Form 8647, Service Coordination Assessment – Intellectual Disability Services

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Documents

Effective Date: 5/2024

Instructions

Updated: 5/2024

Purpose

Form 8647, Service Coordination Assessment is completed for applicants and people enrolled in the Home and Community-based Services (HCS) and Texas Home Living (TxHmL) Programs, General Revenue (GR) Services and Non-waiver Community First Choice (CFC).

The purpose of Form 8647 is to: 

  • Determine if a person is eligible for service coordination. This only applies to people who want to receive GR service coordination. 
  • Identify the frequency for face-to-face* contact. The minimum required frequency of face-to-face contact is every 90 days. 

*For this assessment face-to-face means within the physical presence of another person. Face-to-face does not include audio-visual or audio-only communication.

This form is not required for Enhanced Community Coordination (ECC). 

When to Prepare

The service coordinator completes Form 8647 at enrollment and annually. Update the form when the person’s needs significantly change or a revision to the frequency of face-to-face contact is needed. 

Detailed Instructions

Section 1 Person’s Information 

Name of Person — Enter the person’s first and last name. 

CARE ID No. — Enter the person’s Client Assignment and Registration (CARE) identification number.

Address (Street, City, State, ZIP Code) — Enter the person’s residential address to include street, city, state and ZIP code.

Area Code and Phone No. — Enter the person’s contact phone number with area code. 

Name of LIDDA — Enter name of LIDDA where the person is currently assigned.

Section 2 Assessment 

Each assessment area has three parts: 

  • Considerations 
  • Assessment questions 
  • Ratings

Considerations 

Considerations are a list of questions for the service coordinator to think about when completing this assessment. Documentation of the answers to the questions in this section could be in the person’s record, the service coordinator’s notes or the person’s plan of services, such as the Person-Directed Plan (PDP).

Assessment questions

Service coordinators complete two types of questions to use when rating each domain: 

Yes or No – Service coordinators must make sure each question is answered either yes or no. If not applicable (N/A) is available, it can be used. 

Checklist – Service coordinators must check all items in the list that are applicable to the person. Only check N/A if none of the items listed are relevant to the person. 

Service coordinators should make sure each question is completed and considered when rating the assessment. 

Ratings

Service coordinators or LIDDA representatives must rate each domain based on the interview with the person and their LAR, if applicable. Service coordinators will think about the responses to the questions in the consideration box as well as the assessment questions when deciding on ratings for each domain. 

General rating descriptions: 

A 3 rating means the person is in a situation that is life-threatening or significantly impacts health or safety. This situation must be related to the domain being rated. 

A 2 rating means the person is trying to access services and supports. This may include a change in need or services, but does not rise to concerns about health, safety or crisis. 

A 1 rating means the person may already have needed services and supports in place. A service coordinator is desired to monitor services and supports to ensure they remain in place so the person can remain successful. 

A 0 rating means the person does not need help, services or supports related to this domain. 

Additional rating information is in each domain. 

Rights and Legal Status

Helpful information: 

Physical Health

Helpful information:

Centers for Disease Control and Prevention (CDC) states, “Chronic Diseases are defined broadly as conditions that last 1 year or more and require ongoing medical attention or limit activities of daily living or both, such as heart disease, cancer, diabetes, Alzheimer’s disease or other dementias, COPD and stroke.”

Emotional and Behavioral Health

Example ratings:

Rating 3: Crisis referrals, court or jail involvement, frequent psychiatric hospitalizations or rehab for drug use.

Rating 2: The person needs a Behavioral Support Plan.

Rating 1: The person has behavioral services or a behavior support plan in place that has been working well for over one year. They are stable on all psychotropic medications.

Independent Living

Helpful Information: 

Transportation resources: 

Medical Transportation Program

Call 211 or visit the 211 website to search for transportation resources in your area.

Example ratings:

Rating 3: The person is homeless and has no family to live with, needs help modifying their living environment to meet health, safety, or physical needs. They do not have sufficient income to meet current needs or have no income, bills are due and they are in danger of being evicted.

Rating 2: May need help locating and applying for new housing and accessing community resources and services during moves. May need help locating or accessing transportation. Desires help modifying the living environment (Minor Home Modifications). Needs extensive help performing living skills. Needs help with keeping SSI, reapplying for Medicaid because of loss, desires sufficient skills for managing financial resources (budgeting), or desires increased access to finances.

Rating 1: Needs monitoring to make sure support for managing financial resources, maintaining basic living skills, and household management are enough to meet the person’s needs with current services in place.

Work and School

Helpful information: 

N/A – Not applicable. If the person is too young to work, use N/A.

Per Texas Administrative Code (TAC), Title 26, Part 1, Chapter 284 and instructions for Form 8401, Employment First Discovery Tool.

The service coordinator asks the person about their desire to work during the completion of this form. Document the person’s response on this form.

If the person indicates a desire to work, the service coordinator must complete the Employment First Discovery Tool and make a referral to Texas Workforce Commission. They may also refer the person for employment services through the waiver program where the person is enrolled.

Example ratings:

Rating 3: Is losing their job and has no money to pay bills. Has reduction in school time. Needs help with crisis planning that involves job or school. Has emergency meetings at job or school. 

Rating 2: Desires help locating work or volunteer opportunity. Has change in school, is leaving school or is transition planning. The person is in their last year of high school. 

Rating 1: Has annual involvement in the admission, review, and dismissal (ARD) committee meetings or needs help with development of an individualized education program (IEP).

Rating 0: The person does not attend school, have a job, or have any interest in seeking employment or volunteer work.

Relationships and Social Inclusion

Helpful information: 

Any references to community or community involvement in this domain are not about transportation. Ratings related to transportation are in independent living domain.

Example ratings:

Rating 3: Has concerns about building healthy relationships, loss of significant relationships or has conflicts with family. 

Rating 2: Desires increased participation in the community but has issues with interacting with others and is unsure of social role. Has barriers to friendships. 

Rating 1: The person has a good support system but may need information about community events that meet their interests.

Section 3 Service Coordination

Section 3 has three parts: 

  • Understanding Requirements of Service Coordination 
  • Determining Eligibility for Service Coordination 
  • Determining Frequency for Face-to-Face Service Coordination 

Understanding Requirements of Service Coordination

Review the rules about the requirements of service coordination in 26 TAC Sections 331.7, 331.11, and 331.5. More frequent face-to-face contact may be preferred by the person or may be needed because of health or safety concerns.

Determining Eligibility for Service Coordination 

Service coordinators must check only one of the boxes to state if the person is eligible for service coordination based on the ratings.

There are three options to choose from: 

  • The person has two or more domains with a rating of 3, 2 or 1. 
    The rule at 26 TAC Section 331.7 (a)(1)(A) states a person must have two or more documented needs that require services and supports other than service coordination as evidenced by an assessment conducted by the designated LIDDA and not reside in an institution. Each domain with a rating of 1, 2, or 3 counts as a documented need. 
  • The person meets other eligibility criteria in 26 TAC Section 331.7. 
    Click the link to determine if the person meets other eligibility criteria listed at 26 TAC Section 331.7 (a)(1)(B), (C), (D), (E), or (F). 
  • The person is not eligible for service coordination if there are no domains with a rating of 3, 2, or 1.The person or their LAR may request annual contact. 
    This person is not eligible for service coordination. However, they are eligible to be reassessed annually or if needs change to redetermine eligibility.

Determining Frequency for Face-to-Face Service Coordination

For this assessment face-to-face means within the physical presence of another person. Face-to-face does not include audio-visual or audio-only communication.

After the service coordinator completes all the domain ratings, they review with the person and their LAR to determine the frequency of face-to-face service coordination based on the ratings. The service coordinator must consult the chart to determine high, moderate or minimal frequency for face-to-face contact.

The service coordinator must check the appropriate box about the determined frequency of service coordination which are monthly, at least twice every 90 days, or at least every 90 days. The minimum frequency for face-to-face service coordination is at least every 90 days. 

Section 4 Agreement 

Printed Name of Person or LAR — Enter the name of the person responsible for signing this form. 

Signature of Person or LAR — The person or their LAR will sign the form. 

Date — Enter the date with month, day and year the person or LAR signed the form.

Printed Name of LIDDA Representative Completing this Assessment — Enter the name of the person that completed this assessment.

Title of LIDDA Representative Completing this Assessment — Include the job title of the person from the LIDDA completing this assessment.

Signature and Title of LIDDA Representative Completing this Assessment — The LIDDA representative that completed this assessment will sign the form.

Date — Enter the date with month, day and year the LIDDA representative signed the form.