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Virginia Regulatory Town Hall
Department of Behavioral Health and Developmental Services
State Board of Behavioral Health and Developmental Services
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1/17/19  9:22 am
Commenter: La Voyce Reid on behalf of the Arlington CSB and DD services

SC Manual Comments

Thank you for the opportunity to submit comments for this document (ADDITIONAL COMMENTS TO ENTERED UNDER A SECOND ENTRY)

Page 12: Recommend starting the Introduction with "Use of the Manual" (which is currently on page 14)

Multiple Pages: If org. charts and specific contact information is included in the manual, DBHDS will have to commit to keeping this information current.   If this assurance is not made, suggest not listing individuals but rather titles and roles and refer users to the DBHDS website for current information.   (This assumes that the website will be current.)

Page 26: This is the only real reference to REACH services.  Recommend that this be linked from page 73 also.

Page 43: Are SCs supposed to know what LifeCourse is? Perhaps a better subject heading would just be "LifeCourse" (vs LifeCourse Beliefs and Tools) and then go into what it is, the beliefs and tools. Additionally, it just doesn't flow well where it is placed; consider putting the Community section first and then introducing LifeCourse, since some of what LifeCourse is about is the planning calendar and incorporating natural supports.

Page 53:References ECM applying to individuals on the DD Waiver Waitlist that have the CCC+ Waiver, as well as people on the DD Waiver Waitlist who are eligible for Medicaid.   This requirement may be burdensome for SCs with large caseloads of children. 

Page 62 (Apeals RIghts): States: "An SC may need to assist a person to request an eligibility appeal..." Is this the SC's job? Might this present as a conflict of interest for the CSB?

Page 78: If onine viewing only this is probably fine.  Otherwise, ECM flowchart does not print correctly.

Pages 229-301: Including this PowerPoint presentation without the talking points might not be as helpful as intended and thus information could be easily misconstrued.

Pages 315 - 319: This chapter is largely about soft skills needed to be a good SC.  While probably the most relevant to SCs, it seems random following all of the regulatory language and documents included before it.  In addition, it seems to end abruptly.

Page 322 (under Eligibility for Support Coordination): Does or should this section differentiate between ID Support Coordination and Developmental Disability "Coordination"?  While the criteria is different for ID vs other DD diagnoses, the eligibility for Support Coordination is the same independent of the diagnosis.

Page 322 (under the heading "Diagnostic Eligibility" and the first sentence): suggest adding the word "developmental" ahead of disability.  It is not "any" disability that limits a person's ability to live and work independent that makes him or her eligible for Support Coordination.  It is specifically a DD and thus this should be clarified in the first sentence of this section.

Page 322 (under the heading "Diagnostic Eligibility"):  This section is silent on adaptive functioning as it pertains to diagnostic eligibility.

Page 324 (under Risk Assessment): In the middle of the paragraph the term "Annual Risk Assessment and Fall Risk Assessment" is used.  Recommend this term be changed to Annual Risk Assessment to match the rest of the section.

Page 325 (under the section entitled, "Priority Needs Checklist," first paragraph and last sentence): "Priority status is based on how much and how quickly someone is in need of help."  This seems a broad and rather subjective statement and can be easily interpreted by any number of SCs to mean something different.  Specifically, "how much" of WHAT? "how quickly someone is in need of help"?  Should this be "how quickly the individual is in need of DD Waiver services?  To ensure that people are appropriately placed in the Priority 1 assignment  based "primarily" on objective criteria this sentence should be clarified and written in a manner that gives more concise instruction. 

Pages 325-326 (and wherever else referenced in the manual): Recommend consist use of terms when referring to "wait list" -- there are at least four different references used in one section (Chapter 5) for this topic.  They include: "Wait List," "wait list," "waitlist," and "waiting list."

Pages 325-326: included in the "Key Points to Remember" at the top of page 326, and with the "point" that begins, "Those assigned with a Priority two. . ." the abbreviation for the Family and Individual Supports Waiver should be identified as "FIS" and not "IS."

Page 332: Recommend that the third box be a VIDES box since this is the decision point between the two processes.  Recommend moving the current third box "Documentation of Choice between Inst...."  under the "Meets VIDES criteria..." box.  Recommend that in the "Meets VIDES criteria..." box  stating that this information should be entered into WaMS.

Page 337: Change first sentence from "ID Waiver services" to "DD Waivers."

Page 338: This overview seems pertinent to individuals with DD as well as ID.  Recommend changing it to include all.

Pages 339-341: Recommend completing an indication for each drug.

Page 347: This sample letter is old; it references Level of Functioning and MR/ID.  Replace with a current letter.

Pages 351, 355, and 361: Delete "Anticipated start date after 7/1/2018."

Pages 352 and 353: There is a reference to "See pg.  43." This is not page 43 of the SC Manual so it is confusing.  Recommend deleting these page number references or otherwise providing clarification for the user.

Page 360 (under In-Home Support Services): Recommend re-phrasing the limitation to clearly indicate what  "Support to no more than three individuals" means.

Page 369: Recommend moving "Needed Services"  document after the DBHDS letters that are mailed to individuals on the waiver waitlist ( currently pages 372 - 375) since the letters reference this document.

Pages 370-371:These forms are the same forms found on pages 343 and 344.  Recommend removing the forms on pages 370 and 371.

Page 380 (bottom of page under the "Waiver Slot Assignment Committee Procedures"  section): it reads, "CSBs are encouraged to make use of available technology such as secure video conferencing and conference calling to minimize the need for WSAC members to travel, . . ."  Since the CSB staff are not participating in the WSAC meetings, we would not have a need to "make use of" such recommended technology.  Is the intent here that CSBs should make such technology "available to the WSAC"?

Page 459 (under description for "In-Home Support Services"): It is worded that this service "typically" supplement(s) the primary care provided by the individual, family, or other unpaid caregiver.  Suggest removing "typically" from this description as it suggests that this service could feasibly be delivered outside the context of supplementing a primary unpaid caregiver.  In reality, this service can be extremely difficult to deliver without a readily available and "primary" unpaid caregiver.  Furthermore, the requirement that there be a "back-up" plan "for times when In-Home Supports cannot be provided as regularly scheduled" seems to imply that the In-Home Supports are primary and that the unpaid caregiver is secondary.  This seems to create a conflict within the same description for this service. 

Page 460 (under "Personal Assistance): there is no mention that children/youth up until the date of the 21st birthday are not eligible for this service under the DD Medicaid Waiver, but rather via EPSDT.  Furthermore, since the manual is intended to be a guide for SCs and other CSB staff, it is recommend that there be some guidance in this section for how to use and refer someone to EPSDT, as well as what forms may be required.  This comment is applicable to Private Duty Nursing and Assistive Technology.

Page 462 (under Shared Living): For purposes of the SC Manual, it would be helpful if the role of the SC and other CSB staff, with respect to this service, could be discussed vs. the roles of the facilitator, the individual, and guardian, if applicable.  Furthermore, there is no mention that this service requires a facilitator.  Explanation of this and the role of the facilitator would be helpful for purposes of the manual.

Page 468 (under "Addiction and Recovery Treatment Services"): Recommend a similar section for addressing mental heath/Serious Mental Illness (SMI) and related referrals.  This is especially important (if not more important) since individuals with DD are equally at risks or may present with the same mental health (DSM) symptoms as their non-disabled peers.  For people with DD, mental illness is too often mistaken for symptoms or patterns of behavior related to the DD diagnosis and thus mental illnesses are often left undiagnosed and untreated for this population.  While most SCs are not mental health professionals, they should be expected to use available resources for making referrals for mental health, when indicated. The manual should not be silent on this topic (and the importance of assessing and making referrals) given the prevalence of mental illness for people with DD diagnoses (while at the same time mentioning the importance of making referrals for substance abuse (also important).

Pages 482-484: This section lays out how to pre-plan and conduct a perfectly inclusive PCP meeting with the quintessential individual who is willing and able to drive and participate in their planning process. The statement, "to which they are able to participate" (pg.482) does quite captures how an SC would go about planning and conducting an inclusive PCP meeting with someone who is does not communicate using words and is unable to choose attendees, uninterested in participating, unable to "drive" the planning process, etc. More guidance about what this could/should look like would be helpful.

Pages 490-562: Duplicative PowerPoint from chapter 3

Pages 563-572: Duplicative study from chapter 3

Pages 657-783: Duplicative WaMS User Guide from chapter 2

Pages 885-888: The list of community resources appears to be helpful; however, it will require regular updates and reviews to ensure the links are still active  

Pages 885-889: Recommend adding a short narrative to each link so SCs understand when they may need to use a resource.  For example- briefly explain when it would be appropriate for an SC to seek out resources with the National Gateway to Self Determination.  Alternatively,  recommend listing the resources under certain categories.  For example: The Arc of Virginia, National Gateway of Self Determination, and the Parent Educational Advocacy Training Center would be grouped together.  If the resources are grouped together than a  short narrative for each link wouldn't be necessary.  Instead, the narrative would be placed with each category or group.

Page 891: Recommend combining "Why Work?" and "Impacts of Employment".  The impacts of employment are why someone would choose to work and the benefits of working/earning income.

Page 892: "Definition of Employment" heading should be moved to the beginning of the section so the reader has a clear understanding of Employment and how it is defined by DBHDS.  For example,  the DBHDS definition of employment is not necessarily the same as how others would interpret "employment."  For example, a SC may support an individual and family who identify a GSE enclave position as "employment" even though the person is earning sub minimum wage.   It is important to first and foremost establish DBHDS' definition of employment.

Page 892: Recommend offering a short description for the "Association of People Supporting Employment First"

Pages 895-896: The barriers that are listed under the "Assist" heading are prevalent in the disability population; however, the possible ways to address the barriers are not very realistic, especially in rural areas of the state.  For example: local funding is not an option in most areas of the state and self pay is unrealistic for many families and individuals.  If the state is going to require SCs to have meaningful employment conversations and expects more people with disabilities to become employed, it would be helpful if DBHDS could provide SCs with more realistic ways to address the common barriers. 

Page 896: "Lack of transportation" under the common barriers offers no suggestions or explanations. Recommend saying something along the lines of "absent of waiver funding, transportation services....."

Page 896: "Building a Resume" is under the "Assist" heading.  Is DBHDS suggesting that the SC should be assisting the individual with resume development?  Is this only absent of DARS support (i.e. DARS is on order of selection) and waiver funding?  If SCs are assisting with resume development then should they also be assisting with other aspects of job development?  This seems to blur the line between employment support through DARS or another ESO and the role of the SC.  Recommend elaborating more on this topic.