May 18, 2021

North Carolina Olmstead Plan and TCLI, Strengthening a Community-Based System

Looking at the North Carolina health and human services public system from the 50,000-foot level will show that there is tremendous movement toward innovation and strengthening of the community-based service system.  Medicaid Transformation has been at the forefront of catalysts for shifts in the public system, but that is not the only initiative that is causing a shift in service delivery and focus on whole person care.  There have also been initiatives to develop a North Carolina Olmstead Plan and a continued effort to meet the requirements of the US Department of Justice Settlement Agreement that is being done through the Transition to Community Living Initiative.  These are also moving North Carolina toward a stronger community-based system. 

North Carolina Olmstead Plan

NC DHHS contracted with the Technical Assistance Collaborative (TAC) to assess the North Carolina public system’s strengths, weaknesses, gaps and barriers and that assessment report has just been published.  At a meeting of the Olmstead Planning Stakeholder Advisory (OPSA) meeting, NC DHHS Deputy Secretary of Medicaid Dave Richard noted that this assessment will be used as a baseline to develop a North Carolina Olmstead Plan.  The Olmstead Decision was actually handed down by the U.S. Supreme Court in 1999 and requires states to eliminate unnecessary segregation of individuals with disabilities and instead serve individuals with disabilities in the most integrated setting appropriate to their needs.  North Carolina has addressed Olmstead in various ways but has not developed a comprehensive Olmstead Plan.  The OPSA was established to assist with identifying key components of a plan.  TAC made the following recommendations: 

  1. Build on strengths of the system
  2. Increase use of evidence-based and promising practices
  3. Eliminate gaps in community-based services/supports
  4. Increase access to affordable housing
  5. Increase competitive, integrated employment opportunities
  6. Reduce reliance on institutional settings
  7. Request state bridge funding to expand targeted community-based services until sustainable, long-term funding is established 
  8. Reduce reliance on community-based, congregate residential and segregated day service settings
  9. Adopt policy strategies to address financing challenges and gaps
  10. Increase input into development of the Olmstead Plan from under-represented stakeholders
  11. Create a culture that supports the voices of individuals with lived experience
  12. Address workforce capacity and shortages
  13. Use data for evaluation and quality improvement
  14. Eliminate barriers to services

Transition to Community Living Initiative

In 2012, North Carolina entered into a voluntary Settlement Agreement with the U.S. Department of Justice where the State agreed to develop and implement effective measures to prevent inappropriate institutionalization and to provide adequate and appropriate public services and supports identified through person centered planning in the most integrated setting appropriate to meet the needs of individuals with SMI, who are in or at risk of entry to an adult care home.  The Settlement was scheduled to end on June 30, 2021.  An April 8, 2021 Joint Communication Bulletin #J392 states that an agreement had been reached to extend portions of the Settlement through June 30, 2023.   Both NC DHHS leaders and the Independent Reviewer note that the pandemic has impacted the progression of the settlement. 

The most recent report of the Independent Reviewer provides some insights into areas where work is strong and where work is still needed.  Marti Knisley, Independent Reviewer, notes in the executive summary of the March 2021 report that North Carolina has made substantial progress and on track to meeting compliance with the pre-screening of potential TCLI participants and diversion from adult care homes.  NC is progressing but not yet fully met compliance in the discharge and transition process and with individuals living in Adult Care Homes who choose to move to a more integrated setting getting the opportunity to move to supported housing.

NC has also had success in meeting milestones around providing community-based housing opportunities for TCLI participants who may otherwise seek adult care home placement.  For example, the State reported an increase of 436 TCLI participants living  supported housing in the last year.   

The areas that Knisley notes there is still need for focus, funding and strengthening include community-based mental health services, supported employment, and quality assurance and performance improvement.  Knisley conducts reviews across the State, using records and data for analysis of usage and trends.  This data collection is used to assess the progression of North Carolina in meeting the Settlement requirements.   It is interesting to note that, with the extension of the settlement, the independent reviews will span the transition to BH/IDD Tailored Plans and integrated primary and behavioral healthcare.   

Progress in Housing Opportunities for People with Disabilities For many years housing has been recognized as a critical part of successful resilience and recovery for individuals with severe mental illness.  Additionally, the Olmstead decision and the U.S. DOJ settlement with North Carolina placed a spotlight on the need for housing opportunities across the State.  As the Independent Reviewer noted, the State has met a major milestone in increasing supported housing opportunities for individuals in TCLI who are diverted from adult care homes or otherwise discharged to unstable housing from State Psychiatric Hospitals.  Over the past nine years that the settlement has been in place, NC DHHS and the NC Housing Finance Agency have solidified a working relationship to address barriers to housing and tap into all available funds.  NCHFA received a five-year, $7 million grant from U.S. Housing and Urban Development to develop 188 rental units for TCLI participants.  State agency staff have worked alongside LME/MCO TCLI and housing staff to use funding to the greatest extent possible to build housing options.  NCHFA provides ongoing education and technical assistance to landlords on TCLI.  LME/MCOs work directly with the TCLI participant and landlord to work through specific issues.  The State and LME/MCOs have also assisted 391 individuals to move into supported housing by providing short term “bridge” housing while they secured housing and resources to take this step.  The result is a clear success for North Carolina as the State continues toward addressing all the needs of TCLI participants.