Delivery of Care

An evolving matrix of care

An interview with Rebecca Boss, the director of the BHDDH

Photo by Richard Asinof

Rebecca Boss, the director of the R.I. Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals.

By Richard Asinof
Posted 4/8/18
A sit-down, one-on-one conversation with Rebecca Boss, the director of the R.I. Department of Behavioral Healthcare, Development Disabilities, and Hospitals offers an opportunity to look at long-term challenges.
Is there a need for the R.I. General Assembly to invest more money into community mental health centers in the face of increasing unmet needs for mental health services? Are there specific studies underway at the state level to project the increased levels of care that will be required by aging Baby Boomers? In the way that peer recovery coaches have been adopted as a key component of recovery services, are there similar programs for the developmentally disabled community? What is the status of the consent decree lawsuit pending in federal court?
As part of the interview with Boss, ConvergenceRI raised the issues around the changing paradigms created by the use of non-invasive neuromodulation, both in the treatment of chronic pain and in specific behavioral disorders, such as depression, obsessive compulsion, and PTSD.
What are the opportunities to convene a discussion that would bring together researchers, providers and agency staff to better understand the new dynamics in potential treatments offered by such advances?

CRANSTON – Deep within the John Pastore campus of government office buildings and nearby prisons, in temporary digs in a building on West Road that recently served as the headquarters of the R.I. Executive Office of Health and Human Services, with the distinct white noise of wind whistling through the yet-to-be-rehabbed office windows on a bright, blustery spring day, ConvergenceRI sat down with Rebecca Boss, the director of the R.I. Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals, or BHDDH, know as “Buddha” in government-speak, to talk about the sprawling responsibilities of her job.

In total, illustrated in a kind of Venn diagram that Boss shared with ConvergenceRI, “Buddha” serves an annual population of more than 52,000 Rhode Islanders – 17,000 with substance use disorders, 31,000 with mental health issues, 4,000 with intellectual or developmental disabilities, and roughly 350 in hospital care.

In many cases, as the Venn diagram showed, the populations overlap, making for a complex responsibility to deliver care in a systematic approach.

“If you look at the populations that we serve, in mental health, 31,000 individuals served every year, in substance use disorders, 17,000 individuals served every year, we don’t have that number of state employees to provide case management to each of those 48,000 people,” Boss said

The developmental disability population is 4,000, and that is a little bit more manageable, Boss continued. “But, that’s challenging. And the hospital has a capacity of 350, but on any given day, it’s about 220 people.”

The reason why she shared the diagram of populations served, Boss continued, “is [to show] there is overlap of these populations. We have individuals who have co-occurring mental health and substance use disorders; we have a number of people [being served in the] developmental disability population that have co-occurring mental health disorders as well. They can be very challenging and complex individuals.”

A continuum of care
Boss’s approach to the job differs from her predecessor, Maria Montanaro. When asked by ConvergenceRI whether it might be better to de-construct the large agency into smaller agencies, Boss referenced an interview that ConvergenceRI had conducted with Montanaro, in which Montanaro had suggested that her department “be completely restructured.” [See link below to ConvergenceRI story, “An exit interview with Maria Montanaro.”]

“My response to that is that I have been with the department now going on my 15th year,” Boss began. “And, I know that was Maria Montanaro’s philosophy, when you met with her, I recall the actual quote, which was to blow it up.”

I think the entire department was very much aware of that philosophy, Boss continued, offering her different view, both from a historical perspective and from a vision for the future.

“My view is that this department grew out of the de-institutionalization movement, with two different populations,” Boss said. “The Ladd School closed. And the IMH closed.”

As a result, she explained, “People who would have been cared for in an institution are now being care for in the community.”

The hospitals, Boss continued, are the last remnant of that institutional approach. “We care for individuals who have been committed forensically or who have been committed civilly for their psychiatric diagnoses and issues and inability to be maintained safely in the community.” The population served represents the smallest segment served, roughly 225 people.

Boss said her focus has been on making improvements in the way that care is delivered. “What I have done, as director, is to look to centralize some of the functions to make more sense and [create] harmony,” she said. “I’ve centralized clinical services; I’ve centralized the fiscal unit, so we no longer have fiscal separated in developmental disabilities and in behavioral healthcare. I’ve centralized public relations, so we’re dealing with public relations engaging our stakeholders in developmental disabilities and behavioral healthcare separately. We’re looking at them as a whole, and trying to make more sense of it.”

The reason why she thought the department should stay as it is, Boss continued, is because of the continuum of care provided, at all levels of care.

New deputy director
One bit of breaking news that was shared in the interview is that Boss will be bringing on a new deputy director in two weeks, which she called an exciting development. “I think we can make it public,” she said. “His name is Lou Cerbo; I’m stealing him from the Department of Corrections. He is a clinical psychologist who spent some time in this department and worked at Eleanor Slater Hospital.”

Boss said that the hiring of Cerbo as deputy director was “the last leg of leadership needed here to make this a really strong team.”

When ConvergenceRI asked, in jest, what Boss did in her spare time, given the complexities of her job, she responded: “I have a one and half year old Bullmastiff who takes me for walks.”

A tidal wave coming
When asked about the changing demographics of Rhode Island’s population, with an increasing aging population, Boss cited the warning provided by her chief medical officer about the impact of Baby Boomers.

“Our chief medical officer tells us that we’ve got a tidal wave coming, and we need to be aware of the fact that the Baby Boomer population, just in sheer volume alone, is going to have a big impact on our system,” she said.

“We certainly have an aging population in our group homes, especially in our RICLAS [Rhode Island Community Living and Supports] system,” Boss said, about the state-operated service provider for individuals with developmental disabilities, which includes 24-hour residential support to adult men and women.

“One of the wonderful things about being able to be cared for in developmental disability group home is that you can age in place,” Boss continued. “We have to the ability to care for these individuals for a long time; they don’t have to do into a nursing home.”

In terms of the behavioral health care population being served by the agency, Boss said, the challenges involved are similar, but it involves a different entry point into the system. There was a need to consider the number of Baby Boomers there are that are aging and may develop some kind of psychiatric mental illness and dementia issues related to living longer.

The diseases of despair
When ConvergenceRI asked Boss about the possibility whether the Governor’s Task Force on Overdose Prevention and Intervention, on which she serves as co-chair, would engage in a conversation about the deaths of despair – alcohol, suicide and drugs, Boss responded that she did not think that the Task Force was the best vehicle to move forward on that kind of focus.

The Task Force, she explained, has a specific focus: it is on reducing overdose deaths, and, she emphasized, that was its sole focus, and its success is based on being able to look at one issue.

Instead, Boss felt that the executive order that the Governor signed on mental health, attempting to bring groups together, might be a better fit for encompassing a discussion around the diseases of despair.

“I think the diseases of despair fit into the long-term vision,” Boss said. “How do we invest more in social determinants of health than we do in a health care system that isn’t [producing] the outcomes that we want.”

The social determinants of health, she continued, “involve prevention, involve healthy communities, health equity zones – there are a number of pieces that fit into this puzzle.”

Further, she said: “This is a generation that is not likely to be as successful as their parents were, maybe for the first time in American history. That’s part of the despair, [the sense that] I’m not going to perhaps do as well as my parents, and it’s going to be tougher for me.”

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