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    Purpose

    The purpose of this announcement is to issue updated guidelines regarding service coordination for infants/toddlers and their families/caregivers who are referred to and/or are receiving Early Intervention (EI) services.

    Background

    The Infant/Toddler (I/T) EI program is responsible for assigning a service coordinator to each infant/toddler and their family/caregiver, as soon as possible, after referral. Service coordinators are responsible for serving as the single point of contact and assisting infants/toddlers, and their families/caregivers with accessing needed EI services as well as coordinating and monitoring the provision of such services.

    Before performing service coordination activities, a service coordinator must be able to demonstrate knowledge and understanding about the following:

    • Infants/toddlers who have or are at-risk of having developmental delays or disabilities,
    • Part C of the Individuals with Disabilities Education Act, 20 U.S.C.A, §§ 1431-1445, and the Early Intervention Services System Act, 11 P.S. §§ 875-101 – 875-503, and
    • 55 Pa. Code Chapter 4226, Early Intervention Services.

    A service coordinator shall meet the qualifications and training requirements found in 55 Pa. Code Chapter 4226, including the pre-service and annual training requirements. State approved training on service coordination is available through Early Intervention Training and Technical Assistance (EITA). A service coordinator must also meet the qualifications and requirements described by the Office of Medical Assistance Programs (OMAP).

    All service coordination entities must also be enrolled in the Medical Assistance (MA) Program. To enroll, service coordination entities must complete a provider enrollment application, which is available on the electronic provider enrollment portal.

    Questions about enrollment can be directed to the Office of Child Development and Early Learning at ra-ocdintervention@pa.gov.

    Discussion

    Service coordination is an ongoing set of activities that assist infants/toddlers and the infant’s/toddler’s family/caregiver with gaining access to services and supports appropriate to their needs. Service coordination activities are described further in 55 Pa. Code § 4226. Service coordination activities must be directly related to the management of services or supports for the eligible infant/toddler and the infant’s/toddler’s family/caregiver.

    The initial home visit can be an overwhelming experience for families; therefore, service coordinators must be mindful of the questions they ask and the amount of material they give to families at the first meeting. It is recommended that service coordinators review and/or provide copies of the following during the initial home visit:

    1. A Family’s Guide to Early Intervention
    2. Parent to Parent brochure
    3. Annotated Evaluation Report (ER) and Annotated Individualized Family Service Plan (IFSP) forms
    4. Problem-Solving in EI brochure

    Service coordinators are responsible for providing families/caregivers with unbiased information on child development, community activities, services, and resources on an ongoing basis.

    After a child is determined eligible for EI services, the IFSP team shall incorporate individualized service coordination support activities directly into the IFSP. These activities may include, but are not limited to:

    • Coordinating initial and ongoing evaluations and assessments of children and their families;
    • Screening and tracking children who are at-risk for developmental delays;
    • Facilitating and participating in the development, implementation, and review of the IFSP;
    • Assisting with identifying and gaining access to EI services and other supports identified on the IFSP;
    • Facilitating the timely delivery of EI services;
    • Assisting with identifying available service providers and facilitating communication with and between the family/caregiver and the service provider;
    • Coordinating and monitoring the delivery of EI services;
    • Informing families/caregivers of their rights and available procedural safeguards, as well as the availability of advocacy services;
    • Monitoring progress towards achieving the outcomes included in the IFSP;
    • Assisting with arranging for the medical and health services an infant/toddler needs or is receiving;
    • Offering families/caregivers opportunities and support to participate in community activities and events with other infants/toddlers and families/caregivers;
    • Informing families/caregivers of community resources that may benefit them;
    • Providing information about local support groups and family/caregiver networks; and
    • Facilitating the development of the transition plan as part of the IFSP.

    It is not necessary to embed all the above listed activities into the IFSP. Those activities that directly contribute to the achievement of an outcome or needed as a resource for families/caregivers shall be embedded into the IFSP.

    Service coordinators may incorporate activities as a strategy for an existing child/family outcome/goal or create a separate goal specific to the service coordination service(s). The IFSP team will make this decision based on the knowledge they have gathered regarding the infant/toddler and family/caregiver through the referral, assessment, and IFSP development. The IFSP team may also include SC activities into the child/family information and/or progress monitoring of the outcome/goals.

    The IFSP team shall determine how often a family/caregiver may require contact from their SC. The service shall be individualized, as with all other IFSP services, to meet the infant/toddler and family/caregivers’ needs with the expectation that a comprehensive review of the IFSP will occur, with the family/caregiver, at a minimum of every 6 months.

    A service coordinator shall complete a service note after any meeting or other contact with, or on behalf of, an infant/toddler and their family/caregiver. Service notes provide verification that a meeting or other contact has occurred. It is important that service notes be written so that others can understand what is being documented. Service notes should be written in people first language, be specific and to the point, and include only facts, not opinions. Service coordinators should document service notes that are professional, accurate, unbiased, and objective. Service notes become part of the agency’s records and may be used in legal disputes.

    Medical Assistance Payment for Service Coordination Activities

    MA pays for service coordination services provided to infants/toddlers who are eligible for both EI services and MA. Service coordination is billed and paid in units of service. To determine billable units for each activity, billable minutes should be totaled and divided by 15 at the end of each calendar day.

    Claims must be submitted within 180 days from the date of service. If claims are denied, a service coordination entity has up to 365 days from the date of service provision to correct the claim and resubmit the claim.

    When Medical Assistance can be Billed for a Service Coordinator's Activity

    MA Billable Activities

    • Screening, referring, and tracking activities for infants/toddlers who meet “at-risk” criteria;
    • Informing the family/caregiver of their rights and the available procedural safeguards;
    • Assessing the infant’s/toddler’s and the family’s/caregiver’s service and support needs;
    • Meeting with families and caregivers to develop the IFSP;
    • Facilitating the implementation of the IFSP;
    • Creating the Evaluation Report (ER) and IFSP in PELICAN-EI;
    • Identifying potential providers of all necessary services and supports;
    • Identifying available community resources, activities, and services;
    • Providing information that allows the family’s/caregivers to choose potential providers from the statewide provider list, including information about the type of services offered by each provider;
    • Coordinating services provided to an infant/toddler through on-going information sharing, participation in interagency meetings, telephone calls and/or face-to-face contacts;
    • Facilitating access to health care, community resources, and services needed by the infant/toddler and facilitating the family’s/caregiver’s access to funding sources that can be used to pay for service that will enhance the capacity of the family to meet the needs of their infant/toddler;
    • Assisting the family/caregiver in obtaining transportation for the family/caregiver and infant or child to community resources and activities, if necessary;
    • Monitoring the effectiveness of formal and informal supports and services provided to the infant/toddler and the infant’s/toddler’s family/caregiver;
    • Monitoring the timeliness of delivery and effectiveness of EI services through review of claims, telephone contacts with the family/caregiver, and/or face-to-face meetings with the family/caregiver, infant/toddler, and provider;
    • Problem solving and conflict resolution with the family/caregiver and the provider of service;
    • Reassessing service and support needs with the family/caregiver and IFSP team on an ongoing basis and making changes to the IFSP as appropriate;
    • Discharge planning regarding EI services that are provided within 30 days prior to discharge from a hospital. Discharge planning provided by a service coordinator must not duplicate discharge planning provided by the hospital; and;
    • Developing transition plans and assisting with the transition of a toddler to preschool services.

    Activities That Are Not Billable to MA (not an inclusive list)

    • Duplication of service coordination or case management that is billed under local, state, or federal programs;
    • Clerical activities, such as, setting up a file, filing, copying, data entry, general office telephone coverage, preparing the office’s budget, completing invoices,
    • Data-entry of ER and IFSP into PELICAN-EI by clerical staff;
    • Providing direct hands-on services such as counseling, teaching, delivering goods to the infant/toddler and/or family/caregiver, transporting the infant/toddler and/or family/caregiver to services, or transporting the family/caregiver to purchase goods for the infant/toddler;
    • Missed appointments with the infant/toddler and family/caregiver or service provider; and
    • Eligible service coordination activities delivered to infants/toddlers who are hospitalized more than 30 days prior to discharge;
    • Activities not directly associated with a specific infant/toddler and the infant’s or toddler’s family/caregiver, such as, child find activities, service coordination supervision, or training are not billable service coordination activities.

    Next Steps

    1. Infant/Toddler EI Programs should distribute this announcement to service coordination providers for immediate implementation.
    2. EI 09-11, Service Coordination, including the attachment, titled Early Intervention Service Support Plan are obsolete with issuance of this announcement.

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