RI Budget Adds $100M To Human Services

By Gina Macris

Rhode Island’s next fiscal year promises to turn a corner in restoring services for children and adults with disabilities with about $100 million in new funding and a new long-term plan to reassess the rates the state pays private service providers.

The House and Senate passed the $13.6 billion budget a week apart, with the Senate vote held June 23. The spending plan needs only the governor’s signature before it goes into effect July 1.

About a third of the funding, $35 million from the federal-state Medicaid program, will add $2.25 an hour to the rate paid direct care workers in the private sector who support adults with developmental disabilities. Their starting pay will increase from $15.75 to $18.

There also will be raises for supervisory personnel, but those figures have not yet been made pubic. A spokesman for the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) said June 24 that the plan for the rollout is to have the raises released to providers July 1 so workers do not have to wait for retroactive checks.

The $35-million fund for wage hikes is part of a total Medicaid allocation of $390.3 million to the Division of Developmental Disabilities (DDD) at BHDDH, 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. About 4,000 individuals are eligible for services from DDD.

Across the human services, the state budget also provides for:

• $13 million for repair of state-owned group homes

• $5.5 million in American Rescue Plan Act funding for early intervention services for infants and toddlers with developmental delays

• $4 million for a rate increase for early intervention providers

• $22 million toward rate increases for home-based treatment services (HBTS), personal assistance service support (PASS), applied behavioral analysis (ABA), and respite care

• $1 million enabling adults with developmental disabilities to acquire tablets and cell phones

Separately, the budget requires the health insurance commissioner to hire an outside consultant to conduct a comprehensive review of Medicaid rates paid all private human service providers working for state agencies in time to be incorporated in the state budget July 1, 2024. After that, the rates will be reviewed every two years, according to language in the budget.

The Senate had favored the same approach to rate review for all medical and clinical programs funded by the federal-state Medicaid program, but the House did not go along.

Tina Spears, executive director of the Community Provider Network of Rhode Island, said: “This budget sends a clear message that Rhode Islanders with disabilities, and the people that provide them with services, belong and are valued in our great state.”

She called the health insurance commissioner’s planned rate review a “historic investment” in a long-term plan to address a workforce crisis plaguing community-based supports for children and adults with disabilities and behavioral health conditions.

“The Senate has made the health and human services system a priority this legislative session, and because of the hard work of our legislative leaders, this budget will have an impact on everyday Rhode Islanders,” she said.

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.

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.