2500, Service Planning

2510 Service Plan Development

Revision 17-1; Effective March 15, 2017

Program Standard: Case workers must develop service plans that accurately authorize appropriate services for individuals based on individual needs, eligibility and priority level.

After the completion of Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, to assess the needs and unmet need of the individual, discuss service planning with the individual and/or his family members. Consider all possible resources that may be available through Community Care Services Eligibility (CCSE) services or other community resources. Evaluate if the individual is interested in receiving Home-Delivered Meals, Emergency Response Services or attending Day Activity and Health Services (DAHS) or other community centers. Be sure to review Form 2110, Community Care Intake, and address all services requested at the time of intake. Document any decisions made regarding the use of those services.

To the extent of their abilities, eligible individuals must be involved in the development of their service plans. Discuss service planning with an individual or his caregivers during the initial visit to his home. Whenever possible, complete service planning during the visit. If this is not possible, service planning may be completed after the home visit and after financial eligibility has been determined.

The discussion with the individual (and caregivers) should include the type of services that may be appropriate for purchase after unmet need has been addressed and determined. To maintain self-sufficiency and a level of independence, allow the individual the opportunity to continue performing tasks he prefers to do himself, even though they may be difficult for him. Explain to the individual 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 home visit, ensure that the individual fully understands exactly what HHSC may provide, the limitations of HHSC services and the importance of the existing caregiver arrangement to the development of a service plan.

The service plan should reflect consideration of all these factors:

  • individual's existing problems that resulted in an application for CCSE services;
  • individual's physical and mental health;
  • individual's functional capacities for self care;
  • individual'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 individual;
  • individual's home environment and available community resources;
  • severity of the individual's medical and physical problems and the level of risk the problems cause;
  • other HHSC services necessary to help the individual maintain self-sufficiency, including referral to Adult Protective Services when appropriate;
  • additional services available in the individual's community (The 71st Texas Legislature passed Senate Bill 487 that requires, when appropriate to the individual's needs, the use of services provided by other state agencies. See Appendix XV, Services Available from Other State Agencies);
  • services being provided to other individuals in the household;
  • information secured from the individual's practitioner, friends or associates that may be necessary to develop a service plan suitable for the individual's needs;
  • number of service units to be authorized and the rationale for the authorization;
  • dates on which 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; and
  • the case narrative.

2511 Caregiver Arrangements

Revision 17-1; Effective March 15, 2017

Discuss with the individual, 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, that are marked "C" for caregiver. Be sure the individual and family members understand CCSE services are not intended to serve as a supplement to income. Decisions about service plans cannot be based upon the family's income or financial needs.

2512 Caregiver Support

Revision 17-1; Effective March 15, 2017

Caregiver support is defined as providing relief to a caregiver who provides the majority 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 in order to provide relief.

Examples: Caregiving responsibilities prevent the individual's caregiver from leaving the house to conduct personal business or do the family shopping or the caregiver needs time away from his caregiving duties on a regular basis due to his 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 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: There are a number of services provided through the local Area Agencies on Aging designed to support caregivers. Service availability varies by region. For service availability in a particular area, provide the toll-free telephone number, 1-800-252-9240, to persons interested in potential services.

2513 Caregiver as the Paid Attendant

Revision 17-1; Effective March 15, 2017

If the caregiver expresses an interest in being the paid attendant, inform the caregiver and applicant that the case worker cannot recommend to the provider who to hire as the paid attendant. It is the provider's responsibility to hire an attendant. Individuals who want a specific person to be the attendant should be encouraged to discuss this with provider staff. The case worker must explain to the potential attendant that he will be an employee of a home and community support services agency. He must be able to provide the tasks needed and work the complete specified schedule that will be developed by the provider and the applicant. His performance will be monitored and evaluated by the provider and the case worker.

The case worker must also explain to the applicant and the caregiver that the tasks listed as "C" (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 as long as 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 will be 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 quits a job to provide care for the individual may also be considered as a potential attendant. The case worker must obtain verification the caregiver quit employment within 30 days prior to 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 17-1; Effective March 15, 2017

The Texas Health and Human Services Commission (HHSC) is not responsible for selecting and hiring the individual'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 the paid attendant, the case worker documents this information in the Comments section on the initial and all subsequent submissions of Form 2101, Authorization for Community Care Services. The case worker enters "Do Not Hire" and the name of the individual 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 individual:
Abused, Neglected, Exploited, as Substantiated by Adult Protective Serviceshas abused, neglected or exploited the individual or others.
Parent of a Minor Childis 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 CASis the spouse of the PHC or CAS individual.
Unwilling Household Memberis not willing to help the individual with any of the tasks the individual needs.
Caregiver Supportcaregiver needs relief from providing continuous care and the authorization for purchased services is based on caregiver support.
Individual Designatedis a particular person the applicant/individual does not want hired as the paid attendant.
Caregiver/Paid Attendant at Reassessmentis no longer able or willing to provide tasks previously designated as caregiver tasks. The caregiver may not be hired for those tasks. (See Section 2664, Redetermination of Unmet Need.)

Beyond these limitations, the case worker 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 17-1; Effective March 15, 2017

The applicant has freedom of choice when it comes to his living arrangements. Case workers are, however, required to consider if the individual's needs can be met in the environment chosen by applicant.

Consider the individual's ability to understand whether the services the Texas Health and Human Services Commission (HHSC) can provide are adequate to meet his needs. If the individual 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 individual and the responsible person.

Explain the limitations of Community Care Services Eligibility (CCSE) services and determine how the individual's special needs will be met. Explore the possibility of alternative living arrangements, if feasible and necessary. If the individual insists on remaining in his current residence, despite the fact that his needs may not be met in that environment, assess his mental capacity for making an informed choice and whether he understands the consequences of that choice. See Section 2550, Identifying Individuals at Risk, for additional information.

If he is capable of informed consent, respect his choice and develop a service plan accordingly. If he appears 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 17-1; Effective March 15, 2017

It is acceptable to allow delivery of services intended for the home environment to be provided in alternate locations. Hours diverted to provide services to the individual in alternate locations may not be added back into the service plan. For example, an individual's service authorization includes an hour each day for feeding/eating. The individual will also need this help during a visit to his sister who lives 20 miles away, which will add an additional hour to the time needed to provide this assistance. The individual opts to divert an hour allocated for laundry to feeding/eating in order to make the visit. This hour cannot be added back into the service plan in order to provide the amount of time required to do the laundry.

Do not anticipate the need for additional hours based on delivery of services outside the home and build that time into the service plan. It is also unacceptable for additional hours to be approved because the extra time expenditure does not allow the attendant enough time to do some other task. Hours authorized will be based solely on services that are assumed to be provided within the home environment.

When individuals 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 individual requested these services. The actual transportation, as well as transportation cost, is the responsibility of the individual.

2523 Freedom of Choice in Agency Selection

Revision 17-1; Effective March 15, 2017

Once it appears that the applicant will 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 his choice or to consult with family members or other resources, leave the applicant a return envelope or make arrangements to pick up the agency choice list when the decision is made.

If the applicant refuses to make a choice from all of 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. The rotation log must be maintained and kept up to date.

2530 Other Resource Services

Revision 17-1; Effective March 15, 2017

When determining unmet need, also identify and examine other agencies' services that the individual now receives or is eligible to receive. This prevents service duplication and ensures all service resources have been pursued. Refer to Appendix XV, Services Available from Other State Agencies, for information about services that may benefit the individual. Document the use of other service resources on Form 2059-W, Summary of Individual's Need for Service Worksheet, Item 7. If possible, document information about other service resources in the Service Authorization System Online (SASO) "Support Assisting Client window". If that is not feasible, document using the WordPad function. See Section 7330, Narrative Documentation for SASO Wizards, for specific instructions.

All other services available to the individual 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 18-1; Effective June 15, 2018

Some individuals 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) for the purposes of coordinating and collecting 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 assist in maintaining program integrity and detecting 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 regarding 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 individuals 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) program. 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 case workers to contact the individual and verify the change in VA benefits. For individuals receiving A&A or HB, the case worker must discuss and document how the individual is using the benefits. A list of some of the items/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 individual remain independent and in the community, the case worker documents the information and no funds are applied to the service plan.

The individual may also use the funds to purchase:

  • PAS; or
  • home health aide services.

If the individual 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, this would be noted on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide, as services delivered by another agency. If the individual is able to purchase all the services required, then there is no unmet need and the individual would not be eligible for PAS. If the individual can only purchase part of the required 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 individual 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 individual'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 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 individual's unmet need is more than the benefits he can purchase, authorize the additional needed hours of PAS. Begin these calculations by using the actual number of hours required by the individual'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 individual receives VA benefits.

Example: An individual whose unmet need requires 20 hours per week of PHC receives A&A benefits. Dividing the amount of this individual'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 individual may be authorized 9 1/2 hours per week.

Explain this procedure to the individual. If the authorized hours cannot cover all of the purchased tasks that have been identified on Form 2060, then the individual and case worker 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 amount of savings generated by the application of VA funds. For example, an individual 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 17-1; Effective March 15, 2017

If an individual is receiving or is eligible to receive Medicare/Medicaid skilled home health (SHH) attendant care services, the tasks provided or potentially provided must be considered as resources available to the individual when determining unmet need. SHH is ordered for an individual by his physician and is provided over a short period of time in conjunction with illness.

Use regional procedures to refer any applicant/individual 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 utilized and both services may even be provided on the same day. If an individual is receiving SHH attendant care, determine exactly which services are being delivered and ensure they will not be duplicated by any CCSE service that may be needed by the individual. If SHH provided attendant care on some but not all of 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 individual 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 not be duplicated by any other CCSE service that might be authorized, and is not a consideration in determining 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 individual. If duplication of tasks would occur by authorizing a CCSE service, denial and/or a later revision to the service plan may be necessary.

2533 Hospice Services

Revision 17-1; Effective March 15, 2017

When Medicaid recipients elect the Medicaid Hospice Program, they waive their rights to other programs with Medicaid services related to treatment of the terminal illness(es). 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 individual in a hospice program does not affect eligibility for Community Care Services Eligibility (CCSE) programs.

If an individual chooses to receive hospice services and some of the individual's needs will not be adequately met by the hospice agency, assess the individual and authorize services for the individual's remaining needs on the same basis as any other individual.

For more detailed information about the Hospice program, see Section 2745, Individuals Who Need Hospice Services.

2534 Mutually Exclusive Services

Revision 17-1; Effective March 15, 2017

To determine unmet need for a particular Community Care Services Eligibility (CCSE) service, or determine if an individual can receive other HHSC services, ask the individual or family members if the individual is receiving another HHSC service. Check the Service Authorization System Online (SASO) and the Client Assignment and Registration (CARE) system for services and refer to Appendix XX, Mutually Exclusive Services. See Section 4000, Specific CCSE services.

2534.1 Services Through the Texas Home Living Waiver

Revision 18-1; Effective June 15, 2018

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). See Appendix XX, Mutually Exclusive Services

Case workers must review the services received through TxHmL before authorizing CCSE services to assure there is no duplication of tasks and there is an unmet need for the service. Individuals must meet the eligibility requirements for the specific CCSE service requested. The case worker 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 17-1; Effective March 15, 2017

Some services needed by aged and disabled individuals may be performed by volunteers. When developing an individual's service plan, consider whether volunteers from community resources might meet some of the individual's needs.

Volunteer help may include:

  • shopping and paying bills;
  • transportation;
  • telephone 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 major tasks for functionally disabled individuals. 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 elderly and disabled shut-ins.

Before completing a plan that includes volunteers, discuss the idea fully with the individual and his family or caregiver. If an individual is served completely through planned volunteer services, the case worker may keep the case open as "case management only" as long as the individual's condition warrants regular monitoring. In the case narrative, document all volunteer resource development and 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 Individuals at Risk

Revision 17-1; Effective March 15, 2017

An individual whose unmet medical or functional need constitutes a potential hazard to his health or safety may need individualized case management and monitoring procedures to minimize immediate dangers and to prevent deterioration of his condition. The case worker may identify the unique problems of these individuals at the time of assessment and reassessment, or regional nurses may note them during utilization review visits. Provider staff may also alert the case worker. Address these problems in the individual'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 individual'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 an individual has certain medical, physical and social characteristics that endanger his health and safety in his current living arrangement. Factors that contribute to critical risk are the individual's level of functional impairment, his medical condition, the quality and strength of his caregiver arrangement, and the physical and social conditions of his immediate environment.

The following characteristics are indicators of potential critical-risk situations. If two or more of these are present in an individual or in his situation, the case worker must decide whether he should be handled as an individual at risk.

  • The individual has a score of 40 or higher on Form 2060.
  • No caregiver is available to provide needed assistance or the individual's caregiver may:
    • be unable or unwilling to provide the necessary care; or
    • exhibit abusive, neglectful behavior.
  • The individual 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 individual may be immobile or nonambulatory or may need total assistance with feeding, toileting or medication and exhibit inability to maintain his personal safety.
  • The individual 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 individual's home may be insufficient to provide a safe environment.

Document the critical-risk decision and the reasons for it on Form 2084, Risk Management Team Meeting Summary, and in the case narrative if more space is needed.

2551 Case Worker Actions for Individuals at Risk

Revision 18-2; Effective November 19, 2018

The case worker must discuss the individual's needs and the critical conditions with the unit supervisor and any other person who may have identified the problems. The case worker and unit supervisor determine whether a risk management team meeting is necessary. If necessary, the case worker will:

  • organize and coordinate a team meeting. Include, as needed, 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 individual at risk, the options for dealing with those circumstances and the individual's capacity to consent. Determine whether a team visit to the individual's home is necessary.
  • discuss and agree on how often and by whom monitoring contacts will be made. Document the monitoring plan in the case narrative or according to regional requirements.
  • use information from team members and document the individual'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 individual's home, if necessary. (All team members may not need to attend.) Discuss with the individual, his family and caregiver:
    • specific circumstances that place the individual at risk,
    • options for dealing with those circumstances, and
    • 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 individual, his family members and caregivers. Make certain they understand the proposed service plan and the limitations of CCSE services. If the individual has not previously signed Form 2307, Rights and Responsibilities, have him, a family member or caregiver sign the form. If no one is willing to sign the form, record the refusal on the form and file it in the case record.
  • monitor the individual according to the monitoring plan, documenting contacts in the case narrative until the circumstances or problems that caused the individual to be at critical risk are as stabilized as possible, or until the individual'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 individual's situation or as indicated in the monitoring plan.

If the team members disagree about whether an individual is at risk, the person who first identified the critical-risk indicators should document in the case record the:

  • individual's situation that puts him at risk;
  • notification of other appropriate parties, including the case worker'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 in the discussion process, the regional director makes the final decision.

If, during the service planning process, staff become aware the individual's mental and physical health needs are not likely to be adequately met by authorized HHSC services, inform the individual and his family about alternative living arrangements and nursing home care, if appropriate. Document this conference and the individual's response in the case narrative or on Form 2084. The individual and his family decide whether he is to remain in his present living arrangement, using the available services. The individual is free to refuse any or all services offered.