Consultant Recommends Substantial Hikes To RI DD Rates; Public Comment Invited

By Gina Macris

The average pay of a direct care worker serving Rhode Islanders with developmental disabilities would jump almost four dollars to $22.14 an hour July 1 in a new rate structure recommended by a healthcare consultant to the state Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH).

The proposed rate structure would make Rhode Island’s direct care workers the highest paid of any developmental disabilities caregivers in 26 states, according to the consultant, the Burns & Associates division of Health Management Associates.

Photo HMA-Burns

Stephen Pawlowski, an HMA-Burns official, presented the preliminary recommendations in video meetings Sept. 28 and Sept. 29. HMA-Burns and BHDDDH will accept public comment until Oct. 24 before finalizing the recommendations.

In compliance with a federal court order, the state has agreed to pay direct care workers a minimum of $20 an hour by 2024. To follow the state fiscal year, which begins in July, the new rate would become effective six months earlier than the court deadline. The $20 minimum means the average hourly pay will be $22.14, Pawlowski said. (see graphic, above)

Preliminary recommendations of the HMA-Burns also include significant increases in many other rates as part of a continued fee-for-service reimbursement structure for private service providers that has been in place for more than a decade.

Service providers, consumers and their families, and even a legislative commission have called for alternatives to fee-for-service reimbursements during the last several years.

Three dozen private agencies form the backbone of Rhode Island’s developmental disabilities system. The state relies on them to meet the requirements of a 2014 civil rights agreement mandating a network of individualized community-based daytime services by June 30, 2024 in accordance with the Integration Mandate of the Americans With Disabilities Act (ADA).

DELAY IN PART OF RATE REVIEW

A federal judge set a Dec. 1 deadline for completion of the rate review, but Pawlowski said the portion that deals with individual assessments and individual budgeting cannot be finished until mid-2023.

In August, an independent court monitor said this portion of the rate review should be completed by Oct. 31, underlining his recommendation in bold type in a report to the court.

The process and timeline involving assessments, service plans and developing individual budgets is “one of the most critical aspects of the transition to high quality person-centered practice,“ but the way these elements connect with each other is ‘‘poorly understood,‘‘ said the monitor, A. Anthony Antosh.

‘‘Person-centered practice‘‘ refers to a professional approach that that puts a client’s needs and preferences first in keeping with with the consent decree and the ADA.

Antosh recommended the state do a “comprehensive review“ of its use of the current assessment tool, the Supports Intensity Scale (SIS), citing continued problems with inaccuracies in the results.

The state made it clear a year ago that it will continue using the SIS, but during the recent presentations, the HMA-Burns spokesman , Pawlowski, that the publisher is in the process of revising it.

The second edition of the SIS is expected in January, 2023, he said. It will be incorporated into the new rate structure by mid-year, he said. The graphic below lays out additional details.

REVENUE HIKE FOR PROVIDERS

Overall, the various rate increases would hike revenues for private service providers 20 to 25 percent above current levels, Pawlowski said.

Part of the increase in private agency revenues would come from funding employment-related services, more costly than other types of daytime supports, as a separate add-on allocation.

It remains unclear how much one-on-one time with a direct care worker an individual would get under the proposed new rate model. One-on-one staffing is considered important for community integration.

Pawlowski was asked whether someone choosing one-on-one staff time exclusively would use up their budget allocation faster than someone in a small group. The short answer is “yes,” he said.

Anne LeClerc, a BHDDH official, added quickly that “it depends” on a person’s need and funding level.

On an hourly basis, the rate for one-on-one supports in the community would increase from $37.88 to $65. Not everyone will have a budget big enough to pay for one-on -one staffing for an extended period of time.

One caveat is that one-on-one staffing will be available to all who seek competitive employment in the community, regardless of the size of their individual budgets, BHDDH spokesman said.

Final answers to questions about the availability of one-on-one staffing will be directly linked to the way the new SIS version defines individual need and the funding that results from that definition.

The new system also includes a range of reimbursement rates for group supports in the community involving no more than three people for each worker.

Center-based care will continue, with its own range of reimbursement rates. Centers would be used as gathering places in the morning to prepare for community activities and places for daytime meals and personal care, Pawlowski said.

15-MINUTE BILLING UNITS

During the presentations, Pawlowski said new rate structure will continue 15 minute billing units for daytime services, giving consumers the “flexibility” to “mix and match” their choice of services and service providers.

Private agency providers for years have complained that the administrative cost and time used to bill in 15-minute increments according to staffing ratios detracts from their ability to provide the services themselves.

In one of many court-ordered activities, a cross-section of state officials and community representatives has studied 15-minute billing and found it burdensome, recommending that the 15-minute unit be replaced with one or two rates for community staffing lasting three or four hours at a time.

Pawlowski said the new model would reduce the administrative burden by eliminating the requirement to account for staffing ratios within each 15-minute billing unit.

Reimbursement tables in the proposed rate structure assume there will be five levels of funding, as there are now.

The funding levels are largely based on a person’s perceived ability or inability to complete the tasks of daily living, with the “tiers” of funding running from A, the lowest funding, to E, the highest.

“SELF-DIRECTED” CONSUMERS

About a quarter of consumers receiving developmental disabilities services do not rely on private agencies but direct their own plans, mostly with help from their families.

They are responsible for hiring direct care staff, but a fiscal intermediary handles payroll and helps them stay on track with their budgets.

Going forward, Pawlowski said, fiscal intermediaries will be limited to payroll services.

Support activities will become part of case management - a service now under review for all health and human service departments governed by the Executive Office of Health and Human Services to ensure that Rhode Island complies with federal case management rules.

The removal of support services from the role of the fiscal intermediaries will result in a slight rate decrease, Pawlowski said.

But some fiscal intermediaries listening to the presentation online said the two functions can’t be easily separated.

RESIDENTIAL OPTIONS TO WIDEN

Reimbursement rates would increase substantially for residential services except for the largest group homes, with six or more residents, where the rate reviewers assumed an economy of scale, Pawlowski said.

A few of the largest group homes would see a slight decline in funding, he said.

Rates for shared living, which Pawlowski said have remained the same since the program started, will get substantial increases. Shared living providers host adults with developmental disabilities in their homes.

For the first time, there will be an enhanced reimbursement rate for hosts who also provide all the day services for the people in their homes.

Established provider agencies that now oversee individual shared living arrangements will be required to make monthly visits to each home, Pawlowski said.

There are two new categories of residential services:

  • Supervised living, a shared service for those who don’t need 24-hour care and live near each other, like residents with separate apartments in the same building who are visited by the same “floating” staffer as needed.

  • Room and board arrangements in which an individual with intellectual and developmental disabilities has a roommate who is not the homeowner.

The proposed reimbursement scale also provides for “remote services” in which a worker can check in electronically and follow-up with an in-person visit if needed.

Recordings of two presentations and a packet of information on the proposed rates and other related materials have been posted to the BHDDH website at https://bhddh.ri.gov/developmental-disabilities/initiatives/rate-and-payment-methodology-review-project/public-review

Written comment from the public will be accepted until Oct. 24 at bsmith@healthmanagement.com

Graphics by HMA-Burns

RI APSE To Host Session On Supported Employment Successes; State To Present First Look at DD Rate Review

(This article was updated Sept. 29 to include details for accessing two online rate review sessions. )

Rhode Islanders with developmental disabilities who have received supported employment services over the last six years, their families and the professionals who support them are invited to share their experiences Sept. 29 in an online “community conversation” intended to help shape job-related supports in the future.

The Rhode Island Chapter of the Association of People Supporting Employment First (RI APSE) will host the meeting with the aim of highlighting the successful strategies of pilot programs funded by the Division of Developmental Disabilities (DDD) over the last six years in the hope of informing the next wave of job-related services.

The session has the support of a federal court monitor who seeks to promote compliance with a 2014 consent decree requiring the state to help find competitive employment in the community for adults with developmental disabilities.

The meeting, at noon on Thursday, will be facilitated by Jeannine Pavlak, a board member of the Massachusetts Chapter of APSE who has 32 years’ experience providing supported employment services to people with disabilities.

Pre-registration is required for the session. To pre-register, click here.

Reminder: DD Rate Review Recommendations To Be Aired

Meanwhile, on Sept. 28 and Sept. 29, consultants will make two presentations of preliminary recommendations for new reimbursement rates for private providers of developmental disability services that are intended to help the state comply with the consent decree. No pre-registration is required for these online sessions.

The first, with technical details aimed at providers, is on Sept. 28 from 12:30 to 3 p.m. To join, click here. Update: There is a meeting passcode and it is 186251, according to a BHDDH spokesman.

The second, for consumers, families and the community, is Sept. 29 from 1:30 to 3:30 p.m. To join, click here. (The link allows listeners to join using internet audio and also gives two other options for access. )

Interested stakeholders will have until October 21, 2022 to submit comments. Recordings, materials, and instructions for submitting comments will be posted after September 29 on the website of the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals. To go there, click https://bhddh.ri.gov/developmental-disabilities/initiatives/rateand-payment-methodology-review-project.


BHDDH Invites Public Comment On Rate Review

By Gina Macris

Beginning Sept. 28, the public will have a chance to comment on preliminary recommendations of a consultant’s long-awaited review of rates paid Rhode Island’s private providers of developmental disability services.

The court-ordered rate review is expected to address several barriers to the state’s compliance with a 2014 civil rights consent decree. The agreement requires the state to provide individualized services enabling adults with developmental disabilities to integrate with their communities in accordance with the Americans With Disabilities Act.

That goal means that, among other changes, the the state must offer more competitive rates to private service providers to enable them to greatly expand their direct care workforce.

The Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH) has announced that its consultant will present its initial recommendations in two online meetings Sept. 28 and 29. The public will have until Oct. 21 to submit comments.

The two online presentations will be facilitated by officials of the Burns & Associates Division of Health Management Associates, (HMA-Burns) the healthcare consultant BHDDH hired to conduct the review. The public may attend both sessions, but each one will have a different focus, with the first including technical details of interest to service providers and the second aimed at consumers, their families, and other interested persons.

A BHDDH spokesman said there will be no pre-registration or meeting passcodes for either of the two events, to be hosted on the Zoom platform.

The schedule:

After Sept. 29, the public will be able to view recordings of the meetings, access rate review materials, and find instructions for submitting comments on the BHDDH website at https://bhddh.ri.gov/developmental-disabilities/initiatives/rateand-payment-methodology-review-project.

The recommendations of the rate review will be finalized after the conclusion of the public comment period.

The rate review was timed to enable the state to use it in formulating the annual budget for the fiscal year beginning July 1, 2023.



$2.5 M Unused For Lack of RI DD Jobs Program

CVS Trainee - File Photo

By Gina Macris

This article was updated Sept. 10.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Job Placements Fall Short

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

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

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

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

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

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

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

Rate Review To Finish Nov. 1

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

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

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

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

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

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

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

Administrative Barriers To Integration

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

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

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

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

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

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

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

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

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

Read the monitor’s August 29 report here.

Read the monitor’s Sept. 1 addendum here.

RI Faces Possible Fines For DD Noncompliance

Federal Building, Providence, RI

By Gina Macris

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

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

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

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

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

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

As each month goes by, compliance becomes more difficult.

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

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

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

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

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

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

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

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

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

• long delays in implementation of the plan

• a lack of clarity about its intent and outcomes

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

By Gina Macris

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

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

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

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

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

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

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

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

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

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

  • A lack of individualized budgeting

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

  • Staffing ratios that make integration in the community challenging

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

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

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

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

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

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

  • HMA - $339,680 - 1,516 hours

  • Guidehouse - $499,350 - 2,235 hours

  • Milliman - $1,203,181 - 4,628 hours

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

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

The results:

  • HMA- $490,875

  • Guidehouse - $670,290

  • Milliman - $773,4000

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

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

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

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

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

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

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

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

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

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

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

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

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

RI 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.


RI Katie Beckett Settlement Spotlights Workforce Shortage

By Gina Macris

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

RI's Olmstead Consent Decree Coordinator Moves On

By Gina Macris

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

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

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

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

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

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

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

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

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

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

Judge Steps Up Pressure On RI DD Hiring

By Gina Macris

John J. McConnell, Jr.

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

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

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

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

McConnell’s order included two other steps:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  • recruitment and retention

  • training and professional development

    establishing work standards and a credentialling path for workers

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

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

  • The compliance needs of the state

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

  • “New concepts” for providing services

  • Factors associated with job turnover and factors associated with retention

  • Staff roles and responsibilities. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

To read Judge McConnell’s order, click here.

Low RI Medicaid Rates Strain All Healthcare Services, Witnesses Say

By Gina Macris

Annette Bourbonniere

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

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

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

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

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

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

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

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

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

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

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

Louis DiPalma

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

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

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

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

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

According to the testimony:

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

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

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

Sherrica Randle

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

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

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

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

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

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

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

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

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

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

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

Shannon Sullivan

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The bills heard April 28 are:

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

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

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

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

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

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

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

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

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

    All photos from Capitol TV

RI DD Employment Chief To Join AccessPoint RI

By Gina Macris

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

pHOTO ribhddh

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

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

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

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

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

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

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

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

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

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

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

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

Tina Spears To Challenge Blake Filippi For House Seat

By Gina Macris

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Bills Would Set Competitive Rates For All RI Human Service Workers

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

By Gina Macris

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CONSENT DECREE: Compliance Inches Along; Court Stresses Urgency

By Gina Macris

Amid politely-worded warnings from a federal judge about missing court-ordered deadlines, the state of Rhode Island has laid out a timeline that would put a new system of developmental disability services in place and ready to go by July 1, 2023.

The launching pad for the overhaul will be an outside review by the Burns & Associates Division of Health Management Associates (HMA-Burns) of the rates and associated bureaucracy that governs reimbursement to the private service providers the state relies on to comply with a 2014 civil rights consent decree. 

HMA-Burns will receive nearly $500,000 for five months’ work, from February through June, with an option to renew for up to one year, according to the contract, obtained by Developmental Disability News.

HMA-Burns Budget Table from Contract With State of RI. HSRI is Human Services Research Institute

The rates the state pays private service providers are particularly important in alleviating an acute staff shortage that prevents the state from implementing most, if not all, of the reforms required in the consent decree. 

For example, the decree calls for supported employment and non-work activities in the community, which require a lot of one-on-one staffing.

The existing system was designed to pay for staffing in sheltered workshops and day care centers, with little one-on-one time and a preponderance of staffing at ratios of one-to-five or one-to-10.

State officials told U.S. District Court Chief Judge John J. McConnell, Jr. in a hearing Feb. 3 that the rate review will be completed by Dec. 1, 2022.

McConnell

McConnell told HMA-Burns representative Stephen Pawlowski that “it would have a domino effect on what’s happening here” if the Dec. 1 deadline is not met.

“That Dec. 1 deadline is real. It will be enforced,” the judge said.

The deadline is timed to allow recommendations to be incorporated in the governor’s budget proposal to the General Assembly for the fiscal year beginning July 1, 2023.

“Nearly eight years into the consent decree, it is essential that the state restructure its reimbursement system,” said Jillian Lenson, an attorney for the U.S. Department of Justice. The state is required to ensure all its contractors and vendors comply with the consent decree, she said during the hearing, which was conducted remotely.­­

Antosh - Photo by Anne Peters

Throughout the hearing, A. Anthony Antosh, an independent court monitor, emphasized the “urgency” of moving ahead quickly with all the required reforms if the state is to achieve full compliance with the consent decree by its expiration on June 30, 2024.

“When a timeline is not met, and I ask why, I am told, ‘the system,’” Antosh said.

“The system needs to be on time,” he said.

Even so, the lawyer for the state, Marc DeSisto, could not say unequivocally when already-appropriated funds will be released to 29 private service providers who have been awarded – on paper – a total of $4 million in “Transformation Fund” grants to prepare to shift to individualized, community-based services.

Although the General Assembly appropriated $4 million effective last July 1, the Department of Behavioral Health, Developmental Disabilities and Hospitals (BHDDH) only began accepting grant applications in late November and did not finish reviewing them until the end of December.

Those grants are part of a court-ordered “Action Plan” for compliance with the consent decree over the next two and a half years.

DeSisto said the “target date” for release of the funds is March 15.

“It’s difficult to say we will have the money by that day, other than to say that’s the target date,” DeSisto said, expressing concerns about making an ironclad commitment and then “getting into trouble with the Court and the monitor.”

McConnell’s agenda for the hearing included a discussion about moving up Governor McKee’s timetable for wage increases for direct care workers, who would get a bump from $15.75 to $18 an hour in his budget proposal for the fiscal year beginning July 1.

DeSisto said the state was not prepared to discuss such a mid-year boost at the hearing but would be ready to talk “soon.”

The judge did get an explanation of the reasons for the delay in the award of the rate review contract, originally promised by the state Nov. 1 as part of the Action Plan. 

The contract was awarded Jan. 24 to Health Management Associates (HMA), the parent company of Burns & Associates, which HMA acquired in 2020.

Burns & Associates was the firm which helped the state create Project Sustainability in 2010 and 2011, the fee-for-service system which the DOJ has criticized for incentivizing segregated care through sheltered workshops and isolated day care centers.

Of five bidders for the new rate review contract, three met technical qualifications, according to Amanda Rivers, deputy purchasing agent for the state.

But the three proposals varied so much in terms of cost and the number of hours they would devote to the project that the state asked them to submit revised bids with a benchmark of 3,000 hours of effort, Rivers said.

When the second round of bidding was done, in early December, two of the three bidders were tied in the scoring, she said. The purchasing division recommended HMA on cost alone, she said. Rivers described in detail the steps the purchasing division took to finalize its decision in a timeline that stretched into January.

State officials have emphasized that none of the individuals who worked on Project Sustainability more than a decade ago will participate in the new rate review.

But it is clear that HMA will bring to the project the institutional memory and expertise of Burns & Associates, which retains its identity as a division of HMA. 

Pawlowski, managing director of HMA and former vice president of Burns & Associates for more than a decade, will lead the project.

Pawlawski - HMA-BURNS WEBSITE

In a presentation during the court hearing, he said he provided some background information for Project Sustainability but didn’t actually work in Rhode Island more than a decade ago.

Since it was implemented in 2011, Project Sustainability has been generally regarded by providers, consumers, and advocates in the developmental disabilities community as a smokescreen for budget cuts, judging from comments made in numerous public forums over the years. 

And the role of Burns & Associates in helping the state develop the controversial fee-for-service reimbursement system has been linked to that negative view, although a principal in the firm returned to Rhode Island in 2018 to make it clear that the state did not follow the rate recommendations the firm made.

In November, 2018, Mark Podrazik, president of the formerly independent Burns & Associates, and now a managing director of HMA, said Rhode Island was already overdue for a rate review. Such adjustments should be made every five years, he said.

Another three years and three months passed, with increasing pressure from the court, before the new rate review contract was signed. In the meantime, the state spent more than $1 million on an outside analysis of the developmental disabilities system designed by BHDDH to omit any recommendations.

In the Feb. 3 hearing, Pawlowski said he understands that “a rate-setting project is just as much a statement of policy.”

“It has been impressed upon us that the reimbursement must meet the standards of the consent decree. We have a number of strategies to engage people in the process.

“We’ve done a lot of this work, and we think we’re pretty good at it, but there’s no substitute for on-the-ground knowledge.”

He said the public comment period should last at least three or four weeks.

Antosh, the independent court monitor, said there’s “a lot to be done in the rate review, but I hope it can be done sooner” than Dec. 1.

He said he wants the system to be “simpler,” with “less time on paperwork, and more time spent on ‘real stuff.’ “

Savage - Anne Peters Photo

Kevin Savage, Director of the Division of Developmental Disabilities, said, “Rarely does the state get to say that they appreciate a court order.”

But, he said, “I appreciate the ability to refer back to the court order” in working on consent decree tasks with his colleagues in state government.

The state will put forward only proposals that make the system simpler, as Antosh requested, Savage said.

Earlier in the hearing Savage had suggested there are difficulties in coming up with clear recommendations for solving some of the bureaucratic problems associated with the current fee-for-service system, such as a complex application and eligibility process.

Members of the developmental disability community are involved in discussions on solving bureaucratic problems.

Savage said the state will continue to use the Supports Intensity Scale (SIS), a lengthy interview process, to evaluate applicants. Rhode Island applies a never-disclosed mathematical formula to the scores of the SIS to award individual spending allocations to those eligible for services on the basis of their perceived level of independence in daily living, or lack of it.

Antosh said he has asked to see the mathematical formula, or algorithm, applied to the SIS by Feb. 15.  

The SIS was designed by the American Association on Intellectual and Developmental Disabilities to help planners decide what services individuals need, not as a funding tool.  But Rhode Island is not alone in using the SIS in the budgeting process.

Burns & Associates has helped “more than a dozen states in the design of individualized budgets informed by the Supports Intensity Scale’’ in the area of developmental disabilities, according to its website. Burns & Associates helped Rhode Island introduce the SIS in 2011 and for several years monitored developmental disabilities spending for the state.

Over the years, the way Rhode Island uses the SIS has led to millions of dollars of additional awards for supplemental services on appeal.

There is agreement that an additional assessment is needed to make sure the overall evaluation and funding level meets actual needs and minimizes the need for time-consuming annual appeals, Savage said, but there is difficulty in identifying that tool.

Judge McConnell said that as much as funding issues grab headlines, administrative barriers are often the hard part.

He said he spoke from his experience as a young lawyer working with Antosh, the court monitor; the late James Healy, who for many years headed the original ARC of Rhode Island; and the late Paul Sherlock, founder of the Sherlock Center on Disabilities at Rhode Island College and an influential state legislator.

McConnell represented the three in a lawsuit that forced the state to close the Ladd School, the state’s institution for people with developmental disabilities, which was shuttered in 1994.

McConnell said he was “in awe of the commitment of this team headed by Kevin Savage to move mountains.”

Even though he won’t hesitate to hold the state team’s “feet to the fire,” he said, “you have done yeoman’s work.”

 Below is the Monitor’s latest chart summarizing timelines and tasks for compliance with the consent decree:

The chart is part of the Monitor’s most recent comments to the Court, which includes a letter from the state's lawyer on the status of consent decree compliance.

Read the Monitor’s comments here.

Read the contract between the state and HMA-Burns here.

Consultant with Link to RI DD System Chosen To Recommend Fixes

By Gina Macris

This article has been updated.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This is a developing story.

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

For a history of Project Sustainability, click here.


Action Plan Drives RI DD Funding Increases In McKee Budget

Governor McKee’s Proposed Budget for Developmental Disabilities, Fiscal Year 2022-2023

Caregivers for adults with developmental disabilities would get an average pay boost of about $2.25 an hour, from $15.75 to $18, in the proposed budget of Rhode Island Governor Dan McKee for the fiscal year beginning July 1.

But a federal judge has signaled he may want some wage hikes before July.

McKee submitted the overall $12.8 billion spending plan for the state to the General Assembly on Jan. 19. Raising wages is intended to attract more applicants to a critically understaffed workforce as the state tries to ramp up individualized, community-based services in time to meet a 2024 deadline for complying with a consent decree it signed in 2014.

The pay raise for direct care workers is part of a court-ordered Action Plan designed to speed compliance with the 2014 civil rights consent decree, which requires the state to overhaul its system of developmental disabilities services.

On Jan. 20, the day after McKee submitted his budget, Chief Judge John J. McConnell, Jr. of the U.S. District Court scheduled a hearing for Feb. 3 to discuss whether raises should take effect earlier than July and other aspects of the Action Plan.

The Action Plan, drawn up by the state and approved by McConnell, spans more than a single year. In addition to the $18 hourly rate for the fiscal year beginning July 1, it calls for a jump to $20 an hour in the budget cycle starting July 1, 2023.

A raise from $13.18 to $15.75 last summer appears to have had a slight effect in easing the worker shortage, but a spokeswoman for a provider trade association has said in recent weeks that the organization has not yet completed a full analysis.

The Action Plan also calls for a review of all the rates the state pays providers and the bureaucracy that governs operations, including the kinds of services adults with developmental disabilities receive.

That rate review, intended to spark a system-wide transformation, was to have begun by Nov. 15, and Judge McConnell wants to know why it has been delayed. He has scheduled that question as the first item on the agenda for the Feb. 3 hearing. State officials say they are very “close” to naming an outside consultant to conduct the review but have disclosed no reason for the delay.

In 2014, the U.S. Department of Justice found that Rhode Island violated the Integration Mandate of the Americans With Disabilities Act by relying too much on sheltered workshops paying sub-minimum wage and on isolated day care centers.

To correct the violations, the state agreed in 2014 to create a system of individualized services over the following 10 years to enable adults with developmental disabilities to lead regular lives, including supports helping them to work and enjoy leisure activities as members of their own communities.

The eighth year of consent decree implementation begins April 9, but achieving an individualized, community-based system has remained elusive for many of the 4,000 people eligible for services and their families.

To avoid contempt of court, the state last fall developed the Action Plan, which Judge McConnell turned into a court order.

The funding includes $8 million of a $12 million Developmental Disabilities System Transformation Fund described in the Action Plan, which was allocated $4 million in the current budget, according to a spokesman for the Office of Management and Budget. (OMB)

The Transformation Fund is designed to help private providers and families who direct individual programs for loved ones to create new models for supported employment services and individualized non-work activities integrated in the community. Of the $8 million total, $2 million in state revenue would be set aside for self-directed families.

Nearly eight years into the implementation of the consent decree, Rhode Island is currently hitting only two-thirds of the supported employment targets spelled out in the agreement, according to data in the governor’s budget proposal.

One of the topics Judge McConnell wants to discuss Feb. 3 is the release of current funding from the transformation fund to help individual providers and self-directed families plan ahead. It’s not clear whether any transformation fund money will be available before July.

To fund the Action Plan, McKee also recommends $1 million for the acquisition of technology for adults with developmental disabilities during the next fiscal year, including $458,100 in state funding. One million dollars already has been allocated to the technology $2 million Developmental Disabilities System Technology Fund that is part of the Action Plan.

The technology could be anything from the smartphones or tablets that most people consider basic communication devices to sophisticated computers that some people must rely on to make themselves understood.

The wage increase will cost $35 million in federal-state Medicaid funding, including with the state’s share to be $16 million.

In all, McKee would allocate $391.6 million for the Division of Developmental Disabilities, nearly 66 percent of the overall budget request of $596.5 million for the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals.

McKee’s budget includes $30.2 million for the state-operated group home system, which currently houses 109 persons. McKee has abandoned the efforts of his predecessor, former governor Gina Raimondo, to privatize the state-run group homes. A total of $361.4 million would go to private providers of developmental disability services, who serve nearly 4,000 people in residential and daytime settings, including on-the-job support in the community.

The proposed $361.4 million allocation would add nearly $54 million to the current $307.5 million budget for the private provider system, although McKee has proposeTd an interim increase of about $12.2 million to finish the 2022 fiscal year on June 30.

Chief Judge John J. McConnell, Jr. of the U.S. District has scheduled a remote public hearing via Zoom on the status of consent decree implementation Feb. 3 at 9:30 a.m. The Zoom Meeting ID is 161 290 3311. The Passcode is 056647. The Agenda:

1. Rate Review - reasons for delay, timeline for completion and implementation, court oversight

2. Release of funds for transformation grants

3. Administrative Barriers Review - What will be completed by March 31, 2022

4. Possibility of implementing wage increases earlier than July 2022

5. Overall Status of Consent Decree and Court-Ordered Action Plan

Tight Schedule For RI Consent Decree Compliance Squeezed Further Without Rate Review


By Gina Macris

Rhode Island has two years, five months, two weeks, and four days to correct ongoing violations of the Americans With Disabilities Act and meet a 2024 deadline for complying with a 2014 consent decree in which it agreed to provide appropriate services for adults with developmental disabilities.

But the state hasn’t yet started building the structure for that system, which depends on how much it pays private service providers and the complicated bureaucracy that governs how money is paid and services are delivered.

Indeed, a federal judge has ruled that the state doesn’t adequately fund developmental disability services and can’t comply with the 2014 consent decree unless it conducts a rate review that will map the way forward.

Last fall, as part of an “action plan” to avoid a contempt finding in federal court, the state promised to name a consultant to review existing rates by last Nov. 1. Work was to have begun by Nov. 15, with a completion date in December, 2022, if not earlier.

That timeline, extremely problematic for rolling out a new system and gaining enough experience to warrant the end of federal oversight by mid-2024, has grown even more unlikely.

In the third week of 2022, the consultant has not yet been named.

Randal Edgar, spokesman for the state Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH), said earlier this week that he doesn’t know the reason the rate review contract has not been awarded. But “it’s close” to being announced, he said Jan. 18. He said the same thing last week: “It’s close.”

In 2014, the U. S. Department of Justice found that the state’s fee-for-service reimbursement system for private providers incentivized a segregated system of care, in the form of sheltered workshops and day care centers. Segregated care, in which one person may oversee as many as ten people, is cheaper than than the one-on-one or small group staffing necessary to enable supported employment or other activities in the community.

Sheltered workshops, eliminated in 2018, discriminated against adults with developmental disabilities because they paid sub-minimum wages and denied workers the choice to seek competitive employment in the community. Similarly, day care centers have restricted participants’ access to the daily experiences that most people leading regular lives take for granted.

The fee-for-service system, called Project Sustainability, had been pushed through the Rhode Island House by way of a floor amendment and rubber-stamped by the Senate in the early morning hours of the last day of the General Assembly in 2011.

Project Sustainability lowballed the rates recommended by the rate reviewer of the time, Burns & Associates, which said the minimum wage for direct care workers should be set at $13.97 an hour on July 1, 2011, and raised to $15 an hour a year later.

Those adjustments were never made. It was only last year that the General Assembly, responding to court-ordered negotiations between state officials and providers, raised the hourly rates from $13.18 to $15.75 effective July 1, 2021.

Over the last decade, General Assembly leaders and some BHDDH officials have touted Project Sustainability as a vehicle for the equitable distribution of services.

Asked if that is still the case, spokesmen for House Speaker Joseph Shekarchi and Senate President Dominick J. Ruggerio demurred. They said in a statement Jan. 19: “The Senate and House look forward to reviewing the Administration’s proposals to conform the state to the Consent Decree and subsequent court orders for services for those with developmental disabilities. We anticipate reforms to comply with the Court’s action plan will be included in Governor McKee’s FY2023 budget recommendation.”

The rate review is expected to provide the data and recommendations to develop proposals for reform and calculate the anticipated cost.

Consumers, advocates and providers have protested that Project Sustainability has been just a smokescreen for budget cuts that diminished the quality of life for nearly 4,000 Rhode Islanders and their families.

Project Sustainability resulted in wholesale wage cuts that escalated turnover of front-line workers. Some workers, who had been on career ladders, even lost their homes.

As wages failed to catch up with inflation, the churn in the workforce increased, making it more difficult for private providers to staff existing services, let alone take on new clients and adapt to more labor-intensive, integrated activities required by the consent decree.

And the COVID-19 pandemic only made everything worse, with many adults with developmental disabilities now getting a fraction of the 40-hour service week required by the consent decree, and in many cases affecting family members’ ability to work.

A rate review is intended to address these workforce issues, as well as other features of the bureaucracy of Project Sustainability that holds back the development of integrated, community-based services system-wide.

Indeed, such a review was already overdue in 2018, according to a principal in the consulting firm who helped the state develop Project Sustainability in 2010 and 2011.

Mark Podrazik, co-founder and then-president of Burns & Associates, returned to Rhode Island in November, 2018, to testify before a special legislative commission studying Project Sustainability.

Podrazik said that Burns & Associates recommended rate reviews to its clients every five years.

In 2019 and 2020, BHDDH spent more than $1 million on an outside study of developmental disability services which concluded that the private provider system was on shaky financial ground. But the consultants’ contract with BHDDH did not allow them to make any recommendations, not even for a rate review.

Finally, after the state was called to defend itself against a possible contempt finding in federal court last fall, it unveiled its action plan for compliance, which included a rate review.

The five companies currently under consideration for the rate review include Health Management Associates, based in Lansing, Michigan, the parent company of Burns & Associates, which it acquired in September, 2020. Podrazik is a managing director of Health Management Associates, according to his LinkedIn page.

The other bidders are Guidehouse, Inc., Mercer Health and Benefits LLC, Milliman, and Public Consulting Group. All of them, including Health Management Associates, are national or international firms with a regional presence based in Boston.

The state has not disclosed the budget for the rate review.

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