Home and Community-Based Health Services
|Durable Medical Conditions||Per unit|
Health Resources and Services Administration (HRSA) Description:
Home and Community-Based Health Services (HCBHS) are provided to an eligible client in an integrated setting appropriate to a client’s needs, based on a written plan of care established by a medical care team under the direction of a licensed clinical provider. Services include:
- Appropriate mental health, developmental, and rehabilitation services
- Day treatment or other partial hospitalization services
- Durable medical equipment
- Home health aide services and personal care services
- Skilled nursing medication administration including intravenous and aerosolized therapy
- Routine lab specimen collection and testing services
Inpatient hospitals, nursing homes, and other long-term care facilities are not considered integrated settings to provide Home and Community-Based Health Services.
Services cannot be provided in the following facilities: inpatient hospital facilities, nursing homes, and other long term care facilities.
Home and Community-Based Health Services are therapeutic, nursing, supportive, and/or health services provided by a licensed/certified home health agency in a licensed/certified home or community-based setting (e.g., adult daycare center) in accordance with a written, individualized plan of care established by a licensed physician.
Home and Community-Based Health Services include the following:
- Para–professional care: services by a home health aide, personal caretaker, or attendant. This also includes assistance with cooking and cleaning activities to help clients remain in their homes.
- Professional care: services in the home by licensed providers for mental health, development health care, and/or rehabilitation services.
Home and Community-Based Health Providers work closely with the multidisciplinary care team that includes the client's case manager, primary care provider, and other healthcare professionals as appropriate.
Services providers for Home and Community-Based Health Services must follow HRSA/DSHS Universal Standards 1-46 and 80-85.
Service Standard and Measures:
The following standards and measures are guides to improving healthcare outcomes for people living with HIV throughout the State of Texas within the Ryan White Part B and State Services Program.
Initial Orders and Assessment: The client will be contacted within 1 business day of agency receipt of referral with orders from a licensed medical provider.
Services must be initiated per orders specified by the referring licensed medical care provider or within 2 business days of receipt of the referral with orders, whichever is earlier.
Initiation of service must consist of a comprehensive assessment of the status of the client’s physical, psychosocial, and home safety.
Components of assessments:
Implementation of Care Plan: A care plan will be completed based on the primary medical care provider’s order and will include:
The care plan is updated at least every 60 calendar days.
Coordination of Services and Referrals: If referrals are deemed necessary the agency will:
Transfer/Discharge: A transfer or discharge plan must be developed for any of the following circumstances:
All services transferred must be accompanied by a referral to an appropriate service provider.
Note: Staff should not inactivate clients in Take Charge Texas (TCT) at the time of discharge, unless the case is being closed due to a deceased client.
Division of Metropolitan HIV/AIDS Programs, HIV/AIDS Bureau (HAB). Ryan White HIV/AIDS Program (RWHAP) National Monitoring Standards for RWHAP Part A Recipients. Health Resources and Services Administration, June 2022.
Division of State HIV/AIDS Programs, HIV/AIDS Bureau (HAB). Ryan White HIV/AIDS Program (RWHAP) National Monitoring Standards for RWHAP Part B Recipients. Health Resources and Services Administration, June 2022.
Ryan White HIV/AIDS Program. Policy Notice 16-02: Eligible Individuals & Allowable Uses of Funds. Health Resources and Services Administration, October 2022.
Centers for Medicare and Medicaid Services (CMS), Home and Community-Based Services. Home- and Community-Based Services | CMS. Centers for Medicare & Medicaid, January 2023.