Form 8647, Service Coordination Assessment – Intellectual Disability Services

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Documents

Effective Date: 1/2024

Instructions

Updated: 1/2024

Purpose

Form 8647, Service Coordination Assessment is completed for applicants and people enrolled in the Home and Community-based Services (HCS) and Texas Home Living (TxHmL) Programs and General Revenue (GR) Services.

Form 8647 has two purposes: 

  • Determine if a person is eligible for service coordination. This only applies to people wanting to receive General Revenue service coordination. 
  • Identify the frequency for face-to-face* contact. The minimum required frequency of face-to-face contact is every 90 days. 

*For this assessment face-to-face means within the physical presence of another person. Face-to-face does not include audio-visual or audio-only communication.

When to Prepare

Form 8647 is completed by the service coordinator, at enrollment and annually thereafter. The form is also updated whenever the person’s needs have significantly changed or a revision to the frequency of face-to-face contact is needed. 

Detailed Instructions

Section 1 Person’s Information 

Name of Person — Enter the person’s first and last name. 

CARE ID No. — Enter the person’s Client Assignment and Registration (CARE) identification number.

Address (Street, City, State, Zip Code) — Enter the person’s residential address to include street, city, state and zip code.

Area Code and Phone No. — Enter the person’s contact phone number to include area code. 

Name of LIDDA — Enter name of LIDDA the person is currently assigned to.

Section 2 Assessment 

Each assessment area contains 3 parts: 

  • Considerations 
  • Assessment questions 
  • Ratings

Considerations: 

Considerations are a list of questions for the service coordinator to think about when completing this assessment. Documentation of the answers to the questions in this section could be in the person’s record, the service coordinator’s notes or the person’s plan of services, such as the Person-Directed Plan (PDP).

Assessment questions:

There are two types of questions for service coordinators to complete and use when rating each domain: 

Yes or No – Service coordinators must ensure each question is answered either yes or no. If not applicable (N/A) is available, then this can be used. 

Checklist – Service coordinators should check all items in the list that are applicable to the person. Only check N/A if none of the items listed are relevant to the person being assessed. 

Service coordinators should ensure that each question is completed and considered when rating the assessment. 

Ratings:

Service coordinators or LIDDA representatives should rate each domain based on the interview of the person and their LAR, if applicable. Service coordinators will think about the responses to the questions in the consideration box as well as the assessment questions when deciding on ratings for each domain. 

General rating descriptions: 

A rating of 3 means that the person is in a situation that is life-threatening or significantly impacts health or safety. This situation must be related to the domain being rated. 

A rating of 2 means that the person is trying to access services and supports. This may include a change in need or services, but does not rise to concerns about health, safety or crisis. 

A rating of 1 means that the person may already have needed services and supports in place. A service coordinator is desired to monitor services and supports to ensure they remain in place so the person can remain successful. 

A rating of 0 means that the person does not need assistance, services or supports related to this domain. 

Additional rating information can be found in each domain. 

Rights and Legal Status

Helpful information: 

  • Link to Rights of people with IDD 
  • List of some less restrictive alternatives to legal Guardianship: 
    • Supported Decision Making
    • Surrogate Decision Maker 
    • Medical or Durable Power of Attorney 
    • Advanced Medical Directives

Physical Health

Helpful information:

Centers for Disease Control and Prevention (CDC) states, “Chronic Diseases are defined broadly as conditions that last 1 year or more and require ongoing medical attention or limit activities of daily living or both, such as heart disease, cancer, diabetes, Alzheimer’s disease or other dementias, COPD and stroke.”

Emotional and Behavioral Health

Example ratings:

Rating of 3: Crisis referrals, Court or jail involvement, frequent psychiatric hospitalizations or rehab for drug use.

Rating of 2: The person has a need for a Behavioral Support Plan.

Rating of 1: The person has behavioral services or a behavior support plan in place that has been working well for over 1 year. Stable on all psychotropic medications.

Independent Living

Helpful Information: 

Transportation resources: 

Medical Transportation Program

Call 211 or visit the 211 website to search for transportation resources in your area.

Example ratings:

Rating of 3: Homeless and no family to live with, needs assistance with modifying living environment to meet health, safety or physical needs, does not have sufficient income to meet current needs, or no income and bills are due and in danger of being evicted.

Rating of 2: May need assistance with locating and applying for new housing, as well as accessing community resources and services during moves. May need assistance with locating or accessing transportation. Desires assistance in modifying the living environment (Minor Home Modifications). Needs extensive assistance to perform living skills. Needs assistance with keeping SSI, re-applying for Medicaid due to loss, desires sufficient skills for managing financial resources (budgeting), desires increased access to finances.

Rating of 1: Needs monitoring to ensure that support for managing financial resources, maintaining basic living skills, and household management remain adequate to meet the person’s needs with current services in place.

Work and School

Helpful information: 

N/A – Not Applicable. If the person is too young to work, use N/A.

Per Texas Administrative Code (TAC), Title 26, Part 1, Chapter 284 and instructions for Form 8401, Employment First Discovery Tool.

During the completion of Service Coordination Assessment (Form 8647), the service coordinator asks the person about their desire to work. Document the person’s response on Form 8647.

If the person indicates a desire to work, the service coordinator must complete the Employment First Discovery Tool and make a referral to Texas Workforce Commission or refer the person for employment services through the waiver program where the person is enrolled.

Example ratings:

Rating of 3: Losing job and has no money to pay bills. Reduction in school time. Need assistance with crisis planning that involves job or school. Emergency meetings at job or school. 

Rating of 2: Desires assistance in locating work or volunteer opportunity. Change in school. Leaving school, transition planning. Person in their last year of high school. 

Rating of 1: Annual involvement in the admission, review, and dismissal (ARD) committee meetings, or assistance with development of an individualized education program (IEP).

Rating of 0: Person does not attend school, have a job or have any interest in seeking employment or volunteer work.

Relationships and Social Inclusion

Helpful information: 

Any references to community or community involvement in this domain are NOT about transportation. Ratings related to transportation are in Independent Living domain.

Example ratings:

Rating of 3: Concerns regarding building healthy relationships. Loss of significant relationships. Conflicts with family. 

Rating of 2: Desires increased participation in the community but has issues with interacting with others and is unsure of social role. Barriers to friendships. 

Rating of 1: Person has a good support system but may need information regarding community events that meet their interests.

Section 3 Service Coordination

Section 3 is comprised of 3 parts: 

  • Understanding Requirements of Service Coordination 
  • Determining Eligibility for Service Coordination 
  • Determining Frequency for Face-to-Face Service Coordination 

Understanding Requirements of Service Coordination

Reminder about the rules related to the requirements of service coordination in 26 TAC Sections 331.7, 331.11, and 331.5.

Determining Eligibility for Service Coordination 

Service coordinators must check only one of the boxes to state if the person is eligible for service coordination based on the ratings.

There are three options to choose from: 

  • Person has two or more domains with a rating of 3, 2, or 1. 
    The rule at 26 TAC Section 331.7 (a)(1)(A) states a person must  “have two or more documented needs that require services and supports other than service coordination as evidenced by an assessment conducted by the designated LIDDA and not reside in an institution.” Each domain with a rating of 1, 2, or 3 counts as a documented need. 
  • Person meets other eligibility criteria in 26 TAC Section 331.7. 
    Click the link to determine if the person meets other eligibility criteria listed at 26 TAC Section 331.7 (a)(1)(B), (C), (D), (E), or (F). 
  • Person is not eligible for service coordination if there are no domains with a rating of 3, 2, or 1.The person or their LAR may request annual contact. 
    This person is not eligible for service coordination, however they are eligible to be reassessed annually or if needs change to redetermine eligibility.

Determining Frequency for Face-to-Face Service Coordination

For this assessment face-to-face means within the physical presence of another person. Face-to-face does not include audio-visual or audio-only communication.

After the service coordinator completes all the domain ratings, they will review with the person and their LAR to determine the frequency of face-to-face service coordination based on the ratings. The service coordinator should consult the chart to determine High, Moderate or Minimal frequency for face-to-face contact.

The service coordinator must check the appropriate box regarding the determined frequency of service coordination: monthly, at least twice every 90 days, or at least every 90 days. The minimum frequency for face-to-face service coordination is at least every 90 days. 

Section 4 Agreement 

Do you, or your LAR on your behalf, wish to receive service coordination? — Person or their LAR will check either Yes or No.

Printed Name of Person or LAR — Enter the name of the person that will be responsible for signing this form. 

Signature of Person or LAR — The person or their LAR will sign the form. 

Date — Enter the date (month, day and year) the form was signed.

Printed Name of LIDDA Representative Completing this Assessment — Enter the name of the person that completed this assessment.

Title of LIDDA Representative Completing this Assessment — Include the job title of the person from the LIDDA completing this assessment.

Signature and Title of LIDDA Representative Completing this Assessment — The LIDDA representative that completed this assessment will sign the form.

Date — Enter the date (month, day and year) the form was signed.