Section 213.51 - System of Access and Assistance(a) Purpose and Goals. This rule establishes the requirements for implementation by area agencies on aging of the system of access and assistance. Each area agency on aging shall establish and maintain a system of access and assistance. The program shall incorporate necessary strategies and activities to meet the following goals: (1) to provide persons age 60 years and older efficient access to needed services;(2) to conduct effective screening and assessment of individual needs and preferences;(3) to efficiently and effectively target resources so that persons most in need receive assistance; and(4) to establish a strong local role and clear identity of the area agency on aging as a source of access and assistance for eligible persons and/or their family members or other caregivers.(b) Outcomes. (1) The area agency on aging shall achieve the following system outcomes.(A) The area agency on aging will conduct outreach and marketing efforts to inform eligible persons and/or their family members or other caregivers of available services.(B) The area agency on aging shall serve as a source of connection to comprehensive information on services, benefits and opportunities.(C) The area agency on aging system of access and assistance shall meet specific local needs and take advantage of specific local strengths and resources including volunteers.(D) Access and assistance services are accessible, flexible, coordinated and designed to support an individual's highest level of functioning in the least restrictive environment.(E) Access and assistance services are available to persons age 60 years and older and/or his/her family member or other caregiver regardless of income.(F) The area agency on aging system of access and assistance shall have the capability to respond to racially, culturally and ethnically diverse groups.(2) The area agency on aging shall achieve the following client outcomes.(A) Eligible persons and/or their family members or other caregivers served are provided sufficient information to make informed decisions about services.(B) People in need are connected with existing benefits and services.(C) Clients are provided an opportunity to express their level of satisfaction with access and assistance services received.(D) Services are provided so that clients maintain hope, dignity, respect and independence.(c) The area agency on aging system of access and assistance shall include: (1) Information, Referral and Assistance;(3) Care Coordination; and(d) Professional Staffing. The area agency on aging shall strive to maintain an adequate level of professional access and assistance staff who possess necessary general and specialized knowledge. Where applicable, access and assistance staff must complete the training and certification requirements set forth by the Department.(e) System Integration.(1) The system of access and assistance shall strive to develop cooperative working relationships with local service providers to build an integrated service delivery system which ensures broad access to and information about community services, maximizes the utilization of existing resources, avoids duplication of effort and gaps in services and facilitates the ability of people who need services to easily find the most appropriate provider.(2) Coordination with the Texas Department of Human Services. Area agency on aging access and assistance staff shall work with the local Texas Department of Human Services (TDHS) staff to ensure any person who may be eligible for TDHS services will be referred to that agency. The area agency on aging may provide services to persons who are eligible for TDHS services in the following instances:(A) the person is on an interest list for TDHS services;(B) the person is in need of immediate service provision and awaiting determination of eligibility for TDHS services; or(C) the person is in need of immediate service provision and awaiting location and placement of a TDHS family care or primary home care service provider.(f) Client Eligibility. Eligible clients include any person age 60 years and older and/or his/her family member or other caregiver.(g) Client Intake. The intake process varies with the type of service indicated. For all clients, access and assistance staff will determine client needs and preferences. If clients have multiple or complex needs, access and assistance staff will gather identifying information to determine eligibility for services funded by the area agency on aging or other agencies.(h) Prohibited Service Activities. Access and assistance staff will not perform or participate in any of the following activities:(1) accepting gifts from a client;(2) lending or borrowing money or articles to or from a client;(3) transporting a client in an access and assistance staff person's automobile unless appropriate liability insurance is in force; and(4) driving or riding in a client's automobile.(i) Confidentiality of Client Records. Area agency on aging access and assistance staff shall comply with the requirements described in 40 TAC §270.1(d), regarding confidentiality of client records.(j) Release of Client Information. When referrals are made, access and assistance staff must obtain and clearly document the consent of the client for release of confidential information to other service provider agency(ies). This consent may be obtained from the client verbally or in writing.(k) Client Contributions. (1) Area agency on aging access and assistance staff must comply with the requirements described in 40 TAC §270.1(j), regarding client contributions.(2) Care management clients who meet the criteria identified in Human Resources Code 101, Subchapter C relating to Options for Independent Living shall be encouraged to contribute towards the cost of their care through a suggested contribution schedule.(l) Conflicts of Interest. The area agency on aging shall ensure that any conflicts of interest between the function of access and assistance and the provision of direct client services are disclosed to the Department. The intent is to separate the function of access and assistance from the provision of other client services.(m) Reporting. The area agency on aging must comply with the reporting requirements identified in §260.1(c)(2) of this title (relating to programmatic reports).(n) Information, Referral and Assistance. The information, referral and assistance process consists of activities such as assessing the needs of the inquirer, evaluating appropriate resources, assessing appropriate response modes, identifying organizations capable of meeting those needs, providing enough information about each organization to help inquirers make an informed choice, helping inquirers for whom services are unavailable by locating alternative resources, when necessary, actively participating in linking the inquirer to needed services and following up on referrals to ensure the service was received or provided. (1) Target Population. (A) Information, referral and assistance services shall be provided to any person age 60 years and older and/or his/her family member or other caregiver.(B) Information, referral and assistance services shall be provided to Medicare beneficiaries of any age under the provisions of funds received from the Centers for Medicare and Medicaid Services.(2) Access and assistance staff shall provide telephone, electronic or walk-in information, referral and assistance services in which the inquirer has one-to-one contact with an information, referral and assistance specialist. In accordance with §260.1 of this title, the published phone number will be answered "Area Agency on Aging" when the call is received.(3) Service providers shall coordinate with emergency response organizations, such as local law enforcement agencies or other existing agencies/activities as appropriate to provide the necessary coverage.(4) The area agency on aging telephone messaging system will provide callers with appropriate emergency phone numbers when calls are received after hours.(5) Resource Information. (A) Access and assistance staff shall develop criteria for the inclusion or exclusion of agencies and programs in the resource database or use criteria developed by other information, referral and assistance entities. These criteria shall be uniformly applied and published so that staff and the public will be aware of the scope and limitations of the database.(B) A standardized profile shall be developed for each organization that is part of the community service delivery system.(C) Information in the resource database shall be indexed and accessible in ways that support the information, referral and assistance process.(D) Access and assistance staff shall use the AIRS/Infoline Taxonomy to facilitate retrieval of community resource information and to promote the reliability and consistency of information across the service region and across the state.(E) The resource database shall be updated through continuous revision or at intervals sufficiently frequent to ensure accuracy of information and comprehensiveness of its content.(6) Information, Referral and Assistance Log.(A) Access and assistance staff shall maintain a system for collecting and organizing inquirer information that facilitates appropriate referrals and provides a basis for describing requests.(B) A unit of service is a client's initial request for information or assistance. The area agency on aging shall have a system for recording both initial inquiries and follow-up contacts made by either the client or the agency.(C) The area agency on aging shall use information it records to identify service gaps and overlaps, assist with needs assessments, support the development of products, identify issues for staff training, facilitate the development of the resource information system.(7) Cooperation with Local Information and Referral (I&R) Providers. (A) In communities with comprehensive and/or specialized information and referral (I&R) providers, including Area Information Centers, when applicable, the area agency on aging shall develop cooperative working relationships to build an integrated system of information, referral and assistance which ensures broad access to services, maximizes the utilization of existing resources, avoids duplication of effort and encourages seamless access to community resource information.(B) If the area agency on aging is designated by the Texas Information and Referral Network as an Area Information Center, the area agency on aging must meet the expectations of the designation.(8) Professional Conduct.(A) Access and assistance staff providing information, referral and assistance services shall adhere to the standards of conduct set forth by the Alliance of Information and Referral Systems which are adopted by reference.(B) Area agencies on aging are encouraged to seek and maintain agency accreditation with the Alliance of Information and Referral Systems.(o) Care Coordination. The purpose of care coordination is to assess the needs of a client and effectively plan, arrange, coordinate and follow-up on services which most appropriately meet the identified needs as mutually defined by access and assistance staff, the client, and where appropriate, a family member(s) or other caregiver. (1) Program Design. The operational design of care coordination is dictated by the needs of the area agency on aging service area and includes a combination of levels of care. These levels of care coordination include:(A) Service Authorization without an assessment;(B) Service Authorization requiring an assessment; and(C) Care Management, which includes the model of case management as defined by the program entitled, Options for Independent Living, as required by in Human Resources Code Chapter 101, Subchapter C.(2) Service Authorization. A process which identifies a need for a service(s) and uses the direct purchase of service procedures to obtain and initiate one or more services. There are two types of service authorization. They include service authorization without an assessment and service authorization requiring an assessment. (A) Service Authorization Without an Assessment.(i) Service authorization without an assessment may be used to procure all services except home delivered meals, homemaker, personal assistance, residential repair and respite services .(ii) Service authorization without an assessment may be performed by any area agency on aging-approved access and assistance staff member either by phone or in person.(iii) Service authorization without an assessment must be based on a client intake completed by area agency on aging access and assistance staff or by a qualified source. When authorizing congregate meals a nutritional risk assessment must also be completed.(B) Service Authorization Requiring an Assessment.(i) Service authorization requiring an assessment may be used to procure home delivered meals, homemaker, personal assistance, residential repair and respite services.(ii) Service authorization requiring an assessment may be performed by any area agency on aging-approved access and assistance staff member either by phone or in person.(iii) In addition to completing the client intake and nutritional risk assessment (home delivered meals), a modified assessment must be conducted which may include: (II) Service appropriate assessment.(III) Area agency on aging access and assistance staff may conduct the assessment, procure it or accept it from a qualified source.(C) Care Management. Care management is a process that assists clients with multiple needs by developing and implementing comprehensive plans of care.(i) Care management services may be provided only to persons age 60 years and older and/or his/her family member or other caregiver, with priority given to those: (I) who have recently suffered a major illness or health care crisis or have recently been hospitalized and need additional attention during the recuperation period in accordance with Human Resource Code, Chapter 101, Subchapter C, relating to Options for Independent Living;(II) who live in a rural area;(III) who are moderately to severely impaired in activities of daily living and instrumental activities of daily living;(IV) have insufficient caregiver support; or(V) who are in great economic or social need, particularly low-income, minority older persons.(ii) Care management must include the following:(I) Comprehensive Client Assessment: A needs assessment may be provided, procured or accepted from a qualified source and must include the following components: (-a-) cognitive status (if applicable);(-b-) emotional status (if applicable);(-c-) physical environment (requires on-site evaluation);(-d-) social environment, including informal or family support;(-g-) self-care capacity; and(-h-) services presently received.(II) Care Plan. Care Managers shall develop a written plan that is based upon the client's preferences, as supported by identified priority needs and within available public/private resources. The care plan must specify the amount, frequency and duration of each service to be provided and identify the outcomes to be achieved.(III) Service Arrangement. Care managers shall arrange for services identified in the care plan to begin at the earliest possible date, consistent with the capacity of the provider and may include, but is not limited to: (-a-) exploring the availability and quality of services, eligibility criteria and accessibility of a service to the client;(-b-) making and documenting referrals to community service agencies;(-c-) working with volunteers to provide services;(-d-) working with family and friends of the client to help achieve specific service goals; and(-e-) authorizing services deemed appropriate by the area agency on aging using direct purchase of service procedures.(IV) Monitoring/Follow-up Activities. Care managers shall conduct monitoring and follow-up activities which include verifying service delivery, determining the extent to which services meet the needs and expectations of the client, and where necessary, advocating for improvements in service delivery. Monitoring shall include at least monthly contacts with the client and a home visit not less than every six months.(V) Reassessment. Reassessments shall be conducted and the care plan shall be amended as needed based on changes in client status and provider effectiveness and may be conducted by phone or in person.(VI) Client Case Records. A confidential client case record shall be maintained on each client served and shall be protected from damage, theft and unauthorized inspection and shall contain at least:(-a-) the client needs assessment, including initial referral date and date of completion of assessment; re-assessment(s), if applicable;(-b-) the care plan including amount, frequency and duration of each service to be provided;(-c-) names of service providers and informal caregivers who render services to the client;(-d-) a notation explaining any lapse in service;(-e-) notation of hospital admission and/or discharge, with dates;(-f-) date and signature for each notation;(-g-) record of all care manager contacts and visits;(-h-) record of any client complaints and action taken;(-i-) record of termination or closure; and(-j-) list of names and phone numbers for notification in event of an emergency.(VII) Care management may not be provided by any entity with a vested interest in the delivery of services purchased by the area agency on aging without an approved waiver from the Department.(VIII) Professional Conduct. Care managers must adhere to the pledge of ethics and the standards of practice for professional geriatric care managers as set forth by the National Association of Professional Geriatric Care Managers and adopted by reference.(p) Other key components of the area agency on aging system of access and assistance include Benefits Counseling and Ombudsman Services. The requirements for the Ombudsman Program are identified in §260.11 of this title (relating to Ombudsman Services). (1) Benefits Counseling. Benefits counseling includes both legal assistance and legal awareness services. (A) Legal Assistance. Legal assistance includes the provision of client-specific advice, counseling and representation on matters involving insurance issues, public/private benefits, consumer problems and other legal issues.(B) Legal Awareness. Legal awareness includes general education and outreach on matters involving insurance issues, public/private benefits, consumer problems and other legal issues.(2) Targeting. (A) Benefits counseling services shall be provided to persons age 60 years and older and/or their family members or other caregivers.(B) Benefits counseling services shall be provided to Medicare beneficiaries of any age under the provisions of funds received from the Centers for Medicare and Medicaid Services.(3) The area agency on aging shall focus its benefits counseling services on the following priority issue areas:(A) Income Maintenance/Public Benefit. Food Stamps, Social Security, Social Security Disability, Supplemental Security Income, veterans benefits, pensions, railroad retirement, child support, unemployment compensation, general assistance and other income benefits.(B) Medical Entitlements. Medicare, Medicaid, QMB/SLMB, Veterans Administration Medical, indigent health and other medical entitlements.(C) Insurance. Medicare Supplement, HMO, long-term care policies, individual health policies, group health policies/COBRA and non-health insurance.(D) Surrogate Decision Making. Advanced directives, durable/general powers of attorney, money management, guardianship, custody and other probate matters.(E) Individual Rights. Age discrimination, disability discrimination, abuse, neglect, exploitation and dispute resolution.(F) Housing. Landlord/tenant issues, repair/modification, utilities, rent subsidy, alternative housing, home equity lending/reverse mortgage, homestead tax credit, weatherization, property tax, housing relocation and general property.(G) Institutional Care. Acute care, nursing facility care, assisted living facility care and mental health care.(H) Consumer Issues. Bankruptcy, collections, financial counseling, bill reductions, solicitation and unfair sales practices/fraud.(4) Benefits counseling services shall be provided according to the following:(A) If a request for assistance involving any of the priority issue areas identified in paragraph (3) of this subsection requires intervention by an attorney or paralegal, the benefits counselor shall refer the client shall be referred to an appropriate provider in the area.(B) For the purpose of handling requests or referrals which originate from sources other than the area agency on aging, the benefits counselor, in consultation with the local legal provider(s), shall develop an appropriate and timely referral process.(C) Regardless of the referral source, the benefits counselor shall determine whether or not the client may be assisted with other resources, such as the Legal Hotline for Older Texans, pro-bono or reduced-fee providers or through services funded by the Legal Services Corporation.(5) Relationship with Providers. The area agency on aging shall establish the following procedures when working with providers of benefits counseling and related legal services:(A) To accomplish paragraph (4), subparagraph (A) of this subsection, the area agency on aging shall coordinate with the Legal Hotline for Older Texans, Texas Young Lawyers Association, the private bar and local legal programs (such as law clinics or student law programs), Legal Services Corporation grantees, the Ombudsman Program or other programs.(B) The area agency on aging shall utilize the Legal Hotline for Older Texans to provide legal consultation and back-up to access and assistance staff, as needed.(C) If consultation/back-up is needed for access and assistance staff in addition to paragraph (5), subparagraph (B) of this subsection, such assistance may be obtained through agreements with programs such as pro-bono or reduced-fee attorneys, law school students, local legal programs or Legal Services Corporation grantees.(6) Education and Outreach.(A) Education and outreach activities include the dissemination of accurate, timely and relevant information regarding any issue identified under the priority areas in paragraph (3) of this subsection to persons identified under paragraph (2) of this subsection.(B) Education and outreach may be provided to individuals or through a group setting such as forums, workshops, seminars and training sessions and other public venues, and shall be reported as legal awareness.(7) Classification of Activities. (A) The provision of activities described in paragraph (6) of this subsection to eligible persons in a one-on-one setting or by telephone where detailed information is provided but no client intake is necessary shall be reported as legal awareness.(B) The provision of advice, counseling and/or representation on matters involving insurance issues, public/private benefits, consumer problems and other legal issues shall be reported as legal assistance if a client intake is completed.(C) If a client has a simple request for information on any topic including those identified under paragraph (3) of this subsection, it shall be reported as information, referral and assistance.(D) While education and outreach initiatives that include the dissemination of information through mass media may be budgeted as associated costs under legal awareness, the activities may not be reported as units of service.(E) Presentations or other activities that describe the services of the area agency on aging in general including the benefits counseling program may not be reported as units of service.(8) The area agency on aging shall collaborate with local, state and federal entities to provide education and outreach. Such entities may include but are not limited to the Texas Department of Insurance, Texas Legal Services Center, Texas Medical Foundation, the Centers for Medicare and Medicaid Services and the Social Security Administration.(9) Benefits counselors shall complete the training and certification requirements as set forth in the benefits counseling certification manual issued by the Department.26 Tex. Admin. Code § 213.51
The provisions of this 213.51 adopted to be effective September 3, 2000, 25 TexReg 8438; amended to be effective June 8, 2003, 28 TexReg 4318; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; transferred effective June 15, 2021, as published in the May 28, 2021 issue of the Texas Register, 46 TexReg 3422