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NC Department of Health and Human Services Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

DOJ Settlement - Transition to Community Living Initiative

In Reach | Transition | Quality of Life Survey | PASRR | Supportive Housing | Supported Employment | ACT | Reports

The State of North Carolina entered into a settlement agreement with the United States Department of Justice in 2012. The purpose of this agreement was to make sure that persons with mental illness are able to live in their communities in the least restrictive settings of their choice. The NC Department of Health and Human Services is implementing the agreement through the Transition to Community Living Initiative.


The Transition to Community Living Initiative has six primary components:

  • In-Reach and Transition - Providing or arranging for frequent education efforts and discharge planning targeted to individuals in adult care homes and state psychiatric hospitals.
  • Diversion – Diverting individuals from being admitted to adult care homes.
  • Housing – Providing community-based supportive housing.
  • Supported Employment – Providing services that will assist individuals in preparing for, identifying, and maintaining integrated, paid, competitive employment.
  • Assertive Community Treatment – An evidence-based treatment and support model of services offering customized, community-based services for people with mental illness.
  • Quality Management – using data to evaluate progress and outcomes.

Each component has settlement milestones. Implementation plans are completed during collaborative work group sessions that are open to the public.


Introduction to Transition to Community Living Initiative Webinar
This webinar provides an overview of the Settlement Agreement between the DOJ and NC, including events leading up to the Transition to Community Living Initiative.

Overview of the Transition to Community Living Initiative Process
An overview of the entire process of the Transition to Community Living Initiative with a flow chart for transitioning individuals into supportive housing.

Partnering with Facilities
This webinar, presented by staff from the Division of Health Service Regulation, provides a review of general statutes and licensure rules specifically related to resident's rights and the discharge of residents in adult care facilities.

State Psychiatric Hospitals
This webinar provides information on how the Transition to Community Living Initiative can impact individuals in state psychiatric hospitals.


In-Reach Coordination

In-Reach is an engagement, education and support effort designed to accurately and fully inform adults who have a serious mental illness (SMI) or a serious and persistent mental illness (SPMI) about community-based mental health services and supportive housing options including but not limited to the availability of tenancy support services and rental assistance. (Read more)


In-Reach (2 parts)

  • Part 1
    LME/MCO roles in the In-Reach process including ongoing engagement, education and support efforts.
  • Part 2

In-Reach Tools

Thinking it Through Worksheet regarding In-Reach

In-Reach Tool

Attachment A - In-Reach Guidance Checklist

Attachment B - Choosing Where You Live (Adult Care Homes)

Attachment C - Choosing Where You Live (State Psychiatric Hospital)

Attachment D - Letter to Adult Care Home from the LME/MCO

Attachment E - Letter to Individual from the LME/MCO

Attachment F - Letter to Guardian from the LME/MCO


Transition Coordination

Transition coordination supports individuals who are transitioning from facility-based services to community-based living options. The roles and responsibilities of this function are outlined here.


Transition (2 parts)

  • Part 1
    This webinar outlines the MCO's role in the transition coordination process and transition planning.
  • Part 2
    A review of the tools that are used in the transition planning process.

Transition Tools


Quality of Life Survey


The Consumer Quality of Life Survey
This webinar provides an explanation of the QOL Survey including background of key elements, an overview and guidelines, and the utilization of the survey instrument.

Use of Updated Survey Tools and Links (Effective 4/28/2014):


Pre-admission Screening and Resident Review (PASRR)

Beginning January 1, 2013 any individual being considered for admission to an adult care home must be screened by an independent screener to determine whether the individual has SMI/SPMI. For more information go to Pre-Admission Screening and Resident Review.

The N.C. Division of Mental Health/Developmental Disabilities/Substance Abuse Services (DMH/DD/SAS) has identified staff to serve as liaisons to provide technical assistance, answer questions, and assist with locating PASRR Level I Screeners:

Barbara Flood – EAST - 919-218-3872
Patricia McNear – CENTRAL – 919-981-2580
Bill Joyce – WEST – 336-312-0212


Supportive Housing


N.C. Supportive Housing: The process for moving consumers from In-Reach into tenancy.

Supportive Housing Program
This webinar provides an overview of the steps for transitioning individuals into their communities.

Special Assistance In-Home

This webinar provides information on Special Assistance and Special Assistance In-Home Eligibility for individuals living in an adult care home, individuals diverted from an adult care home, and individuals who have been inpatients in state psychiatric hospitals wanting to live in the community. This PowerPoint goes with the webinar.

SA/IH Program Interagency Communication Form for DHHS Approved Support Housing Slots: IMC to LME Regarding Income Verification or SA/IH Eligibility (Appendix E)

SA/IH Program Interagency Communication Form for DHHS Approved Supportive Housing Slots: LME to DSS Eligibility (Appendix E2)

Instructions for Special Assistance In-Home Approvals for Individuals with Verified Supportive Housing Slots

Housing Milestones

2014 – 250 individuals

2018 - 2,082 individuals

2015 – 708 individuals

2019 - 2,541 individuals

2016 - 1,166 individuals

2020 - 3,000 individuals

2017 - 1,624 individuals



Supported Employment

"Employment in the general workforce is the first and preferred outcome in the provision of publicly funded services for all citizens with disabilities regardless of level of disability, in a job of their choosing with supports and accommodations provided as necessary to achieve and maintain employment." (Find more information about supported employment services in N.C.)

Individual Placement and Support (IPS) Supported Employment & the TCL Initiative Goals

Employment Milestones

2014 – 250 individuals

2017 - 1,624 individuals

2015 – 708 individuals

2018 - 2,082 individuals

2016 - 1,166 individuals

2019 - 2,500 individuals


ACT (Assertive Community Treatment)

Assertive Community Treatment(ACT) is an Evidence-Based Practice Model designed to provide treatment, rehabilitation and support services to individuals who are diagnosed with a severe mental illness and whose needs have not been well met by more traditional mental health services. The ACT team provides services directly to an individual that are tailored to meet his or her specific needs. ACT teams are multi-disciplinary and include members from the fields of psychiatry, nursing, psychology, social work, substance abuse and vocational rehabilitation. Based on their respective areas of expertise, the team members collaborate to deliver integrated services of the recipients' choice, assist in making progress towards goals, and adjust services over time to meet recipients' changing needs and goals. The staff-to-recipient ratio is small (one clinician for every ten recipients), and services are provided 24-hours a day, seven days a week, for as long as they are needed. (Overview)

ACT Milestones

2014 – 34 Teams serving 3467 individuals

2015 – 37 Teams serving 3727 individuals

2016 – 40 Teams serving 4006 individuals

2017 – 43 Teams serving 4307 individuals

2018 – 46 Teams serving 4630 individuals

2019 – 50 Teams serving 5,000 individuals



Transitions to Community Living Initiative Annual Report (4/24/14)

Baseline Report (6/21/13)


State of North Carolina Home Page