Monarch's certified community behavioral health clinic in cleveland county, NC - monarch will leverage four years of launching and operating a successful ccbhc in stanly county to launch a second…

Monarch's certified community behavioral health clinic in cleveland county, NC - monarch will leverage four years of launching and operating a successful ccbhc in stanly county to launch a second ccbhc in cleveland county, providing a comprehensive range of mental health and substance use services to residents in need. Monarch projects IT will serve 3,500 individuals during the lifetime of this four-year ccbhc-PDI grant. Monarch's population of focus for this ccbhc-PDI grant is adults with serious mental illness (SMI), substance use disorders (SUD) and CO-occurring disorders (COD) as well as children and adolescents with serious emotional disorders (SED), in rural cleveland county, north carolina. Project name: monarch's certified community behavioral health clinic in cleveland county, NC goal 1: monarch will use evidence-based screenings, assessments and surveys to determine patient risk and coordinate appropriate support. Goal 2: monarch will address the critical behavioral health needs of cleveland county residents by expanding community education, outreach and partnerships. Goal 3: monarch will implement strategies and services that contribute to the mental and physical health and wellness of ccbhc patients. Goal 4: monarch will complete technology-based enhancements to support care delivery and care coordination for patients. OBJ. 1-a: during the grant period, monarch will complete or obtain a comprehensive clinical assessment for 90% of people in monarch's ccbhc program in cleveland county to screen for CO-occurring substance use and mental health disorders. OBJ. 1-B: during the grant period, monarch will assess social determinants of health for 90% of individuals in monarch's ccbhc program in cleveland county. OBJ. 2-a: during the grant period, monarch will education a minimum of 400 community members on mental health and substance use disorder-related topics through documented contacts to cleveland county schools, the general cleveland county population, and targeted populations including veterans, the hispanic community, and the lgbtq population. OBJ. 2-B: during the grant program, monarch will complete five (5) cooperative agreements per year to establish cooperative relationships with a variety of physical health providers (private clinics, local hospitals, detox/recovery organizations) and local social services organizations (food banks, homeless shelters, employment services) that will facilitate care coordination/referrals for people served. OBJ. 3-a: within one year of award, monarch will be in compliance with ccbhc certification criteria. OBJ. 3-B: during the grant period, monarch will expand post-hospitalization services to provide patient follow up by nurse care manager or peer support within 7 days of discharge from inpatient care, with 50% of patients (estimated N = 75 patients) receiving contact. OBJ. 3-C: during the grant period, monarch will implement the medication-assisted treatment model to address the needs of individuals with opioid use disorders using FDA-approved buprenorphine (SUBOXONE) in combination with evidence-based psychosocial therapies. OBJ. 3-D: during the grant period, monarch will incorporate occupational therapy services specific to MH/SUD with 85% of patients with documented need forsupport receiving internal referrals. OBJ. 4-a: within four months of award, monarch will RE-engage with NC healthconnex to share data and evolve population health capacities during the four-year ccbhc-PDI grant period. OBJ. 4-B: during the grant period, monarch will integrate health record and information with the medisked care coordination suite to enhance care coordination for ccbhc patients.