NC's Transition to Community Living Initiative

In July 2012 the State of North Carolina agreed to an 8-year plan to develop community-integrated housing and services for 3,000 individuals with mental illness living in Adult Care Homes (ACHs). The plan was the State’s attempt to address a July 28, 2011 Letter of Findings issued by the US Department of Justice (USDOJ) which found North Carolina in violation of the Americans with Disabilities Act (ADA). That letter was issued in response to a complaint filed on July 26, 2010 by Disability Rights NC alleging North Carolina’s practice of warehousing people with mental illness in ACHs violated the ADA’s integration mandate.

Since that time the State has developed a more detailed implementation plan and convened a number of stakeholder groups to bring the settlement’s promises to reality. Disability Rights NC is actively participating in the State’s implementation efforts to ensure the rights of people with disabilities are protected. The State hired Jessica Keith to oversee the settlement and other efforts to comply with the ADA’s integration mandate. Marti Knisley now serves as monitor for implementation of the agreement.

The Settlement Agreement provides support for people with mental illness and the creation of community supports and services from several angles. (Scroll down for a summary of the Agreement.)


Progress on Implementation of the Settlement

Every year, an independent reviewer assesses the State's progress in the eight-year plan. The latest report and compliance chart, which were released in early November 2017, include the same themes that the Independent Reviewer Marti Knisley has reported in the previous two years - progress toward compliance is slow with the State missing certain benchmarks of compliance with the terms of the settlement. Knisley reports that progress is uneven: "There has been major progress in Supported Employment, mixed progress in Supported Housing, In-reach, Transition Planning, and Quality Assurance and Performance Improvement and minimal progress in Pre-Admission Screening and Diversion and Services." As in previous years, she emphasized the importance of community-based services as opposed to the institutional bias long held by the State in serving people with mental illness.

Knisley's 2016 report had a few glimmers of good news. For example, North Carolina had improved its Supported Employment system so that more people with mental illness can have jobs in their communities. But overall, she found that the State is far behind where it needs to be to meet its commitment. North Carolina missed its target of moving 1,166 people into housing by July 1, 2016. Furthermore, Knisley's report says, "There are significant gaps and limitations in the array, intensity and availability of community mental health services. "In short, North Carolina has not made adequate progress toward creating the system of housing, supports, and services necessary to allow people with mental illness to live in their communities. The incoming administration will have to play catch-up to meet the 2020 goals.

Knisley's 2015 report said progress was "slow but steady" toward compliance with most of the obligations set out in the settlement. She looked at more than 100 measures in the 61-page document. The report indicated that people leaving state psychiatric hospitals were still very unlikely to get community integrated supportive housing, and the situation iwas not much better for people living in adult care homes. Knisley called for additional capacity and other changes to supported employment services offered pursuant to the settlement as well as better and more consistent access to community-based mental health services necessary for the success of the settlement.

Knisley's October 2015 report prompted a November 6, 2015 letter from the US DOJ to NC DHHS in which the US DOJ cited the State's failure to comply with the settlement agreement in three areas: (1) provision of community supports and services, (2) provision of employment supports, and (3) housing placements. Responding to the US DOJ's request, the State responded on December 22, 2015 with a letter from NC DHHS Secretary Richard Brajer and a corrective action plan.


Annual Reports on Implementation of Settlement


Settlement Agreement in a Nutshell

1.  The State must develop 3,000 new units of supported housing over 7 years for people with serious mental illness, targeting those in large ACHs with high percentages of people with mental illness (for homes with at least 50 beds that have at least 25% people with mental illness and homes with between 20 and 49 beds that have at least 40% people with mental illness). Also targeted are people with serious mental illness coming out of state hospitals who are homeless or have unstable housing, and people with serious mental illness diverted from admission to ACHs. The housing units are permanent, afford tenancy rights, enable people with disabilities to interact with people without disabilities to fullest extent possible, and do not limit access to the community. The State will arrange a rental subsidy plus appropriate support services. All but 250 of these housing units must be scattered site supported housing with no more than 20% of the units in a development occupied by people with disabilities known to the State.

2.  The State must provide the array and intensity of services and supports that people with serious mental illness need to live in integrated settings. The State will rely on ACT, CST, psychosocial rehab, peer supports, crisis intervention, supported employment and other services. The State will significantly expand ACT teams; 50 teams serving 5000 people will be created by 2019.

3.  The State will require each LME/MCO to develop an adequate crisis intervention service system including mobile crisis teams, walk-in crisis clinics, community hospital beds, 24/7 crisis lines, etc.

4.  The State will expand supported employment to serve the populations targeted by the agreement. By 2019, the State will serve 2,500 people.

5.  The Agreement includes provisions requiring frequent in-reach and education efforts focused on people in ACHs and state hospitals to be conducted by teams knowledgeable about resources, supports, and services (including community providers and peer specialists).

6.  The Agreement provides for discharge planning requirements that begin at admission, identify strengths, preferences, needs and desired outcomes, document any barriers that prevent a person from going to more integrated settings, and set forth a plan to address those barriers. The planning must set a date when transition can occur. The State must set up a preadmission screening and review process to divert people with serious mental illness from admission to ACHs.

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