Revision 19-0; Effective July 7, 2019

 

6100 Assigning a Service Coordinator or Enhanced Community Coordinator and Working with the Relocation Specialist

Revision 19-0; Effective July 7, 2019

 

 

 

6110 Assigning a Service Coordinator or Enhanced Community Coordinator

Revision 19-0; Effective July 7, 2019

 

When an HC notifies the appropriate LIDDA staff that an individual/LAR wants to transition to the community and has selected a community program, the LIDDA must assign a service coordinator (SC) or an enhanced community coordinator (ECC) to begin transition planning with the individual and LAR.

Within seven days after notification by an HC:

  • the LIDDA assigns an SC/ECC to the individual and ensures the assigned SC/ECC is identified in CARE screen 490;
  • the assigned SC/ECC meets face-to-face with the individual and LAR to describe the transition planning process and gain an understanding of the individual’s/LAR’s perspective of community living.

 

6110.1 Unassigning a Service Coordinator or Enhanced Community Coordinator

Revision 19-0; Effective July 7, 2019

 

If, during transition planning, an individual indicates that he or she is no longer interested in transitioning to the community, the LIDDA unassigns the SC/ECC and ensures the unassignment is reflected in CARE screen 490.

Before being unassigned, the SC/ECC notifies the RS and the HC that the individual is no longer interested in transitioning to the community.

 

6120 Working with the Relocation Specialist

Revision 19-0; Effective July 7, 2019

 

The SC/ECC reviews the relocation assessment and evaluation and contacts the RS and MCO SC to invite them to 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 individual objects.

 

6130 Relocation Specialist and MCO SC Responsibilities

Revision 19-0; Effective July 7, 2019

 

The MCO SC and RS, as members of the SPT, assist an individual with accessing:

  • housing, transportation, medical, dental and prescriptions, depending on the program the individual chooses; and
  • Supplemental Transition Support (STS) funding, if the individual 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 SC/ECC with a copy of the completed STS form signed by the MCO, the RS and the SC/ECC.

Note: For individuals transitioning to the HCS program, the SC/ECC is responsible for completing and submitting the assessment for TAS funding. For individuals transitioning to the CLASS, DBMD or 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 individual’s new address on relocation day to ensure all services are in place and to assist in setting up the household, as needed.

 

6140 Enhanced Community Coordination Funds to Assist with Certain Costs Related to Transitioning

Revision 19-0; Effective July 7, 2019

 

Enhanced community coordination funds are available to LIDDAs through the HHSC/LIDDA performance contract for an individual who is transitioning to the community. The purpose of the funds is to enhance an individual’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 an individual’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 an individual can develop job skills.

A LIDDA should contact its HHSC contract manager to discuss how to access funds.

 

6200 Transition Planning

Revision 19-0; Effective July 7, 2019

 

An SC/ECC is responsible for:

  • convening and facilitating SPT meetings, as necessary, to conduct transition planning and to develop and implement the individual’s Form 1053, Transition Plan, regardless of the program chosen by the individual;
  • 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 in accordance with Section 6300, Developing and Revising the Transition Plan; and
  • coordinating with the MCO SC and RS, as needed, in accessing community resources the individual may need or be eligible for, including transportation, housing, medical, dental and other services.

For an SPT meeting convened by the SC/ECC, the SC/ECC 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 SC/ECC must ensure that member’s name is included on the sign-in sheet. The SC/ECC must maintain all sign-in sheets.

 

6210 SPT Meeting Participation by Service Coordinator/Enhanced Community Coordinator and Habilitation Coordinator

Revision 19-0; Effective July 7, 2019

 

 

 

6210.1 Service Coordinator/Enhanced Community Coordinator Participation

Revision 19-0; Effective July 7, 2019

 

An SC/ECC must participate in person or by phone at all quarterly SPT meetings convened by the HC.

 

6210.2 Habilitation Coordinator Participation

Revision 19-0; Effective July 7, 2019

 

An HC must participate in person or by phone at all SPT meetings convened by the SC/ECC.

 

6300 Developing and Revising the Transition Plan

Revision 19-0; Effective July 7, 2019

 

In conjunction with the SPT, the SC/ECC develops and revises, as needed, an individual’s Form 1053, Transition Plan. The SC/ECC must develop Form 1053, or revise it, as needed, within 10 days after the SPT meeting.

 

6310 Transition Plan

Revision 19-0; Effective July 7, 2019

 

Information documented on Form 1053, Transition Plan.

Section 1, Individual Information — Name on the individual, CARE ID, Medicaid number and date.

Section 2, Community Program Choice — This section identifies the community program selected by the individual/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 face-to-face meetings between the individual and the SC/ECC, which are pre-printed on the form. The duration of service coordination is throughout the transition process, and the frequency of face-to-face visits is at least monthly. This section also lists all the activities to be coordinated and monitored by the SC/ECC during the transition process.

Section 4, Identified Supports — This section describes all supports the individual 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 individual’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 of time in which a post-move monitoring visit must be conducted by an SC/ECC.

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 an individual. Complete the information 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 SC/ECC to affirm that the Transition Plan was developed based on SPT decisions and includes the SC’s printed name, signature and date.

 

6320 Barriers Preventing a Transition to the Community

Revision 19-0; Effective July 7, 2019

 

The SC/ECC 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 barrier the SPT may identify;
  • ensure the SPT discusses the barriers, with the SPT identifying possible solutions to the barriers, 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 Individual’s Transition Packet

Revision 19-0; Effective July 7, 2019

 

A complete transition packet for an individual has:

 

6340 Individual Profile

Revision 19-0; Effective July 7, 2019

 

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

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

 

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

Revision 19-0; Effective July 7, 2019

 

The SC/ECC is responsible for providing a copy of the individual’s Form 1053, Transition Plan, to all SPT members when it is developed and whenever it is revised.

An SC/ECC must share an individual’s transition packet with an SPT member upon request.

 

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

Revision 19-0; Effective July 7, 2019

 

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

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

 

6400 Pursuing the Selected Community Medicaid Program for Transition

Revision 19-0; Effective July 7, 2019

 

If the individual/LAR chooses the:

  • HCS program, the SC/ECC is responsible for notifying the diversion coordinator to request a transition slot from HHSC as described in Section 6500, Transitioning to the HCS Program, below.
  • CLASS or DBMD program, the SC/ECC works with the RS to request a slot through the CLASS or DBMD interest list unit at HHSC.
  • HCBS program, the SC/ECC works with the RS and MCO SC to arrange for the individual to enroll in the HCBS program.
  • ICF/IID program, the SC/ECC is responsible for assisting the individual/LAR in identifying community ICFs with a vacancy.

 

6500 Transitioning to the HCS Program

Revision 19-0; Effective July 7, 2019

 

HHSC may make available a targeted NF HCS transition slot for an individual 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 19-0; Effective July 7, 2019

 

An individual is eligible for a targeted NF HCS transition slot if:

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

 

6520 Requesting a Targeted NF HCS Transition Slot

Revision 19-0; Effective July 7, 2019

 

If a LIDDA determines that an individual meets the criteria for a targeted NF HCS transition slot, the SC/ECC notifies the diversion coordinator to request a targeted NF HCS transition slot for the individual by completing and submitting Form 1046, Request for HCS Adult NF Transition Slot, in accordance with 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 individual meets the criteria for the targeted NF HCS transition slot, HHSC will send a letter to the LIDDA authorizing the LIDDA to offer the individual the opportunity to enroll in HCS. The LIDDA enrolls the individual in the HCS program in accordance with 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 19-0; Effective July 7, 2019

 

For an individual transitioning to the community by enrolling in the HCS program, the SC/ECC:

  • facilitates trial visits to HCS program providers in the community for the individual, including overnight visits where feasible, as requested by the individual or LAR;
  • develops and revises, as necessary, Form 8665, Person-Directed Plan, using all available assessments, and to include the individual’s:
    • strengths and preferences; and
    • medical, nursing, clinical, nutritional management and 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 individual transitions; and
  • completes the following activities before the individual 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.

 

6600 Transitioning to a Community Medicaid Program

Revision 19-0; Effective July 7, 2019

 

When a slot has been offered to an individual who has selected a community Medicaid program that is not HCS, the SC/ECC:

  • facilitates trial visits to providers in the community for the individual and LAR, as requested by the individual or LAR;
  • assists with service planning by:
    • making available to the entity responsible for service planning all available assessments; and
    • addressing the individual’s:
      • strengths and preferences; and
      • medical, nursing, clinical, nutritional management and support needs; and
  • 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 individual transitions; and
  • completes the following activities before the individual 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.

 

6700 Transition Day

Revision 19-0; Effective July 7, 2019

 

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 SC/ECC is encouraged to be present as well.

 

6800 Post-transition to HCS Program

Revision 19-0; Effective July 7, 2019

 

 

 

6810 Post-move Monitoring Visits

Revision 19-0; Effective July 7, 2019

 

For an individual who transitioned to the HCS program, an SC/ECC 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 days after the individual's move at the following times**:
    • within the first seven days after enrollment in the HCS program;
    • between eight and 45 days; and
    • between 46 and 90 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 any 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 SC/ECC 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 days after enrolling in HCS.

 

6820 Monitoring Activities for One Year Post-move

Revision 19-0; Effective July 7, 2019

 

For at least one year after an individual has transitioned to the HCS program, an SC/ECC must:

  • conduct monthly face-to-face visits with the individual, 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 individual’s needs or if requested by the individual or LAR;
  • revise Form 8665, Person-Directed Plan, as necessary, and coordinate the individual’s services and supports;
  • inquire about any recent hospitalizations, emergency department contacts, increased physician visits or other crises, including medical crises, and if the individual experiences such, convene the HCS SPT to identify all necessary revisions to the individual's Form 8665 to address additional need for services;
  • ensure the individual 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 individual’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 individual’s needs are being met; and
    • monitoring critical incidents involving the individual and convening the HCS SPT to develop a plan for needed prevention or intervention services for the individual; and
  • monitor the individual while on suspension from the HCS program at least monthly, maintain communication with the program provider and provide reports to HHSC upon request.

 

6900 Post-transition into a Medicaid Community Program

Revision 19-0; Effective July 7, 2019

 

For an individual who has transitioned to a Medicaid community program that is not HCS, an SC/ECC 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 days after the individual's move at the following times:
    • within the first seven days after transition;
    • between eight and 45 days; and
    • between 46 and 90 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 any 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 SC/ECC 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 individual enrolled in the CLASS, DBMD or ICF program. The LIDDA may use enhanced community coordination funds if an ECC conducts the activities described in this section.