I am the Legal Guardian and Employer of Record (EOR) for my daughter who receives services under the DD waiver and CL waiver. I have several comments and concerns regarding:
Comments Regarding the 56-hour Per Week Soft Cap:
Imposing a limit of 56 hours/per week whether hard or “soft” can lead to extreme hardships for patients/families who legitimately require hours in excess of the 56-hour limit. Establishing the soft limit implies that families will need to fight for additional hours. It make me think that the 56 hours per week limit will be subject to established budgetary limits from the State versus needs of the participants.
Even though the Facilitator “shall” provide additional hours based on three criteria, this is no guarantee that the criteria is applied based on fairness/need or whether the ultimate decision is based on established budgetary restrictions (similar to DD waiver slot limits).
In cases where profound disabilities require additional care, the 56 hours per week limit will tend to push more patient/ families toward institutionalization. The ultimate arbitrator/criterion may become the threat of institutionalization.
I propose the 56-hour exception be revised to read: “The Department shall provide for individual exceptions to this limit using objective criteria based on dependency in activities of daily living, and/or level of care, and/or taking into account the risk of institutionalization if additional hours are not provided.”
The word “objective” should be added to clarify that the criteria are factual evidence that is objective rather than subjective.
As written, the “and” statements could imply that all three criteria must be met. The three criteria should be independently evaluated and applied and separated by the “and/or’ qualifier. In my daughter’s situation, she is 100% incapable of performing any activities of daily living without full assistance and requires 24/7 care, therefore, she should qualify for personal care hours in excess of 56 hours per week under the first two criteria, regardless of her risk of institutionalization.
Finally, for an EOR that works a full time job and manages the care of a profoundly disabled family member, please explain how 56 hours per week is close to enough hours. Family support and their work is not a criterion.
The Virginia Medicaid website for Waivers describes a plan for the transition to Support Brokers from Services Facilitators. The website does not state when the 56 hour per week limit takes effect. One may assume that the 56-hour limit takes effect only after Support Brokers complete the first quarterly visit with each consumer-directed individual and perform assessments to develop the Plan of Care for personal care/assistance, respite, and/or companion. This is not stated or clear.
In a situation where the participant currently receives in excess of 56 hour per week, implementation of the limit prior to the assessment will likely disrupt the ability of the EOR to maintain current staff and consistent care. Any cut to currently approved hours may cause the caregivers to quit or seek alternative employment. In my case, I have worked very hard as EOR to establish a reliable and consistent care team. Any lag/gaps of approved hours will create a hardship.
Comments Regarding the End of Services Facilitation in Favor of Fiscal-Employer Agent (Support Brokers) for the consumer-directed model:
My concerns about transitioning to the Support Broker model center around implementation. The Fiscal-Employer Agent (PPL) will require substantial time to hire and train competent staff to replace the dozens (or hundreds) of Service Facilitators. This process should be well planned with a phased execution, or consequences may lead to chaos, and lack of support to those individuals in need. The four-month role out plan of Support Brokers to as indicated on the VA Medicaid waiver webpage seems too compressed. The plan seems purposefully rushed.
While the Support Broker timeline may be adequate to roll out the on-line/web-based portion of the plan, it seems inadequate for staffing, training, customer/web support, and in-person quarterly assessments. It seems unrealistic to hire similar numbers of Support Broker staff unless the plan is to dramatically reduce the number of Support Brokers versus Service Facilitators.
It appears that an objective of the implementation plan is to rip off the band aid as quickly as possible to get through the pain, to save some money, and get the Service Facilitators off the payroll as soon as possible (also to save money).
As expressed in numerous other comments, I agree the current Service Facilitator model is working fine, it’s not broken, so why fix it? Families like the personalized support of the Support Facilitator model as it helps them to navigate the Medicaid system. Almost certainly, Support Brokers will result in inferior service.
It appears that a primary objective of the move to Support Brokers is saving money even at the expense of those in need of support, who happen to be the most vulnerable people in Virginia.