1. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ VD-HCBS Training Series IDENTIFYING YOUR VD-HCBS BUSINESS MODEL December 8, 2011 Trainers: Lori Gerhard, Administration for Community Living

2. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Learning Objectives At the end of this one hour session, participants should: 1.Understand the fundamental components of the VD-HCBS Business Model 2.Identify different models that are currently functioning within VD-HCBS 3.Debunk myths regarding VD-HCBS policies and procedures 4.Understand how proper VD-HCBS business model development leads to a more successful and sustainable VD-HCBS Program

3. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Agenda Definition of key terms Policy guidance and procedures Decision points Lessons learned and recommendations Next steps and timelines Questions and answers

4. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Key Terms Veteran Directed Home and Community Based Services (VD- HCBS)— a product that the VA purchases from the Aging Network. The program includes 2 components—Veteran-Directed Budget and VD-HCBS Administration. Veteran-Directed Budget— These are the funds the Veteran uses to purchase services & goods in order to remain independent in the community. This amount also includes a “Respite/Emergency Back-up” fund (rainy day fund) and planned savings fund. The “Respite/Emergency Back-up fund is used for care when agency providers are required as back-up for workers the Veteran hires, or for respite care. Planned savings are for purchases which cannot be supported in a single month’s budget. VD-HCBS Administration— These are the funds for the service coordination and Financial Management Services (FMS) supplied by the Provider and Provider’s administrative costs. Services include assessment, options counseling/care management, Financial Management Services (FMS) and program administration.

5. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Key Terms VD-HCBS Operating Components— Options Counseling/Care Management/Support Broker, Financial Management Services (FMS), Program Administration. Options Counseling/Care Management/Support Broker— A person-centered, interactive, decision-support process whereby individuals receive assistance in their deliberations to make informed long-term support choices in the context of their own preferences, strengths, and values. Options Counselors work with the veterans to develop the veteran spending plan, assist veteran in locating workers, and interact with veterans at least monthly to assure program is working as planned. Financial Management Services— Service/function that assists the family or participant: (a) manage and direct the distribution of funds; (b) facilitate the employment of staff by acting as the participant’s agent with employer responsibilities such as processing payroll, withholding and filing federal, state, and local taxes, and making tax payments to appropriate tax authorities; and (c) performing fiscal accounting and making expenditure reports to the participant and/or family and state authorities. Program Administration— Program management/oversight, financial management, quality assurance, reporting, program performance

6. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ VD-HCBS Product Components Veteran-Directed Budget Spending Plan Respite/Emergency Back-Up Fund (Rainy Day Fund) VD-HCBS Administration Options Counseling/Care Management Services Fiscal Management Services Program Administration Assessment VD-HCBS Administration Case Management Options Counseling Financial Management Services (FMS One Time Initial Assessment (full/partial) AAA Administrative Veteran-Directed Budget/Spending Plan Goods Emergency/Back- up/Respite Fund Self-Directed Services

7. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Business Model Components Assessment Options Counseling Care Management Assessment Options Counseling Care Management Program Administration FMS

8. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Business Model Components Program AdministrationAssessment Options Counseling (Care Management) FMS Program Management Performance Conduct AssessmentPaperwork for Veteran’s employees Quality AssuranceFacilitates Veteran in developing a Monthly Budget/Spending Plan Receives timesheets and invoices for goods Financial Management— Billing, AR, Cash Flow, Budget, Accounts Payable Monthly Contact with Veteran Pays Veteran’s workers, withholds appropriate taxes for Veteran and employee. ReportingReassessmentFiles tax information on behalf of Veteran Relationship with VAMCRelationship with VeteranIssues Monthly reports to Program Administrator

9. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ VD-HCBS Business Models ModelStatesWhich entity signs Provider Agreement (PA) with the VAMC? Who performs the FMS functions? Who provides the options counseling/care management for the Veteran? AAA signs PA, FMS vendor model AR (Little Rock), CT, DC, IL, LA, ME, MI, NJ, NY, OR, SC, TX, VA, WI AAAVendorAAA SUA signs PA, FMS vendor model MA, WASUAVendorAAA Purely AAA-based model AR (AAA of NW AR only), ME, NH AAA AAA signs PA, FMS and support broker vendor model FL, MN, (NJ is planning switch to SUA signs PA) AAAVendor The following slide diagrams four VD-HCBS Business Models The models reflect the work of 18 states and DC: AR, CT, FL, IL, LA, MA, ME, MI, MN, NH, NJ, NY, OR, SC, TX, VA, WA, WI

10. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Key Decisions/Strategies AAA/SUA Vision of Role in Community—Core Competencies What components will be provided by the AAA/SUA? What components will be provided by other entities? What transition strategies will be used to move from current operating system to envisioned operating system? How will the business model work?

11. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Key Decisions/Strategies Gaining economies of scale to get best price for FMS Leveraging existing staff capacity in AAA/SUA (Experience is approximately 20-25 veterans can be served by one FT options counselor/care manager) Effective/efficient cash management system Effective/efficient quality assurance system Moving to a more participant directed operation

12. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Debunking VD-HCBS Myths Myths Fact VD-HCBS is a grant programVD-HCBS is a product the VAMC buys from the AAA/SUA. The monthly bundled rate based on the approved spending plan is billed monthly. The AAA/SAA sends an invoice each month to VAMC for each Veteran in the program. Traditional services are a key component of the VD-HCBS Participant directed services are a key component of VD-HCBS. Veterans hire family, friends and neighbors—non-traditional service providers. The VD-HCBS is only developed in states that have a CLP grant When the program started it began with states that received CLP grants. Building on the positive experience/results--the VA is expanding the program nationwide. Each year the VA in collaboration with ACL identifies the areas where the program will be developed.

13. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Debunking VD-HCBS Myths Myths Fact Payment is slowPayment is typically received within 45 to 60 days from date of service. The timeframe is influenced by several factors— AAA/SUA invoicing process, ability to receive EFT, VAMC processing system. Program isn’t financially viable VA pays a one-time assessment fee for each veteran in the program and a monthly administrative fee. Monthly amount ranges from $325-$525 per veteran. If 10 veterans are in the program the program income for the month is ($3,250 - $5,250) and annually the program income is ($39,000 - $63,000). If 25 veterans are in the program the program income for the month is ($8,125 - $13,125) and annual program income is ($97,500 - $157,500). These calculations do not include the one-time assessment fee which ranges from to $925. The VA form 10- 1170 will reflect the Assessment Fee and the monthly VD-HCBS Administration Fee.

14. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Implications of Successful Business Model Development Clarifies program operating model, enables development of operating policies/procedures and performance indicators Facilitates successful completion of VD-HCBS Program and FMS Readiness Review conducted by NRCPDS Expedites Flowchart Call that reviews the processes within the VD-HCBS Business Model Sites have the background protocols decided, shortening the timeframe for finalizing the VD-HCBS Provider Agreement

15. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Lessons Learned Leverage Participant Direction Infrastructure—It is important to identify participant direction infrastructure (FMS) that is already operating to achieve economies of scale; however, it is also advisable to do some homework and planning to determine if the operating approach will be compatible with the VD-HCBS Business Model you’re seeking to operate. Procurement strategies—many SUA’s/AAA’s have experience procuring an FMS and are willing to share procurement documents.

16. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION FOR COMMUNITY LIVING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | WEB http://www.hhs.gov/acl/ Recommendations Build out options counseling/care management workforce – Determine if current options counselors/care managers are carrying full caseload. – Use contractor temporarily to serve Veterans until program begins to serve quantity of Veterans to support a PT or FT options counselor/care manager. Develop operating budget and roll-out plan. Understand operating costs and income. Bill on approved spending plan with quarterly reconciliation Expand/transform OAA to be more participant directed.