9000, Enhanced Community Coordination Responsibilities for State Supported Living Center and Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions Diversions and Transitions

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Revision 24-1; Effective March 1, 2024

Enhanced Community Coordination (ECC) helps people with intellectual or developmental disabilities move to homes in the community from:

state supported living centers (SSLCs); or
private medium to large intermediate care facilities for individuals with an intellectual disability or related conditions (ICF/IIDs) with nine or more beds.

All people transitioning or diverting from an SSLC or private medium or large ICF/IID and enrolling in a 1915(c) waiver are eligible to receive ECC.

Note: Refer to the Intellectual and Developmental Disability Preadmission Screening and Resident Review (IDD-PASRR) Handbook for ECC responsibilities about diversion from admission to, or transition from, a nursing facility.

9100 Duties Related to Transitioning or Diverting from an ICF/IID or SSLC

Revision 24-1; Effective March 1, 2024

For all people receiving a crisis diversion or transitioning from a state supported living center (SSLC) or medium or large intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), the local intellectual and developmental disability authority (LIDDA) must ensure an assigned Enhanced Community Coordination (ECC) coordinator:

is assigned immediately once a 1915(c) waiver slot is received, and by three business days after the slot is received;
complies with the rules governing service coordination for a person with an intellectual disability as required in 26 Texas Administrative Code (TAC) Chapter 331, LIDDA Service Coordination, and 26 TAC Section 263.901, LIDDA Requirements for Providing Service Coordination in the HCS Program;
provides intensive and flexible support to achieve success in a community setting, including arranging for support needed to prevent and manage a crisis, such as Transition Support Team (TST) or crisis respite;
provides pre- and post-transition services;
monitors the person as required by the LIDDA Performance Contract, for the first 365 days* after transition or diversion;
maintains a case load of no more than 30 people, even if the community coordinator provides service coordination to other people who are not covered under this section; and
enhances the person’s natural supports and promotes successful community living.

* Important: If, after 365 days of ECC, the service planning team (SPT) believes the person requires further enhanced monitoring, the ECC coordinator must contact IDDMFPSupport@hhs.texas.gov for guidance.

Note: SSLC transition monitoring must be performed by the Home and Community-based Services (HCS) service coordinator per 9540, Monitoring Activities for SSLC Transitions Only, of this handbook after the first year.

9110 ECC Funds

Revision 24-1; Effective March 1, 2024

Enhanced Community Coordination (ECC) funds are available to local intellectual and developmental disability authorities (LIDDAs) through the performance contract for a person transitioning to the community. The funds 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.

All other funds, including transition assistance services (TAS) and supplemental transition services (STS), must be exhausted, and all purchases must be approved before ECC designated funds may be used.

LIDDA staff may access ECC funds by completing Form 8658, Enhanced Community Coordination (ECC) Designated Funds Request and Authorization, and submitting it to the Money Follows the Person (MFP) unit at IDDMFPsupport@hhs.texas.gov.

9200 Enrollment in HCS as a Crisis Diversion

Revision 24-1; Effective March 1, 2024

For a person enrolling in Home and Community-based Services (HCS) as a crisis diversion, a local intellectual and developmental disability authority (LIDDA) must enroll the person in the HCS Program per the requirements in the HCS rules and 13000, Medicaid Program Enrollment Requirements. The LIDDA must ensure an assigned Enhanced Community Coordination (ECC) coordinator completes the following:

develops and revises, as necessary, a diversion plan using Form 1050, Nursing Facility or Crisis Diversion Plan, with the person and legally authorized representative (LAR);
develops a Person-Directed Plan (PDP) using Form 8665, Person-Directed Plan, per the HCS Program rules, using all available assessments and to include the person’s strengths and preferences; and
conducts a pre-move site review using Form 1042*, Pre-Move Site Review, to determine if supports are in place and any areas of concern have been addressed before the person enrolls in the HCS Program.

*The receiving LIDDA is responsible for conducting the pre-move site review and post-move monitoring visits when a transfer of LIDDAs occurs due to enrollment in HCS. Both LIDDAs are responsible for collaborating to ensure a smooth transition of services.

9300 Post Enrollment in HCS as a Crisis Diversion

Revision 24-1; Effective March 1, 2024

For one year after a person has enrolled in the Home and Community-based Services (HCS) Program as a crisis diversion, an assigned Enhanced Community Coordination (ECC) coordinator must:

conduct at least three onsite visits of community services delivery sites at the intervals described below to determine if supports continue to be in place, and concerns are being addressed, using Form 1043, Post-Move Monitoring:
- within seven days after enrollment in the HCS Program;
- between eight and 45 days; and
- between 46 and 90 days;
conduct monthly in-person visits with the person and monitor the delivery of all services and supports;
conduct HCS service planning team (SPT) meetings at least every 90 days, or more frequently if there is a change in the person’s needs or if requested by the person or legally authorized representative (LAR);
ensure the person receives timely assessments of behavioral, medical, nursing, specialized therapies and nutritional management needs, as necessary and as indicated on Form 8665, Person-Directed Plan (PDP);
monitor all services identified on the HCS PDP, including:
- reviewing the HCS Program provider’s implementation plans and provider records, as well as 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 provide 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 Texas Health and Human Services Commission upon request.

9400 Enrollment in HCS as an ICF/IID or SSLC Transition

Revision 24-1; Effective March 1, 2024

9410 Enrollment in HCS as an ICF/IID Transition

Revision 24-1; Effective March 1, 2024

For a person planning to transition from a medium to large intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) to the Home and Community-based Services (HCS) Program, a local intellectual and developmental disability authority (LIDDA) must ensure an assigned Enhanced Community Coordination (ECC) coordinator:

completes the initial in-person visit within seven business days of being assigned;
completes Form 1580, Texas Money Follows the Person Demonstration Project Informed Consent for Participation, as detailed in 13238, Money Follows the Person Demonstration Participation Process of this handbook;
develops and revises, as necessary, Form 8665, Person-Directed Plan (PDP), using all available assessments and identifying essential and non-essential supports, considering the PDP as the transition plan for ICF/IID transitions; and
conducts a pre-move site review using Form 1042, Pre-Move Site Review, to determine if essential supports identified in the PDP are in place and any areas of concern were addressed before the person enrolls in the HCS Program.

9420 Enrollment in HCS as an SSLC Transition

Revision 24-1; Effective March 1, 2024

For a person planning to transition from a state supported living center (SSLC) to the Home and Community-based Services (HCS) Program, the local intellectual and developmental disability authority (LIDDA) must ensure an assigned Enhanced Community Coordination (ECC) coordinator:

completes the initial in-person visit within seven business days of being assigned;
completes Form 1580, Texas Money Follows the Person Demonstration Project Informed Consent for Participation, as detailed in Section 13238, Money Follows the Person Demonstration Participation Process, of this handbook;
participates in developing the community living discharge plan (CLDP) with SSLC staff, as required by 26 Texas Administrative Code (TAC), Section 904.107, Community Living/Discharge Plan for Alternative Living Arrangements;
develops and revises, as necessary, Form 8665, Person-Directed Plan, using all available assessments;
gets and reviews a copy of the pre-move site review conducted by SSLC staff to determine if supports are in place and all areas of concern are being addressed; and
complies with the requirements in 26 TAC, Section 904.105, Arrangements for the Move to an Alternative Living Arrangement of an Individual Residing in a State MR Facility, using Form 8630, Continuity of Care.

9500 Post Enrollment in HCS as an ICF/IID or SSLC Transition

Revision 24-1; Effective March 1, 2024

9510 Post Enrollment in HCS as an ICF/IID Transition

Revision 24-1; Effective March 1, 2024

For a person who transitioned from a medium to large intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) to the Home and Community-based Services (HCS) Program, an Enhanced Community Coordination (ECC) coordinator must:

conduct at least three onsite visits of community services delivery sites* at the intervals described below to determine if all supports identified in the Person-Directed Plan (PDP) continue to be in place and any areas of concern are being addressed using Form 1043, Post-Move Monitoring:
- within seven days after enrollment in the HCS Program;
- between eight and 45 days; and
- between 46 and 90 days;
during the post-move monitoring visits:
- assess if supports continue to be in place;
- address any concerns of the person, program provider, staff or family member;
- identify any gaps in care; and
- address such gaps, if any, to reduce the risk of crisis, re-admission to an ICF/IID, or another negative outcome.

*Important: 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 if supports are still in place and any areas of concern are being addressed during the first 90 days after enrolling in HCS.

9520 Post Enrollment in HCS as an SSLC Transition

Revision 24-1; Effective March 1, 2024

For a person who transitioned from a state supported living center (SSLC) to the Home and Community-based Services (HCS) Program, an Enhanced Community Coordination (ECC) coordinator must:

conduct and document on Form 1055, LIDDA State Supported Living Center (SSLC) Transition Reporting, at least three onsite post-move monitoring visits of community service delivery sites* during the first 90 days after the person’s move at the following times:
- within the first seven days after enrollment in the HCS Program;
- between eight and 45 days;
- between 46 and 90 days; and
during the post-move monitoring visits:
- make sure supports identified in the Community Living Discharge Plan (CLDP) are in place;
- address any concerns of the person, program provider, staff or family member;
- identify any gaps in care; and
- address such gaps, if any, to reduce the risk of crisis, re-admission to an SSLC or another negative outcome.

Note: The receiving local intellectual and developmental disability authority (LIDDA) is responsible for conducting the post-move monitoring visits when a transfer of LIDDAs occurs because of enrollment in HCS. Both LIDDAs are responsible for collaborating to ensure a smooth transition of services.

9530 Monitoring Activities for One Year Post-Move

Revision 24-1; Effective March 1, 2024

For one year following a person’s transition from a state supported living center (SSLC) or medium to large intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) to the Home and Community-based Services (HCS) Program, the local intellectual and developmental disability authority (LIDDA) must make sure an Enhanced Community Coordination (ECC) coordinator:

conducts at least monthly in-person visits with the person;
conducts HCS service planning team (SPT) meetings at least every 90 days, or more frequently if the person’s needs change or the person or legally authorized representative (LAR) requests a meeting;
revises Form 8665, Person-Directed Plan, as necessary, and coordinates the person’s services and supports;
asks about any recent hospitalizations, emergency department contacts, increased physician visits or other crises, including medical crises. If the person experiences such, convene the HCS SPT to identify all necessary revisions to the person's Form 8665 to address the additional need for services;
makes sure the person receives timely assessments of behavioral, medical, nursing, professional therapies and nutritional management needs, as necessary, and as indicated on Form 8665;
records the person’s health care status sufficiently to readily identify when changes in the person’s status occurs;
conducts service planning;
makes sure the program provider implements services and monitors 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 if 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
monitors the person while on suspension from the HCS Program at least monthly, maintains communication with the program provider and provides reports to HHSC upon request.

9540 Monitoring Activities for SSLC Transitions Only

Revision 24-1; Effective March 1, 2024

For one year following a person’s transition from a state supported living center (SSLC) to the Home and Community-based Services (HCS) Program, the local intellectual and developmental disability authority (LIDDA) must also make sure the Enhanced Community Coordination (ECC) coordinator:

complies with the monitoring activities and agreement portions set forth in the community living discharge plan (CLDP);
submits reports beginning 90 days from the date of discharge to IDDMFPSubmissions@hhs.texas.gov and at least every 90 days using the SSLC transition report Form 1055, LIDDA State Supported Living Center (SSLC) Transition Reporting*; and
submits the written reports required above to the SSLC Admission Placement Coordinator (APC) and the HCS program.

For years two through five following a person’s transition from an SSLC to the HCS Program, the LIDDA must ensure an HCS service coordinator completes the following monitoring activities:

conducts in-person monitoring at least every 90 days; and
submits reports to IDDMFPSubmissions@hhs.texas.gov at least every 90 days using the SSLC transition report Form 1055.

*Important: Form 1055, along with the required monitoring notes are due the 15th of the month following the 90-day review period. Submissions received after the 15th day of the month will be considered late. If the 15th falls on a holiday or weekend, it is due the next business day. The in-person visit(s) must occur within the 90-day review period.

9600 Transition Planning from an SSLC to a Setting Other than the HCS Program

Revision 24-1; Effective March 1, 2024

For a person transitioning from a state supported living center (SSLC) to a setting other than the Home and Community-based Services (HCS) Program, a local intellectual and developmental disability authority (LIDDA) must make sure an assigned Enhanced Community Coordination (ECC) coordinator:

participates in developing the community living discharge plan (CLDP) with SSLC staff, per 26 Texas Administrative Code (TAC), Section 904.107, Community Living/Discharge Plan for Alternative Living Arrangements;
participates in the pre-move site review conducted by SSLC staff to determine if supports are in place and all areas of concern are being addressed; and
complies with the requirements in 26 TAC, Section 904.105, Arrangements for the Move to an Alternative Living Arrangement of an Individual Residing in a State MR Facility, using Form 8630, Continuity of Care.

9700 Post Transition from an SSLC to a Setting Other than the HCS Program

Revision 24-1; Effective March 1, 2024

For one year following a person’s transition from a state supported living center (SSLC) to a setting other than the Home and Community-based Services (HCS) Program, a local intellectual and developmental disability authority (LIDDA) must make sure an Enhanced Community Coordination (ECC) coordinator:

complies with the monitoring activities and agreement portions set forth in the community living discharge plan (CLDP);
conducts in-person monitoring at least every 90 days, or more frequently if indicated;
submits reports to IDDMFPSubmissions@hhs.texas.gov at least every 90 days using the SSLC transition report Form 1055, LIDDA State Supported Living Center (SSLC) Transition Reporting; and
submits the written reports required above to the SSLC Admission Placement Coordinator (APC) and the program provider as required in the Performance Contract.

9800 Readmission to an ICF/IID or SSLC

Revision 24-1; Effective March 1, 2024

If a person who has already received 365 days of Enhanced Community Coordination (ECC) is readmitted to a medium or large intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) or state supported living center (SSLC) and wants to return to the community, the ECC coordinator must determine if the person:

was in the facility for more than 30 calendar days; or
experienced a significant change of condition* during the readmission.

If the ECC coordinator determines the re-admission exceeded 30 calendar days or the person experienced a significant change of condition, the ECC coordinator must, per Sections 9400, 9510 and 9520 of this handbook:

participate in developing the community living discharge plan (CLDP) with SSLC staff, as required by 26 Texas Administrative Code (TAC), Chapter 904, Continuity of Services - State Facilities (SSLCs only);
develop and revise, as necessary, Form 8665, Person-Directed Plan (PDP), using all available assessments;
conduct a pre-move site review using the designated Texas Health and Human Services (HHSC) form, to determine if supports are in place and any areas of concern have been addressed before the person returns to the community;
conduct and document on the designated HHSC form at least three onsite post-move monitoring visits of community service delivery sites during the first 90 days after the person’s move at the following times:
- within the first seven days after enrollment in the Home and Community-based Services (HCS) Program;
- between eight and 45 days;
- between 46 and 90 days**; and
during the post-move monitoring visits:
- assess if supports identified in the CLDP or PDP are in place (Note: The CLDP is used only for SSLC transitions. The PDP is used as a transition plan for ICF/IID transitions);
- Document on the designated HHSC form:
  - all concerns of the person, program provider, staff or family member;
  - all identified gaps in care; and
- address any identified concerns or gaps in care to reduce the risk of crisis, re-admission to an ICF/IID or SSLC, or any other negative outcome.

*Significant change of condition: any change requiring additional services, equipment or minor home modifications such as new enteral feeding tube, respiratory equipment or wheelchair.

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

For a qualified person who has never received ECC who is admitted or readmitted to an ICF/IID or SSLC from the community, if the stay is for at least 60 calendar days, an ECC coordinator must initiate one year of ECC as outlined in section 9500, Post Enrollment in HCS as an ICF/IID or SSLC Transition, of this handbook, about monitoring activities for ICF/IID and SSLC transitions.

If a person is readmitted to an ICF/IID or SSLC while receiving their initial 365 days of ECC, ECC will resume upon discharge to the community. The 365-day time frame does not re-start. For example, if a person admits on day 181 of ECC and is put on suspension, when they discharge, ECC resumes on day 182.

A person who is readmitted to an ICF/IID or SSLC for the purpose of respite does not qualify for ECC upon discharge unless they were already receiving ECC at the time of readmission.