1. Veteran-Directed Home and Community-Based Services in Oregon Getting Started

2. Welcome and Introductions Nakeshia Knight-Coyle ADRC Project Manager Oregon DHS, Aging and People with Disabilities, State Unit on Aging Lee Girard Community Services Manager Multnomah County Aging & Disability Services Division Jeanie Butler Senior Program Coordinator Washington County Disability, Aging & Veteran Services Lynn Schemmer-Valleau Community Services Program Supervisor Multnomah County Aging & Disability Services Division Jennifer McKenzie Home & Community Based Services Director Portland VA Medical Center

3. Topics Covered in Today’s Webinar Why are we here Getting started Day-to-day-operations Lessons learned and sustainability Next steps Q & A

4. Why are we here?

5. Learning Objectives Augment participant knowledge about Veteran- Directed Home and Community-based program (VD-HCBS) Identify the steps to developing VD-HCBS from the perspective of two existing sites in Oregon

6. Getting Started

7. What is VD-HCBS? The VD-HCBS program serves Veterans of any age who are determined by the Veterans Administration to be at risk of institutional placement. Veterans manage their own flexible spending budgets for their personal care services – deciding for themselves what mix of goods and services will best meet their needs, hiring and supervising their own workers, including family and friends, and purchasing items or services that will help them live more independently. VA Medical Centers (VAMCs) purchase these services on behalf of Veterans from State Units on Aging (SUA), Area Agencies on Aging (AAA), and Aging and Disability Resource Centers (ADRC), known collectively as Aging Network Agencies.

8. 1. Find the right people The Veteran-Directed Home and Community–Based Services (VD-HCBS) program requires partnership between your local VA Medical Center (VAMC) and the Aging Network. Contact the Administration for Community Living (ACL), your State Unit on Aging (SUA), and other Area Agencies on Aging (AAA’s) that may be involved in moving forward. ACL can work with Dan Schoeps at VA Central Office to identify the right contacts at your local VAMC, if needed. Contact information can be accessed through the VD- HCBS homepage on the TAE website.

9. 2. Do your homework There is a wealth of resources for VD-HCBS and consumer direction at www.adrc-tae.org and at www.participantdirection.org. Talk with other states about their experiences with VD-HCBS. Contact your Technical Assistance lead with questions or for help connecting with your peers. The Readiness Review can also be used as a planning tool.

10. 3. Establish mutual buy-in for VD-HCBS Discuss the project with your partners at the VAMC and establish a shared understanding of the program before moving forward. Your VAMC partners may already be excited to start a new program, but they may also want to check with their contacts at other medical centers or at VA Central Office.

11. 4. Work with Federal partners Your federal partners are available to assist you and the VAMC as you plan for implementation. The VAMC will need to be in contact with Dan Schoeps at VA Central Office regarding funding. Kevin Foley is the lead contact at ACL.

12. 5. Determine reimbursement rates Generally, VA Central Office gives the local VAMC a range to fall within, but there is a lot of local flexibility. Sufficient, sustainable payment rates from the VAMC will be essential to supporting the program. New rate structure models are being implemented in 2014.

13. 6. Pass a Readiness Review The Readiness Review is a great opportunity for self-assessment for AAA/ADRCs early in the development process. ▫The Readiness Review document is completed by the AAA/ADRC ▫Verification of readiness is made by the National Resource Center for Participant-Directed Services (NRCPDS), Dianne Kayala dianne.kayala@bc.edu.

14. The Readiness Review: A.Functional Assessment B.Spending/Service Plan Template C.Program Policy Manual D.Program Manual for Veterans

15. Example of the VD-HCBS Readiness Review tool

16. 7. Negotiate a Provider Agreement The VA Medical Center (VAMC) will negotiate a Provider Agreement with the Aging Network Agency. ▫ The Provider Agreement will outline the policies and procedures between the VAMC and Aging Network Agency; including rates for the VD-HCBS Program.

17. Example of a Program Provider Agreement

18. 8. Determine a Financial Management Service Model The Financial Management Service (FMS) model you choose will impact who manages the veterans service budget. ▫The Aging Network Agency may opt to self provide FMS services or contract with an FMS agency who will manage all aspects of the VDHCBS service budget.

19. Day to Day Operations

20. Day to day operations Assessments Case Management Approving monthly spending plans Invoicing Supporting veterans in the program Communicate with VA Home and Community Based Service Director

21. How Veteran-Direction Works Veteran-direction has two basic features: “employer authority”—enables individuals to hire, dismiss, and supervise individual workers (e.g., personal care attendants and homemakers). The comprehensive model—which CMS refers to as “budget authority”—provides Veterans with a flexible budget to purchase a range of goods and services to meet their needs. In actual practice, the term “budget authority” generally refers to both hiring workers (employer authority) and making purchases through an individual budget (budget authority).

22. Choice is the hallmark of self-direction The core feature of Veteran-direction is the choice and control that Veterans have in regard to the paid personnel who provide personal assistance services.

23. Orientation to Veteran-Direction & Enrollment The Veterans Services Coordinator (VSC) will meet with the Veteran/ Representative (and others whom the Veteran may wish to be present) to explain what Veteran-direction involves  It is important that the Veteran/representative understand the responsibilities involved in self- directing services

24. VD-HCBS Program Service Principles Respect, dignity, and a sense of well-being for the Veteran. Respect a Veteran’s rights, strengths, values, privacy, and preferences, encouraging them to direct his or her own plan of care and services to the fullest extent possible. Respect individual self-determination, including the opportunity for the Veteran to decide whether to participate in a program or activity. Services are provided as part of a comprehensive and individualized plan that is developed in collaboration with the Veteran Services are provided in an efficient manner, preventing duplication of services. VDHCBS attempts to maximize the benefits and services available to all Veterans. Services will not be used to secure improper or inappropriate gain for the provider, provider staff, family members, or any other person involved in the Veteran’s care.

25. Assessment in VD-HCBS The VSC will interview the Veteran/ representative and complete a personal care needs assessment using the CAPS Assessment tool  The goal of the assessment process is to identify and document the Veteran’s needs, goals and preferences  The information gathered in the assessment provides the foundation for the Veteran’s spending plan

26. Creating the Veteran Spending Plan (VSP) The VSP documents how the Veteran will spend his/her VD-HCBS budget  VSP developed with VSC and Veteran, (and support person)  Amount is based upon the monthly rate determined by VA HCBS  The VSC will discuss the VSP with the Veteran  Veteran will receive a signed copy  The VSC will be responsible to coordinate to ensure for cost efficiency  Check with the Portland VA Medical Center Home and Community-Based Services (HCBS) Liaison to ensure that any and all benefits available through the VA HCBS are used prior to spending the Veteran’s VDHCBS budget  Check with the aging network or community resources available at little or no cost to the Veteran prior to spending the VDHCBS budget (e.g. home delivered meals)

27. Forwarding the VSP to the Financial Management Service (FMS) The Veterans Services Coordinator (VSC) will enter the Veterans Spending Plan into the web base data system of the FMS (currently Public Partnership, LLC). VA HCBS approves the VSP and the VSC updates it on the PDM. The VSC will be available to consult around any issues or concerns related to serving the VDHCBS Veteran throughout the service year. Veterans may request updates to the VSP. In that case, the update follows the same procedure outlined above, including the Participants reviewing and approving the updated VSP.

28. Ongoing Coaching & Support for the Veteran Veterans in VDHCBS may have little or no experience in assuming responsibility for their own service plan and budget.  The Veterans Services Coordinator (VSC) might need to spend considerable time helping a Veteran understand and embrace his/her role in determining what services will best meet their individual care need in addition to hiring and supervising an employee.

29. Other components of day-to-day operations of VD-HCBS Satisfaction surveys Dis-enrollment Re assessments Support finding respite care as needed Helping when there is a worker’s comp claim Helping when veteran is using funds to make purchase or do home modification

30. Sustainability and Lessons Learned

31. Sustainability Operating reserves to manage VA payment time frames Build in adequate administrative processing and oversight Use flexible staffing model for Service Coordination

32. Lessons Learned Take time to understand the VA systems Vendor vs grant or cost-based reimbursement Understand Participant-directed services model and Fiscal Management Services Build a realistic cost model

33. Next Steps

34. Complete VD-HCBS proposal Continue monthly meetings of VD-HCBS Planning Advisory Group Continue to meet and work with Federal partners Plan local and regional discussions

35. Questions?