Choices for Care (CFC) HCBS-COI Recommendations

Proposed Changes to CFC Case Management

An older woman sits on a bench, wearing headphones and using an MP3 player. Starting in mid-2025, the five current Area Agencies on Aging (AAAs) will provide home and community-based services (HCBS) case management for all CFC participants. More information about Vermont AAAs is available here

Home Health Agencies (HHAs) can continue to deliver direct services. Additionally, CFC participants who live in Adult Family Care (AFC) homes will receive case management from the AAAs. Participants in Flexible Choices will also receive case management services (outside of their self-direction budget). State staff will continue to manage intake, eligibility, and choice counseling for HCBS or other settings (such as Enhanced Residential Care.)

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

  • This plain language table describes key steps in the Choices for Care 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.

    Choices for Care Acronyms Legend
    AFC: Adult Family Care
    ERC: Enhanced Residential Care
    H/H: High/Highest Needs Group
    MNG:Moderate Needs Group

    Case Management Entity
    HCBS: Homes 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


    Initial Assessment

    Choice Counseling
    Person/family seeks information and asks questions.

    Person/family gathers records and information to support eligibility.

    The person participates in the eligibility and intake process.
    State provides information about programs and services.

    State completes intake (clinical assessment and eligibility determination) for Choices for Care (CFC) High/Highest (H/H).

    State completes choice counseling for HCBS case management or other CFC services.

    State makes referrals to nursing homes, Enhanced Residential Care (ERC), or HCBS CME.
    CME completes the eligibility assessment and application package for persons applying to CFC Moderate Needs Group (MNG).

    CME provides options counseling, information and referral at the time of application.
    Providers send interested persons and families to State intake team to learn more and possibly enroll.
    Enrollment with Case Management Entity Person participates with the CME in the enrollment process.State provides referral information and records to regional CMECME enrolls the 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 gets to know the person and their service and support needs.

    CME provides options counseling about available HCBS.

    CME finds out 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.
    Needs Assessment

    The 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 reviews the assessment and care plan proposal annually for approval.CME helps find a time that works for the person/family for the required needs assessment.

    CME reviews the person’s situation, including social, medical, functional, financial, and environmental needs.

    CME completes the Adult Family Care (AFC) Tier worksheet for persons who choose AFC.

    CME completes a reassessment every year.
    Provider gives information to CME for assessment.

    Provider keeps CME informed when person’s needs change.
    Person Centered Plan (Care Planning)

    Authorization Approval
    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, as much as possible.
    State staff review and approve the assessment and care plan proposal every year. CME works with person to develop agenda and schedule meetings.

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

    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 the person’s goals and needs.

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

    CME collaborates with people chosen by the person.

    CME gets final approval of plan from person.

    CME reviews the person centered plan every year and when there is a big change.

    CME seeks approval of plan and service authorizations from State.

    When there are changes, CME updates the needs assessment and care plan and resubmits to State for approval.

    CME makes sure the person-centered plan is completed on time.

    CME provides ongoing options counseling and information and referral.

    If the CME makes a referral to a nursing home or ERC, the nursing home or ERC takes over as CME.
    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 the person on a waiting list. Provider will tell the CME.

    Provider participates in the person-centered planning process if requested by the person.

    Provider contacts CME if there are changes or updates to the service plan are needed. Provider gives recommendations for revisions to plan to CME.

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

    Provider makes sure person-centered care plan is available to home provider and/or direct care workers.

    Provider recruits and trains direct care staff/home providers.
    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 schedules ongoing progress meetings with person/family. CME completes monitoring of services with input from provider and family as needed.

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

    CME updates the person, provider, and outside team members when asked.

    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. 
      • Builds upon existing conflict-free AAA case management, expanding current capacity
        rather than creating a new system or structure. 
      • Allows the state to oversee quality and performance. 
      • About 160 individuals in Flexible Choices will receive case management (outside of self-direction budgets) 
      • About 250 individuals in Adult Family Care will enroll with their local AAA for case management 
      • About 1260 individuals will transition from HHA case management to AAA case management 
      • About 1360 individuals currently receiving AAA case management will experience no changes 
      • In the redesigned system, the current regional AAAs will deliver all HCBS case management. Each AAA will be responsible for the functional assessment process, developing person-centered plans, seeking approval of plans from the State, monitoring ongoing services, and supporting redetermination. 
      • There will continue to be different levels of case management available, depending on needs and preferences. All individuals receiving CFC HCBS will receive case management services, including people who are using Flexible Choices and people living in AFC homes. 
      • In the redesigned system, case management organizations 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 and HCBS case management.) 
      • Quality and performance standards for AAA CFC case management will be updated to ensure continuous quality improvement and positive participant experience. 
  • Each team member has an important role for each step of the process. Regional Area Agencies on Aging (AAA) 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.

    CFC Proposed CM Functions Roles Flow Graphic
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