Peer/In-Reach Form A "North Carolina Transitions to Community Living Initiative Informed Decision-Making Tool" - North Carolina

What Is Peer/In-Reach Form A?

This is a legal form that was released by the North Carolina Department of Health and Human Services - a government authority operating within North Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2021;
  • The latest edition provided by the North Carolina Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Peer/In-Reach Form A by clicking the link below or browse more documents and templates provided by the North Carolina Department of Health and Human Services.

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Download Peer/In-Reach Form A "North Carolina Transitions to Community Living Initiative Informed Decision-Making Tool" - North Carolina

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Peer/In-Reach Form A
N
C
T
C
L
I
ORTH
AROLINA
RANSITIONS TO
OMMUNITY
IVING
NITIATIVE
I
D
-M
T
NFORMED
ECISION
AKING
OOL
This form is designed as a tool for the In-Reach Peer-Specialist to guide conversations and
document an informed decision-making process with individuals who are TCLI eligible and have
declined transitioning into the
are undecided, and who want to remain in an Adult
community,
Care Home or those who are reluctant to discharge from a SPH.
Recognizing decision-making as an ongoing process, the approach outlined in this form is
designed to take place over time with the individual and their guardian (when applicable). The
ultimate goal is to raise the value of self-empowerment and each individual’s right to choose
where they want to live while pursuing pathways to recovery and community integration.
Whether or not their choice remains the same, it is critical that individuals have been fully
informed of the available alternatives to living in a licensed facility and that any barriers have
been identified and addressed.
Before using this form, it’s important for In-Reach Specialists/Staff to acknowledge and explore
the individual’s current preferences and choices. This may be done in consultation with the
individual’s guardian and/or natural supports. For example, if an individual has chosen to remain
in an ACH or SPH you may consider saying:
You are the expert in yourself. May I ask you more about where you are currently
staying (or where you would like to live)?
I remember a time plans were being made for me to move from (name setting) to (name
setting)…. As an In-Reach Specialist, you can share your experience as a peer
considering a transition to an integrated setting.
My role is to just make sure that when a person says they want to live (name setting),
that choice is an informed choice.
May I ask you what you like about where you are staying now?
If the individual says they don’t want to be asked, you may reply:
There is no pressure for you to change your mind or make a decision today. I value your
right to choose. That is one of the main reasons for visiting with you. There’s no wrong
or right answer here but, what have you been told about informed choice?
So your choice is to (restate their decision)? I’ve had the opportunity to meet a lot of
individuals who have made a similar decision. (Offer an example of a person you worked
with who benefited from having more information.)
If the individual’s guardian does not want the person to participate, helpful information is
provided below to guide conversations with guardians:
I understand your role as this individual’s guardian and that you have the responsibility
to make decisions with and for this individual. NC General Statute 35A-1201(5) states:
“Guardianship should seek to preserve for the incompetent person the
opportunity to exercise those rights that are within his comprehension and
NC Transitions to Community Living Informed Decision-Making Tool, Peer/In-Reach Form A (June 2021)
Page 1
Peer/In-Reach Form A
N
C
T
C
L
I
ORTH
AROLINA
RANSITIONS TO
OMMUNITY
IVING
NITIATIVE
I
D
-M
T
NFORMED
ECISION
AKING
OOL
This form is designed as a tool for the In-Reach Peer-Specialist to guide conversations and
document an informed decision-making process with individuals who are TCLI eligible and have
declined transitioning into the
are undecided, and who want to remain in an Adult
community,
Care Home or those who are reluctant to discharge from a SPH.
Recognizing decision-making as an ongoing process, the approach outlined in this form is
designed to take place over time with the individual and their guardian (when applicable). The
ultimate goal is to raise the value of self-empowerment and each individual’s right to choose
where they want to live while pursuing pathways to recovery and community integration.
Whether or not their choice remains the same, it is critical that individuals have been fully
informed of the available alternatives to living in a licensed facility and that any barriers have
been identified and addressed.
Before using this form, it’s important for In-Reach Specialists/Staff to acknowledge and explore
the individual’s current preferences and choices. This may be done in consultation with the
individual’s guardian and/or natural supports. For example, if an individual has chosen to remain
in an ACH or SPH you may consider saying:
You are the expert in yourself. May I ask you more about where you are currently
staying (or where you would like to live)?
I remember a time plans were being made for me to move from (name setting) to (name
setting)…. As an In-Reach Specialist, you can share your experience as a peer
considering a transition to an integrated setting.
My role is to just make sure that when a person says they want to live (name setting),
that choice is an informed choice.
May I ask you what you like about where you are staying now?
If the individual says they don’t want to be asked, you may reply:
There is no pressure for you to change your mind or make a decision today. I value your
right to choose. That is one of the main reasons for visiting with you. There’s no wrong
or right answer here but, what have you been told about informed choice?
So your choice is to (restate their decision)? I’ve had the opportunity to meet a lot of
individuals who have made a similar decision. (Offer an example of a person you worked
with who benefited from having more information.)
If the individual’s guardian does not want the person to participate, helpful information is
provided below to guide conversations with guardians:
I understand your role as this individual’s guardian and that you have the responsibility
to make decisions with and for this individual. NC General Statute 35A-1201(5) states:
“Guardianship should seek to preserve for the incompetent person the
opportunity to exercise those rights that are within his comprehension and
NC Transitions to Community Living Informed Decision-Making Tool, Peer/In-Reach Form A (June 2021)
Page 1
judgment, allowing for the possibility of error to the same degree as is allowed to
persons who are not incompetent.”
Also, given your role as the guardian, you play a critical role in implementing Title II of
the Americans with Disabilities Act (ADA) and the U.S. Supreme Court’s Olmstead
Decision, an integration mandate which:
1.) Prohibits discrimination by public entities in services, programs, and activities on
the basis of disability;
2.) Requires that services, programs, and activities be administered in the most
integrated setting appropriate; and,
3.) Enables people with disabilities to interact with people without disabilities to the
fullest extent possible.
You may follow up these replies by asking the guardian:
What integrated living options have you explored with (name the individual)?
What would it take for (name of the individual) to live in the community?
If the individual and/or guardian absolutely refuses to participate in exploring their options, skip
to end of this form and provide documentation of their decision to refuse (under Section IV:
Summary, Reflections and Signatures).
If the guardian who refuses participation is a public guardian, please report the situation to the
Office of the Senior Advisor for the ADA, Tamara Smith, Project Manager, Community
Transitions & Integration at
tamara.smith@dhhs.nc.gov
with as much detail as possible about
how the public guardian was a barrier to choice. The Office of the Senior Advisor for the ADA
will report the concern to the Division of Aging and Adult Services, which will contact the public
guardian’s office for further discussion, education, and follow-up.
If you’ve engaged them in this way and they have given you permission to explore options more
fully, ask if you can follow up with them to share information about their right to choose and
about resources in the community.
Be sure to offer the individual the opportunity to meet with you in a community setting outside of
the ACH or SPH where they may be currently living.
How to Complete Form A and Form B
Form A is intended to be used as a guide on how to complete Form B to ensure the decision-
making process is occurring over time and steps are being taken to advance transition to
community living.
Meetings should be held face-to-face whenever possible, with alternative ways of meeting (that
is, telephone or other technologies) used as needed, with reasons documented on this form.
Form B is a place for the individual to record their decision-making process, including unique
needs and preferences toward making an informed choice. A copy is to be completed with the
individual and either left with the person or mailed shortly after the visit. The In-Reach Specialist
should make a digital copy of Form B for their records and implement next steps identified
during the visit. Encourage the TCLI member to review and contact the In-Reach Specialist with
any questions. This copy should be brought with you at each follow up visit.
NC Transitions to Community Living Informed Decision-Making Tool, Peer/In-Reach Form A (June 2021)
Page 2
Based on the choices and interests of the TCLI member, use the “NOTES” section as a space
for brainstorming with the individual to mutually develop individualized strategies to be
implemented and/or to advance transition to the community as well as any additional concerns
to address. The “Summary, Reflections, and Signatures” section is to be completed after each
visit to document the outcome of each discussion.
Form B (the individual’s form) consists of five sections that spell out the process of informed
decision-making. Each section is also included in Form A (the guide) so that you can follow
exactly what is included on the individual’s form. The sections are as follows:
Section I
Exercising the Right to Choose
Section II
Exploring Options
Section III
Reflecting on Preferred Options
Section IV
Planning Next Steps on Each Preferred Option
Section V
Summary, Reflections and Signatures
Notice the first and second sections of this process may take more time as you obtain
information related to barriers, brainstorm with the individual, educate the individual about
community-based options, and/or consult with the barriers committee to develop an
individualized plan for moving into a more integrated setting. Share with the individual that it’s
their right to choose and you want to make sure by law that they have made an informed
decision.
At the end of the form, both the In-reach Specialist and the individual will reflect on the following list:
 Information and resources about community services and supports, including supported
housing settings not provided by the operator of the adult care home where they live (if
applicable)
 Opportunities to visit such settings in the community
 Arrangements to meet with other individuals with disabilities who are living, working and
receiving services in an integrated setting, with their families, and with community providers
 In-Reach as a service provided to individuals living in an ACH or SPH regularly and not
less than on a quarterly basis
I. Exercising the Right to Choose
It is essential to establish a connection with the individual through conversations that reflect on
(but are not limited to) the value of informed decision-making. Use a Supported Decision-
Making Aid (SDMA) such as those referenced below.
Supported Decision-Making Aids (SDMA):
(These resources should be available through previous trainings)
Peer In-Reach Specialist shares their story, including a time when they had to make an
informed decision about where to live;
Provisions of the Olmstead Decision;
How two women changed thousands of lives - Who were Lois Curtis and Elaine Wilson?
Letter that was sent to the agency;
Reflections on what is recovery? SAMHSA’s Eight Dimensions of Wellness (video or
materials);
NC Transitions to Community Living Informed Decision-Making Tool, Peer/In-Reach Form A (June 2021)
Page 3
Personal Bill of Rights in the Adult Care Home, and their right to choose where they live,
work, and connect with community-based social supports and networks based on the
unique interests and preferences of the individual.
After each visit, be sure to complete and record the TCLI member’s responses to the following
questions, which can be used to outline next steps:
From Form B, Section I: Exercising Your Right to Choose
a) What does it mean to you that you have a right to choose where you live?
b) Do you want to choose where you live? Why or why not?
c) How have you made important choices in the past?
(examples: ask family and friends, read about choices, try something on a trial basis)
d) How far along are you with making a choice about where you live?
☐ Not thought about it ☐ Thinking about it
☐Close to choosing
☐ Made a choice
What is the choice? __________________________________________
Date: __________________
e) If you have made a decision, how did you go about making that decision?
f)
How can you gain more confidence about this choice?
Support for Your Decision:
Who else is involved? _______________________________________________________________
What option do they prefer? __________________________________________________________
Is the person pressuring you? ________________________________________________________
How can they support you? __________________________________________________________
In what ways can the In-Reach Specialist help you? _______________________________________
What role do you prefer in making the choice?
Share the decision with … ________________________________________________________
Decide myself after hearing views of… ______________________________________________
Someone else decides… _________________________________________________________
NC Transitions to Community Living Informed Decision-Making Tool, Peer/In-Reach Form A (June 2021)
Page 4
II. Exploring Your Options
During your conversation with the individual, you will explore living options with them. On the chart below, with your support, the
individual can list these options, the reasons for choosing or avoiding these options, and how much these things matter to them.
From Form B, Section II: Exploring Your Options
How much it
How much it
matters to you:
matters to you:
0 ♦ =not at all
Reasons to Choose this Option
Reasons to Avoid this Option
0 ♦ =not at all
5 ♦ =a great deal
(Benefits/Advantages/Pros)
(Risks/Disadvantages/Cons)
5 ♦ =a great deal
LIVING OPTION
Choose an item.
Choose an item.
#1
Choose an item.
Choose an item.
Choose an item.
Choose an item.
LIVING OPTION
Choose an item.
Choose an item.
#2
Choose an item.
Choose an item.
Choose an item.
Choose an item.
LIVING OPTION
Choose an item.
Choose an item.
#3
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Which option(s) do you prefer? ☐ Option 1
☐ Option 2
☐ Option 3
NC Transitions to Community Living Informed Decision-Making Tool, Peer/In-Reach Form A (June 2021)
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