Delivery of Care

Budget deficits may jeopardize services for developmentally disabled

Current projected budget deficits are nearly $26 million for developmental disability services, according to officials from BHDDH

Photo by Anne Peters

Reporter Gina Macris covers developmental disabilities in Rhode Island.

By Gina Macris
Posted 11/13/17
The projected deficit for the current fiscal year for developmental disabilities is nearly $26 million, 75 percent of the projected $34.6 million BHDDH budget deficit. The court-ordered mandates to improve the quality of services provide little wiggle room for the state.
How will the R.I. General Assembly respond to the projected budget deficits to protect some of the most vulnerable residents of Rhode Island, individuals with developmental disabilities and their families? Are the problems related to a bigger pattern of neglect: the failure of the state and the R.I. General Assembly to invest in providing adequate resources and services for children under DCYF care, for persons with mental health issues, and for the vulnerable and frail residents whose lives were disrupted by the disastrous roll out of the Unified Health Infrastructure Project? Will the private agency, Community Work Services, a program of the New York-based Fedcap Rehabilitation Services, lose its license in Rhode Island as of Dec. 31, 2017?
Grover Norquist of Americans for Tax Reform and Mike Stenhouse of the Rhode Island Center for Freedom & Prosperity were the guests on WPRI’s Newsmakers this past weekend. Norquist also had a private meeting with R.I. House Speaker Nicholas Mattiello.
Stenhouse said that one idea under consideration for 2018 in Rhode Island is a campaign for a no-tax pledge, according to WPRI’s Ted Nesi.
The decreased revenue forecasts and the projected budget deficits translate into a need to generate additional revenue streams or face the reality of further dramatic cuts to the state’s health and human services budgets. The question is: who are the champions for the most vulnerable, frail residents in Rhode Island, and when will they get equal time on programs such as Newsmakers to counter the arguments of Norquist and Stenhouse?

Supports Intensity Scale [SIS] is an individualized and extensive interview administered by a trained professional to elicit the type and frequency of support a particular person needs in all areas of life, from self-care to employment. It also covers supports needed to address medical and behavioral issues.
SIS was developed by the American Association on Intellectual and Developmental Disabilities [AAIDD] as an aid for developmental disability professionals in shaping individual programs for both children and adults with disabilities. Many states, including Rhode Island, correlate the scores on the SIS to various dollar amounts to set individual levels of funding.
SIS-A was introduced by AAIDD in 2015 for adults, serving as update of the original assessment. SIS-A acknowledges that developmental disabilities are chronic, lifelong conditions, and that for each individual, the need for support remains relatively stable over time, barring a life-altering event such as the death of a parent. Rhode Island adopted the SIS-A in November of 2016.

PROVIDENCE – The budget news looks grim for Rhode Islanders and their families with developmental disabilities. There is a projected deficit of nearly $26 million in cost overruns by the end of the current fiscal year, based upon first quarter results, according to the latest budget projections on spending by the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals.

The $26 million in cost overruns represents about 75 percent of the projected $34.6 million deficit in the agency’s current budget.

Translated, Rhode Island’s efforts to improve services to adults with developmental disabilities, spurred by ongoing federal court oversight, may be in jeopardy without a supplemental budget to increase spending during the current fiscal year.

Largest in recent memory
The projected $26 million shortfall is the largest in recent memory for developmental disability services, which typically have run $4 to $6 million over budget during a fiscal year.

In her first-quarter spending report to Thomas Mullaney, the state budget officer, Rebecca Boss, the BHDDH director, said there are two main drivers of the projected deficit:

Increased costs attributed to an updated assessment for clients of the Division of Developmental Disabilities, what is known as the Supports Intensity Scale-A, or SIS-A. The updated assessments are generally regarded as more accurate than the previous version in capturing individuals’ support needs, particularly for those with complex medical and behavioral issues.

An increase in supplemental authorizations that represent successful appeals of funding levels awarded through fiscal calculations made from the results of the original SIS or the SIS-A.

To meet the projected budget deficit, the agency has asked the state budget office to consider a supplemental appropriation for the current budget cycle to cover much of the short fall, with Boss saying the increased spending is consistent with current caseload projections.

$5 million in cuts also requested

At the same time, BHDDH has also proposed cutting about $5 million from supplemental appropriations before next June 30.

BHDDH’s Boss has ordered officials to deny requests from individuals with developmental disabilities for supplemental funding, except in emergencies related to health and safety, including the risk of hospitalization. She also made an exception for any “court-ordered services” which may occur.

The order to hold the line on supplemental funds is likely to have widespread impact on individuals and their families, who must make the same request for extra money annually if they believe that they may have been short-changed by the SIS or the SIS-A. Alternatively, they may request a re-assessment.

Boss, in a letter to Mullaney, said that BHDDH is working to address the current year’s projected deficit and is determining “potential courses of action which would meet client needs, be accountable to regulatory entities, and meet fiscal constraints.”

In response to the projected budget deficit, the R.I. Office of Management and Budget is working with BHDDH to “thoroughly review its options,” a spokeswoman for Mullaney said on Nov. 9.

Between a rock and a budget gap
BHDDH had requested $22 million for supplemental payments in the current budget, according to testimony before the R.I. General Assembly last spring.

But, in a recent corrective action plan, the department said it authorized more than $28.2 million in supplemental payments – more than 10 percent of all payments to private providers – during the fiscal year that ended last June 30. Actual expenditures exceeded $22.3 million.

“The past volume and approval of supplemental authorizations is unsustainable,” BHDDH said as part of its corrective action plan.

The plan sets a limit of $18.6 million for supplemental payments in the current budget cycle and reduced the ceiling to $14.4 million in the fiscal year beginning next July 1, with the assumption that the number of requests for supplemental payments will decline as more clients are assessed through the updated SIS-A.

The corrective action plan also notes that requests for supplemental funds that are denied by BHDDH may be appealed to the R.I. Executive Office of Health and Human Services.

[The projected $26 million shortfall in the agency’s Division of Developmental Disabilities represents the lion’s share of an overall $34.6 million departmental deficit, based on first-quarter spending, which Boss outlined in an Oct. 27 letter to Mullaney, the state budget officer.]

Court mandates to improve services
The projected budget deficits raise new problems for the agency, which is under two court mandates to improve services to adults with development disabilities.

Specifically, the state is under pressure from the federal U.S. District Court to improve the quality of its daytime services for adults with developmental disabilities by moving its system from isolated day centers and sheltered workshops to supported employment at regular jobs paying minimum wage or higher. Rhode Island also must increase the availability of integrated non-work activities.

These mandates are spelled out in two agreements with the U.S. Department of Justice, in which the state must correct an over-reliance on segregated facilities that violates the federal Americans With Disabilities Act.

The original SIS, accompanied by a $26 million reduction in developmental disability funding, was introduced by BHDDH and approved by the R.I. General Assembly in 2011 as an equitable way of distributing available resources, although advocates complained that it was nothing more than a device to control costs, at the expense of some of Rhode Island’s most vulnerable citizens.

In succeeding years, that dollar amount was restored, but the service system was fundamentally altered, resulting in wage cuts, higher worker turnover, and a dependence on lower–cost services in segregated facilities that can be supervised with fewer staff.

The U.S. Department of Justice began its investigation into these facilities – sheltered workshops and day centers – in 2013.

On an individual basis, persons with developmental disabilities, their families, and service providers routinely appealed the funding awarded through the SIS, and at one point supplemental payments became routine.

In the meantime, there were so many complaints about the SIS that the department ultimately decided to shift to the SIS-A.

Lack of experience
But 13 months ago, when BHDDH submitted projections that ultimately went into the current budget, it had no experience with the SIS-A. The revised assessment was introduced in November of 2016.

By springtime of this year, however, Boss had enough data to tell legislators that the SIS-A was resulting in higher per-person funding allocations. And, she reported that the overall numbers of individuals using developmental disability services was on the rise.

For the future, Boss envisioned a shift away from supplemental payments as the revised assessment tool better responds to individuals’ funding needs.

Other causes of the agency’s projected deficits
Of the overall $34.6 million projected BHDDH deficit, nearly $8.7 million can be attributed to staffing and overtime increases at the Eleanor Slater Hospital for stepped-up patient monitoring in light of a recent warning that the facility may lose accreditation because aging buildings pose too many risks that patients may harm themselves.

A risk assessment for the Eleanor Slater Hospital is currently underway, and the results will inform a request for supplemental funding to remedy concerns of the hospital accreditation agency, the Joint Commission, Boss said.

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