The group home system that cares for adults with intellectual disabilities is on the verge of a major workforce crisis, advocates and leaders of nonprofit agencies say, despite a temporary measure approved by the Legislature last year.
Reimbursement rates from Medicaid, which pays for the group home care, have fallen over the past 10 years under Democratic and Republican administrations. Medicaid is a blended program using federal and state dollars, and states have flexibility to set rates to reimburse the nonprofit agencies that provide services.
In Maine, those rates have spiraled downward and made it difficult for group homes to compete for workers. The jobs of caring for adults with intellectual disabilities are demanding, stressful and sometimes require overnight shifts. If those jobs are essentially minimum wage jobs, advocates say they are competing with employers that pay the same or better for jobs that are easier to do.
Advocates for group homes say the reimbursement rates need to increase in order for many of them to survive, and a bill to ramp up rates is pending in the Legislature.
Karen MacDonald, executive director of Port Resources in South Portland, which operates about 20 group homes in Cumberland and York counties, said it’s “make or break time” not only for Port Resources, but for many group home operators.
“If we don’t have changes, we would need to make painful decisions about whether we can afford to operate all of our group homes,” MacDonald said. “If we could at least stay above minimum wage, people would feel more comfortable choosing this career path over Walmart. This is critical.”
PART OF SYSTEM SHORTCOMINGS
The reimbursement rate is one issue arising out of the troubled state system for adults with intellectual disabilities. The U.S. Department of Health and Human Service’s Office of Inspector General released a scathing audit last summer that exposed numerous shortcomings in the system.
The audit, which reviewed records and incident reports between 2013 and 2015, found that the Maine Department of Health and Human Service did not comply with requirements for reporting and monitoring critical incidents for more than 2,600 Medicaid beneficiaries being cared for by community-based providers during that time, including about 1,800 adults with intellectual disabilities who live in group homes. The report revealed the state failed to investigate the deaths of 133 people in state-managed care.
Many of the problems at the group homes arise from reimbursement rates being so low that agencies can’t attract and retain workers, said Lydia Dawson, executive director of the Maine Association of Community Service Providers, a trade group that represents group homes operators. That makes it difficult to comply with all the reporting requirements and maintain quality of care for clients.
Home-based and community based services, such as group homes, largely replaced bigger institutions in Maine, which at one time was considered a leader in treating people with intellectual disabilities. Pineland Center in New Gloucester, an institution for adults with intellectual disabilities that was plagued with problems, closed in 1996. Pineland’s long and troubled history included forced sterilizations, removing healthy teeth from young people to prevent biting, unnecessary drugging of patients, unsanitary conditions and frequent use of straitjackets and chair restraints.
Pineland’s closing paved the way for a community-based system for adults with intellectual disabilities.
BILL PENDING IN AUGUSTA
And for about a decade or more, the community-based system worked well, experts say. But the erosion of reimbursement rates has led to numerous problems, including a swelling of the waiting list for group home services – which are provided under Section 21 of the Medicaid code. The waiting list has ballooned from about 100 in 2008 to more than 1,000 in recent years.
Dawson said that the slight increase in reimbursement rates approved last spring and set to expire in June 2018 is insufficient. If the rates aren’t increased, group homes will start closing all over the state, she said.
“What was done is absolutely inadequate and doesn’t fix anything. Functionally, it’s no different than it was a year ago,” Dawson said. “It’s a really sad state of affairs.”
Dawson said workers are “asked to provide a complex medical service” for “pennies.”
Betsy Mahoney, 62, sees firsthand what stability at the group homes can do for her son, Brendan Young, 26, who has low-functioning autism. Mahoney said that when Young entered his teenage years, he became too difficult to care for in their home because he would sometimes become aggressive and anxious, and they needed help. They qualified for a Section 21 waiver and got Brendan into a group home when he was 20.
House Majority Leader Erin Herbig, D-Belfast sponsored a bipartisan bill that would restore rates to where they were a decade ago and add 10 percent for inflation, which would give agencies enough funding to pay for workers to earn about $11 per hour, a dollar an hour over minimum wage.
Lawmakers came up with an $11.5 million temporary measure instead that boosted pay from a little over $9 to about $10 an hour. That compromise is set to end in June, and lawmakers are pondering a more long-term solution.
Herbig said the rates approved last year were just the beginning and “barely scratched the surface” of what’s needed. The bill was carried over to the 2018 session and will likely get a vote, she said.
“I’m committed to getting as much funding as we can. It’s shameful we haven’t done more,” she said.
Herbig said she doesn’t know whether DHHS will support the program, but she was heartened to hear Gov. Paul LePage mention helping people with intellectual disabilities in his State of the State speech.
The Maine DHHS opposed the bill on technical grounds last year. This year, spokeswoman Emily Spencer said in an email response to questions that DHHS opposes Herbig’s bill “as written.”
“The department is supportive of paying providers a rate that allows them to provide services to the Mainers who need them most. That being said, the department does not support L.D. 967 (Herbig’s bill) as written. This (bill) would require the department to implement rates from a rate study performed more than a decade ago. It would be imperative to do a more up-to-date rate study that accurately reflects the current cost of providing services, especially in light of the increasing minimum wage,” Spencer said.
The LePage administration had also, in 2017, advocated for changes to the funding formula that would have resulted in further cuts to rates.
STAYING ABOVE MINIMUM WAGE
Meanwhile, minimum wage in Maine is now $10 per hour after a hike went into effect in January, and is set to go to $12 an hour by 2020. Voters approved the minimum wage increase in a November 2016 referendum.
Dawson said if the nonprofits can’t afford to pay at least $1 more per hour than minimum wage, it will be difficult to attract and maintain employees. She said there’s no hope of trimming the waiting list for Section 21 group home services without the rate increases and the ability to hire more workers.
A decade ago, nonprofits were paying direct care workers about $10 an hour, which at the time was $3 per hour over minimum wage. Dawson said that in addition to asking for a rate increase that would result in $11 per hour wages for the workers, the rates should automatically increase so that wages stay ahead of the minimum wage.
The bill would cost state taxpayers $26 million per year, according to official state estimates, but it would also save money in some cases by keeping clients stable and out of crisis situations. Hospitalized patients cost taxpayers far more per day than group homes.
MacDonald said about one-third of the group home workforce is a “revolving door,” with employees staying less than a year because of pay issues. A decade ago, they could get most employees to stay longer, she said.
STABILITY GOOD FOR THE CLIENTS
Mahoney, of Cumberland, said that when the group home that her son stays at in Windham has a run of stable, quality employees, he thrives. For instance, they can consistently get him to his day programs, such as STRIVE in South Portland.
At STRIVE, which Young goes to three days per week, clients socialize and do fun or educational activities. Last week, Young cooked, played basketball and air hockey and ate brownies. Some of the STRIVE clients perform work, such as greeting visitors or cleaning.
Mahoney said transitions are difficult for people who have autism or other intellectual disabilities, and so a revolving door of workers can throw everything off. She said new workers need time to learn the nuances of their clients.
“If you ask Brendan whether he wants to go to STRIVE, he’ll say ‘no’ even though he likes it,” she said. “They have to learn how to coax him out the door.”
Mahoney said that when there are new workers Brendan will sometimes miss a lot of his day programs and spend too much time at his group home, isolated from social activities, and he starts to deteriorate.
“It is so important to get good people working there, but you get what you pay for,” she said. “If the system is so underfunded, it’s hard to make those trains run on time.”
Joe Lawlor can be contacted at 791-6376 or at:
jlawlor@pressherald.com
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