Historic Investment in DD Passes RI House

By Gina Macris

UPDATE: The Rhode Island House of Representatives approved developmental disabilities reform as part of a $14-billion state budget on a 68-3 vote June 9, sending it to the Senate.

The Rhode Island House of Representatives is expected to vote Friday, June 9, on a whopping $75 million for the state to reorganize its services for adults with developmental disabilities to comply with a federal consent decree deadline in a year’s time.

Total spending for developmental disabilities would jump from about $377.3 million to $469.1 million, an increase of about $91.8 million in an overall budget of $619.6 million for the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals. Developmental disabilities spending includes about $32.4 million for a state-run network of group homes, which is receiving an increase of about $3.1 million.

The reorganization includes a wage increase for frontline workers, from an average of $19 to an average of about $22 an hour, and expanded funding for more staffing to permit all daytime services to be offered in the community.

All adults receiving support from the Division of Developmental Disabilities — roughly 4,000 individuals — will be eligible for employment-related services in addition to other assistance included in basic individual budgets.

With several federal court orders in play, the House Finance Committee voted June 2 to send the massive investment in services for adults with developmental disabilities to the full House as part of an overall $14-billion state budget.

The new developmental disabilities system, which promotes the treatment of each participating adult as a unique individual, would replace an approach that incentivized group care in day centers and sheltered workshops and depressed the wages of caregivers for a decade.

In 2014, the state accepted a federal Department of Justice finding that its system for serving adults with development disabilities violated the Integration Mandate of the Americans With Disabilities Act. Rhode Island consented to overhaul that system within ten years, a transition requiring services to be individualized and made available in the community at large which, in almost all cases, is the least restrictive environment that is therapeutically appropriate.

But the state made only incremental changes until 2021, after Chief Judge John J. McConnell Jr. of the U.S. District Court found that a decade-long shortage of workers, exacerbated by the COVID-19 pandemic, was the single biggest barrier to implementation of the consent decree.

With average wages then hovering around $13.18 a year, McConnell issued an order in January, 2021, saying the state must raise the minimum wage for direct care workers to $20 an hour by 2024. But the needle did not move until the judge issued another order requiring the state to negotiate with private service providers and families operating their own programs to arrive at an interim pay increase in the forthcoming state budget.

The General Assembly raised the minimum wage to $15.75 an hour on July 1, 2021 and then to $18 an hour effective July 1, 2022. The budget up for the House vote tonight would raise the minimum wage to $20 an hour, the last step in complying with McConnell’s court order.

Other court orders resulted in a rate review of the entire developmental disabilities system and an initiative to attract new workers to better-paying and more career-oriented jobs in caregiving, among other things.

There appears to have been ongoing negotiations between the ,court and the state on the budget continuing as late as April, when Governor Dan McKee amended his original proposal and asked the General Assembly for more money to fund 100 percent community-based care instead of 60 percent. Until then, the plan was to continue offering 40 percent of services in group day care centers, an approach which is less staff-intensive than providing individual outings in the community.

Still to be answered is whether the state, through its private service providers, can translate the expanded funding into a smooth-running inclusive new system of services in time to meet the consent decree deadline of June 30, 2024.

The director of the trade organization for most private service providers has asked the public to urge their legislators to support funding not only for adults with developmental disabilities but also for vulnerable children.

The trade organization, the Community Provider Network of Rhode Island (CPNRI), is part of a coalition of organizations supporting an estimated 100,000 people eligible for various home and community-based services that have experienced the same labor shortages as the sector focused on adults with developmental disabilities.

Companion bills in the House and Senate would allocate $200 million of federal-state Medicaid funding to shore-up home and community-based services statewide during the coming year while the state’s health insurance commissioner completes a rate review similar to the one conducted for developmental disabilities. Those bills have not advanced.

The CPNRI director, Jenna Husted, applauded the “major investments in adults with disabilities and those that support them.”

“We are, however, concerned about the lack of investment in children with disabilities. Providers of children with disabilities are facing unique challenges and it is our responsibility to provide them the necessary support to thrive.

“We urge legislators to protect the major investment in adults with disabilities, and include investments for children with disabilities,” Husted said. “Together, we will become a more inclusive State.”

The House session is expected to begin at 2:30 p.m., according to the House Calendar.

BHDDH Seeks $18 Hourly Pay For RI DD Workers; $119M In DD ARPA Funding

By Gina Macris

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The $75 million in capital investments would include:

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

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

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

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

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

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