An official State of Texas website.
Revision 24-1; Effective March 1, 2024
26 TAC, Sections 306.163 and 306.201
The local intellectual and developmental disability authority (LIDDA) must provide continuity of care services to help discharge planning when a person with an intellectual or developmental disability (IDD) in a community setting is admitted to a state hospital, also known as a state psychiatric hospital.
The LIDDA’s continuity of care staff:
- participates in treatment team reviews (TTR) for the person;
- identifies the person’s needs in preparation for discharge; and
- monitors the person’s progress in treatment.
Note: TTRs are the service planning meetings conducted by the state hospital for people who are admitted to their care. The state hospital unit social worker convenes these meetings.
Upon admission to a state hospital, the LIDDA’s continuity of care staff is notified of the admission. If the person was previously enrolled in a Medicaid waiver program or intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), the LIDDA’s continuity of care staff makes sure the provider representatives are invited to participate in discharge planning. The continuity of care staff will support the provider’s efforts to identify additional supports needed to prepare the person for a successful re-entry to the community.
If the LIDDA’s continuity of care staff identifies any other services or supports to aid the person’s re-entry into the community, the staff needs to provide this information to the person and their treatment team. If the team agrees to add these services or supports, the LIDDA service coordinator must coordinate those referrals. When the person has a Medicaid waiver provider or ICF/IID provider, the provider representative is responsible for making these referrals.
If the person was not connected to community services before the state hospital admission, the LIDDA’s continuity of care staff coordinates the services and supports the person might need on re-entry into the community. This may include:
- providing information about access to food, clothing or utilities;
- locating specialists or services in the community the person was not previously receiving;
- requesting a Home and Community-based Services (HCS) crisis diversion or HCS nursing facility diversion slot;
- arranging for the crisis intervention specialist to train providers;
- making a referral to the regional transition support team (TST) to determine if additional supports could help address unmet needs that potentially could reduce risk for a return to an institutional setting;
- referring the person to a transitional crisis respite bed; and
- more, per the needs of the person.
The LIDDA’s continuity of care staff coordinates with the community provider, service coordinator and natural supports to make sure follow up for services and supports are identified in discharge planning. Continuity of care staff also makes sure services and supports are delivered as planned in the days immediately following the person’s return to the community.
Should the treatment team agree the state supported living center (SSLC) is the least restrictive environment where the person’s needs can be met, the LIDDA’s continuity of care staff facilitates the person’s application and commitment to an SSLC. If the person is admitted to a state hospital on a forensic commitment and is ordered to transfer to an SSLC under a 46B.103 commitment, the LIDDA’s continuity of care staff facilitates this process. The staff completes the application for SSLC admission and gathers the required support documents. Review 23000 Inter-Facility Transfers for more information.