Traditionally, North Carolinians with mental health support needs have had limited choice in where they receive their services. That is changing with the Transitions to Community Living Initiative. This initiative is the result of a settlement agreement between the North Carolina Department of Health and Human Services (DHHS) and the U.S. Department of Justice (DOJ). The agreement outlines the steps that DHHS will take to ensure that people living with serious mental illnesses or severe and persistent mental illness can choose where they live.
“Over the next eight years, the Transitions to Community Living Initiative will move at least 3,000 individuals in North Carolina from a state psychiatric hospital or Adult Care Home to an apartment in their community,” says Jessica Keith, DHHS special advisor on the Americans with Disabilities Act (ADA). “These transitions into the community will provide long-term housing stability and reduced hospitalizations.”
The initiative is based upon the following guiding principles set by the ADA of 1990 and the Olmstead v. L.C. decision of the U. S. Supreme Court:
- Individual choice is valued and supported;
- Services should be in the least restrictive and most integrated setting appropriate for the individual;
- Services should be built on resiliency and be recovery oriented;
- Housing setting should enable individuals with disabilities to interact with individuals without disabilities to the fullest extent possible; and,
- Housing setting should not limit an individual’s ability to access community activities at times, frequencies and with people of their choosing.
DHHS, in partnership with the Local Management Entity-Managed Care Organizations (LME-MCOs), will administer the initiative and an independent reviewer will evaluate the entire process.
“This initiative is designed to be very individualized,” says Keith. “The services and supports are to be wrapped around the individual and help sustain them wherever they choose to live.”
The following services and supports are provided by the Transition to Community Living Initiative:
- In-reach (information sharing)
- Diversion (screening process)
- Transition planning
- Housing slots with rental assistance and transition supports
- Fidelity to the assertive community treatment team model
- Supported employment
- Quality assurance and performance improvement
- Crisis resources
In-reach is a series of conversations with the individual, their families, and professionals to help everyone fully understand what options may exist so that an informed choice can be made. These conversations will be coordinated by the LME-MCOs and conducted by certified peer specialists. In-reach will begin with residents in adult care homes that have high percentages of individuals with a diagnosis of serious mental illness and will recur at regular intervals to determine if an individual’s needs or desires have changed.
Diversion is a screening process intended to identify individuals with potential mental health needs. Individuals who are seeking admission to an adult care home will be evaluated using the pre-admission screening and resident review. Those individuals with mental health needs will then be informed of all options available to them. Individuals who choose a community placement rather than an adult care home will be directed to community-based services and will work with their LME-MCO to develop their transition plan.
Transition planning assists the individual in developing an effective written plan that will enable them to live independently in an integrated community setting. Transition planning is a person-centered planning process in which the individual has a primary role and is based on the principle of self-determination. The planning is overseen by the LME-MCO’s transition coordinator and should include the individual and the individual’s family or guardian.
The planning process will ensure that the individual has the necessary services and supports needed for successful community living, including but not limited to:
- Medical services
- Housing supports
- Educational supports
- Employment supports
- Behavioral health services
- Financial management services
- Other community supports
Transition planning will also ensure that benefits transfer, provide person-specific risk mitigation strategies and crisis planning, along with any necessary adaptive equipment.
“Transition coordination is a critical element of the process,” says Trish Farnham, project director for the N. C. Money Follows the Person Demonstration Project. “The transition coordinator works with the participant to make sure that numerous details related to their move into the community are effectively identified and addressed.”
The LME-MCOs will assume the responsibility for assisting on moving day by having a moving company do the heavy lifting if necessary and having someone on-site to assist such as a peer specialist, housing specialist or transition coordinator.
Housing slots are a state-supported package of subsidies that include rental assistance, one-time transition supports, and community services. The Transitions to Community Living Initiative will create more than 3,000 housing slots during the life of the program on a first-come, first-served basis and will be based upon geographic availability and individual preferences.
Housing slots include tenancy support services to assist in overcoming the barriers to obtaining and maintaining housing. The housing slots will be at scattered site locations with no more than 20 percent of the units occupied by a person with a disability.
“This will enable individuals with disabilities to interact with non-disabled people to the fullest extent possible,” says Martha Are, director of housing and homelessness with the Department of Health and Human Service’s Division of Aging and Adult Services. “The preference for housing slots is in a non-licensed, single occupancy apartment-style setting. This type of location will allow for choice in everyday activities.”
Assertive Community Treatment Team is a service-delivery model that provides comprehensive, locally-based treatment to people with a serious mental illness or a severe and persistent mental illness. Assertive Community Treatment Team recipients receive the around the clock availability of multidisciplinary, behavioral health staffing within the comfort of their own home and community. There will be 33 teams serving 3,225 individuals by July 2013 and by July 2019 there will be 50 teams serving 5,000 individuals.
Supported employment is a service to assist individuals with job training, job coaching and finding employment opportunities. This service will be based upon the Dartmouth Individual Placement and Support Model. The initial target for supported employment services is 100 individuals by July 2013 and increasing to 2,500 individuals by 2019. Supported employment does not mean sheltered workshops, employment in segregated settings, group employment models or sub-minimum wages.
Using Quality Assurance and Performance Improvement, North Carolina will ensure that services provided by the state are of good quality and are sufficient to help individuals achieve increased independence, gain greater integration into the community, obtain and maintain stable housing, avoid harms, and decrease the incidence of hospital contacts and institutionalization.
This will be done by tracking length of stay, readmissions and tenure in the community. Personal outcomes will also be tracked, including:
- Incidents of harm;
- Repeat admissions;
- Use of crisis beds and community hospital admissions;
- Repeat Emergency Department visits;
- Time spent in congregate day programming; and,
- Number employed, attending school, maintaining living arrangement, engaged in community life.
Quality Assurance and Performance Improvements will also conduct Quality of Life Surveys with the individuals that are part of the initiative and will evaluate the in-reach and discharge activities for the program. An External Quality Review will also help ensure that the state is meeting its responsibilities under the agreement.
The agreement creates an eight-year timeline for the Transitions to Community Living Initiative, during which at least 3,000 individuals across North Carolina will begin living in their community instead of in an institution. Transition efforts are being supported during the first year with an allocation of $10.3 million in the state budget.
- Chris Pfitzer, DMH/DD/SAS
For additional information regarding the Transitions to Community Living Initiative, please visit the program website at www.ncdhhs.gov/mhddsas/providers/dojsettlement/.