Ana Novais, new role as Assistant Sect., RI EOHHS – Richard Asinof

Photo: Ana Novais, the new Assistant Secretary at R.I. EOHHS.

by Richard Asinof, ConvergenceRI.com, contributing writer

We are entering a time of major transitions. We are changing horses in midstream, in the midst of a dangerous storm, making it difficult to talk about hope, as we frantically try to reach the safety of solid ground and not get swept away by the raging currents.

As Gov. Gina Raimondo prepares to depart her elected position to take up the post as Commerce Secretary in the new Biden administration, Lt. Gov. Dan McKee will soon be stepping up to take on his new role as Governor, during a time of crisis, mayhem, anxiety, and pandemic. Who could ask for anything more?

Many of the critical decisions for the state’s future health, business and economic prosperity will now fall upon McKee’s shoulders, as he inherits a state government bureaucracy that has been managed for six-plus years under Raimondo. Be careful what you wish for.

• The Rhode Island health care delivery system is in disarray, with hospitals flooded by an avalanche of new COVID patients, as the spread of new virulent strains threatens to outpace the capability of the state to coordinate the delivery of injecting vaccines into arms of residents.

“Right now we are in an absolute race against time against these variants,” said Dr. Megan Ranney, emergency room physician, speaking on Sunday night on CNN, describing the health system in Rhode Island as overtaxed and stressed out. “Give everyone the doses that you can right now and count on that increased production so you can get people adequately protected,” she argued. Question for the new Governor: Will it become necessary to mandate a new shutdown and to close public schools again?

• A pending merger of the two largest health systems, including Brown University as a partner, is moving forward into an uncertain maw of regulatory and financial hurdles, to be overseen by the R.I. Department of Health and the R.I. Attorney General’s office. Question for the new Governor: Is the status quo in the business model for health care sustainable under a consolidated health enterprise?

• If homes are the place where jobs go to sleep at night, the affordable housing crisis in Rhode Island has been exacerbated by the ever-increasing demand to buy homes, reducing the availability of existing housing stock and escalating prices, which has resulted in moving the goal posts farther and farther out of reach for many families.

The $65 million housing bond, which will go before voters on March 2 for approval, will not provide enough money to save many Rhode Islanders from falling into an abyss of homelessness, if and when the eviction ban is lifted, given the years-long timeline between financing, development, and construction of new housing starts. Question for the new Governor: What kind of financial partnerships will the state invest in to spur new housing developments that are not single-family homes?

• The pandemic has exposed all the ways that systemic racism has afflicted much of our cultural, political and governmental institutions in Rhode Island, making it impossible to ignore, and forcing Rhode Islanders – at all levels of our community – to engage in an uncomfortable conversation about racial equity. The burden of the pandemic has fallen most heavily on communities where the poor, vulnerable Rhode Islanders who are Black and Latinx are the majority. Question for the new Governor: Can you name all of the existing Health Equity Zones in Rhode Island and which communities they are located in?

• Next week, the former President will go on trial before the U.S. Senate for his second impeachment, on the charge of inciting an insurrection, with the trial carried live on all the networks in living color. One of the 10 House impeachment managers will be Congressman David Cicilline, who has promised that a preponderance of evidence will make perfectly clear the culpability of the former President.

After four years of telling more than 30,000 lies and untruths, including the biggest lie of all – that he won the Presidential election – the former President will face the evidence of his crime of inciting an attempted violent overthrow the U.S. government, which he will no longer be able to sweep under the proverbial rug and dismiss as “fake news.” The Republicans in the Senate, it seems, will soon be like the good Germans living nearby the Nazi concentration camps during World War II, forced to bear witness to the horrendous crimes committed against Jews after years of pretending that they didn’t know what was occurring.

Outside the news lens
Still, some of the transitions now underway in Rhode Island have escaped the rampaging of the rhinoceroses of the news media herd, including the move by Ana Novais, former second in command at the R.I. Department of Health, to become the new Assistant Secretary at the R.I. Executive Office of Health and Human Services, working directly under Secretary Womazetta Jones.

During much of the last seven years, Novais has been the diligent shepherd guiding the creation and establishment of the Health Equity Zones initiative in Rhode Island, which most recently attracted an $8 million investment by Blue Meridian Partners in the Central Providence HEZ to explore how to take the work and scale it up statewide. [See link below to ConvergenceRI story, “Changing life trajectories in Providence.”]

Novais now brings that equity lens to R.I. EOHHS, looking to instill a new strategic, integrated, collective approach to the delivery of services across the umbrella of agencies under the aegis of EOHHS, so that “equity is not just a word or a dream but a reality for all.”

ConvergenceRI recently interviewed Novais, the latest in a series of interviews conducted with her dating back to 2014. Following the interview, Novais wrote to ConvergenceRI, seeking to frame the wide-ranging interview in the context of the transitions now underway in the state and in the nation.

“I am looking forward to this next chapter in my career,” Novais wrote. “These are challenging times but also times of opportunity. As we respond to the pandemic, we are doing it with an eye toward the future, making sure we are addressing the systemic issues we have known all along [that] were impacting peoples’ outcomes in health and life, [systemic issues] that have been so exposed with this pandemic.”

Further, she wrote: “At the state level, it is also a time of transitions. As I say to my colleagues, the work is not going away. The people we serve continue to rely on us and on the services we provide. Our local communities continue to demand of us a true engagement, a coordinated and aligned investment, the creation of an integrated vision and policies that puts people’s choices, our communities’ voices, and race equity front and center. Only then we can hope to deliver on the promise of equity for all; on the promise of a fair and just society; on the promise of vibrant, resilient communities.”

Here is the ConvergenceRI interview with Ana Novais, the new Assistant Secretary of the R.I. Executive Office of Health and Human Services.

ConvergenceRI: Looking toward the future, where do you think EOHHS can go? As we come out, God knows when, at some point, into a post-pandemic world, how does EOHHS need to reframe what it is doing?
NOVAIS: I think for me, the power of the EOHHS is in the combined power of all of these key agencies that are impacting people’s life outcomes.

From the Department of Health, which is population health; from the Department of Human Services, which is all of the social services and benefits; [the Department of] Children, Youth and Families; you have behavioral health and mental health and addiction under BHDDH; Medicaid, which is our safety net; and we have close relationships with the Office of Veteran Affairs and the Office of Healthy Aging.

[Taken together], it is all of what surrounds a person and a community to be healthy and to have healthy life outcomes, all under the umbrella of EOHHS.

I think if we can leverage all of these agencies and if we do meaningful, strategic planning  for the state and for the people we serve, collectively, in an integrated manner, leveraging the different resources of the different agencies, we can make a profound change in our health care system, we can make a profound change in how we invest in our communities, and we can make a profound change in people’s outcomes for life.

We also, then, can work with the other key players with whom we have close relationships – with the R.I. Department of Education, with OHIC – not from an individual agency perspective, or from an individual department perspective, but collectively, as the umbrella organization that [supports] you from birth to old age, looking at all of the ways we can improve how we move forward.

A collective agenda that says to people, with equity as a core, at the center of the agenda, with racial equity as a core value, and people’s choices and people’s voices as another core value.

ConvergenceRI: One of the key ways in which people can collaborate or have a collective agenda is around the sharing of data. I often feel like much of the data is siloed. For the last four or five years, I’ve been pushing for an integrated, unified database around what’s called the deaths of despair – deaths from alcohol, suicide, drugs, and gun violence, tied to economic issues – to show how they are all interconnected in Rhode Island. And, there is no one who has yet compiled that data and published it.
NOVAIS: I think you are asking two different questions. I would say that we do have a strategic plan and a desire to – and processes and systems in place – to integrate data.

EOHHS runs a system, as you know, which brings together all kinds of different datasets, from all of the different departments, allowing us to do the kind of analysis that you are referring to.

We might not have a single database [around the deaths of despair], but, for example, we are able to pull data, and look at when people die, looking at people with a history of drug use, for example, and looking at how they are doing from an employment perspective.

Or, what is the average pay, because you can pull data from the Department of Labor and Training, so I think that we may not have the single database, but we have a structure and relationships that allows us to make the necessary connections to have really meaningful analysis.

One example, I can tell you, we just completed an “evidence refresh” for drug overdoses, where we were looking at [the fact that] we had a drug overdose task force and, with the pandemic, once we took a look, we realized that there was a huge impact on drug use and that we were seeing an increase in drug overdose deaths.

And so, we wanted to look at the data, not just straight data on the number of overdose deaths, and so forth, but trying to have a better understanding of what was happening, [looking at] who were those folks.

And so, we were able to convey, and I will share with you the reports that gives us a different understanding of who folks were.

We also engaged in a large, expansive conversation—because I think data is one component of any story – talking with stakeholders. It’s another component of the story.

So, we met with [more than] 100 people to have those conversations, and we are producing that report that takes a different look and makes recommendations. We have a strategic plan that we established – and I know you have attended the Task Force meetings – that established pillars of that task force strategic plan.

We didn’t want to change the strategic plan, but rather change the ways in how we looked at the data, along with the conversations, asking: What are the things that we need to do differently so that we do not continue to have an increase in drug overdose deaths?

[We found that] some of the methods were going in the right direction, such as making treatment more available.

I disagree with you, respectfully, as always. We have taken steps in the ways that we can bring the data together and analyze the data in creative and critical ways that we have not done before.

ConvergenceRI: Well, that is encouraging. I would push back, respectfully, that the data shows, according to the recovery community advocates to whom I have talked, that 80 percent of all drug overdoses have alcohol as a co-morbidity. So, if you are not dealing with alcohol as a primary problem connected with drug overdoses …
NOVAIS: [interrupting] …Absolutely, and we agree with you on that one. We cannot look anymore at just one single drug or just even opioid use.

That is why I say, with drug use in general, it is connected to other co-morbidities, and not just alcohol, but also other issues with mental health, with so many other issues – that’s the work we are doing right now.

Pushing forward – it’s one of the priorities that I have, in fact, under my portfolio, is behavioral health, expanding beyond opioid and drug use in general, but mental health and behavioral health integration in general, that is one of the areas that we are working on. Not only with this drug overdose evidence “refresh” initiative, but we have been working on a behavioral health systems review, where we are also engaging with key stakeholders and providers, to talk about behavioral health and mental health in general.

[We are asking:] What systems should we have in the state? What are the gaps in the system? What are the things we are doing well? What are the things that we are not doing well? And, putting forward very specific implementation plans to move that work forward.

We are focusing on children’s behavioral health. I mean, I remember, for the past 20 years, we have had these conversations in our state about needing to do a better job to create an integrated system of care from a behavioral health perspective for all children in our state. Now, we are doing that. We are pulling different factors together from the different state agencies, and we are going out and talking with our external partners, to say: this is our vision, this is what we think. But what do you think?

How does that fit in with your perception of what is needed? What needs to be changed? What is working well? How do we then move to implementation?

I think for me, that is the key component. Not component, but a key [pausing while searching for the right word] expectations for myself, as I come into R.I. EOHHS as Assistant Secretary.

We have the vision, we need to continue now to develop the implementation plans, and move forward with this initiative so we can truly transform the system.

COVID, this pandemic, has exposed so much of the shortcomings in our health care system; it also showed us where we have strengths, and allowed us to change some things to improve access. Telehealth is one example.

But, all of the attention and the burden the pandemic brought into the health care system puts us on notice that we need to seize the moment, and make sure that every response to the pandemic, as we invest into this health system of ours in response to the pandemic, that we do it with an eye toward the future and addressing these underlying systemic issues that we know we need to address. This may be the moment to do that.

ConvergenceRI: Sen. Josh Miller convened a study commission last year to look at problems with health insurance reimbursement rates And, across the board, almost everyone that testified before that commission talked about the problem of low reimbursement rates from Medicaid – and from commercial health insurers – that they said was crippling any opportunity to create a comprehensive system to address behavioral and mental health care needs, because it was impossible to maintain staffing, and it was problematic to be able to refer clients out to other providers, because the rates were too low.
At what point, in terms of the partnership with the insurers, how does the government get involved in looking at what is perceived to be a gap in reimbursements that limits the ability to provide mental and behavioral health services, which are still one of the greatest unmet needs in Rhode Island?
NOVAIS: I am not going to comment specifically on rates and rate setting, because that is not under my purview.

But I want to say is that I know it is easy to just say, it’s a rate, but I also think that sometimes there are issues with the business model that we have, that the way that we design our system of care is a component [of the problem].

What I would say to you is that it is a joint conversation. We cannot do system redesign without looking at rates. We cannot just change rates and reimbursements without looking at the system.

So, is it going to be part of the conversation? Yes. We will engage in that conversation, to assess and say, as I am designing A, B, and C options in the system of care, how does it fit within the current payment methodology that we have. What does it mean to do this payment reform as we look at the new system? They go together.

But, for me to say, yes, it’s a rate problem, that we need to increase by x percent, it would be wrong, because it would be in a vacuum. What I want to say is that yes, we need to look at those two together.

ConvergenceRI: That makes sense. Another issue may be how people get involved in that ongoing conversation. I think there is a pervasive feeling from many people who are providing behavioral health services that they are not really participating in the decision-making, or having their voices heard.
NOVAIS: I don’t know what to say that. One thing that I can tell you is that there is indeed a commitment to engage with our stakeholders from across the board and from across our agencies from Medicaid, DOH, DCYF, BHDDH.

We value our partnerships with the providers. We value our partnerships with the community. We want you to know how much we believe in the power of collaboration and partnership. It is the only way you can accomplish anything. You can never accomplish it by yourself.

And, we want to hear, and we want to engage. It doesn’t mean that we are always [going to] agree on what is being said at a meeting, or what is going to be what happens. But I think I would say that the value of engaging, and through meaningful engagement with all of our stakeholders, providers, community, recipients of services, residents, it’s what we want to do, because it’s the only way we are going to be able to move this conversation and this transformation that we need forward.

It is the same value that we had brought to when, at the Department of Health, we worked with the Health Equity Zones, where we needed to change the way we did public health. I think it is the same here. I see that same commitment. To put choice, and to put collaboration and partnership and engagement as core principles here at EOHHS, in these concept conversations.

ConvergenceRI: When Secretary Womazetta Jones first began her job, she talked about needing to transfer the power from the agency back to the community. [As ConvergenceRI reported: “My pillars [in the job], for me, are community engagement, racial equity, and working with the whole person,” Jones said, summarizing her vision succinctly. “And, how to do that in a way that is beneficial to all Rhode Islanders.” We have to ensure, Jones continued, “that we are giving up power. We need the community to know that their voices, those voices, are the ones that need to lead how we do this work, to help us shape this work.” [See link below to ConvergenceRI story, “A change is going to come.”]

It seems as if that is the direction in which you are moving, in terms of engagement.
NOVAIS: Absolutely, I think those are values that [flow] from the top, as you mentioned. Secretary Jones is a breath of fresh of air, in the way she looks at moving forward a race equity agenda, moving forward a choice agenda, putting people and communities at the core, a vision that is fully embraced.

And, I think the current leadership within the agencies recognize that and embrace that. We hope that as we try to come out of this pandemic, one thing that I think changed with the pandemic, is that as a whole in government, we are working much more closely together than we ever did.

We understand the interdependencies that exist between our agencies, because at the end of the day, we serve the same people, when you have the Department of Health trying to protect the lives and [institute] infection control measures, we understand that we need to work with our colleagues at Commerce, because it is [all about] economic viability for our state.

We need to connect with our colleagues at RIDE, because we need schools to be open safely and kids to be in school so parents can be at work.

We need to work with our colleagues at Housing because when you talk about quarantine and isolation, people need to be able to safely quarantine.

When you talk about how to make sure that our high-density communities are being protected, it is about engaging with local municipalities and with the mayors, and with emergency management agencies, so we have a full engagement at the local level in a way that makes sense for the local residents. Because residents in Central Falls are different than residents in Pawtucket, who are different from residents in East Greenwich.

How we do this together, that’s been the key in this response, I believe, and one of the more successful outcomes for me, in seeing the level of engagement and collaboration and partnership across state agencies that I had never seen before in these ways.

And, I hope, that we can come out of this pandemic carrying that same desire to continue to work together.

ConvergenceRI: Everyone seems that they are working overtime, because there is so much work to do, and everyone is stretched very thinly. What types of investments are needed in public health infrastructure to move forward?
NOVAIS: I can tell you that during this pandemic the power and the usefulness of the Health Equity Zones became very clear and apparent for everyone that was working on COVID. Early on, the Governor supported an investment of the CARES funds into Health Equity Zones to be part of the response, so we supported an expanded scope of the Health Equity Zones as part of the response. And, we’ve seen the outcomes of that investment in our high-density communities.

The other thing I would say is that the Governor is part of the government. The success of the ONE Neighborhood Builders [to secure the $8 million investment from Blue Meridian Partners], it was done in collaborative application between the state, ONE Neighborhood Builders, and the Rhode Island Foundation. [The result] is a pilot project we have for two years, with the goal that we can demonstrate how the investment will pay off in terms of economic mobility that is focusing on upward mobility for people, focusing on early education, on job training, on housing, and on leadership developing at the residents level.

That we can create good jobs and wages, showing that impact, and then help us go to a statewide expansion.

You cannot do this unless you have government collaborating together, because in terms of sustainability and scalability of these projects, we need statewide policies. If we do not talk about polices that change statewide, it is not going to be sustainable, it cannot be done just a local level.

That is the process we have had with the investment in the Health Equity Zones and we are committed as a whole to continue to work on expanding, scaling up and the sustainability of the project.

ConvergenceRI: One of the more innovative projects that ONE Neighborhood Builders accomplished, in response to COVID, was building out its own wire mesh WiFi network, using its own buildings, so that two-thirds of the all the households in Olneyville now have access to free WiFi, enabling residents to connect online as a survival tool during the pandemic, for remote education, for health care, and for jobs. [See link below to ConvergenceRI story, “Healing the digital divide.”] Would scaling up that kind of connectivity in other communities fit into the concept of what you have called wider collaboration?
NOVAIS: That policy is not my area of expertise. I had no idea how they did that. But if they were able to accomplish something successfully that way, I hope that they are sharing. As you know, part of the Health Equity Zone initiative is having a learning collaborative, where folks can share successes, in a way that others can learn from best practices.

So, I hope that they will be sharing that with the other HEZs, so that other communities can benefit of what appears to be a very creative and efficient, innovative program.

ConvergenceRI: We have a dire need for affordable housing in Rhode Island. We have a new $40 million bond on the ballot on March 2 to invest in new affordable housing. But, thinking in terms of collaboration, is there a way that government can become involved with hospital systems and health insurers, who currently invest their capital in financial markets, to invest instead in the creation of affordable housing, so that they can achieve a return on investment from their capital and earn the same if not better rate of return on their money?
It might require some changes to the way that state regulations are written, I know that in Phoenix, Arizona, UnitedHealthcare has invested in housing for the homeless.
NOVAIS: Absolutely. There are some very creative models out there on how some corporations manage their investments.

I think that at this stage, I am very happy that we are putting forward before the voters a bond for the creation of affordable housing in our state. I hope that we are successful in doing that. I think we should, as part of the ongoing strategy of engagement, work with hospitals and other corporations that want to talk to us about those core determinants of health.

Housing is absolutely one of the most important determinants of health. And I say, not just affordable housing, but affordable, safe, healthy housing, housing that is truly affordable for our low-income population, for our young families that are starting out and cannot afford what we call the median average for affordability right now.

ConvergenceRI: What questions haven’t I asked, should I have asked, that you would like to talk about?
NOVAIS: I started my career in public health many, many years ago, I thought I was going to finish my career in public health.

The Health Equity Zones was work that I truly enjoyed, expanding that project. The opportunity to come to EOHHS that was offered to me, it was as much a challenge as it was an accumulation of many years of promoting engagement at the community level, and being able to bring that same vision of population health, with people at the core of equity, to all of these agencies that are under the EOHHS umbrella.

I feel lucky that there was someone at the leadership level – Secretary Jones – that shares that same vision and goals, the same kind of partnership that I had with Dr. Alexander-Scott at the R.I. Department of Health.

I truly look forward to the future, and I hope to be able to continue that journey at EOHHS.

To read the story in its entirety, go to: http://newsletter.convergenceri.com/stories/a-new-dawn-a-new-day-a-new-life-at-ri-eohhs,6314

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Richard Asinof is the founder and editor of ConvergenceRI, an online subscription newsletter offering news and analysis at the convergence of health, science, technology and innovation in Rhode Island.