Include the criteria and processes utilized to identify individuals for transitioning. Describe the process that will be implemented to identify eligible individuals for transition from an inpatient facility to a qualified residence during each fiscal year of the demonstration. Please include a discussion of: the information/data that will be utilized (i.e., use of MDS or other institutional data); how access to facilities and residents will be accomplished; and the information that will be provided to individuals to explain the transition process and their options as well as the state process for dissemination of such information.
Identifying Individuals for Transition
Children. Texas has a strong permanency planning process for children in institutional settings. The 77th Texas Legislature (2001) passed Senate Bill 368 which mandates a proactive permanency planning process which requires a plan to be established upon institutional admission with subsequent six month reviews. The Mental Retardation Authority works with the family or the LAR to review community options and identify activities to return the child back into the community.
Nursing Facilities. As Texas has operated a MFP program for several years, most referrals of transition to a community setting are from word of mouth and from the organizations listed in the Nursing Facility Recruitment Strategies of this section (see above). Additionally, DADS maintains contracts with relocation contractors who in turn visit all nursing facilities in the state, help identify individuals who want to relocate, and facilitate the relocation process for return to the community.
Texas also uses information contained in the MDS dataset to the fullest extent possible in identifying eligible nursing facility residents, including those with complex supportive needs and those with behavioral health conditions. MDS Q1A information also is available on an aggregate level on the DADS Promoting Independence website for stakeholders to review. This data is the basis for identification of prospective participants, outreach to nursing facility residents and conducting a “transition” assessment. Identification of individuals with co-occurring behavioral health conditions also will be accomplished by matching DADS’ nursing facility MDS data to the Department of State Health Services (DSHS) Mental Health and Substance Abuse (MHSA) service records for the last five years. Information from the Preadmission Screening and Resident Review (PASRR) process and DSHS data system also will be used to assist in the identification of persons with behavioral health needs.
The information from these data sources is refreshed monthly and provided to relocation contractors.
ICFs/MR and State Supported Living Centers. As a result of the CLO process, an individual may be referred to the community through a designated Mental Retardation Authority (MRA). In accordance with the MRA’s Performance Contract, the MRA is required to provide an Explanation of Services and Supports (Appendix F).
The CLO helps ensure that the individual makes an informed choice regarding movement to an alternative living arrangement or registration on the most appropriate interest (waiting) list for 1915(c) waiver services.
Individuals who reside in ICFs/MR that voluntarily close will automatically be provided residential options through the CLO process.
It should be noted that under the Texas Promoting Independence Plan, individuals who live in medium and large community ICFs/MR or State Supported Living Centers have expedited access to the HCS 1915(c) waiver program (twelve and 6 months, respectively).
Access to Facilities and Residents
Nursing Facilities. Relocation contractors spend a considerable amount of effort to build working relationships with nursing facilities throughout the state. As part of the original Texas MFP Initiative, nursing facility administrators and directors of nursing were advised of DADS’ relationship with relocation contractors. Periodically, DADS sends out Provider Letters (Appendix B) to nursing facility administrators to remind them of the MFP Initiative and that relocation contractors are authorized to work with nursing facility residents.
Relocation specialists typically carry a copy of the most recent Provider Letter in case they encounter resistance in accessing a nursing facility. In the rare cases of a nursing facility refusing access to a relocation specialist, one of DADS Regional Directors will contact the nursing facility to remind them of the MFP policy and request that the relocation specialist be granted access to any resident who desires to talk to the relocation specialist. Relocation specialists are required to contact DADS toll-free complaint hotline to initiate a formal investigation of nursing facility non-compliance. (Nursing facilities are required to provide client access under the provision of DADS rule, 40 TAC § 19.413.)
ICFs/MR and State Supported Living Centers. Access to residents in community ICFs/MR has not been an issue as the residents have the right to have guests and meet privately with individuals. Access to state supported living centers is also not an issue because they are owned and operated by the State of Texas. As mentioned previously, various advocacy organizations meet with residents in ICFs/MR and state supported living centers to discuss community living options.
As has been stated, the Promoting Independence Plan and the Texas legislature require the Community Living Option (CLO) process for all residents of large community ICFs/MR and state supported living centers. Under this policy, at least annually or more frequently if requested, the ICFs/MR or state school must discuss alternative living arrangements with the resident or the resident’s Legal Authorized Representative (LAR).§ These discussions also are attended by all members of the Interdisciplinary Team (IDT). Each quarter, the Promoting Independence Advisory Committee receives aggregate reports on all CLO referrals. Information on the Community Living Options program will be discussed in greater detail in the next section of the Operational Protocol.
Information about the Transition Process and Options
Nursing Facilities. As previously mentioned, information about the transition process and various services options can come from a number of sources. The three primary sources of information are identified below.
Relocation Contractor. The relocation contractor will provide relocation assistance and intensive service coordination activities to assist NF residents to transition to community settings of their choice.
Relocation assistance will consist of but will not be limited to:
- Providing information about Medicaid 1915(c) waiver and non-waiver, non-Medicaid services and supports.
- Providing for Transition to Life in the Community (TLC), and for all program placements other than Adult Foster Care and Assisted Living, Transition Assistance Services (TAS).
- Developing person/family-directed transition plans and arrangements.
- Advocating for individuals making the transition and their family.
- Coordinating needed services/resources to transition into the community, with such entities as the local housing authority, the Mental Health Authority (MHA), the Texas Department of Assistive and Rehabilitative Services (DARS) regarding its relocation activities, and for:
- Mental health services.
- Transportation (particularly in rural areas).
- Medical/dental services, including prescriptions.
- Durable medical equipment.
- Securing access to needed community services, such as:
- Banking/bill payment/direct deposit.
- Household items/furniture.
- Special transit and local transportation providers.
- Follow-up assessment after transition for at least six months after the transition:
- Once a week for the first month.
- Twice a week for the second month.
- At least once during the third month.
- As frequently as the MFP participant requests.
In addition to generic policies developed for the overall MFP effort, the Behavioral Health Pilot will include the following activities:
- The local Community Mental Health Center and OSAR will be included on the transition team and will train their staff.
- The transition team and the Department State Health Services (DSHS) will periodically present information on the pilot to local mental health advocacy groups and substance abuse provider organizations.
- The DSHS Client Rights’ 1-800 Hotline staff will be provided with training on the pilot so that they may refer individuals to the pilot.
DADS case managers and Managed Care Organization service coordinators will work with nursing facility residents to determine their service needs and choices. Among the topics to be discussed are:
- How to qualify for services under the MFP policy.
- What happens if the person leaves the facility before the DADS’ enrollment is complete.
- Discussion of the various 1915(c) waiver programs offered by DADS and HHSC.
- Discussion of the community options available under the MFP program.
- Other services available to assist in the successful transition to a community setting:
- Relocation services.
- Transition to Live in the Community (TLC) services.
- Transition Assistance Services (TAS).
- Housing voucher programs.
- Discussion of the MFP Informed Consent Form.
- Relevant telephone numbers.
- With advent of the roll-out of STAR+PLUS in February 2007, the state recognized the need to clarify the various roles and responsibilities of the relocation contractors and the managed care service coordinators. The Texas Department of Aging and Disability Services in conjunction with the Medicaid/CHIP Division held a statewide training meeting with its relocation contractors, the managed care organizations, and DADS local regional staff to detail each entities specific activities.
- Briefly, the relocation contractor helps to provide outreach, education, and identification for potential nursing residents (NF) who want to relocate. Once identified, the NF resident is directed to the local DADS office for assistance in choosing a managed care provider. Upon that selection, a managed care service coordinator is provided who then takes the lead in relocation. However, the relocation contractor continues to have an important role in arranging housing and providing other relocation supports (and post-transition supports). It is the responsibility of the service coordinator to coordinate all relocation activities with the relocation contractor.
Lead Responsible Party
Contact consumer after initial call to DADS. DADS makes referral to relocation contractor.
Star Plus Service Unit (SPSU)
SPSU posting of Form 3676-SPW, STAR+PLUS Waiver Program Pre-Enrollment HMO Assessment Authorization, to Tex Med. SPSU also send Form 3676-SPW to the Relocation contractor at the same time the form is sent to the HMO.
Complete assessment including Form 3652-A, Client Assessment, Review and Evaluation (CARE); develop ISP; post ISP to TexMed.
Coordinate with Medicaid Eligibility
Relocation contractor makes initial contact with consumer and completes TLC application and forwards to DADS Provider Services, State Office. HMO works with the relocation contractor.
Relocation Contractor with support from HMO
Develop relocation plan
HMO with support from the Relocation Contractor
Arrange transition components of relocation plan:
HMO is responsible for overall coordination of the relocation plan.
Relocation Contractor will support and provide specific components of the plan.
Follow up assessment/monitor process after transition is completed
HMO and Relocation Contractor
ICFs/MR and State Supported Living Centers. The Mental Retardation Authority (MRA), for individuals residing in state supported living centers, or the Interdisciplinary Team (IDT), for individuals residing in large community ICFs/MR, will meet with the individual or their Legally Authorized Representative (LAR) to provide information regarding community living options. These meetings will occur at least annually or upon the request of the resident or LAR. The IDT/MRA must use the CLO instrument. The information discussed during the CLO meeting is summarized below (see Appendix C and F for all information discussed) and the meeting is conducted based on the self-determination philosophy and using an approach that is focused on the preferences of the resident/LAR.
When an alternative living arrangement is requested, the subsequent information will be used by the local Mental Retardation Authority (MRA) to identify appropriate community resources and to develop the individual’s service coordination plan.
- Individual Preference.
- Where does the individual want to live?
- What information has been provided on living options?
- LAR/Family Preference.
- What information has been provided to the LAR/family member related to living options and permanency planning?
- What is the LAR/family member’s stated preference?
- Medical/Behavioral/Psychiatric Issues.
- If present, how can these needs be met in alternative living arrangement?
- What can the facility or MRA staff do to support/facilitate these needs in an alternative living arrangement?
- What are the treatment needs?
- Quality of Life.
- If a minor, has permanency planning been incorporated into the service plan and reviewed as required?
- What efforts have been made to ensure LAR/family participation?
- If a minor, have educational issues been addressed?
- What are the most important factors for this person in choosing a place to live?
- What would enable these factors to take place for the individual to live in an alternative living arrangement?
- What can the facility or MRA staff do to support/facilitate these needs in an alternative living arrangement?
- MRA Recommendations/Input.
- What alternative living arrangements are available to meet the individual’s needs?
- Within what timeframe could placement in an alternative living arrangement occur?
- Was the MRA representative at the planning conference?
- If not, what was the source of the MRA input?
If an alternative living arrangement is requested, the MRA will discuss with the individual/LAR the various living arrangements and services available. During this discussion, the following topics are discussed (also see the DADS’ brochure, Explanation of Services and Supports located at Appendix F).
- Services and Supports Provided through DADS.
- General Revenue funded services.
- Determination of eligibility for mental retardation services and supports.
- Service coordination.
- Community supports.
- Employment assistance.
- Supported employment.
- Behavioral support.
- Specialized therapies.
- Vocational training.
- Day habilitation.
- In-Home family support.
- Services under DADS’ Medicaid 1915(c) waiver Programs.
- Types of 1915(c) waiver programs and services available.
- Various living arrangements allowed under the 1915(c) waiver.
- Eligibility criteria.
- Enrollment process.
- Consumer preferences and choice.
- Selection of providers.
- Consumer directed service options.
- Useful telephone numbers.
Closure of Community ICFs/MR. As part of the MFP Demonstration, Texas plans to target providers of community operated ICFs/MR who agree to voluntarily close. The actual procedures that will be followed for these facilities will be addressed in Section 1, Part B of this Operational Protocol. In addition to the above information provided to individuals residing in an ICF/MR, a facility that has chosen to voluntary close will discuss the following issues with the individual/LAR:
- Types of living options for each individual.
- Description of the CLO process to be conducted prior to the closure which includes:
- Update the current CLO documentation.
- Identification of the proposed timelines for the closure and relocation of residents.
- Preferred choice of living arrangements for individuals.
- Description of the relocation assistance to be furnished by the provider.
- Actions the provider will take to ensure the facility remains in compliance with regulations during the closure process.
- Whether or not the provider intends to continue as a provider of ICF/MR services, and if provider’s plan includes the conversion to Home and Community-based Services (HCS).
- Notification procedures, which will include the provider’s written and verbal notice to each individual and the individual’s legally authorized representative (LAR) or family at least thirty calendar days prior to the facility closure. The notice shall include a description of assistance that is available from: (1) the provider during the relocation process, (2) from the local MRA, (3) the fact that the provider will work in cooperation with the applicable MRA to assist individuals to make an informed choice, and (4) contact information.
Texas also provides additional support in the relocation of children. In these situations, DADS provides HHSC with a list of individuals who are under 22 years of age to ensure that these individuals and their families/LARs are offered assistance through the Family-based Alternatives Project.
The Family-based Alternatives project is operated by HHSC to assist children in institutions to return home to their birth families. When relocation to the family home is not possible, the project arranges for alternate families called “support families” who are carefully matched with children and their birth families to jointly care for the child on a long-term basis with the birth family. The Family-based Alternatives contractor will work with permanency planners and relocation specialists to assist in the identification and transition of children from institutional settings to their homes or to support families.
Dissemination of Information
Staff from HHSC, DADS and DSHS will market the MFP Demonstration by providing educational seminars and information about the MFP demonstration to the following organizations. (Please see the Outreach/Marketing/Education section of the Operational Protocol for a list of additional organizations that will assist in marketing the MFP Demonstration.)
- The Money Follows the Person Demonstration Advisory Committee.
- The Texas Promoting Independence Advisory Committee.
- The DADS Council.
- All appropriate state business units concerning the MFP Demonstration.
- Representatives from Managed Care systems.
- Behavioral Health Providers in the pilot area.
- DADS case managers and MCO service coordinators.
- Guardianship staff.
- Meetings of various Long-Term Services and Supports provider associations.
- Statewide housing associations.
- Nursing Facilities, ICFs/MR and state supported living centers.
- The DADS, HHSC, and Texas Promoting Independence websites.
Updated: May 1, 2015