Revision 23-1; Effective Dec. 20, 2023

6610 Post-Move Monitoring Visits

Revision 23-1; Effective Dec. 20, 2023

For a person who transitioned to the HCS program, an ECC coordinator must:

  • conduct and document on Form 1043, Post-Move Monitoring, at least three onsite post-move monitoring visits of community service delivery sites* during the first 90 calendar days after the person’s move at the following times**:
    • within the first seven calendar days after enrollment in the HCS program;
    • between eight and 45 calendar days; and
    • between 46 and 90 calendar days; and
  • during the post-move monitoring visits:
    • assess whether essential supports identified in Form 1053, Transition Plan, are in place;
    • ensure concerns of the program provider, staff or family member are being addressed;
    • identify gaps in care; and
    • address such gaps, if any, to reduce the risk of crisis, re-admission to an NF or other negative outcome.

*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 whether supports continue to be in place and any areas of concern are being addressed during the first 90 calendar days after enrolling in HCS.

6620 Monitoring Activities for One Year Post-Move

Revision 23-1; Effective Dec. 20, 2023

For one year* after a person has transitioned to the HCS program, an ECC coordinator must:

  • conduct monthly in-person visits with the person, or more frequently if determined by the HCS SPT based on risk factors, and monitor the delivery of all services and supports;
  • conduct HCS SPT meetings quarterly, or more frequently if there is a change in the person’s needs or if requested by the person or LAR;
  • revise Form 8665, Person-Directed Plan, as necessary, and coordinate the person’s services and supports;
  • inquire about any recent hospitalizations, emergency department contacts, increased physician visits or other crises, including medical crises, and if the person experiences such, convene the HCS SPT to identify all necessary revisions to the person’s Form 8665 to address additional need for services;
  • ensure the person receives timely assessments of behavioral, medical, nursing, professional therapies and nutritional management needs, as necessary, and as indicated on Form 8665;
  • record health care status sufficient to readily identify when changes in the person’s status occurs;
  • conduct service planning, ensure the program provider’s implementation of services, and monitor all services identified on Form 8665, including:
    • reviewing the HCS program provider’s implementation plans and provider records;
    • visiting service delivery sites, as needed, to determine the 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
  • monitor the person while on suspension from the HCS program at least monthly, maintain communication with the program provider, and provide reports to HHSC upon request.

*If, after one year of ECC, the SPT believes the individual requires further enhanced monitoring, the ECC coordinator must contact for further guidance.