9000, Enhanced Community Coordination (ECC) Responsibilities for SSLC Diversions and Transitions

Revision 20-2; Effective August 7, 2020

This program helps adults and children with intellectual and/or developmental disabilities move from state supported living centers (SSLCs) to homes in the community.

Note: Refer to the Intellectual and Developmental Disability Preadmission Screening and Resident Review (IDD-PASRR) Handbook for ECC responsibilities related to diversion from admission to, or transition from, a nursing facility.

9100 Duties Related to Transitioning from an SSLC

Revision 19-4; Effective September 9, 2019

For all persons receiving a crisis diversion or transitioning from a state supported living center (SSLC), the local intellectual and developmental disabilities authority (LIDDA) must ensure an assigned enhanced community coordinator:

  • complies with the rules governing service coordination for a person with an intellectual disability (40 Texas Administrative Code, Chapter 2, Local Authority Responsibilities, Subchapter L, Service Coordination for Individuals with an Intellectual Disability);
  • provides intensive and flexible support to achieve success in a community setting, including arranging for support needed to prevent and manage a crisis, such as Transition Support Team or crisis respite;
  • provides pre- and post-transition services;
  • monitors the person, as required by the LIDDA Performance Contract, for one year after transition or diversion;
  • maintains a case load of no more than 30 persons, regardless of whether the community coordinator provides service coordination to other persons who are not covered under this section; and
  • enhances the person’s natural supports and promotes successful community living, such as:
    • one-time emergency assistance:
      • rental or utility assistance;
      • nutritional supplements;
      • clothing; and
      • medication;
    • addressing a person’s special needs, including minor home modifications not funded by other sources;
    • providing transportation to and from trial visits with community providers; and
    • providing education tuition assistance, such as vocational programs through community colleges so a person can develop job skills.

9110 Reporting Requirements

Revision 19-4; Effective September 9, 2019

The local intellectual and developmental disability authority (LIDDA) must submit quarterly reporting to the LIDDA Performance Contract’s mailbox by the 15th day of the month that follows the previous fiscal quarter, using a format prescribed by Texas Health and Human Services Commission (HHSC). A quarterly report must contain:

  • narrative of the results of the provision of enhanced community coordination (ECC), including positive and negative outcomes and barriers encountered during the provision of ECC;
  • a list of the names of persons receiving ECC at any time during the quarter being reported, and the date the person began receiving ECC; and
  • an expenditure report including, but not limited to salaries, employee benefits, training, travel and other operating expenses.

9200 Enrollment in HCS as a Crisis Diversion

Revision 19-4; Effective September 9, 2019

For a person enrolling in Home and Community-based Services (HCS) as a crisis diversion, a local intellectual and developmental disabilities authority (LIDDA) enrolls the person in the HCS Program in accordance with the requirements in the HCS rules and Section 13000, Medicaid Program Enrollment Requirements. A LIDDA ensures an assigned enhanced community coordinator completes the following:

  • Develops and revises, as necessary, a diversion plan using Form 1050, Nursing Facility or Crisis Diversion Plan, with the person and LAR;
  • Develops a Person-Directed Plan using Form 8665, Person-Directed Plan, in accordance with the HCS Program rules, using all available assessments and to include the person’s strengths and preferences; and
  • Conducts a pre-move site review using Form 1042, Pre-Move Site Review, to determine whether supports are in place and any areas of concern have been addressed before the person enrolls in the HCS Program.

9300 Post Enrollment in HCS as a Crisis Diversion

Revision 19-4; Effective September 9, 2019

For one year after a person has enrolled in the Home and Community-based Services (HCS) Program as a crisis diversion, an assigned enhanced community coordinator must:

  • conduct HCS service planning team (SPT) meetings at least quarterly, or more frequently if there is a change in the person’s needs or if requested by the person or legally authorized representative (LAR);
  • conduct monthly face-to-face visits with the person and monitor the delivery of all services and supports;
  • conduct at least three onsite visits of community services delivery sites at the intervals described below to determine whether supports continue to be in place, and any areas of concern are being addressed, using Form 1043, Post-Move Monitoring:
    • within the first seven days after enrollment in the HCS Program;
    • between 8 and 45 days; and
    • between 46 and 90 days;
  • ensure the person receives timely assessments of behavioral, medical, nursing, specialized therapies and nutritional management needs, as necessary and as indicated on Form 8665, Person-Directed Plan (PDP);
  • monitor all services identified on the HCS PDP, including:
    • reviewing the HCS program provider’s implementation plans and provider records, as well as 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 provide needed prevention or intervention services for the person; and
  • monitor the person while on suspension from the HCS Program at least monthly and provide reports to Texas Health and Human Services Commission upon request.

9400 Enrollment in HCS as an SSLC Transition

Revision 19-4; Effective September 9, 2019

For a person planning to transition from a state supported living center (SSLC) to the Home and Community-based Services (HCS) Program, a local intellectual and developmental disability authority (LIDDA) must ensure an assigned enhanced community coordinator:

  • participates in developing the community living discharge plan (CLDP) with SSLC staff, as required by 40 Texas Administrative Code (TAC), Chapter 2, Subchapter F, Division 4, §2.278, Community Living/Discharge Plan by Alternate Living Arrangements;
  • develops and revises, as necessary, Form 8665, Person-Directed Plan, using all available assessments;
  • obtains and reviews a copy of the pre-move site review conducted by SSLC staff to determine whether supports are in place and all areas of concern are being addressed; and
  • complies with the requirements contained in 40 TAC, Chapter 2, Subchapter F, Division 4, §2.277(b)-(d) (relating to Arrangements for the Move to an Alternate Living Arrangement of a person Residing in a State MR Facility) using Form 8630, Continuity of Care.

9500 Post Enrollment in HCS as an SSLC Transition

Revision 20-2; Effective August 7, 2020

For one year following a person’s transition from a state supported living center (SSLC) to the Home and Community-based Services (HCS) Program, a local intellectual and developmental disability authority (LIDDA) must ensure an enhanced community coordinator:

  • conducts at least monthly face-to-face visits with the person; and
  • complies with the monitoring activities and agreement portions set forth in the community living discharge plan (CLDP).

For five years following a person’s transition from an SSLC to the HCS Program, the LIDDA must ensure an enhanced community coordinator completes the following monitoring activities:

  • conducts monitoring at least every 90 days and, using the Texas Health and Human Services Commission (HHSC) prescribed format, develops written reports of monitoring that addresses specific findings for any significant monitoring activity, including:
    • psychiatric or medical hospitalization;
    • any visits to an emergency room within the period being reported;
    • death;
    • arrest or incarceration;
    • any contacts with law enforcement within the period being reported;
    • unable to locate or left program (left community program, moved out-of-state);
    • HCS Program provider issue – change of homes;
    • HCS Program provider issue – closure;
    • HCS Program provider issue – confirmed abuse, neglect or exploitation;
    • HCS Program provider issue – change of program provider;
    • return to the SSLC; and
  • submits the written reports required above to the SSLC admission placement coordinator (APC), HHSC and the HCS Program provider, as required by the LIDDA Performance Contract.

For years two through five, the HCS service coordinator will complete the listed activities above and submit the written reports.

9600 Transition Planning from an SSLC to a Setting Other than the HCS Program

Revision 19-4; Effective September 9, 2019

For a person transitioning from a state supported living center (SSLC) to a setting other than the Home and Community-based Services (HCS) Program, such as a community intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID) or family’s home, a local intellectual and developmental disability authority (LIDDA) must ensure an assigned enhanced community coordinator:

  • participates in developing the community living discharge plan (CLDP) with SSLC staff, as required by 40 Texas Administrative Code (TAC), §2.278, Community Living/Discharge Plan by Alternate Living Arrangements;
  • participates in the pre-move site review conducted by SSLC staff to determine whether supports are in place and all areas of concern are being addressed; and
  • complies with the requirements contained in 40 TAC, §2.277(b)-(d) (relating to Arrangements for the Move to an Alternate Living Arrangement of a person Residing in a State MR Facility) using Form 8630, Continuity of Care.

9700 Post Transition from an SSLC to a Setting Other than the HCS Program

Revision 20-2; Effective August 7, 2020

For one year following a person’s transition from a state supported living center (SSLC) to a setting other than the Home and Community-based Services (HCS) Program, a local intellectual and developmental disability authority (LIDDA) must ensure an enhanced community coordinator:

  • complies with the monitoring activities and agreement portions set forth in the community living discharge plan (CLDP);
  • conducts monitoring at least every 90 days and, using the Texas Health and Human Services Commission (HHSC) prescribed format, develops written reports of monitoring that addresses specific findings for any significant monitoring activity, including:
    • psychiatric or medical hospitalization;
    • any visits to an emergency room within the period being reported;
    • death;
    • arrest or incarceration;
    • any contacts with law enforcement within the period being reported;
    • unable to locate or left program (left community program, moved out-of-state);
    • program provider issue – change of homes;
    • program provider issue – closure;
    • program provider issue – confirmed abuse, neglect or exploitation;
    • program provider issue – change of program provider;
    • return to the SSLC; and
  • submits the written reports required above to the SSLC admission placement coordinator (APC), HHSC and the program provider, as required by the contract.