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Instructions
Updated: 5/2025
Purpose
LIDDAs use this form to assist a person remain in the community when they may be at risk for nursing facility (NF) or other institutional admission.
When to Prepare
The Enhanced Community Coordination (ECC) coordinator fills out the form when a person receives a Home and Community-based Services (HCS) slot as an NF diversion or a crisis diversion. The form is updated as necessary.
Detailed Instructions
Plan Date — Enter the date the form is developed or revised.
Date HCS slot authorized by HHSC — Enter the date HHSC notified the LIDDA that the slot was authorized.
Date enrollment to be completed by — Enter the date enrollment must be completed. The LIDDA receives this date via the slot notification email.
Section 1, Person’s Information
Person’s Name — Enter the name of the person who is diverting.
CARE ID — Enter the person’s Client Assignment and Registration (CARE) System identification number.
Medicaid No. — Enter the person’s nine-digit Medicaid number.
Date of Birth — Enter the person’s date of birth.
Person’s Current Address — Enter the person’s current physical address.
Area Code and Phone No. — Enter the person’s area code and phone number.
Nursing Facility Diversion or Crisis Diversion — Check to indicate the type of diversion.
Section 2, Profile Information
____________’s Profile — Enter the person’s name.
These are my strengths and what people like and admire about me — Enter the person’s unique strengths and the characteristics others admire about them.
These are my preferences and what is important to me — Enter the person’s preferences that are unique to them and what they consider to be important to them.
This is what others need to know and do to support me in the following areas — Enter information important and unique to the person’s needs as they relate to the bulleted items.
Historical Information — Enter background information that continues to significantly affect the person or their services and is not reflected elsewhere in this document.
Section 3, Service Planning Team (SPT) Meeting Summaries
Date — Enter the date of the SPT meeting.
ECC Coordinator — Enter the name of the ECC coordinator facilitating the SPT meeting.
Summary of SPT Meeting — Enter a summary of the SPT’s discussions and decisions.
Section 4, Enhanced Community Coordination Plan
The ECC coordinator must meet with the person in person at least monthly throughout the HCS enrollment process and for one year after the person has diverted to the community.
List all activities to be coordinated and monitored by the ECC coordinator during the diversion process — List all activities to be coordinated and monitored by the ECC coordinator throughout the diversion process. Add more rows as needed by clicking Add an Activity.
Section 5, Identified Supports
Description of Support/Comments — Next to each support, provide details about the support the person requires to remain in the community. If a listed support is not necessary enter NA.
Essential Support — Check if the support has been identified as essential and needs to be in place before the Individual Plan of Care (IPC) begin date.
Due Date — For supports identified as essential, enter the same date as the projected IPC begin date identified in Section 6. For all other supports the person requires, enter the date the support needs to be in place.
Does the selected program provide this support? – Check to indicate if the selected program provides the listed support.
Name of Person Responsible for Arranging Support — Enter the first and last name of the person who will arrange the identified support.
Section 6, Diverting to HCS
The person or their LAR has selected _______________ (provider) as their HCS program provider. — Enter the name of the HCS program provider selected by the person or legally authorized representative (LAR) in the blank.
The SPT, which now includes the provider, agrees that all identified essential supports are necessary for the person to remain in the community. The essential supports and the following pre-move preparations must be in place before the IPC begin date, which is projected to be: — Enter the projected IPC begin date.
The SPT agrees the following pre-move preparations must be arranged before the IPC begin date — Complete the list of items that must be arranged before the IPC begin date. Fill in specific numeric amounts for the daily supply of medication, nutritional and dietary products, and medical supplies. This may not apply if the person remains in their own home or family home. List any adaptive, assistive or protective equipment that will accompany the person. Describe anything else that must be arranged in the Other field. Enter NA if the item is not applicable.
Responsible Party — Enter the first and last name of the person who will arrange for each item listed.
Section 7, Diversion Plan Outcome
Enrolled in HCS with Diversion slot on, Declined HCS Diversion slot on, Other, explain — Check the appropriate outcome and enter the date the outcome occurred.
Comments — Enter any additional comments related to the outcome of the diversion plan.
Section 8, Post-Move Monitoring Dates
1-7 calendar days, 8-45 calendar days, 46-90 calendar days — Dates will auto-populate based on the projected IPC begin date from Section 6.
Section 9, Community Living Data
List all community living contact information in this section. Include names, addresses and phone numbers. It is a quick reference for important information about serving a person in the community. Enter the information as it becomes known.
Section 10 Signatures
The signatures in this section affirm that the development of this diversion plan was based on decisions by the SPT.
ECC Coordinator Name — Enter the name of the ECC Coordinator.
ECC Coordinator Signature — The ECC coordinator signs the form.
Date — Enter the date the ECC coordinator signed the form.
Provider Representative Name – Enter the name of the program provider representative.
Provider Representative Signature – The provider representative signs the form.
Date – Enter the date the provider representative signed the form.
Person or LAR Name – Enter the name of the person or LAR.
Person or LAR Signature – The person or their LAR signs the form.
Date – Enter the date the person or their LAR signs the form.