Developmental Disabilities Budget: Cause for Optimism, Cause for Concern

By Gina Macris

Rhode Island Governor Gina M. Raimondo is moving “in the right direction” by proposing to spend roughly $20 million more on efforts to more fully integrate developmentally disabled adults into the community, says the executive director for a network of private agencies that will do the lion’s share of the work.

 “That is a pretty remarkable show of commitment for this community,” Donna Martin, who oversees the 23-member Community Provider Network of Rhode Island (CPNRI ), said in a telephone interview Feb. 11.

 The community provider agencies, largely dependent on state contracts, have been operating at a loss for several years, and it is not yet clear how far Raimondo’s budget will go in shoring them up financially.

 Martin says she needs to confirm the details of the plan with the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) before commenting further on the prospects of the agencies getting out of the red.

 “Regardless of how we slice it, it’s a big step forward,” she said.

 Accomplishing a court-ordered shift toward community integration depends on millions of dollars in additional funding from the General Assembly and millions of dollars in savings, achieved primarily by moving 500 of 1300 people living in group homes into shared living arrangements with families throughout the state.

 Whether the state can accomplish a voluntary transfer of 500 individuals to new living arrangements in a 17-month period remains to be seen. Martin says the private agencies which arrange shared living situations, support host families, and provide quality control for BHDDH have expressed concern about the pace of the transition. 

Andrew McQuaide, Chief Transformation Officer for BHDDH, says that goal is achievable. No one will be forced to move, he says.

The state finances most supports for adults with intellectual challenges in two ways:  through state-run group homes and apartments, special care facilities and a day site that serve 210 individuals; and through similar residential arrangements and an array of other services run by the private agencies for about 3500 people — nearly everyone with an intellectual disability in Rhode Island eligible for some level of service.

High Court Mandated Change

 Raimondo’s multi-million dollar booster shot for the beleaguered private agencies is intended to help shore up chronic underfunding and launch a transformation of services for people with developmental disabilities that aligns with a 1999 U.S. Supreme Court civil rights decision. 

 Called the Olmstead decision for short, the Supreme Court ruling affirms the rights of people facing intellectual challenges to live, work, and play in their communities, just like anybody else.

 A 2014 civil rights consent decree between Rhode Island and the federal government – the first of its kind in the country – gets its authority from the Olmstead decision.

 Requiring the state to move people with developmental disabilities out of segregated workshops into community-based employment, the consent decree, in effect, results in the federal court ultimately having more power than the General Assembly over the amount of money that goes into developmental disability services and how the money is spent.

As budgetary discussions progress in the state legislature in the months to come, the ramifications are sure to surface at hearings bringing together the U.S. Department of Justice, state lawyers, and an independent Court monitor before U.S. District Court Judge J. McConnell, Jr.

At the first hearing in Providence in late January — about a week before the Governor announced her budget plan — all sides agreed that the state, so far, was making insufficient progress toward the 10-year goals in the consent decree.

 They acknowledged the Court’s authority to find the state in contempt and order any remedies it sees fit. Judge McConnell said he hoped to avoid such proceedings and in the near term would advise the parties at status hearings to be held every three months.

Millions More for Community Services

 In the fiscal year which begins July 1, Raimondo proposes an increase totaling $12.8 million to strengthen and expand community-based services for people with developmental disabilities.

The total includes:

• $5.8 million to pay for growth in the developmental disability caseload as more children with special needs, particularly autism, reach the age of 21. The increase is now running at a rate of 100 a year, according to a       BHDDH  spokesman. Families are having trouble securing services for which their young adults are legally entitled. In addition, youth in transition to adulthood is one demographic that is a priority in the 2014 consent  decree. 

• A $1.9-million increase for model programs intended to show the way for private agencies as they shift toward community-based employment and other integrated daytime activities.

• $5.1 million for wage increases of roughly 4 percent, or 45 cents an hour, for private agency staff, some of whom are making minimum wage and eligible for public assistance.

Depressed wages and eroding benefits have fueled high turnover and caused instability in staffing since 2011, when the legislature enacted cuts that ultimately slashed $26.5 million from the appropriation to the private agencies.

Martin said the state initially calculated the budget cut would mean an average hourly rate of $12, but agencies were forced to further reduce wages to help pay for health benefits and other fixed employer costs, including taxes and workers’ compensation.

The average hourly rate dropped to about $10.50, she said. The rate has inched up to about $11.55 an hour, on average, but employers have had to sharply cut benefits to help offset even these minimal wage increases.

The upshot is this: Private agencies operate at a loss for each person they employ, Martin said.

The $5.1 million line item designated for wage hikes does not cover the related labor costs or benefits, according to McQuaide.

Call for Supplemental Funds Now

Raimondo’s budget message also addresses funding issues in the current fiscal year intended to cover a shortfall of as much as $6 million while also expanding community-based services.

The governor plans to spend an additional $11.3 million for developmental disabilities, with some of that money coming from a supplemental appropriation and the rest from the savings realized by moving 100 adults from group homes to shared living arrangements by June 30, the close of fiscal 2016.

An additional 100 people would move to shared living in each of the four quarters of the next fiscal year to reach the goal of 500 transfers by June 30, 2017. On average, BHDDH saves $19,400 a year for every individual who moves from a group home to a shared living arrangement, according to a department spokeswoman.

The consent decree, which affects only daytime activities, is not the only pressure on the state to make changes.

New federal Medicaid rules for Home and Community Based Services (HCBS) address round-the-clock supports; saying, among other things, that people with developmental disabilities must be allowed to live in the least restrictive settings possible. Developmental disability funding comes from federal and state Medicaid dollars at a ratio of roughly one to one.

The changed Medicaid rules, as well as the high cost of running group homes, are reflected in Raimondo’s planned shift from group home residential care to shared living arrangements.

To help balance the budget, Raimondo would cut an overall $15.5 million in operating expenses for 23 state-run group homes. Non-personnel expenses for these group homes would drop 46 percent, from the current allocation of about $33.2 million to about $17.8 million in the next fiscal year.

The 296 unionized employees now assigned to the state-operated network of facilities would keep their jobs; changes in their duties would be subject to labor-management talks, according to McQuaide.

McQuaide said community living aides on the state payroll who are employed seasonally are paid at a rate that amounts to $35,688 a year. For full-time aides, the annual salary range is $37,280 to $49,618. Those figures do not include overtime.

Employees who do essentially the same work in the private system make an average of $11.55 an hour, which adds up to a little more than $24,000 for a full time staffer.

A pay increase to $12.00 an hour would just put the private agency workers back to where the state figured they would be after the 2011 budget cuts.  “We would like to pay our staff dramatically more,” Martin said.

Ambitious Expansion of Shared Living

The goal of shifting 500 adults to new living arrangements in the next 17 months suggests that dozens of state and privately-operated group homes will be closed. A BHDDH spokeswoman says that number is not immediately available.

“Philosophically the provider community embraces shared living as an element in the continuum of care,” Martin said.

“We’re trying to balance the state’s initiative, which is not unique to Rhode Island, but we will do everything we can to make sure each person has a choice,” she said.

 “That said, the number of 100 a quarter is very ambitious,” Martin said.

Shared living is not foster care, perceived as a temporary arrangement, but instead is based on a lasting relationship that takes time to develop, she said. Many times shared living arrangements occur between group home residents and people who they already know and like, Martin said.

”We really try to stress helping people find that home provider they have a connection with,” Martin said. Even if the private agencies locate 100 potential family providers every quarter, “it doesn’t mean we have 100 matches.”

There is extensive preparation for shared living and the process is stopped if at any time anyone involved – the client, a family member, community provider, or state social worker- forms an opinion that the arrangement would not be a good fit, McQuaide said.

Shared living has been an option in Rhode Island for 10 years, McQuaide said, and in that time 267 people with developmental disabilities have chosen that living arrangement.

The state “has not necessarily done a good job” in making sure that host homes have the supports they need, he said.

Whether or not BHDDH creates 500 new shared living arrangements in the next year and a half, he said, the experience will “provide us with an opportunity to assess what we need to do differently.”

“This is the direction we want to go in and we want to do it right,” he said. 

RI Governor's DD Budget: More for Community Services, Less for Group Homes

By Gina Macris

Rhode Island Governor Gina Raimondo on Tuesday proposed unprecedented increases in spending to expand community-based services for people with developmental disabilities over the next 18 months.

At the same time, Raimondo would offset much of the increased cost of services by shifting residents from expensive group home care to shared living arrangements involving individual families throughout the state, an approach that already is controversial among relatives of people with developmental disabilities.

The governor’s plan covers both the current fiscal year, ending June 30, and the next one. 

An additional $11.3 million in the current budget would go to a network of private providers, which forms the backbone of services for adults with disabilities. Those agencies, which have received shrinking reimbursements for the last several years, would get another $12.2 million in the next budget, which begins July 1.

The dollar figures reflect combined federal and state revenue at roughly one-to-one ratios.

Raimondo delivered her written budget proposal to a joint session of the Rhode Island General Assembly.

Her combined state-of-the state and budget address did not mention people with developmental disabilities, but the written message acknowledged that the current allocation to the private agencies does not include enough money for them to provide adequate services to this population.

Besides direct hikes to the providers, Raimondo would earmark an extra $1.9 million in the next fiscal year for innovative programs to comply with a 2014 statewide consent decree with the Department of Justice requiring more integrated employment and daytime activities for people with intellectual challenges.

Her 2017 budget also would provide $5.8 million for meeting the needs of an expanding caseload in the Division of Developmental Disabilities..

And there would be a 45 cent-per-hour increase next year for employees of private agencies who work directly with clients, a hike that is expected to cost an overall $5.1 million.

The wage increase is geared to helping providers better retain current employees and attract more highly skilled workers to support those facing intellectual challenges in jobs in their communities.

The fiscal strategy over the next 18 months is banking on big savings from moving people out of group homes into shared living arrangements.

Raimondo projects a $3.1 million cut in group home expenses before the current budget period ends June 30 and an additional $16.2 million in savings in that line item in fiscal year 2016-2017.

Maria Montanaro, director of the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH), testified in January before the House Finance Committee that she hoped to put a $3.7 million dent in a $6 million budget deficit in the current fiscal year by moving as many as 300 people out of group homes into shared living arrangements by the end of March. About 1,300 people now live in group homes.

But the negative reaction from family members – one has started a petition against the shift – was enough for her to issue a statement emphasizing that changes in housing are voluntary .Many group home residents do not have close relatives or legal guardians to help them decide whether to move.

Montanaro’s statement, posted on the BHDDH website, also sought to reassure families about the safety and benefits of shared living arrangements. She said there are 276 people in shared living arrangements now and “as the individuals will attest, they are very happy and living a more independent life.”

Apart from the reduction in group home expenditures, there would be several million dollars’ savings in other categories of spending on behalf of people with developmental disabilities.

All together, the budget hikes and the offsets would result in a net increase of $8 million to the current developmental disabilities budget – from $229.7 million to $237.7 million,

In the next fiscal year, the division would receive $235.2 million.  Developmental disabilities gets slightly more than 60 percent of the entire BHDDH budget. 

Will the Budget Pass Muster with the Judge in Disabilities Case?

By Gina Macris

When Rhode Island Governor Gina Raimondo proposes a new state budget on Tuesday, Feb.
2, U.S. District Court Judge John J. McConnell, Jr. will be watching to see how the state plans to keep its promise to reform employment opportunities and other daytime services for people with disabilities.

 Rhode Island isn’t spending enough money to meet the deadlines set out in two and three-year-old consent decrees reached in landmark cases involving the Americans with Disabilities Act (ADA).

 And an independent Court monitor overseeing the state’s efforts has said that if Rhode Island doesn’t meet certain benchmarks now, it will be unable to accomplish long-term goals at the end of the decade-long federal supervision spelled out in the consent decree.  

 But at a hearing Jan. 26, a state lawyer told McConnell that Raimondo’s budget would be a “game changer” in advancing Rhode Island’s response to the mandates.

 An internal committee of the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) tasked with redesigning services for people with developmental disabilities recommended $36 million in reforms last May,  but in an interview last Friday, a BHDDH spokesman said it is “very unlikely” that sum might appear in the governor’s proposal. 

If the Governor’s proposal falls short of McConnell’s expectations, it could set the scene for some courtroom drama during the upcoming months of budget deliberations at the State House.

The Court has the power to find the state in contempt – if it comes to that – and McConnell made it clear on Jan. 26 that he would not hesitate to use his authority if it is necessary. But said he hoped to avoid it.

 Let’s follow the case and the money at the heart of the issue before the Court.

The case surfaced in 2013 with a consent decree between the U.S. Department of Justice and the City of Providence over Providence teenagers with developmental disabilities, who had been segregated in a program called the Harold A. Birch Vocational School. Birch prepared them for a lifetime of rote assembly-line jobs –at sub-minimum wage – in a sheltered workshop for adults at an agency called Training Through Placement in adjoining North Providence.

 The 2013 settlement – the first of its kind in the nation - asserted the young people’s right to receive services to support them in employment and day activities in more integrated, community-based settings in accordance with the Americans with Disabilities Act.

 "The Supreme Court made clear over a decade ago (in the so-called Olmstead decision of 1999) that unnecessary segregation of people with disabilities is discriminatory. Such segregation is impermissible in any state or local government program, whether it be residential services, employment services or other programs,” a U.S. Justice Department spokeswoman said at the time.

A year later, in June, 2014, the Justice Department’s Civil Rights Division reached a statewide agreement with then-Governor Lincoln Chafee which mirrored the Providence settlement.

Today, 31 percent of Birch graduates are employed in community-based settings – up from 14 percent six months ago – but those numbers fall far short of the mandated goal of 100 percent, according to the independent Court monitor, Charles Moseley, whose oversight continues through 2024. 

 He and a Justice Department lawyer, Victoria Thomas, each laid out a laundry list of other deficiencies in the Jan. 26 hearing before McConnell, who said he wanted to see the parties before him again in three months. 

 Now to the money:

 In the fiscal year that ended June 30, 2005, Rhode Island paid $187.3 million in state and federal dollars to private agencies providing services to Rhode Islanders with intellectual disabilities, according to state figures. Currently, the state allocates $188.4 million to those services.  It’s all Medicaid money, with the state providing 45 cents on the dollar and the federal government paying the rest, according to the BHDDH spokesman.  

In the meantime, the number of people reaching adulthood with developmental disabilities has been increasing. The current annual rate is about 100, and the average yearly cost of supporting one person is $55,000. 

 From 2005 through fiscal 2008, the DD budget rose to $215.3 million. But as the shockwaves of the 2008 economic crash reverberated, the budget shrank, as did DD allocations in other states.

 While some other states started restoring money to DD services, Rhode Island slashed further.

 For the fiscal year ending June 30, 2012, the Rhode Island General Assembly chopped nearly $26.5 million off the allocation, reducing it from $206.5 million to just under $180 million. That’s a cut of 12.8 percent in one year.

And BHDDH put in place a reimbursement system that does not cover all the services that agencies provide during daytime activities – only face-to-face contact with clients. The legwork necessary to set up job interviews or community activities, for example, is excluded. This arrangement “incentivized” the segregation of people with developmental disabilities in sheltered workshops and day facilities, Thomas, the Justice department lawyer, told McConnell on Jan. 26.

 Even though the BHDDH administration changed with the inauguration of Raimondo as Governor in 2015, the reimbursement system remains in place. Moreover, BHDDH allows agencies to collect the money owed for daytime supports only through a burdensome reporting process that requires documenting each worker’s time in 15-minute blocks, for each client. If a client is sick, the agency does not get its client-specific incremental payment for that day.   

Since 2011,  private nonprofit providers have cut workers’ pay to an average of $11 an hour, staff turnover has skyrocketed, and two agencies have closed their doors.

 In an interview on Friday, the BHDDH spokesman, Andrew J. McQuaide, acknowledged that satisfying the mandate for integration “fundamentally costs more than the system we have now.” He agreed that the system is geared toward “congregate centers for day programs and employment.”  Service providers should be held accountable, though, said McQuaide, the department’s new Chief Transformation Officer.

 Last October, Maria Montanaro, the BHDDH director, told a group of parents that the $36 million in redesign recommendations had been tabled because of the cost.

 On Friday, McQuaide said it’s “very unlikely” the $36 million in reforms would re-surface in the Governor’s budget proposal. 

“I’m unaware of anyone who thinks the state can afford to increase the DD funding by $36 million in a single year,” he said. “It would be unprecedented in a single fiscal year.”

“The question becomes how to sequence this,” McQuaide said.

 He said he couldn’t speculate on how the court will react.

 “There’s no way of knowing what would please the court,” he said. But “at the end of the day I am optimistic we will move in the right direction.” 

Rhode Island Federal Judge Holds First Hearing on Olmstead Consent Decree

By Gina Macris

PROVIDENCE _Without added funding for adults with developmental disabilities, Rhode Island will continue to segregate them in violation of the Americans with Disabilities Act, a lawyer for the U.S. Justice Department told U.S. District Court Judge John J. McConnell on Tuesday.

McConnell listened to reports on the implementation of a 2014 consent decree requiring the state to shift an estimated 3,000 people with intellectual disabilities into community-based employment and daytime activities by 2024. 

The Justice Department lawyer, Victoria Thomas, and a Court monitor, Charles Moseley, each noted some early progress in implementation but said the state had failed to keep up with interim steps necessary to achieve the long-range goal in a decade’s time.

McConnell said it is "disturbing" that members of a “vulnerable population” are not receiving services to which the law entitles them. 

Alluding to possible contempt proceedings, he said the “Court will not be shy to use the powers vested in it” to enforce the consent decree, but he emphasized that he hoped process might be avoided.

Jennifer Wood, deputy secretary and chief legal counselfor the Executive Office of Health and Human Services,  suggested that the state’s path toward implementation might be clearer after Governor Gina Raimondo announces her budget proposal next week.

She said officials of the state budget office and the central agency for implementation, the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH), have met “dozens of times” in the last six months to discuss fiscal issues.

McConnellsaid, “Are you saying we may be a week early, but the consent order has been central to the budget deliberations?”

Wood said,  “We have specific commitments” to change the funding structure.  She called the forthcoming budget proposal “a game changer.”

Thomas said the Justice Department’s main concern was to hear specific details of plans to improve services.

Budget proposals aside, she said, she also wanted to know whether BHDDH is making changes that do not depend on funding.

Mosely urged BHDDH and other agencies responsible for providing services to build relationships with people with disabilities, their families, and businesses that might offer employment, as required by the2014 statewide agreement, as well as a 2013 decree affecting Providence high school students.

“I hear the families don’t feel they’re involved,” he said.

A lawyer for the state, Mark DeSisto, said the 2013 and 2014 agreements,  represent “models for the nation,” and “a cultural change.”

“There’s a lot to this, a lot to go forward on,” he said.

He encouraged McConnell to become involved in an informal way in guiding the implementation of the two agreements.

McConnell agreed. The way he read the order, he said, “In dealing with vulnerable populations the Court can get involved more than making an order, and clearly should.”

“It’s a balancing act between enforcing the decree and ensuring the protection of vulnerable populations,” he said, “getting practical about it but not using the hammer.”

McConnell said he would hear status reports in open court every three months

The 2013 and 2014 consent decrees resulted from an investigation of the Civil Rights division of the U.S. Department of Justice, which concluded that that segregating Rhode Island residents with developmental disabilities in sheltered workshops violated the so-called Olmstead decision of the U.S. Supreme Court and the Americans with Disabilities Act.

In 1999, the High Court ruled that the state of Georgia violated the ADA by keeping two developmentally disabled women in an institutional setting against their wishes. 

Court to Hear Status of 2014 Consent Decree in Rhode Island

A landmark federal consent decree ordering the state of Rhode Island to move people with developmental disabilities from sheltered workshops toward community-based employment will mark its second anniversary in April. 

What has been accomplished? What remains to be done? 

Tuesday  Jan. 26, U.S. District Court Judge John J. McConnell is scheduled to hear a status report on the order – the first decree of its kind in the nation. Oregon entered into a similar agreement in September, 2015.

An investigation of the Civil Rights division of the U.S. Department of Justice found that segregating Rhode Island residents with disabilities violated the Americans With Disabilities Act and the Olmstead decision of the U.S. Supreme Court. 

In 1999, the Supreme Court ruled that keeping two developmentally disabled Georgia women in a mental hospital for years after they finished their treatment violated the Americans with Disabilities Act. 

In Providence on Tuesday, McConnell is expected to preside in an open session at 11 a.m. 
The U.S. District Court has jurisdiction over the case through June 30, 2024, with an independent monitor, Charles Moseley, given broad authority to investigate and verify details of implementation.