Developmental Services (DS) HCBS-COI Recommendations

Proposed Changes to DS Case Management

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Vermont will pursue statewide competitive contract(s) with one or more organizations to deliver case management for the DS system.

Interested case management entities (CMEs) will apply through a state-run competitive process. The State hopes to award multiple statewide contracts depending upon the number of qualified respondents. (The State will hold a contest between different agencies to apply. The State will decide which case management agencies will work best for the DS system. Depending on who applies, there could be more than one agency for people to choose from.)  

Starting in mid-2025, the chosen CME(s) will begin the transition to delivering case management for participants in the DS system.

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

  • This plain language table describes key steps in the Developmental Services 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.

    Developmental Services Acronyms Legend
    CME: Case Management Entity
    DA: Designated Agency
    DS: Developmental Services
    HCBS: Home and Community-Based Services


    ISA:
    Individual Support Agreement
    SIS-A: Supports Intensity Scale-Adult
    SSA: Specialized Services Agency

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

    Eligibility and Enrollment

    DDSD and Medicaid Applications

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

    Person/family gathers records and information to support eligibility.

    Person/family meets with the State to participate in intake and eligibility process.

    Once eligible, person/family makes choice of case management entity (CME).
    State provides information about programs and services.

    State completes intake (DDSD and Medicaid application) and helps persons and families in gathering records.

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

    State determines eligibility.

    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 Comprehensive Person’s Story.

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

    CME ensures urgent needs are met. (This may include a short-term plan for services before SIS-A and ISA are complete.)

    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 timeline to start each type of service for new clients.
    Needs Assessment

    Reassessment
    Person/family work with case manager and assessment team to schedule 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 and schedules when updated assessment is needed.
    Provider gives information to CME for assessment.

    Provider keeps CME informed when person’s needs change.
    Person Centered Planning

    Individual Support Agreement (ISA) Development

    Service Authorization Approval

    ISA Revisions/Changes
    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 ISAs 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 works with ISA team to review requested rights restrictions, determine whether they are needed. As appropriate, CME documents the restrictions in the plan, including how rights will be restored.

    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.

    If more funding is needed, CME decides if updated assessment is necessary and seeks State approval as appropriate.

    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.
    Provider reviews application for services from CME, communicates whether they can initiate requested services timely.

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

    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.

    Provider distributes plan to provider staff, as needed.

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

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

    Provider gives recommendations for revisions to plan to CME. Provider may request CME set up team meetings as needed.
    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 person, family and Provider 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 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. 
      • If more than one contract is awarded, offers individuals choice of case management entities. 
      • Allows the state to oversee quality and performance. 
      • In the redesigned system, DAIL Developmental Disabilities Service Division (DDSD) staff will take care of eligibility, intake, and enrollment. They will help individuals choose 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. 
      • There will likely be different levels of case management for individuals, depending on needs and preferences. All individuals receiving Medicaid-funded DS HCBS will receive case management services, including people who are self-managing or family-managing their services. Participants in the Bridge program will also receive case management services from a new case management entity.
      • CMEs applying for contracts will need to show they meet state requirements to deliver quality DS 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 developed through the DDSD Quality Plan and 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.

    DS Proposed CM Functions Roles Flow Graphic
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