Transitions to Community Living

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.
DHHS TCL Letter

Local Management Entities/Managed Care Organizations (LME-MCO) / Providers 

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 sucessfully transition and live in the community.
  3. Supported employment (Individual Placement Supports) - supported employement 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 - 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.

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.
Click here to complete a referral for screening.

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.

Resources

NC DHHS Permanent Supportive 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.

NCDHHS Strategic Housing Plan

The Technical Assistance Collaborative (TAC) is working with NC DHHS on developing a Strategic Housing Plan for North Carolina. This Housing Plan will provide a strategic guide to focus DHHS’s policies and resource decision making in creating and maximizing community-based housing opportunities for people with disabilities who are experiencing homelessness, living in an institution or at risk of institutionalization over a five-year horizon. It is available below.

NCDHHS Strategic Housing Plan  (Date: May 5, 2023)

  • Public Comment for Strategic Housing Plan

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.

Transition Coordination 

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

Community 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.

Supported Employment 

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: https://ipsworks.org/.

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.

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.

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.

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

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.

Training

TCL News

Contact

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

Documents