CRANSTON – When Maria Montanaro announced her resignation as the executive director of the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, it left a number of unanswered questions about her tenure, the challenges she faced, and the takeaways from her experience.

As a way to begin to have a conversation around the issues and challenges Rhode Island faces moving forward, ConvergenceRI invited Montanaro to respond to a series of eight questions. Here are the responses:

ConvergenceRI: What have you learned from your experience of managing the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals?
MONTANARO: I deeply appreciate the opportunity that Gov. Gina Raimondo and Secretary Elizabeth Roberts at the R.I. Executive Office of Health and Human Services have given me to serve as a member of the Governor’s cabinet, managing such a complex array of services in mental health, substance use disorder, public hospitals and developmental disabilities.

I learned a great deal about the system, its challenges and also about myself, and my overall tolerance for a work environment that is, by nature, highly political.

The experience helped me learn about the system itself, and some of the challenges it faces. First, the current construction of the department, I believe, disadvantages the systems that it is designed to support.

I am recommending that the administration work with the Legislature to restructure the service units that are under the department’s authority to better serve the system.

Second, after a four-year absence from the state, I was surprised at how fragile the mental health provider delivery system had become.

This seems to be due, in large part, through cuts in funding at the state level over the past decade. However, I don’t believe the answer is simply to restore funding to a system that has not changed much or enough over the past decade to integrate itself into the large health care delivery framework.

I do believe that Rhode Island is spending less than it should; yet the costs in some areas of the system still remain higher than they should be, particularly when one looks at the outcomes the system delivers.

The SIM project and other Medicaid initiatives give us an opportunity to make changes, but not in a zero-sum game.

Investments that are long overdue will have to be made as well, to support the types of system transformation needed among the community mental health centers, substance use treatment providers, and the developmental disability providers.

I applaud the Governor for recognizing those needs and recommending budget increases that address some of them. I am also hopeful that the additional federal funding that BHDDH has been able to secure from SAMSHA will directly benefit these efforts for community mental health centers and mental health providers.

ConvergenceRI: Is it a task that's manageable? Would the department function better as separate entities?
MONTANARO: I have recommended that the department be completely restructured. In today’s funding environment, the bulk of funding for these services lies in the Medicaid budget.

While BHDDH has statutory and regulatory authority over the systems of care, it has very little funding to pay for services or influence system reform.

As a result, the department had tended, over the past six years, to increase its regulatory control over the providers it licenses in DD, MH and Substance Use Disorder services.

Expert staff from our department need not simply collaborate with Medicaid, which is housed at EOHHS, they should be a part of EOHHS – designing, monitoring and implementing an integrated system of care for the populations we serve.

Mental health systems should not remain fragmented from other part of the health system, because the people we serve have needs across the whole health and human service system.

The formation of EOHHS has given the state a great opportunity to integrate its own agency functions to provide comprehensive services to populations of people in its care.

I recommend that mental health and substance use services be placed, as a division, at EOHHS, with a Mental Health Commissioner who has as much authority over system design and payment as the Medicaid Director.

The same should be done for the Division of Developmental Disabilities, which should lie at EOHHS with a Commissioner at the helm of the division.

Those departments should look across the entire system of care – medical, behavioral, human services – for the populations they serve.

As for the hospital system, my experience managing the ongoing crises at Eleanor Slater has convinced me that the hospital must function as a hospital, if it is to adequately serve its patients.

The same is true for RICLAS. Both must function in a system of care that is released from some of the current fiscal and structural constraints faced by placing a provider delivery system in a state department.

As a provider, the hospital should have a proper provider relationship with Medicaid at EOHHS and the R.I. Department of Health for licensing and oversight.

While the hospital should remain public, and accountable to state governing bodies, it ought to have a mission-focused, autonomous governing board and professional staff that can address its needs and ongoing performance in terms of clinical quality, cost and overall community responsiveness.

We have laid the groundwork for these changes by having executive positions created and professional recruiters assisting the Department in hiring qualified executive staff. We were fortunate enough to recruit Dr. Elinor McCance Katz as the Hospital [and the Department’s] chief medical officer; now the same effort is needed to recruit a CEO, COO, CNO and chief of quality improvement.

ConvergenceRI: Why do you believe there has been such an upsurge in demand for mental health and behavioral health services in Rhode Island?
MONTANARO: The Truven Study as well as the health population plans and assessments that are being conducted through the SIM process, along with BHDDH and Medicaid utilization data, give us a good picture of Rhode Island’s identified needs for behavioral health and mental health services.

As is the case in every one of the 50 states, there is no question that we are seeing an exploding epidemic in substance use disorder due to opioid addiction. The number of people identified in the Medicaid system with a serious mental illness has remained relatively stable over the past decade, while we have seen modest increases in those diagnosed with a developmental disability, largely due to an increase in autism diagnosis nationwide.

ConvergenceRI: Are there adequate resources allocated from the state? If not, where do you think those resources should come from?
MONTANARO: We will need additional resources to address the demands associated with treating substance use disorders and addiction. There are new federal resources being channeled at this effort as the nation comes to grip with the scope of the epidemic.

We have done a great job at BHDDH in leveraging those federal resources through the development of successful grant applications. The Governor has made the appropriate recommendations for additional funding to DD providers, while the lLegislature has appeared to support a good portion of that recommendation, I would argue that her entire recommendation should be supported.

The Truven Study clearly indicated that Rhode Island remains a high spender in the area of mental health services, yet seems to be paying for high levels of institutional and hospital care while under-funding community-based and preventive care that would ultimately change the high utilization experienced by the state.

It takes time, investments and active transformation efforts to change outcomes for those using our system’s services and ultimately to lower their utilization of high cost institutional care. We have efforts funded though the SIM initiative and reinventing Medicaid that are evidence-based and will hopefully produce those outcomes over time.

ConvergenceRI: Is there a need to develop and implement a comprehensive, statewide health plan moving forward?
MONTANARO: I cannot tell you how many state, federal and organizational plans I have seen developed in my long career, at great time and expense to many involved stakeholders, only to have them gather dust on the shelves of policy makers and industry leaders and become obsolete before they can be enacted.

However, under the leadership of the Governor, the Secretary and the EOHHS directors, Rhode Island has many promising planning and reform efforts underway, including SIM, which has demanding components of population based needs assessment and planning.

We have an excellent strategic plan to tackle the Opioid Overdose issue that has been broadly endorsed statewide. Our Justice Reinvestment Commission has plans to systematically address the mass incarceration issues and their intersection with mental illness over the next few years.

Reinventing Medicaid and other statewide health reform efforts include long-term plans to address high utilization, population based health, payment reform, service redesign and system transformation.

I have been a health care leader and reformer my entire career, and most of it has connected me deeply to the efforts here in Rhode Island as well as nationally. I would say that Rhode Island has the plans it needs to enact the necessary reforms to our system. We know what to do. We need support to get it done.

ConvergenceRI: You are planning to spend the some time in France. What do you think the U.S. – and Rhode Island – can learn from what other countries are doing with health care?
MONTANARO: We plan to spend some time visiting our son and daughter-in-law and our soon-to-be-born grandson in France in the coming year.

From listening to their experience over the past few years as consumers in France’s health care system, I think we have a long way to go in providing comprehensive health care for all U.S. residents at a price they can afford.

I have read the horror stories of people straddled with astronomical bills following an episode of illness, despite having health insurance. All states, including Rhode Island, are facing the demands of a growing Medicaid system that we collectively try to leverage to fill in the gaps of insufficient health care coverage, particularly for services in mental and behavioral health, long term care and residential care. We need to assess how other nations have assured that health care is available and affordable to its residents.

ConvergenceRI: Do you believe that a community-based model of care – such as that proposed under the Neighborhood Health Station being developed in Central Falls – offers a better model of care, based on community needs?
MONTANARO: Yes, I do. I am a big proponent of community-based care. That won’t solve all the problems, but it is an important component of the system. Community health centers have been great front runners in showing the nation what community oriented, population based care can provide and achieving great results in some of the poorest neighborhoods in the nation.

Thundermist proved that for decades, as has Blackstone Valley Community Health Care and all of our community health centers. They are integrating into ACOs and continue to blaze important trails in health care delivery. I hope they will take a more active role in leading us out of the opioid addiction crisis as well. CHC, Inc. in Middletown, Conn., has been a national leader in this. I am very grateful that EBCAP, CCAP and Thundermist are taking the lead on this in Rhode Island through their work in the ECHO project.

ConvergenceRI: How critical is the need to have access to affordable, healthy housing as a basic fundamental of better health outcomes?
MONTANARO: It is extremely important to have access to affordable, healthy housing for better health outcomes. We have been working closely with RI Housing for quite some time to ensure that the individuals have choice, stability, affordability, and support in housing.

To that end, the Department has partnered with RI Housing on programs that increase the supply of affordable, community-based integrated housing through the Thresholds program and the 811 program, which was more recently awarded to RI Housing in partnership with BHDDH and EOHHS.

The 811 program provides project based rental assistance to units within larger affordable housing developments, which means residents pay 30 percent of their income for housing, the units must pass housing quality standards, are developed across the state and services are provided that focus on housing retention and stability.