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PRE-ADMISSION SCREENING AND RECORDS REVIEW (PASRR)

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Continuity of Services

CONTINUITY OF SERVICES

In addition to determining the eligibility of Individuals for Developmental and Disability services, the intake unit assures the continuation of or transition to services from one setting to another, with the least amount of service interruption as possible. Transitions can be a difficult time, and assuring that the important services a person receives are transferred seamlessly as they transition from one setting to another is the goal of Continuity of Services. Typical transitions occur in the following ways:

  • Transition from a State Supported Living Center or Nursing Facility to an HCS waiver program, ICF Group Home or Community setting;
  • Transition from a State Hospital to a crisis respite facility and then back into a community setting;
  • Transition from a General Revenue program into an HCS, Texas Home Living, or ICF program;
  • Transition from a family home into a more restrictive, yet necessary, treatment program, such as a Psychiatric facility or State Supported Living  Center;

If an individual is receiving training in self-help skills, this training needs to take place regardless of the setting within which they live.  If an individual has a behavior support plan, it is important for COS staff to educate people in the new program as to the type of program in place and to assure it continues in the new setting. If the individual has diabetes or other medical issues, it is extremely important for COS staff to be forthcoming about these issues so that the new program is ready to provide the best medical care.  There are a number of ways COS assures the continuation of programs and services, and it is the COS role that plays the biggest part in assuring that individuals continue to receive the services they need when transitioning from one program to another.

Staff in Continuity of Services are prominent in carrying out the processes necessary to enroll people into Waiver programs or ICF group homes, and to complete the PASRR evaluations necessary for someone to be served in a Nursing Facility. These enrollment functions demand that staff have extensive knowledge about the wants and needs of each individual, and also demand that they dig deep when the information is difficult to find.