9000, ECC Responsibilities for Diversions and Transitions from SSLCs and ICF/IIDs

Body

Revision 26-2; Effective June 1, 2026

Enhanced Community Coordination (ECC) helps people with intellectual or developmental disabilities move to homes in the community from:

  • state supported living centers (SSLCs); or
  • medium to large community-based intermediate care facilities for individuals with an intellectual disability or related conditions (ICF/IIDs) with nine or more beds*.

*ECC is not to be used for transitions into an ICF/IID. Refer to 24000, LIDDA Responsibilities in Community ICF/IID Programs for local intellectual and developmental disability authority (LIDDA) responsibilities in community ICF/IIDs.

Note: Refer to the Intellectual and Developmental Disability Preadmission Screening and Resident Review (IDD-PASRR) Handbook for ECC coordinator responsibilities for diversions or transitions from a nursing facility.

9100 Duties Related to Transitioning or Diverting from an ICF/IID or SSLC

Revision 26-2; Effective June 1, 2026

For all people receiving a crisis diversion or transitioning from an SSLC or medium or large community-based ICF/IID, the LIDDA must make sure an assigned ECC coordinator:

  • is assigned within three business days after a 1915(c) waiver slot is received;
  • complies with the rules governing service coordination for a person with an intellectual disability as required in 26 Texas Administrative Code (TAC) Chapter 331, LIDDA Service Coordination, and 26 TAC Section 263.901, LIDDA Requirements for Providing Service Coordination in the HCS Program 
  • provide 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 (TST), crisis respite or crisis intervention services;
  • provides pre- and post-transition services;
  • monitors the person as required by the LIDDA Performance Contract, for the first 365 days* after transition or diversion;
  • maintains a case load of no more than 30 people, even if the ECC coordinator provides service coordination to other people who are not covered under this section; and 
  • enhances the person’s natural supports and promotes successful community living.

When a person transitions or diverts to a home in another LIDDA’s service area, the transferring LIDDA’s ECC coordinator should invite the receiving LIDDA to all transition or diversion planning meetings. The receiving LIDDA may attend planning meetings either in person, by audio-visual technology or by phone.

The transferring and receiving LIDDAs must work together to make sure essential supports are in place before the person’s move. This includes determining who will be responsible for conducting the pre-move site review and considering time and distance to the site. The transferring LIDDA should document any discussions with the receiving LIDDA. 

The transfer of LIDDAs must not occur until all essential supports have been verified through a pre-move visit. For information about determining and changing the designated LIDDA, refer to 5000, Guidelines for Determining and Changing Designated LIDDA.

* Important: If, by 30 days before ECC is scheduled to end, the service planning team (SPT) believes the person will require more than 365 days of enhanced monitoring, the ECC coordinator must contact IDDComplexCoordination@hhs.texas.gov for guidance.

Note: After the first year, SSLC transition monitoring must be performed by a Home and Community-based Services (HCS) service coordinator per 9540, Monitoring Activities for SSLC Transitions Only. The HCS service coordinator is responsible for completing Form 8647, Service Coordination Assessment – Intellectual Disability Services, to determine the frequency of in-person visits.

9110 ECC-Designated Funds

Revision 26-2; Effective June 1, 2026

ECC-designated funds are available to LIDDAs through the performance contract for a person diverting or transitioning to the community. The funds enhance a person’s natural supports and promote successful community living. Funds are intended to pay for:

  • one-time emergency assistance, such as:
    • security deposits or utility assistance;
    • nutritional supplements;
    • clothing; and
    • medication;
  • items to address a person’s special needs, including minor home modifications not funded by other sources;
  • transportation to and from trial visits with community providers; and
  • educational tuition assistance, such as vocational programs through community colleges so a person can develop job skills.

All other funds, including transition assistance services (TAS), supplemental transition services (STS), waiver, non-waiver and third-party or community resources must be exhausted, and all purchases must be approved before ECC designated funds may be used.

LIDDA staff may access ECC funds by completing Form 8658, Enhanced Community Coordination (ECC) Designated Funds Request and Authorization, and submitting it to IDDComplexCoordination@hhs.texas.gov.

9200 Enrollment in HCS as a Crisis Diversion

Revision 26-2; Effective June 1, 2026

For a person enrolling in HCS as a crisis diversion, a LIDDA must enroll the person in the HCS Program per the requirements in the HCS rules and 13000, Medicaid Program Enrollment Requirements. The LIDDA must make sure an assigned ECC coordinator:

  • completes the initial in-person visit within seven business days of being assigned;
  • develops and revises, as necessary, a diversion plan using Form 1050, Nursing Facility or Crisis Diversion Plan, with the person and legally authorized representative (LAR);
  • develops a Person-Directed Plan (PDP) using Form 8665, Person-Directed Plan, per the HCS Program rules, using all available assessments and includes the person’s strengths and preferences; 
  • initiates development of the individual plan of care (IPC) as outlined in 13240, Individual Plan of Care;
  • conducts, in person, a pre-move site review using Form 1042, Pre-Move Site Review, to determine if supports are in place and any areas of concern have been addressed before the person enrolls in the HCS Program; and
  • completes the following activities before the person enrolls in HCS if, during the pre-move site review, any one of the essential supports is not in place or if issues are raised about the suitability of the site:
    • convenes the SPT to resolve the issues; and
    • conducts another pre-move site review following resolution.

9300 Post Enrollment in HCS as a Crisis Diversion

Revision 26-2; Effective June 1, 2026

For one year* after a person has enrolled in the HCS Program as a crisis diversion, an ECC coordinator must:

  • conduct at least three on-site visits of community services delivery sites at the intervals described below to determine if supports continue to be in place and concerns are being addressed, using Form 1043, Post-Move Monitoring:
    • within seven days after enrollment in the HCS Program;
    • between eight and 45 days; and
    • between 46 and 90 days;
  • conduct at least monthly in-person visits with the person; 
  • conduct HCS SPT meetings at least every 90 days**, or more frequently if the person’s needs change or if the person or LAR requests one;
  • ask about any recent hospitalizations, emergency department contacts, increased physician visits or other crises, including medical crises, and if the person experiences such, convene the HCS SPT to identify all necessary revisions to the person's Form 8665, Person-Directed Plan (PDP), to address the added need for services;
  • make sure the person receives timely assessments of behavioral, medical, nursing, specialized therapies and nutritional management needs, as necessary and as indicated on Form 8665;
  • record the person’s physical, behavioral and mental health care status sufficiently to readily identify when changes occur in the person’s status;
  • conduct service planning;
  • monitor all services identified on the HCS PDP, including:
    • making sure the program provider implements services;
    • reviewing the HCS Program provider’s implementation plans and provider records; 
    • visiting service delivery sites, as needed, to find out if the person’s needs are being met; and
    • monitoring critical incidents that involve 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, maintain communication with the program provider, and provide reports to Texas Health and Human Services Commission upon request.

*If, by 30 days before ECC is scheduled to end, the SPT believes the person will require more than 365 days of enhanced monitoring, the ECC coordinator must contact IDDComplexCoordination@hhs.texas.gov for guidance.

**SPT meetings may be held up to 10 business days before the next SPT meeting due date. The SPT meeting schedule does not reset

9400 Enrollment in HCS as an ICF/IID or SSLC Transition

Revision 24-1; Effective March 1, 2024

9410 Enrollment in HCS as an ICF/IID Transition

Revision 26-2; Effective June 1, 2026

For a person planning to transition from a medium to large community-based ICF/IID to the HCS Program, a LIDDA must enroll the person in the HCS Program per the requirements in the HCS rules and in 13000, Medicaid Program Enrollment Requirements. The LIDDA must make sure an assigned ECC coordinator:

9420 Enrollment in HCS as an SSLC Transition

Revision 26-2; Effective June 1, 2026

For a person planning to transition from an SSLC to the HCS Program, a LIDDA must enroll the person in the HCS Program per the requirements in the HCS rules and in 13000, Medicaid Program Enrollment Requirements. The LIDDA must make sure an assigned ECC coordinator:

9500 Post Enrollment in HCS as an ICF/IID or SSLC Transition

Revision 24-1; Effective March 1, 2024

9510 Post Enrollment in HCS as an ICF/IID Transition

Revision 26-2; Effective June 1, 2026

For a person who transitioned from a medium to large community-based ICF/IID to the HCS Program, an ECC coordinator must:

  • conduct at least three on-site visits of community services delivery sites* at the intervals described below using Form 1043, Post-Move Monitoring:
    • within seven days after enrollment in the HCS Program;
    • between eight and 45 days; and
    • between 46 and 90 days;
  • during the post-move monitoring visits:
    • assess if supports identified on Form 1053, Transition Plan continue to be in place;
    • address any concerns of the person, program provider, staff or family member;
    • identify any gaps in care; and
    • address such gaps, if any, to reduce the risk of crisis, re-admission to an ICF/IID, or another negative outcome.

*Important: The ECC coordinator must conduct post-move monitoring at all sites where essential supports are provided. More frequent on-site visits may be required to find out if supports are still in place and any areas of concern are being addressed during the first 90 days after enrolling in HCS.

9520 Post Enrollment in HCS as an SSLC Transition

Revision 26-2; Effective June 1, 2026

For a person who transitioned from an SSLC to the HCS Program, an ECC coordinator must:

  • conduct and document on Form 1055, LIDDA State Supported Living Center (SSLC) Transition Reporting, at least three on-site post-move monitoring visits of community service delivery sites* during the first 90 days after the person’s move at the following times:
    • within the first seven days after enrollment in the HCS Program;
    • between eight and 45 days; 
    • between 46 and 90 days; and
  • during the post-move monitoring visits:
    • make sure supports identified in the CLDP are in place;
    • address any concerns of the person, program provider, staff or family member;
    • identify any gaps in care; and
    • address such gaps, if any, to reduce the risk of crisis, re-admission to an SSLC or another negative outcome.

*Important: The ECC coordinator must conduct post-move monitoring at all sites where essential supports are provided. More frequent on-site visits may be required to find out if supports are still in place and any areas of concern are being addressed during the first 90 days after enrolling in HCS.

Note: The receiving LIDDA is responsible for conducting the post-move monitoring visits when a transfer of LIDDAs occurs because of enrollment in HCS. Both LIDDAs are responsible for collaborating to ensure a smooth transition of services.

9530 Monitoring Activities for One Year Post-Move

Revision 26-2; Effective June 1, 2026

For one year* following a person’s transition from an SSLC or medium to large community-based ICF/IID to the HCS Program, the LIDDA must make sure an ECC coordinator:

  • conducts in-person visits at least every 30 days with the person; 
  • conducts HCS SPT meetings at least every 90 days**, or more frequently if the person’s needs change or the person or LAR requests a meeting;
  • revises Form 8665, Person-Directed Plan, as necessary, and coordinates the person’s services and supports;
  • asks about any recent hospitalizations, emergency department contacts, increased physician visits or other crises, including medical crises. If the person experiences such, convenes the HCS SPT to identify all necessary revisions to the person's Form 8665 to address the need for more services;
  • makes sure the person receives timely assessments of behavioral, medical, nursing, professional therapies and nutritional management needs, as necessary, and as indicated on Form 8665;
  • records the person’s physical, behavioral and mental health care status sufficiently to readily identify when changes in the person’s status occurs;
  • conducts service planning;
  • monitors all services identified on Form 8665, including:
    • making sure the program provider implements services;
    • reviewing the HCS Program provider’s implementation plans and provider records;
    • visiting service delivery sites, as needed, to determine if the person’s needs are being met; and
    • monitoring critical incidents that involve the person and convening the HCS SPT to develop a plan for needed prevention or intervention services for the person; and
  • monitors the person while on suspension from the HCS Program at least monthly, maintains communication with the program provider and provides reports to HHSC upon request.

*If, by 30 days before ECC is scheduled to end, the SPT believes the person will require more than 365 days of enhanced monitoring, the ECC coordinator must contact IDDComplexCoordination@hhs.texas.gov for guidance.

**SPT meetings may be held up to 10 business days before the next SPT meeting due date. The SPT meeting schedule does not reset.

The LIDDA must also submit quarterly reports related to ECC activities per the MFP performance contract.

9540 Monitoring Activities for SSLC Transitions Only

Revision 26-2; Effective June 1, 2026

For one year following a person’s transition from an SSLC to the HCS Program, the LIDDA must also make sure the ECC coordinator:

For years two through five following a person’s transition from an SSLC to the HCS Program, the HCS service coordinator must complete the following monitoring activities:

  • conduct in-person monitoring at least every 90 days; and
  • submit reports to LIDDA Connect at least every 90 days using the SSLC transition report Form 1055.

The HCS service coordinator is responsible for completing Form 8647, Service Coordination Assessment – Intellectual Disability Services, to determine the frequency of in-person monitoring visits.

*Important: Form 1055, along with the required monitoring notes are due the 15th of the month following the 90-day review period. Submissions received after the 15th day of the month will be considered late. If the 15th falls on a holiday or weekend, it is due the next business day. The in-person visit(s) must occur within the 90-day review period.

The LIDDA must submit any other quarterly reports required by the LIDDA Performance Contract.

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

Revision 26-2; Effective June 1, 2026

For a person transitioning from an SSLC to a setting other than the HCS Program*, a LIDDA must make sure an assigned ECC coordinator:

*ECC may not be used for transitioning from an SSLC into an ICF/IID. Refer to 24000, LIDDA Responsibilities in Community ICF/IID Programs.

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

Revision 26-2; Effective June 1, 2026

For one year following a person’s transition from an SSLC to a setting other than the HCS Program, a LIDDA must make sure an ECC coordinator:

  • complies with the monitoring activities and agreement portions described in the CLDP;
  • conducts in-person monitoring at least every 90 days, or more frequently if indicated;
  • submits reports to LIDDA Connect at least every 90 days using Form 1055, LIDDA State Supported Living Center (SSLC) Transition Reporting; and
  • submits the written reports required above to the SSLC Admission Placement Coordinator (APC) and the program provider as required in the Performance Contract. 

The LIDDA must submit any other quarterly reports required by the LIDDA Performance Contract.

9800 Readmission to an ICF/IID or SSLC

Revision 26-2; Effective June 1, 2026

If a person who has already received 365 days of ECC is admitted or readmitted to a medium or large community-based ICF/IID or SSLC and wants to return to the community, the LIDDA must determine if the person:

  • was in the facility for more than 30 calendar days; or
  • experienced a significant change of condition* during the admission.

If the LIDDA determines the admission exceeded 30 calendar days or the person experienced a significant change of condition, an ECC coordinator must:

  • for SSLCs, participate in developing the CLDP with SSLC staff, as required by 26 TAC, Chapter 904, Continuity of Services - State Facilities; or
  • for ICF/IIDs, develop or revise as necessary Form 1053, LIDDA Transition Plan, with the SPT; 
  • develop and revise, as necessary, Form 8665, Person-Directed Plan (PDP), using all available assessments;
  • use the designated HHSC form to conduct a pre-move site review. The review is to find out if supports are in place and any areas of concern have been addressed before the person returns to the community. Note: Form 1042, Pre-Move Site Review is used for ICF/IIDs; Form 8630, LIDDA Continuity of Care, is used for SSLCs;
  • conduct and document on the designated HHSC form at least three on-site post-move monitoring visits of community service delivery sites during the first 90 days after the person’s move at the following times:
    • within the first seven days after returning to a community program;
    • between eight and 45 days; 
    • between 46 and 90 days**; and
      Note: Use Form 1043 for ICF/IIDs and Form 1055 for SSLCs.
  • during the post-move monitoring visits:
    • assess if supports identified in the CLDP or Transition Plan are in place;
    • document on the designated HHSC form:
      • all concerns of the person, program provider, staff or family member;
      • all identified gaps in care; and
    • address any identified concerns or gaps in care to reduce the risk of crisis, re-admission to an ICF/IID or SSLC, or any other negative outcome.

*Significant change of condition: any change that requires more services, equipment or minor home modifications such as a new enteral feeding tube, respiratory equipment or wheelchair.

**If, by the 60th day after the person returns to the community, the SPT believes the person may require more than 90 days of enhanced monitoring, the ECC coordinator must contact IDDComplexCoordination@hhs.texas.govfor guidance.

For a qualified person who has never received ECC who is admitted or readmitted to an ICF/IID or SSLC from the community, if the stay is for at least 60 calendar days, an ECC coordinator must initiate transition planning and one year of ECC as outlined in this handbook. 

If a person is readmitted to an ICF/IID or SSLC while receiving their initial 365 days of ECC, ECC will resume upon discharge to the community. The 365-day time frame does not restart. For example, if a person admits on day 181 of ECC and is put on suspension, when they discharge, ECC resumes on day 182. 

If the person was readmitted for fewer than 30 days but is discharging to a new residence, the ECC coordinator must document a pre-move visit on the designated HHSC form to:

  • address any concerns of the person, LAR or program provider; and

  • determine if all previously identified essential supports are in place.

    Note: Form 1042 is used for ICF/IIDs, Form 8630 is for SSLCs.

A person who is readmitted to an ICF/IID or SSLC for respite does not qualify for ECC upon discharge unless they were already receiving ECC at the time of readmission.