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 Person Centered Planning/Developing the Veteran-Directed Budget January 10, 2012: Lori Gerhard, U.S. Administration for Community Living Kevin Foley, U.S. Administration for Community Living Dianne Kayala, National Resource Center For Participant Directed Services Susanne Crisp, National Resource Center For Participant Directed Services

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 3 approaches to establishing the Veteran- Directed Budget. 2.Understand the difference between traditional planning and person centered planning and how the Veteran Directed Budget is used by the Veteran to develop the spending plan. 3.Appreciate lessons learned and recommendations from early experience with VD-HCBS. 4.Know where to get more information and assistance with person centered planning and developing the Veteran- Directed Budget.

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 Overview of Budget Methodology Options and State Examples Overview of Person-Centered Planning Developing the Veteran’s Spending Plan 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/ Definition of Key Terms Veteran-Directed Budget – These are the funds the Veteran uses to purchase services and goods in order to remain independent in the community. This amount also includes a “rainy day” fund and planned savings. The “rainy day” 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 the purchase of goods which cannot be supported in a single month’s budget. Person Centered Planning– A process to develop an individual support plan that is directed by the participant and/or their representative and is intended to identify their preferences, strengths, capacities, needs, and desired outcomes or goals.

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/ Definition of Key Terms Budget Methodology – The approach used to establish the monthly dollar amount of the Veteran- Directed Budget. There are 3 budget methodologies that may be used: Case-Mix, Tier System or Individual Calculation. An AAA/SAA and VAMC will select one approach to use with all veterans served. Budget Appeal Process – The process that will be followed if during the development of the spending plan, the Veteran does not have enough in the Veteran-Directed Budget to meet his/her basic needs or conversely is assigned a budget amount that is significantly more than the cost of the goods and services he/she identifies. Spending Plan – The plan that the Veteran develops that reflects how the Veteran plans to use the funds in the Veteran- Directed Budget to purchase services and goods.

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/ Referral Intake Assessment Candidate Not Appropriate for CD Bill 1 time half assessment fee Candidate Not Appropriate for CD Bill 1 time half assessment fee Candidate Appropriate for CD Candidate Appropriate for CD Authorization of Plan AAA bills 1 time full assessment fee Authorization of Plan AAA bills 1 time full assessment fee 8 Authorization of Budget Amount 6 Propose a Monthly Budget Amount 5 Develop Plan Plan Distribution Employer Paperwork Hiring Assistance 11 Employee Paperwork Establish Employment Initiate Services 14 Programmatic Quality Assurance (QA) Monitoring Reports Planned Savings Fund Rainy Day Fund Timesheets and Invoices 13 Payments 16 Reassessment Reimbursement Quarterly Reconciliation Fiscal QA Monitoring 4a 11 8 3 2 1 7 12 910 15 2017 1819 24 232221 4b VD-HCBS Model Work Flow

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/ Overview of Budget Methodologies There are 3 Types of Budget Methodologies Used in VD-HCBS: – Case Mix – Tier System – Individual Calculation The AAA/SAA proposes a budget methodology to the VAMC. The VAMC and AAA/State Agency on Aging (SAA) need to agree on the budget methodology that will be used. Regardless of the budget methodology selected, the amount of the budget should fit within the range for the Veteran- Directed Budget provided by the VAMC. There may be times when the budget exceeds this range, this is an exception and requires approval by VA Central Office

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/ Budget Methodologies—Case Mix Case Mix— This method assigns a score to each assessed ADL and the sum of that score determines the case mix, usually with consideration also given for skilled nursing and/or behavioral/cognitive issues. Example: MN

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/ Budget Methodologies—Case Mix Example of Case-Mix Methodology—See pdf—MN example

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/ Budget Methodologies—Tier System Tier System— This method usually involves a Low, Medium and High budget tier into which each Veteran is assigned based on overall needs. Tier assignment relates to how the individual Veteran’s functional needs lie between the lowest need that would meet eligibility for the program to a need for total assistance Example TX or CT

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/ Budget Methodologies—Tier System Example An assessment is completed with the veteran using the 2060 form. The information is totaled to arrive at an overall score for the veteran. The Veteran’s Veteran-Directed Budget is:  2060 Score 17-24 Basic $1540  2060 Score 25-39 Intermediate $2345  2060 Score 40-60 Extensive $ 3150 Example of Tier System—see Word Doc—TX example

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/ Budget Methodologies—Individual Calculation Individual Calculation— In this method each Veteran’s assessed baseline need is converted into a budget through a formula-type system. The formula is often based on calculating what level of personal care services is required for the individual from the assessment and converting that into a budget amount. Examples: Presently no AAA/SAA is using the individual calculation example. VT uses this approach in their Medicaid CD program.

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/ Developing the Veteran-Directed Budget—Process Overview Regardless of which budget methodology is used, the Veteran-Directed budget: – The AAA/SAA has responsibility to develop a proposed budget for each Veteran. – The VAMC must approve the Veteran-Directed budget for each Veteran. Authorization of Plan AAA bills 1 time full assessment fee Authorization of Plan AAA bills 1 time full assessment fee 8 Authorization of Budget Amount Develop Veteran Monthly Budget Develop Plan

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/ Person-Centered System The focus of a person-centered system is on the individual, their strengths, and their network of family and community support in developing a flexible and cost effective plan to allow the individual maximum choice and control over the supports they need to live in the community.

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/ Traditional Support PlanningPerson-Centered Planning Decisions are to be made by “consensus” of a planning team that typically consists primarily of staff and professionals and are driven by medical needs. The participant drives decisions and invites people who they feel have important contributions to make, often including family, friends, community members and trusted allies from the service system. Focus of planning is primarily defined by a menu of service options that are offered under the HCBC waiver or other programs. Natural supports are sometimes used to augment programmatic supports. Focus of planning is defined by desired outcomes of the participant. Programmatic supports are used to augment natural supports. Planning occurs periodically during annual meetings or isolated problem solving events. Planning occurs as a process that evolves over time. Attention is focused on problems and “fixing.” Attention is focused on strengths and “building.” Traditional Support Planning vs. Person- Centered Planning

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/ Developing the Veteran-Directed Budget and Spending Plan Process Overview After the Veteran-Directed Budget is developed and Approved. The next step is to develop the Veteran- Directed Spending Plan 16 8 Authorization of Plan AAA bills 1 time full assessment fee Authorization of Plan AAA bills 1 time full assessment fee Authorization of Budget Amount Develop Veteran Monthly Budget Develop Plan

17. 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/ Developing the Veteran’s Spending Plan After the Veteran-Directed Budget is approved by the VAMC, the Veteran develops the monthly spending plan using the Veteran-Directed Budget. The options counselor facilitates the process to develop the spending plan The Veteran has budget authority and employer authority— – he/she can negotiate rates with those he/she wishes to employ; – establish the schedule of his/her employees; – determine the number of hours the employees will work; and/or – choose to save a portion of the monthly amount for a large purchase (Obtain VAMC approval that purchase cannot be made through other VA benefits)

19. 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/ Developing the Veteran’s Spending Plan When developing the spending plan, the Veteran should also develop a back-up plan of what will occur if an employee isn’t able to work as scheduled. After the spending plan is developed the AAA/SAA sends it to the VAMC for review and approval. Upon receipt of approval of the plan, the Options Counselor works with the Veteran and Financial Management Services entity (FMS) to enact the plan The spending plan is kept at the AAA/SAA and the FMS and will serve as the guide for the use of the Veteran’s Veteran- Directed budget. 19

20. 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/ Veteran’s Spending Plan Quality Assurance The Options Counselor should compare the plan to the monthly report the FMS produces that reflects services delivered and paid. This is a quality assurance component that should occur at least quarterly. The Veteran may adjust the spending plan as needed. Any changes to the plan should be shared with the VAMC; the AAA/SAA should obtain the VAMC agreement/approval of the change. After the change is approved, the adjusted spending plan should be shared with the FMS.

21. 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/ Steps and Decision Points Determine if Options Counselors are performing person- centered planning or need training Train staff in the importance of recognizing and understanding that the Veteran has budget and employer authority. Work with the VAMC to determine the budget methodology that will be used to develop the Veteran-Directed budget. Draft Policies and Procedure to reflect the processes that will be used to establish the Veteran-Directed Budget and develop/activate the Spending Plan.

22. 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 and Recommendations Meet early and often with the VAMC partner when developing the program. Important to develop a budget appeal process when designing the program so that the process to resolve appeals is clear to both the AAA/SAA and VAMC Veteran-Directed Program—the veteran has budget authority and employer authority. This is not a program where the veteran uses traditional services. Some veterans are interested in the program but need help in finding workers—solutions include: talking with the VAMC, Worker Registries, Community Colleges

23. 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/ Appendix MN VD-HCBS Case Mix Classification http://www.adrc-tae.org/tiki-download_file.php?fileId=31123 Tarrant County, TX: VD-HCBS Assessment Tools – Instructions for Completing a VD-HCBS Needs Assessment http://www.adrc-tae.org/tiki-download_file.php?fileId=31120 – VD-HCBS Needs Assessment Questionnaire http://www.adrc-tae.org/tiki-download_file.php?fileId=31121 – Tiered Model Example http://www.adrc-tae.org/tiki-download_file.php?fileId=31122