Billing Instructions, (Oct. 2021), (Accessed Nov. 2022). Occupational Therapy Compact Map (Accessed Nov. 2022). I have chosen Virginia's Nursing Home Staffing and Care Standard bill. Looking for fee assistance or respite care? This electronic communication must include, at a minimum, the use of audio and video equipment. A Mobile Unit shall also be permitted to operate as an extension of an established Preferred OBATs primary location. Medicaid Memo. Regulation is at the agency level. VA Dept. Book D - Insurance. (Accessed Nov. 2022). VA Board of Medicine. Multiple organizations provide data to help people identify high-caliber home health agencies. WebThe West Virginia Medicaid Home Health Program does not follow the Medicare guideline definition for homebound status. independent research before making any education decisions. VA Code Annotated Sec. VA Dept. of Medical Assistant Svcs. VA Dept. Medicaid Provider Manual, Mental Health Services, Ch. Requirements on the coverage of telemedicine services include medically necessary remote patient monitoring services to the full extent that these services are available. No person shall practice dentistry unless a bona fide dentist-patient relationship is established in person or through teledentistry. The highest reported wages were in Winchester ($12.17), followed by Charlottesville ($11.46). SOURCE: VA Dept. Prescribing controlled substances requires the establishment of a bona fide practitioner-patient relationship in accordance with 54.1-3303 (A) of the Code of Virginia. (Accessed Nov. 2022). (Accessed Nov. 2022). and section 16.1-335 et seq. In cases in which a dentist is providing teledentistry, the examination required by clause (ii) shall not be required if the patient has been examined in person by a dentist licensed by the Board within the six months prior to the initiation of teledentistry and the patients dental records of such examination have been reviewed by the dentist providing teledentistry. On this page: Permanent Medicare changes Temporary Medicare changes through December 31, 2024 Temporary changes through the end of the COVID-19 public health emergency Physical Therapy Compact. Bulletin Coverage of Remote Patient Monitoring/Update to Telehealth Services Supplement, (Mar. Medicaid Provider Manual, Mental Health Services, Ch. of Medical Assistant Svcs., Medicaid Provider Manual, Addiction and Recovery Treatment Services Manual, Ch. WebVirginia home care agencies are licensed unless they fall under an exemption. The following Manuals and Supplements can be found on the Provider Manuals Library. Speech therapy services; 5. Are You Ready to Open a Child Care Business? VA Dept. Doc. SOURCE: VA Code Annotated Sec. SOURCE: VA Statute 54.1-2711, (Accessed Nov. 2022). SOURCE: VA Code Annotated Sec. Home health aides carry out duties that require relatively little training and are regarded as unskilled. SOURCE: Telemedicine Guidance. WebThe mission of the Virginia Department of Medical Assistance Services (DMAS) is improving the health and well-being of Virginians through access to high-quality health care coverage. Medicaid Provider Manual, Local Education Agency Provider Manual, Covered Svcs. SOURCE: Telemedicine Guidance. The Interpretive (Mar. 54.1-3408.3. SOURCE: 18VAC110-60-30(C). Web15 HOURS REQUIRED For a minor in Systems Technology and Information Management, the following courses are required: course STIM 2311 - Enhancing Software User Interfaces STIM 3301 - Information Systems for Management STIM 3310 - Information Systems Analysis and Design (S-L) STIM 3320 - Web Page Design Medicaid Memo. Attachment A in the Telehealth Supplement lists covered services that may be reimbursed when provided via telehealth. of Medical Assistance Svcs., Medicaid Provider Manual, Home Health Manual, Covered Services and Limitations. VA Department of Medical Assistant Services. Telehealth includes services delivered in the dental health setting (i.e., teledentistry), and telehealth policies for dentistry are covered in the dental manuals. # 85-12. Psychiatric evaluation may be provided through telemedicine. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), (Oct. 2022) (Accessed Nov. 2022). Join us for partnership and thought leadership as we unpack todays child care challenges and opportunities. (Accessed Nov. 2022). Under that definition, telemedicine services, as it pertains to the delivery of health care services, means the use of electronic technology or media, including interactive audio or video, for the purpose of diagnosing or treating a patient or consulting with other health care providers regarding a patients diagnosis or treatment. Medicare Compare, an official federal website, includes survey-based and outcome-based ratings for certified home health agencies. Billing Instructions, (July 2022) (Accessed Nov. 2022). Adds to the conditions aprescriber must meet for a bona fide practitioner-patient relationshipfor the purpose of prescribing Schedule II through VI controlled substances by an examination through face-to-face interactive, two-way, real-time communications services or store-and-forward technologies. See Telehealth Supplement for requirements. Public Participation Guidelines - revised December 15, 2016. WebHealth Care Policy Board, the regulations necessary to implement the provisions and purpose of Chapter 8 of the Act (35 P.S. Webcomplete regulations are online at the links provided at the end. All prescription drugs shall be prescribed and properly dispensed to clients according to the provisions of Chapters 33 ( 54.1-3300 et seq.) DMAS reimburses for telemedicine services under limited circumstances. (Mar. (Accessed Nov. 2022). Providers must maintain a practice at a physical location in the Commonwealth or be able to make appropriate referral of patients to a Provider located in the Commonwealth in order to ensure an in-person examination of the patient when required by the standard of care. VA Dept. 2022). of the Code of Virginia that and are billed using modifiers HK and 32. # 85-12. They apply to the Board of Nursing (https://www.dhp.virginia.gov/nursing/nursing_forms.htm). Community Stabilization Level of Care Guidelines. Initiated additional diagnostic tests or referrals as needed. (Accessed Nov. 2022). See Update for list of codes. Virginia Medicaid reimburses for live video, store-and-forward, remote patient monitoring and certain audio-only codes under certain circumstances. Treatment, including issuing a prescription based solely on an online questionnaire, does not constitute an acceptable standard of care. See our Privacy Policy. Doc. DMAS recognizes telemedicine as a means for delivering some covered Medicaid services. Preferred OBAT Providers, previously known as Preferred OBOTs, deliver addiction treatment services to members with OUD as well as other primary SUD. If the Member does not receive emergency ambulance transportation subsequent to and based on the facilitated telemedicine consultation, submit one claim for Q3014 on a CMS-1500. Web4.2.a. Medicaid Provider Manual, Addiction and Recovery Treatment Services, Covered Svcs and Limitations, (Mar. SEIU Virginia has a home care chapter (http://seiuva512.org/home-care). A pharmacist may initiate treatment with, dispense, or administer drugs, devices, controlled paraphernalia, and other supplies and equipment pursuant to this section through telemedicine services, as defined in 38.2-3418.16, in compliance with all requirements of 54.1-3303 and consistent with the applicable standard of care. Facility fee is only available for synchronous telehealth services. The practitioner shall use his professional judgement to determine the manner and frequency of patient care and evaluation and may employ the use of telemedicine provided that the use of telemedicine includes the delivery of patient care through real-time interactive audio-visual technology. 54.1-3408.3. Telehealth is permissible for prescreening activities pursuant to section 37.2-800 et. Highly Rated Home Care Agencies in Virginia, Career Outlook and Average Home Health Aide Salary in Virginia, Online programs at the Certificate (Medical Assisting, Medical Billing & Coding), Associate's (Fire Science and many others), Bachelor's (Fires Science, Fire and Emergency Management, Health & Wellness, Nutrition, Health Care Administration, Health Information Management, Psychology, Legal Studies, and more), Johns Hopkins Bloomberg School of Public Health, http://www.fairfaxcounty.gov/dfs/olderadultservices/in-home-care-guide.htm, https://www.law.cornell.edu/cfr/text/42/484.36, https://www.dhp.virginia.gov/nursing/nursing_forms.htm, https://www.medicare.gov/homehealthcompare, https://www.caring.com/articles/caringstars2017-in-home-care, Maintaining a safe and livable environment, Reading and recording pulse and other vitals, Understanding body functions and changes in function that require reporting, Providing safe, appropriate hygiene and grooming (for example, bed baths, oral hygiene, shampoos), Positioning clients and promoting normal range of motion, Using safe ambulation and transfer techniques, Maintaining adequate fluid and nutrition intake, Recognizing emergencies and following the proper procedures, Southern Virginia Regional Home Health Emporia, Home Nursing Services of Southwest VA Inc. Abingdon, Home Instead Senior Care Fredericksburg. Assisted living facility means a non-medical group residential setting that provides or coordinates Home attendants are also known as home care aides, home health aides, and personal care aides. Article. Medicaid Provider Manual, Local Education Agency Provider Manual, Covered Svcs. https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set. Store-and-forward means the asynchronous transmission of a members medical information from an originating site to a health care Provider located at a distant site. DMAS expects Preferred OBAT services to be primarily delivered in-person/on-site and utilize telemedicine as an option to increase access to services as needed. The following topics are covered: A home health agency cannot consider that a worker has met requirements for competency evaluation if the person has not passed all skills but one (https://www.law.cornell.edu/cfr/text/42/484.36). Providers shall contact DMAS Provider Enrollment (888-829-5373) or the Medicaid MCOs for more information. Web ABQ VA: Veteran Services: 7 week outpatient clinical/ home health PT maintaining +75% of the caseload. 4.2.b. of Title 54.1 of the Code of Virginia and the regulations of the Virginia Board of Pharmacy, except for prescription drugs authorized by 54.1-3408 of the Drug Control Where an existing practitioner-patient relationship is not present, a practitioner must take appropriate steps to establish a practitioner-patient relationship consistent with the guidelines identified in this document, with Virginia law, and with any other applicable law. Provider manuals that incorporate the supplement include: See the Provider Manual home page to access all manuals. VA Statute 32.1-122.03:1. 2022). Nursing services; 2. The National Telehealth Policy Resource Center project is made possible by Grant #U6743496 from the Office for the Advancement of Telehealth, Health Resources and Services Administration, DHHS. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Physician/Practitioner), (Oct. 2022) (Accessed Nov. 2022). of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), (Oct. 2022) & VA Dept. WebLegislation Clinical Laboratory Improvement Amendments (CLIA) Conditions for Coverage (CfCs) & Conditions of Participations (CoPs) Deficit Reduction Act Economic Recovery Act of 2009 Promoting Interoperability (PI) Programs Emergency Medical Treatment & Labor Act (EMTALA) Freedom of Information Act (FOIA) Legislative Update Payment will be set at a of Medical Assistance Svcs. A provision for the payment of medical assistance for medically necessary health care services provided through telemedicine services, as defined in. (Homemakers are allowed limited tasks that involve touch, for example, fastening articles of clothing or stabilizing someone while they walk. (Oct 2022). Covered service components of Mobile Crisis Response include: At the start of services, a LMHP, LMHP-R, LMHP-RP or LMHP-S must conduct an assessment to determine the individuals appropriateness for the service. WebVirginia Department of Health | Virginia.gov Home Agencies VDH Virginia Department of Health http://www.vdh.virginia.gov/ Contact Phone (804) 864-7000 About Locations Connect Services About the Agency The Virginia Department of Healths vision statement is Healthy People in Healthy Communities. Locations & Additional Contacts Main Location SOURCE:VA Dept. VA Board of Medicine. (Accessed Nov. 2022). SOURCE: VA Department of Medical Assistance Services. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), (Oct. 2022) (Accessed Nov. 2022). 4.3. (Accessed Nov. 2022). An agency might be exempted because it was regulated by an acceptable national organization or because it provided only very basic services like homemaking and chores. VA Board of Medicine. View our latest report, The Year in Child Care: 2021 Data, Analysis and Recommendations, Fee Assistance and Respite Care for Military/DoD Families. Billing codes covered by this policy, when conditions of coverage are met, and for services with dates of service on and after April 18, 2022, include the following: The term Provider refers to the billing provider either a qualified, licensed practitioner of the healing arts or a facility who is enrolled with DMAS. Medicaid Provider Manual, Durable Medical Equipment and Supplies Manual, Covered Svcs. Addiction and Recovery Treatment Services (ARTS). VA Code Annotated Sec. Expand the Medicaid program to cover all adults with income below 138% of the FPL. DMAS will reimburse an originating site fee to emergency ambulance transport providers for facilitating a telemedicine consultation between a Medicaid member and a Medicaid- enrolled provider for the purposes of identifying whether the Medicaid member is in need of emergency ambulance transportation. view of titles, agencies, chapters and sections The Virginia Register of Regulations home page Emergency Regulations currently in effect. See:VA Medicaid Live Video Eligible Sites. Certain RPM services are eligible for reimbursement in VA Medicaid. Credentialed Addiction Treatment Professional means: An individual licensed or registered with the appropriate board in the following roles: Preferred OBAT services must be provided by a buprenorphine-waivered practitioner and a co-located Credentialed Addiction Treatment Professional and may be provided in a variety of practice settings including primary care clinics, outpatient health system clinics, psychiatry clinics, Federally-Qualified Health Centers (FQHCs), Community Service Boards (CSBs), local health department clinics, and physicians/physician extenders offices. It is the expectation of the Board that practitioners recognize the obligations, responsibilities, and patient rights associated with establishing and maintaining a practitioner-patient relationship. of Medical Assistance Services. Book H - Loan Guaranty. Certain audio-only codes are eligible for reimbursement in VA Medicaid. Oct. 23, 2019, (Accessed Nov. 2022). CCHP does not share or sell personal data. Reauthorizations will be permitted for select services, as appropriate and as per criteria in the DMAS Form DMAS-P268. # 85-12. Subsection (A)(15) reads as follows: Any legally qualified out-of-state or foreign practitioner from meeting in consultation with legally licensed practitioners in this Commonwealth. This statute is intended to have a Virginia practitioner involved in the care of the patient when a practitioner in another state/country consults with the Virginia practitioner or the patient. MCOs will adopt equivalent service authorization criteria and quantity limits as FFS. Occupational therapy services; 4. All Home Health services that exceed 60 visits in a calendar year require prior authorization. and Limitations, (Oct 2021). Services must be provided in-person with the exception of the telemedicine assisted assessment and care coordination activities. 32.1-122.03:1 (C(1),(Accessed Nov. 2022). STATUS: Extends Waivers out to six months after end of PHE. VA Dept. Bulletin Coverage of Remote Patient Monitoring/Update to Telehealth Services Supplement. The Medicaid member is in a physical location where telemedicine services can be received per requirements set forth in the Telehealth Supplement. Telehealth means the use of telecommunications and information technology to provide access to medical and behavioral health assessment, diagnosis, intervention, consultation, supervision, and information across distance. Many listings are from partners who compensate us, which may influence which programs Telemedicine Guidance from VA Medical Board includes: See guidance for details and statutory references. Section 38.2-3418.16 defines telemedicine as the use of electronic technology or media, including interactive audio or video, for the purpose of diagnosing or treating a patient, providing remote patient monitoring services, or consulting with other health care providers regarding a patients diagnosis or treatment, regardless of the originating site and whether the patient is accompanied by a health care provider at the time such services are provided. To practice telemedicine into Virginia requires a license from the Board of Medicine. An informal or relative family child care home shall be registered under the name of only one caregiver per residence. Before providing a telehealth service to a member, the Provider shall inform the patient about the use of telehealth and document verbal, electronic or written consent from the patient or legally-authorized representative, for the use of telehealth as an acceptable mode of delivering health care services. The originating site is the location of the member at the time the service is rendered, or the site where the asynchronous store-and-forward service originates (i.e., where the data are collected). See Telehealth Supplement for Documentation and Equipment/Technology Requirements. The first is the consultant exemption found in 54.1-2901 which lists Exceptions and Exemptions Generally to licensure. Telemedicine is available for selected services. As noted in the Telehealth Supplement (Attachment A), all FFS claims for audio only codes should be billed directly to DMAS, including those delivered in the context of mental health and substance use disorder services. The Provider at the distant site deems that the service being provided is clinically appropriate to be delivered via telehealth; The service delivered via telehealth meets the procedural definition and components of the CPT or HCPCS code, as defined by the American Medical Association (AMA), unless otherwise noted in Table 1 Table 6 in this Supplement; The service provided via telehealth meets all state and federal laws regarding confidentiality of health care information and a patients right to his or her medical information; Services delivered via telehealth meet all applicable state laws, regulations and licensure requirements on the practice of telehealth; and. Webalso covered by Medicare may be recovered by the home health agency if the member resides outside of a 15-mile radius of the home health agency. Preferred OBATs services must have regular access to in-person/on-site visits and services shall not be delivered solely or predominantly through telemedicine. See: VA Medicaid Remote Patient Monitoring. SOURCE: VA Code 54.1-3303.1. Outstanding communication skills accompanied by excellent organizational and interpersonal skills. The practitioners must be credentialed by DMAS, the DMAS fee-for-service contractor or MCOs to perform Preferred OBAT services. VA Board of Medicine. Web4.2.a. Telehealth shall not include by telephone or email. 118.801a 148.820) and to assure that its Home Health Care Agencies licensed under this subpart shall comply with applicable environmental, health, sanitation, and professional licensure standards, which The telehealth originating site facility fee is not authorized. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Available in multiple manuals, including physician/practitioner, see overview for full list), (Oct. 2022). Services can be provided face-to-face or by telemedicine according to DMAS policy regarding telemedicine. A nurse practitioner or physician assistant working under the licensed psychiatrist may provide this coverage for the psychiatrist. Telemedicine shall not include by telephone or email. Telehealth encompasses telemedicine as well as a broader umbrella of services that includes the use of such technologies as telephones, interactive and secure medical tablets, remote patient monitoring devices, and store-and-forward devices. Medicaid Bulletin: Clarification of DMAS Requirements Related to the Use of Telemedicine in Providing MAT for OUD. Learn more about child care in public policy, access advocacy resources, and get updates on opportunities to engage in the effort to change the child care landscape. Coverage Continuous Glucose Monitoring is limited to members with: Service authorization is required. Nursing homes are also subject to co-extensive federal government regulation. It is rare to have a complementary, yet overlapping system of regulation for an industry, but each level of regulation serves its own purpose. For the federal government, it is the Department of Health and Human Services that is the applicable regulator. VA Dept. VA Dept. No insurer, corporation, or health maintenance organization shall require a provider to use proprietary technology or applications in order to be reimbursed for providing telemedicine services. VA Dept. VA Code Annotated Sec. The indication, appropriateness, and safety considerations for each prescription provided via telemedicine services must be evaluated by the practitioner in accordance with applicable law and current standards of practice and consequently carries the same professional accountability as prescriptions delivered during an in-person encounter. WebMedicaid is the largest source of funding for medical and health-related services for people with low income in the United States, providing free health insurance to 74 million low-income and disabled people (23% of Americans) as of 2017, [3] [4] [5] as well as paying for half of all U.S. births in 2019. An informal or relative family child care home shall comply with the provisions of this rule. SOURCE: VA Dept. SOURCE: VA Dept. (Oct 2022). By law, the persons licensed as health care practitioners have a duty to report to the Virginia Department of Social Services or the local departments of social services any known or suspected incidences of abuse, neglect, or exploitation of children or elderly and incapacitated adults. Durable Medical Equipment (DME) and Supplies. (Accessed Nov. 2022). Payment will be set at a rate per mile as established by the General Services Administration in the Federal Travel Regulations. However, no license shall be issued to a person who has been sanctioned pursuant to 42 The Center for Connected Health Policy is a program of the Public Health Institute. VA Statute 54.1-2711. Code Ann. Under federal nursing home regulations, nursing homes must:Have sufficient nursing staff. Conduct initially a comprehensive and accurate assessment of each residents functional capacity. Develop a comprehensive care plan for each resident. Prevent the deterioration of a residents ability to bathe, dress, groom, transfer and ambulate, toilet, eat, and to communicate. More items All Manuals, (Accessed Nov. 2022). Current Preferred OBAT Providers shall notify the MCOs and the DMAS fee-for-services contractor prior to providing services in a Mobile Unit. No health care provider who provides health care services through telemedicine shall be required to use proprietary technology or applications in order to be reimbursed for providing telemedicine services. # 85-12. Providers must follow the requirements for the provision of telemedicine described in the Telehealth Services Supplement, including the use of telemedicine modifiers. A psychiatric evaluation may be provided through telemedicine. A supervisee in social work who is under the supervision of a licensed clinical social worker and is registered with the Virginia Board of Social Work (18VAC140-20-10). SOURCE: VA Dept. MCO contracted providers should consult with the contracted MCOs for their specific policies and requirements for telehealth. (Accessed Nov. 2022). In this circumstance, the Provider shall be reimbursed only for services successfully delivered. Additional requirements apply. At a minimum, the assessment must include the following elements: risk of harm; functional status; medical, addictive and psychiatric co-morbidity; recovery environment; treatment and recovery history; and, the individuals ability and willingness to engage. 104-4 Before you start getting your home health care, the home health agency should tell you how much Medicare will pay. (Accessed Nov. 2022). VA Medicaid Telehealth Questions and Answers (Aug. 2021). Currently, the home health aide job classification represents a smaller portion of the direct care workforce than nursing assistant or personal care aide. VA Department of Medical Assistance Services. An informal or relative family child care home shall be located in the residence of the caregiver. Medicaid Provider Manual, Residential Treatment Services, Covered Services and Limitations, (Accessed Nov. 2022). Doc. In the event it is medically necessary for a Provider to be present at the originating site at the time a synchronous telehealth service is delivered, said Provider may bill an originating site fee (via procedure code Q3014). This electronic communication must include, at a minimum, the use of audio and video equipment. Medicaid: Behavioral Health and ARTS Provider Flexibilities Related to COVID-19 (3/27), Medicaid: Home and Community Based Services Waivers (HCBS) COVID-19 Policy Continuation and Timeline, Medicaid: COVID Active Flexibilities Update for April 19, 2022, Medicaid: Frequently Asked Questions: Personal Care/Assistance, Respite, and Companion Services, Medicaid:Virginia Medicaids Response to COVID-19New Emergency Flexibilities, Medicaid: Delivery of Group Based Services in Behavioral Health and Addiction (ARTS) during COVID-19 (7/1), Medicaid 1915(c) Waiver: Commonwealth Coordinated Care Plus, Family and Individual Supports, Community Living, and Building Independence, Medicaid 1915(c) Waiver:Commonwealth Coordinated Care Plus, Family and Individuals Supports, Community Living, and Building Independence, STATUS: Active, expires six months after the end of the public health emergency. 32.1-325 (Accessed Nov. 2022). Transmits information in a manner that protects patient confidentiality. Employees must go through a criminal background check. Psychotherapy and SUD counseling may also be provided via telemedicine by a qualified provider who is a credentialed addiction treatment professional as defined in this memorandum and DMAS ARTS Provider Manual. Child Care Aware of America is dedicated to serving our nations military and DoD families. # 85-12. SOURCE: Occupational Therapy Compact Map (Accessed Nov. 2022). The Consolidated Appropriations Act of 2023 extended many of the telehealth flexibilities authorized during the COVID-19 public health emergency through December 31, 2024. Code Ann. (Accessed Nov. 2022). P. 4 (Aug. 19, 2021). National Telehealth Resource Center Partners, Continuing COVID flexibilities based on federal authority, Virginia Medicaid FAQs for Accessing ARTS Services during COVID-19, Virginia Medicaid FAQs for Accessing Behavioral Health Services During COVID-19, Virginia Medicaid Recommendations for Therapeutic Day Treatment Service Delivery During COVID-19, New 1135 Waiver and Administrative Provider Flexibilities (5/26), Appendix K Commonwealth Coordinated Care Plus, Family and Individuals Supports, Community Living, and Building Independence, Appendix K Addendum Commonwealth Coordinated Care Plus, Family and Individuals Supports, Community Living, and Building Independence, Behavioral Health and ARTS Provider Flexibilities Related to COVID-19 (3/27), Home and Community Based Services Waivers (HCBS) COVID-19 Policy Continuation and Timeline, COVID Active Flexibilities Update for April 19, 2022, Frequently Asked Questions: Personal Care/Assistance, Respite, and Companion Services, ew 1135 Waiver and Administrative Provider Flexibilities (5/26), Delivery of Group Based Services in Behavioral Health and Addiction (ARTS) during COVID-19 (7/1), Commonwealth Coordinated Care Plus, Family and Individual Supports, Community Living, and Building Independence, Commonwealth Coordinated Care Plus, Family and Individuals Supports, Community Living, and Building Independence.