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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

Community Mental Health Services | Supported Employment | ACT | Reports

In-Reach and Transition Manual | Communication Guidelines

New Independent Reviewer Announcement - January 9, 2015

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 with tenancy supports.
  • Supported Employment – An evidence-based service to 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 intensive 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.

Downloading Webinars:
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TCLI Webinars

  • Introduction to Transition to Community Living Initiative: 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.

    Root Cause Analysis for Transitions to Community Living Initiative (TCLI)
    Memo | Document


TCLI Communication Guidelines (LME/MCO)


In-Reach and Transition Manual


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)

Webinars (For download instructions, see above)

In-Reach Tools

In-Reach Tool 7/1/14

In-Reach Tool Guidance Manual 7/1/14



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.

Webinars (For download instructions, see above)

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

Transition Tools



Quality of Life Survey

Webinar (For download instructions, see above)

  • 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 2/2/2015):



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

Special Assistance In-Home

Webinar (For download instructions, see above)

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





Community Mental Health Services

The Department of Health and Human Services (DHHS) is responsible for providing evidence-based and recovery oriented wrap-around supports for individuals transitioning to the community. As part of the community-based adult mental health (AMH) service continuum for individuals with SMI/SPMI, TCLI emphasizes high-fidelity Assertive Community Treatment (ACT) and Supported Employment (SE). The service approach for AMH is based upon Psychiatric Rehabilitation (PsychRehab) that is designed around "Helping People with Psychiatric Disabilities Lead Fulfilling Lives". As such, the Department has enhanced these policies and implemented fidelity evaluations to ensure quality and positive outcomes.




Supported Employment (SE)

The Individual Placement and Support (IPS) model of Supported Employment helps people with severe mental illness work at regular jobs of their choosing. Although variations of supported employment exist, IPS refers to the evidence-based practice of supported employment for individuals with mental illness and co-occurring substance use challenges. Some of the characteristics of IPS Supported Employment include: practitioner focus on client strengths, work as a pathway to recovery and wellness, and a multidisciplinary team approach. An IPS approach changes the way employment services are delivered, as "employment readiness" is replaced by a "place then train" approach in which the only requirement to seek employment is a desire to work. Furthermore, an Employment First approach is supported and promoted by practitioners so that work is the expectation for individuals receiving mental health services.

IPS-SE was developed by the Dartmouth Psychiatric Research Center in 1996 and was later endorsed by SAMHSA and included in the SE Evidence-Based Practices (EBP) KIT.

Fidelity Evaluations are being conducted on all IPS-SE teams in the state using the SE Fidelity Scale and tools:

Training and Technical Assistance

Please contact us and also visit the NC Employment First Technical Assistance Center

Other Resources

Supported Employment Milestones


2014 – 250 individuals

2017 - 1,624 individuals

2015 – 708 individuals

2018 - 2,082 individuals

2016 - 1,166 individuals

2019 - 2,500 individuals




Assertive Community Treatment (ACT)

ACT is an evidence-based practice that is comprehensive and includes a multi-disciplinary clinical team that utilizes the expertise of medical, therapeutic, social work, vocational, substance abuse, and peer support professionals to assist individuals diagnosed with severe and persistent mental illness to achieve and sustain recovery in the community of their choice. ACT services are holistic, frequent, intensive, and provided directly in the community to enhance the overall quality of life through building self-confidence and proficiency across all domains of life functioning. ACT is often known as the "hospital without walls" bringing comprehensive psychiatric rehabilitation supports to individuals where they live. ACT has undergone a significant evolution from where it started in the 1970's in Madison, Wisconsin. Core elements remain the same, with a more focused adoption of contemporary evidence-based psychosocial practices that focus on growth-oriented outcomes reflecting community integration, transition, and recovery

Fidelity Evaluations are being conducted on all ACT teams in the state using the Tool for Measurement of ACT (TMACT). If you would like the full scale and are an LME-MCO or NC contracted ACT team, please email TMACT Summary Scale

Training and Technical Assistance

Please contact us and also visit the UNC ACT Technical Assistance Center

Other resources:

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 (5/15/2015)

Transitions to Community Living Initiative Annual Report Appendix (5/15/2015)

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

Baseline Report (6/21/13) Ready NC Connect NC