Behavioral Health Agencies Sound the Alarm

Staffing Shortage leaves Rhode Island's Neediest Without Services

by G. Wayne Miller of The Providence Journal.
Photo Credits: The Providence Journal
Published October 10, 2021

WOONSOCKET — One recent day, Christa Thomas-Sowers sat outside discussing the workforce crisis that her agency and others in the community behavioral-health field are experiencing — and its calamitous effect on people who need services.

One of those people, a man named John, sat with her, listening.

"It's been incredibly challenging," said Thomas-Sowers, community outreach coordinator for Community Care Alliance, which serves homeless people and people living with substance-use disorders and other behavioral health challenges.

Unfilled vacancies have placed a rising burden on already stressed front-line workers, Thomas-Sowers said, and recruiting is stymied by the higher wages and incentives that hospitals and other large health-care entities can offer. In the highly competitive COVID era, nonprofit organizations, which receive much of their funding from the state and federal governments, can lose.

As a result, so do people in need.

John, for example.

A cascade of events, including job loss and the death of his wife after years of illness, put him out on the streets. A shortage of beds at homeless shelters in northern Rhode Island and across the state has kept him there.

"I've been sleeping on the ground for the past week," John said.

Awake, he lives in fear of being victimized. This year, he has been beaten and robbed, and out of concern it could happen again, he asked not to be photographed or fully named.

Not yet 60, John is severely limited in his mobility by what appears to be an osteoarthritic hip.

"The cartilage is gone," he said. "It's bone on bone."

Every step, even with his cane, causes excruciating pain.

A person with insurance or means could get a replacement joint, but John has neither. And with its reduced workforce, Community Care Alliance has been able to provide him and others in his situation only basic services, including food, clothing and harm-reduction supplies (such as clean needles, wound kits and Narcan) from its Safe Haven drop-in center on Main Street. Family physician Dr. Nithin Paul from Thundermist Health Center visits once a week.

"There's no place in Woonsocket for people to shower, and this is in the middle of a pandemic," Thomas-Sowers said. "We have fallen so sorely short of where we should be in order to even meet the very basic needs of the people who are out here."

Said John: "That's when you really start to feel down: When you can't wash up, you can't clean up, and you've got no place to go."

A dire staffing shortage, years in the making

Ben Lessing, president and CEO of Community Care Alliance, can recall the time when Rhode Island's community behavioral health system was a national model. He has labored in human services as deficiencies in that system have mounted over the years, but never, he says, has the situation been as dire as today.

"We have a staff of 500 and we have 81 vacancies now," Lessing said. "We’re having a very difficult time recruiting bachelor-level case managers and clinicians with master’s degrees in social work and counseling that are trained to serve populations with addiction and mental illness. We've been saying to the state for many years that reimbursement rates aren't adequate; we can't pay people enough."

Lessing’s agency pays a starting rate of $15 an hour for case managers, “but it needs to be higher,” he said. Case managers in residential services make less, he said. Master’s-level clinicians start at $42,000, but “they need to be a minimum of $50,000 in order for us to be competitive, Lessing said. Rates at other agencies are similar.

Lessing cites an erosion of support from many previous governors and the General Assembly as a prime factor in the workforce crisis. So does Jamie Lehane, president and CEO of Newport Mental Health, which serves people on Aquidneck Island. Fully staffed, his agency would have 147 employees — but there were 49 open positions as of mid-September, a third of the workforce.

“An unfortunate legacy within the state of Rhode Island is one of systemic cuts to behavioral health-care providers over many years," Lehane said. "State agency leaders, politicians and the insurance companies have driven down the payments that providers receive for the therapy, counseling and more complex mental health services that Rhode Islanders receive. This has driven wages so low that not a single mental health-care provider in Rhode Island can offer competitive wages.

"Smart and successful therapists, counselors and psychiatrists take up shop in Massachusetts and Connecticut. It’s simple economics. This is an issue of life and death for the thousands of Rhode Islanders struggling and failing to find a therapist, counselor or psychiatrist that will see them.”

On the other side of the Bay, Warwick-based Thrive Behavioral Health (formerly the Kent Center), which serves about 3,500 clients a year, has 34 open positions in its workforce of 300.

"The shortage of clinicians has resulted in our need to establish a waiting list for outpatient treatment for all populations: kids, adolescents and adults," Thrive president and CEO, Daniel J. Kubas-Meyer said.

He added: "We are simply not paying what we need to be competitive, and this can be traced directly to our rates of service reimbursement. We are private, not-for-profit, and this sector is particularly vulnerable, as we are competing not just with for-profit corporations but with the state as well."

Staff 'can't live on what we are able to pay them'

Beth Bixby is CEO of Tides Family Services, which operates several programs for young people and receives 79% of its budget from the state Department of Children, Youth and Families. More than 700 youngsters were helped during the agency's 2020 fiscal year.

"Because the state has frozen our rates for six years, we lack adequate funding to attract and retain the skilled clinical staff necessary to meet the needs of all of the children DCYF asks us to serve," Bixby said.

The Tides workforce consists of 130 budgeted positions — but today, only 98 are filled. Like Community Care Alliance, Newport Mental Health, Thrive and similar organizations, Tides is at a competitive disadvantage in today's labor market.

"Our dedicated staff does not seek compensation at the same levels paid by the state for its employees performing comparable work," Bixby said, "but they cannot continue to be expected to perform the outstanding work that has been our hallmark when they can't live on what we are able to pay them.

"This staffing situation has now reached crisis levels for Tides Family Services and many other service providers who serve our state’s most vulnerable children. If this is not addressed soon ... programs will close, leaving children in need without the services they depend on."

During a virtual interview with The Journal, Bixby and Lessing described the economic reality today, when companies outside the human services field are offering higher wages, signing bonuses and educational reimbursement opportunities.

“Folks can go to Starbucks for $17 an hour,” Bixby said. “We lost a staff member to Lowe's for $22 an hour.”

Some employees who stay at behavioral health organizations, according to Bixby and Lessing, have taken second and even third jobs in order to make ends meet. Vacancies heighten the stress on workers who remain in what is already a stress-filled occupation.

“Whenever someone leaves, the staff who remain often become overextended and take those cases, because we don't want to not serve families who are high-need, vulnerable families,” Bixby said. “A lot of my supervisory staff is carrying full caseloads. I've been stepping in providing oversight and supervision, but morale has been a challenge.”

Many clients at Tides and other agencies come from economically challenging circumstances. Many are people of color.

“The cases that we see come in are very, very difficult and challenging,” Bixby said. “There’s a lot of poverty, a lot of issues connected to social determinants of health, and also a lot of trauma. There's a lot of violence in the city at the moment. A lot of the kids we work with are living in those urban areas and being exposed to that, on top of losing almost a whole year of their schooling.”

Structural deficiencies 'must be addressed immediately'

On Sept. 28, a coalition of agencies and advocacy groups representing some 70 organizations sent a letter to House Speaker K. Joseph Shekarchi requesting a meeting “to discuss the serious workforce crisis that is crippling the health and human service industry,” according to a copy of the letter that was provided to The Journal.

 “The instability of the community-based health and human service system impacts Rhode Island children, individuals with disabilities and behavioral health conditions, and elders who rely upon this workforce and the viability of organizations we represent,” the coalition wrote. “The pandemic has revealed the structural deficiencies within the HHS delivery system that must be addressed immediately.”

The solution, leaders wrote, can be found in using some of the $1.1 billion Rhode Island has in bank accounts from the American Rescue Plan Act. Among the coalition’s recommendations:

• “Immediately appropriating minimally $100 million in American Rescue Plan Act” and additional Medicaid funding to “increase wages across the community-based health and human service system.”
• Providing "appropriate funding to cover additional costs associated with operating in the pandemic.”
• Initiating "a robust workforce development strategy."
• “Investing in sustainability planning and rate reform to ensure the health and human service system has the capacity to meet the needs of the community, ensure all health and human service workers receive a living wage [and] compensate clinical and professional staff competitively with labor market demand.”

After meeting with coalition members on Thursday, Shekarchi told The Journal, “I was happy to meet with a dedicated group of providers who are delivering vital services to Rhode Islanders in need. I listened to their detailed concerns and I will ensure that these issues are considered before the House Finance Committee in the near future.”

Greg Pare, director of communications for Senate President Dominick J. Ruggerio, told The Journal on Monday that the president "is aware of the crisis and working with his colleagues and stakeholders. He is willing to consider solutions."

McKee also weighs in on 'workforce challenges'

Meanwhile, meetings have been held with officials at the state Department of Behavioral Healthcare, Developmental Disabilities and Hospitals. DCYF has been made aware of the issue, but there has been no “appreciable outcome,” according to a coalition member.

No formal meetings have yet been held with the office of Gov. Dan McKee or the Executive Office of Health and Human Services, which manages BHDDH and DCYF and administers the federal Medicaid program in the state.

Asked for the governor's stance, McKee's office sent a statement to The Journal: "Thegovernor and his team absolutely understand there are workforce challenges affecting our health and human service providers, and recognize the need for federal funding to ensure access to services for Rhode Islanders. Children, the elderly, people with disabilities, and people with behavioral health challenges rely on a dedicated workforce to provide the services they need.

"Rhode Island needs to invest some available federal funds to support these workers and the people they serve. The governor and his administration will be connecting with stakeholders and our partners in the legislature to discuss this issue further."

An email blast sent Tuesday to staff and board members of more than 50 human-services providers urged recipients to call and email their legislators.

"The individuals our organizations support are counting on us to make sure our policy makers are working toward stabilizing this industry," read the blast, sent by Horizon Healthcare Partners, a consortium that includes Community Care Alliance, Newport Mental Health, Thrive, Tides and CODAC.

The question recipients were urged to ask legislators: "Will you support investing minimally $100 million of American Rescue Plan funds toward the health and human workforce crisis?"

Changing lives: 'You guys never gave up'

Leaders and front-line workers at human services agencies tell many stories of success — of lives they have helped to better. These outcomes, they say, are what drew them to their profession and keep them there when it is economically sustainable.

During a late-September interview, Bixby shared the story of a child Tides served for many years. An adult now, he was recently sworn into the Army. His mother sent Tides a video of the ceremony.

“He came to our alternative school when he was in sixth grade,” Bixby said. “He would come to school every day with a hood over his head cinched up so we couldn't see his face. He hunched over and wouldn't speak to anyone.

“He had exhausted all sorts of [other] school placements, had different issues in his life, and he stayed with us and graduated from our school two years ago. He had a job. He would come to volunteer. He would come to all our graduations. And last week, he got sworn into the Army … and his mom said he wouldn't be where he is today without all you have done for him and I could never repay you for that.

“And one of the reasons he went into the military was because he wanted to give back, because people gave to him when that family was desperate and didn't know where to turn.

… He said, ‘You guys never gave up,’ and that's one of our tag lines. And it was very emotional for me to see that video because I can remember him just being like in the fetal position.”

'This is an issue of humanity'

Back in Woonsocket, John related how he finally was offered a bed in a homeless shelter — one that allows clients to sleep but requires them to leave during the day.

"They want me to go gallivanting up in Providence on my leg all day," he said. "I can't do that, especially with winter coming. I'm falling down already. I went in the rescue four times in the past month."

"That's something we hear regularly: people who are being hospitalized over and over or ending up in the emergency room," said Christa Thomas-Sowers. This puts further strain on hospitals, already stressed by the pandemic, she said.

And there are other avoidable costs, community behavioral health leaders assert: the costs of prosecution, incarceration, emergency department visits, hospital admissions and more.

Plus costs that cannot be calculated with dollars: the loss of parents, children and friends who, with the proper help, might better themselves and become positive influences on others.

The daughter of retired ministers who incorporated social work into their ministries,

Thomas-Sowers frames her profession's workforce crisis in philosophic terms.

"This is an issue of humanity," she said. "We live in the wealthiest country in the history of the world, and it's completely mind-boggling to me that we have people living out on the street."

She added: "When COVID hit, everyone told us, 'You're the front-line workers, you're the health-care heroes, and help is on the way.' You know, 'The cavalry is coming. You just hold the front lines, and we'll come and we'll bring the help you need to get through.'

"And it feels to me like the cavalry wasn't sent."

To view the article and more photos online click here.

Thrive encourages Rhode Islanders to contact their legislators to bring attention to the workforce crisis in our human services and behavioral health industry stemming from non-competitive wages.  Find your legislator here.