Nonprofit Workforce Crisis Testimony: 11/22/2021

Testimony Submitted to Senate Finance Committee
By: Margaret Holland McDuff, CEO, Family Service of Rhode Island
Date: November 22, 2021

Good Afternoon. My name is Margaret Holland McDuff and I’m the CEO of Family Service of Rhode Island (FSRI). We provide a wide continuum of health and social services to children and families– in multiple languages– around health, healing, hope, and homes. In 2020, with our 22 million dollar budget, our team of close to 300 human service professionals served over 39,000 Rhode Islanders, the majority of who were children with their families. We did this with the support of over 70 different funding sources that included state contracts with the Department of Health, Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, Department of Human Services, Executive Office of Health and Human Services, Rhode Island State Police, Office of the General Treasurer, RI Department of Education, RI Housing, Municipal police departments, various cities usually through the Community Development Block Grant funds, Accountable Entities, Providence Community Health Center, Blue Cross Blue Shield, United Health Care, Neighborhood Health Plan, TriCare (the military health system) Tufts, over a dozen school departments including Providence, Central Falls, Coventry, Johnston, Westerly and others, local and national foundations too numerous to mention, over 50 local corporate investors such as IGT, Cooley Group, Hinckley Allen, Go East Products, H. Carr, and thousands of generous individual donors. In addition to this, FSRI brings millions of dollars of Federal grants into Rhode Island to support the work we do, and these funders include Administration for Children and Families, SAMHSA (Substance Abuse and Mental Health Administration), Office of Justice, Office of Juvenile Justice and more.

I share this with you in order to display how incredibly complex delivering and managing a social service business in Rhode Island has evolved to be over the years. I have been CEO since 2002 when 90% of our funding was from the State of Rhode Island and we had very few donors. Over the years we have diversified our funding. We started doing this to innovate and incubate new services, but more and more in the last decade, we needed to do it to supplement losses in state service contracts. These include contracts that the state is federally mandated to provide like Early Intervention. The majority of our rates paid through state contracts, by RITE CARE and commercial insurance plans, and by Medicaid or Medicare, are not adequate to cover the costs. For example, First Connections contracted to providers by the Department of Health has not had an increase in 20 years; so not surprisingly, it only covers 50% of the cost today. During the last decade, Rhode Island social and behavioral health organizations have to had to spend an enormous amount of time and organizational capacity every year to raise money to supplement essential state-contracted services. The gap is too large now due to several years of underfunding often dressed up as “shared risk contracts,” “efficiency efforts” or using “business practices.” The majority of these were ill-informed, sometimes by consultants who never ran a social service/behavioral health business and it resulted in the irresponsible neglect and dismantling of any foundation of a social safety net in Rhode Island.

I often wonder what it would be like if other quality state contractors had to supplement their state contracts. What if Lynch Construction had to have a luncheon to raise funds to finish a state highway project? What if Deloitte Consulting had to have a walkathon to cover their costs on their RI state contracts? It sounds absurd, doesn’t it? Do we value the work of nurses, social workers, physical therapists less than consultants? Do we value our children less than our highways? Why are our businesses treated differently in contracting? Questions I often struggle with when I think about this crisis and how did we get here?

As has been outlined by over 70 social service organizations – Rhode Island’s safety net is in crisis. There is so much to say, but I will limit my remarks today to:

  1. The immediate need to get the funding to organizations to stabilize Early Intervention (EI), DCYF contractors, and other services. If we wait 4 weeks, more staff will leave and the crisis will worsen!
  2. We need long-term solutions for the entire system. Families don’t need services in the silos. Programs paid by different EOHHS departments and insurance companies are dependent on each other and must be seen holistically as an integrated system. Fixing one program at a time is not the answer beyond these very immediate weeks. For example – children do not get better or thrive if their parents are not well, so having access to appropriate, adequately funded services across EOHHS- not just DCYF- is critical to the future of our children.

First, I will talk about our First Connections team. FSRI is contracted to provide First Connections- a nurse home visiting service – by the Department of Health for newborns referred to us by birthing hospitals. These newborns are referred to because they have health risk factors or other family circumstances that may impact the parenting of a newborn. This could be issues such as homelessness, a newborn with substances in their system, parental depression, and more. This program has been flat-funded for 20 years. Yes, 20 years flat-funded regardless of inflation or even if caseloads increase. Increased birthing rates, better assessment systems by birthing hospitals, and an excellent program reputation has caused the referrals to the FSRI First Connections program to explode in the last two years.

Our First connections team of four nurses is receiving over 250 newborn referrals a month on top of their current caseloads. The program is in crisis and the lack of recognition or state immediate response to this reality is placing newborns at risk. We all know when programs are overwhelmed and staff are overworked risk increases. Adding to this crisis is the intake closures of Early Intervention programs. First Connections relies on Early Intervention so they can transfer many children to a longer-term intervention program. The Early Intervention crisis has caused a “log jam” of families in First Connections- increasing the crisis. Our nurses in First Connections do not feel comfortable closing families who need support in their home because of EI intake closures so they are seeing families 4, 5, 6 times or more when the program is intended to see them 1-2 times and refer to a long-term service.

We need the support recommended by EOHHS for EI to happen immediately to start the process of serving the families waiting and we need also need immediate relief in the form of support to increase the compensation of the nurses in First Connections and to immediately expand the number of nurses to deal with the increase of newborn births/referrals at-risk. While EOHHS submitted a budgeted increase for First Connections for FY23 – it is not sufficient and will need to be increased. Also, EOHHS is aware of this current crisis yet relief for First Connections was not included in the “down payment” proposal, so we are forced to ask the legislature to become involved. I ask that the Senate work with me and other First Connections providers to determine the amount needed to bridge the gap for FY22 before an infant is hurt or worse by this overwhelmed system.

Another example of why we need relief for the full system is the crisis in children’s behavioral health. The RITE CARE and commercial insurance rates for children’s outpatient do not cover the cost of providing the service. This has been a chronic problem for over a decade yet there has been no substantial effort to remedy this in all of this time. Outpatient is the first step for children to receive treatment when behavioral symptoms are identified, but for children in low-middle income families across Rhode Island, this service is extremely hard to access through a health care plan. Clinics have closed their children’s outpatient programs and those who offer them have waiting lists for months. This limited supply and high demand has allowed clinicians to leave organizations like FSRI and CMHCs to open private practices that have a self-pay financial model (families pay $80-$120 an hour for child therapy) in their practices. Most of these families have commercial insurance but do not access the benefit on the health plan and self-pay for their children’s therapy as it is the only way to access help. This has created an inequity for years where the only children with timely access to behavioral health treatment are those with parents who can afford $5000 or more out of pocket a year for the care. This is not health care parity or health equity we say we strive for in Rhode Island. It has caused countless children to go without treatment for years and now we see the results of this neglect with the families in the emergency rooms, teens overwhelming psychiatric hospitals, and parents reaching out to the already overwhelmed DCYF desperate for help for their child. Yet nothing has been included in the “down payment” plan or the use of the FMAP funds in the Home and Community Based plan developed by EOHHS to address the children’s behavioral health crisis. This is a public health crisis. Children are suffering and DCYF is not the only system that needs to solve it. We need the insurance plans – commercial and Medicaid- EOHHS, DOH, BHDDH, RIDE, and others to immediately address this crisis. We need immediate support to BHDDH licensed facilities that are experts in children’s behavioral health, like FSRI and others, so we can expand our outpatient and intensive community-based services for children. Children have been gravely impacted by COVID-19 and now we need your help to help them recover. If no is action taken, children’s conditions will worsen- emergency rooms will remain packed, more children will be boarded in hospitals and the list of children waiting for residential treatment will grow.

This is a crisis. Contracted services providers on the front lines – nurses, pediatricians, social workers, community health workers, case managers- across all EOHHS departments are being asked to stretch their caseloads like never before. Social Service organizations have over 25% of their positions vacant because similar organizations in surrounding states are funded to pay higher salaries. Even if relief starts flowing tomorrow, it is going to take months if not longer to get out of the dangerous situation we are in now. We cannot wait another day!

We need the first installment of help now, not after the holidays. To make a strong social safety net in Rhode Island it will take all the support offered by the federal government and the next three years to build back the workforce while developing a sustainable workforce pipeline. Some would like to wait to see what “pots” of money are coming down in the coming months, but it must be recognized that neglecting our children who are in crisis now is part of that financing strategy. Every day that we wait, the risk to human life worsens.

All this talk of equity and caring about our communities of color is just that- talk- if we don’t act to change it. We can have anti-racist and diversity workshops but they do not change systemic racism. We know that low-income, Black, and LatinX families are overrepresented in the families waiting for services including those involved with DCYF. Any further delay or lack of action to get immediate relief to providers of DCYF, Early Intervention, First Connections, and children’s behavioral health- a day – a week a month- is deepening the health and economic inequities in Rhode Island.

Shame on all of us who made decisions over the years that dismantled our social safety net and got us to the disaster we are in. This includes leaders like me who have tolerated chronic underfunding of essential services and not walked away from unfair, unethical contracts. It also includes government leaders who have ignored the calls to increase funding, to change unfair funding models, and have been a barrier to adequately funded contracts. But the fact is- here we are – so NOW who is going to be on the right side of history today? Who is going to act now to save our children? And who is going to wait? Who is going to allow the suffering to continue as we enjoy our holidays?

I ask all of us here to think about if it was our child on a waiting list for early intervention- every day caring for them, knowing they will never get this critical time back to reduce their delay in speech or improve their life-long physical functioning like being able to run or throw a ball as they go without EI services. How would we act if it was our child who was severely depressed but we could not find a therapist and watched as they deteriorated on a waiting list, every day scared for their life? Or if we were the parent of the many children stuck in hospital beds and not being offered an appropriate education and confined to their room because there are no intensive services available that can help them.

On this day- November 22nd – 58 years ago, John F Kennedy- was killed. President Kennedy moved the needle on human rights and expanded the social safety net. In honor of him- I choose to close my remarks with advice from his wise mother – Rose Kennedy:

“When you don’t know what to do…. do the right thing!”

Thank you.

Respectfully submitted,
Margaret Holland McDuff

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