The Transition Tracking Tool

1. The Transition Tracking Tool Training to aid in the successful use and submission of this form

3. Quality of Life Survey • The Quality of Life Survey has gone live! • The site to find the Quality of Life Survey is: • Full Link: https://www.ncsurveymax.com/TakeSurvey.aspx?SurveyID=l613n5l • Shortened Link: http://goo.gl/mCsFO

4. TYSR UPDATES • Reminder: • In a call a couple months ago we talked about how TYSR are not to be used for entertainment items. This is still our expectation. It has been brought to our attention that there was a slide on one of our original housing trainings that talked about basic bedroom items including televisions. • Clarification please do not use TYSR on Televisions, gaming consoles, etc.

5. Format of Presentation • This webinar will be posted at: http://www.ncdhhs.gov/mhddsas/providers/dojsettlement/ • The presenter is Drew Kristel • Please type your questions/comments in the chat box, where they will be answered by Joyce Young • Thank you all for your hard work, it sincerely is appreciated

6. Table of Contents I. Rationale for the tool’s existence II. Instructions on When to Submit III. Instructions on How to submit IV. How to Use the Transition Tracking tool V. Q&A

7. I. Rationale for the Tool’s existence • North Carolina’s voluntary settlement agreement with the U.S. Department of Justice necessitated the establishment of a 8-year transition program, including housing, appropriate treatment and supportive services • This voluntary agreement lays out rigorous reporting requirements to an independent reviewer, mutually agreed upon by DHHS and U.S. DOJ • The voluntary settlement agreement is available, for review at: http://www.justice.gov/iso/opa/resources/172012823125624712136.pdf • This agreement has resulted in the formation of the NC Transitions to Community Living Initiative (TCLI)

8. I. Rationale Continued • The Tracking Tool is designed to follow the basic track of activities associated with implementing the N.C. TCL program: • Each sheet within the whole tool is designed to be filled out as different steps in the process occur • For example: there’s no need to fill out the Transition Status – General tab until a consumer has been approved for a housing slot

9. I. Rationale Continued • These spreadsheets contain almost all of the data needed to fulfill reporting requirements of the NC TCL Program • The Tracking Tool feeds into an automated database at the state level, making it easier to produce reports • After the annual report for SFY 2013 has been created, LME-MCO report options will be explored

10. I. Rationale Continued • But here’s the good news: • The most time-consuming portion of the Tracking Tool is the initial entry. After entering data on the first tab (Required Individual Info-Status), only a fraction of the fields will have to be entered for future months • These Tracking Tools are short-term and will be replaced by a more efficient long-term solution

11. II. When to Submit • Send the Tracking Tool when requesting a housing slot • State clearly in the email that you are requesting a housing slot as this helps ensure priority processing • Send the Tracking Tool in on a monthly basis for any consumer with whom you performed: • Diversion activities • In-reach activities • Transition Planning activities • After a transition is complete, please send the final copy of this tool so the state can gather critical data needed for reporting

12. II. When to Submit Continued • Your monthly group of Tracking Tools (for the preceding month’s activities) are due by the 10th calendar day of each month. • Please submit all the Tracking Tools within one or two emails, and on the same day • State staff has internal reporting deadlines, and late submissions result in inaccurate counts and delayed credit for reporting your activities • There is a different form to fill out after someone has settled into housing (the Post-Transition Status Tool) that will need to be completed throughout the life of the settlement agreement

13. III. How to Submit the Tracking Tool • The Tracking Tool should be sent encrypted and password protected • Options for encryption include: • An encrypted mail service, such as ZixMail (recommended) • Zipping the file with encryption and requiring a password to extract the file • Passwords must be sent separately or communicated via the phone

14. III. How to Submit the Tracking Tool Continued • Send Housing Slot Approvals and status reporting on In-Reach and Transition Planning activities to: Community@dhhs.nc.gov • Also send updates about people to be removed from the In-reach list to this email address • Send Diversion status reporting to your accountability team representative as well as Community@dhhs.nc.gov

15. IV. How to work with the Tracking Tool • This section is intended to: • Impart an understanding of how to fill out the Tracking Tool property, resolve common errors and clarify confusing portions of the tool • Impart an understanding of what purpose certain fields fulfill • Identify what doesn’t need to be filled out • We have found out some data can be gathered from other sources at this time • An important reminder: Complete one Tracking Tool per consumer, and update that original file to report ongoing status • Also, there are Help notes that display in a yellow box to the side of the selected field to provide guidance on what to enter • Tips to remember: • Use current spreadsheets posted on the DHHS website • Enter or select your values directly on the spreadsheet – copying from other spreadsheets could create data load errors

16. IV. Required Individual Info - Status • This is a very important worksheet as it “feeds” initial columns in the rest of the worksheets (“tabs”) • It is important to supply a Medicaid ID (also known as a Common Name Data Service ID), as this information helps us to ensure a quick turnaround time for Special Assistance Benefits and helps us match with other DHHS data needed • If consumers do not have a Medicaid ID, request a CNDS # from your IT staff (also used for IPRS) • Always enter the Population Category field, as it’s required for the selection committee to approve someone for a housing slot • The In-reach lists will identify those in Population Categories 1-3 • Population 4 will be state hospital residents per in-reach discussions with hospital social worker • Population 5 will be those that come to you through a PASRR Referral

17. IV. Required Individual Info Continued • Whenever you submit the Tracking Tool, update the Transition Status field to reflect the current situation • On In-Reach Target List: No direct contact has occurred yet • Referred to the LME through the PASRR: Received a referral, but haven’t made contact yet • Community Living Counseling Options in Progress: For a Diversion individual who has been contacted and diversion/community living options counseling is in process • In-Reach in Progress: In-Reach is occurring via phone calls, letters and in-person visits • Withdrew from In-Reach: No longer being In-reached • Under DHHS Review: Means you have sent in the form and are awaiting housing slot approval • DOJ Planning in Process: Transition planning after a consumer has been approved for a housing slot • Transitioned to Community with DOJ housing slot: Consumer has moved into permanent housing with a DOJ housing slot • Transitioned to Community (no DOJ housing slot): The consumer was housed some other way without a housing slot. Use for placement into MH Group Homes as well as a permanent home • Withdrew Pre-Transition: The consumer changed his/her mind after a housing slot was approved • Removed from Population/Does not meet criteria: Consumers that are not financially eligible, or do not qualify for the program otherwise • Removed from Population due to violation of program rules: For Fraud and Abuse cases only

18. IV. Required Individual Info Continued • Most important fields on this slide: • Program Aid Category, Program Aid Termination Date, Medicaid Termination Reason, Special Assistance Termination Reason: These may affect eligibility for program participation • Medicaid County: This helps us to expedite the transition of Special Assistance Funding • Home LME-MCO: This helps us to expedite the transition of services and assigns accountable parties • The other fields displayed here are not necessary, but will be helpful

19. IV. Required Individual Info Continued • Current Living Arrangement: Not necessary at this time • If the individual is residing in an ACH/FCH or State Hospital, supply the facility info

20. IV. Required Individual Income • The second tab gathers income info and is the second most important – List each income type on a separate row • The green fields will be auto-populated from our previous work on the Required Individual Info-Status tab • There are several income/benefit types - Most TCL consumers would have SSI or SSDI • If the source of income isn’t listed as an option, select “Other” as the type and describe the income in the Other Income/Benefit Type field

21. IV. Required Individual Income Continued • Enter only numbers in the Monthly Income Benefit Amount field as that is the only value that can be calculated • EXCEPTION: For Special Assistance or SNAP benefit types, list the amount in the Comments field to avoid adding these amounts into the total • 1/3 of the consumer’s income is used for rent and adding these benefits would negatively impact this formula

22. IV. Diversion Tracking • This only needs to be filled out for Diversion consumers referred by the PASRR process • Columns A-E will be auto-populated from data entered in A-E on the Required Individual Info-Status tab; click the link to enter this data if you skipped that step • Veteran Status is needed because certain vouchers are available to veterans or those with veteran family members • Diverted? • “Yes” = Did not go into ACH; Indicate in comments placement (MH Group Home, other community placement) • “No” = Went into ACH or FCH; enter date of admission to facility • Blank = Consumer is still in the hospital or facility that completed the PASRR, OR MCO hasn’t started working with the consumer yet

23. IV. Diversion Tracking Continued • K, L, and R will take you to the appropriate tab for entering data so will not auto populate • S and T take you to the tab that needs data entry, but the columns that need data entry are each two fields over to the right • Temporary Housing: When a consumer has been put into a hotel or into Alternate Family Living while working on getting a consumer into permanent housing

24. IV. Diversion Tracking Continued • Provide additional info as appropriate: • Temporary Housing Start Date • Date Community Integration Plan Developed • Date Moved into Permanent Housing • Click the link in R to enter data about permanent housing or licensed bed housing temporarily provided on the Final Transition Plan – Housing tab • While you are “diverting” and not “transitioning from an ACH” the Final Transition Plan tabs and related statuses are how the workbook is set up to collect this data for now

25. IV. Diversion Tracking Continued • The Diversion Tracking tab does not have choices that explain every situation – Please use the Comments field to provide necessary details • Provide contact information so we can follow up if need be

26. IV. In-Reach Visit Tracking • This tab should be filled out when In-Reach activities are conducted • Remember to update Transition Status • “Withdrew from In-reach” should not be a option after only one or two conversations • There are two In-Reach types: • Telephone/Letter: first contact • In-person • Next in-reach date • In-person Visit + Transition Decision of anything other than Yes or Withdrew = 90 day deadline for next in-reach contact • Telephone/Letter + Transition Decision of anything other than Yes or Withdrew = 30 day deadline for next in-reach contact

27. IV. In Reach Results Data • Columns A-E auto-populate from the Required Individual Info-Status tab • Column F takes you to the Required Individual Income tab to enter the data • Indicate Veteran Status for housing voucher data • Use fields in Columns I and J to document what kind of housing is wanted

28. IV. In-Reach Results Data Continued • Please make sure to fill out the Desired City and Desired County fields • Needed to check for any Targeted/Key program units as NC TCL consumers get some precedence in these units • Prepare the NCSH subsidy administrator for upcoming housing efforts (inspections, landlord agreements, etc.) • Notify potentially impacted county DSS and LME-MCO of possible changes in county of eligibility/catchment area • The Comments field is a good chance to paint a picture of what is happening in this consumer’s situation

29. IV. DHHS Review Tab • Ignore this tab, the data on it is being tracked internally within DHHS • In the future you may also receive the housing slot number via email from DHHS

30. IV. Transition Status - General • Fill out this tab after someone has been approved for a housing slot to provide transition planning status info • “Soft” Transition Meeting Date: recommended to occur 7 days after slot approval • Date of First Full Team Transition Meeting: This starts the 90-day housing/transition completion clock; This meeting is recommended to occur within 10 days of Soft Mtg Date • Transition Deadline: Calculated by the spreadsheet based on the Date of First Full Team Transition Meeting entered • State Hospital CCP Completed? and CCP Completion Date: Enter for State Hospital residents • 30-Day Transition Status and 60-Day Comments: Provides DHHS with detailed status of transition planning so we can be aware of current situation

31. IV. Transition Status - Housing and TYSR • Critical data needed on this tab is in Columns F-V and Z-AC • Columns F-I highlighted here provide DHHS with status needed about • General housing status 30 and 60 days into transition planning

32. IV. Transition Status - Housing and TYSR Continued • Columns J-O highlighted here provide DHHS with status needed about • Dates of criminal background and credit checks • Housing barriers experienced • Homelessness history

33. IV. Transition Status - Housing and TYSR Continued • Columns P-V highlighted here provide DHHS with status needed about • Online housing searches • In-person unit visits • History of tenant applications filed for housing units • TYSR data (columns W-Y) is not needed as you will be providing this via forms processed by Quadel on DHHS’ behalf

34. IV. Transition Status - Housing and TYSR Continued • Columns F-I highlighted here provide DHHS with status needed about • Any referrals made for housing subsidies (vouchers) other than NCSH or Targeted/Key • General comments related to housing efforts • Reminder: you should always get your consumer signed up for the waiting list for Section 8

35. IV. Final Transition Plan - Services • Fill out as the consumer is connected to services – needed for QA and Performance Improvement • It’s very important to indicate what services the person is receiving; included on this list are • Behavioral health • I/DD • Supported employment • Congregate day programming • Any other services or supports provided to help successful community living

36. IV. Final Transition Plan – Services Continued • Also needed are • Name and contact information for the provider/s • Service start and stop dates • Why a consumer stops receiving a Supported Employment service

37. IV. Final Transition Plan – Services Continued • This portion is where you document • Date of the initial Quality of Life Survey • General comments related to services or the survey • Contact information for the Transition Coordinator • Date the full Final Transition Plan and Schedule was sent to DHHS

38. IV. Final Transition Plan - Housing • We’re almost done! • We need to understand what kind of housing is provided to consumers; include • Housing Type Found: use the list provided • Number of Bedrooms • Single Occupancy? (Y/N) • Licensed Facility Name is for Diversion consumers who are not in permanent community based supported housing

39. IV. Final Transition Plan – Housing Continued • This portion of the tab includes basic information about the unit, such as address and landlord contact information

40. IV. Final Transition Plan – Housing Continued • Housing Subsidy Program: Specifies if they received a voucher from the N.C. Supported Housing program, or what other program (KEY, section 8, VASH, etc.) • Supplemental Housing Subsidy: Most will be eligible and receive Special Assistance In-Home. Some will be over-income after leaving the ACH for SA-IH, and will receive Community Living (CLV) funding that works the same way • Transition Deadline: Automatically entered based on the Date of First Full Transition Team Meeting you entered on the Transition Status – General tab • Post Transition Medicaid County: Helps to coordinate funding and services and indicates who will provide status after the 3 month follow along period ends

41. IV. Final Transition Plan – Housing Continued • Post Transition Home LME: Also helps to coordinate services • Transition Barriers Experienced/Comments: Also needed for QA and Performance Improvement

42. V. Q&A • Additional questions can be sent to Drew.Kristel@dhhs.nc.gov