1100 Letter from DADS Commissioner

Revision 10-0; Effective June 1, 2010

Commissioner Letter 2010 (PDF) 

1200 Philosophy of Service Delivery

Revision 10-0; Effective June 1, 2010

A Historical Overview of Service and Supports for Individuals with Intellectual or Developmental Disabilities

Prior to 1960, the prominent model for providing services to individuals with intellectual or developmental disabilities (IDDs) was a medical model with services typically provided in an institutional setting. In the 1960s, a paradigm shift began that resulted in the development of other models of service delivery. In particular, Congress began to provide funds to states to begin developing services in community settings for the first time. Texas established community mental health and IDD centers in tandem with these changes in federal funding and expectations.

By the 1970s the federal government developed regulations and standards for treatment of individuals with intellectual or developmental disabilities who lived in institutions, which included requirements for developing Individual Program Plans (IPPs). These regulations and standards marked the shift from what was largely “custodial care” to a system that promoted “active treatment.” Active treatment, while still requiring that basic care needs be met, is notably different from custodial care by emphasizing the teaching of new skills to individuals with intellectual or developmental disabilities. Active treatment guidelines also required the individual to participate in the interdisciplinary team (IDT) that develops the individual’s IPP.

Following the adoption of the active treatment model, professionals and other stakeholders in the field began developing tools and resources to facilitate person-centered planning. The ultimate outcome of person-centered planning is to further improve the quality of life for people with disabilities. Person-centered planning represented a fundamental shift from service planning that required providers to keep people with disabilities safe to a service planning and service delivery system that provides supports necessary for individuals to achieve their desired outcomes.

In the 1980s the U.S. Health Care Financing Administration (HCFA), now the Centers for Medicare & Medicaid Services (CMS), started granting waivers from the existing Medicaid rules. Waivers allow states the flexibility to design alternatives to institutional services, including the option for states to provide services in community settings as an alternative to institutional settings. In 1985 the Home and Community-based Services (HCS) waiver program was developed by Texas to waive the requirements of intermediate care facilities for individuals with an intellectual disability or related conditions (ICF/IID) services. HCS allows flexibility in the development of services for individuals who have intellectual and developmental disabilities that choose to receive their services in the community instead of an institutional setting. The federal government requires HCS be cost-effective and to include safeguards to protect participants’ health and safety.

Current and Future Direction

Today we strive to support individuals with intellectual and developmental disabilities in achieving their desired lifestyles and in becoming valued members of the community by:

  • addressing health and safety issues in the context of their desired lifestyles;
  • offering opportunities to better achieve their goals; and
  • making the most efficient use of all available resources to accomplish these goals.

Thus, waiver services are shifting from prescribing service delivery to outlining minimum requirements that must be met when designing services to support people to achieve the lifestyles they desire. Developing services that capture what is important to and for individuals who receive HCS services, as well as balancing choice and protection of health and safety, is a challenge for the service delivery system.

The Department of Aging and Disability Services (DADS) uses the term person-directed planning instead of person-centered planning to talk about the ongoing planning process that helps to determine an individual’s life path. Person-directed planning ensures it is the individual who is directing the process.

DADS supports the expectation that every individual should have the opportunity to participate in the community, gain and maintain relationships of their choosing, express preferences, make choices, fulfill goals, and live with dignity and respect. Person-directed planning is used to represent an individual and their family’s vision about how the person wishes to live, including aspirations for the future. Person-directed planning challenges DADS, HCS providers and Local Authorities (LAs) to work in cooperation to provide meaningful services and supports for the individuals who receive services.

Person-Directed Planning in the Home and Community-based Services Waiver Program

The LA service coordinator (SC) uses a person-directed planning process to gather information necessary to develop a Person-Directed Plan (PDP) that accurately reflects the individual’s goals and desires. The PDP is a written plan developed for an applicant or individual in accordance with Form 8665, HCS Person-Directed Plan, and Appendix IV, Discovery Tool. It describes the supports and services necessary to preserve the applicant’s or individual’s health and safety, and to achieve the desired outcomes identified by the applicant or individual or legally authorized representative (LAR) on behalf of the applicant or individual. The person-directed planning process:

  • empowers the individual/LAR on behalf of the individual to direct the development of the plan of services and supports that meets the individual’s personal outcomes;
  • identifies existing supports and services necessary to achieve the individual’s desired outcomes;
  • identifies natural supports available to the individual and negotiates needed service system supports;
  • occurs with the support of a group of people chosen by the individual (and LAR on the individual’s behalf); and
  • accommodates the individual’s style of interaction and preferences regarding time and setting.

The SC, using the PDP Discovery Tool as a basis for information gathering, conducts interviews with the individual, LAR, provider staff or others who know the person well. The results of these information-gathering interviews are compiled to:

  • prioritize what outcomes and needs are included on the PDP; and
  • identify which outcomes and needs will be met through waiver services and which will be met through non-waiver services.

The individual, SC and the HCS provider develop the Individual Plan of Care (IPC) based on the PDP. The provider is then responsible for developing an Implementation Plan (IP) with the individual and LAR. The IP is a written document developed for each HCS Program service on the individual’s IPC not provided through the Consumer Directed Services option that identifies how HCS services will be implemented to accomplish the outcomes identified in the PDP.

The SC is expected to implement an ongoing person-directed planning process, not a single event planning process. In order to accomplish that, the SC will need to monitor and update the PDP as preferences or needs change and additional information is learned about the individual. When an individual’s preferences or needs change or additional information is discovered, the SC will notify the HCS provider and submit a copy of the HCS Person-Directed Plan Outcome Summary (Page 10 of Form 8665) that will identify the desired addition/change/deletion based on the individual’s preferences/needs. The program provider may then have to revise the IP(s) and/or IPC.

The system must be flexible enough to keep up with the current needs and wishes of the individuals who receive HCS services.

The desired outcome of the HCS service delivery model is to promote services and supports that contribute to the acquisition of meaningful outcomes for each individual. The success of this model depends on the individuals who receive HCS services, their LARs and family members, the program provider, the service coordinator and DADS. 

1300 Overview of Service Delivery System

Revision 10-0; Effective June 1, 2010

June 1, 2010, brings major changes to the Home and Community-based Services (HCS) service delivery system. The purpose of this section is to introduce program providers and Local Authorities to what HCS services will look like in the future. The success of HCS services will depend on individuals, their legally authorized representatives (LARs) and family members, the program providers, Local Authorities and Department of Aging and Disability Services (DADS) staff understanding the concepts behind the new system and developing the relationships that will support individuals in the HCS Program.

For the individuals who receive services, their LARs and family members: The transition from an Individual Service Plan (ISP) to a Person-Directed Plan (PDP) will require that personal outcomes be communicated to the service planning team (SPT). In the past, the interdisciplinary team, which included the individual, the LAR and often family members of the individual, decided what would be included in the ISP. The PDP will place even more emphasis on the results the individual desires from services and supports. Development of an effective PDP is dependent on the SPT knowing what is important to and for the individual who is receiving HCS services. Communication between the individual, the LAR, the individual’s family and the Local Authority service coordinator is critical to the development of a PDP that is meaningful for the individual. It is important that the SPT act not only on preferences that are communicated through words, but also on those preferences that are communicated through body language and maladaptive behaviors. Identifying natural supports and their roles and limits in supporting an individual is essential when linking an individual to HCS services and non-HCS services. Communication is also needed from individuals, their LARs and family members to determine whether the services being delivered are meeting the individual’s needs and preferences or whether revisions are necessary.

For the Local Authorities: Delivery of effective service coordination requires commitment to the individual who receives HCS services and to the collaboration with HCS and non-HCS service providers. A concerted effort must be made to get to know the individual and their natural supports very well. Collecting information from HCS and non-HCS service providers is essential in developing a PDP that is meaningful and will result in the desired outcomes. The ability to recognize service needs, to communicate the service needs to natural supports and HCS and non-HCS service providers, to link the individual to available resources, and to analyze the effectiveness of service delivery is essential to successful service coordination.

Service coordinators must also have extensive knowledge of non-HCS service resources to develop a PDP and to determine what HCS services need to be purchased on behalf of an individual. Knowledge of the HCS Program Billing Guidelines is critical in order to ensure that the services being purchased from the HCS program provider can be reimbursed.

For the HCS program providers: Eliminating the case management function from the array of services offered by the HCS program provider will likely require many changes to the program provider’s organizational structure. Most program providers assigned case management duties that exceeded HCS rule requirements. However, many of the case management functions that previously were defined in rule, including coordinating the development and implementation of the service plan, coordinating and monitoring the delivery of HCS and non-HCS services, integrating various aspects of services delivered through HCS and non-HCS services, recording progress and lack of progress, record-keeping, and developing a pre-discharge plan, are now the responsibility of the Local Authority service coordinator. The program provider will need to perform some parallel functions to ensure that services are effective and that individuals are healthy, safe and satisfied with their services. For example, the program provider is responsible for developing the Implementation Plan (IP) that describes specifically how the program provider’s services will achieve the assigned desired outcomes. In addition, program providers will be responsible for supervising their employees and contracted staff to ensure that they are following the IP and that progress or lack of progress is documented. If an individual receives foster/companion care, Supervised Living or Residential Support Services and possibly Supported Home Living or Respite, it is probable that the program provider’s staff will communicate and collaborate with the non-HCS service provider to integrate various aspects of service delivery. The program provider will be required to maintain a record that contains documentation relevant to the delivery of the program provider’s HCS services.

In cases in which the program provider provides foster/companion care, Supervised Living or Residential Support Services, the program provider must be able to respond to emergency situations 24 hours per day, seven days per week. The program provider may also be required to provide emergency services to an individual who lives in their own home or family home, as documented in the PDP. In the event that an unanticipated emergency arises and emergency services not included in the individual’s IPC are required, it is expected that the program provider will be responsive to that emergency and that units are added to the IPC later (if necessary) to allow reimbursement to the provider.

Program providers are encouraged to maintain frequent communication with the individuals to whom they provide services, as well as LARs and family members, to evaluate their satisfaction and to determine if changes are needed to the IP. Since case management is no longer included in the program provider’s array of HCS services, it is critical to develop effective communication systems among program provider staff and that staff know when and how to contact the individual’s service coordinator.

For DADS employees: DADS staff must prepare for these changes in the service delivery system. All DADS staff who serve individuals who receive HCS services must be knowledgeable of how the elimination of the case management function from the program provider’s array of services and the assignment of Local Authority service coordination to individuals receiving HCS services will affect the way they perform their jobs. These DADS staff must understand the concepts of person-directed planning and how to promote the acquisition of outcomes. New monitoring processes and tools will be used by the following DADS areas:

  • Access and Intake – Local Authority Section, Contract Accountability and Oversight Unit; Utilization Management and Review, IDD Waivers, Program Enrollment and UR; and Billing and Fiscal Monitoring
  • Regulatory Services – Waiver Survey and Certification

Click here for a table describing many of the major changes that result from the removal of case management services from the program providers’ service array and the performance of service coordination by the Local Authorities.