**Attachment B**

Administration for Community Living

Veteran Directed Care Tool 
**According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number.  Public reporting burden for this collection of information is estimated to average 2,400 hours per response, including time for gathering and maintaining the data needed and completing and reviewing the collection of information.  The obligation to respond to this collection is required to retain the****statutory authority for the****Aging and Disability Resource Center/No Wrong Door System (ADRC/NWD) in Title IV of the Older Americans Act (OAA) (42U.S.C. 3032), as amended by the Older Americans Act Amendments of 2006, P.L. 109-365. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Administration for Community Living, U.S. Department of Health and Human Services, 330 C Street, SW, Washington, DC 20201-0008, Attention Ami Patel, or email ami.patel@acl.hhs.gov.**

Table of ContentsInstructions	3Registration/Contact Information	3Veteran Directed Care (VDC) Program	5VDC Provider Information	5Hub and Sole Proprietor Questions	6

# Instructions

The Veteran Directed Care (VDC) Tool is designed to provide the Administration for Community Living (ACL), the Veterans Health Administration (VHA), and its partners with qualitative and quantitate data elements necessary to evaluate the impact of the VDC program. The VDC tool will track key performance measures and identify best practices and technical assistance needs. 

VDC program providers designated as *Hubs* or *Sole Proprietors* shall complete this tool on a monthly basis. Text in red indicates notations for skip logic or other functionality that will be in place once the VDC tool is loaded onto a web-based platform. In addition, answers to questions will be pre-populated from the previous month’s submission. Additional information about the VDC program can be found at https://nwd.acl.gov/. Questions or comments regarding this tool can be sent to veterandirected@acl.hhs.gov. 

# Registration/Contact Information

1. Organization's Name: 

2. Organization's Physical Address

Street Address:  

City:   

State:        

Zip Code:   

3. Organization’s Service Area and Type Skip logic applied – only visible to non-state entities

Organization Type (i.e. Area Agency on Aging, Center for Independent Living, Aging and Disability Resource Center, etc.):

County (or counties) Served: 

4. Organization’s Contact Name 

First Name:   

Last Name:   

5. Contact Email:

6. Contact Phone Number (Ex: 555-555-5555):

7. VDC program provider representative, validation, and date

First Name:   

Last Name:   

As a VDC program provider representative, I certify that the information submitted is accurate as of the date of submission. ☐ *(Check box to validate.)*

Date: 

# 

# Veteran Directed Care (VDC) Program 

## VDC Provider Information

1. Organization's Name: 

2. Organization's Physical Address

Street Address:  

City:   

State:        

Zip Code:   

3. Service Area and Type 

Provider Type: 

☐Area Agency on Aging

☐Center for Independent Living

☐Aging and Disability Resource Center

☐State Unit on Aging

County (or counties) Served by Veteran Directed Care (VDC) Program (If you are a Hub, include the counties served by the Spokes): 

4. VDC Provider Role: 

☐Hub

· Name of Hubs your agency partners with: *Skip logic applied, only visible if “Hub” is selected*

· Name of Spokes your agency partners with: Skip logic applied, only visible if “Hub” is selected

· Type of organization the Spokes are designated as: Skip logic applied, only visible if “Hub” is selected

☐Area Agency on Aging (AAAs)

☐Center for Independent Living (CILs)

☐Aging and Disability Resource Center (ADRCs)

☐ University Centers of Excellence in Developmental Disabilities Education, Research and Services (UCEDDs) 

☐Other (please explain):

☐Sole Proprietor

## Hub and Sole Proprietor Questions

*Unless otherwise indicated, answer the following questions based on the last 30 days.*

1. Select the Person Centered Counseling (PCC) training program that is used to train VDC options counselors/person centered counselors: *Select all the apply.*

☐ ACL person centered counseling Training Program

☐ LifeCourse Framework

☐ Graphic Approaches (PATH, MAPS)

☐ Other equivalent program (please explain)

2. As a Sole Proprietor, what is your current ratio of PCC to Veterans?

As a Hub organization, what is the current ratio of PCC to Veterans by organization?

3. Do you submit UB-04 forms electronically? 

4. Are you invoicing on actual spending?

5. What is the average number of business days between the end of the month and the date invoices are submitted to the VA Medical Center (VAMC)?

6. What is the average number of business days between submitting an invoice and receipt of payment?

7. How many invoices were rejected in the last month?

8. Do you have unpaid invoices that are more than 60 days old?

a. How many unpaid invoices are 60-90 days old? *Skip logic applied – only visible if question above is yes*

i. Of these unpaid invoices, what is the total amount owed to your organization? 

b. How many unpaid invoices are 90 or more days old?*Skip logic applied – only visible if question above is yes*

i. Of these unpaid invoices, what is the total amount owed to your organization? 

9. What issues are you encountering related to these unpaid invoices?

10. Name of Financial Management Services (FMS) Provider:

For **each** VAMC your organization partners with for the VDC program, complete the following six questions: 

VAMC #1:

1. Name of VAMC:

2. Number of Veterans currently enrolled in the VDC program:

3. What was your total Veteran enrollment in your VDC program on the first day of the previous month?

4. How many new referrals for VDC were received in the month you are reporting on?

a. Of those referrals, how many are enrolled:

5. How many Veterans dis-enrolled in VDC within the last month?

6. How many Veterans receiving VDC in the last month served in Afghanistan and Iraq after 9/1/2001 (Operation Iraqi Freedom, Operation New Dawn and Operation Enduring Freedom)?

VAMC #2:

1. Name of VAMC:

2. Number of Veterans currently enrolled in the VDC program:

3. What was your total Veteran enrollment in your VDC program on the first day of the previous month?

4. How many new referrals for VDC were received in the month you are reporting on?

a. Of those referrals, how many are enrolled:

5. How many Veterans dis-enrolled in VDC within the last month?

6. How many Veterans receiving VDC in the last month served in Afghanistan and Iraq after 9/1/2001 (Operation Iraqi Freedom, Operation New Dawn and Operation Enduring Freedom)?

VAMC #3:

1. Name of VAMC:

2. Number of Veterans currently enrolled in the VDC program:

3. What was your total Veteran enrollment in your VDC program on the first day of the previous month?

4. How many new referrals for VDC were received in the month you are reporting on?

a. Of those referrals, how many are enrolled:

5. How many Veterans dis-enrolled in VDC within the last month?

6. How many Veterans receiving VDC in the last month served in Afghanistan and Iraq after 9/1/2001 (Operation Iraqi Freedom, Operation New Dawn and Operation Enduring Freedom)?

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