Developmental Disabilities Budget: Cause for Optimism, Cause for Concern

By Gina Macris

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

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

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

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

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

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

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

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

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

High Court Mandated Change

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

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

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

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

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

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

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

Millions More for Community Services

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

The total includes:

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

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

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

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

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

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

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

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

Call for Supplemental Funds Now

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

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

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

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

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

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

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

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

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

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

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

Ambitious Expansion of Shared Living

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

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

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

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

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

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

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

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

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

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

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