Active Community Care Transition (ACCT) Process Overview

Selecting a living arrangement for a loved one with developmental disabilities is a very important decision. You want the safest and most appropriate setting for the person's individual needs. That's why Illinois implemented the Active Community Care Transition (ACCT) process for the purpose of State Operated Developmental Center (SODC) closure and rebalancing. The ACCT process requires the transition process be person-centered, meaning individuals and their families/guardians will be a significant part of designing the program that best fits their needs and desires.

The ACCT Team

The Active Community Care Transitions (ACCT) Team is made up of the following:

The DDD obtained the services of an independent entity, Community Resource Associates (CRA), to provide transition planning and support. CRA has been extensively involved in transitioning individuals, including those with significant behavioral, psychiatric, intellectual/developmental, and physical service needs to the community from institutions. Established in 1982, CRA has provided training and consultation in all 50 states.

A variable that makes CRA unique in the market place is that the consultants and sub-contractors of CRA are not only professionals in the field, but many of them are family members of individuals with disabilities and live it daily. Click to learn more about the consortium of national and state professionals assembled through CRA.

The ACCT process will be most successful when family/guardians participate and engage in the process. Read more and learn how you can get involved at Active Community Care Transitions Family/Guardian Involvement.

ACCT Process Overview

The ACCT process begins with an independent comprehensive needs evaluation, which includes a Person-Centered Planning (PCP) session.

Person-Centered Planning (PCP)

Department of Human Services works closely with family or guardians during every step of the process which involves first conducting an independent Person-Centered Planning (PCP) session. This session secures critical information for planning for the transition of care of the individual into the community. The process is adapted for each individual and the PCP sessions are scheduled at the individual's and family/guardian's convenience. Read more on the Person-Centered Planning Approaches.

Assessments

At the same time, staff carefully analyze current and past records and conduct assessments. These independent assessments are conducted by trained, licensed clinicians and expert consultants. Assessments are functional in nature - "What do we need to do to help the individual be successful in the community?" is the primary question to be answered.

The assessments examine 15 domains of the person's life.

  1. Medical
  2. Dental
  3. Nursing
  4. Physical Therapy
  5. Mobility
  1. Psychiatric/Psychological
  2. Community Risk/Monitoring
  3. Behavioral Support (w/Basic Plan)
  4. Communication
  5. Occupational Therapy
  1. Sensory
  2. Adaptive/Assistive Technology
  3. Home and Vehicle Modifications
  4. Vocational/Meaningful Life/Community Integration
  5. Person Centered Plan Specific

There are 3 Levels of Intensity within the Assessment Process for each of the Areas Above

  1. Screening: Review of existing assessments and records, interviews with staff, individual, family members/guardians. If information seems complete, accurate, and provides sufficient information for recommendations, no further action is needed. This also includes completion of HRST (Health Risk Screening Tool) and Basic Community Behavioral Risk Assessment on all individuals.
  2. Internal Evaluation: More extensive evaluation utilizing formal and informal methods, including new evaluations of the individual, to obtain clarifying, additional, or otherwise necessary information. If the information obtained at this level is considered sufficient to make the necessary recommendations for a successful transition to the community no further action is required.
  3. Positive Behavioral Support Plan/External Evaluation: This level of assessment is utilized if the individual presents with significant behavioral challenges that cannot be sufficiently addressed with simply making recommendations to the provider and requires a more detailed formal plan for behavioral support. This is typically provided by the ACCT team.

Likewise, if the individual has some other behavioral, forensic, or health challenge (such as needing a swallowing study), or they are expected to require specific communication devices or other adaptive supports (ramps, specific type of vehicle, etc.) which are beyond the scope of practice of the ACCT Assessment Team, we make arrangements for the additional assessments and/or specialists whenever possible. In the event that this is not possible the ACCT Person Centered Plan clearly identifies that these issues must be addressed by the provider upon transition.

Individual Budget Support Plan Narrative and Individual Planning Budget

Information from the PCP, individual assessments, housing, employment and community preferences are combined into a document called an "Individual Budget Support Plan Narrative" which serves as a roadmap to the services the individual will receive in the community. In addition, an individual planning budget is prepared to identify the costs which will result from implementation of the Individual Budget Support Plan Narrative. The completed Individual Budget Support Plan Narrative is then reviewed by members of the SODC Inter-Disciplinary Team (IDT). This step serves as a check and balance to ensure all areas of need are provided for in the individual plan.

Provider Interest

The ACCT process includes providers across the state who have chosen to participate in the process. All participating providers are fully licensed, and have committed to the ACCT process, its values and principles.  Individuals and guardians are welcome to suggest additional providers in addition to those already identified in the database.

The development of a person centered Individual Budget Support Plan Narrative coupled with a personalized individual planning budget will assist in the process of identifying providers who possess strengths in areas necessary to meet each individual's needs. The ACCT Team will cross reference those identified and willing providers information to determine their capability to support the needs of the person. Based on the ACCT Team analysis, they will identify which potential provider(s) appears to be the most appropriate match to the persons needs.

Provider Exploration

The ACCT Team prepares a list of all the identified providers to share with the Pre-Admission/Screening (PAS) agency and SODC team members. Individuals and guardians meet with the PAS/Independent Service Coordination (ISC) agency serving the community to discuss the service options for which the individual is eligible (ICF/DD or home and community based services wavier options) and will share the list of potential willing and qualified providers.

Individuals and guardians have the opportunity to visit identified potential community service providers of their choice. The list of potential providers is also invited to visit the SODC in order to meet and visit the individual. Both guardians and potential providers are encouraged complete the following activities:

  • Review the PCP summary and have the ACCT Team present the PCP summary
  • Review the Individual Budget Support Plan Narrative
  • Review the Individual Planning Budget (IPB)
  • Review the various assessments
  • Review individual records
  • Meet with ACCT Team members (which includes SODC staff)

After the initial potential provider exploration, the individual and their families/guardian confirm interest in a provider and the provider confirms interest in potentially serving the person. The family/guardian chooses which provider will ultimately serve their loved one.

Service & Home Development

The process of securing the home, staff and supports begins by the selected provider based on the individual needs of the person as identified in the Individual Budget Support Plan Narrative.

Home Development

Providers will either lease or purchase, and in some cases, build a home. It is also possible for the individual or family to lease or purchase the home.

The majority of the transitions will be to homes developed by the provider based on the individual needs of the person as identified in the Individual Budget Support Plan Narrative once the individual/guardians has selected the provider.

The ACCT Team has facilitated the building or purchase of homes in various communities across the region that can be leased or purchased by providers or the individuals when appropriate. The ACCT Team will work with guardians/families to develop homes and supports in communities of individual/guardian preference whenever possible.

Community of Individual/Guardian Preference and Guardian Proximity

The ACCT Team will work with family/guardians to develop homes and supports in communities of individual/guardian preference whenever possible. Through the person-centered planning process, we will explore what communities offer the best opportunities to meet the needs of the individual. Our desire is to identify a community that would be within a 30-45 minute travel time from the family/guardian, if possible.

A key element for success is not just the physical community of preference but the community supports that are available, including access to medical, dental, psychiatric care and programming or activities that are of interest to the individual. Because all of these may not be available in every community of preference, the ACCT team works closely with guardians/families to determine the best option. In some cases, it may be close to the existing SODC. The most important thing is that this is determined with each person individually.

A visit to a home that was developed as part of the JDC or Murray closure can be arranged. It will provide a concrete example of what is possible. Many of the persons who have transitioned have become more independent in many areas of their life and are much more capable than they when they first transitioned.

Smaller Setting Sizes

Numerous studies show that individuals living in the community have a better quality of life than those living in large institutions. Each person will have their own bedroom. If there are circumstances in which alternatives need to be considered they are addressed on a case by case basis.

Reasons for smaller settings include:

  • Smaller settings offer greater flexibility in adjusting supports.
  • Studies suggest and data and providers report that smaller settings in which persons have their own bedrooms tends to be more successful than larger settings. 
  • Families have sometimes expressed concerns about smaller homes, especially as it relates to the safety of their loved one. Again, each of these homes are fully licensed and reviewed on a regular basis. If there is a concern, such as the staff in an all female home, it is possible to request where possible, an all female staff etc. Safety is always the primary concern.
  • The private bedroom offers more privacy, a quite place to unwind or de-compress, a place that you can keep you personal effects from others if you chose.
  • Smaller settings have less persons living in them, so less potential conflicts and often more space per person.
  • Less negative behaviors of others that may be difficult for a person to deal with.
  • More available housing choices in typical community neighborhoods since most homes have 2-4 bedrooms and do not require as large of a footprint or lot.
  • Most adults typically live in homes/apartments with one other adult of their choice (usually a spouse). If other adults live in the setting, it is most likely family members (adult children, parent(s), and siblings). For adults who do choose a roommate, it is most often 1-2 others persons based on a current or previous relationship.
  • Federal CMS (the agency that sets policy for people with Developmental Disabilities) emphasizes and incentivizes through Money Follows the Person (MFP) the development of smaller settings of 4 persons or less.

Service and Staff Development

The ACCT team will discuss the specific details and services outlined in the Individual Budget Support Plan Narrative with the selected provider. Providers will work with the ACCT team in determining the profile of skills and attributes of the potential staff. We encourage the person and families/guardian to engage in the interview and selection process of potential staff or support personnel. Once the home and services are developed as outlined in the Individual Budget Support Plan Narrative, a pre-transition visit is scheduled.

Pre-Transition Visits

The pre-transition visit may vary, depending on whether the person is moving into an existing CILA or a home created specifically around their needs.

If a person is moving into an existing CILA, they will be able to visit for short periods of time for dinner, a movie with their new roommates or an overnight visit prior to moving in.

If a home has been created specifically around a persons needs, based on Individual Budget Support Plan Narrative, the first visit may be an extended one, which ultimately will lead to discharge once it is clear the person is doing well in their new home.

Overnight stay for existing CILA's could result in any of the three (3) options:

  1. Person visits and enjoys the home/services and does not return to the SODC but remains on a visit status until a transition meeting held and other paperwork is finalized. The majority of the pre-transition visits result in the person enjoying the home/services and not returning to the SODC.
  2. Person visits and enjoys the home/services but returns to SODC while provider makes final arrangements for support, a transition meeting held and other paperwork is finalized.
  3. Person visits and does not match well with the home/services and returns to the SODC while other potential providers are considered.

During the pre-transition visit, significant monitoring, feedback and support is provided to the home to ensure a successful transition.

Pre-transition visits are individualized and based on the needs of the person, which can last a few hours or several weeks.

SODC Discharge

Once the individual, family/guardian and the provider feel comfortable with the assembled supports and service the discharge process begins.

  • Transition plan is finalized
  • Individual rate set
  • Award letter processed
  • Transition meeting held
  • Any personal belongings, adaptive equipment, and records/files of the persons that have not already been transitioned to the new home are inventoried, packed and transported to the new home.
  • The person's status is then changed from visit to discharge.

Follow-Up & Monitoring

For every individual transitioning from the state operated developmental center through the ACCT process, extensive follow-along services are being provided in order to support the individual's transition to the new service arrangement.

First Year

Pre-Admission Screening (PAS)/Independent Service Coordination (ISC) Agency

During the first eight (8) weeks in the new community setting, the individual will receive weekly face-to-face visits from the receiving PAS/ISC agency. During these visits, staff will review medication changes, dietary changes, daily activities, social functioning, individual's satisfaction, safety, and behavior patterns.

If the individual experiences transition difficulties, the PAS/ISC agency representative will continue to conduct face-to-face on-site visits with the individual. If the individual appears to be experiencing a smooth transition following the first eight weeks, the PAS/ISC agency representative will visit monthly to discuss the individual's transition status for the remaining 10 months. More frequent follow up and monitoring is done when necessary.

Bureau of Transition Services (BTS)/ACCT Team

In addition, during the first four (4) weeks in the new community setting, the individual may also receive weekly face-to-face visits from Division of Developmental Disabilities staff in the Bureau of Transition Services (BTS) and ACCT Team members. During the following eleven (11) months, BTS staff may visit on a monthly basis. Visits include review of individual's overall well being and other concerns.

BTS staff and PAS/ISC staff will share information to prevent unnecessary duplication of services and to promote efficient use of resources.

BTS staff and PAS/ISC staff will participate in the 30-day residential services staffing for the individual.

Additional follow-up services will be provided as necessary according to the findings of the PAS/ISC and BTS visits and/or contacts. These additional follow-up services may include technical assistance from BTS staff, SODC staff, PAS/ISC staff, staff from other community providers, CRA staff and staff under contract with the Division of Developmental Disabilities.

SODC Personnel (if available)

In addition, during the first four (4) weeks in the new community setting, the individual may also receive weekly face-to-face visits from SODC social worker or Habilitation Plan Coordinator (HPC) who is familiar with the individual. All visits involving SODC staff should be conducted jointly with the PAS/ISC if possible.

Second Year

During the second year and the years after that, PAS/ISC and Individual Service and Support Advocacy (ISSA) personnel will visit quarterly, as they do for all participants in Developmental Disabilities Waiver programs. After that, routine programmatic follow-along services will occur, according to the requirements for the particular residential and vocational service setting.

Other follow-up activities may include:

  • The Office of State Guardian (OSG) staff will be providing additional visits to homes that house their wards.
  • Families and guardians are encouraged to visit as often as possible and to engage other liaisons or other individuals to provide additional visits. 
  • Peer mentors may visit to discuss and explore an individual's concerns.

ACCT Ultimate Purpose

The goal of the ACCT process is not simply to change the location or address of the individual. It is to offer the needed community supports and services that will allow the individual to be close to their family, and to participate in their community. It includes going to a church of one's choice, visiting family and friends, and to lead an ordinary life. That is the ultimate purpose of the ACCT process.