Transitions to Community Living Initiative

The Transitions to Community Living Initiative (TCLI) 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. 

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

The Transitions to Community Living Initiative has six primary components:

  1. In-Reach and Transition — Providing or arranging for frequent education efforts and discharge planning targeted to individuals in Adult Care Homes (ACHs) and state psychiatric hospitals.
  2. Diversion — Providing informed choice regarding housing options to individuals with Serious Mental Illness (SMI) or a Serious and Persistent Mental Illness (SPMI) considering admission to an ACH.
  3. Housing — Providing community-based supportive housing with tenancy supports.
  4. Supported Employment — An evidence-based practice to assist individuals in preparing for, identifying, and maintaining integrated, paid, competitive employment.
  5. Assertive Community Treatment — An evidence-based treatment and support model of services offering intensive customized, community-based services for people with mental illness.
  6. 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.

Pre-admission Screening and Resident Review (PASRR)

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 Pre-Admission Screening and Resident Review (PASRR) process 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 an ACH PASRR number.

The Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS) Level I PASRR screeners provide technical assistance to professionals completing Level I PASRR screens for Adult Care Homes.

North Carolina has engaged the services of a contractor, HP and Earthmark to perform the PASRR reviews. The PASRR information is sent to DMH/DD/SAS staff for a final determination of whether or not an individual has a serious mental illness or a severe and persistent mental illness.

DMH/DD/SAS has identified staff to serve as liaisons to provide technical assistance, answer questions and assist with locating Level 1 Screeners.

Patricia McNear - EAST
919-715-2198
patricia.mcnear@dhhs.nc.gov

Bill Joyce - WEST
336-312-0212
bill.joyce@dhhs.nc.gov

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, TCLI 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 TCLI 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 TCLI. The state uses the data to generate reports and in decision-making for program changes.

Guidelines and Tools

In-Reach and Transition

Annual Reports

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