Project Grant H79SM086817

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.