Consent Decree Drives Proposed Hike In RI DD Spending

By Gina Macris

Rhode Island Governor Dan McKee would add more than $30 million to developmental disabilities spending to raise starting pay for direct care workers to $20 an hour, hike dozens of reimbursement rates to private service providers, and add ten new staff to help implement a 2014 consent decree.

The pay increase, costing $29.9 million in federal-state Medicaid funding, would be the third annual hike intended to help private agencies and the so-called “self-directed” population managing their own service programs. The wage increase would comply with a federal court order that dates back two years.

In 2021, when the starting wage for direct care workers was $13.18 an hour, Chief Judge John J. McConnell, Jr. ordered the state to raise wages to $20 an hour by 2024, calling a lack of staff the single biggest barrier to implementing the day-to-day requirements of the consent decree, albeit not the only one.

In 2022, with pay raised to $15.75 an hour, the Rhode Island system added 106 new direct care workers from January through June.

On July 1, 2022, the starting pay increased again to $18 an hour, and the state, prodded by the court, launched a workforce initiative to recruit candidates for direct care jobs. In September alone, the system filled 146 vacancies, according to data collected by an independent court monitor.

Yet there were still 693 vacancies in some three dozen private agencies and as many as 1,000 job openings among self-directed consumers and families, the monitor reported in early November.

overview of proposed DD spending - RI Department of Administration

In all, McKee seeks a total of nearly $417.4 million for all developmental disability services in the fiscal year beginning July 1, including slightly more than $385 million for the privately-run system, the backbone of consent decree compliance. That figure for private agency and self-directed services represents a bump of about $32.2 million over the current allocation of about $352.9 million.

A parallel network of state-run group homes would get $32.4 million in the next budget, or almost $1.8 million more than the current funding level of $30.8 million.

The budget for the next fiscal year, July 1,2023-June 30, 2024, will finance the state’s final push to comply with the consent decree before the deadline on June 30, 2024.

The state agreed in 2014 that by mid-2024, it would eliminate sheltered workshops paying sub-minimum wages and move away from isolated day care centers. Instead, there would be a de-centralized network of individualized services enabling adults with developmental disabilities to become integrated in their communities.

The Department of Justice (DOJ) has said that Rhode Island will likely miss the 2024 deadline if it moves at the current pace. The DOJ cited numerous factors contributing to a lack of services, particularly the individualized services in the community that are the cornerstone of the consent decree. A far-reaching federal court order issued Dec. 6 lists some 50 requirements that must be completed by the deadline on June 30, 2024.

McKee wants the new consent decree implementation staff on board as early as possible.

A spokesman for the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) said the department hopes to complete the hiring process by the fourth quarter, which runs from April through June. The cost for these added workers would be $203,275 for the first full year, taking into account federal Medicaid reimbursements and savings from staff turnover in other positions, according to McKee’s executive summary of the spending plan.

Eight of the ten positions will be permanently added to the Division of Developmental Disabilities (DDD), the BHDDH spokesman said.

The DDD jobs include:

• an “interdepartmental project manager”

• a “chief of staff for development training and continuous quality improvement”

• ·an “associate administrator for community services”

• five positions promoting community development as it relates to adults with developmental disabilities

The salaries will range from $66,162 to $95,552 a year, the BHDDH spokesman said.

Two other employees not attached to BHDDH will help implement an outside consultant’s recommendations for reimbursement rates for private providers.

Undertaking a rate review itself was part of a court order issued in October, 2021. Consultants disclosed preliminary recommendations last September that called for increases ranging from about 25 percent to 97 percent in dozens of reimbursement categories to private providers.

But McKee said in an executive summary of the budget that the consultant’s report is “currently under review and may further increase the recommended amount of financing” allocated to the private developmental disabilities system.

Among other actions, the Dec. 6 court order requires the state to identify successful pilot programs promoting integration that have been developed by private service providers during the past year and make those programs available to all those who want them, regardless of the way consultants have structured reimbursements to the private sector.

The consent decree has brought more transparency to budgeting by generating pressure on the General Assembly to include adults with developmental disabilities in the biannual caseload estimating conference, a public process used to project the state’s obligations for public assistance, like food stamps. Developmental disability costs were added in 2021.

The most recent caseload estimating conference, in November, projected there will be $8.5 million less in reimbursements to private service providers than budgeted for the current fiscal year because the population is expected to use fewer support services than initially budgeted.

McKee’s proposal takes the caseload estimating conference projections into account, as well as other related costs, in reducing developmental disabilities services by about $4.4 million, from about $352.9 million to about $348.5 million, in the current fiscal year.

The caseload estimating conference also highlighted the fact that consumers and families often must appeal individual budget allocations to get needed services – a feature of the current reimbursement system which the federal court has cited as a weakness.

Projections for the current fiscal year include $22.8 million in successful appeals, or $5.8 million more than budgeted. An independent court monitor has said consumers should not have to make lengthy appeals to get the individualized services to which they are entitled.

The consent decree draws its authority from the Supreme Court’s Olmstead decision, re-affirmed the Integration Mandate of the Americans With Disabilities Act, requiring public services for all persons with disabilities to help them lead regular lives in the their communities.

Developmental disabilities funding makes up about two thirds of the overall BHDDH budget, which is currently funded at about $597.1 million. McKee would raise the BHDDH total to about $619.6 million in the next fiscal year, with more than half the revenue coming from federal Medicaid reimbursements.

RI Advocates In Action To Host Information Session

Rhode Island’s Advocates in Action, a non-profit educational organization aimed at empowering adults with disabilities to advocate for themselves, will sponsor a free informational session Thursday, March 30,  on “Frequently Asked Questions” about federal and state-funded Medicaid services offered through the Division of Developmental Disabilities.

Members of the organization’s current leadership class have surveyed recipients of developmental disability services on their primary concerns and will share the top questions and answers during the session, from 7 to 9 pm. at the Crowne Plaza Hotel in Warwick, according to a spokeswoman. The leadership class includes recipients of developmental disability services and individuals who support them. 

Topics on the agenda include applying for services, finding a place to live, looking for a job, planning for supports, appealing decisions made by the state, and living in the community.

Pre-registration is not required, but those planning to attend are asked to RSVP by phone to 877-532-5543 (toll free) or by email to aina@advocatesinaction.org

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

Jane Gallivan   Photo by Anne Peters

By Gina Macris

In just the few months she has served as interim director of Rhode Island’s Division of Developmental Disabilities, Jane Gallivan has been instrumental in changing the state’s approach to providing services for individuals with intellectual challenges.

On the most concrete level, she has set plans in motion to adopt an improved version of a controversial assessment – the Supports Intensity Scale (SIS) – to more accurately determine the needs of clients.

With help from the Executive Office of Health and Human Services, Gallivan also has shifted strategies for presenting the division’s budget so that the state Budget Office and the General Assembly better understand what it means to support individuals with developmental disabilities.

The initiatives Gallivan has begun, and the tone she has set, are expected to continue after her role changes Friday, Sept. 30, to that of long-distance consultant.

Gallivan, 68, is taking her 101 year-old mother to Florida for the winter, a commitment she made before Rhode Island officials approached her for short-term help in leading the developmental disabilities division.

She will continue to monitor and guide reforms and will serve on the committee that will screen applicants for the division’s permanent chief.

A former state-level director in Maine and Delaware, Gallivan already has been spreading the word about the director’s job through her nationwide contacts in the field of developmental disabilities.

As she prepared to end her full-time role in Rhode Island, Gallivan shared her perspective on the future of developmental disability services in Rhode Island.

Major Changes Coming to Every State

Gallivan says all state developmental disability service systems are in the midst of a sea change because of sweeping new Medicaid regulations.

The rules say that all services for the elderly and individuals with all types of disabilities must be provided in the least restrictive setting that is therapeutically appropriate, which is presumed to be the community.

After March, 2019, Gallivan said, Medicaid will no longer pay for sheltered workshops or segregated day programs after March, 2019.  Sheltered workshops don’t fit the Medicaid’s definition of “community,” she said.

Federal Medicaid dollars pay for half the cost Rhode Island’s developmental disability services.

The federal consent decree requiring Rhode Island to shift to community-based jobs and activities may put the state ahead of the curve, she said.

Both the consent decree in Rhode Island and the changed Medicaid regulations nationwide get their authority from the 1999 Olmstead decision of the U.S. Supreme Court, which is in effect a desegregation order for individuals protected by the Americans with Disabilities Act. 

Individuals and families who struggle to find appropriate services may not yet see any change in their lives.

Gallivan says she worries about a caseload ratio that is “way too high” - one social worker to every 205 clients.

Social workers are “really concerned about helping people out,” she said, “but like any other service system, they are often, because of the ratios, dealing more with people in crisis”  or those just entering the system, rather than “supporting the people who are not the squeaky wheel.”

“No one wants to expand state government,” but state government must still “figure out how we’re going to put more resources into case management,” Gallivan said.

A New Way to Assess Service Needs

Since taking the interim director’s job in July, Gallivan has been “looking under the hood,” as she put it, to understand the barriers that need to be removed to allow “people to really get out and enjoy activities in the community, to get better connected, to explore new job options and so forth.”

She’s been searching for hindrances in state regulations, the way programs are funded, and the way clients have been assigned individual funding based on “tiers,” or levels of need.

The Supports Intensity Scale, (SIS) is a lengthy questionnaire used since 2011 to determine the individual level of funding according to “tiers” labeled A through E, with E being the costliest.

In the last few years, the SIS been the single most emotional flashpoint for families, many of whom have complained bitterly not only about results that yield insufficient funding, but that interviewers argued with them or recorded answers different than the ones they gave.

In the next several months, Gallivan said, the state will move to what she hopes will be a more accurate version of the assessment, with additional questions focusing on medical and behavioral needs.

SIS Interviewers will be retrained in the new version by representatives of the organization which developed the SIS, the American Association on Intellectual and Developmental Disabilities (AAIDD).

Gallivan said training also will be offered to family members and representatives of service provider agencies, who attend the interviews and help answer questions.

The state will monitor the new approach to determine whether it leads to a reduction of a high number of exceptions now granted to the assessment results. 

The exceptions, in which a client may have more funding than warranted by the official level of support, have raised numerous questions in the General Assembly about how the Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH) manages its budget. 

Gallivan offered some background on the SIS, which is used in Rhode Island as a basic building block of the developmental disability budget.

On its face, the SIS is a better assessment than some others in use across the country because it frames questions in terms of an individual’s strengths and the supports he or she may need to achieve a particular goal, rather than focusing on deficits, Gallivan said.

But it has its limitations, she readily acknowledged. It is recognized nationwide that the SIS does not address extensive medical needs or behavioral issues, Gallivan said.

“You also have to be sensitive to people who are very independent, but they may get themselves into trouble with the law,” or in some other way, because of their disabilities, she said.  For example, some individuals may appear independent, but if they don’t have the proper support and guidance, they may end up at a homeless shelter, or picked up by police for shoplifting.

The SIS was developed as a tool for planning individualized programs of support, not as a funding mechanism, although many states use it for budgeting, Gallivan said..

As a result of the gaps inherent in the original assessment, the state of Oregon developed a number of questions on behavioral and medical support needs that were tried out by other states and ultimately incorporated into a new version of the questionnaire called the SIS-A, Gallivan said.

“Everyone came to the conclusion that these supplemental questions really did add a more robust, accurate assessment,” she said.

AAIDD released the SIS-A in 2015, according to the organization’s website.

Gallivan said arrangements are being made for AAIDD representatives to come to Rhode Island for training in the SIS-A. At the same time, the consultants who developed the formula for turning SIS scores into individual funding levels have been asked to revise that algorithm to correspond to the SIS-A, she said.

Disability Services: a Lifetime Commitment

Meanwhile, Gallivan has tried to set a different tone for presenting the needs of individuals with developmental disabilities to the state Budget Office. 

“I’m not saying that people don’t know” what the Division of Developmental Disabilities does, “but a lot of people really don’t know,” she said with a chuckle.

“So I think it’s really important to paint a picture” of the service system and the people in the middle of it, Gallivan said.

Budget officials should know who the division serves, whether they live with their families or elsewhere, the kinds of services they receive, why the services are important to them and their families, the actual costs of providing those services, and the expected outcomes, Gallivan said.

That’s a different approach than seeing the system as a list of line items, she said.

It’s important for the fiscal arm of state government to understand that “we are the long-term care system,” Gallivan said.

“People think of the elderly as being the long-term care system, but they’re only in there for a few years,” she said.

“We’re talking birth to 100” in developmental disabilities, she said.

Legislators must understand that they can’t take money from individuals with developmental disabilities and give it to someone else, Gallivan said.

“In this system, everyone who comes through the door will have a life-long need for some kind of support because of the nature of their disability,” she said.

It’s not analogous to the mental health system, where funds may be shifted because one person is in recovery and another is not, Gallivan said.

A Focus on Families

In any presentation she makes, Gallivan said, she tries to emphasize the need to support families who have a member with developmental disabilities living at home with them.

Many families want their loved one at home, she said. "Ffrom a bureaucratic perspective, it’s (generally) the safest place they’ll be,” she said, “and the cost of services in the family home will be less than they will be anywhere else.”

“So how can we invest in families and recognize them as caregivers? We talk about people as caregivers of those with Alzheimer's, but we have people who are caregivers of people with developmental disabilities who face a lot of challenges” and have their own need for support, Gallivan said.

She suggested families should have access to more respite care and should be able to get financial support for modifications like wheelchair ramps.

Gallivan also indicated technology might help families keep tabs on their loved ones, although options like bedroom cameras might not be universally welcome in some homes.

The full range of supports for families “need to become a very strong focus,” Gallivan said, “and the type of planning we need to do with families is very different.”

“You need to talk about the whole family and what the family needs are,” she said.  

Families and individuals who advocate for themselves must be part of the conversation, Gallivan said.

RI Officials Correct Figure in Monitor's Report; Say Rate Hike Will Go To DD Service Agencies

By Gina Macris

All the workers who provide direct support services to adults with developmental disabilities in Rhode Island won’t be getting raises to at least $11.55 an hour, as indicated in the most recent report of a federal court monitor in the so-called “sheltered workshop” consent decree case.

The report from the monitor, Charles Moseley, says that the state Department of Behavioral Health, Developmental Disabilities and Hospitals (BHDDH) “will adjust all rates for Direct Support Professionals to a base rate of $11.55 an hour.”

 In reality, BHDDH will raise the “base rate” the state pays to the private agencies from $11.55 to $11.91 an hour, an increase of 36 cents; the private agencies, in turn, must use that new hourly figure to cover both salary increases and fringe benefits for their employees.

That was the word Sept. 13 from Mary Madden, the state’s consent decree coordinator, and Jennifer Wood, Deputy Secretary of Health and Human Services.

Wood also said it is impossible to determine how much of an hourly wage increase each worker will actually receive.  

 Approximately 4,000 workers staff the private agencies serving Rhode Islanders with developmental disabilities under contracts with the state. These direct support workers now make an average of about $10.75 an hour, although starting pay is typically minimum wage, or $9.60 an hour.

Different agencies have different pay scales and different arrays of benefits, Wood said. The General Assembly set aside about $5 million in the current budget for raises to direct support workers and for increased employer costs, but did not specify how much was to go into each category, she said.

One part of an order issued in May by U.S. District Court Judge John J. McConnell, Jr., required the state to “appropriately increase salaries, benefits, training, and supervision for Direct Support Professionals and Job Coaches” by Aug. 1.

The increases, retroactive to July 1, have not yet gone into effect, but Moseley, the monitor, said the judge’s order had been “provisionally met” because the state had submitted a plan that describes how the increases would be handled.

Before Moseley will sign off completely, he said, he needs more documentation in the plan, as well as confirmation that BHDDH has disbursed the money for the rate increases to developmental disability service agencies.

The issue of pay for workers was one of numerous points covered in Moseley’s report, submitted to McConnell Sept. 9 in anticipation of the judge’s review of the case Sept. 16. The session begins at 2 p.m.

Task Force Commentary on Monitor’s Report

Meanwhile, the monitor’s report also prompted criticism at a meeting of the Employment First Task Force Sept . 13.

Claire Rosenbaum questioned Moseley’s conclusion that the state had met the Judge’s Aug. 1 deadline for making it easier for providers to offer employment-related services to adults with developmental disabilities.

“I haven’t seen anything that offers supported employment services for my daughter, and we’re a month and a half past the implementation date,” Rosenbaum said. She serves on the task force as Adult Supports Coordinator for the Sherlock Center on Disabilities at Rhode Island College.

Nor did her daughter’s counselor at the state Office of Rehabilitation Services (ORS) know anything about career development planning, Rosenbaum said, even though the monitor said ORS, as well as BHDDH, and the Rhode Island Department of Education (RIDE) had all implemented training in the process of career development planning by the end of July as required by the judge’s order.

The judge’s order included several mandates related to supported employment, all with an Aug. 1 deadline.

 The requirements included a change in the model for reimbursing provider agencies, and a change in the financial authorizations made to individuals to pay for what Moseley called the “Person Centered Supported Employment Services Program.” 

The current authorization method requires individuals seeking job-related services to trade in time allocated to another category of support.

Madden acknowledged that the model for changing reimbursement to service providers had not yet been put into practice.

“What irks me,” Rosenbaum said, “is this status report says ‘provision met’, when it clearly has not been met.”

The state has said the reimbursement model would change for clients of agencies chosen to participate in a pilot program of performance-based contracts intended to provide the supports necessary to enable individuals with developmental disabilities to find and keep regular jobs.

BHDDH is not yet accepting applicatios for that pilot program, although Moseley said he is satisfied with the state's plan for the program . The state's lawyer will file the detailed plan with the court some time this week, according to Wood. 

In any event, the judge is requiring performance-based contracts for all service providers in the state by Dec. 31. 

Kevin Nerney, the task force chairman, took issue with the term “Person Centered Supported Employment Services Program” to describe what supported employment services are supposed to provide.

Such individualized, employment-related services have not been rolled out to direct support staff at provider agencies, he said. Until employment-related services have been put in place, he said, they should not be elevated with an important-sounding title.

The task force was created by the 2014 federal consent decree, in which the state agreed to correct violations of the Americans with Disabilities Act by moving from segregated sheltered workshops and day programs to supports for community-based employment and activities for adults with developmental disabilities.

The consent decree envisioned the task force as a bridge between state government and the community, although the group is still exploring how its role will play out.  Its next meeting is scheduled for Oct. 11.

Rhode Island Considers Reorganizing BHDDH; Finding "Strong" DD Director Is Top Priority

By Gina Macris

The Rhode Island Department of Behavioral Healthcare, Developmental Disabilities and Hospitals  may undergo restructuring, if it is determined that a different organization of services would better serve the  needs of it clients, a spokeswoman for the Executive Office of Health and Human Services (EOHHS) confirmed on Friday, Sept. 9  

Asked whether a departmental reorganization is on the table, Sophie O’Connell replied in an email: “No decisions have been made, but we are considering the option to make sure that we are delivering the best quality care and services to some of the most vulnerable people in our state.” 

Before she left in June, former BHDDH Director Maria Montanaro recommended that BHDDH be split up. The Eleanor Slater Hospital should be run by a dedicated board of directors, she said, while mental health and developmental disability services each should have a commissioner under the direct supervision of EOHHS. 

Such sweeping changes would require gubernatorial and legislative approval. On an ad-hoc basis, however, EOHHS has established direct oversight of the Division of Disabilities in recent months, primarily in response to the demands of a federal consent decree. 

O’Connell said there is no timeline for recruiting a permanent BHDDH director while EOHHS and BHDDH work on a plan that would take into account “how we can most effectively blend fragmented program, policy and funding streams to ensure Rhode Islanders are receiving the best possible care and services.”  Rebecca Boss serves as interim director of BHDDH. 

“Secretary (Elizabeth) Roberts as well as the BHDDH and EOHHS management teams are personally committed to ensuring continued progress on the important reforms taking place at BHDDH. This includes the ongoing work to improve services for individuals living with developmental disabilities and to recruit talented DD leadership into the agency,” O’Connell said. 

“Our most pressing concern at the present moment is recruiting a strong leader for the Division of Developmental Disabilities,” she said. 

The developmental disability director’s post is particularly critical as the state tries to comply with the federal consent decree by shifting away from sheltered workshops and segregated day programs toward integrated employment and community-based non-work activities. 

The division has been without a permanent director since July 22 when Charles Williams retired.

Jane Gallivan, who was coaxed out of retirement to serve as interim director of developmental disabilities, will step down at the end of the month because of family responsibilities, according to O’Connell. 

Although Gallivan will remain a consultant – primarily a long-distance one – the state has not announced who will administer developmental disability services in the short term or when a new director might be named. 

 As of Friday, September 9, the post had not been advertised on the state’s employment website. Nor has a search committee been seated.  

In response to repeated inquiries, over the past week, O’Connell said that Gallivan would providemore information Sept. 14 about the search for a director for the division. 

Gallivan, former developmental disabilities director in Maine and Delaware, plans to spend the winter in Florida with her 101-year-old mother, who has been staying on Cape Cod for the summer. 

RI Leadership in Developmental Disabilities Starts With Office of Health and Human Services

Jennifer Wood    Photo by Anne pETERS

Gina Macris

Jennifer Wood, a longtime state policy wonk with an exacting work ethic and a broad reach, is orchestrating an effort to usher in a new era for Rhode Islanders with intellectual and developmental disabilities. 

And she’s creating a brand new management team to help her do it,  including Brian Gosselin, a veteran of former Massachusetts Governor Deval Patrick’s administration, to serve as Chief Strategy Officer.  

Wood is the Deputy Secretary of Health and Human Services, the top aide and top lawyer to Secretary Elizabeth Roberts, and a former chief of staff at the state Department of Education. 

Since January, when a federal judge agreed to oversee Rhode Island’s compliance with a consent decree, Wood has emerged at the forefront of the state’s response to the court case.

Wood says she is working “all day and every day” to fulfill the state’s pledge to integrate Rhode Island adults with intellectual and developmental disabilities into the larger community of work, living and leisure. 

That pledge was made two years ago when then-Governor Lincoln Chafee signed the consent decree, promising the federal government that Rhode Island would end the segregation of more than 3,400 adults, most of them working in sheltered workshops or spending their days in isolated programs.

The consent decree gets its authority from the 1999 Olmstead decision of the U.S. Supreme Court, which says individuals with intellectual or developmental disabilities must receive supports in the least restrictive setting that is therapeutically appropriate.

 In a recent interview, Wood emphasized that the goals of the consent decree “are the changes we should and would be making anyway, and it’s just beneficial in certain ways that we’re doing it within that structure.”

Wood presented most of the state’s testimony during a day-long evidentiary hearing on compliance before Judge John J. McConnell, Jr. in U.S. District Court in April.

Other evidence before McConnell included statements from families and advocates recounting failures in service and the opinion of a court monitor that Rhode Island must immediately lay groundwork to implement the consent decree if it is to achieve its ultimate goals by the time the agreement expires in 2024.

McConnell subsequently ordered the state to complete nearly two dozen tasks - each with a short-term deadline - or face contempt of court proceedings. (Read the order here.)

Several deadlines occurred July 1, and a new wave will hit at the end of the month or the beginning of August.

In the meantime, two top developmental disabilities officials announced their departure. Maria Montanaro, the director of the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) left June 24. Charles Williams, Director of the Division of Disabilities, will retire July 22. 

A third official, Andrew McQuaide, the Chief Transformation Officer at the Division of Disabilities, recently announced that he, too, will leave July 22. (Read related article here. ) 

“There’s a lot of change going on, especially in the leadership area,” Wood said.

“We’re the stability factor,” she said of the Executive Office of Health and Human Services.

Wood said she is building a very skilled management team, with leadership and authority coming from the Executive Office of Health and Human Services, to work on the consent decree and begin transforming a system mired in myth or what she calls “urban legend.”

“I use the metaphor that we’ve got a lot of plates spinning, and we need to move on all of these fronts at one time,” she said.

“We’ve got to prioritize the specific deadlines and commitments made in Court, but none of those things happen without a lot of other pieces being in place,” like getting “basic payment systems in place; getting basic communication systems in place with our own staff.”

 According to the consent decree itself, the appropriate staff were to have been trained in how to carry out its provisions by Sept. 1, 2014.

 “Our own staff, I think, need substantial orientation and awareness of what the consent decree actually requires, as opposed to what everyone says and thinks it requires, which are two different things,” Wood said.

“In the absence of clear and transparent communication, and authoritative communication, then, always, rumor, innuendo, and urban legend will rule the day,” she said.

Wood says the state needs to do better with its external communications because, “Families are out there wondering: What are you doing? When are you doing it?”

A communications plan - one of the tasks McConnell wanted done by July 1 - has been submitted to the federal court. Like the staff training, the communication plan should have been in place nearly two years ago, according to the consent decree. 

Wood emphasized that the communications plan is not a “static” document but a blueprint for action.                                                        

Much of what she and her staff have had to confront in trying to implement the consent decree is “gaps in basic management systems at BHDDH,” Wood said.

“I find it wholly unacceptable that sometimes what we’re talking about in court is: ‘Did an invoice get paid?’ ” Wood said.

 “One embarrassing example, which I shouldn’t even bring up, is ‘Can you get the consent decree monitor paid?’ ” Wood said.

 “I don’t trivialize the bureaucratic and administrative processes, because when those don’t work, nothing works,” Wood said.

 “Before I get out of bed in the morning, that should just be done,” she said, “but you know what? It’s bureaucracy, so you don’t always have that in place.”

McConnell’s detailed order, issued May 18, gave the state 12 calendar days to get itself up to date with payments due the court monitor, Charles Moseley, and the Consent Decree Coordinator, Mary Madden. The judge also said the state must never again miss a payday for either of them as long as their respective contracts run.

The order touched the tip of an iceberg, for the state pays its bills so slowly that many direct service providers must borrow to meet payroll while they wait for the reimbursement to which they are entitled.

“I hate to hear those stories, but, of course, I’ve heard those stories,” Wood responded.

The focus should not be on paying the bills, but on “transforming basic services that are fundamental to the success of our clients,” Wood said.

Initially, “we had struggles in getting people working together, to have everyone pointed in the same direction as to what the consent decree meant and how it should be implemented,” Wood said.

 Besides BHDDH, two other state agencies are directly involved in implementing the consent decree:  the Rhode Island Department of Education and the Office of Rehabilitation Services at the Department of Human Services.

(According to testimony during budget deliberations, there is a growing opinion that the Department of Labor at Training also should be at the table.)

Each agency is a like a silo with its own way of doing things, and the purpose of the Executive Office of Health and Human Services is to get them to function as an “integrated whole,” Wood said.

Wood explained the role of each member of the management team:

• Brian Gosselin, new Senior Strategy Officer at EOHHS, will focus exclusively on developmental disabilities for the foreseeable future. He is an expert on performance-based contracting, which must be in place by August 1, according to McConnell’s order. Raises in staff wages and several other changes related to the financial arrangements the state has with private service providers also must be in place by Aug. 1. Gosselin is a fellow in the Government Performance Lab at the Kennedy School of Government at Harvard University. The Performance Lab, along with the National Association of State Directors of Developmental Disabilities Services, has consulted with the state in developing the new payment methods McConnell implemented. An accounting professional, Gosselin worked his way up in the Massachusetts budget office to the position of Chief of Staff in the Executive Office of Administration and Finance.

• Dacia Read, until now the director of the Children’s Cabinet, has taken on an expanded role as Interagency Policy and Implementation Director at EOHHS. In that capacity, she is providing analysis and support for key initiatives at BHDDH and other agencies, according to a spokeswoman for Wood. 

• Kim Paull, Director of Analytics at EOHHS, is working with Consent Decree Coordinator Madden and others to create an interim data solution to a requirement in McConnell’s order that the state make available client-specific information on employment and other services by the end of July.

• Mary Madden was hired in January as EOHHS Consent Decree Coordinator in response to pressure from the court monitor and the U.S. Department of Justice that the implementation of the consent decree lacked leadership. Wood said she works closely with Madden on a daily basis.

• Jane Gallivan, who will serve as acting Director of the Division of Developmental Disabilities, is newly retired from the same post in Delaware and has extensive experience in the equivalent position in Maine, where she led the implementation of a long-running federal consent decree in a de-institutionalization case..

• BHDDH recently hired Tracey Cunningham as an Employment Specialist to lead a shift toward the supported employment services required by the consent decree. McConnell’s order gives the state until August 1 to hire a Program Developer or Quality Improvement Officer who will lead improvements in services and supports for clients. An existing quality improvement unit at BHDDH investigates neglect and abuse.

• The Division of Disabilities at BHDDH will also have a new Transformation Officer and a yet-to-be named Chief Operations Officer.

• Fiscal support will come from Christopher Feisthamel, the chief financial officer at BHDDH, and Adam Brousseau, the department’s fiscal analyst.  

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

Photo by Anne Peters 

By Gina Macris

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Charles Williams to Retire; Second RI Developmental Disabilities Official to Announce Departure

By Gina Macris

Williams                                          Image courtesy BHDDH

Charles Williams, Director of the Division of Disabilities of the Rhode Island Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH), confirmed today (June 3) that he will retire July 22.

 Williams is the second high-profile figure within BHDDH to announce his departure in two days. On June 2, the department director, Maria Montanaro, announced her resignation effective June 24. 

Williams, who joined BHDDH in 2005, said he had always planned to remain in state government for ten years, long enough to become vested in the state pension system. Williams marked his 10th anniversary in state government last October and celebrated his 71st birthday in January. 

In a telephone interview, Williams said that his retirement has nothing to do with either the federal government’s ongoing intervention in daytime programs for adults with developmental disabilities or the recent death of a resident in a group home that is both licensed and run by the state. 

He said the department plans to hire a chief operating officer and an employment specialist to fill out an administrative team in the developmental disabilities unit. Those moves, he contended, will help ensure continuity as BHDDH complies with a 2014 federal consent decree. 

Another position created by BHDDH to respond to the consent decree is that of chief transformation officer. 

Reached by phone, Andrew McQuaide, the transformation officer, declined any comment on whether he will stay with the department. 

BHDDH must comply with a series of strict deadlines in the coming months to start helping more persons with intellectual or developmental disabilities find regular jobs and enjoy activities in their communities, or face possible contempt hearings in U.S. District Court over violations of the Americans With Disabilities Act. 

Title II of the ADA, reaffirmed by the 1999 Olmstead decision of the U.S. Supreme Court, is a sweeping mandate requiring states to offer services to people with intellectual or developmental disabilities in the least restrictive environment appropriate for each individual.  

The developmental disabilities division also faces scrutiny of 25 group homes that are both licensed and run by BHDDH. In addition to supervising the developmental disabilities division, Williams heads the residential unit, called Rhode Island Community Living and Supports (RICLAS.) 

A native of Connecticut, Williams had worked as head of preventive services in mental health, behavioral healthcare and developmental disabilities for the state of Missouri before coming to BHDHHD to take a similar position.  

Montanaro put Williams in charge of developmental disabilities when she became Department director, in February, 2015, but did not select a new chief for RICLAS. 

Since early April, it has become evident that Jennifer Wood, Deputy Secretary of Health and Human Services, has taken the lead on the state’s response to the consent decree, providing much of the state’s testimony during a day-long evidentiary hearing on compliance issues in U.S. District Court. 

More recently, when state Senator Louis DiPalma (D-Newport, Middletown, Tiverton and Little Compton) asked for information about BHDDH, he said he was invited to a meeting hosted by Wood; transformation officer McQuaide; the Consent Decree Coordinator, Mary Madden; and Dacia Reed, policy director of the Rhode Island Children’s Cabinet. 

Madden’s job was created at the insistence of the court monitor in the federal case as a secretary-level position with authority to enforce cooperation among three agencies responsible for compliance with the consent decree. Madden reports to the Secretary of Health and Human Services, Elizabeth Roberts, who is also head of the Children’s Cabinet, which was revived by Governor Gina Raimondo in 2015. 

The Children’s Cabinet has an interest in the consent decree because the decree is designed to protect teenagers with developmental disabilities as well as adults. Teenagers often struggle with the transition from special education in high schools to the adult system of developmental disability services. 

Asked about Wood’s future role in connection with developmental disabilities, a spokeswoman for EOHHS issued this statement today: 

“We remain fully committed to meeting the goals of the Consent Decree to provide integrated, community based services for Rhode Islanders living with developmental disabilities. Compliance with the Consent Decree has improved significantly under Director Montanaro’s tenure, and EOHHS Deputy Secretary Jennifer Wood will continue to work with Secretary Roberts and the team at BHDDH, under the leadership of Interim director Becky Boss, to ensure all requirements are met going forward. 

Additionally, Governor Raimondo has included significant funding in her proposed budget, including investments in integrated services. In the weeks ahead, Director Montanaro is committed to working with leaders in the General Assembly to secure the additional funding that Governor Raimondo has recently advocated for to provide higher-quality services for Rhode Islanders living with developmental disabilities.”

DOJ: No Merit to Rhode Island's Objections to Compliance Fund

By Gina Macris

Saying Rhode Island’s objections have no merit, federal lawyers for a second time have urged a U.S. District Court judge to set aside state dollars to fund the so-called “sheltered workshop” consent decree – or to fashion whatever remedy he sees fit.

“The State’s objection to funding the Consent Decree is concerning and brings into questions its commitment to making the changes required,” lawyers for the U.S. Department of Justicewrote in a May 16 filing with the Court.

“Thus this Court must act to provide adequate incentive to the State to fund theConsent Decree, which it undoubtedly has the power to do,” the DOJ lawyers wrote to Judge John J. McConnell, Jr.

The DOJ’s plan would require the state to pay $5,000  each day it misses various compliance deadlines, and an additional $100 a day for each person whose services are delayed or interrupted as a result of inaction, with a cap of $1 million a year.

As an alternative to paying into the proposed Consent Decree Compliance Fund , the DOJ lawyers suggested that McConnell  come up with his own remedy.

The government’s remarks came in a filing in which it expressed surprise that the state is now offering “meritless objections” to paying into the proposed fund to  fulfill its responsibilities under provisions of the Americans with Disabilities Act (ADA).

In 2014, a DOJ investigation found the state for decades had illegally segregated adults with disabilities in sheltered workshops that paid sub-minimum wage, and in day programs cut off from the community. Rhode Island then agreed to federal supervision over a ten-year period to transform its system to emphasize supported employment in the community, adopting an “Employment First” policy.

The 2014 agreement marked the first such consent decree in the nation aimed at turning around daytime services that violate the 1999 Olmstead decision of the U.S. Supreme Court.

But the decree is just one part of a much broader, aggressive push begun by the Obama administration in 2009 to enforce the  Olmstead order, which said that Title II of the ADA requires agencies to serve individuals with a variety of disabilities, day and night, in the least restrictive environment that is appropriate.

In Rhode Island, the DOJ’s civil rights division earlier in May asked McConnell to put the court monitor in the case in charge of a Consent Decree Compliance Fund, citing the state’s continued failure to implement reforms.

The court monitor, Charles Moseley, would decide how to spend the money to benefit adults with disabilities.

Marc DeSisto, the state’s lawyer, objected, saying, in part, that the proposal amounts to a contempt order without the procedural rights enabling a defendant to show it made its best efforts to comply but was thwarted by forces beyond its control.

On May 16, the DOJ replied that “a finding of contempt would be appropriate at this juncture,” but its proposal does not ask for that. Instead, the Consent Decree Compliance Fund is envisioned as a vehicle for funding the consent decree, something the state said it wanted to do, according to the latest DOJ arguments.

During the last few months, all sides have agreed – in open court – that the developmental disabilities system does not have enough money to meet the consent decree requirements.  

Moseley, the monitor, told McConnell at one point that if the state didn’t meet certain benchmarks now, it would be impossible to achieve overall compliance by the time the decree expires on Jan. 1, 2024.

It was the state’s lawyer, DeSisto, who initially approached the DOJ and the monitor to ask for an evidentiary hearing so that the judge could gauge the state’s progress on compliance and decide what yet needed to be done to put the state on track to meet long-term goals.

At the hearing, held April 8, the state could not provide an accurate census of the individuals covered by the consent decree, the DOJ noted, but it did present evidence about a plan for achieving compliance going forward.

Now, the state is objecting to its own plan,  the DOJ lawyers said.

“After two years of noncompliance,” federal lawyers wrote, “it is appropriate and necessary, in the absence of commitment by the State to the basic compliance measures outlined in the Proposed Order, for the Court to take action.”