Brain Injury Program (BIP) HCBS-COI Recommendations

Proposed Changes to BIP Case Management

A person in a wheelchair smiles at the camera. Vermont will pursue statewide competitive contract(s) to deliver case management for participants in BIP, along with the Developmental Services (DS) program.

 Interested case management entities (CMEs) will apply for contracts through a state-run competitive process. The State will ask respondents to show they can meet both the unique requirements for BIP case management and DS case management. Current providers of BIP services will continue to deliver home and community-based services (HCBS) to people with brain injuries, except for service coordination (case management) that will begin to transition to new CMEs in mid-2025. (The State will hold a contest between different agencies to apply. The State will decide which case management agencies will work best for the BIP and DS system. The transition to the new system will start in mid-2025.)  

Expand the “Case Management Functions and Roles for the Brain Injury Program” section below for a plain language table describing the key steps in the Brain Injury Program case management process, and the roles of HCBS team members at each step.

  • This plain language table describes key steps in the Brain Injury Program case management process, and the roles of HCBS team members at each step. The table does not include every detail. This is still a draft. Some parts of the process may change as more decisions are made. You can also download the table as a PDF here.

    Brain Injury Program Acronyms Legend
    BIP: Brain Injury Program
    CME: Case Management Entity
    DS: Developmental Services

    Home and Community-Based Services
    ILA: Independent Living Assessment

    Case Management FunctionsPerson and (as applicable) Family, Guardian and/or Legal RepresentativeState AgencyCase Management Entity (CME)HCBS Providers
    Information and Referral

    Eligibility and Enrollment

    BIP and Medicaid Application

    Choice Counseling to access HCBS case management
    Person/family seeks information and asks questions.

    Person/family gathers records to support eligibility.

    Person/family meets with the State to participate in intake and eligibility process.
    State provides information about programs and services.

    State completes intake and helps persons and families in gathering records.

    State supports persons to complete any needed assessments with qualified providers.

    State informs person/family of case management entity (CME) options.
    CME sends persons and families interested in services to State intake team.

    CME provides list of CME choices to person/family.
    Providers offer basic information about programs and services.

    Providers send interested persons and families to State intake team to learn more and possibly enroll.
    Enrollment with HCBS Case ManagementPerson/family works with State to understand CME options.

    Person/family chooses CME.

    Person/family may request a specific case manager.
    State provides referral information and records to selected CME.CME enrolls person upon referral from the State.

    CME identifies the language the person prefers to speak, how the person wants to communicate, information about the person’s culture, and the role of family members in the person’s life.

    CME completes social history.

    CME gets to know person and their service and support needs.

    CME ensures urgent needs are met. CME identifies which providers can help right away.

    CME helps person/family complete applications for other public benefits as needed.
    Providers make sure each CME understands how quickly the provider could start work with a new client. Providers also share their timelines to start each type of service for new clients.

    As needed, providers establish waitlist procedures.
    Needs Assessment: Independent Living Assessment (ILA)

    Person/family works with the case manager and assessment team to schedule and complete the needs assessment.

    Person participates in the needs assessment.

    Family or others provide information for assessment, as appropriate
    State assigns need level and budget resources available to person.CME helps find a time that works for person/family for required needs assessment.

    CME shares results of assessment with person.

    CME tracks when updated assessment is needed, completes new assessment periodically.
    Provider gives information to CME for assessment.

    Provider keeps CME informed when person’s needs change.

    The Provider participates in the reassessment.

    The Provider completes other service-based assessments as needed.
    Person Centered Plan (Care Planning)

    Authorization Approval

    Revisions or Changes to Care Plan

    Person Centered Plan (Care Planning)

    Authorization Approval

    Revisions or Changes to Care Plan
    Person/family and case manager work together to make agenda for person-centered planning process.

    Person/family and case manager meet to prepare for annual meeting(s), as needed and as desired by person.

    Person chooses who will be part of planning process.

    Person/family communicate where and when they would like the meeting(s) to take place.

    Person shares their goals, preferences and needs with planning team.

    Person leads development of person-centered plan with support from family, case manager and others they have chosen.
    State approves services authorized in person’s plan.

    State approves exceptions to funding limits and crisis placements.

    State tracks and makes sure annual needs assessments are happening on time.
    CME works with person to develop agenda and schedule meetings.

    CME supports person in leading meeting and process as much as possible.

    CME collaborates with people chosen by Person.

    CME documents the goals, outcomes, services and supports decided in the meeting into the plan.

    CME helps find service providers, other programs, supports and resources that can meet Person’s goals and needs.

    CME gets final approval of plan from person.

    CME seeks approval of plan and service authorizations from State.

    CME helps person enroll with providers and develop service agreements as needed.

    CME schedules and facilitates team meetings for any changes or updates to plan.

    CME takes notes of all discussions and decisions made at team meetings.

    CME updates plan based on revisions agreed to by person and team.

    CME shares team meeting minutes with those attending.

    CME provides ongoing options counseling and information and referral support.
    Provider reviews application for services from CME, communicates whether they can initiate requested services timely.

    If Provider cannot provide services, the provider will decline the referral or place Person on a waiting list. provider will tell the CME.

    Provider participates in Person-centered plan meeting if requested by person.

    Provider contacts CME if there are needed changes or updates to the service plan.

    Provider gives recommendations for revisions to plan to CME.

    Provider may request CME set up team meetings as needed.

    The Provider recruits and trains direct care staff/home providers.

    Provider completes other service-related assessments as decided by the team.

    Provider distributes plan to provider staff, as needed.

    Provider provides services described in plan and documents the services provided.

    Provider develops specific strategies to implement services and support when requested in the plan.
    Monitoring and Follow UpPerson/family tells CME and Providers about their experiences, how services and supports are working.

    Person/family asks CME for help as needed, including any problem-solving related to services and supports.

    Person/family tells CME and Providers about any life changes.
    State sets and oversees quality requirements for CMEs and Providers.CME completes monitoring of services with input from person, family and Provider as needed.

    CME schedules ongoing progress meetings with person/family.

    CME makes sure plan is implemented as team has agreed.

    CME tracks and documents person’s health and wellbeing, needs, service goals and outcomes. CME makes sure Person-centered plan is completed on time.

    CME completes regular plan reviews with person/family and gets feedback.

    CME gets sign off from person/family and others on plan review when needed.
    Provider tracks progress on goals, outcomes, services and supports and gives CME regular updates.

    Provider reviews plan reviews and implements recommendations.
      • Meets federal requirements and creates clear boundaries to eliminate conflict of interest.
      • Aligns with the goals and principles for Vermont’s HCBS-COI effort.
      • Easy solution for individuals and families to understand and navigate.
      • Statewide contracts offer more consistency and equity across different parts of the State.
      • Supports current BIP providers to continue to deliver direct services.
      • Allows the state to oversee quality and performance.
      • In the redesigned system, DAIL Adult Services Division (ASD) staff will continue to take care of eligibility, intake, and enrollment. They will help individuals enroll with their case management organization. 
      • The role of the case manager will be clearly defined. Case managers will serve as the agent working on behalf of the individual. Case managers will be responsible for coordinating and overseeing the assessment process, developing person-centered plans, seeking approval of plans from the State, monitoring ongoing services, and supporting redetermination. Their job is to make sure each person’s preferences are honored, their needs are met, and their quality of life is supported. 
      • CMEs applying for contracts will need to show they meet state requirements to deliver quality BIP case management. They will be expected to have local staff living across the state. The state will set standards for caseloads and qualifications of case management staff. 
      • In the redesigned system, CMEs may not have any interest, financial or otherwise, in any Vermont home and community-based service provider, and vice versa. Members of governance boards and agency employees may not serve in both types of agencies (direct HCBS providers and HCBS case management.) 
      • Quality and performance expectations for the CMEs will be reflected in the case management contracts.
  • Each team member has an important role for each step of the process. Case Management Entities will take the lead in helping eligible people through many key activities, while HCBS Providers will continue to deliver services to people on a day-to-day basis.

    BIP Proposed CM Functions Roles Flow Graphic
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