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Transitions to Community Living Initiative (TCLI)

youngman smiling holding a keyThe State of North Carolina entered into a settlement agreement with the United States Department of Justice (DOJ) in 2012. The purpose of this agreement was to make sure that persons with mental illness are able to live in their communities in the least restrictive settings of their choice. The Trillium Transitions to Community Living Initiative (TCLI) Department works in collaboration with the NC Department of Health & Human Services and other MCOs across the state to meet the goals specified in the Department of Justice (DOJ) Settlement Agreement.

The Transitions to Community Living Initiative (TCLI) staff primarily works to ensure individuals with serious mental illness identified within the DOJ Settlement Agreement are:

  • given choice in determining where they would like to live

  • provided access to supports and services to assist with safe and successful transitions into the community

  • linked to evidence-based, person-centered, recovery-focused, and community-based supports and services

TCLI staff is working to ensure:

  • In-reach, diversion, transition planning, supported housing, and care coordination

  • A comprehensive, person-centered approach

  • Collaborative service development, improvement, and implementation

  • Community outreach, education, and coordination with providers, hospitals, local Departments of Social Services, Community Care of North Carolina, adult care homes, homeless shelters, health departments, and other stakeholders

  • In-reach: Certified Peer Specialists will go into facilities and build relationships with individuals to discuss community-based mental health services and potential housing resources.
  • Diversion: Pre-admission Screening and Resident Review (PASRR) is a screening tool used prior to any admission into an adult care home to determine if the candidate has mental illness.
  • Transition planning: Once an individual is identified by In-reach as interested in community-based mental health or housing services, then they are assigned to a Transition Coordinator. The Transition Coordinator helps develop a plan to transition an individual into the community.
  • Available services:
    • Housing slots with financial rental assistance
    • Tenancy Support to help with moving, setting up household supplies and furniture, and explaining what to do in an emergency 
    • Individual Placement and Support-Supported Employment service (for individuals with mental health and substance use disorders) to obtain competitive employment in an integrated work setting
    • Work Incentives Planning and Assistance (WIPA) (for individuals with disabilities who receive Social Security benefits) to help acquire, retain, and increase meaningful employment with the goal of improving financial independence
    • Special Assistance-In Home provides cash supplement to help low-income adults who are at risk of placement in a licensed residential care setting to reside in a private living setting

As part of the DOJ settlement, NC DHHS has determined that the following members are potentially eligible for inclusion in the TCLI. Approval for inclusion in the TCLI program comes from NC DHHS and is not determined by Trillium.

  • Individuals with severe and persistent mental illness (SPMI) who reside in adult care homes that are determined to be Institutes of Mental Disease (IMD)
  • Individuals with SPMI who reside in adult care homes licensed for at least 50 beds, and in which 25% or more of the population has a mental illness
  • Individuals with SPMI who reside in adult care homes licensed for 20-49 beds, and in which 40% or more of the population has a mental illness
  • Individuals with SPMI who are or will be discharged from a State psychiatric hospital, and who are homeless or have unstable housing
  • Individuals diverted from entry into adult care homes pursuant to the preadmission screening and diversion 

For more information, please visit DOJ Settlement - Transitions to Community Living Initiative or call Trillium at 1-866-998-2597.

For further information, please check out the following resources:

Our Transitions to Community Living (TCL) participants have been so successful, we have a whole page devoted to their testimonials. Go to Transitions to Community Living Stories to read about their personal victories!


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