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6/27/ VD-HCBS Status Map Operational VD-HCBS Programs States 27 and the District of Columbia VISNs17 out of 21 VAMCs47 out of 154 Aging & Disability Network Sites (SUAs, AAAs, ADRCs) 104

6/27/ VA Update Commitment to future growth and expansion Issuing policy guidance to enhance VD-HCBS Operations Focus on sustainability planning with VAMCs

6/27/ VHA/ACL VDHCBS Sustainability VHA and ACL are focused on assisting VAMCs and A&D Network develop sustainable VD-HCBS Programs 1. Part A 1:1 Sustainability & Expansion Calls 1. Initial and 6-month Follow-up Calls 2. Completion of VD-HCBS Sustainability & Expansion Templates 3. Achieving statewide access and census of 35 Veterans per VAMC 2. VD-HCBS Sustainability Guide (NRCPDS) 3. VD-HCBS Ticker Report

6/27/ VD-HCBS Sustainability What is VD-HCBS Sustainability? 1. Environmental 2. Social 3. Economic Sustainability EnvironmentalSocialEconomic BearableViable Equitable

6/27/ What are the Challenges to VD- HCBS Sustainability Environmental Challenges ► Pressure to reduce non-VA care spending ► Focus on priority issues and dealing with crises at hand ► Competing against other service lines ► Concerns with self-direction? Social Challenges ► Veterans not fully-aware of what it means to self-direct their own care Economic Challenges ► VD-HCBS requires a larger investment in HCBS ► NH/HCBS Rebalancing is a transformational shift ► Veterans may have other forms of coverage

6/27/ Overview of the VA LTSS The Department of Veterans Affairs has made a commitment over the past ten years to expand access to community LTSS for Veterans needing a nursing home level of care The Administration for Community Living (ACL) works collaboratively with the VA to offer Veterans-Directed Home and Community Based Services (VD-HCBS) The VD-HCBS program enables Veterans to remain at home, maintain their independence, participate in their communities and have choice and control over their services and supports

6/27/ Veterans Directed Home and Community Based Services The VD-HCBS program started in 2008 VD-HCBS provides an alternative to traditional non-institutional VA services VD-HCBS offers a consumer-directed and individualized budget model of services and supports 47 VAMCs partner with 104 State Units on Aging (SUAs), Aging and Disability Resource Centers (ADRCs), and Area Agencies on Aging (AAA) Over 1,600 Vet erans have been served by VD-HCBS

6/27/ Determining efficacy and effectiveness VD-HCBS programs continue to grow with new sites being added in several states ► California, Utah and Idaho have new VD-HCBS Programs in 2014 ► Colorado, Utah, North Carolina, Missouri and Oklahoma are all developing VD-HCBS The VA provides two years of funding and then the VAMC assumes the financial responsibility for continuation of the program VAMCs must demonstrate the efficacy and effectiveness of this program to sustain and expand VD-HCBS enrollment and add new sites of operation within their service areas One strategy to demonstrate success and cost-effectiveness of VD- HCBS is to use a Veteran’s experience survey to determine satisfaction, quality and increase or maintaining of independence

6/27/ The Analysis of the Veterans Experience Surveys

6/27/ Methodology Requests were sent to all VD-HCBS sites to determine which sites used a Veteran’s Experience Survey Questions were asked about the type of survey and the administration of the survey including frequency, process of collecting responses, and use of survey results In total, the Lewin Project Team collected 22 survey tools, some of which were used by multiple sites in a state Surveys questions were cross-walked to identify similar questions and overall themes which were organized into domain categories

6/27/ Methodology (Cont)

6/27/ Findings

6/27/ Veterans’ satisfaction Overall 89% of Veterans responded positively to each question asked in the surveys Veterans experience high level of satisfaction regarding choice and control. Of 70 respondents*, 52% strongly agree and 48% agree they are able to choose who provides their care Veterans strongly agree or agree (99%) that caregivers do things the way they want them done (79 respondents) Veterans strongly agree or agree (91%) that they control how they spend their VD-HCBS budget (53 respondents) *Please note that the number of Veteran respondents change s because not every site asks each question

6/27/ Veterans’ Independence Veterans report that the VD-HCBS program is highly successful in maintaining independence while improving the quality of the Veteran’s life Of 237 respondents, 210 (or 89%) reported it was certain, very likely, or somewhat likely they would enter a nursing facility without these services Of 231 respondents, 95 % reported that VD-HCBS helps them a lot Of 159 respondents, 157 (or 99%) reported that VD-HCBS improves the way they live 100% respondents either strongly agree or agree that VD-HCBS has helped them to stay as independent as possible

6/27/ Veterans’ Choice & Control Other areas of satisfaction with choice and control ► 98% of respondents report they are satisfied with the care was provided to them ► 100% of respondents report they receive services in the place they most desire ► 99% of respondents report having enough choice over the services and products they use ► 96% of respondents report they have support to engage in the activities that are important to them

6/27/ Domain Definitions The report includes the findings for the five domain areas: DomainMeasure Services and supportsmeasures overall program satisfaction, satisfaction with counselors/brokers, the quality of written materials, assistance to be an employer, and the quality and amount of care and services Caregiversmeasures satisfaction with the choice, responsiveness and quality of caregivers and the Veteran’s role as an employer Interests and Activitiesmeasures satisfaction with the Veteran’s ability to engage in activities of their choosing and remaining active in the community Independencemeasures the program’s ability to support the Veteran to maintain independence and improve how the Veterans live their lives Personal relationships, Autonomy and Privacy measure satisfaction with maintaining information about the Veteran confidentially and if the Veteran feels safe and secure in the home

6/27/ Summary of surveys The majority of sites insert use a mail survey Most sites conduct an annual survey but some report conducting semi- annual surveys Veteran census in VD-HCBS programs varies resulting in a range of responses per site The response rate varied from 56%-100% with an average of 81% Designated representatives can complete the surveys The most common reasons sites administer surveys are to determine satisfaction and for program improvement

6/27/ Results The results of the Veteran Experience Surveys analyzed indicate: ► The program is meeting its goals ► The program provides high levels of satisfaction with services and supports ► The program is fulfilling the program goals of the VA and ACL to assist Veterans to achieve improved health outcomes and meaningful community lives that afford them choice, control and independence

6/27/ Recommendations for National Surveys

6/27/ Overview The Lewin Team recommends two core standardized surveys are recommended: one at the three month post-enrollment point, and the second on an annual basis The two recommended surveys use questions from the existing surveys with the addition of specific questions to enhance the breadth and depth of the content. Surveys can be made available to all VD-HCBS sites with recommended scales and the methodology to conduct the survey The use of standardized surveys will encourage sites that currently do not administer a survey to do so and will assist the VA and ACL to evaluate the overall program on a national level in a standardized reliable way

6/27/ The three month post-enrollment survey Administer a survey to all Veterans three months after initial enrollment Survey is administered using an in-person interview by someone not directly serving the Veteran Survey data would be used to determine if services and supports are in place for the Veteran, determine their satisfaction and for program improvement The recommended survey includes 22 questions about services and supports; caregivers; and independence The survey uses a consistent scale: strongly agree, agree, neither agree or disagree, disagree or strongly disagree

6/27/ The annual satisfaction survey Administer the survey on an annual basis to all Veterans enrolled in the VD-HCBS program Survey is administered via USPS mail Survey data would be used to determine overall satisfaction and for program improvement The survey includes 22 questions about services and supports; caregivers; and independence The survey uses a consistent scale: strongly agree, agree, neither agree or disagree, disagree, or strongly disagree

6/27/ Comparison of the surveys In-person interview Primary Purpose: immediate program and quality improvement Questions focus on process and procedures and the program’s responsiveness Mail survey Primary Purpose: satisfaction Questions focus on the Veteran’s level of satisfaction and the program’s responsiveness Three Month Post EnrollmentAnnual Satisfaction

6/27/ Other Resources on VD-HCBS Sustainability NRCPDS Sustainability Guide ► VD-HCBS Sustainability Studies: available at ADRC-TAE site under VD-HCBS Resources ( ► Boston, MA ► Chillicothe, OH ► Milwuakee, WI Past VD-HCBS Educational Webinars ( Today’s slide deck and additional resources will be posted to the ADRC-TAE site ACL/VHA is scheduling the next VD-HCBS Educational Webinar for the Fall 2014