Revision 23-1; Effective Dec. 20, 2023

6110 Assigning an Enhanced Community Coordination (ECC) Coordinator

Revision 23-1; Effective Dec. 20, 2023

When the habilitation coordinator notifies the appropriate local intellectual and developmental disability authority (LIDDA) staff that a person or legally authorized representative (LAR) wants to transition to the community and has selected a community program, the LIDDA must assign an ECC coordinator to begin transition planning with the person and LAR.

Within seven calendar days after notification by the habilitation coordinator:

• the LIDDA assigns an ECC coordinator to the person and ensures the assigned ECC coordinator is identified in the Client Assignment and Registration system (CARE) screen 490; and
• the assigned ECC coordinator meets in person with the person and LAR to describe the transition planning process and gain an understanding of the person’s and LAR’s perspective of community living.
   

6110.1 Unassigning an ECC Coordinator

Revision 23-1; Effective Dec. 20, 2023

If, during transition planning, a person indicates that they are no longer interested in transitioning to the community, the LIDDA unassigns the ECC coordinator and ensures the un-assignment is reflected in CARE screen 490.

Before being unassigned, the ECC coordinator notifies the relocation specialist (RS) and the habilitation coordinator that the person is no longer interested in transitioning to the community.

6120 Working with the Relocation Specialist

Revision 23-1; Effective Dec. 20, 2023

The ECC coordinator reviews the relocation assessment and evaluation and contacts the RS and managed care organization (MCO) service coordinator (SC) to invite them to service planning team (SPT) meetings for transition planning. The RS becomes a member of the SPT.

Note: The MCO SC is already an SPT member and is invited to all SPT meetings unless the person objects. The habilitation coordinator should ask the person or LAR, if applicable, directly whether they are okay with or object to the MCO service coordinator’s attendance at interdisciplinary team (IDT) and service planning team (SPT) meetings and must document evidence of this discussion in the person’s record. 

6130 Relocation Specialist and MCO SC Responsibilities

Revision 23-1; Effective Dec. 20, 2023

The MCO SC and RS, as members of the SPT, assist a person with accessing:

• housing, transportation, medical, dental and prescriptions, depending on the program the person chooses; and
• Supplemental Transition Support (STS) funding if the person qualifies.

STS is available to pay for essential items not covered by Transition Assistance Services (TAS), which is a waiver program service. STS may be used when TAS funds have been exhausted. The RS will provide the ECC coordinator with a copy of the completed STS form signed by the MCO, the RS and the ECC coordinator.

Note: For people transitioning to the Home and Community-based Services (HCS) program, the ECC coordinator is responsible for completing and submitting the assessment for TAS funding. For people transitioning to the Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiple Disabilities (DBMD) or Home and Community Based Services (HCBS) (STAR+PLUS Waiver) program, the RS is responsible for completing and submitting the assessment for TAS funding.

The MCO SC and RS are required to be present at the person's new address on relocation day to ensure all services are in place and to assist in setting up the household, as needed. The ECC coordinator is encouraged to be there as well.

6140 Enhanced Community Coordination Funds 

Revision 23-1; Effective Dec. 20, 2023

Enhanced community coordination (ECC) funds are available to LIDDAs through the performance contract for a person who is transitioning to the community. The purpose of the funds is to enhance a person’s natural supports and promote successful community living. Funds are intended to pay for:

• one-time emergency assistance, such as:
  • rental or utility assistance;
  • nutritional supplements;
  • clothing; and
  • medication;
• items to address a person's special needs, including minor home modifications not funded by other sources;
• transportation to and from trial visits with community providers; and
• educational tuition assistance, such as vocational programs through community colleges so a person can develop job skills.

A LIDDA should contact IDDMFPSupport@hhs.texas.gov to discuss processes and how to access funds prior to any purchases.

Revision 23-1; Effective Dec. 20, 2023

An ECC coordinator is responsible for:

• convening and facilitating SPT meetings, as necessary, to conduct transition planning and to develop and implement the person’s Form 1053, Transition Plan, regardless of the program chosen by the person;
• ensuring that the members of the SPT (specifically providers of specialized services, the nursing facility and the MCO) receive sufficient notice to participate in the SPT meeting (at least 10 business days before the scheduled SPT meeting); 
• ensuring the SPT uses the relocation assessment and evaluation, other assessments (e.g., medical and behavioral), and the latest Form 1054, Community Living Options, to guide the development of Form 1053;
• documenting the SPT discussions and decisions in a progress note;
• developing and revising the Transition Plan per Section 6300, Developing and Revising the Transition Plan; and
• coordinating with the MCO SC and RS, as needed, in accessing community resources the person may need or be eligible for, including transportation, housing, medical, dental and other services.

For an SPT meeting convened by the ECC coordinator, the ECC coordinator must ensure a sign-in sheet is provided to document the attendance of each participant, as well as the meeting date. If an SPT member participated by phone, the ECC coordinator must ensure that member’s name is included on the sign-in sheet. The ECC coordinator must maintain all sign-in sheets.
 

6210 SPT Meeting Participation

Revision 23-1; Effective Dec. 20, 2023

6210.1 ECC Coordinator Participation

Revision 23-1; Effective Dec. 20, 2023

The ECC coordinator must participate in person or by phone at all SPT meetings convened by the habilitation coordinator.

6210.2 Habilitation Coordinator Participation

Revision 23-1; Effective Dec. 20, 2023

The habilitation coordinator must participate in person or by phone at all SPT meetings convened by the ECC coordinator.

6210.3 Program Provider and Relocation Specialist Participation

Revision 23-1; Effective Dec. 20, 2023

The ECC coordinator and habilitation coordinator must ensure the community program provider and RS are invited to all SPT meetings, including those convened by the habilitation coordinator. However, the program provider and RS are only required to attend SPT meetings convened by the ECC coordinator related to transition planning.

Revision 23-1; Effective Dec. 20, 2023

In conjunction with the SPT, the ECC coordinator develops and revises, as needed, a person’s Form 1053, Transition Plan. The ECC coordinator must develop Form 1053, or revise it as needed, and send it to the SPT members within 10 calendar days after the SPT meeting.

6310 Transition Plan

Revision 23-1; Effective Dec. 20, 2023

Information documented on Form 1053, Transition Plan.

Section 1, Individual Information — Name of the person, CARE ID, Medicaid number and date.

Section 2, Community Program Choice — This section identifies the community program selected by the person or LAR, the name of the responsible party for requesting a slot and the projected date of request.

Section 3, Service Coordination Plan — This section describes the service coordination plan, including duration and frequency of in-person meetings between the person and the ECC coordinator, which are pre-printed on the form. The duration of service coordination is throughout the transition process, and the frequency of in-person visits is at least monthly. This section also lists all the activities to be coordinated and monitored by the ECC coordinator during the transition process.

Section 4, Identified Supports — This section describes all supports the person needs to live in the community, whether they are essential or non-essential, whether the selected living option provides the support, the due-date for the provision of non-essential support, and the name of the responsible party for ensuring the support is provided.

Section 5, Plan for Choosing a Program Provider — This section has a summary of the person's or LAR’s plan for choosing a program provider, such as conducting interviews and trial visits with potential program providers, the name of the responsible party for implementing the plan, and the projected date of completion.

Section 6, Barriers to Transitioning to a Program — The barriers listed in this section originate in Section 8 of Form 1054, Community Living Options, and additional barriers may be identified by the SPT. As transition planning progresses, some of the barriers may change and some will be resolved. This section also describes the SPT’s possible solutions to the barriers, how the SPT can implement the solutions, and any needed follow-up activities.

Section 7, Transitioning from the Nursing Facility — This section identifies the selected program provider and the projected move date. It also includes the pre-move preparations that must be arranged before the day of transition and the name of the responsible party for ensuring the arrangement is made.

Section 8, Post-Move Monitoring Dates — This section auto-populates the period in which post-move monitoring visits must be conducted by an ECC coordinator.

Section 9, Community Living Data — This section is for listing all community living information, including names, contacts, addresses and phone numbers. It serves as a quick reference for important information related to serving a person. This information must be included as it becomes known.

Section 10, Agreements — This section describes the agreements between the LIDDA and the community program provider.

Section 11, Service Coordinator Signature — This section is for the ECC coordinator to affirm that the Transition Plan was developed based on SPT decisions and includes the ECC coordinator’s printed name, signature and date.

6320 Barriers Preventing a Transition to the Community

Revision 23-1; Effective Dec. 20, 2023

The ECC coordinator must:

• ensure that if barriers preventing a transition to the community are identified in Section 8 of Form 1054, Community Living Options, they are included in Section 6 of Form 1053, Transition Plan, in addition to any barriers the SPT may identify;
• ensure the SPT discusses the barriers, possible solutions to the barriers, and how the SPT can implement the solutions and any needed follow-up activities; and
• document the resolutions and actions for implementation in Section 6 of Form 1053.

6330 Documents in an Person's Transition Packet

Revision 23-1; Effective Dec. 20, 2023

A complete transition packet for a person has:

• Form 1063, Individual Profile – Nursing Facility (see Section 5460.1, Individual Profile);
• Form 1053, Transition Plan (see Section 6310, Transition Plan); and
• Form 1042, Pre-Move Site Review, when completed, as described in Section 6530, Transitioning to the Community by Enrolling in HCS, or Section 6600, Transitioning to a Community Medicaid Program.

6340 Individual Profile

Revision 23-1; Effective Dec. 20, 2023

Form 1063, Individual Profile – Nursing Facility, is addressed in Section 5460.1, Individual Profile, and is developed and revised by the habilitation coordinator.

Note: If revisions to the person’s Form 1063 are necessary based on discussions during an SPT meeting convened by the ECC coordinator, then the habilitation coordinator is responsible for making the necessary revisions and sharing the revised Form 1063 with the ECC coordinator and the other SPT members.

6350 Sharing the Transition Plan, Individual Profile, and Transition Packet

Revision 23-1; Effective Dec. 20, 2023

The ECC coordinator is responsible for providing a copy of the person’s Form 1053, Transition Plan, to all SPT members within 10 calendar days after the SPT meeting during which it was developed or revised.

The ECC coordinator must also share a person’s transition packet with an SPT member upon request.

6360 SPT Member Believes Transition Plan Does Not Accurately Reflect SPT Decisions

Revision 23-1; Effective Dec. 20, 2023

If an SPT member believes Form 1053, Transition Plan, does not accurately reflect SPT decisions, then:

• if the ECC coordinator agrees with the SPT member, the ECC coordinator corrects Form 1053 to accurately reflect the SPT decision; or
• if the ECC coordinator does not agree with the SPT member, the ECC coordinator presents the issue to the SPT to resolve the discrepancy.
   

Revision 23-1; Effective Dec. 20, 2023

Based on the Medicaid program the person or LAR chooses, the ECC coordinator is responsible for the following:

• HCS-- Notifying the diversion coordinator to request a transition slot from HHSC as described in Section 6500, Transitioning to the HCS Program. 
• CLASS or DBMD--  Working with the RS to request a slot through the CLASS or DBMD interest list unit at HHSC.
• STAR+PLUS HCBS--  Working with the RS and MCO SC to arrange for the person to enroll in the STAR+PLUS HCBS program.

Revision 22-1; Effective Nov. 28, 2022

HHSC may make available a targeted nursing facility (NF) HCS transition slot for a person who meets the criteria described in Section 6510, Criteria for Transitioning to the HCS Program, below.

6510 Criteria for Transitioning to the HCS Program

Revision 22-1; Effective Nov. 28, 2022

A person is eligible for a targeted NF HCS transition slot if:

• the person has a PASRR Evaluation (PE) that was conducted when the person was admitted to the NF and the PE is positive for intellectual disability (ID) or developmental disability (DD);
• it is after the 30th day of the person’s admission if the person was admitted to the NF for rehabilitative purposes;
• the person is at least 21 years old;
• the person currently lives in a NF; and
• the person has expressed a desire to live in a community setting.

6520 Requesting a Targeted NF HCS Transition Slot

Revision 22-1; Effective Nov. 28, 2022

If a LIDDA determines that a person meets the criteria for a targeted NF HCS transition slot and the person or LAR wants to enroll in HCS, the  diversion coordinator requests a targeted NF HCS transition slot for the person by completing and submitting Form 1046, Request for HCS Adult NF Transition Slot, per the form’s instructions.

Upon receipt, HHSC staff reviews the completed Form 1046. HHSC staff may request additional information or documentation. If HHSC determines the person meets the criteria for the targeted NF HCS transition slot, HHSC will send a letter to the LIDDA authorizing the LIDDA to offer the person the opportunity to enroll in HCS. The LIDDA enrolls the person in the HCS program per the requirements in the HCS rules, LIDDA Handbook and Section 6530, Transitioning to the Community by Enrolling in HCS, below.

6530 Transitioning to the Community by Enrolling in HCS

Revision 23-1; Effective Dec. 20, 2023

For a person transitioning to the community by enrolling in the HCS program, the ECC coordinator:

• facilitates trial visits to HCS program providers in the community for the person, including overnight or weekend visits where feasible, as requested by the person or LAR;
• develops and revises, as necessary, Form 8665, Person-Directed Plan, using all available assessments, and to include the person’s:
  • strengths and preferences; and
  • medical, nursing, clinical, nutritional management and other support needs;
• conducts a pre-move site review using Form 1042, Pre-Move Site Review, to:
  • ensure any concerns of the program provider, staff or family member are being addressed; and
  • determine whether all essential supports identified on Form 1053, Transition Plan, are in place before the person transitions; and
• completes the following activities before the person transitions if, during the pre-move site review, any one of the essential supports is not in place or if issues are raised about the suitability of the site:
  • convenes the SPT to resolve the issues; and
  • conducts another pre-move site review following resolution.

When a person expresses the desire to transition from an NF to a home in another LIDDA’s service area, the sending LIDDA’s ECC coordinator must invite the receiving LIDDA to all transition planning meetings.

The sending and receiving LIDDAs must work together to ensure essential supports are in place prior to the person’s discharge from the NF. This includes scheduling the pre-move visit at a time when the receiving LIDDA’s ECC coordinator is available to be present.

The transfer of LIDDAs must not occur until all essential supports have been verified through a pre-move visit.

6540, Transition Day

Revision 23-1; Effective Dec. 20, 2023

The MCO SC and RS are expected to be present at the new address on transition day to ensure all services are in place and to assist in setting up the household, as needed. The ECC coordinator is encouraged to be present as well.

 

Revision 23-1; Effective Dec. 20, 2023

6610 Post-Move Monitoring Visits

Revision 23-1; Effective Dec. 20, 2023

For a person who transitioned to the HCS program, an ECC coordinator must:

• conduct and document on Form 1043, Post-Move Monitoring, at least three onsite post-move monitoring visits of community service delivery sites* during the first 90 calendar days after the person’s move at the following times**:
  • within the first seven calendar days after enrollment in the HCS program;
  • between eight and 45 calendar days; and
  • between 46 and 90 calendar days; and
• during the post-move monitoring visits:
  • assess whether essential supports identified in Form 1053, Transition Plan, are in place;
  • ensure concerns of the program provider, staff or family member are being addressed;
  • identify gaps in care; and
  • address such gaps, if any, to reduce the risk of crisis, re-admission to an NF or other negative outcome.

*The ECC coordinator must conduct post-move monitoring at all sites where essential supports are provided.
**More frequent onsite visits may be required to determine whether supports continue to be in place and any areas of concern are being addressed during the first 90 calendar days after enrolling in HCS.

6620 Monitoring Activities for One Year Post-Move

Revision 23-1; Effective Dec. 20, 2023

For one year* after a person has transitioned to the HCS program, an ECC coordinator must:

• conduct monthly in-person visits with the person, or more frequently if determined by the HCS SPT based on risk factors, and monitor the delivery of all services and supports;
• conduct HCS SPT meetings quarterly, or more frequently if there is a change in the person’s needs or if requested by the person or LAR;
• revise Form 8665, Person-Directed Plan, as necessary, and coordinate the person’s services and supports;
• inquire about any recent hospitalizations, emergency department contacts, increased physician visits or other crises, including medical crises, and if the person experiences such, convene the HCS SPT to identify all necessary revisions to the person’s Form 8665 to address additional need for services;
• ensure the person receives timely assessments of behavioral, medical, nursing, professional therapies and nutritional management needs, as necessary, and as indicated on Form 8665;
• record health care status sufficient to readily identify when changes in the person’s status occurs;
• conduct service planning, ensure the program provider’s implementation of services, and monitor all services identified on Form 8665, including:
  • reviewing the HCS program provider’s implementation plans and provider records;
  • visiting service delivery sites, as needed, to determine the person’s needs are being met; and
  • monitoring critical incidents involving the person and convening the HCS SPT to develop a plan for needed prevention or intervention services for the person; and
• monitor the person while on suspension from the HCS program at least monthly, maintain communication with the program provider, and provide reports to HHSC upon request.

*If, after one year of ECC, the SPT believes the individual requires further enhanced monitoring, the ECC coordinator must contact IDDMFPSupport@hhs.texas.gov for further guidance.
 

Revision 23-1; Effective Dec. 20, 2023

When a slot has been offered to a person who has selected a community Medicaid program that is not HCS, the ECC coordinator:

• facilitates trial visits to providers in the community for the person and LAR, as requested by the person or LAR;
• assists with service planning by:
  • making available to the entity responsible for service planning all available assessments; and
  • addressing the person’s:
    • strengths and preferences; and
    • medical, nursing, clinical, nutritional management and support needs; 
  • conducting a pre-move site review using Form 1042, Pre-Move Site Review, to:
    • ensure any concerns of the program provider, staff or family member are being addressed; and
    • determine whether all essential supports identified on Form 1053, Transition Plan, are in place before the person transitions; and
• completes the following activities before the person transitions if, during the pre-move site review, any one of the essential supports is not in place or if issues are raised about the suitability of the site:
  • convenes the SPT to resolve the issues; and
  • conducts another pre-move site review following resolution.

6710, Transition Day

Revision 23-1; Effective Dec. 20, 2023

The MCO, SC and RS are expected to be present at the new address on transition day to ensure all services are in place and to assist in setting up the household, as needed. The ECC coordinator is encouraged to be present as well.
 

Revision 23-1; Effective Dec. 20, 2023

For a person who has transitioned to a Medicaid community program that is not HCS, an ECC coordinator must:

• conduct and document on Form 1043, Post-Move Monitoring, at least three onsite post-move monitoring visits of community service delivery sites during the first 90 calendar days after the person’s move at the following times:
  • within the first seven calendar days after transition;
  • between eight and 45 calendar days; and
  • between 46 and 90 calendar days; and
• during the post-move monitoring visits:
  • assess whether essential supports identified in Form 1053, Transition Plan, are in place;
  • ensure any concerns of the program provider, staff or family member are being addressed;
  • identify gaps in care; and
  • address such gaps, if any, to reduce the risk of crisis, re-admission to an NF or another negative outcome.

The ECC coordinator should conduct additional post-move monitoring visits, if indicated.

The LIDDA may not use targeted case management funding for an SC’s activities described in this section if the person is enrolled in the CLASS or DBMD. The LIDDA may use ECC funds if an ECC coordinator conducts the activities described in this section.

Revision 23-1; Effective Dec. 20, 2023

If a person who has, at any time, received 365 days of enhanced community coordination (ECC) is readmitted to a nursing facility (NF) and wishes to return to the community, the ECC coordinator must determine: 

• if the person was in the NF for more than 30 calendar days; or
• if the person experienced a significant change of condition* during readmission to the NF.
• If the ECC coordinator determines the readmission exceeded 30 calendar days or the person experienced a significant change of condition, the ECC coordinator must:
• when appropriate, facilitate trial visits to program providers in the community for the person, including overnight or weekend visits where feasible, as requested by the person or LAR;
• develop and revise, as necessary, Form 8665, Person-Directed Plan, using all available assessments, and include the person’s:
  • strengths and preferences; and
  • medical, nursing, clinical, nutritional management and any other support needs;
• conduct a pre-move site review using Form 1042, Pre-Move Site Review, to:
  • ensure any concerns of the program provider, staff or family member are being addressed; and
  • determine whether all essential supports identified on Form 1053, Transition Plan, are in place before the person transitions; and
• complete the following activities before the person transitions if, during the pre-move site review, any one of the essential supports is not in place or if issues are raised about the suitability of the site:
  • convene the SPT to resolve the issues; and
  • conduct another pre-move site review following resolution.
• conduct and document on Form 1043, Post-Move Monitoring, at least three onsite post-move monitoring visits of community service delivery sites during the first 90 calendar days after the person’s move at the following times:
  • within the first seven calendar days after enrollment in the HCS program;
  • between eight and 45 calendar days after enrollment in the HCS program;
  • between 46 and 90** calendar days after enrollment in the HCS program; and
• during the post-move monitoring visits:
  • assess whether essential and non-essential supports identified in Form 1053, Transition Plan, are in place;
  • document and address all concerns of the environment, program provider, staff or family member on Form 1043;
  • document all identified gaps in care on Form 1043; and
  • address such concerns and gaps, if any, to reduce the risk of crisis, re-admission to an NF or other negative outcome.

* Significant change of condition: any change requiring additional services, equipment, or minor home modifications (e.g., new enteral feeding tube, respiratory equipment, wheelchair).

**If, by the 60th day after the person returns to the community, the SPT believes the person may require more than 90 days of enhanced monitoring, the ECC coordinator must contact IDDMFPSupport@hhs.texas.gov for further guidance.

If a qualified person who has transitioned to the community is admitted or readmitted to an NF, and has never received ECC, an ECC coordinator must initiate one year of ECC as described in Section 6000 of this handbook, relating to monitoring activities for NF transitions.

If a person is readmitted to an NF while receiving their initial 365 days of ECC, ECC will resume upon discharge to the community, however, the 365-day time frame does not re-start after the discharge. For example, if a person is admitted to an NF on day 181 of ECC and is put on suspension, when the person discharges from the NF, ECC resumes on day 182.

A person who is readmitted to an NF for the purpose of respite does not qualify for ECC upon discharge unless the person is already receiving ECC at the time of readmission.