandate of the Americans with Disabilities Act (ADA).

Together, Rhode Island’s developmental disabilities commissioner and the state Medicaid administrator “should have a sight line over the whole experience,” so they are able to see how day supports affects utilization of medical services, Montanaro said.

“It’s pretty easy to look at caseload and utilization and set your budget,” she said. This exercise should be carried out as part of the state’s twice yearly caseload estimating conference, she said. Prior to Governor Raimondo, every administration has set an arbitrary budget target that did not reflective of projected costs, and BHDDH has responded by either lowering rates paid to private providers or running a deficit without worrying about the consequences, Montanaro said.

There’s an assumption in state government that the Division of Developmental Disabilities can lower costs by better managing the utilization of services, she said, but that’s not true.

 “The population is “fairly static,” and the needs of clients are stable, she said. Individuals who meet certain criteria are entitled by law to residential services and employment and other social supports.

The only way to reduce costs is to cut reimbursement rates to providers, which has been done in the past, she said. 

Montanaro said it appears that prior to her arrival, BHDDH may have created bureaucratic delays to save money by delaying the adjudication of appeals.

“We tried to terminate unfair practices,” she said. “We have a responsibility to plan for the service to clients.” In nearly 18 months at BHDDH, Montanaro said, her team “removed those operational barriers that we found in place here."

"Were they in place deliberately, or were they here because the department was wildly inefficient, with eligibility delays and claims lagging as a result? I won’t speculate on that,” she said.

The amount of time and effort necessary to bring about change in the state bureaucracy leads to “a lot of crisis management,” Montanaro said. “It’s designed to protect institutions from constant, fast change that could come with changes in administration every four to eight years,” she said.

In addition to having a realistic budget, Montanaro said the ideal developmental disability agency would be staffed by experts needed to move reforms forward.

As it is, she said, “the Division of Disabilities has lacked critical leaders in critical roles for all the years far back that I can see.”

For about 16 months, Charles Williams, the outgoing director of developmental disabilities, has split his time between that job and running RICLAS. His professional expertise is in mental health services rather than developmental disabilities, Montanaro said.

As a result of the consent decree - and Montanaro's efforts - BHDDH now has a chief transformation officer, Andrew McQuaide, and has just hired Tracey Cunningham of the James L. Maher Center in Newport as an Employment Specialist.

Funding has been authorized for a quality improvement officer to focus on programmatic improvements for BHDDH staff and private service providers. In addition, a high-level chief operations officer will be hired to round out the leadership team.

As for her own future, Montanaro, 58, said she will take the summer off to recharge. She plans to visit her son and daughter-in-law in France, where the couple are expecting their first child.

General Assembly Approves $15.4 Million Increase For DD; Worker Raises Are Assured

By Gina Macris 

Rhode Island’s developmental disability budget for the next fiscal year includes assurances that aa total of $9.1 million in Medicaid money will be spent to raise pay for direct support workers and to begin transforming the state’s system of services for those with intellectual challenges.

Shortly after 1:30 am on Saturday, June 18, The Senate approved total developmental disability funding of $246.2 million beginning July 1 in concurrence with the House vote taken Wednesday. That total, almost all of it state and federal Medicaid funds, is nearly $15.4 million more than the General Assembly approved last year at this time for the current budget, which closes on June 30.

New budget language ensures that $4.5 million in state revenue earmarked for worker raises and performance-based contracts can’t be used for anything else in the overall appropriation of the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) in the fiscal year that begins July 1.

The language is significant. In the recent past, as much $9 million has been budgeted in a single year to raise the wages of some 4,000 workers who provide direct support services, but the money has gone instead to help close deficits in the BHDDH budget.

The workers make an average of about $11.50 an hour, often less than the clients they support in jobs in fast food restaurants. Many of the direct support staff receive public assistance,  according to testimony presented to the House and Senate finance committees during the current legislative session.

The big difference between this year and past legislative sessions has been a federal court case aimed at enforcing a 2014 consent decree in which Rhode Island agreed to transform sheltered workshops and segregated day programs into a community-based system of services over a 10-year period. The decree settled a U.S. Department of Justice investigation that found the sheltered workshops violated the integration mandate of the Americans with Disabilities Act and the 1999 so-called Olmstead decision of the U.S. Supreme Court which clarified that requirement.

In late January of this year, Judge John J. McConnell, Jr. of U.S. District Court became actively involved in monitoring the state’s compliance with the consent decree. In May, he issued an order putting the state at risk for contempt if it does not meet any one of nearly two dozen specific goals.

One of the requirements in the order is that the state adopt increased funding sought by Governor Gina Raimondo for developmental disabilities in the next fiscal year “in order to fund compliance with the Consent Decree.” The order does not mention a specific dollar amount.

Several other requirements in the order collectively set an August 1 deadline for implementing appropriate raises for direct support staff, regular supervision of workers, and a pilot group of performance-based contracts for supported employment services.

It’s not yet clear how much money the raises will add to the workers’ pay, or what the incentives will be in the performance-based contracts.

Initially, Raimondo’s budget proposal included a little more than $5 million for raises of 45 cents an hour, but that sum was not considered enough to provide performance initiatives to the private agencies that provide most of the developmental disability services in Rhode Island. .

After improved state revenue projections in May, Raimondo added another $4 million to wages and other increases to providers. .  

Raimondo sought protective language to segregate state revenue budgeted for pay increases for developmental disability workers, but that wording was eliminated in the budget passed by the House Finance Committee.

Sometime before the June 15 vote on the House floor, however, new and more detailed language was inserted, a House spokesman confirmed Friday night. 

The new language says that $4.5 million of general revenue “shall be expended on private provider direct support staff raises and associated payroll costs to include targeted increases associated with performance-based contracting and system transformation incentives” authorized by BHDDH.

Because funding for developmental disability services is part of the state’s Medicaid program, the $4.5 million in state revenue set aside for raises would be matched by federal funds, for a total of slightly more than $9 million..

Raises also must be approved by the Office of Management and Budget and the Executive Office of Human Services, according to the budget language. Changes in reimbursement methods must be approved by the Governor’s office and OMB.

RI House Passes DD Budget Unchanged From Finance Committee Recommendation

By Gina Macris

(Correction: While the House did not change the appropriation recommended by the House Finance Committee, language was inserted prior to the floor debate that makes sure $5 million in state revenue cannot be used for anything else other than wage increases for direct support workers and performance incentives for the private agencies that employ them.) 

Rhode Island's developmental disability budget passed the House unchanged from the last week's finance committee recommendation in a floor vote shortly before midnight June 15. The House sent the entire $8.9 billion state budget to the Senate.

In developmental disability spending, the bottom line would be $246.2 million, part of $1.4 billion in human services expenses for the fiscal year beginning July 1.

 In June, 2015, the General Assembly authorized $230.9 million in developmental disability spending for the current fiscal year, which ends in two weeks.  As part of its action late Wednesday night, the House added nearly $9.6 million to that figure as a supplemental appropriation. 

The bottom line difference between the start of Fiscal Year 2016 and Fiscal Year 2017, which takes effect July 1, is nearly $15.4 million.

The new budget would include $9.1 million to raise the pay of staff of private providers who work directly with adults having developmental disabilities and to change the way the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) reimburses service providers.

These steps are necessary to satisfy some of the requirements of a federal court order issued in May to enforce a 2014 consent decree requiring a shift from sheltered workshops and segregated day programs to supported employment and community-based activities that comply with the Americans With Disabilities Act.

Pay increases would be coupled with yet-to-be negotiated performance-based contracts between the state and private agencies that help their clients get regular jobs and enjoy integrated leisure activities. 
 
Governor Gina Raimondo had proposed language that would specifically allocate $2.5 million in state funds for the raises. Each of those dollars would be matched by roughly an equal amount of federal Medicaid funding, for a total of about $5.1 million.

The House Finance Committee, however, removed the protective language around the $2.5 million in state funding, meaning that if BHDDH runs a deficit – as it has for the last eight years – the money set aside for raises could be used to help close the gap. (See correction at top of story.) 

Raimondo originally sought to pay for requirements of the consent decree in both the current fiscal year and the new fiscal year by using savings that would result from encouraging group home residents to move to less expensive shared living arrangements in private homes, but that initiative fell far short of its goal.

Her initial budget figured on saving $3.1 million in the current budget and $16.6 million in the next budget, by making as many as 500 new shared living arrangements.

However, the slow pace of these transfers led the governor to ask the General Assembly to put back all $3.1 million in group home costs in the existing fiscal year, and to reduce savings by $10.2 million in group home costs in the budget beginning July 1. The House agreed.  As a result, BHDDH is expected to save $6.4 million in group home costs in Fiscal Year 2017.

The House refused Raimondo’s request to add $5.8 million to the next budget for a caseload increase, with the finance committee recommendation saying the caseload has been stable at about 4,000 persons.

The House budget language adds extensive reporting requirements intended to keep the General Assembly abreast of BHDDH compliance with the federal consent decree, Rep. Eileen Naughton, D-Warwick, said on the House floor.

BHDDH is already required to provide key fiscal officials in the General Assembly and the governor’s office monthly reports on the developmental disability caseload and expenditures.

The new language encompasses not only information required by the U.S. District Court but other factors affecting the budget. It says:

“The department (BHDDH) shall also provide monthly the number of individuals in a shared living arrangement and how many may have returned to a 24-hour residential placement in that month. The department shall also report monthly any and all information for the consent decree that has been submitted to the federal court as well as the number of unduplicated individuals employed, the place of employment and the number of hours working. The department shall also provide the amount of funding allocated to individuals above the assigned resource levels, the number of individuals and the assigned resource level and the reasons for the approved additional resources.  The department shall also provide the amount of patient liability to be collected and the amount collected as well as the number of individuals who have a financial obligation.”

(This article has been updated.)

• UPDATE: The Rhode Island House passed the developmental disabilities budget unchanged June 15 and sent it to the Senate. Details to come. 

DD Service Provider Takes 'Wait and See' Attitude on Budget, Citing History of Disappointment

By Gina Macris

Until Rhode Island’s appropriation for developmental disabilities is released to the agency that administers it, the amount of money that is finally approved by the General Assembly will be  “just a number,” according to a member of the Employment First Task Force who follows legislative affairs.

photo by anne peters 

Tom Kane, (left), CEO of AccessPoint RI, a provider of developmental disability services, said that in the past several years, there have been three unsuccessful attempts to raise the pay of support staff for adults with developmental disabilities.

All the extra money, between $4 million and $9 million in a single fiscal year, has gone instead to fill a structural deficit in the budget of the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH), Kane said.

On Wednesday, June 15, the House is expected to vote on an appropriation that would add $9.1 million for raises for about 4000 workers and create a new reimbursement method for some two dozen agencies providing most of the direct services for individuals with intellectual or developmental disabilities.(

The budget proposal voted out of the House Finance Committee, however, does not include Governor Gina Raimondo’s request for $5.8 million for a caseload increase.

Kane indicated that amount of money could also represent the structural deficit in the next fiscal year's developmental disability budget. BHDDH officials say the deficit averages $4.6 a year.

Based on past experience, the money set aside for raises could once again be reserved to fill the deficit, Kane told the group.

The Employment First Task Force was created by a 2014 federal consent decree to serve as a bridge between the community and state governmental agencies that administer developmental disability services. The decree resulted from a federal investigation that found Rhode Island’s sheltered workshops violated the the integration mandate of the Americans with Disabilities Act., clarified in the 1999 Olmstead decision of the U.S. Supreme Court.

Mary Madden, the state’s consent decree coordinator, said, “People at the General Assembly are not into the consent decree at all.”

They don’t understand why developmental disability services cost so much, she said,  because they don’t understand “what it is to provide support 24 hours a day.”

Whatever figure is adopted – the current proposal has a bottom line of about $246 million dollars – the U.S. Department of Justice and an independent court monitor will review it. If either of them has the opinion it is not enough for the state to comply with the consent decree, they could ask the judge in the case to hold a show-cause hearing as to why the state should not be held in contempt.  

More Money for Developmental Disability Services; Is it Enough to Satisfy the Court?

By Gina Macris

The Rhode Island House Finance Committee’s recommended budget for developmental disabilities could represent a glass half full or a glass half empty. 

Neither description is likely to satisfy the U.S. District Court, which recently issued an order saying, in effect, that the state must provide developmental disabilities programs a full glass.  

The House Finance Committee would give Governor Gina Raimondo most of what she asked for in the next fiscal year, including $5.1 million to raise the pay of direct care workers making poverty wages and another $4.1 million to restructure the way private service providers are reimbursed. 

But the recommended budget also is built on two iffy assumptions – that the developmental disability agency will be able to save $6.4 million in housing costs and that the caseload will remain the same, with about 4,000 people receiving services. Raimondo’s budget asked for a $5.8 million increase for 100 new cases. 

If either assumption misses the mark, there might not be enough money in the budget to shore up the private service providers, putting at risk at least some of a total of $9.1 million set aside for the raises the service providers want and performance-based contracts the state wants in order to restructure the way it reimburses the private agencies and satisfy part of the U.S. District Court order. 

All of the Governor’s request – a total of  $16.9 million in added federal and state Medicaid revenue-  is needed to correct chronic underfunding in the budget of the Department of Behavioral Health, Developmental Disabilities and Hospitals (BHDDH), the department director, Maria Montanaro, told the House Finance Committee in a recent hearing.

 For the last eight fiscal years, including the current one, the bills BHDDH gets from service providers have exceeded budgeted amounts, Montanaro said. 

Raimondo sought to protect wage increases by specifying in her original proposal that $2.5 million of general revenue “shall be expended on private provider Direct Support Staff raises” in the next fiscal year. That sum would be matched by federal Medicaid dollars for a total of $5.1 million that would pay for 45-cent hourly wage increases.

 The protective language around the $2.5 million in state revenue has disappeared from the House Finance Committee’s recommendation. 

With the protective language gone, there could be a replay of the current budget, in which $4 million was originally set aside to boost workers’ pay but never made it into their pockets, going instead to help narrow a hole in the budget. 

Raimondo herself is counting on the first assumption, that BHDDH will save $6.4 million in the next fiscal year by convincing group home residents that they would be happier living with able-bodied housemates in private homes in the community. These are called shared living arrangements. Simply relocating people would run counter to federal law.

The $6.4 million in savings represents a fraction of Raimondo’s original estimate. In February, when she first released her budget for the 2017 fiscal year, she proposed saving $16.6 million by moving 400 group home residents to shared living in 12 months’ time. The House Finance Committee agreed with her subsequent request to restore $10.2 million of that total. 

The prospects of achieving even $6.4 million in savings are not strong if the efforts of the past six months are any indication.  What BHDDH director  Montanaro describes as a “full court press” to increase the number of shared living arrangements in the second half of the current fiscal year has yielded results that are about the same as the first half. There were 11 new shared living arrangements from July to December of 2015 and 10 new placements since January.

The governor’s budget proposal called for $3.5 million in group home savings during the current fiscal year with 100 new shared living arrangements,  but the actual savings will be more like $200,000, Montanaro told the Senate Finance Committee at the end of April.  

The House Finance Committee’s recommended budget acknowledges this development by adding $3.5 million back into to the department’s supplemental appropriation for the current fiscal period, which ends June 30. 

While approving major elements of the governor’s developmental disabilities budget proposal, the House Finance Committee rejected a $5.8-million request to cover an estimated caseload increase of 100 in the coming fiscal year, saying that the developmental disability caseload has been stable at about 4,000. 

Yet there is a backlog of about 240 individuals who have applied for an eligibility determination, according to a BHDDH spokeswoman. Two thirds of them are under the age of 21, according to another BHDDH official. That would mean that roughly 80 are over 21.   

And the numbers of young adults with developmental disabilities who are turning 21 and leaving school - 74 in the current academic year alone – suggest that the caseload should be growing. 

Persons with developmental disabilities between the ages of 14 and 21, who are at risk of segregation as adults, are one of the main concerns of the U.S. Department of Justice in enforcing a 2014 consent decree requiring community-based adult services, with an emphasis on supported employment. 

The consent decree, in effect until Jan. 1, 2024, resulted from a DOJ investigation that found the state’s sheltered workshops and segregated day centers for adults with disabilities violated the integration mandate of the Americans With Disabilities Act (ADA), which was clarified in the 1999 Olmstead decision of the U.S. Supreme Court.. 

In a hearing in April in U.S. District Court, the DOJ presented evidence that BHDDH does not determine eligibility until a few months before an applicant turns 21. 

State law says that persons with developmental or intellectual disabilities are eligible for services when they turn 18. 

Newly eligible young adults and their families often have trouble finding appropriate services, according to the evidence presented in court.  

Many of the two dozen private service providers in the state are not accepting new clients because they say they are operating at a deficit.  Montanaro has confirmed that assertion, telling the House Finance Committee recently that the private agencies have opened their books to BHDDH. 

With the federal court case continuing under terms of a judge’s order, there is likely to be pressure on the state to make sure that all applicants for adult services get timely consideration and an appropriate array of supports, a factor that could push up the caseload numbers. 

In its budget recommendation, the House Finance Committee said it would reconsider its refusal of a caseload increase if the numbers do go up. 

It is possible that decision was at least partly influenced by frustration in the House leadership with a history of poor record-keeping at BHDDH, something that also has worked against the department in the U.S. District Court case. 

The House Finance budget added extensive language requiring BHDDH to report monthly on a variety of statistics, including everything submitted to the court as part of the consent decree requirements. 

After the court experienced delays in getting an accurate count of individuals protected by the consent decree, Judge John J. McConnell issued an order May 18 that requires the state “to create a live database that will allow for efficient and effective tracking of each member of each target population outlined in the Consent Decree and all related and required services and outcomes.” The order then describes all the reporting requirements in extensive detail. 

In all, the order contains 22 requirements, most of them with deadlines in July and August. In the event of a violation of any part of the order, the DOJ or an independent court monitor in the case could ask McConnell for a show-cause hearing as to why the state should not be held in contempt. Fines start at $1,000 a day and max out at a total of $1 million for the year.

The first requirement of the order is that “the State will appropriate the additional money contained in the Governor’s budget for fiscal year 2017 in order to fund compliance with the Consent Decree.” No dollar amount is cited.  

RI House Finance Chairman Asks Whether DD Services Really Need Money; Gets Emphatic Yes in Reply

Maureen Gaynor uses assistive technology to testify before the Rhode Island House Finance Committee May 26. She says people with disabilities want the same thing everyone else does; a job, a role in their communities, and purpose in their lives. To her left is Lisa Rafferty, executive director of Bridges, a disability service provider.

By Gina Macris

Rhode Island’s developmental disability agency needs more revenue in the next fiscal year because it will not come close to saving a target of $16.2 million in group home expenses, the agency’s director, Maria Montanaro, told the House Finance Committee in a hearing May 26.

Montanaro emphasized that after eight years of cost-cutting in the developmental disability budget, the state now needs to add revenue to ensure that Rhode Island residents who live with intellectual challenges get the Medicaid-funded services to which they are entitled by law.

The Committee chairman, Rep Marvin L. Abney, (D-Newport), wasn’t necessarily convinced by Montanaro’s testimony, asking rhetorically, “Is money really the problem?” 

ABNEY                                          Image by Capitol TV

“We’re going on and on and on and on,” Abney said. “I’ll leave you with this thought. It’s not a question, but we are concerned,  is money really the problem? When we’re talking about efficiencies to the system, is money always the answer to that? You don’t need to respond, but just think of that as a director,” he said.

Montanaro did not reply, but other witnesses did say a lack of money is a key factor in ongoing federal court oversight of the state’s compliance with a two-year-old consent degree in which Rhode Island agreed to bring its disabilities services in line with the Americans With Disabilities At (ADA).

The agreement, with the U.S. Department of Justice, requires the state to enable more persons with disabilities to work in regular jobs, rather than in “sheltered workshops.” The decree also requires the state to help persons with disabilities participate in other community-based activities.

In an order issued May 18, Judge John J. McConnell, Jr. laid out 22 short-term deadlines the state must meet. Missing even one of them could trigger a contempt of court hearing. If the state is found in contempt, the judge would require the state to pay a minimum of $1,000 a day for violations of the consent decree, or as much as $1 million a year.  

The first requirement in McConnell’s order is that “the State will appropriate the additional money contained in the Governor’s budget for fiscal 2017 in order to fund compliance with the Consent Decree.”

The subject of the House Finance Committee’s hearing was Governor Gina Raimondo’s proposed budget amendments for the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH),  for 2016-2017 fiscal year, which begins July 1.

In all, Raimondo has requested $18.7 million in added revenue for developmental disabilities, offset by an accounting shift of $1.8 million in home health aide services from BHDDH to the Executive Office of Health and Human Services.

Also on the table is a proposal for about $6.8 million in additional appropriations in the current fiscal year to address a current budget deficit in developmental disabilities. 

If the General Assembly approves the supplemental appropriation, the bottom line in BHDDH’s Division of Developmental Disabilities would increase from $230.9 million to $237.7 million before June 30. Raimondo’s request for an additional $16.9 million in the coming fiscal year would push the overall disabilities budget up to $254.6 million, with about half that amount coming from state coffers. 

In fiscal 2016-2017, Raimondo seeks to make up $10.2 million of the $16.2 million she originally envisioned saving in reduced group home costs.

The governor also wants an additional $9.2 million in funding to raise salaries for staff who work with adults with intellectual challenges, or $4.1 million more than she asked for in February. 

In addition:

• $180,000 would be set aside for an ombudsperson to protect the rights of persons with developmental disabilities

• ·4.4 million would be restored to the BHDDH budget to prevent the inadvertent loss of professional services like occupational and physical therapy for some persons with developmental disabilities.

All the money comes from Medicaid, with a roughly dollar-for-dollar match in federal and state spending.

Montanaro, the BHDDH director, said adequate funding of developmental disabilities in the next budget would prevent BHDDH from running a deficit every year.

The developmental disability caseload, 4,000 to 4200 annually, also should be included in calculations of the state’s semi-annual Revenue and Caseload Estimating Conference to prevent unexpected surprises in the budget, she said. 

Montanaro                                                               Image by Capitol TV

The twice-yearly conference is a forum for top fiscal advisors to the Governor, the House and the Senate to reach consensus on the state’s revenues and Medicaid caseload expenses for the coming budget year.  

Montanaro said the $9.1 million in raises for direct care workers are necessary to satisfy the consent decree.

Without being able to offer higher pay, the private agencies that provide most of the direct services won’t be able to re-direct their efforts toward supporting their clients in jobs as the consent decree requires, Montanaro explained.

Workers make an average of about $11.50 an hour, often less than the clients they support in jobs in fast food restaurants, according to testimony at the hearing.

BHDDH originally counted on achieving $16.2 million in savings in the next fiscal year by convincing hundreds of group home residents to move into less expensive shared living arrangements with individual families, Montanaro said.

However, that effort has encountered resistance by individuals and families who find safety and security in group home living, she said.

Since BHDDH began what Montanaro described as a “full court press” on shared living at the beginning of this year, 10 group home residents have moved into private homes with host families, according to BHDDH statistics.

There are now 288 adults with developmental disabilities in shared living – an option that has been available for a decade in Rhode Island – and about 1300 persons living in group homes in Rhode Island.

Tobon                                                           Image by Capitol TV 

When Montanaro originally testified in January about the plan to shift to shared living, it was in the context of closing a projected $6 million deficit in the current fiscal year.

Recalling that testimony, Rep. Carlos E. Tobon, (D-Pawtucket), a Finance Committee member, said he had been “really concerned” about the timetable.

“You had to sit over there and pretty much, not  convince us, but tell us that this is what you were going to do,” Tobon said. “What was your confidence in actually achieving that?”

“I think I was very clear with the committee that it was a very aggressive approach,” Montanaro replied.

“But the problem, Representative, that I want you to understand, is that we are mandated by (state) law to come up with a corrective action plan” to close a budget deficit, she said.

The choice was either to continue the eight-year pattern of cutting benefits or eligibility, while the federal court watched “the crumbling of that system,” Montanaro said, or to try to get savings by encouraging persons with disabilities to move into more integrated living arrangements.

Montanaro described it as a “Sophie’s Choice,” a dramatic allusion to a forced decision being forced to decide between two terrible options.

 “We knew we might have to come back and tell you our actual experience with that,” she said alluding to the fact that the short-term shared living effort has fallen far short of the goal.

 A gradual shift toward shared living is in keeping with a broad, long-range federal mandate to desegregate services for individuals with a variety of disabilities, but it does not address the Rhode Island consent decree, Montanaro said.

 
In the past several months, as the federal court watched BHDDH spending nearly all its efforts to try to save more money instead of working on the employment requirements of the consent decree, Montanaro said, the judge and the court monitor in the case became “very worried.”

The monitor, Charles Moseley, has said that timing is critical.

Unless the state meets certain benchmarks now, Moseley has said in reports to the court, it will not be able to fulfill the long-range requirements of the consent decree, which calls for a ten-year, system-wide shift from segregated to integrated day time supports for adults with developmental disabilities to comply with the ADA. The decree, signed April 8, 2014, expires Jan. 1, 2024. 

Montanaro said that concerns of the monitor and the judge over the state’s emphasis on cost-cutting instead of the consent decree requirements prompted a recent court order that spells out conditions under which Rhode Island could be fined as much as $1 million this year for contempt. 

In her testimony before the House Finance Committee, Montanaro drove home her point.

“The last thing I’ll say about it is that we really can’t afford to direct all of our departmental activity toward an effort that isn’t actually the effort that the consent decree is obligating us to pay the most close attention to, which is the employment issue,” Montanaro said.

“Judge McConnell and the court monitor want to see the state of Rhode Island make the necessary financial investments in transforming the system, and you can’t transform everything at once,” she said, alluding to Moseley’s concerns about timing.

Montanaro continued to explain, but that’s when Abney, the committee chairman, interrupted, asking his rhetorical question: “Is money really the problem?” 

Later in a hearing that lasted nearly two hours, Tom Kane, CEO of a private service agency, and Kevin Nerney, associate director of the Rhode Island Developmental Disabilities Council, each told Abney that “it is about the money.”

Nerney said, “Whether I think it’s about money, or whether anyone else thinks it’s about money, there’s a federal court judge that thinks it’s about money, and the Department of Justice does, as well.”

Kane, CEO of AccessPoint RI, said “The reason the DOJ is here is a money problem,” he said. “We have jobs available for people (with disabilities) waiting to work,” he said, but providers of developmental disability services can’t hire the support staff “to make that happen,” he said.

Of 77 job applicants at AccessPoint RI during the month of April, 35 refused a job offer because of the low pay, Kane said. “They tell me they can make more sitting home collecting” unemployment benefits, he said.

Serpa                                                  Image by RI Capitol TV 

As he has testified at previous State House hearings on the developmental disabilities budget, Kane said private service providers operate at an average loss of about $5,000 a year for each person they employ. 

Rep. Patricia A. Serpa, (D-West Warwick, Coventry and Warwick), asked whether executives of developmental disability agencies have received raises while their workers have been paid low wages in recent years.

Kane said he gave all AccessPoint RI employees a 3 percent raise in January, the first time since 2006. At the start of the 2011-2012 fiscal year, after the General Assembly voted to cut $24 million from the developmental disabilities budget, everyone took a 7.5 percent pay cut, he said.

Donna Martin, executive director of the Community Provider Network of Rhode Island, CPNRI, said all the member agencies that cut pay that year started at the top.

A review of IRS reports from organizations exempt from taxes shows that executives of developmental disability agencies with budgets less than $5 million make 25 percent less than those of other non-profit agencies in Rhode Island, Martin said.

In developmental disability agencies with budgets greater than $5 million, the executives make 30 percent less than those of other non-profit organizations in the state, she said.

Kane, meanwhile, asked the committee to think of the governor’s budget proposal as a “jobs request.”

KanE                                                    ImAge by Capitol TV 

Kane submitted a copy of research done by the University of Massachusetts Amherst which indicates that every million dollars invested in disability services in Rhode Island creates a total of 25 jobs. Based on that research, Kane said later, the $9 million Raimondo has requested to raise pay for direct care workers would translate into a total of 225 jobs.

Kane also said the state should “braid” funding from BHDDH with the Office of Rehabilitation Services of the state Department of Human Services (ORS) to fund “employment teams” that would be more effective than the two agencies working separately to try to do the same thing.

That idea came out of recent discussions between state officials and private agencies about a system-wide redesign of services, Kane said.

Bob Cooper, executive secretary of the Governor’s Commission on Disabilities, said he would add the state Department of Labor and Training (DLT) as another “braid” in Kane’s analogy.

Federal rehabilitation dollars channeled through DLT reimburse the state 78 cents for every dollar the state spends; a better deal than the 50-50 match from the Medicaid program, he said.

The federally-funded Disability Employment Initiative, a workforce development demonstration grant run by DLT, “was making a difference” before the grant ended and the program shut down March 30, Cooper said.

If the state is to comply with the consent decree, disability-related job supports involving BHDDH and ORS must be merged with DLT, the state’s primary economic development agency, Cooper said.

RI Governor's New Request for More DD Funding To Go Before House Finance Committee Thursday

By Gina Macris

Rhode Island Governor Gina Raimondo has proposed adding nearly $16.9 million in state and federal revenue funds during the next fiscal year to shore up the state’s developmental disability system, which is under a federal court order to expand participation of adults with intellectual challenges in work and leisure activities in their communities to comply with the Americans With Disabilities Act (ADA). 

The addition of these funds, in four disability-related categories, will be heard by the House Finance Committee May 26, along with dozens of other proposed amendments Raimondo submitted in light of positive revenue estimates made a few weeks ago by state fiscal analysts. 

The new revenue reflects a change in the Governor’s approach to budgeting for developmental disability reforms, which originally depended on cost-shifting within the Division of Disabilities in the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH).

The disability-related amendments are:

•  An additional $4 million - about equally divided between state and federal funds – to raise the wages of some 4,000 direct care workers for private agencies that provide most of the services to adults with developmental disabilities. The amendment would raise the total allocation for worker raises from $5 million to $9 million.

• A $10 million increase in reimbursements to private providers, including $5 million in additional state revenue, to restore most of the cuts in housing costs made in the Governor’s original budget. That proposal projected 500 adults with developmental disabilities would move from group homes to shared living arrangements with individual families by June 30, 2017, although those estimates were later lowered to 300.  A total of 21 individuals have moved during the current fiscal year, according to the latest figures released by BHDDH. The added revenue will enable BHDDH to take a “more appropriate, more deliberative approach to transition individuals from group homes to shared living arrangements” in the future, according to Michael Raia, a spokesman for the Executive Office of Health and Human Services.

• A total of $170,000 in state and federal funding for an ombudsman who would protect the rights of adults with developmental disabilities. Legislation has been introduced in both the House and Senate to define the office and its duties, in response to the death of a resident of a state-run group home in February.

• Restoration of $4.4 million in state and federal funds used to pay for professional services like physical therapy in day centers, In February, the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) sought to shift the entire $2.2 million to Medicaid managed care organizations, but families complained that services had in fact been denied. The action was rescinded in March.

One of many provisions of a U.S. District Court order issued by Judge John J. McConnell, Jr. on May 18 is that “the State will appropriate the additional money contained in the Governor’s budget for fiscal year 2017 in order to fund compliance with the Consent Decree.” 

Any violation of that or any other requirement in the 21-point court order would allow the U.S. Department of Justice or the independent court monitor in the case to ask the judge for a contempt hearing. If the state is found in contempt, it will be fined a minimum of $5,000 a day for the duration of the violation, up to $1 million a year. 

In a telephone interview May 25, BHDDH director Maria Montanaro emphasized the need for the total $9 million Governor Raimondo has earmarked for wage hikes for direct care staff in the private service system, in addition to the other adjustments.  

Part of what the court wants is a redesign of reimbursement rates, which is more complicated than only raising wages, Montanaro said. The changes in reimbursement that the judge wants, however, can’t be accomplished without paying the workers more, she said. 

Raimondo’s budget originally envisioned an increase of $5 million in state and federal funds to pay for a 45-cent hourly wage increase for a workforce now making an average of roughly $11.50 an hour, according to testimony in recent House and Senate committee hearings. 

Montanaro could not say exactly how the additional $4 million in federal and state funds would further affect wages, but it would allow BHDDH management and agency representatives to discuss factors like the salaries of supervisors of direct care staff and the cost of employer taxes and benefits, she said. Those discussions would be held after the budget is adopted, she said. 

 Currently, private agencies are not fully reimbursed for those employer costs, spokesmen for the service providers have testified at recent budget hearings, and they operate at loss for each person they employ.  

Judge in Disabilities Case to Mull Costly Sanctions Against RI

By Gina Macris

U.S. District Court Judge John J. McConnell, Jr. said May 2 he is prepared to take “swift and dramatic action” if the state of Rhode Island fails to adequately fund a 2014 consent decree intended to correct longstanding  violations of the Americans with Disabilities Act.

U.S. District Court RI

Nicole Kovite Zeitler, lawyer for the U.S. Department of Justice, said she plans to file a formal request  asking the judge to order the state to contribute to a “consent decree compliance fund” unless adequate funding is secured by “a date certain” through the budgetary process, now underway in the General Assembly.

Neither Zeitler nor the judge put a specific dollar amount on the cost of the consent decree, although McConnell said he wants to see the money in Governor Gina Raimondo’s budget proposal enacted “at a minimum.”

Zeitler and the state’s lawyer, Marc DeSisto, will take one week to decide whether they can jointly submit a proposed order to McConnell, according to an informal schedule the judge approved from the bench.

If the two sides cannot work together, the DOJ will draft its own proposal. McConnell will hear arguments and then make a decision. The date of the next hearing has not yet been set.

The developmental disability system in Rhode Island has been underfunded for a decade, Zeitler said.

Moreover, she said she is concerned that the cost of the consent decree is being misrepresented in budgetary discussions. 

Families fear that the state is shutting sheltered workshops and providing nothing in their place, and “we share those concerns,” she said.

Zeitler, meanwhile, said the cost of the consent decree is being characterized in budget hearings at the State House as $1.8 million, but the consent decree requires changes throughout the developmental disability system.

The sum of $1.8 million happens to be one line item in the budget of the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) for subsidizing one-time start-up costs incurred by direct service providers who convert to community-based services from the segregated employment and day programs that the DOJ found in violation of the ADA.

Impact of Budget Plan Unclear

In the next 14 months, Raimondo wants to put an additional $24.1 million into private agencies that provide most of the direct services to adults with developmental disabilities, but whether her budget actually will achieve that goal remains open to question.

The way the budget document is now written, $19.3 million of that sum would come from savings in residential costs as occupants of group homes move into less costly shared living arrangements with individual families throughout the state. The proposal counts on 100 group home residents making the transition by June 30 on a strictly voluntary basis and another 200 moving in the next fiscal year, which runs from July 1 to June 30, 2017.

In the last ten months, however, only 21 individuals have entered shared living arrangements, accounting for a projected savings of about $200,000 in the current fiscal year, according to BHDDH figures.

There are other uncertainties about the budget.

The independent monitor in the case, Charles Moseley, and the DOJ are looking for a reconfigured method of reimbursing service providers that would allow them flexibility to individualize community-based services while requiring that they meet performance targets.

The new reimbursement model would come with increased funding to the agencies, but BHDDH director Maria Montanaro told the Senate Finance Committee last week there isn’t enough money in the Governor’s budget plan to extend this methodology to all the service providers. Instead, Montanaro proposed a pilot program involving a “subset” of the service providers.

A spokeswoman for the provider agencies, Donna Martin, said she “respectfully disagreed” with Montanaro’s  approach. 

“If we target certain agencies (for pay hikes), we will not be able to recruit staff for any other program,”  said Martin, executive director of the Community Provider Network of Rhode Island (CPNRI) .

“We are facing an incredible staffing crisis,” she told the Senate Finance Committee.

 “Our staff are working minimum wage jobs. We are competing with McDonald’s” for workers, Martin said.

According to the current reimbursement rules, BHDDH pays service providers only for the time clients spend in direct contact with daytime support staff. That person-to-person interaction must be reported for each client and each worker, in 15-minute increments, throughout the day. Agencies are not paid when clients are absent, for whatever reason.

Job-scouting activities, in which a service provider might meet with a potential employer, are not part of the standard funding allocation package for individual clients.Clients who want employment supports must give up some hours in another category to get this funding. 

Until 2011, service providers received a set per-person allocation for a bundle of services that could be individualized, depending on a client’s needs.  Martin indicated that providers need a similarly flexible arrangement going forward to meet their obligations under terms of the consent decree.

Montanaro, meanwhile, said during the Senate Finance Committee meeting that a recent planning exercise came up with a $30 million price tag for applying a redesigned reimbursement model to all the service providers. She said that price tag was “impossible,” at a time when the department faced a $7 million deficit in the current budget.

Delays in Eligibility Decisions

Meanwhile, a backlog of applications for adult services that has caught the attention of the court could put additional strain on the budget that is not yet defined.

A BHDDH official told parents last week that there is a “very significant backlog” of pending applications for eligibility. At an average annual cost of $50,000 per client, an increase of 100 to the BHDDH caseload would add $5 million to the BHDDH budget.

BHDDH has been under pressure from the court to determine eligibility for young people promptly as they approach their 18th birthday, when they are defined by law as eligible for adult developmental disability services as long as they meet certain criteria.  

Since March, the Consent Decree Coordinator, Mary Madden, and other state officials have met with representatives of applicants for adult services who have experienced “inordinately long delays” in getting eligibility determinations as well as “receiving inadequate communication about the progress of their applications,” according to a report to the court submitted by the state last week.

“Those individual cases have been resolved,” the report said, but Madden told the court Monday the backlog still exists. She could not say how many applications are stuck in the pipeline.

Action Items Long Past Due

Many of the questions put to Madden and to Jennifer Wood, Deputy Secretary of the Executive Office of Human Services, had to do with pending consent decree action items that are long past due.

The state and the monitor were to have settled on a protocol for reporting compliance by Oct. 1, 2014, but it became common knowledge to dozens of individuals following the implementation of the consent decree that Moseley was having trouble getting access to BHDDH data throughout 2015.

Wood reported Monday that a confidential electronic data base allowing the monitor to track compliance according to each individual affected by the consent decree will go online in 2017, although an interim solution, in a quarterly report, will be available July 1.  

A Quality Improvement initiative was to have been launched by Nov. 1, 2014, but it is still waiting for the appointment of a quality improvement director. Funding for the position has been authorized. Each individual affected by the consent decree was to have an individual career development plan by Jan. 1 of this year, but those are not all in place.

The performance-based contracts that Montanaro said would be part of a new pilot reimbursement program with a portion of the service providers were to have been implemented system-wide by Jan. 1, 2015. 

A public education plan to explain the requirements and the philosophy of the consent decree was to have been up and running Sept. 1, 2014.

BHDDH officials submitted what they believed was the final version of the public education plan to the monitor on April 1, but Madden told the monitor Monday that “events of late have caused us to think how many more people need to be involved.”

She did not elaborate. BHDDH officials who hosted a “town hall” meeting with families and consumers in Warwick last week were met with a wave of hostile comments about the consent decree and disability services.

RI Families Blast Consent Decree and DD Services

By Gina Macris

Officials of Rhode Island’s developmental disability system hit blowback Wednesday from family members who oppose a 2014 federal consent decree that requires the state to move from sheltered workshops and segregated day programs to community-based work and leisure activities.

Debra Feller

Debra Feller, whose son has developmental disabilities, challenged the basis of the decree, saying it is contrary to the very law on which it is based, the Americans With Disabilities Act (ADA), by limiting, rather than expanding, opportunities for employment.

The decree, “violates the ADA“ for people like her son, who cannothandle outside employment, Feller said. She also contended that“sheltered workshops are being allowed to deteriorate at the expense of the consent decree.”

Michael Carroll, who works at a day facility in Middletown run by the James L. Maher Center of Newport, mocked a consent decree mandate that the state help adults with disabilities find and keep jobs in the community.

“The emperor has no clothes,” Carroll declared. “These jobs don’t exist. What happens then?”

The “same individuals who were working before at subminimum wage are now doing nothing,” Carroll said.

Their comments came during  a two-hour “town hall” meeting at the Buttonwoods Community Center on West Shore Road in Warwick, where about 100 consumers, their families and state officials discussed both the philosophical as well as the practical underpinnings of the consent decree.

The decree was signed after the U.S. Department of Justice found Rhode Island violated Title II of the ADA because it unnecessarily segregated adults with developmental disabilities in day programs or workshops that paid sub-minimum wage.

Title II of the ADA, underscored by the 1999 Olmstead decision of the U.S. Supreme Court, says that services must be provided to individuals with developmental or intellectual disabilities in the least restrictive setting that is appropriate.

Maria Montanaro, director of the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH), was to lead the session in Warwick, but she was ill Wednesday. Other BHDDH officials, including Andrew McQuaide, chief transformation officer, and Charles Williams, director of the Division of Developmental Disabilities, responded to the comments.

Thee sister of a man who is significantly impaired said the employment mandate of the consent decree was being carried out to an illogical extreme, at least in her brother’s case.

Lidia Goodinson said her brother is 56 years old and “doesn’t know the concept of work. ““Nobody would expect a two year-old to go out and get a job,” she said.

And yet her brother’s social worker told her that “to get funding, he has to look for work.”

Williams, of BHDDH, said, “Your response is to say that ‘I don’t believe he can work.’ “

Goodinson, however, said she did make herself clear. Nevertheless, the social worker said, “This is what the state requires,” according to Goodinson.

Williams asked Goodinson to give him the name of the social worker after the meeting.  

When Debra Feller asked whether “a sheltered workshop is a reasonable or appropriate environment for anybody,” the BHDDH transformation chief, McQuaide, said:  “The consent decree says it is not.”

McQuaide said there are many individuals with developmental disabilities who can and want to work in the community but can’t access the supports they need. The consent decree is designed to give them that choice.

“Nobody’s arguing about that,” Feller replied, but individuals like her son “can’t be left out of the conversation, either.”

The government is “stepping on their rights by saying they can’t be in a sheltered workshop,” Feller said. The audience applauded her remarks.

 McQuaide said the Department of Justice will say the consent decree “does not close sheltered workshops, but effectively it does.”

He said the state still has sheltered workshops, but at some time in the future, the state will no longer fund those.

He agreed with Feller that a sheltered workshop can provide space for a meaningful activity and foster long-lasting relationships, but he said those same meaningful relationships and activities can occur in the community.

As to Michael Carroll’s challenge that community-based jobs don’t exist, McQuaide said the employment targets in the consent decree are not “so astronomical” as to be difficult to achieve.

McQuaide scotched a rumor that the consent decree requires the state to close all segregated day facilities.

One center in Bristol is closing because its neighbor, Roger Williams University, wants to buy the property and the state has agreed to sell it, McQuaide said.  He said some of the people who attend that program will go to the Middletown center operated by the Maher Center and others will have community-based day programs.

McQuaide, after hearing the comments during the town meeting, said that “we have to do a much better job communicating about the consent decree.”  He offered to give Feller contact information for DOJ lawyers.

At the very least, the families’ comments underlined a gap between the promise of the consent decree and its day-to-day implementation in a service system hindered by poverty-level wages for professional staff workers and restrictive rules that prohibit flexibility and innovation.

Between 2008 and 2011, funding for developmental disability services was cut 20 percent, according to statistics presented in February to the state Senate Committee on Health and Human Services by the director of the Sherlock Center on Disabilities at Rhode Island College.  

A. Anthony Antosh said a smaller percentage of individuals with developmental disabilities had community-based jobs in 2015, a year after the consent decree was signed, than had been employed earlier at minimum wage or higher.  

“What has increased is the number of people who are essentially doing nothing” during the day, he told the committee.

After the consent decree was signed in 2014, sheltered workshops began closing abruptly under pressure from a previous BHDDH administration. Private agencies strapped for cash had no alternative programs already in place to support their clients in the transition to work and leisure activities in their communities.

At the Buttonwoods Community Center on Wednesday, BHDDH's Williams touched a nerve when he told parents they needed to be frank about their loved ones’ support needs during a periodic assessment called the Supports Intensity Scale (SIS).

Debra Feller said she was direct but “the SIS intake person refused to accept my answer,” a comment which again drew applause from the audience.

“I asked, ‘How long before I get this back?’ “ she said.  The BHDDH worker told her she didn’t know, “because I didn’t answer the questions the way she wanted,” Feller said.

The Department of Justice found that that the SIS was being used improperly as a funding mechanism. The multiple choice questionnaire was developed by the American Association of Intellectual and Developmental Disabilities as a guide in defining the supports necessary to help a particular person achieve his or her individualized goals.

The consent decree requires an outside health consulting firm to do an annual analysis of the way BHDDH uses the SIS and to submit the report to the independent court monitor in the case.

Devlin Allen, who hosts a man with developmental disabilities as a shared living provider, said that after a recent SIS, his client’s funding was cut by $8,000 a year, a 24 percent cut in reimbursement, which makes it “very difficult to maintain that  person in my home.” 

“They’re cutting the funding because we’re doing a good job with an individual,” he said. The SIS should take into account that if the supports are removed, a client’s level of need will increase, he said.

Williams told Allen to file an appeal. Almost all, if not all, appeals are granted, Williams said.

In closing, McQuaide said Montanaro, the department director, would reschedule her appearance for sometime in May. 

Funding Shift in RI Developmental Disabilities Budget Falling Far Short of Goal

By Gina Macris

Rhode Island Governor Gina Raimondo’s strategy for funding federally-mandated reforms to developmental disability services is in trouble, according to updated figures that emerged in a Senate Finance committee hearing Tuesday. 

Raimondo’s proposed budget puts an overall price tag of $24.1 million on expanded community-based services funded through the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) over the next 14 months to satisfy a first-in-the-nation consent decree designed to correct violations of the Americans with Disabilities Act (ADA).

        MARIA MONTANARO

The BHDDH budget plan relies on a total of $19.3 million savings in group home costs to pay for most of that $24 million bill, but the actual savings are materializing at a trickle. BHDDH director Maria Montanaro told the Senate Finance Committee only $200,000 in reductions are expected by the end of the current fiscal year June 30.

The $200,000 savings comes from an increase of 21 individuals who have moved from costly group home care to less expensive shared living arrangements since the start of the current fiscal year July 1, 2015, a BHDDH spokeswoman said Wednesday. In the last ten months, the total number of individuals in shared living has risen from 267 to 288. BHDDH had projected 100 new additions to shared living by June 30 of this year and 200 more in the next budget.

The $200,000 in savings is less than a tenth of the $3.1 million in housing cost reductions that BHDDH had hoped to realize in the current budget. 

The figures raise big questions about a huge revenue gap in Raimondo’s plan, which is due for its next review in U.S. District Court Monday, May 2 at 1:30 p.m. before Judge John J. McConnell, Jr. The state faces contempt proceedings and fines if it fails to adequately finance supported employment and other community-based services as required by the consent decree.

On Tuesday, the gap between projected and actual savings in the BHDDH budget caught the attention of Sen. Louis DiPalma,  (D-Newport, Middletown, Tiverton and Little Compton), who chaired the hearing.

DiPalma questioned Montanaro sharply.

“What are we doing about achieving $16.2 million?” he asked Montanaro, referring to the lion’s share of the $19.3 million cut in group home costs that is projected for the next fiscal year. 

First Montanaro said it is possible BHDDH will meet the targeted $16.2 million in savings as more individuals move into shared living.

“The pace will be slow,” she said. Shared living is “a completely voluntary activity.” Families are making a decision about something that is “a new concept and a scary concept.”

“With that said, I believe the target for (fiscal) 2017 will be realistic,” Montanaro said.

The goal may be possible, DiPalma said, “but the probability is zero.”

Exacerbating the financial situation at BHDDH is the short-term failure of a plan to shift a total of $4.4 million in professional services like physical and occupational therapy out of the BHDDH budget to Medicaid Managed Care. After BHDDH officials sent out letters in February telling clients to seek reimbursement directly from Medicaid, the Division of Developmental Disabilities received numerous complaints that individuals were, in fact, being denied services.

BHDDH rescinded the move in a subsequent letter of apology sent to consumers and families, at the same time nullifying planned savings of $2.2 million through June 30. Christopher Feisthamel, chief financial officer of BHDDH, said after the hearing Tuesday that the Executive Office of Health and Human Services (EOHSS) hopes to eliminate some of the bureaucratic hurdles that stand in the way of that cost-shifting during the next fiscal year. He could not be more specific.

DiPalma, meanwhile, indicated after Tuesday’s budget hearing that legislators will have a clearer idea of where BHDDH stands after the May revenue estimating conference, which concludes May 9. At the twice-yearly conference, the top fiscal officers for the governor and each legislative branch reach consensus on estimates for state revenue and caseload expenditures that are used in final budget deliberations.

Montanaro’s testimony put the shift toward shared living in a philosophical and budgetary context.

The single underlying principle of the Rhode Island consent decree and similar settlements in other states is that the “state should try very hard to move to the most inclusive, community-based system possible,” she said. Supported housing and shared living is part of that movement, she said.

“It’s not going to happen overnight,” Montanaro said.

At the same time, “we are faced with a targeted goal from OMB (the state Office of Management and Budget). There are very few places we can go to make those cuts,” Montanaro said.

Seven years of rate cuts to the private agencies that provide most of the developmental disability services in Rhode Island “have dramatically weakened the system,” she said. These funding reductions “have left clients very vulnerable.”

After a devastating cut of more than $24 million in the 2011-2012 fiscal year, the General Assembly has added a total of $18 million to the Division of Developmental Disabilities in succeeding budgets, but none of that money has reached the private service providers, according to Tom Kane, CEO of Access Point RI.

Instead, the money repeatedly has gone into plugging a structural hole in the BHDDH budget, he said.

Kane warned that if a $5.2 million supplemental increase to the current budget is not carried forward to the next fiscal year, the structural deficit will continue and the money Raimondo has set aside to shore up the private agencies will once again be diverted, threatening the stability of the entire service system. 

Earlier this month, Kane told a House Finance subcommittee that the private agencies operate at a loss of $5,700 a year for each person they employ, because the state does not cover the full amount of employer-related taxes and benefits.

On Tuesday, he indicated that said that if the agencies are forced to continue operating in the red, “there will be fewer of us next year.”

The General Assembly must “stabilize the system,” Kane said.