PROVIDENCE – This story occurred far, far below the radar screen of media visibility, even during a time of heightened sensitivity around the fraying safety net for vulnerable populations in Rhode Island.

A community agency, Community Care Alliance, struggling with staffing capacity to provide services to clients as part of its psychiatric residential programs – a staffing crisis precipitated in large part by the state’s chronic under-funding and low reimbursement rates for such services through its Medicaid program, exacerbated by the increasing contagion of the COVID pandemic, agreed to consolidate two such residential programs, relocating 21 clients and staff, to a new location, in a state-owned building on Putnam Pike, on Nov. 10, 2021.

The consolidation of the two psychiatric residential programs and the move into the state-owned building had been made in partnership with the R.I. Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals, in an attempt to solve the funding crisis, as a creative solution to caring for the clients, particularly during the hioliday season.

The goal, according to the agency executive, Benedict Lessing, Jr., had always been “to maintain the continuity of their clinical caregivers and the people with whom they have lived for an extended period of time,” in order to maintain “the stability” of a psychiatrically “fragile population.” It is “always the right time to do the right thing,” according to one person involved with managing the agency's programs.

The problem, however, was that two months after the move to the state-owned facility, the state’s acting director of the R.I. Medicaid program determined that the new location was not eligible for Medicaid funding.

The community agency was informed, in a letter dated Jan. 5, 2022, from Kristin Pono Sousa, the Acting Medicaid Program Director, that, “Unfortunately, given the makeup of the location, it is considered an IMD and not eligible for Medicaid reimbursements.”

Pona Sousa promised that “EOHHS and BHDDH are working to address the billing concerns you have and BHDDH will be back in touch with alternative solutions as quickly as possible to assist in this crisis.”

Translated, BHDDH had proposed a solution to the agency's staffing problems by suggesting the agency consolidate two of its residential treatment programs and move them into a state-owned building. The agency agreed. Then Medicaid apparently reneged on paying for the services provided. The funding for the relocated residential treatment program is still up in the air, unresolved, but sources have told ConvergenceRI that BHDDH is working to make CCA whole

The details of what happened had been revealed in an urgent email, sent on Thursday, Jan. 6, by Dr. Susan Storti, Ph.D., president and CEO of the Substance Use and Mental Leadership Council of Rhode Island, to Sen. Joshua Miller and to Sen. Louis DiPalma, on behalf of Lessing, which was obtained by ConvergenceRI.

Here, as detailed in an email sent by Lessing to Pona Sousa, on Dec. 15, 2021, is what happened:

“I am reaching out to you as I understand that you are in an Interim Medicaid Director role subsequent to the recent resignation of Ben Schaffer.

“Well over a month ago, Community Care Alliance had been consistently communicating with BHDDH that we were struggling with staffing capacity for our psychiatric residential programs. We had reached a point where we felt that we may need to seriously consider closing at least one facility as a means of maintaining sufficient capacity to staff another. In response to attempting to address this Emergency Staffing crisis which has been well documented, BHDDH recommended that we consider consolidating the populations of two sites [Singleton House and Chicoine] into one location at a state-owned site on Putnam Pike previously used for Developmentally Disabled persons and more recently as a COVID Emergency site. On or about November 10, 2021, this consolidation occurred, relocating 21 clients plus the staff of the two sites mentioned above.

“From the outset of this initiative, we have attempted to have Medicaid clarify that we will in fact continue to be paid per our usual rates for the delivery of these services. We have yet to receive a definitive response from either Medicaid or BHDDH. CCA should be paid for these services from the point of the programs being consolidated to the present. That we have not yet received clarity on this issue is a concern as this is not a small amount of funding.

“We have had two objectives in working through this process. First, we wanted to do everything possible to maintain the stability for what is psychiatrically a fragile population. This included having these individuals maintain the continuity of their clinical caregivers and the people with whom they have lived for an extended amount of time. As such, we also wanted to avoid the disruption of necessitating our clients placed elsewhere across the State. Our second objective was to work in collaboration and coordination with BHDDH who recommended this solution. We felt that it was a viable strategy formulated as a response to a staffing emergency that is undeniable. Moreover, it has proven to be so thus far.

“I need to have a response from Medicaid in the next 72 hours [emphasis added] as to whether this is viable from a billing perspective. If it is not, Community Care Alliance will initiate closure of its Singleton House site immediately after the holidays and work with BHDDH to secure placement for the residents of these facilities elsewhere. We will then transition our staff and clients back to Chicoine House. If CCA is unable to obtain Medicaid reimbursement, we will work with EOHHS and the Governor's Office if necessary, as to how our organization will be reimbursed.

“I want to emphasize one last time, this initiative occurred as a result of an emergency staffing crisis. A similar approach could have occurred relative to COVID or other disaster declarations. That being said, it is impossible for an organization such as CCA to navigate this type of bureaucratic challenge without the support of State Government. I look forward to a response one way or another as soon as possible.”

The email request made by Lessing to Pono Sousa on Dec. 15, 2021, had requested an answer within 72 hours [three days].

Six days later, Pono Sousa emailed back to Lessing, saying: “I am exploring all options to assist in this matter. I am in communication with BHDDH and we are working to determine if there is a pathway to resolution. I do not have a decision at this time but am working to provide a decision as soon as possible. I will provide any updates as we move through this process.”

For two weeks, there was no update from Pona Sousa, until Wednesday, Jan. 5, 2022, when Pona Sousa informed Lessing that the Putnam Pike location was not eligible for Medicaid funding.

Context and nuance
On Tuesday, Jan. 4, the R.I. General Assembly opened its 2022 session by formally voting on a budget proposal to invest some $119 million in American Rescue Plan State Fiscal Recovery Funds in Rhode Island’s children, families, workers, housing and small businesses, which was then immediately signed into law by Gov. Dan McKee, according to the news release by the Governor.

“Today, we move forward with a crucial investment in Rhode Island’s future,” Gov. McKee said, according to the news release, voicing optimism. “RI Rebounds [the name given by the Governor to the funding request] directs federal funding to where it is needed most – to children, families, workers, housing, and small businesses.”

At the same time, as reported by Katherine Gregg at The Providence Journal, the situation at the state-run Eleanor Slater Hospital kept worsening, with an outbreak of COVID cases among patients at the hospital, which a BHDDH spokesperson claimed was unrelated to a decision by the agency to use asymptomatic COVID positive workers at Eleanor Slater to deal with a severe staffing shortage.

The decision to share the email exchanges between Lessing and Pono Sousa by Dr. Storti with Sens. Miller and DiPalma was remarkable for a number of reasons, the foremost being:

•  Sen. Miller, Sen. DiPalma and Dr. Storti are members of Senate legislative commission tasked with reviewing the organization of the R.I. Executive Office of Health and Human Services, entitled “The Special Legislative Commission To Review and Make Recommendations Regarding the Efficient and Effective Administration of Health and Human Services in the State of Rhode Island.” The Commission has met several times during the last two months; the meetings that have gone mostly uncovered by the news media, save for ConvergenceRI. [See links below to ConvergenceRI stories, “To have and have not,” “Can we have an honest conversation,” and “Will Medicare remain a part of RI EOHHS?”]

Moving forward
The machinations around the future of Medicaid funding, the Governor’s proposed FY 2023 budget, the future of the Eleanor Slater Hospital and the accountability of leadership at R.I. EOHHS all appear  to be interconnected, it seems, with what went wrong with the proposal to consolidate services at two residential treatment programs to a state-owned facility, and the failure to come up a way to pay for such services.

So many questions abound, including:

•   Why did it take so long [three weeks] for the acting director of R.I. Medicaid, Kristin Pona Sousa, to inform Community Care Alliance that the state-owned facility on Putnam Pike was not eligible for Medicaid funding?

•   Who at R.I. EOHHS was responsible for approving the decision to move the community agency’s clients and staff to a state-owned facility? And, who at R.I. EOHHS was involved in the decision to deny Medicaid funding for the operations at the state-owned facility?

•   At a time when the state is being ravaged by a renewed COVID contagion, why aren't there emergency funds available to support community agencies grappling with staffing shortages?

•   What is the responsibility of the leadership of the R.I. General Assembly to take action and provide emergency funding for the consolidated programs currently located at the Putnam Pike facility?