The Transition Tracking Tool

1
The Transition Tracking Tool

• Training to aid in the successful use and
  submission of this form

2
LME/MCO Leased Inspected- contracts in process Total
Alliance BH 5 0 5
PBH 1 1 2
CPHS 1 2 3
CoastalCare 11 1 11
ECBH 0 0 0
EastPointe 5 1 6
MeckLINK 3 0 3
Partners BHM 3 5 8
Sandhills 4 3 7
Smoky Mount Ctr 2 4 6
WHN 0 1 1
Total 36 24 60
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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?SurveyIDl613n5l
• Shortened Link http//goo.gl/mCsFO

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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.

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Format of Presentation

• This webinar will be posted at
  http//www.ncdhhs.gov/mhddsas/providers/dojsettlem
  ent/
• 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

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Table of Contents

• I. Rationale for the tools existence
• II. Instructions on When to Submit
• III. Instructions on How to submit
• IV. How to Use the Transition Tracking tool
• V. QA

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I. Rationale for the Tools existence

• North Carolinas 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/reso
  urces/172012823125624712136.pdf
• This agreement has resulted in the formation of
  the NC Transitions to Community Living Initiative
  (TCLI)

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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 theres no need to fill out the
  Transition Status General tab until a consumer
  has been approved for a housing slot

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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 heres 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

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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

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II. When to Submit Continued

• Your monthly group of Tracking Tools (for the
  preceding months 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

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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_at_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_at_dhhs.nc.gov

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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 doesnt 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

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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
  its 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

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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 havent 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

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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

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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 isnt 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 consumers income is used for rent and
  adding these benefits would negatively impact
  this formula

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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 hasnt
  started working with the consumer yet

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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

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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

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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

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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 consumers
  situation

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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

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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

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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

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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

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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

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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

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IV. Final Transition Plan - Services

• Fill out as the consumer is connected to services
  needed for QA and Performance Improvement
• Its 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

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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

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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

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IV. Final Transition Plan - Housing

• Were 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

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IV. Final Transition Plan Housing Continued

• This portion of the tab includes basic
  information about the unit, such as address and
  landlord contact information

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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

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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

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V. QA

• Additional questions can be sent to
  Drew.Kristel_at_dhhs.nc.gov