Subject: Public Comment: Strong Opposition to the Elimination of Service Facilitation in Consumer-Directed Care

To the Virginia Department of Medical Assistance Services,

On behalf of Junction Center for Independent Living, Inc., a Center for Independent Living serving Southwest Virginia, I am writing to express strong opposition to the proposed elimination of Service Facilitation in Consumer-Directed Personal Care Assistance Services (CDPAS). I strongly urge DMAS to halt or substantially reform this proposed structural transition.

Service Facilitators do not merely complete administrative tasks or conduct routine home visits. They act as vital advocates, assist individuals in navigating complex policy changes, ensure essential needs are met, and build lasting, trusted relationships with the consumers they serve. As a Center for Independent Living, our mission centers on advocacy and assisting individuals with disabilities so they can live as independently as possible. This waiver is far more than a mechanism to deliver support for Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs); it is a life-changing framework that grants real freedom and autonomy. Qualities that will be severely compromised under the proposed shift to a centralized Support Broker model.

Key Concerns Regarding the Proposed Model

1. Erosion of Consumer Choice and Autonomy

Removing Service Facilitation directly undermines the principle of self-direction and risks violating the spirit of the Virginians with Disabilities Act. Forcing consumers to transition to a Support Broker model strips away meaningful consumer choice and marginalizes the long-standing philosophy of "Nothing About Me Without Me." Individuals with disabilities deserve to retain the right to direct their own care in partnership with facilitators they know and trust. Those who utilize these services must have a central voice in system design, rather than having major operational changes imposed by administrative mandate.

2. Geographical and Infrastructure Realities in Rural Virginia

A standardized, centralized model fails to account for the geographic realities of rural regions. In our catchment area that is comprised of Lee, Wise, and Scott Counties and the City of Norton, our staff routinely travel up to 90 minutes one way over terrain that frequently requires all-wheel-drive vehicles, particularly during severe winter weather.

Furthermore, approximately 80% of our service area lacks reliable cellular service and high-speed internet access. Expecting out-of-region, contracted Support Brokers to navigate unmapped rural roads, complete real-time electronic documentation without connectivity, and maintain consistent 90-day face-to-face visits is unrealistic. Recent attempts by other state programs to centralize local field operations, such as remote annual housing inspections, have led to missed deadlines, administrative failures, and compromised services for vulnerable residents. Virginia’s regional geography is far too diverse for a one-size-fits-all approach. In the event of a non-compliancy that results in lapse of coverage or any amount of loss in an attendant’s wages, that could mean individuals are not getting fed, bathed, dressed, toileted, and many other Activities of Daily Living provided for them. At present, attendants work extremely hard and receive an arguably small compensation for such. If that compensation is delayed or lost for reasons mentioned above, individuals will lose the ones they rely on.

3. Overburdening Fiscal Agents

Consolidating service facilitation duties, enrollment, and payroll disbursements under Fiscal Agents raises significant operational concerns. Based on years of observing the systemic challenges and delays associated with fiscal intermediary operations, placing sole administrative and operational responsibility on these entities risks widespread payment delays, enrollment bottlenecks, and diminished oversight. Not to mention the sheer amount of control this awards them.

4. Loss of Direct, Realistic Oversight

Service Facilitators observe the daily realities inside the home. This includes complex behavioral supports, elopement prevention, cognitive care, and intensive physical assistance. This hands-on presence ensures that safety, compliance, and quality of care are continuously monitored by professionals who understand the consumer's complete environment and needs. These factors are critical to creating the plan of care for the individual’s services that sets the framework to get their needs met.

Recommendations and Alternatives

Eliminating Service Facilitation jeopardizes the quality of care for over 20,000 Virginians who rely on CDPAS. To prevent severe disruptions in service delivery and protect consumer autonomy, we respectfully submit the following recommendations:

1. Maintain Consumer Choice: Keep Service Facilitation as an available option, allowing waiver recipients to decide whether to retain their traditional Service Facilitator or utilize a Support Broker model. Let the individual advise what is working for them and what is not.
2. Local Agency Contracting: If DMAS proceeds with a Support Broker structure, allow existing local Service Facilitation agencies in good standing the opportunity to contract as Support Brokers to preserve continuity of care and regional expertise. If this proposed change has been created to remove unproductive Service Facilitators, the ones that perform badly should not be afforded the opportunity to participate further. However, it should not be a punishment to all agencies and Service Facilitators.
3. Formal Stakeholder Engagement: Delay implementation until structured public forums are conducted with waiver recipients, family caregivers, and rural service providers to co-design a viable framework.

We welcome the opportunity to discuss these concerns further and work collaboratively toward a solution that preserves service quality and consumer choice.