2500, Service Planning
2510 Service Plan Development
Revision 24-5; Effective Nov. 1, 2024
Program Standard: Caseworkers must develop service plans that accurately authorize appropriate services for people based on their needs, eligibility and priority level.
After completing Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, to assess the needs and unmet needs of the person, discuss service planning with the person or their family members. Consider all possible available resources through Community Care Services Eligibility (CCSE) services or other community resources. Evaluate if the person is interested in receiving Home-Delivered Meals (HDM), Emergency Response Services (ERS), or attending Day Activity and Health Services (DAHS), or other community centers. Review Form 2110, Community Care Intake, and address all services requested at the time of intake. Document any decisions made about the use of those services.
To the extent of their abilities, eligible people must be involved in the development of their service plans. Discuss service planning with a person or their caregivers during the initial visit. Whenever possible, complete service planning during the visit. If this is not possible, service planning may be completed after the visit and after financial eligibility has been determined.
The discussion with the person, and caregivers, should include the type of services that may be appropriate for purchase after the unmet need has been addressed and determined. To maintain self-sufficiency and a level of independence:
- Allow the person the opportunity to continue performing tasks they prefer to do themself, even though they may be challenging for them.
- Explain to the person that Texas Health and Human Services Commission (HHSC) programs are not designed to replace the care that caregivers now provide or are able and willing to provide over time.
- At the conclusion of the initial visit, ensure that the person fully understands precisely what services HHSC may provide, the limitations of HHSC services, and the importance of the existing caregiver arrangement in the development of a service plan.
The service plan should reflect consideration of all these factors:
- person's existing problems that resulted in an application for CCSE services;
- person's physical and mental health;
- person's functional capacities for self-care;
- person's need for, or availability of, self-help or adaptive devices;
- existing caregivers and the specific amounts and types of assistance they give and can continue to give the person;
- person's home environment and available community resources;
- severity of the person's medical and physical problems and the level of risk the problems cause;
- other HHSC services necessary to help the person maintain self-sufficiency, including referral to Adult Protective Services when appropriate;
- additional services available in the person's community:
- The 71st Texas Legislature passed Senate Bill 487 which requires, when appropriate to the person's needs, the use of services provided by other state agencies.
- Review Appendix XV, Services Available from Other State Agencies.
- services provided to other people in the household;
- information secured from the person's practitioner, friends, or associates that may be necessary to develop a service plan suitable for the person's needs;
- number of service units to be authorized and the rationale for the authorization;
- dates that services are expected to begin; and
- any special monitoring or case management procedures to be followed.
Document service planning information on:
Form 2110, Community Care Intake;
Form 2059-W, Summary of Individual's Need for Service Worksheet, which is entered in the Service Authorization System for Form 2059, Summary of Client's Need for Service;
Form 2101, Authorization for Community Care Services;
Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, which is entered in the Service Authorization System.
2511 Caregiver Arrangements
Revision 24-5; Effective Nov. 1, 2024
Discuss with the person and any family members or caregivers that Community Care Services Eligibility (CCSE) services are not designed to replace the care family members and other caregivers now provide or are able and willing to provide over time. Explain that the existing caregiver arrangement is very important to the development of a service plan. If possible, confirm with the caregivers that they are able and willing to perform the tasks listed on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, which are marked C for the caregiver.
Be sure the person and family members understand that CCSE services are to serve as something other than a supplement to income. Decisions about service plans cannot be based on the family's income or financial needs.
2512 Caregiver Support
Revision 24-5; Effective Nov. 1, 2024
Caregiver support is providing relief to a caregiver who provides most of the applicant's care or continual care for the applicant. This support is always provided by an attendant other than the applicant's regular caregiver. Caregiver support may be appropriate when the initial functional assessment results in no unmet need, but the caregiver needs relief. The paid attendant will provide some of the tasks that the caregiver has been performing to give relief.
Examples: Caregiving responsibilities prevent the person's caregiver from leaving the house to conduct personal business or do the family shopping. Or, the caregiver needs time away from their caregiving duties on a regular basis due to their health needs or for periods of rest due to the continual care.
Discuss with the caregiver how many days per week and what tasks may be needed to provide relief. Mark the appropriate items on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide with a P, and document on each task in the comments section when that support care is needed. Indicate on Form 2101, Authorization for Community Care Services, that the service plan is for caregiver support and list the caregiver as someone not to be hired. Support care may be temporary. If so, authorize it only for the time needed.
Note: The local Area Agencies on Aging provide several services designed to support caregivers. Service availability varies by region. To find out if services are available in an area, provide the toll-free phone number 800-252-9240 to persons interested in potential services.
2513 Caregiver as the Paid Attendant
Revision 24-5; Effective Nov. 1, 2024
If the caregiver expresses an interest in being the paid attendant, inform them and the applicant that the caseworker cannot recommend to the provider who to hire as the paid attendant. It is the provider's responsibility to hire an attendant. Encourage people who want a specific person to be the attendant to discuss this with provider staff. The caseworker must explain to the potential attendant that they will be an employee of a home and community support services agency. They must be able to provide the tasks needed and work the complete specified schedule the provider and the applicant develop. Their performance will be monitored and evaluated by the provider and the caseworker.
The caseworker must also explain to the applicant and the caregiver that the tasks listed as C for caregiver under the service arrangement on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, must remain as caregiver tasks if the caregiver is hired as the paid attendant. Those tasks may not be purchased tasks if this caregiver is the paid attendant. If circumstances change and the attendant can no longer perform or is no longer willing to perform either the purchased tasks or the caregiver tasks, then the provider is requested to hire a new attendant for those tasks. The caregiver will be designated as someone not to be hired for those tasks on Form 2101, Authorization for Community Care Services.
In situations as described in Section 2433, Determining Unmet Need in the Service Arrangement Column, where the caregiver has recently quit employment to provide care, note the tasks the caregiver will continue to provide voluntarily and mark them as C in the service arrangement column of Form 2060. Other needed tasks may be purchased.
For ongoing cases, a caregiver who had been listed as working full time and quit a job to provide care for the person may also be considered as a potential attendant. The caseworker must get verification that the caregiver quit employment within 30 calendar days before the requested change. Any tasks previously identified as performed by the caregiver may not be purchased tasks.
2514 Who Cannot Be Hired as the Paid Attendant
Revision 24-5; Effective Nov. 1, 2024
The Texas Health and Human Services Commission (HHSC) is not responsible for selecting and hiring the person's paid attendant. The only role HHSC plays in the hiring process is notifying the provider when a particular person must not be hired.
Based on the following chart, if a person is identified as someone who must not be hired as a paid attendant, the caseworker documents this information in the Comments section on the initial and all later submissions of Form 2101, Authorization for Community Care Services. The caseworker enters Do Not Hire and the name of the person on the form. The following chart lists the persons who must not be hired and must be specified as Do Not Hire.
Do Not Hire: | If the person: |
---|---|
Abused, Neglected, Exploited, as Substantiated by Adult Protective Services | has abused, neglected or exploited the person or others. |
Parent of a Minor Child | is the legal or foster parent of the minor child receiving Community Attendant Services (CAS). There is no prohibition against hiring the parent of an adult child to be the paid attendant. |
Spouse in Primary Home Care (PHC) or CAS | is the spouse of the PHC or CAS person. |
Unwilling Household Member | is not willing to help the person with any of the tasks the person needs. |
Caregiver Support | caregiver needs relief from providing giving care and the authorization for purchased services is based on caregiver support. |
Person Designated | is a particular person the applicant or person does not want hired as the paid attendant. |
Caregiver/Paid Attendant at Reassessment | is no longer able or willing to provide tasks previously designated as caregiver tasks. The caregiver may not be hired for those tasks. (Review Section 2664, Redetermination of Unmet Need.) |
Beyond these limitations, the caseworker will not specify who cannot be hired as the paid attendant.
2520 Freedom of Choice
Revision 17-1; Effective March 15, 2017
2521 Freedom of Choice in Living Arrangements
Revision 24-5; Effective Nov. 1, 2024
The applicant has freedom of choice regarding their living arrangements. However, caseworkers are required to consider if the person's needs can be met in the environment chosen by the applicant.
Consider the person's ability to understand if the services the Texas Health and Human Services Commission (HHSC) can provide are enough to meet their needs. If the person has medical needs that cannot be addressed with personal care and housekeeping services, or if the environment poses a threat to health and safety, discuss these issues with the person and the responsible person.
Explain the limitations of Community Care Services Eligibility (CCSE) services and determine how the person's needs will be met. Explore the possibility of alternative living arrangements, if feasible and necessary. If the person insists on remaining in their current residence, even though their needs may not be met in that environment, assess their mental capacity for making an informed choice and if they understand the consequences of that choice. Review Section 2550, Identifying People at Risk, for additional information.
If they are capable of giving informed consent, respect their choice and develop a service plan accordingly. If they appear incapable of making an informed choice or if abuse, neglect, or exploitation is suspected, make a referral to Adult Protective Services.
2522 Service Delivery in Alternate Locations
Revision 24-5; Effective Nov. 1, 2024
It is acceptable to allow delivery of services meant for the home environment to be given in alternate locations. Hours diverted to provide services to the person in alternate locations may not be added back into the service plan. Example: A person's service authorization includes an hour each day for feeding or eating. The person will also need this help during a visit to their sister, who lives 20 miles away, which adds an hour to the time necessary to provide this help. The person opts to divert an hour allocated for laundry to feeding or eating to make the visit. This hour cannot be added back into the service plan to provide the amount of time required to do the laundry.
Do not anticipate the need for more hours based on the delivery of services outside the home and build that time into the service plan. It is also unacceptable to approve additional hours because the extra time expenditure does not allow the attendant enough time to do some other tasks. Hours authorized are based solely on services assumed to be provided in the home.
When people receive services outside the home, providers must document in the comments section of Form 3054, Service Delivery Record, the specific services provided and in which location. Documentation must also be available to substantiate the person who requested these services. The actual transportation, as well as the transportation cost, are the responsibility of the person.
2523 Freedom of Choice in Agency Selection
Revision 24-5; Effective Nov. 1, 2024
Once the applicant looks likely to meet the eligibility criteria for Community Care Services Eligibility (CCSE) services, offer the applicant the choice of selecting an agency contracted to deliver the requested service in the applicant's area. Either the applicant or the responsible person may make the selection. The selection must be documented on an agency choice list or other document in the case record.
If the applicant requests time to consider their choice or to consult with family members or other resources, leave the applicant a return envelope. You can also arrange to pick up the agency choice list when the decision is made.
If the applicant refuses to choose from all the contracted agencies in the service area, an agency may be selected for the applicant as a last resort. The selection is assigned from a regional agency rotation log, which must be maintained and kept up to date.
2530 Other Resource Services
Revision 24-3; Effective July 1, 2024
When determining unmet need, identify and examine the services of other agencies' that the person receives or is eligible to receive. This prevents service duplication and ensures all service resources are pursued. Refer to Appendix XV, Services Available from Other State Agencies, for information about services that may benefit the person. Document the use of other service resources on Form 2059-W, Summary of Individual's Need for Service Worksheet, Item 7. Document information about other service resources in the Service Authorization System Online (SASO) Support Assisting Client window.
All other services available to the person must be considered and used before services are authorized by the Texas Health and Human Services Commission (HHSC).
2531 Veterans Affairs Aid and Attendance and Housebound Benefits
Revision 24-5; Effective Nov. 1, 2024
Some people receive Aid and Attendance (A&A) or housebound benefits (HB) from Veterans Affairs (VA). These benefits must be considered the primary source of funds to pay for in-home services.
HHSC has an information sharing program between HHSC, the Texas Veterans Commission (TVC), and the Veterans Land Board (VLB) to coordinate and collect information about the use and analysis among state agencies of data received from the Public Assistance Reporting Information System (PARIS) VA match. The PARIS system is a federal-state partnership that provides states with detailed information and data to help maintain program integrity and detect improper payments.
This information-sharing program helps identify HHSC recipients who may be eligible for veteran’s benefits. HHSC creates a file of active recipients in the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), and Medicaid programs. The file of active recipients is sent to the Defense Manpower Data Center (DMDC) on a quarterly basis for PARIS matching. DMDC returns a file of the matched recipients with veterans’ benefit information back to HHSC. This file is shared with the TVC and VLB to contact veterans who may be eligible for benefits or may be eligible for increased benefits and report those benefits back to HHSC.
HHSC will receive reports about A&A and HB that may affect the level of service currently authorized for personal attendant services (PAS). HHSC will verify the information on any people currently receiving Community Attendant Services (CAS), Primary Home Care (PHC), Family Care (FC), Home and Community-based Services (HCS), Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiple Disabilities (DBMD), Texas Home Living (TxHmL), or STAR+PLUS Home and Community Based Services (HCBS) programs. Since financial eligibility for CAS is determined by HHSC, any changes to eligibility status will be processed by HHSC.
Actions Required Upon Receipt of the Report
When the report is received, the region must distribute the information to the assigned caseworkers so they can contact the person and verify the change in VA benefits. For people receiving A&A or HB, the caseworker must discuss and document how the person is using the benefits. A list of some of the items or services that can be purchased using A&A or HB funds includes:
- medical supplies;
- medical equipment;
- nursing services;
- therapy;
- skilled services;
- medications; or
- other medically necessary items.
If all the A&A or HB funds are being used to purchase items that help the person remain independent and in the community, the caseworker documents the information, and no funds are applied to the service plan.
The person may also use the funds to purchase:
- PAS; or
- home health aide services.
If the person is using the funds to purchase PAS or home health aide services, this must be considered when developing the plan of care. For FC, PHC, and CAS, note this on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, as services delivered by another agency. If the person can purchase all the services required, then there is no unmet need, and the person is not eligible for PAS. If the person can only purchase part of the necessary services, or if the funds are not used to purchase services, then the amount of the A&A or HB funds is applied to the purchase of attendant care per Form 2060 instructions.
If the funds are not used to purchase services that help the person remain independent and in the community, apply the funds to the purchase of non-skilled attendant care. Calculate the number of hours of non-skilled attendant care that could be paid for with the person's unused portion of A&A or HB. To do this, divide the unused portion of the monthly benefit by the maximum non-priority attendant care limit rate without regard to the service authorized. If the person meets the priority status criteria, use the maximum priority status attendant care limit rate. Subtract the resulting amount from the person's authorization. If the number of hours required by the person's unmet need is more than the benefits they can purchase, authorize the additional needed hours of PAS. Begin these calculations by using the actual number of hours required by the person's unmet need, even if this exceeds the maximum HHSC can purchase.
These procedures apply only to the purchase of PAS. Do not reduce the amount of other services because the person receives VA benefits.
Example: A person whose unmet need requires 20 hours per week of PHC receives A&A benefits. Dividing the amount of this person's A&A benefits by the current maximum attendant care limit rate yields 46 hours per month.
46 ÷ 4.33 = 10.6 hours per week
20 − 10.6 = 9.4 hours per week
This person may be authorized 9 1/2 hours per week.
Explain this procedure to the person. If the authorized hours cannot cover all of the purchased tasks that have been identified on Form 2060, then the person and caseworker should jointly decide which PAS tasks will be purchased and authorize only those tasks on Form 2101, Authorization for Community Care Services. Update the Service Arrangement Column of Form 2060 to match the tasks/hours authorized on Form 2101.
Reporting Requirements
Regional management will be required to report the savings generated by the application of VA funds. Example: A person requires 20 hours per week of PAS but is now receiving A&A funds. The A&A funds can purchase five hours per week, reducing the weekly service plan to 15 authorized hours per week. The cost of the five hours per week is reported as a savings for HHSC.
2532 Skilled Home Health Services
Revision 24-5; Effective Nov. 1, 2024
If a person is receiving or is eligible to receive Medicare or Medicaid skilled home health (SHH) attendant care services, the tasks provided or potentially provided must be considered as resources available to the person when determining unmet need. SHH is ordered for a person by their physician and is provided over a short period of time in conjunction with illness.
Use regional procedures to refer any applicant or person who requests or appears in need of SHH services.
It is possible to authorize other Community Care Services Eligibility (CCSE) services, including personal attendant services (PAS), at the same time SHH attendant care is being used. Both services may even be provided on the same day. If a person is receiving SHH attendant care, determine exactly which services are being delivered and ensure they will not be duplicated by any CCSE service that the person may need. If SHH provided attendant care on some but not all the days of a week, PAS may be authorized to provide attendant care on the other days, if needed. If SHH is providing all the personal care needed by the person but housekeeping services are needed, Family Care or Home-Delivered Meals may be suitable options to consider.
If SHH is providing only skilled nursing services by a registered nurse or licensed vocational nurse, the service would be unique from any other CCSE service that might be authorized and is not a consideration to determine unmet need. Consider how long SHH has been in use and how long it will continue as the CCSE service plan is developed with the person. If duplication of tasks would occur by authorizing a CCSE service, denial or a later revision to the service plan may be necessary.
2533 Hospice Services
Revision 24-3; Effective July 1, 2024
Medicaid recipients waive their rights to other programs with Medicaid services related to treatment of the terminal illness(es) when they elect the Medicaid Hospice Program. These waived services are limited to services also provided under Medicare. Recipients do not waive their rights to HHSC services unrelated to the treatment of the terminal illness(es). Therefore, participation of the person in a hospice program does not affect eligibility for Community Care Services Eligibility (CCSE) programs.
If a person chooses to receive hospice services and some of their needs will not be adequately met by the hospice agency, assess the person and authorize services for their remaining needs on the same basis as any other person.
Review Section 2745, People Who Need Hospice Services for more detailed information about the Hospice program.
2534 Mutually Exclusive Services
Revision 24-3; Effective July 1, 2024
Ask the person or family members if the person is receiving another HHSC service to determine:
- unmet need for a particular Community Care Services Eligibility (CCSE) service; or
- if a person can receive other HHSC services.
Check the Service Authorization System Online (SASO) and Texas Integrated Eligibility Redesign System (TIERS) for services and refer to Appendix XX, Mutually Exclusive Services. Review Section 4000, Specific CCSE services.
2534.1 Services Through the Texas Home Living Waiver
Revision 24-5; Effective Nov. 1, 2024
Due to the limited services provided through the Texas Home Living (TxHmL) waiver, some Community Care Services Eligibility (CCSE) services are not mutually exclusive and can be received at the same time as Texas Home Living (TxHmL). Review Appendix XX, Mutually Exclusive Services.
Caseworkers must review the services received through TxHmL before authorizing CCSE services. This is to ensure there is no duplication of tasks and there is an unmet need for the service. People must meet the eligibility requirements for the specific CCSE service requested. The caseworker must document there is no duplication.
2534.2 Targeted Case Management and Other HHSC Services or the STAR+PLUS Program
Revision 18-1; Effective June 15, 2018
Local Authorities (LAs) provide service coordination through Targeted Case Management (TCM) to Individuals with Intellectual and Developmental Disabilities (IDD) in the HHSC LA priority population.
TCM authorizations are processed through the Service Authorization System Online (SASO). TCM services are identified in SASO as Service Group 14, Service Code 12A or 12C. TCM can be authorized along with Home and Community-based Services (HCS), Texas Home Living (TxHmL) or as a general revenue (GR) service.
TCM and Other HHSC Services
Other HHSC waiver services (excluding HCS and TxHmL) are mutually exclusive with TCM. An individual receiving any of the following waiver programs cannot receive TCM at the same time:
- Community Living Assistance and Support Services (CLASS)
- Deaf Blind with Multiple Disabilities (DBMD) Waiver
If an individual on TCM is applying for one of these waivers, then the SASO Service Codes 40, 40A and 60, for assessments, pre-assessments and prescriptions, are the only service codes allowed to overlap with TCM service authorizations.
Since the waiver programs identified above provide more comprehensive services to the individual, they will take precedence over TCM services in order to maximize the benefit to the individual. The HHSC case worker must contact the LA to coordinate closing TCM for the waiver service to begin. Individuals receiving the STAR+PLUS program may receive TCM. These services are not mutually exclusive.
The Program for All-Inclusive Care for the Elderly (PACE) is not a waiver program but an all-inclusive program. PACE is mutually exclusive with all other services including TCM. See Appendix XX, Mutually Exclusive Services
TCM and Other HHSC Services
Determining whether an individual who receives TCM services can receive other HHSC services, including Community Care Services Eligibility (CCSE) services, depends on whether he is receiving TCM services through HCS, TxHmL or as a GR service.
Once the case worker identifies an individual is receiving TCM, he or a regional designee must check the Client Assignment and REgistration (CARE) system to determine if the individual is receiving HCS or TxHmL. If the individual is receiving HCS or TxHmL, the case worker must refer to Appendix XX, to determine if the individual can receive other HHSC services, as some services are mutually exclusive and others are not.
If the individual is receiving HCS or TxHmL and the requested CCSE service is mutually exclusive, then the case worker will contact the individual to allow a choice of services and document the individual's choice. If the individual elects to continue receiving HCS or TxHmL, then the request for CCSE services is denied. If the individual elects to receive the CCSE service, then the case worker must contact the LA to coordinate closing services.
If the individual is not receiving HCS or TxHmL and is receiving TCM as a GR service, then he can receive other CCSE services.
2535 Involvement of Volunteer Resources
Revision 24-5; Effective Nov. 1, 2024
Volunteers may perform some services needed by people who are older and people with disabilities. When developing a person's service plan, consider if volunteers from community resources might meet some of the person's needs.
Volunteer help may include:
- shopping and paying bills;
- transportation;
- phone reassurance;
- friendly visits;
- recreation activities, such as reading aloud, games, help with sewing, knitting, art, or other handwork; or
- writing letters.
Some organizations may contribute group volunteer efforts to accomplish significant tasks for people with functional disabilities. These tasks might include:
- clothing care and distribution;
- yard work;
- hauling trash;
- cleaning windows;
- critical home repair;
- construction of ramps and assistive devices in the house;
- provision of medical equipment or apparatus;
- facilitation of support groups for caregivers; and
- transportation for older people and people with disabilities who are shut ins.
Before finalizing a plan that involves volunteers, it's important to have a thorough discussion with the individual and their family or caregiver. If a person's needs are fully met through planned volunteer services, the case can be kept open as Case Management only. This means that the person's condition necessitates regular monitoring, but their needs are being met through volunteers. It's crucial to document all aspects of volunteer resources and their use.
2536 Program of All-Inclusive Care for the Elderly
Revision 18-1; Effective June 15, 2018
The Program of All-Inclusive Care for the Elderly (PACE) is an all-inclusive program that provides all required services for an individual enrolled in the program.
PACE Referral
- PACE services are available in designated areas of El Paso, Lubbock and Amarillo/Canyon.
- Bienvivir Senior Health Services has two sites in El Paso that provide PACE services to participants. For referrals of potential participants, contact the Intake Department at Bienvivir Senior Health Services by telephone at 915-599-8812.
- The Basics at Jan Werner has a site in Amarillo that provides PACE services to participants. For referrals of potential participants, contact The Basics at Jan Werner by telephone at 806-374-5516.
PACE Eligibility
To be eligible for PACE, the individual must:
- be at least 55 years old;
- be certified as nursing home eligible;
- meet medical necessity criteria for nursing facility care;
- choose PACE services; and
- reside in a designated catchment area.
PACE Services
The PACE interdisciplinary team provides preventative, rehabilitative, curative and supportive services in day health centers, homes, hospitals and nursing homes. Required services include all Medicare and Medicaid covered services and any other services the multidisciplinary team identifies as a need.
The PACE Integrated Model of Care includes any health-related service needed, including but not limited to:
- in-home services;
- day health care;
- primary care;
- acute hospital care;
- lab, x-ray and ambulance services;
- skilled nursing facility care;
- medical specialty services;
- all in-patient and out-patient medical care;
- specialty services such as dentistry and podiatry;
- social services;
- meals; and
- transportation.
Texas Health and Human Services Commission (HHSC) intake screeners in the catchment areas must be aware of the PACE service and referral procedures for the service. Intake screeners must provide information about PACE to individuals during the intake and referral process when the individual requesting services is determined to be 55 years of age or older and resides in a PACE service area. Individuals in the PACE catchment areas may request services through the local HHSC intake office or through the PACE service site.
Since PACE is an all-inclusive program, it is mutually exclusive with all other HHSC programs and STAR+PLUS programs. See Appendix XX, Mutually Exclusive Services
2540 Priority Status
Revision 23-1; Effective March 1, 2023
A recipient priority status is assigned if an applicant or recipient cannot perform one or more of the following ‘priority tasks’ without hands-on help from another person:
- feeding;
- eating;
- toileting;
- transfer; or
- meal preparation.
Assign priority status if at least one priority task is purchased and the recipient's:
- functional score for that task is 3; and
- support score for that task is 4.
Complete the service arrangement column on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide for each task where the recipient’s impairment score is 1, 2 or 3. Complete the support score column for each priority tasks where the recipient scores 3 and the service is being purchased.
If the attendant does not show up during a normally scheduled service shift, the recipient's health, safety or well-being may or may not be jeopardized. Always assess the potential impact on the recipient's health, safety or well-being when determining the effects of an attendant not providing service.
Do not designate a recipient as having priority status if the failure of the attendant to report to work would not result in any risk to the recipient's health, safety or well-being. If the recipient appears to be at risk (scores a 3 on a priority task with little or no caregiver support), document the reason(s) why a support score of 4 was not assigned.
In determining if health, safety or well-being is endangered, consider the worst result that might follow from the attendant not providing service.
Example: A recipient may have a friend who visits daily when they can, but the friend is regularly out of town on business. Determine the consequences of the attendant not showing up on a day when the recipient's friend is out of town.
Consider each recipient's condition and situation. One recipient may be able to miss a meal during a scheduled service shift because their caregiver will be home later to prepare the meal. Another recipient may not be able to miss a scheduled meal without risk to their health because of their nutritional needs or no caregiver to prepare the meal later. Contact the regional nurse if help is needed in assessing the risk that would result from an attendant not working during a scheduled shift.
Advise priority recipients of:
- the importance of being available in their homes during the hours designated in the service plan; and
- to contact the provider in advance if the recipient knows they will not be at home during a normally scheduled shift.
If information is received that a priority recipient will not be home, inform the provider.
Inform a priority recipient that the provider may monitor the attendant's work performance by making frequent calls or home visits. If a priority recipient objects to this increased monitoring of the attendant, the recipient has the option of withdrawing from priority status.
For priority cases, note in the comments section of Form 2101, Authorization for Community Care Services, this is a priority case. Use verbal referral procedures for new priority recipients negotiated with the provider.
Providers may not allow a service interruption for a recipient designated as priority status unless the:
- service interruption is caused by suspension of services;
- recipient is not at home when the attendant is scheduled to provide services; or
- recipient requests that services not be provided on specific days.
The provider must notify CCSE staff within seven calendar days of a priority recipient not receiving scheduled services. This notification is for CCSE staff's information only. No response is required. Do not approve or disapprove service interruptions for priority recipients.
Recipients can refuse priority status. If a recipient refuses priority status, document in the case record the recipient's decision and the reason for it.
Because the unit rate for priority recipients is higher than the rate for non-priority, the maximum allowable service authorization is less for priority recipients. A priority recipient receiving the maximum hours per week may not be able to receive another Community Care Services Eligibility service for which they may be eligible. This could exceed the total expenditures allowed by the average daily nursing facility rate. A priority recipient can exercise the option to receive less than the maximum hours to receive another needed service or they can decline priority status. CCSE staff must give the recipient the choice and explain the options, including the advantages or disadvantages of each. Document the recipient's decision in the case record.
Related Policy
Support Score and Establishing Priority, 2434
Negotiated Referrals, 2631
Priority Status Determination, 4624
Suspension of Services and Interdisciplinary Team Procedures, 4677
Cost Limit for Purchased Services, Appendix II
2550 Identifying People at Risk
Revision 24-5; Effective Nov.1, 2024
A person whose unmet medical or functional need constitutes a potential hazard to their health or safety may need individualized case management and monitoring procedures to minimize immediate dangers and to prevent deterioration of their condition. The caseworker may identify the unique problems of these people at the time of assessment and reassessment, or regional nurses may note them during utilization review visits. Provider staff may also alert the caseworker. Address these problems in the person's service plan and document the information on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, or on Form 2059-W, Summary of Individual's Need for Service Worksheet. This information is entered into Form 2059, Summary of Client's Need for Service, in the Service Authorization System. Consult with the unit supervisor and the regional nurse about threats to the person's health and safety and about unmet medical and functional need issues. Use a team approach to develop service and monitoring plans whenever necessary and feasible.
A critical level of risk exists when a person has specific medical, physical, and social characteristics that endanger their health and safety in current living arrangement. Factors that contribute to critical risk are the person's level of functional impairment, their medical condition, the quality and strength of their caregiver arrangement, and the physical and social conditions of their immediate environment.
The following characteristics are indicators of potential critical-risk situations. If two or more of these are present in a person or in their situation, the caseworker must decide if they should be handled as a person at risk.
- The person has a score of 40 or higher on Form 2060.
- No caregiver is available to provide needed assistance, or the person's caregiver may:
- be unable or unwilling to provide the necessary care; or
- exhibit abusive, neglectful behavior.
- The person may not have sufficient mental clarity to make an informed choice and understand the consequences of that choice (scores of 2 or 3 on Item 23, Form 2060).
- The person may be immobile or nonambulatory or may need total assistance with feeding, toileting, or medication and exhibit an inability to maintain their safety.
- The person may have complex health problems that create the need for skilled nursing assistance with personal care tasks, specialized technical skills in daily management of personal care, or total assistance with several personal care tasks.
- The person's home may need to be improved to provide a safe environment.
Document the critical-risk decision and the reasons for it on Form 2084, Risk Management Team Meeting Summary.
2551 Caseworker Actions for People at Risk
Revision 24-5; Effective Nov. 1, 2024
The caseworker must discuss the person's needs and the critical conditions with the unit supervisor and any other person who may have identified the problems. The caseworker and unit supervisor determine if a risk management team meeting is necessary. If necessary, the caseworker will:
- Organize and coordinate a team meeting. Include the provider supervisor, the unit supervisor and the regional nurse. If the situation indicates possible abuse, neglect, or exploitation, report this to Adult Protective Services staff at the Department of Family and Protective Services.
- Discuss with the team the specific circumstances that place the person at risk, the options for dealing with those circumstances, and the person's capacity to consent. Determine if a team visit to the person's home is necessary.
- Discuss and agree on how often and by whom monitoring contacts will be made. Document the monitoring plan per regional requirements.
- Use information from team members and document the person’s circumstances or condition on Form 2084, Risk Management Team Meeting Summary. Have available team members sign the form. Keep the original in the case record and provide copies to team members.
- Coordinate the team visit to the person's home, if necessary. All team members may not need to attend. Discuss with the person, their family, and caregivers:
- specific circumstances that place the person at risk;
- options for dealing with those circumstances;
- the proposed monitoring plan; and
- the limitations of Community Care Services Eligibility (CCSE) services.
- Discuss Attachment 2307-A, Family Care, Community Attendant Services and Primary Home Care Rights and Responsibilities, with the person, their family members, and caregivers. Make sure they understand the proposed service plan and the limitations of CCSE services. Review Form 2307, Rights and Responsibilities, with the person, family member or caregiver. The caseworker must sign the form and file it in the case record.
- Monitor the person per the monitoring plan, documenting contacts until the circumstances or problems that caused the person to be at critical risk are as stabilized as possible or until the person's circumstances or degree of risk changes. Coordinate monitoring contacts with provider staff and with the regional nurse.
- Conduct functional reassessments every 12 months, or more often if needed, depending on the person's situation or as indicated in the monitoring plan.
If the team members disagree about whether a person is at risk, the person who first identified the critical risk indicators should document the following:
- person's situation that puts them at risk;
- notification of other appropriate parties, including the caseworker's supervisor; and
- responses to the notification.
If service plan disagreements cannot be resolved through team discussions, the unit supervisor consults with the lead regional nurse and, if necessary, the program director. Any difficulties with providers that cannot be resolved through discussion should be reported to the contract manager. If the problem cannot be resolved during the discussion process, the regional director will make the final decision.
If, during the service planning process, staff become aware the person's mental and physical health needs are not likely to be adequately met by authorized HHSC services, inform the person and their family about alternative living arrangements and nursing home care, if appropriate. Document this conference and the person's response on Form 2084. The person and their family decide if they are to remain in their present living arrangement, using the available services. The person is free to refuse any or all services offered.