McKee: RI DD Services Need $510.6 Million

By Gina Macris

RI Governor’s FY 25 Budget Proposal-

In a budget plan largely driven by the federal court, Rhode Island Governor Dan McKee has proposed $510.6 million in overall developmental disabilities spending for the fiscal year beginning July 1, about $41.5 million more than the General Assembly enacted for the current fiscal year.

Roughly 55 percent, about $283.4 million, of the proposed developmental disabilities budget would be reimbursed by the the federal-state Medicaid program.

At the same time, McKee seeks to close a projected deficit of $28.3 million in the current budget of $469.1 million as the state tries to integrate adults with developmental disabilities into their communities to comply with a 2014 consent decree with the Department of Justice (DOJ).

Much of the shortfall reflects upward cost adjustments made by the Caseload Estimating Conference (CEC), a budget-planning panel which meets twice a year, advising the governor in November and the General Assembly in May.

McKee also would add $2.9 million to the current budget, and $1.1 million in the next one, for “conflict-free case management,” not only to adhere to Medicaid regulations but to comply with the consent decree. Almost all that funding would come from the federal government.

State social workers from the Division of Disabilities will be assigned to check in monthly with those receiving services and their families to determine if their needs are being met, according to a BHDDH spokesman.

It is not clear whether – or how - this arrangement meets the expectations of an independent court monitor overseeing the consent decree changes. The monitor, A. Anthony Antosh, hasn’t issued a report since last August. Antosh has called for “independent facilitators” to help each individual develop a purposeful program of services and to keep track of how the plan works out.

Developmental disabilities programs account for more than $7 out of every $10 spent at the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH), which would get a total of $706.3 million in McKee’s proposal. McKee’s proposed budget for all state spending in the new fiscal year is nearly $13.7 billion.

The latest proposal represents nearly a third more funding for developmental disabilities than the $339.3 million the General Assembly approved just three years ago, in the spring of 2021.

Much of the investment, in recent years, has been used to hike wages for caregivers and their supervisors, for education and training, and for the development of innovative approaches to supporting adults with developmental disabilities.

In three steps since July, 2021, the state has raised the pay for direct care workers by about 49 percent, from $13.18 an hour to a minimum of $20 an hour, in keeping with orders from Chief Judge John J. McConnell of the U.S. District Court, who has been monitoring the state’s efforts to meet the requirements of the consent decree since 2016.

McConnell found that, apart from the impact of the Covid-19 pandemic, historically depressed wages had led to an exodus of workers that prevented the state from offering employment and other services in the community as promised in a 2014 consent decree.

Beginning last July, the $20 minimum hourly rate for workers has been wrapped into a new reimbursement system for private agencies intended to accurately evaluate the needs of individuals, allow them bigger spending limits to get employment and other supports, and to implement administrative changes promoting integration in the community.

The ultimate impact of higher funding on the lives of adults with developmental disabilities remains to be seen. A decade after the state adopted an “Employment First” policy as part of the consent decree, the governor’s figures say that 24.8 percent of the population protected by the consent decree is working in the community, far short of the target 73 percent.

In November, BHDDH told the CEC that private service providers still don’t have the number of workers they need to offer employment-related services and community-based supports for all who want them. A BHDDH report called the shortage “critical.”

 Still, the state’s eye-opening investment in historically underfunded services during the last few years has begun to show results. While a big staff shortage remains, private agencies are beginning to see improvement in their ability to attract new workers.

The recent pay hikes, along with support from a statewide workforce initiative, helped private providers add 274 direct support staff between January and September of 2023, BHDDH officials reported in November.

McKee’s proposal for Fiscal Year 2025, which begins this July, includes nearly $462.4 million in reimbursements to the three dozen private agencies, or subcontractors, who serve as the backbone of the service system the state relies on to carry out the requirements of the 2014 consent decree.

These reimbursements also cover the cost of one-person programs managed by so-called “self-directed” individuals or families. The number of self-directed programs has grown to more than a quarter of the caseload of about 4,000 persons, in part because of the staff shortage at private agencies. Individuals and families, however, report the same kinds of problems finding qualified caregivers as the agencies, especially when it comes to securing employment-related services.

A separate line in the budget would allocate $15.6 million for other costs related to private services, according to a spokesman for the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH).

These expenses include the salaries of state social workers and administrators assigned to clients of the private providers, as well as human resources support, building maintenance, information technology support, and contracts for electronic records and for education and training provided by the Sherlock Center at Rhode Island College, the spokesman said.

The state also maintains its own network of group homes, which McKee would fund with $32.6 million in the next fiscal year.

All together, these budget categories add up to nearly $510.6 million.

No additional wage increases are planned for the fiscal year beginning July 1, except for those who provide in-home services to adults with developmental disabilities and were included in a comprehensive Medicaid rate review conducted by the Office of the Health Insurance Commissioner (OHIC). For the in-home workers, the governor’s budget seeks about $844,000. The final OHIC report, issued last September, said that the developmental disabilities workforce will be part of the next rate review in two years.

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.

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.

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

Tri-State Human Service Coalition To Press For More Funding

Photo By Remi Walle/Unsplash

By Gina Macris

Non-profit agencies in Connecticut, Massachusetts, and Rhode Island will hold a virtual presentation for Monday, Dec. 6, asking legislators to fund solutions to a workforce crisis that has curtailed services to some of the region’s most vulnerable people.

Clients of the agencies include those with mental health and addiction issues, developmental disabilities, victims of domestic violence, and elderly persons trying to stay in their own homes.

The Community Provider Network of Rhode Island, The Providers’ Council of Massachusetts, and the Connecticut Community Nonprofit Alliance, representing a total of more than 500 human service agencies, have scheduled the two-hour presentation from 10 a.m. to noon on Monday. Pre-registration is at https://ctnonprofitalliance-org.zoom.us/webinar/register/WN_JJDc9bY9SXSAMHyuGOJCYA

The forum, open to the public, is aimed at policy makers and state legislators, said Tina Spears, executive director of CPNRI, a trade organization focused on services for adults with developmental disabilities.

“While workforce shortages across industries have been well documented, the shortage in the nonprofit sector has been amplified by historic underfunding,” the organizers say. (The Massachusetts legislature appears to be on the verge of passing a $4 billion human services package.)

In Rhode Island most recently, all nine early intervention providers have stopped taking new cases of families with infants and toddlers needing a variety of therapies to treat developmental delays. The children are entitled to these services by law.

Without an influx of money, early intervention and other types of human services “will continue to shrink,” increasing the odds that providers will shut their doors all together, Spears said in a telephone interview December 3.

In the areas of early intervention and children’s services, Rhode Island Governor Dan McKee proposed a budget amendment in October that would include $5.5 million for early intervention and $12.5 million for direct care staff of service providers for children in state care, with some of them languishing in hospital psychiatric programs because there are no beds for them in the community.

The state is being fined $1,000 each day that situation continues.

McKee’s proposal for early intervention and children in state care, part of a $113 million plan for using funds from the federal American Rescue Plan Act (ARPA), would have immediate effect if it passed the General Assembly.

In October, spokesmen for House Speaker Joseph Shekarchi and Senate President Dominick Ruggierio said they are “aware of the crisis and working with their colleagues and stakeholders. They are willing to consider solutions. “

Since then, the House Finance Committee has taken testimony on the workforce crisis, but the House leadership has signaled it will not meet before the regularly-scheduled session of the General Assembly in January.

Asked again whether the General Assembly might meet before the end of the year, the spokesmen for Shekarchi and Ruggierio said Dec. 3 in a statement to Developmental Disability News:

“The House and Senate Finance Committees are in the process of conducting a series of hearings on potential ARPA expenditures, including the Governor’s proposal and ideas from other groups. We are meeting regularly with Governor McKee, as recently as Wednesday, December 1. Our intent remains to act in the near future to address the immediate needs of Rhode Island residents and businesses.”

The category that has undergone perhaps the greatest scrutiny and analysis has been Rhode Island’s services for adults with developmental disabilities, the subject of a 2014 consent decree and multiple court orders intended to correct violations of the Americans With Disabilities Act by transforming a segregated system of care to one that is individualized and integrated in the communities of participants.

The federal oversight connected to the consent decree – which has now run seven years and nearly eight months – is due to expire in another two and a half years, on June 30, 2024.

And the U.S. Department of Justice has made it clear that a new system must be up and running smoothly for at least a year before it will sign off on compliance. That timeline, in effect, allows only 18 months, until July 1, 2023 for the transformation to be complete and full implementation to roll out without a hitch.

But so far, the state has not even put a dollar figure on the cost of such an overhaul.

Still, a spokesman for the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) says the department has every intention of complying with the 2024 deadline.

To avoid contempt of court – and hefty fines - the state laid out a wide-ranging action plan for compliance in October.

The first step is the selection of a consultant to review the rate structure for developmental disability services – expected by the end of the year, according to a BHDDH spokesman. The target date of Dec. 31 is two months beyond the Nov. 1 deadline the state set for itself, although BHDDH has told the court it is working in good faith with the state purchasing division to complete the task.

In the meantime, many adults with developmental disabilities have had their service hours reduced by half or more as the system has failed to recover from the pandemic lock-down of 2020. The consent decree requires 40 hours of service a week. Some service recipients are currently getting less than 10 hours.

After court-ordered negotiations between state officials and providers, the General Assembly raised the starting hourly wage for direct care workers from $13.18 to $15.75, effective July 1.

There has been no detailed analysis yet on the effect of the wage increase on the workforce. But Spears, the CPNRI director, said that anecdotally, the raise seems to have been most effective in persuading existing direct care personnel not to quit their jobs.

The raise seems to have had a modest impact effect in attracting new employees, but “nowhere near” the number needed to comply with the consent decree, she said.

In 2020, a consultant for providers calculated that the state needs to expand the direct care workforce by about 38 percent – to a total of 2845 - to implement the community-based system required by the consent decree.

BHDDH has proposed an $18 starting wage effective next July 1 in its budget request to McKee. By 2024, that rate must move up to $20 an hour, according to an order by Chief Judge John J. McConnell of the U.S. District Court.

With the higher wages, recruitment efforts are expected to emphasize training and professional standards for caregivers, who have complex responsibilities.

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.

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.

DOJ, RI Spar Over Contempt In Olmstead Case

Federal Courthouse in Providence

By Gina Macris

The state of Rhode Island told a judge it cannot be held in contempt of a 2014 civil rights consent decree seeking to integrate adults with developmental disabilities in their communities because of circumstances beyond the state’s control.

But the U.S. Department of Justice (DOJ) says that the state has only itself to blame for its failure to comply.

The state’s “persistent choices to under-fund the system have created a dramatic provider shortage” that has left the target population isolated, the DOJ said in a counter-argument submitted Friday, Sept. 10, to the U.S. District Court.

The “refusal to adequately fund the Consent Decree is precisely the kind of self-imposed inability to comply” that undermines the state’s arguments in its defense, the DOJ said.

The decree stems from a 2014 finding by the DOJ that the state violated the Americans With Disabilities Act by relying too much on sheltered workshops paying sub-minimum wages and isolated day care centers, which kept people with disabilities out of mainstream society. The Olmstead decision of the U.S. Supreme Court has re-affirmed the rights of people with disabilities to receive support in their communities to give them a chance to live regular lives.

The DOJ further cites warnings of an independent court monitor a year ago that the state will be unable to comply with the consent decree by 2024 unless it came up with a multi-year plan to overhaul its developmental disabilities system, which for a decade has encouraged segregated care over integrated services. Such a plan has not been forthcoming.

The state’s lawyers, Marc DeSisto and Kathleen Hilton, submitted arguments Sept. 1 in response to a DOJ motion two weeks earlier that asked the Chief Judge of the U.S. District Court to find the state in contempt of the consent decree and impose fines ranging up to $1.5 million per month. Chief Judge John J. McConnell, Jr. has scheduled a hearing the week of Oct. 18 through Oct. 22.

The state’s lawyers maintained the state could not meet benchmarks for integrated employment and other criteria because of the COVID-19 pandemic, as well as resistance by adults with developmental disabilities themselves to work and non-work activities in the community.

But in its reply Sept. 10, the DOJ said the state’s characterization of the population “paints an inaccurate and offensive picture of people with developmental disabilities” and “reflects a profound misunderstanding of the nature, purpose, and obligations of the Consent Decree.”

DeSisto and Hilton, meanwhile, also argued that numerical targets for employment of adults with disabilities were not required by the consent decree, even though, as the DOJ said, documents show that state officials have admitted the opposite in numerous statements to the court since 2014, in writing or in person..

The state’s lawyers also maintained the state cannot be held in contempt until after the agreement expires on June 30, 2024 – an interpretation the DOJ said is unheard of in litigation involving system-wide reform.

In picking apart the state’s position over 28 pages, the DOJ said the state is urging the court “to adopt an interpretation of the consent decree that is “at odds with the decree’s text and purpose,” the DOJ said.

The state maintained the consent decree “imposed what could only be described as a cultural shock on the targeted community. After years of receiving services in “non-community” settings, “they are being told that their lifestyle must change,” the state’s lawyers said.

The DOJ disagreed. Rather than being told what they must do, the DOJ said, those eligible for services and their families have the right to make informed choices after receiving education and support about what working and enjoying leisure activities in the community might mean for them.

The state’s own data show that it “dramatically overstates” the resistance to integrated services, with 80 of 1,877 persons, or 4 percent, opting out of integrated services through a formal variance process, the DOJ said. And it cited a report from a court monitor in 2016 who had said he found “strong broad-based acceptance of the goals and desired outcomes of the consent decree.”

Similarly, the DOJ lawyers rejected the state’s argument that the COVID-19 pandemic prevented compliance with the annual employment targets in the consent decree. The pace of new job placements had slowed significantly more than a year before the onset of COVID-19, the DOJ said.

While the pandemic did make compliance more challenging, the state made “minimal efforts” to serve the consent decree population during the pandemic, the DOJ’s civil rights division argued.

“Given the availability of enhanced federal matching funds for providing integrated Medicaid services like those the Consent Decree requires, the State has the opportunity to increase funding for integrated employment services, provide the full amount of integrated day services to each target population member, and enhance wages to attract the required number of service providers,” the DOJ said. Its memorandum is signed by Rebecca B. Bond, chief of the DOJ’s civil rights division, as well as trial attorneys expected to litigate the case in October.

The state did earmark $39.7 million in federal-state Medicaid money to raise the wages of workers and their supervisors by $2 to $3 an hour in the current budget, a roughly 15 percent increase, but only at the conclusion of court-ordered negotiations between state officials and providers.

DeSisto and Hilton, the state’s lawyers, also said the state is finalizing the language in a request for outside proposals “for evaluation and implementation of new rate and payment options for (the) Developmental Disabilities Services System.” The preparation for the request for proposals indicates that BHDDH plans to go out to bid through the state purchasing system, which can take several months.

The state last conducted a rate review in 2010 and 2011, but the General Assembly did not follow the recommendations of the consultant, Burns & Associates. Instead, it set dozens of reimbursement rates for private providers roughly 17 to 19 percent lower than Burns & Associates recommended, with the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) saying that it still expected providers to maintain the same level of service.

In November 2018, a principal in Burns & Associates, Mark Podrazik, testified before a special legislative commission that that a rate review was already overdue. Rates should be reviewed every five years, he said.

A few months later, BHDDH hired NESCSO, the nonprofit New England States Consortium Systems Organization, to analyze Rhode Island’s developmental disabilities system from top to bottom.

Although the NESCSO contract called for a rate review and analysis of alternatives to the state’s fee-for-service reimbursement system, NESCSO was asked to present options for change but to make no recommendations.

The BHDDH director at the time, Rebecca Boss, said the department wanted to expand its analytical capability and make its own choices going forward.

The 18-month contract, which cost $1.1 million, produced a final report and supplementary technical materials which, among many other things, said the provider system was significantly underfunded. Since the report was completed July 1, 2020, BHDDH has remained silent on its findings, and has not exercised options for renewal of NESCSOs services.

In their memorandum, the state’s lawyers said that “the intention of the rate review process is to strengthen the I/DD system and services provided to individuals, as well as to address provider capacity to deliver those same services. Thus, the State can and will at hearing clearly demonstrate that it has been ‘performing its obligations’ under the various sections of the Consent Decree.”

The DOJ has scoffed at that notion. The DOJ said in its original filing in August that it is prepared to show the “State failed even to ask its Legislature for a sufficient appropriation, and that the State 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.

Employers Advancing DD Worker Raises While State Updates Reimbursement System

By Gina Macris

Most providers of services for adults with developmental disabilities in Rhode Island have passed along wage increases enacted by the General Assembly for the fiscal year that began July 1, even though the state’s developmental disabilities agency has not yet programmed the higher rates into its reimbursement system.

The raises, negotiated between state officials and representatives of some three dozen private provider agencies under pressure from the U.S. District Court, increase hourly wages for direct care workers by more than $2, from about $13.18 to an estimated $15.75 per hour, depending on variations in payroll taxes and other employer costs related to employment.

The General Assembly approved hikes of well over $3 for supervisory personnel, from $18.41 to $21.99 an hour.

Providers who can afford it are “floating” the pay hikes to staff for a few weeks with the assurance that they will be reimbursed when the increases are fully implemented by the state’s Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH), said Tina Spears.

“Providers are desperate for staff,” said Spears, executive director of the Community Provider Network of Rhode Island (CPNRI), a trade association representing about two dozen private agencies. The worker shortage, exacerbated by the pandemic, has increased employers’ overtime costs and forced many supervisors to provide direct care.

The General Assembly set aside $39.7 million in the BHDDH budget for the raises and “associated payroll costs,” which BHDDH says should put the “minimum” pay at $15.75 an hour for direct care workers and $21.99 an hour for supervisors.

But providers say the mathematical formula BHDDH uses to calculate the minimum pay doesn’t allow enough for the added payroll taxes employers must pay every time they hire a new staffer or give someone a raise.

Spears said providers are making every effort to pass on as much of the extra money as possible to their employees. Everyone should be making at least $15 an hour, she said.

In a newsletter last week, BHDDH officials encouraged those “self-directed” individuals or families managing a loved one’s individualized program to advance raises to the workers they hire even though their funding authorizations have not yet been adjusted to reflect higher rates. Self-directed individuals, who do not have overhead, pay more than the provider agencies but don’t offer benefits.

It’s not yet clear whether the pay hikes will be enough to cut into the workforce deficit, one of the reasons holding BHDDH back from implementing requirements of a 2014 consent decree mandating that adults with developmental disabilities be integrated in their communities.

Massachusetts and Connecticut both pay higher hourly rates than Rhode Island for similar jobs, one factor that is said to contribute to the state’s worker shortage.

A consultant has estimated that Rhode Island needs at least 1000 more individuals working with adults with developmental disabilities to implement the consent decree. The worker shortage is one of several reasons the Chief Judge of the U.S. District Court, John J. McConnell, Jr., has scheduled a week-long hearing in mid-October to gather evidence for holding the state in contempt for its failure to overhaul its developmental disabilities system as required by the consent decree.

DiPalma: $184 M DD Wage Settlement In CT Should Guide RI Talks

DiPalma Photo by Anne Peters

By Gina Macris

Will higher wages for workers who help persons with developmental disabilities in neighboring Connecticut and Massachusetts force increased pay for similar workers in Rhode Island?

State Sen. Louis DiPalma says they should; particularly a two-year contract settled just a few days ago in Connecticut that gives frontline workers $16.50 an hour in the fiscal year beginning July 1 and $17.25 in July, 2022.

While leaders of private agencies in Rhode Island that provide services to persons with disabilities have tentatively agreed to a $15.75 reimbursement rate for entry-level caregivers, they did so reluctantly, saying that it’s not competitive enough to help them stabilize or expand their workforce.

And it’s not yet known whether that figure is acceptable to Chief Judge John J. McConnell, Jr. of the U.S. District Court, who has involved himself in workforce issues because they are connected to the state’s compliance with a 2014 civil rights decree requiring the integration of adults with developmental disabilities in their communities.

DiPalma, a strong advocate for those with disabilities and an influential legislator, said in a telephone interview with Developmental Disability News that the $15.75 hourly reimbursement rate the private providers tentatively accepted from the state is “necessary but not sufficient.”

Connecticut’s eleventh-hour settlement with the Service Employees International Union (SEIU) averted a strike of 2,100 group home workers who had planned to walk out June 4.

In addition to the wage hikes, the agreement provides 3-percent raises to those already making more than entry-level pay, as well as a a pool of $30 million over the next two years for enhanced medical and retirement benefits. The entire package will cost a total of $184.1 million, according to a statement from the Connecticut state policy office and department of developmental disability services.

In Massachusetts, personal care attendants who work with adults facing intellectual challenges, as well as with others who need daily assistance, make $16.10 an hour, according to the website of their union, 1199 SEIU East, a different branch of the same overall organization representing the group home workers in Connecticut. Rhode Island routinely loses some of its best developmental disability professionals to Massachusetts, and DiPalma said Connecticut is “not that far.”

The strike threat in Connecticut was “a means to an end,” DiPalma said.

“Never mind how they got there,” he said. The state wouldn’t have put up the $184.1 million in the two-year package unless it valued the workers, DiPalma said.

For the most part, the employees of some three dozen private providers of developmental disability services in Rhode Island are not unionized. Wage talks have involved their employers and state officials and revolve around reimbursement rates to the private agencies, not the wages themselves.

Because of differences among agencies in employee-related overhead costs, like workers’ compensation, the actual wages are not exactly the same as the reimbursement rates negotiated between employers and the state, according to Tina Spears, executive director of the largest provider trade association, the Community Provider Network of Rhode Island (CPNRI)

The most recent CPNRI calculations indicate that the average starting pay for direct care workers is $13.18, but there are other reports that some agencies pay $13.40 or a little higher.

Those organizations paying a little more have transferred revenue from other programs to subsidize services for adults with developmental disabilities, in a pitch to be a as competitive as they can in the midst of a huge worker shortage, DiPalma said. Not all the agencies have multiple sources of income, he said.

Judge McConnell has heard testimony that low pay and high turnover has adversely impacted the workforce that the state relies on to comply with the 2014 civil rights consent decree, which requires adults with developmental disabilities to be integrated in their communities. The state is nearly 1100 workers short of the number it needs to guide community-based services, according to a consultant’s report.

McConnell has ordered the state to set starting wages at $20 by 2024, with any interim raises being competitive with direct care pay in neighboring states.

McConnell has a private conference scheduled today, June 8 with lawyers in the consent decree case.

RI DD Providers Agree to $15.75 Hourly Rate; Hike May Not Address Worker Shortage

By Gina Macris

Private agencies serving adults with developmental disabilities have asked for an additional $31 million in the next Rhode Island state budget to offer workers about $17.50 an hour – a bump of more than $4 on the current starting hourly pay.

The $31 million in state revenue would generate an additional $48 million in federal funds under the Medicaid program, for a total of $79 million. The private service system is currently funded at $260.4 million in federal-state Medicaid money.

A trade association of providers says its members need a significant wage hike to begin filling a huge hole in the workforce needed to implement a 2014 consent decree aimed at correcting violations of the civil rights of adults with developmental disabilities.

The state, meanwhile, has offered an estimated hourly pay of $15.75 for direct care workers.

Providers have agreed to the state’s figure, a bump of $2.57 over the current average starting pay of $13.18, as well as to an hourly rate of $21.99 for supervisory personnel. It was not immediately clear how much of a raise the supervisors are to receive.

But the providers, represented by the Community Provider Network of Rhode Island, say they are concerned that the state’s proposal will have little, if any, effect on their attempts to chip away at the worker shortage.

These latest developments in negotiations involving state officials, providers, families running independent support programs for loved ones, and other stakeholders emerged primarily in a budget briefing for the House Finance Committee June 3 and in a separate June 4 report to the federal court from an independent monitor.

The monitor, A. Anthony Antosh, said the consent decree requires the state not only to make certain reforms but to maintain the capacity to carry them out on a continuing basis. The worker shortage, the equivalent of about 1,081 full time positions, means the state lacks that capacity, Antosh said.

FERLAND

In the June 3 budget briefing, the House Fiscal Advisor, Sharon Reynolds Ferland, told the finance committee about the providers’ $31 million request but offered few details as she described the many moving parts of the state’s overall spending plan for Fiscal 2022, which begins July 1, in less than four weeks.

She said that the $31 million was not a negotiated figure or “anything other than what was asked” by provider agencies

Ferland told the finance committee that the proposed privatization of the state-run group home system is off the table, evaporating an estimated $20 million in savings that the administration had written into the budget.

The privatization depended on the existing network of private agencies – the same ones with the 1,000 worker shortage - to take on some 116 residents of the state-run group home system, without an increase in private-sector pay.

Ferland said that “was not something they (private providers) could support, or handle.”

The state pays its group home workers about $5 more an hour than it allows for frontline caregivers in privately-run homes.

In offering wage increases, the state withdrew all funds that previously had been earmarked for transition and transformation of the service system from a model based on segregated care to one that puts people in their communities.

Antosh

Antosh was not pleased, saying that “it is critical that the State provide transformation and innovation funds in FY 2022,” the fiscal year that begins July 1.

Antosh noted in several places in the report that there has been no discussion of wages or system reform for 2023 or 2024 – the last two years of the consent decree.

He recommended that the state meet with providers and other stakeholders once a week until they reach an agreement on wages for 2022 and 2023 and complete a comprehensive review of the rate structure that governs reimbursement to private providers.

The current rate structure is a dizzying array of dozens of figures and codes, with some rates presented in 15-minute increments of service for each client in the care of a single staff person. For example, providers must enter 20 fifteen-minute service units to get paid for one staffer working with five persons for an hour during the day, according to the current reimbursement methodology.

The state has agreed in principle that the rate structure should be simplified and initially told Antosh it would be done during the next fiscal year, the monitor said. More recently, he said, the state informed him the new rate structure would not be fully fleshed out until 2024.

He recommended that the new rate structure be completed in time for the governor to include it in his budget proposal for the fiscal year that begins July 1, 2023.

Often in the last year, Antosh’s recommendations to Judge McConnell have been transformed into court orders, with the judge becoming increasingly specific on the way he wants the state to address particular issues.

McConnell

For example, to attract high-quality job applicants, McConnell issued an order in January saying the state must increase wages to $20 an hour by 2024. Shortly after that, legislative leaders withdrew their representatives from ongoing talks among officials of the executive branch, the private providers, family members, individuals who receive services, and other advocates.

Spokesmen for the House and Senate said at the time that the General Assembly would deal with compliance issues as part of the legislative process.

Governor McKee’s initial budget proposal included no pay increase for direct care workers or supervisors.

And in a budget hearing June 2 for members of the finance committee’s human services subcommittee, Ferland said some of the court orders, like the one dealing with wages, appear to go “beyond” the consent decree. She did not explain the worker shortage or any other context for McConnell’s order on wages.

The instability of the labor force existed well before the pandemic. According to a detailed analysis commissioned by service providers, before the pandemic the private system had filled the equivalent of 2088 of the 2845 fulltime positions it needed to serve people in the community as the consent decree required, leaving 757 vacancies.

COVID made the situation worse, with the number of vacancies increasing by 324, for a total of 1,081, the consultants, the Approach Group, told Judge McConnell in a report delivered in April.

As a means of ensuring consistent funding on the basis of the latest data available, McConnell has ordered that the developmental disabilities caseload be incorporated into the Caseload Estimating Conference by November of this year.

The twice-yearly caseload estimating and revenue estimating conferences are used in budget preparations both by the executive and legislative branches.

The governor has proposed that the developmental disabilities caseload into the Caseload Estimating Conference beginning in November, 2022.

But in his latest report, Antosh asked the judge to remind the state that the deadline for participation in November, 2021 was “a court order, not a request.” A spokesman for the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals said recently that the timing of the switch to the Caseload Estimating Conference was “under review.”

BHDDH has not explained exactly why the change could not be made in 2021 in accordance with the court order.

Another change from the court’s expectations is that there is no funding in the budget to switch from quarterly to annual budget authorizations for each person who receives services, according to Ferland’s June 2 presentation to the human services subcommittee of the finance committee.

The quarterly authorizations, applied to the existing fee-for-service model, mean that all clients must have 100 percent participation for all the funding to be used – a virtual impossibility. Because funding cannot be transferred from one quarter to another, the state counts on saving about $6.7 million a year from program absences.

The governor’s initial proposal for Fiscal 2022 added that money so that the funding matched the annual authorization for an entire year. Providers, those receiving services, and their families have long complained that the quarterly authorizations do not allow them any flexibility in planning individualized programs.

Read the monitor’s latest report.

Read the consultants’ report on the worker shortage.

Federal Judge Presses RI To Raise DD Worker Wages In Wake Of Severe Shortage Of Services

By Gina Macris

The U.S. District Court has put pressure on the state of Rhode Island to increase the pay of front-line workers who support adults with developmental disabilities in the budget beginning July 1, a year earlier than the disability service agency had planned.

Indeed, two human services officials have recommended that privately-employed front-line workers serving adults with developmental disabilities get $15 an hour – a hike of nearly $2 –in light of a new report that the post-pandemic workforce will fall far short of the number needed for complying with a 2014 civil rights decree.

On April 28, the day after hearing about the worker deficit, Chief Judge John J. McConnell, Jr. issued an order saying the rates must be “reasonably comparable” with those paid in the state’s own group home system and in neighboring Massachusetts and Connecticut.

Massachusetts and Connecticut pay $15.75 and $15.78, respectively.

The state pays its own group home workers an average of $18.46 an hour and sets rates for private providers that allow them to pay front-line employees an average of $13.18 – about five dollars less than the workers make in the state-run group homes, according to figures provided to McConnell.

Moreover, the budget now under consideration by the General Assembly assumes the private sector will absorb more than 100 residents of state-run group homes, without any rate increases.

COVID Exacerbated Worker Shortage

A report submitted to the court April 27 indicated private providers simply don’t have the staff to take on any new clients, let alone meet the demands of the 2014 consent decree by the time it expires in 2024.

The report, compiled by the same consultants the state used for a $1.1 million analysis completed last July, started with the premise that a “stable and skilled workforce is a necessary pre-condition” to implementing changes required by the consent decree.

The consultants concluded that at the end of 2020, the privately-operated system had 1,764 direct care workers, only 62 percent of the 2,845 full time employees it needed to ensure that adults with intellectual and developmental challenges have access to jobs and other activities in their communities, as required by the consent decree. That’s a gap of 1,081 full-time positions.

Currently, the system is staffed at 62 percent of the capacity it would have if all positions were filled, said the consultants. Except for those living in group homes, eligible adults at the end of 2020 generally received less than half the services they got before the pandemic. For those living in family homes, the reduction was calculated at 71 percent, according to the consultants.

The consultants previously worked for the New England States Consortium Systems Organization (NESCSO,) a non-profit regional organization under contract to the Department of Behavioral Healthcare, Developmental Disabilities and Hospital (BHDDH) to analyze the developmental disabilities system top-to-bottom – but provide no recommendations.

The latest report, presented to McConnell April 27, was commissioned by the Community Provider Network of Rhode Island, (CPNRI), a trade association.

CPNRI seeks an hourly rate of $17.50 an hour for front-line workers and proportional increases for supervisory and other personnel. CPNRI’s executive director, Tina Spears, told McConnell during the court hearing that the proposed $15 hourly rate would only address direct care worker pay.

The pay hike would cost nearly $26.9 million and would require legislative approval in the next two months if the change were to take effect in the budget beginning July 1.

Will The Governor Amend Budget Plan?

During the April 27 court hearing, an independent court monitor in the case, A. Anthony Antosh, said he understood a new budget article is to be drafted in early May.

Neither the office of Gov. Dan McKee nor BHDDH have responded to questions about any top-level support of a $26.9 million expenditure to raise worker pay or how they would fund it.

The Director of the Developmental Disabilities, Kevin Savage, was one of the two officials recommending the $15 hourly wage. The other was Kayleigh Fischer, Director of Budget and Finance at the Executive Office of Health and Human Services.

In January, McConnell raised eyebrows at the State House when he ordered the state to raise direct care wages to $20 an hour by 2024.

Both the House and Senate leadership withdrew their representatives from talks organized by the court monitor about consent decree reforms, which must be up and running by July 1, 2023, a year before consent decree is set to expire.

Instead, legislative spokesmen said at the time, the respective chambers would consider reforms in the context of the budget process.

But with only two months left until the start of the next fiscal year, that process has been silent on developmental disability reform.

McConnell Tightens The Reins

The apparent passivity of the legislative process, combined with the fresh data showing that non-compliance with the consent decree has accelerated during the pandemic, apparently prompted McConnell to tighten the reins in his oversight of the case.

He has been adamant that the state cannot meet the integration requirement at the heart of the consent decree without beginning implementation of a three-year plan in the next budget.

The current system, now ten years old, comes with a reimbursement system built on congregate care – a violation of the Integration Mandate of the Americans With Disabilities Act.

While BHDDH officials had said they wanted to tackle structural reforms first, McConnell’s latest order accepts the position of providers that they cannot get their clients into the community unless they first have an adequately paid, stable workforce.

Roughly one in three workers leave within a year, and one in five jobs goes begging, with the majority of supervisory staff frequently filling in for front-line workers, according to various reports.

McConnell’s latest order says the state must continue to meet in person or by teleconference with providers and at least one representative of families who direct their own programs to address the immediate fiscal and administrative issues in several court orders dating back to last July. The judge wants a progress report by the end of May, he said.

The annual state budget typically is finalized in early June for the next fiscal year, but McConnell said state officials should continue talking with providers and at least one family representative to prepare for the following two fiscal cycles leading up to the deadline for full compliance with the consent decree in 2024.

In addition, McConnell’s order said the developmental disability caseload should be part of the twice-yearly process the governor and the General Assembly use to determine public assistance obligations beginning in November of this year. He said he will continue to look at job turnover and vacancy rates, as well as client participation rates, to determine the effect of the wages on the system.

Governor McKee’s budget proposal would have the developmental disability caseload become part of the twice-yearly meeting, the “Caseload Estimating Conference,” in November, 2022.

The caseload and revenue-estimating conferences in May and November are considered critical tools in budget-planning.