Transitions to Community Living

Update Oct. 20, 2023: NC DHHS submitted its Transitions to Community Living (TCL) Implementation Plan to the United States Department of Justice and Independent Reviewer on August 25, 2023.  The Plan reflects North Carolina’s extensive investment in resources, time, and service infrastructure to achieve substantial compliance with the TCL Settlement Agreement before July 1, 2025. 

The Department’s key accomplishments under the Settlement Agreement over the past 11 years include:

  • Currently are over 3,500 individuals in supportive housing.  From July 2021 June 2023, there was an increase of 474 individuals.
  • Of TCL participants who were housed, 68.9% were still in housing at 24 months and the average length of time in tenancy is 2.1 years.
  • Over 4,800 people have been diverted from institutional care since 2018.
  • North Carolina received an unprecedented 1,889 mainstream housing vouchers from 2017 through 2022.
  • Over 1,500 individuals who have received Person Centered Plan (PCP) training to date.
  • Over 2,500 individuals are receiving Supported Employment.
  • ACT and CST have been expanded to cover 23 rural counties. 

NC DHHS appreciates the ongoing cooperative work with our key partners, including the LME/MCOs and service and support providers, as the State continues to advance toward substantial compliance with the remaining components of the Settlement Agreement. The dedication and hard work of our key partners are critical for the success of the TCL Implementation Plan. NC DHHS also acknowledges and appreciates the investments that the General Assembly have made that support our priorities of Behavioral Health and Resilience, Child and Family Well-Being, and a Strong and Inclusive Workforce. The State continues to demonstrate its commitment to these priorities. The TCL Implementation Plan is linked below.

TCL Implementation Plan

*Reminder: The TCL Implementation Plan is intended to be a dynamic plan that will continue to evolve as we continue to advance towards substantial compliance.

Background

The Transitions to Community Living (TCL) provides eligible adults living with serious mental illnesses the opportunity to choose where they live, work and play in North Carolina. This initiative promotes recovery through providing long-term housing, community-based services, supported employment and community integration.

The six pillars of the Settlement are as follows and provide for:

  1. Community-based Supported Housing - permanent, integrated, affordable housing for people who are TCL-eligible and choose to live and receive services in the community. Tenancy supports are provided to every person with a housing slot.
  2. Community-based Mental Health Services - access to the array and intensity of services and supports necessary to enable a person who is TCL-eligible to successfully transition and live in the community.
  3. Supported Employment (Individual Placement Supports) - supported employment services that assist the person to identify and maintain integrated, paid, competitive employment.
  4. Discharge and Transition Process - informed decision making and assistance in transitioning from a State Psychiatric Hosptial or from an Adult Care home into permanent supported housing.
  5. Pre-admission Screening and Diversion - effective diversion from entry to and Adult Care home and movement into permanent, supported housing.
  6. Quality Assurance and Performance Improvement - a quality assurance and performance improvement monitoring system that ensures that a community-based placement and services are developed in accordance with the Settlement Agreement and that the person receives services and supports they need to ensure health, safety, and welfare.

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

Community-Based Permanent Supported Housing

The North Carolina Department of Health and Human Services provides eligible adults living with serious mental illnesses the opportunity to attain and maintain integrated, affordable housing with flexible tenancy supports. The purpose of the community-based housing is to help prevent inappropriate institutionalization and to provide adequate and appropriate services and supports identified through person centered planning in the most integrated setting appropriate to meet the needs of individuals with serious mental illness, who are in or at risk of entry to an adult care home. This housing model helps rebuild lives, offers hope, and provides critical stability for individuals and families.

Strategic Housing Plan

NC Strategic Housing Plan

The NC Strategic Housing Plan addresses the housing needs of individuals with disabilities, including people with disabilities who are currently receiving or eligible for NCDHHS-funded services at the state and local levels, who are either:

  • experiencing homelessness or
  • currently residing in congregate settings or
  • at risk of entry into these settings  

The plan provides a strategic guide to focus policy efforts and resource decision-making in creating and maximizing community-based housing opportunities for identified populations over the next five years. It builds on existing Olmstead efforts within the NCDHHS, such as Transitions to Community Living (TCL) and Money Follows the Person (MFP).

Executive Summary: A high-level overview of the development and implementation of the strategic housing plan.

1-Year Action Plan: These are goals/strategies that NC will aim to complete within year 1 (one) of the Strategic housing plan.

Housing Leadership Committee: A diverse group of key stakeholders and NCDHHS staff that offers broad-based, diverse leadership during the development and execution of the plan.  This committee meets quarterly, is open to the public, and provides updates on the key strategies completed during plan implementation.

Community-Based Mental Health Services 

The Department of Health and Human Services (DHHS) provides evidence-based and recovery-oriented supports for individuals transitioning to the community. As part of the community-based Adult Mental Health (AMH) service continuum for individuals with SMI/SPMI, TCL emphasizes high-fidelity Assertive Community Treatment (ACT) and 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 provide quality and positive outcomes.

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.

Supported Employment (Individual Placement Services)

The Individual Placement and Support - Supported Employment (IPS-SE) model 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. 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. Fidelity Evaluations are being conducted on all IPS models of SE teams in the state. For more information on IPS-SE visit Individual Placement and Support (IPS)

IPS Infographic Flyer FINAL.pdf 

Discharge and Transition Process 

In-Reach Coordination
In-Reach is an engagement, education and support effort designed to accurately and fully inform adults who have an SMI or 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

DHHS TCL Letter (September 2024)

Transition Coordination
Transition coordination supports individuals who are transitioning from facility-based services to community-based living options.

Pre-Admission Screening and Diversion

Referral Screening Verification Process (RSVP)
As of Nov. 1, 2018, the Referral Screening Verification Process (RSVP) replaced ACH Pre-Admission Screening and Resident Review. Under Medicaid clinical policy, all Medicaid beneficiaries who are referred to or seeking admission to Adult Care Homes licensed under NC General Statute (G.S.) 131D-2.4 must be screened through the to determine whether the individual has SMI or SPMI. Adult Care Home providers licensed under G.S. 131D-2.4 will not receive prior approval to bill for State Plan Personal Care Services without verification of a referral screening ID.

LME/MCOs or their contracted entities will be responsible for completing the screening verification process. The referral will be sent to the LME/MCO’s for verification of whether an individual has an SMI or SPMI as well as verification of the individuals Medicaid/financial eligibility in order to determine eligibility for TCL.

Complete a referral for screening.

RSVP Resources

Quality Assurance and Performance Improvement

Quality Management Quality Management is the oversight of all the TCL tasks and activities needed to achieve the requirements of the Settlement with the Department of Justice (DOJ). To do so, DHHS must aggregate data, analyze their findings, and act on those findings, being able to change where necessary, and point out what is working when possible. DHHS must have access to meaningful and complete data in order to functionally report to the DOJ.

Barriers Committee
The Barriers Committee is a team of experts from across the North Carolina Department of Health and Human Services (NC DHHS).  Each month, we review challenges to community integration for people with serious mental illness.  Our goal is to resolve issues immediately.  If that is not possible, the team brings in others to assist us.  Your barrier will stay in our barriers log and on our agenda until it is resolved.
If you, or someone you support, 18 years of age or older, 1) receives publicly funded services through NC DHHS, including the Transitions to Community Living (TCL), or may be eligible for such services; 2) has a serious mental illness or serious and persistent mental illness;* 3) wants to receive services in the community near family or friends; and 4) is unable to do so because of a barrier to community living, please share your challenges by clicking here.  Some examples of challenges are concerns about benefits, services, community resources, health care coordination, housing and barriers to employment.  The Barriers Committee will make every effort to resolve your issue in a way that makes community integration possible.

* For the TCL program, a person with “serious mental Illness” (SMI) is defined as an individual who is 18 years of age or older with a mental illness or disorder (not including a primary diagnosis of Alzheimer’s disease or dementia) that is described in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, that impairs or impedes functioning in one or more major areas of living and is unlikely to improve without treatment, services and/or supports. For the TCL program, a person with “serious and persistent mental illness” (SPMI) is defined, consistent with North Carolina’s Local Management Entity/ Managed Care Organization (LME/MCO) Operations Manual.  The manual defines a person with SPMI as an individual who is 18 years of age or older:  1) with a mental illness or disorder (but not a primary diagnosis of Alzheimer’s disease or dementia or acquired brain injury) so severe and chronic that it prevents or erodes development of functional capacities in primary aspects of daily life such as personal hygiene and self-care, decision-making, interpersonal relationships, social transactions, learning and recreational activities; or 2) who is receiving Supplemental Security Income (SSI) or Social Security Disability Income (SSDI) due to mental illness.  
The definitions of SPMI and SMI include people who otherwise satisfy the relevant criteria and who have a co-occurring condition, such as a substance abuse disorder; intellectual/developmental disability; acquired brain injury; or other condition.

If you know about a barrier to community living, please submit the barrier details to:  Olmstead.Barriers@dhhs.nc.gov

TCL Database
The TCL Database is the main mechanism for the LME-MCO to report individual data to the state, and a means for the LME/MCOs to track their own activity with TCL. The state uses the data to generate reports and in decision-making for program changes.

TCL Resources

Tenancy Support Toolkit for Community Support Teams (CST) and Leading Community Support Teams (CST): A Toolkit

We are pleased to announce the publication of two new Toolkits available for Community Support Teams and agency leadership:

In 2022, the North Carolina Department of Health and Human Services (NCDHHS) contracted with the Technical Assistance Collaborative (TAC) and the University of North Carolina Center for Excellence in Community Mental Health to provide coaching and training to Community Support Team (CST) providers serving individuals in Transitions to Community Living (TCL). As part of this effort, we have developed this toolkit to help CST providers effectively support individuals receiving services. We hope this toolkit will be beneficial to providers of tenancy support services through other programs as well, such as Assertive Community Treatment, Transition Management Services (TMS) and tailored care management. The insights and resources you will find in this document can help you gain a foundational understanding of CST, TCL, and tenancy supports.

Highlights of the Tenancy Support Toolkit for Community Support Teams (CST) include:

  • Recovery Oriented Language
  • Fillable templates and forms used to enhance services
  • How to engage landlords
  • Effective use of Peer Support Specialists
  • Crisis Planning
  • Strategies for keeping individuals housed
  • How to identify & utilize natural supports

Housing Tenancy Support Toolkit

As part of this work, TAC began working with agency leadership to assist them in improving their infrastructure to better support the needs and challenges CST Team Leads were experiencing. This toolkit was developed to help enhance leadership’s approach to overseeing CST to ensure quality tenancy support services are being provided. We hope this toolkit will be beneficial to providers of tenancy support services through other programs as well, such as Assertive Community Treatment, Transition Management Services (TMS) and tailored care management.

Highlights of the Leading Community Support Teams (CST): A Toolkit include:

  • Defining leadership roles and expectations
  • Forming a Community Support Team
  • Best Practices for supporting CST staff
  • CST program oversight and evaluation

Leading Community Support Teams (CST): A Toolkit 

NC ABLE Program – A New Way for People with Disabilities to Save
The North Carolina Achieving a Better Life Experience (ABLE) Act, allows people with disabilities to save money in a tax-advantaged account for eligible expenses related to health and wellness, employment supports, education, certain housing expenses, and other costs associated with living with a disability. A total of $15,000 per year can be contributed to an ABLE account and even more if the account owner has earned income. Up to $100,000 saved to this account will not be counted toward a person’s eligibility for federal means-tested programs such as Supplemental Security Income (SSI). Learn more about Savings and Investment Accounts for People with Disabilities.

Training

TCL News

TCL Documents and Tools 

Contact

If you have feedback or questions email community@dhhs.nc.gov.

Documents

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