$2.5 M Unused For Lack of RI DD Jobs Program

CVS Trainee - File Photo

By Gina Macris

This article was updated Sept. 10.

A total of $2.5 million dedicated to helping adults with developmental disabilities find new jobs remains unused because the Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH) hasn’t yet decided on a program for spending the money..

 A department spokesman has clarified an earlier statement about the amount of money lacking a spending program.

In addition, the Division of Developmental Disabilities (DDD) is still seeking a replacement for the chief employment administrator, who left May 1.

The lack of readily available BHDDH funding dedicated to expanding the number of job placements was disclosed by the Director of Developmental Disabilities at a virtual public forum in August.

The situation represents one factor threatening the promise of a 2014 federal court consent decree to change the lives of people who once spent their days in sheltered workshops or day centers cut off from the rest of the community.

A parallel issue at the top of the list of concerns of an independent monitor is a shortage of skilled workers who assist people with disabilities to find meaningful jobs and expand their activities in the wider community.

The workforce shortage has taken on heightened urgency since the monitor recommended last week that the U.S. District Court accelerate recruitment of workers and possibly impose multi-million dollar fines against the state for noncompliance of the consent decree. (See related article.)

Until a new DDD employment program is adopted, adults with developmental disabilities must either seek state-sponsored employment services funded outside BHDDH or reduce other types of BHDDH service hours to pay for help finding a job.

Limitations on employment supports built into the current developmental disabilities system are part of a comprehensive review now underway of reimbursement rates for private service providers and administrative barriers to integrated services,

The 2014 consent decree anticipated that by 2022 – eight years later – Rhode Island would be scaling up pilot programs of supported employment that would reach some 4,000 people.

But BHDDH has never scaled up. Its first pilot program emphasizing individualized employment supports began in 2016 and underwent several iterations until the final version, the “Person-Centered Employment Performance Program 3.0” ended June 30.

The DDD director announced in February that the program would not be renewed but did not explain the reasons.

At the same time, the director, Kevin Savage, hinted at frustration on the part of the chef administrator for employment services, Tracey Cunningham, saying that she would be “leading the charge” in designing a new supported employment program “if Tracey stays with us, and puts up with us longer.”

But Cunningham, Associate Director for Employment Services since 2016, announced her departure in early April. BHDDH has posted the position twice but has not yet found a replacement for Cunningham.

The BHDDH spokesman could not say why a new supported employment program has not yet been put in place but said the “the DD team is meeting with stakeholders to determine a spending and engagement plan.”

Job Placements Fall Short

In an August 29 report to Chief Judge John J. McConnell, Jr., the independent monitor, A. Anthony Antosh, documented the state’s limited capacity to serve adults with developmental disabilities.

For example, 23 of 31 agencies serving people with developmental disabilities said in a survey they had to turn away clients or stop taking referrals between July and December of 2021 because they did not have the staff to provide services,

By July, 2022, the state had found jobs for only 67 percent of the consumers that it had promised in the consent decree – 981 of 1,457. (The new-job totals span the entire term of the consent decree, whether or not a particular individual is currently working.)

Antosh said that job placement numbers have remained flat throughout 2021 and 2022, increasing by only 17 in a 12-month period.

In general, he described the developmental disabilities system as being in the “messy middle,” borrowing a phrase from Michael Smull, a developmental disabilities expert on system change.

Antosh said elements of the system desired in the future have been defined, and some individuals are beginning to see progress. But he said most still face the restrictions of the current system, “which needs to be funded and maintained while the future is being built.”

Funding will depend on the results of the ongoing program review that is now underway and how the recommendations will be received by the governor and the General Assembly.

Rate Review To Finish Nov. 1

Under court order, BHDDH moved forward with the comprehensive review, hiring Health Management Associates, the parent company of Burns and Associates, earlier this year. Burns and Associates helped the state a decade ago to implement the current system, which the DOJ found violated the Integration Mandate of the Americans With Disabilities Act. (Burns & Associates says the state did not implement its recommendations for that program.)

The DD director, Kevin Savage, said the review will be completed Nov. 1, a month earlier than expected. He told a public forum in August that he plans to schedule another public meeting shortly after the review is completed to gather feedback from the community before the BHDDH budget goes to the Governor, who must present a proposal to the General Assembly in January.

The review is expected to address not only funding issues but controversial administrative features that the monitor says are barriers to a community-based network of services, starting with the eligibility process.

For a decade, BHDDH has used the standardized Supports Intensity Scale (SIS), a lengthy interview process, to determine the intensity of a person’s disability and assign one of five funding levels for services.

Antosh has pushed back against the state’s stated intention to continue using the SIS, saying it needs yet comprehensive review. Despite the re-training of interviewers in 2016, families still report the SIS does not result in the funding necessary for needed services. And they have complained for years that they sometimes felt humiliated and emotionally drained by the SIS interviews.

The state has developed a supplemental questionnaire intended to improve the accuracy of the SIS, but Antosh said very few families report that they have seen it or understand its purpose.

The families of young people applying for adult services for the first time “continue to report being overwhelmed” by the process, which the state has promised to streamline. And families also generally don’t understand how to appeal a funding decision they believe is inadequate for the services their loved one needs, Antosh said. He recommended that intensive training of social caseworkers continue about communicating new policies to families.

Administrative Barriers To Integration

Antosh’s report also outlined the concerns of service providers about some features of the reimbursement rules, including:

• A requirement that they document the time each daytime worker spends with each client in 15-minute increments, a time-consuming and costly process.

• Another rule that dictates staffing ratios for different kinds of activities, which sometimes results in results in group activities in the community instead of individualized experiences.

Antosh reiterated recommendations of a workgroup on administrative barriers that said:

• The ratios should be replaced with reimbursement rates which allow workers to have 1,2, or 3 clients in their care

• Documentation of worker time should be done in three or four-hour units

Antosh said he expects the reviewers will reach conclusions that are similar to the workgroup. He made numerous other detailed recommendations in the 50-page report.

With the consent decree set to expire in 22 months, on June 30, 2024, Antosh said that all of his recommendations must be “fully implemented with urgency,” using boldface for emphasis.

All the state’s reforms eventually must be approved by the Court.

Read the monitor’s August 29 report here.

Read the monitor’s Sept. 1 addendum here.

RI Faces Possible Fines For DD Noncompliance

Federal Building, Providence, RI

By Gina Macris

For a second time, the state of Rhode Island is facing multi-million dollar fines for non-compliance with a 2014 consent decree which seeks to enforce the rights of adults with developmental disabilities to live regular lives in their communities

The state was in the same position about this time last year, when the U.S. Department of Justice (DOJ) had asked Chief Judge John J. McConnell, Jr. of the U.S. District Court to find Rhode Island in contempt of court and impose penalties of up to $1.5 million a month.

Instead, the state produced a multi-faceted “action plan” approved by the Court last October to meet the requirements of the consent decree by the time its term expires on June 30, 2024.

But now, an independent court monitor says the state has not understood the urgency of the situation and has failed to meet the expectations of the court-ordered action plan, particularly in recruiting a sufficient number of direct care workers needed to implement a community-based system of services.

McConnell has scheduled a private conference with lawyers in the case for Oct. 11.

The monitor, A. Anthony Antosh, said a filing Sept. 1 that the judge will consider levying fines retroactive to Sept. 1 unless the state can convince him, in yet another plan, that it can step up recruitment to meet compliance deadlines. That three-page report amended a much lengthier analysis Antosh delivered earlier in the week.

As each month goes by, compliance becomes more difficult.

By July 1, 2023, ten months from now, the state must pull together an adequate workforce, sufficient funding, and new individualized community-oriented services system-wide to have a shot at full compliance by June 30, 2024, Antosh said.

The new system will have to be fully operational for at least a year before the DOJ agrees to end federal oversight, according to DOJ statements in past consent decree hearings.

With less than two years remaining in the decade-long term of the agreement, the state’s capacity to fully implement consent decree requirements “continues to be limited,” Antosh said in a report to the Court Aug. 29.

Antosh said the state has “failed to realize the urgency and scope of effort needed” to address a shortage of 1081 direct care workers – roughly a third of the workforce that would be necessary to implement a community-based system of services.

Antosh’s analysis focused on remedial steps Judge McConnell ordered in the state’s 2021 action plan to push the state along in reforming the disabilities system after it had failed to meet earlier goals.

In the plan, filed last Oct. 19, the state agreed to hire an outside consultant to “coordinate and implement an intensive statewide recruitment initiative” to expand the ranks of frontline caregivers.

Six months passed without progress in selecting a recruitment consultant, Antosh said. On May 3, Judge McConnell issued a court order spelling out a numerous recruitment-related activities that were to take place over the summer and deadlines for pulling in potential new-hires.

While the state has begun in recent weeks to implement several activities, Antosh said that as of mid-August, “the Court has not received a comprehensive plan that addresses all the required components” of the recruitment and retention initiative.

In the supplementary report filed Sept. 1, Antosh said he had spoken to more than 50 people involved in workforce recruitment and found consistent criticism about

• long delays in implementation of the plan

• a lack of clarity about its intent and outcomes

• a lack of connectivity between various activities involved in the overall plan

Antosh noted that the state, in its request for proposals to hire a consultant to speed the hiring process, did not require the successful bidder to supplement the recruitment efforts of the private service agencies or families who self-direct individual service programs.

The state’s $326,500 contract with the successful bidder, Sage Squirrel Consulting, specifies that it will “develop and establish statewide mechanisms for ongoing recruitment, onboarding, training and retention of Direct Support Professionals (DSPs)” for the system serving adults with intellectual and developmental disabilities.

Antosh, in his supplemental report Sept. 1, reiterated that the outside consultant hired by the state must become involved in recruitment and must coordinate with private service provider and families who seek workers for individually-designed service programs.

He spelled out detailed requirements of a revised recruitment plan which he expects the state to finalize by Oct. 7, four days before the lawyers in the case meet with the judge.

Provider agencies working on their own to close the gap of 1081 workers needed to implement the consent decree have made little recruitment progress on their own, Antosh concluded in his Aug. 29 report.

Between July and December, 2021, 32 agencies responding to a survey added a total of 131 people to their combined workforce. More recent figures are not yet available.

All together, the agencies still reported they had 618 vacancies, including 390 full-time positions and 228 part-time posts.

Of 350 front-line supervisors, 160 worked overtime to cover direct care shifts that otherwise would be unstaffed.

Antosh devoted attention to the staff woes of families who directed their own program of services for a loved one with developmental disabilities. Since 2017, their number has doubled, from 489 to 976. And this sector is expected to continue growing as more teenagers move into the adult service system in the future.

One factor in the growth of self-direction is that provider agencies are serving fewer numbers of people than they did before the COVID-19 pandemic. About two thirds of service providers licensed by the state reported turning away clients or declining referrals during the last half of 2021, according to Antosh’s report.

In two meetings, Antosh said, families “described their fear of imminent crisis if one or two of their primary staff depart.”

A total of 178 families responding to a survey reported having 416 support staff and 213 job openings, for a vacancy rate of almost 34 percent.

The families also had concerns about an inability to provide time for staff to participate in professional development and the lack of funding for medical or dental benefits – an important tool in recruiting and retaining workers. Without agency-level overhead, they are able to pay their workers an average of $19.94, or nearly $4 an hour more than the average starting pay at a licensed provider organization.

RI DD Rate Review: "Refresh" Or "New Analysis" of Project Sustainability?

By Gina Macris

Under court order, Rhode Island is conducting a comprehensive review of how it provides services for adults with developmental disabilities – a study that could have a profound effect on the quality of their lives.

Will the rate review go far enough to realize the goal of a 2014 consent decree – a system of services individualized enough to enable persons with developmental disabilities to become integrated in their communities?

In seeking a consultant for the rate review, the state said it wanted to “shift toward a system of community based supports that promote individual self-determination, choice and control.”

In the end, the state’s evaluation committee selected the firm that offered “more a refresh of a prior model than a new analysis,” Health Management Associates, the parent company of Burns & Associates (HMA-Burns). Under an independent corporate structure more than a decade ago, Burns & Associates helped the state create the problematic reimbursement system now in place, called Project Sustainability.

With completion of the study not expected until December, it’s too early to tell what the final recommendations might look like.

But the selection process suggests the state does not want to stray too far from the structure of Project Sustainability.

One of the three finalists for the rate review, Guidehouse Inc., said as much in its proposal:

“Guidehouse assumes in our proposed approach that BHDDH is not looking for an overhaul of those mechanisms now in place.”

While there have been some changes in Project Sustainability, a federal judge has found that that some of its features amount to administrative barriers to the system of individualized, integrated services required by the 2014 consent decree.

Those barriers, which are expected to be addressed in rate review, include

• A lack of individualized budgeting

• Exhaustive documentation of staff time with each client that detracts from services and is a costly burden for providers

• Staffing ratios that make integration in the community challenging

The state scored five bidders in two categories. Before cost could be considered, a four-member committee conducted a technical evaluation, valued at 70 percent of the overall score, which determined how closely the submissions matched objectives of the state’s request for proposals. Three firms, Guidehouse, Milliman and HMA-Burns exceeded the minimum of 60 points to be considered finalists.

HMA-Burns scored 61 points in the technical evaluation, one more than the 60 points necessary to qualify.

The evaluation committee found the HMA-Burns approach was “clearly defined, and the data approach is strong. However the methodology seems more a refresh of a prior model than a new analysis.” The proposal also “has a continuation of ‘buckets’ for funding rather than a robust approach to individual budgeting,” the committee said.

By comparison, the committee said Guidehouse, the top scorer, had an “engaging proposal, well written, visually engaging with good content.” There was also a “wide range of relevant experience, including recent experience assessing self-direction. (families and individuals designing their own service programs.)”

Among other things, the committee noted that Guidehouse had a “good understanding” of supplementary needs assessments that could lead to more accurate budgeting and reduce appeals that have resulted in the award of millions of dollars annually for supplemental services to which adults with developmental disabilities were entitled.

The cost proposals counted for 30 percent of the overall evaluation, but the committee did not score the originals from the three finalists. The original bids were:

• HMA - $339,680 - 1,516 hours

• Guidehouse - $499,350 - 2,235 hours

• Milliman - $1,203,181 - 4,628 hours

In its evaluation memo, the committee expressed concern that the bids reflected too much of a variation in the effort that would be devoted to the project. It did not interview the vendors, a common practice among public purchasing officials.

Instead, the committee asked for a second round of bids for a project that would encompass 3,000 hours, which the committee said would be sufficient to complete the rate review.

The results:

• HMA- $490,875

• Guidehouse - $670,290

• Milliman - $773,4000

After the second round of bidding, HMA-Burns tied with Guidehouse in the overall scoring but remained the lowest bidder. The final decision was made on the basis of cost.

ISBE MEANS A SMALL BUSINESS ENTERPRISE OWNED BY AT LEAST ONE PERSON WHO IS A WOMAN, MINORITY OR HAS A DISABILITY

During two meetings encompassing the evaluation process, the four-member committee awarded a single score in each category for each proposal through a collective group decision, or consensus, rather than individual scoring.

Individual, independent scoring is recommended as a “best practice” by the Center for Procurement Excellence. The Center is a non-profit organization that promotes education and training of pubic procurement officers and excellence in solicitation practices.

Members of the evaluation committee were Kevin Savage, Director of the Division of Developmental Disabilities; Anne LeClerc, Associate Director of Program Performance at BHDDH; Marylin Gaudreau, Data Analyst II at BHDDH, and Ashley Bultman, Senior Economic & Policy Analyst in the Office of Management and Budget at the Department of Administration.

In the end, the second round of bidding narrowed the range between the lowest and highest cost proposals but their relative positions didn’t change. Nor did the evaluation committee gain any additional information about the differing approaches.

In their cover letters with the second bids, both HMA and Guidehouse reiterated that they believed the work could be done in less than 3,000 hours.

Milliman, on the other hand, stated again that it believed the rate review would take more time. In fact, the letter said that if they were chosen, they would have to revise their technical proposal to conform with 3,000 hours’ work.

Gomes, the DOA spokesman, said purchasing rules gave the committee the choice of scoring proposals individually and interviewing the finalists, but he did not say why the committee did not do so.

Asked whether the evaluation process was designed to steer the project to a refresh of Project Sustainability instead of a new analysis of the system, Gomes said: “The goal of a competitive bid is to retain the best services at the most competitive price.”

“The request for proposals process evaluates both the technical aspects of the proposal and the submitted cost,” he said.

“When there is a wide discrepancy in the cost proposals, the Division of Purchases and agency initiating the procurement will provide an estimated level of effort (i.e. number of hours needed to complete the scope of work) and ask the respondents to submit a best-and-final offer.”

He said a “best and final offer process” is described in state Rules and Regulations 220-RICR-30-00-6(D) and state law R.I. Gen. Laws § 37-2-20(b) read in conjunction with state law R.I. Gen. Laws § 37-2-19(d) and (e).

RI House Finance: Big Bucks for DD, Human Services

By Gina Macris

Last June, direct care workers serving adults with developmental disabilities in Rhode Island were making an average of about $13.18 an hour.

In July, 2021, their starting pay jumped to about $15.75 an hour. And beginning July 1, they will make about $18 an hour – a $2.25 increase - if the state budget passed by the House Finance Committee last week becomes law.

The latest proposed raise, costing about $35 million in state and federal Medicaid funding, has been driven by the state’s efforts to comply with federal court orders reinforcing a 2014 consent decree that requires a shift to community-based services as mandated by the Americans With Disabilities Act.

A central issue in the court case is an inability to attract enough workers to carry out the reforms. With the blame for the shortage on low wage scales, the state is under court order to raise the direct care rate to $20 by 2024.

In all, the House Finance Committee would allocate $390.3 million from the federal-state Medicaid program to the Division of Developmental Disabilities, about $59.4 million more than in the current budget. The total includes $35 million for the raises, another $10 million to help private service providers move toward community-based services, and roughly $30 million for the operation of a separate state-run group home system.

The privately-run system the state relies on to provide most services for adults with developmental disabilities has been underfunded for a decade, according to the state’s own consultants.

In a bid for new consulting work last fall, Health Management Associates said that in 2011, the General Assembly underfunded the recommendations of its Burns & Associates division by about 18 percent and didn’t catch up until the rate increases of 2021 – a decade later. That’s when direct care wages exceeded $15, a rate Burns & Associates had proposed for 2012.

Tina Spears, executive director of the Community Provider Network of Rhode Island, applauded the House leadership, including Speaker Joseph Shekarchi, Majority Leader Christopher Blazejewski, and House Finance Committee Chairman Marvin Abney for “putting working families first.”

This year’s spending plan also recognizes that the workforce shortage in developmental disabilities extends to all sectors of the human services.

The proposed budget would authorize the health insurance commissioner to oversee an outside review all private human service programs licensed or contracted to state agencies, with the aim of recommending fair market reimbursement rates.

Once the baseline is established, a rate review would occur every two years for privately-run programs used by BHDDH, the Department of Human Services, the Department of Children, Youth and Families, Department of Health, and Medicaid.

The baseline analysis of Medicaid reimbursement rates would enable Rhode Island to become more competitive in attracting caregivers and the periodic rate review would prevent the system from slipping below market rates in the future.

“I’m excited about that. We’re doing something we’ve never done before,” said Sen. Louis DiPalma, D-Middletown, of the proposed changes in the way the state would approachMedicaid reimbursement for private human services.

The comprehensive review and the biennial rate update may seem mundane to many people, but ”it’s a critical thing to vulnerable populations in the state,” DiPalma said.

He and Rep. Julie Casimiro, D-North Kingstown, sponsored companion stand-alone legislation calling for the two-step rate review process.

Spears, the CPNRI director, called the budget an “investment in Rhode Island’s most vulnerable populations.” It sends a “clear message that people of all abilities should be able to access the care they need to live full, inclusive lives in our communities,” she said in a statement.

The House Finance Committee shifted responsibility for the comprehensive rate study from the Executive Office of Human Services to the health insurance commissioner and eliminated a community advisory committee that some critics said might pose a conflict of interest.

The committee also extended the deadline for the initial review for several months, until October, 2023. The extension means that rate changes could not be enacted until mid-2024, instead of next year, as DiPalma and Casimiro had hoped.

In separate legislation, DiPalma and Casimiro had called for a companion baseline study and biennial rate reviews for all Medicaid-funded medical and clinical programs in the state, but these services were not included in the House Finance Committee’s budget. There were substantial one-time reimbursement rate increases for some medical services, like maternity labor and deliver and dental care.,

Other initiatives aimed at strengthening children’s services and mental health come from federal American Rescue Pan Act (ARPA) funding. They include:

• $30 million for community behavioral health clinics

• $12 million for a children’s residential psychiatric treatment center

• $8 million for a short-term stay unit at Butler Hospital, the state’s only private psychiatric hospital for adults

• $7.5 million to shore up pediatric primary care, which lost capacity during the COVID-19 pandemic

• $5.5 million to attract early intervention professionals and reduce waiting lists for therapy among infants and toddlers with developmental disabilities.

Developmental disabilities spending for adults, meanwhile, contains about $10 million in expenses to conform with an in “Action Plan” the state proposed last fall to avoid a hearing over contempt allegations over non-compliance with the consent decree.

Most of that money, $8 million in federal-state Medicaid money, would continue a “transition and transformation fund” to help private agencies and those who direct their own service program change over to individualized, community-based services. Two million of the $8 million would be reserved for the “self-directed” individuals and families.

Another $1 million would fund technology like cell phones and tablets for adults with developmental disabilities to give them access to the same tools that many people take for granted today. And $1 million would provide for state infrastructure to implement and manage compliance with recent consent decree initiatives.

The full House will consider the overall proposed state budget- $13.6 billion - on Thursday.

RI Katie Beckett Settlement Spotlights Workforce Shortage

By Gina Macris

Two community organizations have questioned whether Rhode Island’s Executive Office of Human Services (EOHHS) can comply with a recent civil rights settlement agreement that requires the state to make available home and community-based services to all those children who are entitled to them by law.

On May 18, the U.S. Department of Justice (DOJ) and the U.S. Attorney’s Office in Rhode Island announced a settlement agreement with the EOHHS involving a boy with autism who had received only about half of the home-based therapeutic services the state had promised to provide under the “Katie Beckett” Medicaid program for children and teenagers with disabilities and complex medical needs living at home.

As a result, the boy was placed in a residential program out of state. But his parents withdrew him out of concern for alleged abuse and neglect. After about six weeks in the family home, the child moved to an in-state group home, according to the settlement agreement.

The DOJ found that the state “failed to ensure sufficient provider capacity” to deliver home and community-based services in the appropriate quantity, with the result that the boy was “unnecessarily segregated in an out-of-state residential treatment facility.”

Among other provisions, the agreement requires the state provide all the appropriate services to each eligible child in the state – an estimated 1,000 - through privately-run case management agencies called Cedar Family Centers, which would be responsible for individualized planning and coordination of care.

But the Community Provider Network of Rhode Island (CPNRI) and the Rhode Island Parent Information Network (RIPIN) have said the private service providers the state relies upon for therapeutic children’s services “do not have the capacity to help the state do what it has promised to the DOJ.”

In a statement, both agencies said they “applaud the DOJ’s decision to investigate the State’s failure to meet its obligations to provide services and support” for children with disabilities in Rhode Island.” The statement referred to the investigation that led to the settlement agreement.

Sam Salganik, CEO of RIPIN, said there simply aren’t enough workers to provide direct care or enough Cedar Family Centers to do individualized planning and coordination. 

He said the two Cedar Family Centers in the state, one run by RIPIN, have a total capacity of about 300 cases. That’s fewer than a third the estimated number of children eligible. It is believed there are roughly 1,000 children in Rhode Island who qualify for the Katie Beckett Medicaid program, but EOHHS has not provided an exact number. 

The settlement agreement gives EOHHS two months – until July 18 - to assign each eligible child to a Cedar Family Center.

The workforce shortage that prompted the boy’s family to file a complaint in 2018 is the same one plaguing other sectors of direct care, including services for adults with developmental disabilities. In that case, the lack of an adequate workforce is regarded as a major obstacle in implementing a 2014 consent decree requiring the state to provide daytime services that will enable adults with developmental disabilities to become part of their communities.

EOHHS has not responded to questions from Developmental Disability News about its strategy for complying with the settlement agreement.

The complaint from the boy’s family said the state authorized him to receive 25 to 34 hours a week of home-based therapeutic services and/or applied behavior analysis therapy since at least 2014,but failed to provide back-up care when scheduled staff became unavailable.

The settlement agreement requires the state to pay $75,000 in “alleged damages” to the boy and his family, although both DOJ and EOHHS say in the agreement that the document is not to be construed as an admission of liability by the state.

Other provisions of the agreement address detailed changes in policies and procedures to ensure that eligible children receive appropriate services as part of well-coordinated and individualized service plans.

The Katie Beckett Medicaid waiver program is named after an Iowa woman who became a pioneer in advocacy for home and community services. Katie Beckett suffered inflammation of the brain shortly after she was born in 1978 and remained hospitalized until she was nearly 3 because Medicaid regulations would not pay for ventilator care at home. The advocacy of Katie’s mother, Julie Beckett, eventually reached President Reagan, who in 1981 ordered a waiver in Medicaid rules for Katie. Katie died at the age of 34 in 2012, and her mother died about a month ago at the age of 72. Today, all 50 states have Katie Beckett Medicaid programs.

Both the recent settlement agreement between EOHHS and the DOJ and the long-running consent decree affecting adults with developmental disabilities draw their authority from the Integration Mandate of the Americans With Disabilities Act, as reinforced by the Olmstead decision of the U.S. Supreme Court. The mandate says people with disabilities are entitled to receive services in the least restrictive environment that is therapeutically appropriate – which is presumed to be the community.

The consent decree, which focuses on daytime services for adults, and the May 18 settlement agreement with EOHHS are the only two Olmstead-related agreements between the state and the DOJ since 2014, but the legalities of the two are different.

The consent decree is a negotiated agreement entered as a court order that is enforceable by court action, according to a DOJ spokesperson.

A settlement agreement is an out-of-court resolution that requires a signed agreement and certain actions to be performed by the defendant, with periodic assessment of compliance handled by the parties without involving a court.

If there is a breach of the agreement by EOHHS, DOJ may file a lawsuit to seek corrective action, 

RI's Olmstead Consent Decree Coordinator Moves On

By Gina Macris

Aryana Huskey, Rhode Island’s latest  statewide coordinator for implementing the 2014 Olmstead consent decree, has stepped down after 14 months to accept a job with the Healthcare Workforce Management Initiative run by the state’s Executive Office of Health and Human Services. 

She is the sixth person in eight years to work as consent decree coordinator, a position created at the request of an independent federal court monitor to unify the state’s response to the consent decree.

Responsibility for implementing the decree is spread across several departments of state government, while the General Assembly holds the purse strings.

In the last two years, legal proceedings in the case have made it clear that a community-based service system required by the consent decree cannot become reality without significant additional funding and legislative change to certain administrative practices. Only two years remain for the state to fully comply with the consent decree.

Huskey, who worked out of the state Executive Office of Health and Human Services (EOHHS), made the announcement in an email to the “DD Provider Community” on Friday, May 27, her last day as consent decree coordinator.  

EOHHS did not have any immediate announcement about plans to hire another consent decree coordinator or say who might serve as interim coordinator.  

In addition to EOHHS, responsibility for implementing the consent decree is spread across the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH), the Department of Human Services, the Department of Education, and the Department of Labor and Training.  

BHDDH delegates the day-to-day work of carrying out the changes mandated by the consent decree to private agencies it licenses to care for adults with developmental disabilities.  

The consent decree draws its authority from the Olmstead decision of the U.S. Supreme Court, which says people with disabilities have the right to receive services in the least restrictive environment that is therapeutically appropriate. That environment is presumed to be the community, the high court said.

For more background on the position of consent decree coordinator, click here.

Judge Steps Up Pressure On RI DD Hiring

By Gina Macris

John J. McConnell, Jr.

With the state of Rhode Island six months behind in its promise to recruit and hire  critically-needed caregivers for adults with developmental disabilities, a federal judge has stepped in to jump start expansion of the work force. 

On May 3, Chief Judge John J. McConnell Jr. of the U.S. District Court ordered the state to prepare a recruitment strategy by Aug. 1. He also ordered specific steps the state must take to boost hiring.  

McConnell said that by Aug. 1, the state must bring on a sufficient number of recruiters, who, in turn, can attract 60 job candidates that will result in 35 new hires each month between August and next May.  

“The workforce shortage continues to be a primary barrier to substantial compliance,” McConnell said in the order. 

McConnell’s order included two other steps:

• Beginning in June, the state will be required to report every two weeks to the court’s independent monitor showing its progress in four areas in establishing and training an adequate workforce.

• By June 30, the state must conduct focus groups with provider organizations, families and individuals who run their own service programs, as well as other relevant organizations, to gather the information necessary to develop a statewide recruitment strategy.. 

McConnell’s order is his latest in a long-running effort, initiated by the U.S. Department of Justice, to get the state to comply with a consent degree in which it agreed to reinvent a developmental disabilities system organized around day care centers and sheltered workshops into one providing broad job and social opportunities for men and women. 

The workforce recruitment initiative is but one part of a comprehensive “Action Plan” the state proposed to McConnell last October to avoid a hearing on contempt charges and possible hefty fines. But now, the state is far behind in its promised hiring effort. 

The state was to have hired a consultant by last Nov. 15 to coordinate a statewide initiative to expand the number of direct care workers. 

But the state is still working on the wording of a bid proposal for the consultant’s contract, with the bid next having to go through the state purchasing system, according to a spokesman for the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH). 

Since late February, individual provider agencies have had access to money from the first phase of a $12 million Transformation Fund designed to help them and individuals and families directing their own programs to strengthen community services. Individuals and families who direct their own programs will also have access to the fund.

There was a $15 million Transformation Fund in Governor McKee’s original budget proposal for the current fiscal year, but it was never enacted.

The idea of a Tranformation Fund re-appeared in the Action Plan adopted by McConnell in October, but the providers had to wait five months to access their portions of money because funding - $12 million from the federal American Rescue Plan Act (ARPA) - was not allocated by the General Assembly until Jan. 4. Then the actual funding had to wend its way through the state bureaucracy before it was released to the providers.

Now many of the providers are launching individual workforce recruitment initiatives as the first step in transforming services, but they have been unable to leverage any statewide coordination.  

One section of the consent decree requires the state to maintain an adequate workforce.  

But McConnell noted that earlier consultants ’ reports to the court “documented more than 1,000 direct support vacancies.” The consultants said the state had nearly 1,800 of some 2850 front-line workers needed to staff community-based, individualized activities.  

And the state has only a little more than two years to turn the situation around before the full compliance deadline of the consent decree on June 30, 2024.  

McConnell’s May 3 order speeding up the workforce initiative includes reports by the state to the court monitor in these areas:

• recruitment and retention

• training and professional development

  establishing work standards and a credentialling path for workers

• the involvement of institutions of higher learning in growing a trained workforce. 

The focus groups McConnell also ordered are to develop a recruitment strategy addressing these areas:

• The compliance needs of the state

• Possible career pathways for workers and possible pipelines for new talent

• “New concepts” for providing services

• Factors associated with job turnover and factors associated with retention

• Staff roles and responsibilities. 

Depressed wages for front-line caregivers are the primary cause of high turnover and vacancy rates. These two factors have led to a lack of sufficient services for vulnerable people who are entitled to them by law.  

In January, 2021, McConnell ordered the state to raise starting wages, then about $13.18 an hour, to $20 an hour by 2024.

Governor Dan McKee’s initial budget proposal for the current fiscal year, released in  March, 2021, contained no wage increase. But as a result of court-ordered negotiations between the state and private service providers, base pay jumped from $13.18 to $15.75 last July 1.  

This year, McKee has proposed raising direct care wages to $18.00 an hour, but recent inflationary pressures on the job market has prompted Sen. Louis DiPalma, D-Middletown, and Rep. Evan Shanley, D-Warwick, to propose companion bills that would hike that  hourly rate to $21 on July 1.

While the workforce shortage has been exacerbated by the COVID-19 pandemic, it has been building for more than a decade, ever since the General Assembly enacted the fee-for-service reimbursement system known as “Project Sustainability” in 2011 in conjunction with rate cuts of about 18 percent overall to private service providers.

Project Sustainability resulted in layoffs, double-digit pay cuts, and a growing exodus of workers. Jobs which once paid a living wage and had opportunities for advancement were turned into subsistence work.  

In 2014, the federal Department of Justice  found that Project Sustainability’s over-reliance on sheltered workshops and day care centers violated the rights of individuals to choose individualized services in their communities. Sheltered workshops were eliminated in 2018. 

Even after the state agreed to correct these civil rights violations, it did not follow through with the necessary funding.

From 2011 through 2018, funding for developmental disabilities never caught up with the cost-of-living, according to an analysis prepared by the Senate Fiscal Office for Sen. DiPalma in 2018 He is first vice-chairman of the Senate Finance Committee.  

McConnell took the bench in January, 2016 to oversee the case at the request of the DOJ and an independent court monitor, who in 2015 had found implementation lagging after an initial flush of success with former sheltered workshop employees who quickly found competitive employment.  

Beginning in 2016, the main fiscal strategy of the state was a multi-year effort to shift funding to daytime services from residential care by moving people from costly group homes to less-costly shared living arrangements in private homes.   

While shared living has grown slowly, it has not resulted in the significant savings that state officials originally envisioned.   

In response to pressure from the court in 2016, the Division of Developmental Disabilities hired professional staff to work on supported employment and community inclusion initiatives, but core requirements of Project Sustainability remain in place.  

They include staffing requirements geared to center-based care that are impractical in the community.  

In August, 2021, with the state falling farther behind in the number of job placements required by the consent decree, the DOJ asked McConnell to find the state in contempt of court and levy hefty fines.  

The state responded with the Action Plan, which McConnell turned into a court order.  

A key portion of the Action Plan is a rate review that is being conducted by Health Management Associates, a healthcare consultant which bought the firm responsible for creating Project Sustainability in 2011 There hasn’t been a rate review since then.  

In 2018, the lead consultant on Project Sustainability testified publicly that a rate review of developmental disability services was already overdue.  

Mark Podrazik, a co-founder of the former Burns & Associates, told a legislative commission that his firm recommends rate reviews every five years at a minimum. (Proposed legislation separate from the ongoing rate review would require Rhode Island to update reimbursement rates to developmental disability service providers every two years.)  

Podrazik, who now works for Health Management Associates on hospital projects, also said that the state undercut Burns & Associates rate recommendations in creating Project Sustainability in 2011. 

The current rate review is to be completed by Dec. 1, 2022, giving the state just 18 months to enact changes and get the federal government to sign off on its oversight role before the 2024 compliance deadline.  

To read Judge McConnell’s order, click here.

Low RI Medicaid Rates Strain All Healthcare Services, Witnesses Say

By Gina Macris

Annette Bourbonniere

Without a personal care assistant, Annette Bourbonniere of Newport needs up to five hours each day to get herself dressed in the morning.

For the past year, she hasn’t been able to find regular help for a position that pays $15 an hour, the Rhode Island-approved Medicaid rate for the services she needs, unchanged for the last 18 years.

Not only is it impossible for her to engage in productive activity, Bourbonniere says, but “I worry every day how I am going to survive.”

Bourbonniere, seated in a high-backed power chair, was one of hundreds of people from all walks of life who converged on the Senate Finance Committee April 28 to hammer home the message that the state’s Medicaid program is broken.

The witnesses testified for a cluster of bills which, taken together, would stabilize Medicaid-funded services with one-time rate increases and set up a rate review process every two years, with a 24-member committee drawn from the community advising the Executive Office of Health and Human Services (EOHHS). There is no estimate of the overall cost of the bills.

In a letter to the Senate Finance Committee, the Director of Administration, James E. Thorsen, and the acting Secretary of Health and Human Services, Ana P. Novais, indicated that the prospects for immediate changes appear gloomy.

Thorsen and Novais said there are 74,000 separate Medicaid rates in the state’s program, all of which cannot be revised in one year as the legislation requires. A rate review “of this magnitude” would take at least five years, they said.

They said the bill establishing a 24-member advisory committee for Medicaid rate review instead might be seen as “establishing policy and rate setting”, rather than advising EOHHS, the agency with the legal authority to set rates.

There is also an appearance of a conflict of interest in that the potential make-up of the committee includes members who would be recommending rates for other members of the same group, Thorsen said.

Support for Medicaid reform remains uncertain in the House, where Rep. Julie Casimiro, D-North Kingstown, has organized companion legislation adding up to a Medicaid overhaul..

At the outset of the hearing, State Sen. Ryan Pearson, D-Cumberland, the chairman of the Senate Finance Committee, said the Senate has already made Medicaid reform one of its top priorities in the current session.

Louis DiPalma

The legislation was spearheaded by Sen. Louis DiPalma, D-Middletown, first vice president of the Senate Finance Committee, who received repeated praise from the speakers for his relentless focus on equity issues in the human services.

Dozens of witnesses told the committee that the reimbursement rates to community-based health and social service programs fall so far below costs that:

• Access is shrinking to out-patient services that can prevent costly hospitalizations and even life-threatening situations.

• Caregivers ranging from doctors and dentists to nursing assistants and personal assistants to those with disabilities are either leaving their fields or leaving the state.

• Hospitals are left to deal with more patients who have nowhere else to go, while they lean on private insurers for more money to fill the gap. In the end, those who buy private insurance must foot the bill for escalating premiums.

According to the testimony:

• Four hundred infants with special needs are waiting for early intervention services to which they are legally entitled.

• Nearly six hundred elderly are waiting for home care services that will prevent them from going into nursing homes.

• Almost 200 children and youth are waiting for psychiatric care, sometimes in hospital emergency rooms.

Sherrica Randle

At the hearing, Sherrica Randle said her 13-year-old daughter has been hospitalized three times in the last six months for behavioral issues. During the most recent episode, her daughter spent nearly two weeks in the emergency room of Newport Hospital for lack of a pediatric psychiatric bed at Bradley Hospital, Randle said.

Elsewhere, a teenage girl who had made a “serious” suicide attempt nevertheless had to wait four months for mental health services, according to Alexandra Hunt, clinical director of Tides Family Services.

The COVID-19 pandemic exacerbated the labor shortage in front-line human services but many agencies have struggled for years to pay enough money to prevent workers from leaving the field, the witnesses said. Jamie Lehane, President and CEO of Newport Mental Health, said he had to sell a building a few years ago to continue making payroll and avoid a shut-down.

Like other community social service and home care agencies, providers of services for adults with developmental disabilities can’t get qualified personnel to work for Medicaid-approved rates, starting at $15 an hour.

These providers compete with retail and fast food chains, which pay more for jobs that are less demanding, said Casey Gartland, representing the Community Provider Network of Rhode Island, a trade association.

Unlike other sectors of the Medicaid program, services for adults with developmental disabilities are subject federal oversight because of a 2014 civil rights consent decree and several court orders, one of which requires the state to raise wages to $20 an hour by 2024.

The proposed budget of Governor Dan McKee would raise the wages of front line developmental disability workers to $18 an hour as an intermediate step on July 1.

But the most recent data about the workforce and inflation has prompted DiPalma to sponsor legislation that would raise the pay of developmental disability workers to $21 an hour on July 1. Rep. Evan Shanley, D-Warwick, has filed a companion bill in the House.

The Rhode Island Federation of Teachers and Health Professionals held a press conference in favor of that proposal just before the start of the hearing on Medicaid reform.

Doctors, dentists, and hospital executives testified in person and in writing that the state’s Medicaid program has a ripple effect on the healthcare of all Rhode Islanders.

The case of Women and Infants Hospital, where 80 percent of Rhode Island mothers give birth, illustrates that point.

Shannon Sullivan

Shannon Sullivan, President and CEO of Women and Infants, said it is the ninth largest stand-alone maternity hospital in the United States.

Nearly forty-five percent of its revenue comes from Medicaid Managed Care, which pays half of the Massachusetts managed care rate for obstetrical births, she said.

Simple math shows that the situation is unsustainable, she said. “This is not an issue that will go away, and it is not an issue that we have much time on,” Sullivan said.

Without Women and Infants, women experiencing difficulties in their pregnancies would have to go to Boston or New Haven to receive the same level of care, she said.

Gail Robbins, senior vice president of Care New England, the parent company of Women and Infants, said that because of low Medicaid rates, hospitals must put pressure on private insurers, whose rates are 200 to 300 percent more than Medicaid.

“It’s not a healthy bottom line,” Robbins said.

DiPalma said hospitals are not awash in cash. They absorb considerable costs in uncompensated care of uninsured patients, and must pay hefty licensing fees to the state, he said.

The Department of Administration and EOHHS support the programs funded by Medicaid and recognize the need for regular rate reviews, Thorsen and Novais said.

But “any changes to the rate setting process should be carefully measured and balanced to avoid significant negative funding impacts of other important programs such as education, public safety, and natural resources,” they said in their letter.he said.In their letter,

The state already spends 40 percent of its general revenue on human servicesm the two administrators said. By comparison, Massachusetts pays considerably more on the human services, up to 56 percent of its budget, according to DiPalma.

Others at the hearing saw the situation as a question of values.

Bourbonniere, a consultant on accessibility and inclusion, said she was dismayed when she attended an online meeting with EOHHS officials last fall and they said at the outset, with apparent pride, that Rhode Island has a lower Medicaid expenditure per person enrolled than the median in the United States.

For her and others going without services, “this was crushing,” she said in a letter to the committee.

Paying personal care assistants and other essential workers a living wage contributes to the state’s economy in the goods, services, and taxes they pay and the businesses they support, Bourbonniere said.

These essential workers also enable people with disabilities to earn a living. “Isn’t that better than the current investment in maintaining poverty,” she said.

The bills heard April 28 are:

• S2200- provides a rate-setting review every two years for all medical and human service programs licensed by the state or having a contract with the state, including those funded by the federal-state Medicaid program.

• S2306 - provides one-time increases to base rates in the Medicaid program for home care services

• s2648 - funds pass-through wage increases to those who work in long-term care in the community with $17.7 million in the established “Perry-Sullivan” law, rather than allowing the governor to use one-time funding from the American Rescue Plan in the next budget. Proponents say the state could be penalized by the federal government from using ARPA to replace or “supplant” existing funds.

• S2311 - provides for a 24-member advisory committee to EEOHS for the rate-setting process

• S2546 - provides for one-time Medicaid rate increases to early intervention and outreach programs for young children with special needs.

• S2588 - provides one-time increases to Medicaid rates for dental services and includes chiropractic care for the first time in the Medicad program.

• S2598 - increases the daily reimbursement rate to nursing homes by 20 percent for single-occupancy rooms with private bathrooms.

• S2884 - Provides a substantial increase to the Medicaid managed care rate for hospital births

• S2597 - eliminates the need for annual eligibility review for the eligible for the federal Katie Beckett program for children with disabilities, as long as a doctor says their condition is unlikely to change. the bill also allows families of eligible children to request additional service hours.

  All photos from Capitol TV

RI DD Employment Chief To Join AccessPoint RI

By Gina Macris

Tracey Cunningham, a key figure in Rhode Island’s employment efforts for adults with developmental disabilities, will leave state service to become head AccessPoint RI, a private non-profit provider of services to children and adults with intellectual and developmental (IDD) challenges.

pHOTO ribhddh

She will succeed longtime CEO Tom Kane on May 2, according to an open letter on the agency’s website from the chairwoman of the AccessPoint Board of Directors.

Cunningham’s departure from the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) comes at a critical time in the implementation of a 2014 civil rights consent decree, which emphasizes “employment first” for adults with developmental disabilities.

With a 2024 deadline looming for full implementation, Rhode Island faces a severe shortage of the workers needed to meet the employment goals spelled out in the consent decree. To reach full compliance, the U.S. District Court judge overseeing the consent decree has ordered the state to overhaul the entire service system for adults with intellectual and developmental disabilities.

Cunningham’s boss hinted earlier this year that she might be leaving BHDDH.

At a virtual public forum Feb. 9, Kevin Savage, Director of the Division of Developmental Disabilities, said Cunningham would be “leading the charge” in implementing any new supported employment program in the next fiscal year “if Tracey stays with us, and puts up with us longer.”

Savage was responding to a viewer’s question about the future of supported employment services at BHDDH. The third version of a Person Centered Supported Employment Performance Program (PCSEPP) expires June 30.

Savage said that program probably will not be renewed but funding for supported employment services will continue.

Last week, a BHDDH spokesman said of Cunningham: “We greatly appreciate her work to improve employment options for adults with intellectual and/or developmental disabilities. She will be missed, and we wish her the best in her new position.”

Cunningham has served as Associate Director for Employment Services in the Division of Developmental Disabilities since July 2016, according to her LinkedIn page. The post was created in response to the demands of the consent decree.

Elissa O’Brien, chairwoman of the AccessPoint Board, said Cunningham has more than 30 years’ experience in the field of intellectual and developmental disabilities, as well as two masters’ degrees, one in rehabilitation counseling and the other in strategic management and innovation.

AccessPoint has “lots to be thankful for” as Cunningham takes the reins from Kane, O’Brien said. “Under his leadership, the organization has grown and now services close to 1,000 children and adults annually. We are forever grateful to Tom for his hard work and dedication to our organization and to individuals living with IDD,” she said.

With April 9 marking the start of the eighth year of consent decree implementation, BHDDH could not say who might succeed Cunningham or describe specific plans for supported employment services in the next fiscal year, just three months away. A spokesman said only that “BHDDH will work with the stakeholder community to determine what that future programming will look like.”

Tina Spears To Challenge Blake Filippi For House Seat

By Gina Macris

Tina Spears, executive director of the Community Provider Network of Rhode Island (CPNRI), has announced she will run for the House seat now held by House Minority Leader Blake Filippi. 

Spears is the first Democrat to challenge Filippi since he was first elected to the House in 2014. 

Spears, a Rhode Island native and Charlestown resident for the last 30 years, is known at the State House as a persistent advocate for people with disabilities.  

Spears said, “I am excited to announce that I am running for State Representative in District 36, to bring the voices of my southern Rhode Island neighbors to the State House. 

She said the district she hopes to represent wants quality education, good jobs that keep people in their communities, and preservation of the environment of the beautiful coastline towns of  Charlestown, South Kingstown, Westerly and Block Island. 

Spears filed campaign papers with the state Board of Elections March 11.  

As executive director of CPNRI, Spears represented private providers of social services for adults with developmental disabilities in court-ordered negotiations which resulted in significant wage hikes for direct care workers last July.  

She also has been instrumental in the last year in organizing a broader coalition of more than 60 organizations to lobby for a living wage for frontline workers in a wide range of human service programs licensed by the state.  

Spears formerly worked as an analyst in the Senate fiscal office and as the coordinator of the state’s compliance with a 2014 civil rights decree affecting adults with developmental disabilities.  

She has a masters degree in public administration from the University of Rhode Island.  

Her path to advocacy began with her first son, Taquonck, who suffered a birth injury that resulted in significant disabilities.  

Spears said, “I love southern Rhode Island. I am part of the fabric of this community. And I know how to make change at the State House. I’m looking forward to an active campaign knocking on doors and hearing from neighbors - so I can effectively bring our community’s voices to the State House with me.” 

Filippi, one of the most prominent Republicans in the state, was regarded as a likely candidate for governor until he announced in December that he would run for re-election from his District 36 seat.  

He was first elected as an Independent in 2014 and later switched to the Republican party. A lawyer and organic cattle farmer, Filippi lives on Block Island.  

Bills Would Set Competitive Rates For All RI Human Service Workers

L TO R, Rep. Julie Casimiro, Sen. Louis DiPalma, Christina Battista. Audience Applauds Battista While DiPalma Hands Battista’s Notes to Battista’s Personal Care Assistant, Center.

By Gina Macris

Christina Battista, a supported employment coordinator for Skills For Rhode Island’s Future, says she never would have been able to earn a master’s degree or hold a job if it weren’t for a personal care assistant.

“Someone is literally my hands,” says Battista, who has a physical disability. Her personal care assistant helps her shower, cook, do laundry, take her shopping, help her meet up with friends, “and so much more.”

“Being able to live, rather than just exist, means more to me than I can express in words,” she said.

Likewise, Patricia Sylvia says she wouldn’t have been able to live happily at home for three and a half years after her stroke if it hadn’t been for a certified nursing assistant who helped her with everything from bathing to laundry to cleaning.

But Sylvia’s caregiver died last August. As a result, she’s lost 15 pounds and she feels her health and independence are threatened.

A wide range of medical and human service programs established to serve Sylvia and Battista and hundreds of thousands of others are facing a critical workforce shortage caused, in large degree, by the state’s low reimbursement rates for the pay of direct care workers.

Sylvia and Battista both spoke at a State House press conference March 8 in support of companion legislative bills that would address the critical need for direct care workers through mechanisms designed to set fair market pay rates every two years.

All members of the Senate have signed on as co-sponsors of legislation introduced by Sen. Louis DiPalma, D-Middletown setting up a rate review process that draws community representation into an advisory committee working with the Executive Office of Health and Human Services (EOHHS).

DiPalma said it’s the first time in his 14 years in the Senate that any of his bills has received unanimous support from his colleagues.

“This is about investing in hundreds of thousands of Rhode Islanders to ensure they have the services they need, for which they’re eligible, and for which the state is authorized,” DiPalma said.

Rep. Julie A. Casimiro, D-North Kingstown, has introduced the same legislation in the House; one bill aimed at reimbursements for privately-run human service programs licensed by the state and another for medical and clinical programs.

”Our health care system is suffering a crisis of care that has only gotten worse because of the pandemic,” Casimiro said.

“Severely underpaid” direct care workers in an “understaffed and under-supported” system are crossing the Rhode Island border to find better-paying jobs outside the state, she said.

Maureen Maigret, a decades-long advocate for the human services, said, “Everyone would rather get services at home, and it is also the clear law of the land that services be provided in the least restrictive setting possible.

And yet we have failed to build the kind of system that allows this, largely because we have failed to recognize the value of our direct care workers.”

Patrick Crowley, Secretary-Treasurer of the Rhode Island AFL-CIO, spoke from the workers’ perspective. “When working people are uplifted and they can lift up the community that they service, our entire community here in Rhode Island is better off.”

Crowley added: “If these bills can build the scaffolding we need, I say, let’s do it.”

In each case, the rate-setting process would be conducted every two years by the EOHHS with the advice of a 24-member advisory committee.

Tina Spears, executive director of the Community Provider Network of Rhode Island, said “Everyone deserves a living wage.”

“This solution would evaluate the costs” faced by providers and respond to them, she said.

Because the legislation would not have an immediate impact, Rhode Island must use some of its unspent funds from the American Rescue Plan Act to shore up human service agencies, Spears said.

The legislation gives EOHHS until March 1, 2023 to complete the first rate review recommendations to the governor and the General Assembly.

EOHHS would collect data from the state’s Medicaid administration, the state Department of Health, and agencies responsible for addressing poverty, child welfare, mental and behavioral health, developmental disabilities, and aging.

Then EOHHS would analyze the data in conjunction with separate 24-member advisory committees for medical and human services programs.

“It will cost money two years from now, but this is money we should invest,” DiPalma said, so that the state never again goes back to a situation in which a lack of staff forces infants and toddlers with developmental disabilities to wait for early intervention, as they have in recent months.

At least two other states, Massachusetts and Colorado, have adopted similar rate-setting processes, DiPalma said.

He noted that in Massachusetts, health and human services makes up 56 percent of the state budget, although that doesn’t mean Rhode Island should invest the same proportion in its human services sector.

At the same time, DiPalma said, Rhode Island is accountable for a wide swath of services, including child welfare, services for those with disabilities and the elderly, medical care for the poor, and behavioral health and substance abuse programs, among others.

Without a change in the way the state sets rates, those services will become increasingly unavailable, he said.

In 2014 a lack of integrated community-based services for adults with developmental disabilities resulted in a consent decree with the U.S. Department of Justice that is still dogging the state.

In that case, a review of rates paid to private providers of developmental disability services is underway under court order.

For the full text of the bills, follow these links: S 2311, S 2200, H 7180, H 7489

Consultant with Link to RI DD System Chosen To Recommend Fixes

By Gina Macris

This article has been updated.

The parent company of the healthcare consulting group Burns & Associates, instrumental in setting up the Rhode Island developmental disability system that led to a federal civil rights investigation, has been selected to help fix the problem.

Burns & Associates is now a division of Health Management Associates (HMA), which has been awarded a contract for a rate review expected to shape the state’s ultimate compliance with a 2014 consent decree.

Rhode Island’s Director of Developmental Disabilities, Kevin Savage, shared the news in a remote meeting Jan. 25 with a community advisory group on developmental disabilities that was created by the consent decree.

Savage did not disclose the cost of the contract or other terms of the agreement, except to say that he expected the review would be completed by the end of 2022 as part of the state’s court-ordered “Action Plan” for compliance by June 30, 2024..

Savage said HMA “won it ethically and fairly,” meeting all requirements of the state purchasing division. There were four other bidders.

Savage did not say whether anyone from the Burns & Associates division of HMA will work on the rate review. (Clarification: He did say no person who worked on Project Sustainability in 2010 and 2011 would return for the new review.)

HMA will engage with the developmental disabilities community in drawing up its recommendations, Savage said.

HMA’s connection with its Burns & Associates division will bring a lot of baggage to to the rate review.

A decade ago, Burns & Associates worked a year on a review that gave state officials the foundation for a new fee-for-service system called “Project Sustainability.”

State officials promoted Project Sustainability as a way of bringing equity and flexibility to the developmental disabilities system. But consumers, their families, and providers said the bureaucracy was nothing but a smokescreen for budget cuts.

Years later, the president of Burns & Associates said that while flexibility was the goal, the final version of Project Sustainability was shaped by intense pressure on BHDDH to control costs.

Going into the work, “we did not know what the budget was” for Project Sustainability, said Mark Podrazik, president and co-founder of Burns & Associates, who is now a managing partner in Health Management Associates. “We were not hired to cut budgets.”

In the final version of Project Sustainability, the state undercut Burns & Associates’ recommended menu of rates by 17 percent to 19 percent and used the bureaucracy built into the new system for a second round of cuts three months later.

For example, Burns & Associates recommended a starting rate of $13.97 an hour for front-line workers, effective July 1, 2011. By October the actual hourly rate was $10.66.

In 2014, the U.S. Department of Justice found that the system incentivized segregated care through sheltered workshops and day care centers in violation of the Integration Mandate of the Americans With Disabilities Act, which enshrined the righte of individuals with disabilities to choose to live regular lives in their communities, like everyone else.

The DOJ investigation resulted in the consent decree, which requires the state to overhaul its system to provide individualized, integrated services by June 30, 2024.

In 2018, Burns & Associates co-founder, Mark Podrazik, returned to Rhode Island to testify before a special legislative commission studying Project Sustainability at the behest of the commission chairman, State Sen. Louis DiPalma, D-Middletown.

Podrazik said he agreed because DiPalma was very persuasive and because he wanted to set the record straight on his firm’s role in Project Sustainability.

Overall, Podrazik said, Burns & Associates believed the Division of Developmental Disabilities (DDD) had neither the capacity or the competence implement Project Sustainability or to carry out the mandates of the 2014 consent decree.

“I think people were a little shocked” by the requirements of the consent decree and the question of who would implement the changes, Podrazik said of the DDD staff in place at the time.

Podrazik worked for the state monitoring the spending of Project Sustainability funding until January, 2016. His firm was paid more than $3 million in all.

In 2018, Podrazik told DiPalma’s commission that working on Project Sustainability wore him down. He has since switched to working with hospitals, he said.

This is a developing story.

For complete coverage of Mark Podrazik’s testimony before the Project Sustainability Commission, click here.

For a history of Project Sustainability, click here.

New Relief Funding Welcome, But Forum Says Caregivers Still Undervalued

By Gina Macris

In the last week, both Rhode Island and Massachusetts have taken steps to slow the exodus of workers from the community-based human service agencies the states depend on for critical mental health and social services.

The problem is that, through the federal-state Medicaid program, states set rates for human services workers in the private sector far below the salaries they pay state employees to do comparable work. The pay for private-sector human services jobs also lags behind he starting wages at major employers such as Amazon and Costco.

The two states are taking a variety of actions to raise pay and make the jobs more competitive, but a panel of human service executives from Connecticut, Massachusetts and Rhode Island says one-time infusions of cash do not address the core issue.

Massachusetts Governor Charles Baker is poised to sign a bill that passed both houses of the Massachusetts legislature last week giving $30 million in coronavirus relief funding to human service agencies to stabilize the workforce and provide college loan relief to workers.

In Rhode Island, the governor and the leadership of the House and Senate agreed Dec. 6 to use nearly $50 million in relief funds to re-open early intervention programs to new referrals and shore up staffing for agencies caring for children removed from their homes, child-care providers, and pediatric primary care medical practices.

The General Assembly also promised to tap $57.4 million in enhanced Medicaid reimbursements to support workers in home and community-based services, as long as the federal government approves that use for the money.

“It’s a step in the right direction,” said Tina Spears, executive director of the Community Provider Network of Rhode Island (CPNRI), of the announcement by Governor Dan McKee, House Speaker Joseph Shekarchi, and Senate President Dominick Ruggerio.

As she spoke, she was helping to lead a tri-state virtual public forum on the plight of nonprofit human service organizations – and how to stabilize them.

The forum described a regional slice of a national problem which threatens the quality of life essential to a thriving economy, the speakers agreed.

Community-based human service organizations, which provide a wide array of services, are the “connective tissue of the economy,” said Rhode Island Rep. Liana Cassar, speaking to more than 200 people in Connecticut, Massachusetts and Rhode Island who were listening or watching the two-hour presentation.

In the long run, one-time fixes, like coronavirus relief funds, will not address a system that has been long undervalued, Cassar said.

The pandemic did not create the problem, all agreed. Instead, it served as an accelerator.

Massachusetts State Senator Cindy Friedman said legislators were “blown away” by the statistics provided by non-profit human service agencies during State House testimony.

Massachusetts benchmarks the wages of employees in community-based human service organizations to a median of $16.79 an hour, said Michael Weekes, CEO of the Providers’ Council, a trade association of more than 220 community agencies that serve all types of people in need.

That median wage lags behind even starting wages at several large employers. Costco starts at $17 an hour and Amazon hires at a minimum of $18 an hour in Massachusetts, Weekes said.

“We just can’t compete,” he said. State employees in the human services make an average of $1,274 a week, but those in the private sector doing similar work get an average of $548 a week – a gap of more than 100 percent, Weekes said.

And whatever Connecticut and Massachusetts are paying for health and human services, Rhode Island is below that, said State Sen. Louis DiPalma. Rhode Islanders seeking better pay live within minutes of the Massachusetts and Connecticut borders, he said.

“We are treading water and taking on water,” said Spears, the director of CPNRI. The low salaries in human services have impacted the quality of life for a disproportionate number of minorities and women. They are essential workers, just like firefighters, police, and teachers, and should be treated that way, she said.

The consequences of the workforce shortage have become dire:

In Rhode Island, all nine early intervention programs for infants and toddlers with developmental delays were closed to new applicants programs at the end of November – a situation that is expected to soon be reversed soon with Governor Dan McKee’s release of $3.6 million in coronavirus relief funds from the CARES Act. That was part of the relief package announced Monday, Dec. 6.

In Connecticut, State Rep. Catherine Abercrombie said she had been hearing that a lack of mental health workers is an underlying issue in the three-day closure of one high school that had received threats of violence. Hamden High School, closed last Friday and again Monday and Tuesday. It reopened Wednesday with heighten security, and school officials planned to beef up mental health services, according to local news reports.

Diane Gould, CEO of Advocates, a large human services provider west of Boston, connected school violence and suicide risks to children’s mental health concerns.

The number of children who have attempted suicide increased “significantly” over the summer, she said. In August, her organization saw four children aged 11 to 17 who had tried to kill themselves.

“As many as 50 percent of the kids we’re seeing have aggression, suicidal thoughts, and anxiety,” she said, and there has been a 46 percent increase in calls to Advocates’ information and referral line since the pandemic struck in 2020, she said.

“There has been a terrible convergence of inadequate staffing with a dramatic increase in need,” she said.

Gould and other providers said they have been forced to create waiting lists for critically needed services or have stopped taking new cases.

In Rhode Island, service cuts for adults with developmental disabilities violate a 2014 civil rights consent decree that was supposed to bring them 40 hours a week of supported employment and individualized activities of their choice in their communities.

To keep staff from quitting, some providers described raises, signing bonuses, and other incentives they have given in the last few months – even though they are overspending their budgets.

“It’s a little nervous-making,” said Chris White, CEO of Road to Responsibility, provider of services to adults with developmental disabilities on the South Shore of Boston. “We’re doing this with one-time funds,” he said. “If there are Massachusetts legislators on this call, I hope you are hearing that. We are eating into our reserves.”

Abercrombie, the Connecticut legislator, said “this is a crisis.” The state still has $300 million in coronavirus relief funds to allocate, “and I’m glad we do,” she said.

The non-profit human service sector is a “vital business,” said Cassar of Rhode Island. “Our families depend on it and our economies depend on it,” she said.

“When people say, ’We need to bring well-paying jobs to Rhode Island,” they should be told, ‘We have jobs in Rhode Island. We need to make them well-paying,’” she said.

State senators DiPalma in Rhode Island and Friedman in Massachusetts have sponsored bills to permanently raise the pay of caregivers in the non-profit sector. Friedman’s bill would link salaries to the amount Massachusetts pays state employees for similar work, with a phase-in period of five years.

DiPalma has introduced a bill for several years that would fix minimum pay at at 55 percent above the state’s minimum wage, although he says he considers it a “work in progress.” DiPalma plans to re-introduce a revised measure in January.

Rhode Island will have a court-ordered review of the rates paid to private providers of developmental disability services, many of whom are members of Spears’ organization, CPNRI. A federal judge has ruled that without such a rate review, Rhode Island’s developmental disability system cannot fund the changes necessary to comply with the 2014 consent decree.

But that review will not affect other segments of the non-profit human services.

DiPalma said, “When we, the legislators, value the profession of the front-line workers, we will address the issue. Anything else will be a band-aid.”

DiPalma, the first vice president of Rhode Island’s Senate Finance Committee, acknowledged that solving the crisis is “categorically in the hands of the legislature.”

He said that every day, citizens should be asking their legislators what they are doing for the public. he said.

Meanwhile, Monday’s announcement by McKee, Shekarchi and Ruggerio signals the release of significant coronavirus relief funding in the short term:

• $38.5 million for children, families and social supports; $32 million to small business; $29 million to housing; and $13 million to tourism and hospitality industries; all from a total of $113 million in what McKee calls his “Rhode Island Rebounds” plan, funded by the American Rescue Plan Act (ARPA).

• $57.4 million from the enhanced federal Medicaid match, which community-based agencies may use to shore up their workforce through hiring bonuses, raising pay and benefits, shift differentials, and other incentives

The three leaders also announced funding to supplement the human services portion of McKee’s “Rhode Island Rebounds” plan:

• $ 6 million for childcare providers, on top of the $13 million in the original plan. Ruggerio, the Senate president, said, “Childcare is a top priority. We can’t get people back to work if they can’t get childcare.”

• $3.64 million from unspent CARES Act funding for early intervention, in addition to the $5.5 million McKee originally put in Rhode Island Rebounds.

The House Finance Committee is expected to vote next week on the funding. The unusual display of unity among the executive and legislative leadership of state government Monday signals swift passage of the funding measures. (McKee does not need legislative approval to release CARES Act funding.)

Rhode Island is the only New England State that has not spent any ARPA funds, and critics have put increasing pressure on the General Assembly in recent weeks to take action on McKee’s proposal, especially after the start of a waiting list for early intervention services last week.

View the entire public forum on YouTube: https://www.youtube.com/watch?v=PLS18en74A8

RI Misses First Deadline in DD 'Action Plan'

By Gina Macris

A week has passed since the state of Rhode Island was to have awarded a contract for a review of the rates it pays private providers of developmental disabilities services – the first step in an “Action Plan” for correcting long-standing civil rights violations.

The plan, approved by Chief Judge John J. McConnell, Jr. of the U.S. District Court, avoided a contempt hearing and the risk of heavy fines.

The Action Plan says the contract would be awarded Nov. 1, and work would begin Nov. 15.

But on the morning of Nov. 9, the state’s website for the Division of Purchases indicated that the bids were still under review.

A total of five consulting agencies submitted bids. They are Guidehouse, Inc., Health Management Associates, Inc.; Mercer Health and Benefits LLC, Milliman, and Public Consulting Group. The rate review is considered the foundation for changes that would overhaul the service system to promote inclusion of adults with developmental disabilities in their communities - a transformation intended to comply with the Americans With Disabilities Act and a 2014 consent decree.

The bid amounts have not been disclosed, nor has the state made public its budget for the work, which is projected to take about a year.

Asked about the amounts the five firms bid, a spokesman for the state Department of Administration said in a statement late last month:

“As this in an RFP, (request for proposals) the proposals will undergo the technical and cost evaluation review. We cannot comment on the cost until an award is made, nor do we have an estimate when that will happen.”

Efforts to reach several state officials for comment on the delay in awarding the contract were not immediately successful.

In the last two and a half years, the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) has spent more than $1 million on an analysis of the developmental disabilities system by the New England States Consortium Systems Organization (NESCSO).

NESCSO, which worked 18 months on the project, was instructed to develop various scenarios for change but told not to make any recommendations. The BHDDH director at the time of the contract award, Rebecca Boss, said the work was intended to expand the department’s analytical capability.

Since the project was completed in 2020, BHDDH has not had any public comment on the work.

RI Dodges Contempt With DD Action Plan

By Gina Macris

The Chief Judge of the U.S. District Court welcomed Rhode Island’s action plan to turn around the lives of adults with developmental disabilities, saying in a hearing Oct. 20 that the state has taken “historic and comprehensive” measures to set it on a path to comply with a 2014 civil rights consent decree.

Judge John J. McConnell, Jr. (left) approved the plan, which commits at $50 million in the next few years to stabilize and expand a skilled workforce and promises a structural overhaul of the way services are delivered and providers are paid, according to summaries provided by a lawyer for the state and an independent court monitor.

“This a major step in improving the lives” of adults with developmental disabilities, McConnell said in the hearing, which was streamed remotely via the Internet.

McConnell said that in his 30 years as a lawyer and ten years on the bench, he’s “never seen the state move as quickly, effectively and positively.”

“Make no mistake about it. Moving that mountain was a mammoth undertaking,” McConnell said.

“You have my thanks,” he said, singling out State Sen. Louis DiPalma, D-Middletown, and Kevin Savage, Director of the Division of Developmental Disabilities, for their roles in negotiating the action plan.

Without the action plan, the state could have faced fines of up to $1.5 million a month for contempt of court for continued violations of the consent decree.

The ultimate goal is the systemic restructuring of the system so that those with intellectual and developmental disabilities can live the lives they want in their communities, consistent with the Olmstead decision of the U.S. Supreme Court, McConnell said. The Olmstead decision re-affirmed the Integration Mandate of the Americans With Disabilities Act.

Making a real difference in the lives of those protected by the consent decree “will be another heavy lift,” the judge said. “That’s a long-winded way of saying, good job; there’s a lot of work ahead of you.”

Both the monitor, A. Anthony Antosh, and a lawyer for the U.S. Department of Justice (DOJ), said they will be watching very closely to measure the real-life impact of the action plan on life circumstances of individual service recipients.

Victoria Thomas, the DOJ lawyer, said she and her colleagues in the civil rights division are “cautiously optimistic” that the action plan will achieve the goals of the consent decree by the time it is set to expire in 2024.

“Recent comments indicate that there are many people in Rhode Island that are not getting what they need, want, or are entitled to get” under the law, Thomas said.

Those eligible for services say “they want to be working,” Thomas said.

Families who “rely on day services to function” are essentially trapped,” she said. “They can’t go to work and in some cases can’t leave their homes.”

To focus on the state’s progress, the DOJ and the monitor will review data every 90 days to determine what services eligible persons receive and their duration, Thomas said.

“Rhode Island businesses are eager to hire, and people with developmental disabilities are eager to work,” she said. “The action plan has multiple strategies to do that,” both on a short-term and long-term basis, Thomas said.

Antosh, the court monitor, said the action plan responds to a years-long drive to stabilize and expand the private provider workforce which the state relies on to bring it into compliance with the consent decree, and more recently, a series of court orders spelling out what that effort should look like.

The one that sent ripples through the State House said the state wages must hit $20 an hour by 2024. The action plan says the state will deliver on that pay hike, along with an interim raise, from $15.75 to $18 an hour effective July 1, 2022.

McConnell said “the court’s role is not to tell state what it should do or to run the agency,” a reference with the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH.)

“The court’s role is to ensure compliance with the consent decree. The state, after many years, agreed it has systemically violated the rights of people with developmental disabilities All parties agreed the consent decree would be the vehicle to ensure (those) rights,” McConnell said.

Antosh, meanwhile, said the significant investment in funding higher wages will be accompanied by a shift in strategy for recruiting and retaining new staff to offset the fact that the traditional population interested in caregiving jobs is shrinking.

He said there will be a public-private partnership led by the Department of Labor and Training, the Community College of Rhode Island and other workforce and educational organizations. Together, they will re-define the roles of caregivers and creating targeted training programs, professional credentialling, and career ladders.

“A major strategy is to help people to achieve individual career goals,” Antosh said.

He explained other highlights of the action plan including an upcoming rate review, which he described as “the instrument” for changes that hopefully will create a better-functioning system.

Five consulting firms have bid for the job, and the state has committed to awarding the contract by November 1, with the work to be completed in a year’s time. It will include a reimbursement rate schedule that is indexed to the cost of living, Antosh said.

He said he will push to have a finished report sooner than that. The rate review, or portions of it, should be reflected in the next three budgets, he said.

In another change intended to stabilize financing, the state for the first time will include the developmental disabilities caseload in the semi-annual Caseload Estimating Conference, giving policy makers a realistic projection of developmental disability costs as a basis for budget preparations. The first such Caseload Estimating Conference will be later this month.

There will also be changes that will help increase individuals’ access to services by decreasing administrative burdens on providers. For example, the state plans to eliminate a requirement that staffers document their time individually in 15-minute increments for each person in their care, he said.

Another requirement on its way out is linking reimbursement to pre-determined staffing ratios based on each client’s general level of independence, or lack of it. These staffing ratios do not individualize needs, except for those with the most extreme disabilities, and do not take into account the amount of support necessary to carry out a particular task. Antosh said the complicated billing system will be replaced by two different rates.

The state has said the work on the administrative changes will be done by March 31.

Other innovations in the works will aim at increasing funding for transportation enabling the Rhode Island Public Transit Authority to become a Medicaid provider and by setting aside $2 million for the acquisition of technology for people with intellectual and developmental disabilities, Antosh said.

There are already specialized 400 apps available which aim at improving the quality of life for people with varying intellectual and developmental challenges, he said.

Kate Sherlock, the lawyer representing Antosh in recent negotiations, said the will to “get there” by restructuring the system “has been there all along, among consumers, their families, providers, and state officials, but change has been held back by a lack of funding.”

The action plan is a “significant step in the right direction,” she said. “We’ll be watching carefully to see what happens.”

To read the state’s action plan, click here.

To read the monitor’s memorandum on the action plan, click here.

RI Proposes DD Action Plan To Avoid Contempt Of Court

By Gina Macris

The state of Rhode Island would raise the pay of caregivers for adults with developmental disabilities to $20 by mid-2023 as part of an “action plan” submitted Tuesday, Oct. 19, to fend off a contempt hearing in federal court over continued violations of a 2014 consent decree mandating the integration of this population in their communities.

The contempt hearing, which had been scheduled to begin Oct. 18 and run through Oct. 22, was canceled last week without explanation by Chief Judge John J. McConnell, Jr., of the U.S. District Court. There previously had been indications the state was working on a settlement proposal.

The action plan also promised that workers would get an interim raise, from $15.75 an hour to $18 an hour, to take effect July 1, 2022, as well as the development of an “intensive” and coordinated statewide initiative involving the Department of Labor and Training, the Community College of Rhode Island, and other organizations to recruit and retain skilled candidates to fill gaps in the workforce necessary to support adults with developmental disabilities who want to be integrated into their communities.

In addition, a total of $12 million would be set aside for a “transformation fund” aimed at supporting private service providers as they go through the first two parts of a three-part transition period from a system originally framed around segregated group care to one that promotes individualized services in the community. Of the $12 million total, $2 million would be reserved to help families who self-direct their own programs, essentially acting as independent employers and program directors for staff serving individual loved ones.

The remaining $10 million would be divided into grants to enable provider agencies to begin shifting to integrated services during the next 12 months, with provisions for considering more funding to expand program innovations during a third phase.

In addition, the action plan commits the state to setting aside $2 million to help adults with intellectual and developmental challenges acquire technology. While smartphones and tablets have become ubiquitous, many adults with developmental disabilities do not have access to the internet.

Overall, the plan appears to conform to several orders issued by McConnell since the summer of 2020 to bring the state into compliance with the consent decree.

A permanent budgetary, operational, and bureaucratic framework for a new developmental disabilities system would emerge from a rate review study that is expected to begin in coming weeks. The Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, (BHDDH) plans to award the contract by Nov. 1. BHDDH originally required the work to be done in six months, but the action plan said the deadline will be December 1, 2022, a little more than a year from now.

The governor’s budget proposal for the fiscal year beginning July 1, 2022 (Fiscal Year 23) “will recognize” preliminary recommendations of the rate review consultants, and “the State will work in good faith to incorporate the reasonable recommendations set forth in the final rate review project” in the governor’s following budget proposal for the fiscal year beginning July 1, 2023 (Fiscal Year 24), the action plan says.

Because the state needs to expand the workforce and hike wages to deliver on the individualized, community-based supports required by the consent decree, reforms are expected to require a significant financial commitment by the General Assembly.

The upcoming rate review would add dollars and cents to the picture and include recommendations for reimbursement models that would stabilize the finances of provider agencies. Providers say the current fee-for-service model does not pay their actual costs, including free care often given to individuals while the agencies appeal service cuts.

The monetary changes and any new provider reimbursement model would have to be approved by the General Assembly. To move forward, the action plan also needs approval from the U.S. Department of Justice and the court..

To read the state’s action plan, click here.

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.

Judge Cancels Contempt Hearing

By Gina Macris

A federal judge has canceled a civil contempt hearing that was to begin Monday, Oct. 18 against the state of Rhode Island over continued for violations of a 2014 consent decree designed to help Rhode Islanders with developmental disabilities lead regular lives in their communities.

Chief Judget John J. McConnell, Jr. of U.S. District Court entered the notice in the court record Oct. 13 but did not give a reason for the cancelation.

State officials have been trying to negotiate a settlement to the contempt proceedings with an independent court monitor. Any agreement would also require the consent of the U.S. Department of Justice (DOJ) and Judge McConnell.

In a separate note on the court record, McConnell denied a recent request of the DOJ to depose the House and Senate fiscal advisors in preparation for the hearing, saying the issue is “moot.”

Coalition Seeks $100M To Fix RI Caregiving Crisis

By Gina Macris

Rhode Island Governor Dan McKee and the leadership of the House and Senate say they are working on solutions to the staffing crisis that has constricted access to healthcare and social services for people of all ages with disabilities or special needs.

McKee made his first move Oct. 7 by proposing a wide-ranging budget amendment that includes $12.5 million in retention bonuses for direct care staff of private providers of services to children in state care, and another $5.5 million to stabilize early intervention services to very young children with developmental disabilities and their families.

Four of nine agencies providing early intervention services have stopped taking new cases, the governor said. One in four families slated for early intervention in 2020 did not complete the program. And since the start of the pandemic, there has been a 30 percent reduction in beds available to the Department of Children, Youth, and Families (DCYF), leaving some children in hospital psychiatric programs where they do not belong, and creating waiting lists for services.

The statement from McKee’s office said the situation has left DCYF in jeopardy of violating Family Court orders on placing children in residential programs consistent with their therapeutic needs.

These targeted increases, totaling $18 million, amount to “the tip of the iceberg” in addressing the labor shortages and service gaps affecting all of the state’s most vulnerable populations, says a spokeswoman for a coalition of 70 human service organizations with about 35,000 to 40,000 employees.

Tina Spears said $100 million is the minimum the state must invest to stabilize the workforce serving children and adults with developmental disabilities, youth and adults with substance abuse and behavioral healthcare needs, those with other mental health issues, and elderly people trying to remain in their own homes. Spears is executive director of the Community Provider Network of Rhode Island, a trade association whose members provide developmental disability services.

A day before McKee released the budget amendment, a spokeswoman for the governor, in response to questions from Developmental Disability News, said that he and his team “absolutely understand there are workforce challenges affecting our health and human service providers, and recognize the need for federal funding to ensure access to services for Rhode Islanders.”

And spokesmen for House Speaker Joseph Shekarchi and Senate President Dominic Ruggiero said, in a joint statement, that the two leaders are “aware of the crisis and working with their colleagues and stakeholders. They are willing to consider solutions.”

McKee’s overall spending plan totals $113 million. It would mark the state’s first use of its $1.1 billion allocation from the American Rescue Plan Act (ARPA). The governor characterized it as a “down payment” on Rhode Island’s future.

He proposes that $32 million go to small business, $13 million to the tourism and hospitality industry, $29.5 million to affordable housing and $38.5 million to the human services, including early intervention and children in DCYF care, as well as child care providers, and pediatric health care providers.

Rhode Island is the only New England state that has not spent any of its ARPA allocation.

In a letter to General Assembly leaders and the governor last month, the coalition of human service providers referred to other potential sources of additional aid. The organization asked the state to stretch the state’s investment in the human services workforce by using an enhanced federal Medicaid reimbursement rate for home and community services and dipping into a $51-million budget surplus for the fiscal year that ended in June.

“We simply cannot wait to respond to the current crisis until January, particularly when there is funding available today,” said Spears.

The pandemic has exacerbated a pre-existing worker shortage to crisis proportions, threatening the collapse of the privately-run network of services that in many cases, recipients are entitled to by law.

Higher caseloads and stressful conditions “have led to increased turnover, lower morale, and unparalleled levels of burnout among existing staff,” the coalition wrote in a letter to the governor and General Assembly leaders in late September.

The coalition leaders are Spears, Susan A. Storti, President and CEO of the the Substance Abuse and Mental Health Leadership Council of Rhode Island, and Tanja Kubas-Meyer, executive director of the Rhode Island Coalition for Children and Families.

The state of the developmental disabilities system, which is involved in a federal court case, illustrates the challenges faced by all the caregiving organizations across the board.

In January, 2020, two months before COVID-19 struck Rhode Island, the state’s own consultants found that some three dozen private providers of developmental disabilities services were on shaky financial footing because of inadequate funding to attract and retain enough skilled, trained workers.

In April of this year, some of the same consultants, who were no longer working for the state, found that adults with developmental disabilities living with their families experienced about a 72 percent reduction in the duration of support services they had before the pandemic.

Those in shared living and independent living situations had service reductions of 57 and 49 percent, respectively, according to the consultants.

While the General Assembly approved funding effective July 1 which raised the pay of direct care workers and their supervisors about $2 to $3 an hour, it is not known what impact, if any, the increases have had on attracting new staff.

Connecticut, Massachusetts, and Rhode Island’s own state-run group home system all pay more than the $15 to $15.75 an hour that employees of the private agencies now receive.

An independent court monitor found that the state’s failure to maintain an adequate workforce continues to violate a 2014 consent decree calling for the overhaul of the service system to provide adults with developmental disabilities individualized support services to help them become part of their communities.

With many adults with developmental disabilities sitting at home for much of the week, and only two and a half years remaining in the term of the consent decree, the state’s next steps remain unclear.

Unless Rhode Island can reach an out-of-court agreement with the monitor, the U.S. Department of Justice, and the Chief Judge of the U.S. District Court, the state must defend itself against civil contempt charges in a hearing that begins Oct. 18. If it is found in contempt, the state faces fines of up to $1.5 million a month.

Judge Will Settle Argument Over Witnesses In Consent Decree Case

By Gina Macris

Sometime in September, the state of Rhode Island drafted a settlement agreement, aimed at avoiding upcoming federal court contempt proceedings, for continuing violations of a 2014 civil rights consent decree case affecting adults with developmental disabilities.

But as the state’s lawyers were planning to show the proposal to the U.S. Department of Justice (DOJ), pre-trial legal sparring moved front and center, and the chances for any settlement to resolve the contempt charges remain unknown.

In an email chain made public in a court filing, the state’s lead lawyer told a counterpart at the DOJ on Sept. 30 that his team hoped to confer with DOJ lawyers in the following days about the proposed settlement.

Those emails also showed the two sides sparred over pre-trial procedures, coming to an impasse over the deposition of witnesses in the contempt hearing, scheduled to begin Oct. 18. A longstanding lack of funding and staff to carry out compliance with a 2014 consent decree would be a be a key issue in the contempt hearing.

The DOJ asked Chief Judge John J. McConnell, Jr. of the U.S. District Court to intervene, and compel the state to make available a total of 15 witnesses, including the House and Senate fiscal advisors, in time for the DOJ to depose all of them in accordance with a pretrial deadline already established in a court order.

McConnell has scheduled a teleconference with the lawyers for 4 pm on October 7.

In asking McConnell to intervene, the DOJ included a Sept. 30 chain of emails between DOJ lawyer Victoria Thomas and two state lawyers, Marc DeSisto and Kathleen Hilton.

In the emails, DeSisto and Hilton pushed back the start of depositions, in the process postponing a deposition that had already been scheduled with the state’s chief auditor in the Office of Management and Budget.

In addition, DeSisto and Hilton said they could not make the House and Senate Fiscal Advisors available for deposition at all. Sharon Ferland holds the House post and Stephen Whitney advises the Senate.

Hilton wrote: “Without more information as to the reasons you are seeking to call Sharon and Stephen as witnesses, we cannot make a determination on whether we could agree to make them available. There very well may be privileges that need to be preserved by way of a motion for protective order. Additionally, we do not have the authority to accept a subpoena on their behalf.”

DOJ’s Thomas replied: “We are seeking the testimony of Sharon and Stephen based on the Court Monitor’s opinion that they have valuable information relevant to the funding provision of the Consent Decree. We have now exhausted our good faith efforts to resolve this dispute and will be filing a motion to compel shortly.”

Earlier in the email chain, DeSisto had mentioned the proposed settlement:

“As we discussed in last evening's phone call,” he wrote to Thomas, “it is my hope that in the next few days we can confer regarding the terms of settlement. We are waiting for some feedback from Tony (A. Anthony Antosh, the independent court monitor) in this regard. Once we receive his input, we would like to have a settlement conference with you, maybe as early as tomorrow.”

Thomas replied:

“We are eager to see the State's written settlement proposal and to conference with you tomorrow. That said, while we remain hopeful that a settlement may potentially resolve our contempt motion, we must preserve our litigation rights.” Thomas continued to press for assurances on the depositions.

In its contempt motion, The DOJ has stated that, if necessary, it is prepared to present evidence that the state “failed even to ask its Legislature for a sufficient appropriation” and that it “failed to make efficient use even of the resources it had – for example, by failing to modify State rules and incentives that favor providers of less integrated services over providers of more integrated services.”

The DOJ has proposed an escalating scale of fines, from $500,000 on the first day of each of the first two months to $50,000 a day beginning on the 70th day. At that rate, the fines would add up to about $1.5 million a month.