Delivery of Care

What will be the future of R.I. BHDDH?

With the R.I. BHDDH agency in turmoil, community advocates are asking to be included as partners in the state’s decision-making around future investments

Photo by Richard Asinof

Womazetta Jones, secretary at the R.I. Executive Office of Health and Human Services, has been chosen by Gov. Dan McKee to serve as interim director at R.I. BHDDH, following the resignation of Director Kathryn Power.

By Richard Asinof
Posted 4/12/21
The turmoil at the R.I. Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals may provide the state with the opportunity to redesign the system of care delivery – but only if the state is willing to engage with providers as partners in the conversation, and to “think like a patient.”
Is the R.I. General Assembly willing to provide more targeted resources to invest in community-based mental health and behavioral health care? How will the state put renewed emphasis on “human” relationships in the delivery care, and design programs by thinking like a patient? What is the connection between toxic stress on the development of chronic mental health and behavioral health conditions? How can the lessons hopefully learned from the UHIP debacle be applied to R.I. BHDDH? How can climate justice become part of the conversation around behavioral health and mental health needs?
A funny thing occurred in a “conversation” on Twitter last week, when Providence Journal reporter Kathy Gregg demanded that ConvergenceRI share my documentation with her.
I had posted that Ryan Erickson had been hired in August of 2020 as an Associate Director of Operations at $130,000 a year, in a newly carved out position at the agency, despite the fact that many behavioral health and mental health advocates had raised concerns about his lack of clinical or educational training.
Apparently, neither Gregg or Rep. Patricia Serpa, the chair of the House Oversight Committee, were aware of Erickson’s actual title and salary, which I had detailed eight months ago in a story August of 2020, “This pestilential thing.”
Erickson, who had previously served as a policy analyst for former Gov. Raimondo, played a pivotal role at an legislative oversight hearing, assuring Power that she could leave the lengthy Zoom legislative hearing and he would be able to handle the questions.
Gregg had initially pushed back at my post, asking me if I felt that that clinical and educational training were necessary to provide public relations advice. Her source about what Erickson’s alleged public relations duties were was a LinkedIn post by Erickson.
I responded to Gregg that my job was not to serve as her source; she was welcome to read what I had already published. She apologized, saying she did not have time to read all the different things being published.
The moral of the story: there is need for people in journalism and in government to practice the art of convergence, to break free of silos of their own making, and value other sources of news coverage beyond the usual suspects. Reading matters.

PROVIDENCE – The very name – the R.I. Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals – is a mouthful to say. Often referred to by its acronym – BHDDH, or “Buddha,” the agency has served as a model of bureaucratic consolidation promoted by state government during the last two decades.

What was once touted as a fiscal strength – the idea that by combining distinct, disparate divisions under one management umbrella, the state could achieve economies of scale in delivering care – has instead emerged today as a fundamental weakness.

The agency has become stuck, according to many behavioral health and mental health providers. Indeed, the agency name serves as an apt metaphor for the current crisis: there are too many patients, too broad a mandate, and too few resources to go around. The robust community support network that once under-girded the system of care has been allowed to wither away, falling victim to intentional policy decisions by the state to no longer make investments in it.

Today, the agency is boiling over in turmoil, beset by a crumbling physical and human infrastructure that appears to be falling apart. The recent departure of Kathryn Power, director of R.I. BHDDH, who resigned following a disastrous legislative Oversight Committee hearing looking into ongoing problems at Eleanor Slater Hospital, underscores the depth of the problems.

As an interim fix, Gov. Dan McKee chose to place Womazetta Jones, the secretary of the R.I. Executive Office of Health and Human Services, at the helm in charge of the agency temporarily. The question is: What kind of change is going to come to the agency, and how much will it cost?

ConvergenceRI asked John Tassoni, Jr., vice president at The Substance Use and Mental Health Leadership Council of RI, to map out what a new vision of care delivery for behavioral health and mental health care for Rhode Island might look like – and to identify the nature of the partnership that is needed to move forward in these challenging times.

But, before getting to that conversation, it seems important to sketch in the history of what happened, why it happened, to understand how we arrived at the current crisis.

Chronic
The agency’s chronic care model was designed decades ago – but as the complexities and needs of the patient population being served changed, the agency has often found itself mired in the past.

The problems were never a secret. In 2015, the state released four Truven Health Analytics studies quantifying the costs, the demand, the health care supply and the analyses of Rhode Island’s behavioral health conundrum. [See link below to ConvergenceRI story, “Looking for a sanity clause in Rhode Island.”] All one had to do was read the report.

The agency did demonstrate some nimbleness in response to the opioid epidemic. R.I. BHDDH developed a number of innovative, successful interventions – BH/Link, a 24-hour crisis hotline, peer recovery coaches at emergency rooms, expanded treatment options for recovery from substance use disorders, and working in partnership with the R.I. Department of Health to create better data analyses. In many cases, what worked best was listening to what community recovery advocates were saying.

All the existing problems were exacerbated by the coronavirus pandemic, which exposed the weaknesses of the entire health care delivery system in the state – particularly around mental health and behavioral health unmet needs, as demand for services surged.

Who is being served?
In total, the agency serves an annual population of more than 52,000 Rhode Islanders – some 17,000 with substance use disorders, another 31,000 with mental health issues, 4,000 with intellectual or developmental disabilities, and roughly 350 in hospital care [the number fluctuates], according to 2018 data provided by former R.I. BHDDH Director Rebecca Boss. [See link below to ConvergenceRI story, “An evolving matrix of care.”]

The populations often overlap, making it a complex responsibility to deliver care in a systematic approach, according to Boss in a 2018 interview. “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.”

The roots of conflict
While the hospital division within R.I. BHDDH serves the fewest number of patients, care for those patients has proven to be increasingly complex and expensive. The hospital division has become the lighting rod for the current crisis, with the state apparently seeking to dismantle its current hospital model of care, in order to reduce the growing costs of care for an aging population. The ugly conflict has pitted doctors and nurses against administrators and made for sensational headlines.

The hospital system now under the auspices of R.I. BHDDH cares for patients with severe mental health diagnoses, many often accompanied by debilitating chronic conditions. In 2019, it was determined that Medicaid could not longer be billed for the psychiatric care of the patients within the R.I. BHDDH hospital system, causing an abrupt cash flow problem for the agency.

To put the current crisis in context, the hospital system at R.I. BHDDH is a residual of the former institutional settings, which gave way to a new strategy of care known as “de-institutionalization” in the 1970s – moving patients back into community settings at group homes and providing them with wrap-around supports.

The most severe patients, however, were never candidates to move back into the community. “De-institutionalization” worked when there was an abundance of state and federal dollars to sustain the initiative. But then, as health care costs kept increasing, in an effort to contain and to reduce those costs, the state moved toward consolidation.

Think like an administrator?
For the last few years, under the direction of then-Gov. Gina Raimondo, R.I. BHDDH has been pursuing a corporate reorganization with an administrative zeal, seeking to find efficiencies to lower and control costs.

To do so, the state has invested millions of dollars, enlisting high-priced corporate consultants to redesign the processes in how the agency delivers care, which has included hiring new executive positions at the administrative level. [See link below to CopnvergenceRI story, “This pestilential thing.”]

Translated, the agency keeps thinking “like an administrator,” when it is being challenged to “think like a patient.”

Under former Gov. Raimondo, in the last six years, there have been three different directors at R.I. BHDDH – Maria Montanaro, Rebecca Boss, and Kathryn Power. The first person Raimondo chose to be in charge, Maria Montanaro, lasted two years. [See link below to ConvergenceRI story, “An exit interview with Maria Montanaro.”]

Next came Rebecca Boss, who served three years. [See link below to ConvergenceRI story, “Boss lady leaves with an attitude of gratitude.”]

Then came Kathryn Power [See link below to ConvergenceRI story, “Galvanizing the human spirit.”]

A pattern of behavior
Under Raimondo, the impetus was always on reorganizing the systems of health care delivery – with the disastrous Unified Health Infrastructure Project, or UHIP; with the still unproven Reinvention of Medicaid; and with the failed Integrated Care Initiative [begun as Rhody Health Options].

The common thread in all of these efforts was the hiring of high-priced corporate consultants to redesign public policy and the privatization of health care delivery under Medicaid. In a behavioral context, the Raimondo administration’s dependence on corporate consultants might be called a “co-dependent relationship” that keeps reinforcing bad patterns of behavior.

The next steps
The challenge facing Gov. Dan McKee is to figure out how to move beyond the current crisis and redesign the structure at R.I. BHDDH. What remains unclear is how much money from the federal government will be available under the American Rescue Plan and previous federal investments to move forward.

To map out what some of the options might be, ConvergenceRI spoke with John Tassoni, Jr., vice president at The Substance Use and Mental Health Leadership Council of Rhode Island. Here is the interview:

ConvergenceRI: There is a lot of federal money from The American Rescue Plan coming into Rhode Island. Did you know how much is targeted for behavioral and mental health?
TASSONI: According to Rele Abiade in Sen. Sheldon Whitehouse’s office, here is a listing of the various pots of money coming into Rhode Island from the federal government in the last year, targeting behavioral and mental health. They include:

• $4 million in a State Opioid Grant to Thrive Behavioral Health in Warwick. Newport County Community Mental Health also got $2 million in that tranche.

• Rhode Island got $6.8 million in funding for substance abuse treatment from the CARES Act and an additional $2 million to BHDDH in emergency grants.

• In addition, Rhode Island got $7,122,113 in Supplemental Substance Abuse Prevention and Treatment block grants and $3,069,963 for Mental Health block grants, but that money came from the end of year package not the CARES Act.

ConvergenceRI: How would you like to see that money invested in rebuilding the community infrastructure in mental and behavioral health? Do you have a plan?
TASSONI: Funding for the community-based behavioral health infrastructure was removed from the general budget many years ago. As a result, the system has survived on the ingenuity of R.I. BHDDH staff and providers to secure federal, foundational, of other types of funding.

As we know, this type of funding does not lead to long-term stabilization of a system. In short, the behavioral health care system needs an infrastructure that places them on par with other health care providers – appropriate reimbursement rates, the recruitment and retention of a credentialed workforce, and the financial support to develop programming to address the behavioral health needs of children, adolescents and their families.

This needs to be considered in determining how the funds the state will be receiving will be utilized. For this to happen, behavioral health representatives must be a part of these discussions.

ConvergenceRI: Is there too much reliance on outside consultants to determine policy? Why is it that state government does not engage with its in-house expertise?
TASSONI: That’s a great question. But you need to ask them that; we are considered a vendor, not a partner.

ConvergenceRI: If you had the opportunity to sit down with Gov. McKee, what would you tell him?
TASSONI: The state needs to conduct a comprehensive study of the agency and the roles of individuals within R.I. BHDDH. The rest is too long to write.

ConvergenceRI: Is there a need to look at health insurance reimbursement policies at the same time?
TASSONI: Most definitely. The current reimbursement rates are old and don’t meet the needs of the providers to provide adequate care. Several members of the legislature are working with the community groups to examine the development of legislation to assist with this effort.

ConvergenceRI: How does the need for wrap-around services, rather than emergency response to crises, need to be part of a strategic reinvention of R.I. BHDDH?
TASSONI: Wrap-around services are much needed. In turn, duplication [of services] needs to be looked at for potential savings.

ConvergenceRI: What questions haven’t I asked, should I have asked, that you would like to talk about?
TASSONI: The system, as it was designed many years ago, was based upon a chronic care model as that was needed at the time.

As time went on, the complexities and needs of the patient population being served and the way in which services needed to be delivered have changed. Unfortunately, the system wasn’t able to respond in full, for many reasons.

We are at a critical point in Rhode Island where leadership can take this opportunity and reverse the course of history by working with partners to design a behavioral health care delivery system that is adaptable and flexible to meet today’s challenges – as well as those we may be faced with tomorrow.

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