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CT Examiner — Emilia Otte, 9.14.2023
Nonprofit agencies have long offered a plethora of low-cost health services to Connecticut residents. But providers of in-home psychiatric services, outpatient clinics, and group homes recently told CT Examiner they face an ongoing lack of funding from the state and can’t hire enough workers to serve patients.
In January, the state increased the payment rates to in-home service providers by 15 percent. But nonprofit agencies say even this isn’t enough to keep adequate staffing.
“We just cannot keep fully staffed and have waiting lists in most of our ambulatory behavioral health care programs,” said Steve Girelli, CEO of Klingberg Family Centers, a nonprofit that runs school-based clinics, outpatient programs, group homes, and screens children for mental health needs. “What we can offer our employees and candidates is less than what they need to live the life they want to lead.”
He said the workforce shortage was being exacerbated by a combination of low Medicaid rates and a lack of grant funding from the state. Girelli also believed changes in programming during the pandemic — such as conducting services remotely — may have made those services less effective, leading to an increase in young people requiring higher levels of care.
Girelli said all the programs he runs have been understaffed for months.
Victoria Stob, a program manager for IICAPS, an intensive in-home services program for children developed at Yale, noted that Medicaid had reduced the funding for intensive in-home services from 2018 through 2021, despite the high demand for mental health services.
According to a presentation Carelon made in May to the child-focused subcommittee of the state’s Behavioral Health Partnership Oversight Council, Medicaid’s total spending on intensive in-home services decreased from $27 million in 2018 to about $17.4 million in 2022.
David Aversa Carelon’s medical director for the Children and Family Division, explained the drop was a combination of a lack of staffing and people’s reluctance to have outsiders in their homes during COVID.
Girelli, who is also chair of the subcommittee, said this reflects what happened in his organization during the pandemic as well.
But Dr. Irvin Jennings, chief medical officer for the nonprofit Family and Children’s Aid, said the lack of staffing was still the key problem. He said his agency has lost a fifth of staff members for the intensive in-home programs since the pandemic began.
Depending on the site, he said, wait times for intensive in-home services are anywhere from two weeks to three months, and are often double that for Spanish speakers.
Jennings, whose organization runs outpatient clinics in Danbury, New Milford, and Waterbury and is the largest provider of intensive in-home services for children across the state, said he felt the expansion of telemedicine was a driving force behind staff leaving intensive in-home services.
“The fact of telemedicine makes it a different game. Simply put, you can make more money and have a better work environment by doing telemedicine than you can by going into some building and sitting there and waiting for patients to come in. That’s a huge issue. It’s a ground change right now,” he said.
Before the pandemic, Jennings said, the intensive in-home services program would make between $1 million and $1.5 million a year, enough to support other programs like outpatient clinics, which lost money. But over the last few years, in-home services have lost $1 million per year because his organization doesn’t have enough staff to provide the services.
At the same time, he said, the annual state grant they receive has remained fairly steady — around $300,000 — while the program’s annual budget has grown from less than $500,000 to $23 million.
Jennings also said Family and Children’s Aid has lost clinicians to the Department of Children and Families, which generally can offer better pay. At the subcommittee meeting in May, he said one of his mental health workers, who had been making $40,000 at his agency, was hired at DCF for an $80,000 yearly salary.
Outpatient clinics are also suffering from staffing shortages. In Danbury, there are 123 English speakers and 77 Spanish speakers on the waitlist to enter the clinic. The other clinics in Waterbury and New Milford also have waitlists, though not as high.
Jennings said many staff who used to work in outpatient clinics are leaving for private practice, and that cases are becoming more difficult, leading to staff burnout.
“We’re dealing with the people that nobody else wants to deal with, that are the most difficult to deal with, that have experiences that most children do not, thank God, have,” he said. “They’ve [had] multiple placements. They’ve been abused. They’ve been neglected. They’ve been physically abused, sexually abused, suicide attempts.”
‘We literally are walking them out’
The state recently opened four new urgent crisis centers across Connecticut, which many clinicians, like Girelli, said was a positive development. Girelli said he had a lot of respect for the nonprofits that would be running those centers, and that he felt “optimistic” about the new model.
“It is really supposed to be something that, if I have a family crisis, I can access immediately, in order to contain that crisis. And then get connected up to whatever resources I need to eliminate the aftermath of the crisis, and to reduce the likelihood of the recurrence of the crisis,” he said.
But Stob told CT Examiner she felt the newly opened centers for children and young adults were only a Band-Aid for chronic, complex trauma and psychiatric disorders.
“The nature of these psychological and psychiatric family system problems are not treated via crisis intervention. They are chronic,” she said.
Gary Steck, who runs one of the Urgent Crisis Centers at Wellmore in Waterbury, said the new centers could get children out of the emergency room – where the majority of them don’t need to be – but added there should be more funding for programs like his, so young people who are discharged from urgent care have services when they get home.
According to Steck, a majority of children coming into his center arrive with family problems, anxiety or depression, or serious psychiatric issues. He said these young people leave with a discharge plan, and so far only one has had to visit a hospital emergency room.
“We literally are walking them out with our home-based service staff that are seeing them that night or the next day in their home,” Steck said.
But Steck also told CT Examiner that IICAPS was “strained.” At the end of August, Wellmore had a waitlist of 34 young people for IICAPS, and Steck said he expected the demand to “skyrocket” once school began. Steck said none of the in-home programs — Multisystemic Therapy, FFT, or IICAPS — were fully staffed.
“My impression is it’s very difficult to quickly get any intensive service in Connecticut, with the exception of the urgent crisis centers, which just opened,” Steck said.
Medicaid rates
State Rep. Liz Linehan, D-Cheshire, told CT Examiner she had not seen data to support the need for more funding for intensive in-home services or outpatient services, nor had she heard such complaints from nonprofits.
“If they’re saying it’s an issue, then absolutely it needs to be looked at,” she said.
Linehan said she hoped the support included in a series of children’s mental health bills passed in 2021, including funding for more mental health professionals in schools, would reach children when they were beginning to struggle and reduce the demand for higher-level interventions like IICAPS or outpatient services.
She also hoped the urgent crisis centers, which were designed to work together with other mental health interventions, could lead to a reduction in need.
“The nonprofits absolutely did get an increase, and I know it was not exactly what they asked for. And that’s the hard work of the legislature, is making those decisions,” Linehan said. “Would I love to be able to give them the largest influx ever? Absolutely, but it’s just not always possible.”
State Sen. Heather Somers, R-Groton, told CT Examiner she wasn’t surprised that nonprofits expressed concerns about lack of funds, adding that the state needed to examine nonprofit funding on a yearly basis.
“The issue that you have is when people hear the types of increases — if it’s a 15 percent increase, if it’s a 10 percent increase — it sounds like a lot. But in reality, when your base is so low, it’s really nothing,” she said.
Somers noted that the legislature formed a group to examine Medicaid rates and what needed to be changed or adjusted.
“Obviously, if you can’t pay people enough that they can afford to provide the service, they’re not going to provide the service,” she said. “The need is great. It continues to grow, especially in the area of behavioral health with children. … And the budgets don’t increase at the same rate that the need has.”
Giovanni Pinto, spokesperson for the state Department of Social Services, which is responsible for setting the state’s Medicaid reimbursement rates, told CT Examiner in a statement that, in addition to the rate increase, they were also studying Medicaid reimbursement rates with a special focus on behavioral health.
“DSS recognizes the vital services these children’s behavioral health providers offer to numerous families throughout Connecticut, and we know there is more that needs to be done regarding Medicaid behavioral health rates,” the statement read. “Our hope is that following the report submissions in 2024 and 2025, DSS will be in a better position to evaluate the current state rates against peer state rates to better inform any future rate consideration proposals.”
Meanwhile, financial pressures are mounting for nonprofits and their staff.
Family and Children’s Aid CEO Kevin McNellis told CT Examiner they have to raise about $500,000 yearly in donations to continue their services.
Another challenge for clinicians, he said, was not being able to make appointments for children after school hours or on weekends, because that would cut into activities that “normalize their lives.”
Since Medicaid pays about $90 per therapy session, and the hours limit each clinician to about 25 sessions per week, the total amount isn’t enough to pay livable salaries and benefits, McNellis said.
Medicaid also pays about $155 for a psychological evaluation, he said, but the hourly rate for a psychologist is between $200 and $225.
And when a clinician leaves, he added, the child they are working with has to start again with someone new.
“That turnover — it’s a killer for the kids,” he said.
Steck said there’s no indication that the demand for mental health services will come down anytime soon. He said demand is expected to increase by 5 percent each year for the next three to four years.
“I think that there’s many who believe at this point that somewhere between a third and 40 percent of the entire population of children and youth need a mental health intervention at any given time,” Steck said.