Welcome to the training on Transition Services for Children and Youth with Special Health-Care Needs provided by the Texas Health and Human Services Commission (HHSC) and the Texas Department of State Health Services (DSHS).
The goal of this module is to equip Texas Health Steps providers and other health-care professionals to initiate and implement health-care transition planning services for children and youth with chronic health conditions or disabilities at pivotal points, especially as youth approach school age, adolescence, and adulthood.
Texas Health Steps providers and other interested health-care professionals.
Specific Learning Objectives
After completing the activities of this module, you will be able to:
- Formulate a strategy to address the health, education, and social needs of all children and youth, with emphasis on those with special health-care needs, at key transition points, especially as they approach school age, adolescence, and adulthood.
- Differentiate and integrate the functions of health-care professionals involved in transition assistance for youth with special health-care needs.
- Apply legal requirements and appropriate guidelines for aiding the transition of children and youth with special health-care needs as they approach school age, adolescence, and adulthood.
Please note this module expires on 3/12/2023.
This module was released on 3/12/2020.
Continuing Medical Education
The Texas Department of State Health Services, Continuing Education Service is accredited by the Texas Medical Association to provide continuing medical education for physicians.
The Texas Department of State Health Services, Continuing Education Service designates this enduring material for a maximum of 1.50 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The Texas Department of State Health Services, Continuing Education Service is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. The Texas Department of State Health Services, Continuing Education Service has awarded 1.50 contact hour(s) of Continuing Nursing Education.
The Texas Department of State Health Services, Continuing Education Service under sponsor number CS3065 has been approved by the Texas State Board of Social Worker Examiners to offer continuing education contact hours to social workers. The approved status of The Texas Department of State Health Services, Continuing Education Service expires annually on December 31. The Texas Department of State Health Services, Continuing Education Service has awarded 1.50 contact hour(s) of Continuing Social Work Education.
Certified Community Health Worker
The Texas Department of State Health Services, Promotor(a)/Community Health Worker Training and Certification Program has certified this course for 1.50 contact hour(s) of continuing education for Certified Community Health Workers and Community Health Worker Instructors.
Certificate of Attendance
The Texas Department of State Health Services, Continuing Education Service has designated 1.50 hour(s) for attendance.
One of the requirements of continuing education is disclosure of the following information to the learner:
- Notice of requirements for successful completion of continuing education activity. To receive continuing education credit the learner must successfully complete the following activities:
- Create a Texas Health Steps account.
- Complete on-line registration process.
- Thoroughly read the content of the module.
- Complete the on-line examination.
- Complete the evaluation.
- Commercial Support.
The THSTEPS Web-based Continuing Education Series has received no commercial support.
- Disclosure of Relevant Financial Relationships.
The THSTEPS Continuing Education Planning Committee and the authors of these modules have no relevant financial relationships to disclose.
- Non-Endorsement Statement.
Accredited status does not imply endorsement of any commercial products or services by the Department of State Health Services, Continuing Education Service; Texas Medical Association; or American Nurse Credentialing Center.
- Off-Label Use.
Using a disclosure review process, the THSTEPS Continuing Education Planning Committee has examined documents and has concluded that the authors of these modules have not included content that discusses off-label use (use of products for a purpose other than that for which they were approved by the Food and Drug Administration).
The following are policies and definitions of terms related to continuing education disclosure:
The intent of disclosure is to allow Department of State Health Services (DSHS) Continuing Education Service the opportunity to resolve any potential conflicts of interest to assure balance, independence, objectivity and scientific rigor in all of its Continuing Education activities.
All faculty, planners, speakers and authors of Department of State Health Services (DSHS) Continuing Education Service sponsored activities are expected to disclose to the Department of State Health Services (DSHS) Continuing Education Service any relevant financial, relationships with any commercial or personal interest that produces health care goods or services concerned with the content of an educational presentation. Faculty, planners, speakers and authors must also disclose where there are any other potentially biasing relationships of a professional or personal nature.
Glossary of Terms
Conflict of Interest: Circumstances create a conflict of interest when an individual has an opportunity to affect Continuing Education content about products or services of a commercial interest with which she/he has a financial relationship or where there are any other potentially biasing relationships of a professional or personal nature.
Commercial Interest: Any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
Financial Relationships: Those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, teaching, membership on advisory committees or review panels, board membership, and other activities for which remuneration is received or expected. Relevant financial relationships would include those within the past 12 months of the person involved in the activity and a spouse or partner. Relevant financial relationships of your spouse or partner are those of which you are aware at the time of this disclosure.
Off Label: Using products for a purpose other that that for which it was approved by the Food and Drug Administration (FDA).
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Transition Resources by Topic
General Information about Transition:
American Academy of Pediatrics guidelines:
- American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians, and Transitions Clinical Report Authoring Group. (2018). Clinical Report: Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home. Pediatrics, 142(5): e20182587.
- American Academy of Pediatrics, American Academy of Family Physicians, & American College of Physicians. (2011, reaffirmed 2015). Clinical Report: Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home. Pediatrics, 128(1):182-200. (This version of the report contains the AAP algorithm).
Got Transition. Resources about a variety of transition topics for youth, families, and health-care providers.
- Coding Tip Sheet: Portable medical summary (English).
- Sample Transition Readiness Assessment for Youth
- Six Core Elements of Health Care Transition.
- Transition plan templates.
- Portable medical summary (English).
- Portable medical summary (Spanish).
- Transfer of Care Checklist (English).
- Transfer of Care Checklist (Spanish).
Health Care Transition Initiative, Institute for Child Health Policy, University of Florida Health Care Transition Workbooks.
Health Services for Children with Special Needs. Health Care Transition for Adolescents and Young Adults CME training.
Navigate Life Texas: Transition to Adulthood. In-depth information for families of children with disabilities or special health-care needs about support, resources, and links to available services.
Texas Parent to Parent. Peer support and training to improve the lives of Texas children who have disability, chronic illness, and/or special health-care needs.
Texas 24-Hour Residential Services web page. Information about residential care, including nursing homes and assisted living facilities in the community.
Texas Health and Human Services Commission's Area Agencies on Aging web page, for information on supportive housing resources.
Texas Health and Human Services Commission. Case Management Providers for Children and Pregnant Women.
- Download the case management referral form (scroll down to Forms) and fax it to the Texas Health Steps Special Services Unit at 512-533-3867.
- Find a case manager with the DSHS Case Management Providers locator map and make a direct referral to a case management provider.
- Find a community-based organization that provides case management and support services to children with special health-care needs and their families.
Early Childhood Intervention
ECI Qualifying Diagnosis Search web page.
Texas Education Agency (TEA) auditory and visual impairment rule, 10 TAC Section 89.1040.
Education and Employment Resources
Communities in Schools, works within the publicschool system to provide students with needed resources.
Early Childhood Special Education (ESCE) program (formerly known as Preschool Program for Children with Disabilities [PPCD], a title that still may be used on some websites). Provides the many supports and opportunities for Local Education Agency (district and charter schools) staff who provide educational services for children ages birth through 5 years who have disabilities.
- Preschool Program for Children with Disabilities
- Services for Texas Students with Disabilities Ages 3-5
Easterseals. Information about education, employment training, and life services for children and adults through community and home-based services.
Individualized Education Programs (IEPs). Transition in the IEP web page.
Head Start, promotes school readiness for children ages 4 years and younger.
National Center on Secondary Education and Transition. Resources, technical assistance, and information about secondary education and transitions for youth with disabilities.
National Technical Assistance Center on Transition. Resources to prepare high school graduates for success in postsecondary education and employment.
Texas Council for Developmental Disabilities. Resource Guide on Higher Education for People with Disabilities.
Texas Education Agency Educational Service Centers. The TEA has 20 Educational Services Centers in Texas that answer questions about the transition process in schools.
Texas Project First. A parent-to-parent website sponsored by the Family to Family Network that provides resources for parents and families of students with disabilities in Texas.
Texas Workforce Commission. Resources for those who want to go to school, seek job training, or find employment.
Think College. Resources and tools for students with disabilities, families, and professionals.
University of Washington’s DO-IT (Disabilities, Opportunities, Internetworking, and Technology) Center. College: You Can Do It! web page.
Financial Matters and Resources
American Academy of Pediatrics, policy statement. (2015). Supplemental Security Income (SSI) for Children and Youth With Disabilities.
Social Security Administration. Supplemental Security Income Program Entry at Age 18 and Entrants' Subsequent Earnings.
University of Washington. DO-IT's College Funding for Students with Disabilities.
Social Security Administration. Disability Evaluation Under Social Security, prepared for physicians and other health-care providers.
STAR Kids. Texas Medicaid managed care for children with disabilities who are ages birth through 20 years. Provides benefits such as prescription drugs, hospital care, primary and specialty care, preventive care, personal care services, private duty nursing, and durable medical equipment and supplies.
STAR+PLUS. Texas Medicaid managed care program for adults with disabilities.
Social Security Administration. Disability Office.
Texas Health and Human Services Commission. Case Management for Children and Pregnant Women.
Texas Health and Human Services Commission. Children with Special Health Care Needs Services.
Texas Department of State Health Services: Consumer Guide to Health Care, for information about Medicaid, Medicaid managed care, and Children’s Health Insurance Program (CHIP) benefits in Texas.
Texas Health and Human Services Commission. Intellectual Disabilities & Related Conditions Assessment Resources.
Texas Insurance Code, Title 8, Chapter 1201, Section 1201.059. Maintaining coverage for adults dependent on their parent’s health insurance.
Texas Medicaid Waiver programs and interest list (wait list):
- Navigate Life Texas. Waivers.
Signing up for the interest list (a recommended step as early in a child’s life as possible). Call the Texas Health and Human Services Commission (HHSC) toll-free at 877-438-5658 for these Medicaid Waiver programs:
- Community Living Assistance and Support Services
- Deaf Blind with Multiple Disabilities
- Medically Dependent Children Program
- Contact the local mental health authority (LMHA) or the local intellectual and developmental disability authority (LIDDA) for these Medicaid Waiver programs:
- Home and Community-based Services
- Texas Home Living
- Youth Empowerment Services
Texas Medicaid Buy-in Program
Health Care for Adults with Intellectual and Developmental Disabilities
Intellectual and Developmental Disabilities (IDD) Toolkit Telehealth Project. Developed for Tennessee health-care professionals, this site provides checklists for preventive care needs, typical screening approaches for individuals with certain disabilities, and other resources.
Some agencies that may provide local housing information and resources:
- Arc of Texas.
- Disability Rights Texas. Helpful information for young adults with disabilities who have a goal of buying their own home, including a video about the right to rent or buy a home.
- U.S. Department of Housing and Urban Development, rental assistance.
Texas Health and Human Services Commission. Independent living services, including a list of independent living centers in Texas.
United Cerebral Palsy. Provides a variety of resources about independent living, including home modification information.
Disability Rights Texas. Protection and advocacy agency for people with disabilities in Texas.
Supported decision-making options—Guardianship:
- Disability Rights Texas.
- Got Transition. Guardianship and Alternatives for Decision-Making Support.
- Navigate Life Texas. Legal Options for Age 18 and Beyond.
- Texas Council for Developmental Disabilities. Supported Decision-Making Agreement Form.
- Texas Guardianship Association website.
- Texas Parent to Parent.
Texas Council for Developmental Disabilities. Extending Health Insurance: What You Need to Know.
Texas Department of State Health Services, Adolescent Health Guide. Downloadable guidelines on health and legal issues during the adolescent years.
Texas Health and Human Services Commission, Medical Transportation Program.
- Texas Parent to Parent.
- Medical Home Portal.
- American Academy of Pediatrics’ (AAP) National Center for Medical Home Implementation Care Notebook pages.
Surveys & Studies
American Academy of Pediatrics, clinical report. (2018). Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home.
American Academy of Pediatrics, clinical report, with algorithm endorsed by AAP 2018 clinical report. (2011). Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home.
Texas Department of State Health Services. Children and Youth with Special Health Care Needs 2018 Outreach Survey Report.
Quality Indicators for Assistive Technology (QIAT). Identifies, disseminates, and implements a set of widely-applicable quality indicators for assistive technology in school settings.
Texas Health and Human Services Commission. Texas Specialized Telecommunications Assistance Program (STAP).
Texas Technology Access Program. List of resources and possible funding sources in Texas for a variety of adaptive needs.
Texas Workforce Commission (TWC). Assistance with acquiring adaptive aids, vehicle modifications, or other technologies, including services for those who are blind or who have hearing impairments.
78th Texas Legislature. (2003). Texas Insurance Code, Title 8, Chapter 1201, Section 1201.059.
Agree, E. M. (2014). The potential for technology to enhance independence for those aging with a disability. Disability and Health Journal, 7(1): 533-539.
American Academy of Pediatrics, Got Transitions. (2019). 2019 Coding and Reimbursement Tip Sheet for Transition from Pediatric to Adult Health Care.
American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians, and Transitions Clinical Report Authoring Group. (2018). Clinical Report: Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home. Pediatrics, 142(5): e20182587.
American Academy of Pediatrics, American Academy of Family Physicians, & American College of Physicians. (2011, reaffirmed 2015). Clinical Report: Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home. Pediatrics, 128(1):182-200. (This version of the report contains the AAP algorithm).
American Academy of Pediatrics, Department of Research. (2009). Survey: Transition services lacking for teens with special needs. AAP News 2009, 30(11):12. (Log in required.)
American Academy of Pediatrics, American Academy of Family Physicians, & American College of Physicians. (2002). A Consensus Statement on Health Care Transitions for Young Adults With Special Health Care Needs. Pediatrics, 110(Supplement 3):1304-1306.
Bryant, B. R., Seok, S., & Ok, M. (2012). Individuals with Intellectual and/or Developmental Disabilities Use of Assistive Technology Devices in Support Provision. Journal of Special Education Technology, 27(2):53.
Centers for Disease Control and Prevention. (2012). Childhood Overweight and Obesity.
Child and Adolescent Health Measurement Initiative, Data Resource Center on Child and Adolescent Health. (2018). 2017/2018 National Survey of Children with Special Health Care Needs.
Council on Children with Disabilities. (2009). Supplemental Security Income (SSI) for Children and Youth With Disabilities. Pediatrics, 124(6):1702-1708.
Davis, A. M., Brown, R. T., Taylor, J. L., Epstein, R. A., & McPheeters, M. L. (2014). Transition Care for Children With Special Health Care Needs. Pediatrics, 134(5):900-908.
Disability Rights Texas. (2011). Legally Adequate Consent.
Disabato, J. A., Mannino, J. E., & Betz, C. L. (2019). Pediatric Nurses' Role in Health Care Transition Planning: National Survey Findings and Practice Implications. Journal of Pediatric Nursing, 49:60-66.
Fortuna, R. J., Halterman, J. S., Plucino, T., & Robbins. B. W. (University of Rochester School of Medicine and Dentistry). (2012). Delayed transition of care: a national study of visits to pediatricians by young adults. Academic Pediatrics, 2(5):405-11.
Goldenring, J. M. & Rosen, D. S. (2004). Getting into adolescent heads: an essential update. Contemporary Pediatrics, 21(64).
Goossens. E., Bovjin. L., Gewillig. M., Budts. W., & Moons, P. (2016) Predictors of Care Gaps in Adolescents With Complex Chronic Condition Transitioning to Adulthood. Pediatrics, 137(4): 2015-2413.
University of Massachusetts Boston, Institute for Community Inclusion. (2012).
Institute of Medicine of the National Academies, Committee on Disability in America and Board on Health Sciences Policy. (2007). The Future of Disability in America. The National Academies Press, Washington, D.C.
Lebrun-Harris, L. A., McManus, M. A., Ilango, S. M., Cyr, M., McLellan, S. B., Mann, M. Y., White, P. H. (2018). Transition Planning Among US Youth With and Without Special Health Care Needs. Pediatrics, 142(4):e20180194.
Lebensburger, J. D., Bemrich-Stolz, C. J., & Howard, T. H. (2012). Barriers in transition from pediatrics to adult medicine in sickle cell anemia. Journal of Blood Disorders, 3:105-112.
McPherson, M., Arango, P., Fox, H., Lauver, C., McManus, M., Newacheck, P.W., … Strickland, B. (1998). A new definition of children with special health care needs. Pediatrics, 102:137-40.
Minihan, P. M., Fitch, S. N., & Must, A. (2007). What Does the Epidemic of Childhood Obesity Mean for Children with Special Health Care Needs? The Journal of Law, Medicine, & Ethics, 35(1): 61-77.
National Center for Medical Home Implementation. (2012). What has your experience as a parent of a child with special health care needs been like? - Brad Thompson [Video]. AAP Medical Home's YouTube channel.
National Center for Medical Home Implementation (Producer). (2012). What is important for care coordinators to know about patients and their families? - Brad Thompson [Video].
National Center for Medical Home Implementation. (2012). Example of when a care coordinator helped to navigate your child's care - Brad Thompson [Video].
National Center for Medical Home Implementation. (n.d.). Building Your Care Notebook.
NEMJ Catalyst. (2017). What Is Patient-Centered Care?
Newman, L., Wagner, M., Cameto, R., & Knokey, A. M. (2009). The Post-High School Outcomes of Youth with Disabilities up to 4 Years After High School. A Report of Findings from the National Longitudinal Transition Study-2 (NLTS2) (NCSER 2009-3017). Menlo Park, CA: SRI International.
North Carolina Division of Public Health, Children and Youth Branch. (2010). Health Care Transition: A Health Care Provider’s Guide to Helping Youth Transition from Pediatric to Adult Health Care. Appendix D: Provider Transition Checklist and Timeline, Institute for Community Inclusion at Children’s Hospital, Boston.
Olsen, D. G. & Swigonski, N. L. (2004). Transition to Adulthood: The Important Role of the Pediatrician. Pediatrics, 113(3):e159-e162.
Texas Department of Family and Protective Services. (n.d.). Transitional Living Services.
Texas Department of State Health Services. (2019). Children and Youth with Special Health Care Needs 2018 Outreach Survey Report.
Texas Department of State Health Services. (n.d.). Adolescent Health – A Guide for Providers.
Texas Department of State Health Services, Division for Family & Community Health Services. (2015). Scientific Analysis of the Current State and Needs of the Maternal and Child Health Population in Texas, Children with Special Heath Care Needs: Stand Alone Needs Assessment.
Texas Department of State Health Services. (2012). Facts About Case Management.
Texas Education Agency. (2012). Education Service Centers Map.
Texas Health and Human Services Commission. (n.d.). Person-centered Planning.
Texas Medicaid & Healthcare Partnership. (2020). Texas Medicaid Provider Procedures Manual.
U.S. Department of Education, National Center for Special Education Research. (2011). The Post-High School Outcomes of Young Adults With Disabilities up to 8 Years After High School: A Report From the National Longitudinal Transition Study-2 (NLTS2).
U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2019). National Survey of Children’s Health NSCH: Fact Sheet, October.
U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2018). 2017-2018 National Survey of Children's Health (NSCH) Interactive Data Query (2016-2018).
U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2014). Transition Care for Children With Special Health Needs, Technical Brief, No. 15.
U.S. Department of Health and Human Services, Health Resources and Services Administration. (2013). The National Survey of Children with Special Health Care Needs Chartbook 2009–2010.
U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2007). Healthy People 2020.
University of Massachusetts Boston, Institute for Community Inclusion. (2012).
University of Washington. (2003). Sarah Goes to College.
Weissberg-Benchell, J., Wolpert, H., & Anderson, B. J. (2007). Transitioning from Pediatric to Adult Care: A New Approach to the Post-Adolescent Young Person with Type 1 Diabetes. Diabetes Care, 30(10):2441-2446.
Youth Engaged 4 Change. (2019). Transition Planning and Self-Determination for Youth with Disabilities.
Health Day: News for Healthier Living. (2014). Coordinated Care Through ‘Medical Home’ Best for Chronically Ill Kids: Study.
Garcia-Iriarte, E., Balcazar, F., & Taylor-Ritzler, T. (2007). Analysis of case managers' support of youth with disabilities transitioning from school to work. Journal of Vocational Rehabilitation, 26(3):129-140.
Rosenau, N. (2000). Do We Really Mean Families for All Children? Permanency Planning for Children with Developmental Disabilities. Policy Research Brief 11(2).
Schor, E. L. (2015). Transition: Changing Old Habits. Pediatrics, 135(6):958-960.
White, P., Schmidt, A., McManus, M., & Irwin, C. E. (2018). Readying Youth and Young Adults for Transition to Adult Care During Preventive Care Visits: New Clinician Toolkit. Journal of Adolescent Health, 63(2018):673−674.
Building a Comprehensive and Effective Medical Home
Learn how and why to create and sustain a medical home in your primary care practice.
Case Management Services in Texas
Integrate case management services to support patients and families dealing with special health-care needs or chronic conditions. Includes information about eligibility for Case Management for Children and Pregnant Women.
* Required course for MCO service coordinators. A certificate will be provided upon course completion.
Texas Health Steps Guidance
Texas Health Steps Guidance
Anticipatory guidance—age-appropriate education and counseling—is a required component of every Texas Health Steps preventive medical and dental checkup. Texas Health Steps offers age-appropriate education and counseling topics so providers can assist patients, families, and caregivers to understand growth, development, and healthy practices. Texas Health Steps recommends that health-care providers personalize anticipatory guidance depending on the needs of their patients. Anticipatory guidance topics should be individualized and prioritized based on questions and concerns of the child or adolescent and their parent or guardian. Specific guidance should also be based on findings obtained during the health history and physical exam.
Texas Health Steps offers Anticipatory Guidance-A Guide for Providers, which includes guidance topics for every age group birth through 20 years. It mirrors anticipatory guidance topics included on the Texas Health Steps Child Health Clinical Record Forms.
Families and caregivers of children with chronic medical conditions face complex challenges and extended stress. Providing long-term care for a child with a disability or chronic illness can take a physical, emotional, and financial toll. It also requires a time commitment that can be difficult to achieve.
As a pediatric health-care provider, you “have a responsibility to recognize caregiver burden (Adelman, Tmanova, Delgado, Dion & Lachs, 2014). Research has shown that caregivers are at increased risk for depression, anxiety, and other negative health effects of what can be a crushing responsibility. At each pediatric checkup, make it part of your routine to inquire whether family or caregivers have questions or concerns about their roles, their own health, or navigating the health-care system.
The health of your young patients and the health of their caregivers are interwoven.
Caregivers who feel overwhelmed may not be able to provide appropriate care for a child in need. You must be alert to outcries for help or signs of health problems related to caregiving, including loss of sleep and diet imbalance. Open communication allows you to be a sounding board for caregivers who are struggling with their duties. At the same time, be on the watch for signs of fatigue or stress in caregivers who try to project an “all’s well” attitude even when they are having problems.
Your role includes providing practical counseling about stress and offering resources designed to help families and caregivers cope.
Top 10 Caregiver Coping Skills
Sharing this Top Ten list of coping skills can help caregivers learn strategies that may reduce stress:
- Understand your feelings.
- Express your emotions.
- Educate yourself about your child’s illness or condition.
- Keep communications open.
- Talk to other parents.
- Focus on the strengths and goals that are achievable.
- Believe in your child.
- Establish routines.
- Maintain your sense of humor! There is no co-pay for laughter!!
- Remember that taking care of yourself is caring for your family.
Source: Parent to Parent of New York State
Resources to share with families and caregivers
Aging and Disability Resource Centers (ADRCs) operated by Texas Health and Human Services (Texas HHS). The centers are welcoming and offer information about state and federal health benefits as well as local programs and services. The trained staff can connect caregivers with services such as home care, meals, transportation, legal help, attendant care, respite support, and housing. Visit the ADRC website for a list of resource center locations in Texas.
Family Support Services, a program to help families care for children with special health-care needs at home. Services are provided by the Children with Special Health Care Needs (CSHCN) Services Program, a branch of the Texas Department of State Health Services.
Navigate Life Texas, a multilingual website created by parents for parents of children with disabilities and special health-care needs. This unique site offers comprehensive, relevant, and reliable information for families, professionals, advocates, and anyone working with children who have disabilities and their families. Sponsored by the Texas Interagency Task Force on Children with Special Needs.
Take Time Texas, a website offered by Texas HHS that includes a state inventory of respite services.
Texas Parent to Parent offers peer support for parents of children with special health-care needs.
All Medicaid managed care organizations (MCOs) provide case management services (called service management for STAR members with special health-care needs). In the other Medicaid managed care programs, everyone gets some level of case management. Patients should first be referred to the plan’s service coordinator and then referred to Case Management for Children and Pregnant Women if patient needs cannot be met by the plan’s services. Health plans are also required to make appropriate referrals to case management services.
For patients enrolled in STAR Medicaid, STAR Health, or Fee-For-Service (FFS) Medicaid, providers can make a referral by one of these methods:
- Calling 877-847-8377 (877-THSteps).
- Contacting a case manager (“Find a Case Manager” web page accessed from the Resources for this module).
- Submitting the Case Management Referral Form (the form is also accessed from Resources).
For patients enrolled in STAR Kids:
- Health Plan service coordinators and others can refer by submitting the STAR Kids Case Management Request Form (the form is also accessed from Resources).
Early Childhood Intervention (ECI) is a statewide program for families with children birth through 35 months who have disabilities and developmental delays. All health-care providers are required by federal and state regulations to refer children 35 months and younger to the local ECI program as soon as possible but no later than seven days after the suspicion or identification of a developmental delay.
To qualify for ECI services, a child must have:
- A qualifying medically diagnosed condition that has a high probability of resulting in a developmental delay. For more information, visit the ECI Qualifying Diagnosis Search web page.
- An auditory or visual impairment as defined by the Texas Education Agency (TEA) rule at 10 TAC Section 89.1040.
- A documented delay of at least 25 percent in one or more of the following areas of skills and development: gross motor, communication, cognition, fine motor, social, emotional, or self-help. Or, a documented delay of at least 33 percent when the delay occurs only in expressive language.
- A qualitative determination of delay, as indicated by responses or patterns that are disordered or qualitatively different from what is expected for the child’s age.
To refer a child, providers should use the ECI Provider Referral and Feedback form. The form, which requires a parent or guardian signature, helps ensure that ECI’s evaluation results and service plan are shared with the referring provider.
To refer families for services, providers can call the local ECI program.
Texas Health Steps requires that all federal- and state-mandated checkup components be documented in the medical record in order for the checkup to be considered complete and to qualify for provider reimbursement. Any checkup component that is not completed must be noted in the medical record, along with the reason it was not completed and a plan to complete it. The medical record must also contain documentation of all screening tools used, screening results, and referrals. Texas Health Steps child health clinical record forms are optional but are recommended to assist providers with documentation of all required checkup components. Providers should be aware that Texas Health Steps checkups are subject to retrospective review and recoupment if the medical record does not include all required documentation.
A medical home is the patient’s primary point of contact when accessing health care. The medical home concept was developed by the American Academy of Pediatrics (AAP) and is promoted by Texas Health Steps. A medical home is defined as one in which care is accessible, family-centered, continuous, comprehensive, compassionate, coordinated, and culturally effective. It is a partnership between a child, the family or caregiver, and the child’s primary health-care setting. The primary health-care setting can be a physician’s office, a hospital outpatient clinic, a school health center, a community health center, or a health department clinic.
Providers who need assistance finding a specialist or subspecialist who accepts patients enrolled in Medicaid can find a specialist or subspecialist by using the Texas Medicaid & Healthcare Partnership (TMHP) Online Provider Lookup or by calling the Texas Health Steps toll-free help line for providers at 800-964-2777 Monday through Friday from 8 a.m. to 6 p.m. Central Time. Select option 3 to speak with a representative.
Providers can access a set of child health clinical record forms to document Texas Health Steps preventive medical checkups. The set includes a form for each checkup under the Texas Health Steps Periodicity Schedule, for patients from up to 5 days old through 20 years. Providers can save or print the forms.
Each form includes the required components for that age’s checkup, along with space for documenting routine, non-required components of a medical checkup. The backside of the form includes a helpful list of suggested anticipatory guidance topics and checklists such as the Hearing Checklist for Parents and Lead Risk Factors.
Texas Health Steps is the preventive care services program for children birth through 20 years who are enrolled in Medicaid. Texas Health Steps provides regular checkups and screenings as part of the Early and Periodic Screening, Diagnosis, and Treatment program, also known as EPSDT.
In Texas, EPSDT is known as Texas Health Steps, which includes the preventive care components—or Early and Periodic Screening (EPS)—of the total EPSDT service. Required medical checkups and preventive care services are provided in accordance with the latest Texas Health Steps Periodicity Schedule, which is modeled after the one developed by the American Academy of Pediatrics (AAP). Additional checkup components are required in Texas to meet federal and state guidelines, and checkups are encouraged as part of the medical home. The Periodicity Schedule specifies when each of the checkup components is due. Providers should always refer to the latest schedule available. To download a PDF of the Periodicity Schedule online, visit the Texas Health Steps Provider Information web page.
The Texas Medicaid & Healthcare Partnership (TMHP) updates the TMPPM monthly. The policy updates are published on the TMHP website and in banner messages, which appear weekly on a provider’s Remittance and Status Report as well as on the website. Providers can find updates on the web page in two ways:
Release Notes—Changes to the TMPPM arranged by date, with most recent at the top of the list.
Change History—Changes to the TMPPM arranged by chapter. (If a chapter has not changed, it will not appear on the list).
NOTE: Providers should always check the TMHP website for the current TMPPM, banner messages, and policy and procedures updates. Archived versions of the TMPPM will remain online for reference purposes.