I am a Registered Nurse with approximately 35 years of nursing experience and the owner of Adult Healthcare Services Appomattox. I have spent approximately 15 years building my business, developing my professional expertise in home- and community-based care, and serving Virginia Medicaid recipients. Adult Healthcare Services Appomattox is a licensed Home Care Organization regulated by the Virginia Department of Health, Office of Licensure and Certification.
I strongly oppose the proposal to eliminate Services Facilitation as a standalone service and replace established Services Facilitators with Support Brokers employed through the Fiscal/Employer Agents.
This proposal is not simply changing an administrative process. For established Services Facilitators, it eliminates a profession and potentially dismantles businesses that providers have spent years building. For consumers, it risks eliminating trusted, individualized relationships with professionals who know their medical conditions, functional limitations, family circumstances, attendants, living environments, and community needs.
My concerns about placing Support Brokerage under PPL and Consumer Direct Care Network are not theoretical. They are based on my direct professional experience working with these entities on behalf of Medicaid consumers.
In my experience, these organizations do not currently provide the level of individualized, personalized assistance that Services Facilitators provide.
Consumers and providers routinely need assistance with enrollment packets, attendant enrollment, payroll, EVV, authorizations, and other administrative issues. I have personally experienced situations in which packets were not processed efficiently, problems took excessive time to resolve, and consumers received different answers depending upon which representative answered the telephone.
This inconsistency leaves vulnerable consumers confused and frequently leaves the Services Facilitator trying to determine what actually needs to be done to resolve the problem.
I have also experienced situations in which responsibility for problems has been shifted to the Services Facilitator even when the underlying problem involved Fiscal/Employer Agent processes.
Before DMAS transfers additional responsibilities to these organizations, including assessment, Plan-of-Care development, quarterly monitoring, consumer education, and ongoing Support Brokerage, DMAS should first demonstrate that the Fiscal/Employer Agents can consistently and accurately perform the responsibilities they already have.
Adding more responsibility to a system that consumers and providers already struggle to navigate does not automatically create efficiency.
Services Facilitation is not simply processing forms.
The people I serve know me. I know them.
As a Registered Nurse, when I enter a consumer's home, I am evaluating much more than whether paperwork has been completed. I understand disease processes, medications, functional limitations, changes in condition, safety risks, caregiver limitations, nutrition, mobility, cognition, and the relationship between a person's medical condition and the assistance that person requires to remain safely in the community.
But my work frequently extends far beyond what Medicaid reimburses.
I help consumers locate food when they do not have enough to eat.
I help them find housing and shelter resources.
I help locate clothing and other basic necessities.
I help them navigate physicians, specialists, hospitals, insurance companies, Medicaid managed-care organizations, pharmacies, community resources, and the larger healthcare system.
I answer health questions within my professional scope and teach consumers and families how to make healthier and safer choices.
I help families understand what questions they need to ask their healthcare providers.
I advocate when someone does not understand the system or does not know where to turn.
Much of this work is never billed to Medicaid. I do it because these are human beings whom I have come to know and because nursing does not stop simply because a reimbursable task has ended.
What happens to that care when the relationship is replaced by a centralized Support Broker responsible for a large caseload?
Who will know that a consumer has no food?
Who will recognize that a person's functional ability has declined?
Who will notice that the home situation has changed?
Who will help the consumer navigate the healthcare system when the problem does not fit neatly into a Fiscal/Employer Agent transaction?
Those questions deserve answers before Virginia dismantles the existing system.
I am particularly concerned that Support Brokers will be responsible for assessments and the development of Plans of Care affecting personal care, respite, and companion services without a clear requirement that these individuals possess healthcare licensure or meaningful clinical education.
A functional limitation is not simply a box on an assessment.
Understanding why an individual cannot safely bathe, transfer, ambulate, prepare food, toilet independently, remember medications, or complete another activity may require understanding neurological disease, cardiopulmonary limitations, pain, weakness, cognitive impairment, fall risk, medication effects, progressive disease, and numerous other clinical factors.
If Virginia believes these assessments are important enough to determine Medicaid-funded care, then the qualifications of the individuals conducting them should reflect the importance of the work.
DMAS should seriously consider requiring Support Brokers who perform functional and health-related assessments to be licensed healthcare professionals, such as Registered Nurses or appropriately qualified Licensed Practical Nurses working within their lawful scope and with appropriate RN oversight.
At a minimum, Virginia should establish a clinically qualified level of Support Brokerage for individuals with significant medical and functional complexity.
The solution should not be to lower professional qualifications simply because a less-qualified workforce may be less expensive.
There is another critical function that should not be overlooked: program integrity.
As a Registered Nurse, I have a professional license and ethical obligations that exist independently of Medicaid reimbursement.
When I identify suspected fraud, inaccurate documentation, inappropriate utilization, exploitation, or other serious concerns, I report them. I will not ignore conduct that could jeopardize a Medicaid recipient, the Medicaid program, or my nursing license.
I have also experienced situations in which I reported concerns through managed-care channels and did not believe the response adequately addressed the seriousness of the issue.
Services Facilitators can provide an independent layer of observation between the consumer, attendant, MCO, and Fiscal/Employer Agent. Eliminating that independent relationship and placing Support Brokerage within the same organizations responsible for fiscal/employer-agent functions raises an important program-integrity question:
What independent safeguard will replace the oversight currently provided by Services Facilitators?
Virginia should be strengthening independent oversight, not eliminating it without demonstrating that an equal or stronger safeguard will replace it.
I have spent approximately 15 years building this business and 35 years building my nursing career.
I complied with Virginia's requirements. I established a licensed healthcare organization. I developed policies and procedures. I built relationships with consumers, families, care coordinators, managed-care organizations, and community resources. I invested financially and professionally in serving Medicaid recipients.
Now the Commonwealth proposes to eliminate the service upon which that portion of my business was built and transfer the work to two large Fiscal/Employer Agents.
What consideration has been given to established Virginia providers whose businesses and livelihoods are being displaced?
Why were experienced Services Facilitators not given a meaningful pathway to continue independently providing this service?
Why are licensed healthcare professionals with decades of experience not being incorporated into a system that increasingly depends upon assessment of medically and functionally complex individuals?
And most importantly, why should consumers lose the right to choose the qualified professional they trust?
Consumer direction should be centered on the consumer.
It should not become a less-personalized system simply because centralization may appear administratively easier or less expensive.
If DMAS believes Services Facilitation needs improvement, then improve Services Facilitation.
Strengthen qualifications.
Require meaningful training.
Establish clinical standards.
Create reasonable caseload limits.
Increase accountability.
Require measurable response times.
Strengthen fraud reporting and investigation.
Recognize advanced qualifications such as RN licensure and extensive LTSS experience.
Require Services Facilitators who perform health-related functional assessments to possess appropriate healthcare education and competency.
But do not eliminate experienced local providers and replace them with a system that may provide less individualized attention to the very people Medicaid waivers are intended to protect.
Before this transition proceeds, I respectfully request that DMAS publicly address:
I support accountability and responsible use of Medicaid funds. I also support improving Virginia's consumer-directed system where improvement is needed.
But improvement should mean better care, better oversight, stronger qualifications, greater accountability, and meaningful consumer choice.
It should not mean eliminating experienced professionals simply because their work can be reassigned to a centralized organization.
For approximately 15 years, I have built a business around serving Virginia Medicaid recipients. For approximately 35 years, I have carried the responsibilities of being a nurse. My nursing license requires me to protect patients, recognize risk, advocate, educate, document accurately, and report concerns rather than look the other way.
Those qualities should be viewed as assets to Virginia's Medicaid program—not as something disposable in the name of restructuring.
I respectfully ask DMAS to reconsider eliminating independent Services Facilitation and instead strengthen the existing program by establishing meaningful professional standards, recognizing licensed healthcare professionals, preserving qualified independent providers, strengthening program-integrity protections, and protecting each consumer's ability to choose the person who helps them navigate consumer-directed care.
Virginia should build upon the professionals who are already doing this work rather than dismantling the relationships, expertise, businesses, and unpaid community support that have taken years to build.
One final question. Will experienced Services Facilitators be offered a meaningful pathway to become Support Brokers, contract with the Fiscal/Employer Agents, retain their existing caseloads, or continue serving members in another professional capacity? If not, what does DMAS expect established providers like me to do when the Commonwealth eliminates the service around which we were encouraged to build compliant businesses?
Dana Gunn, RN
Adult Healthcare Services Appomattox