Monarch's certified community behavioral health clinic (CCBHC) in stanly county, NC - monarch's certified community behavioral health clinic in stanly county, NC will increase the depth and breadth of…

Monarch's certified community behavioral health clinic (CCBHC) in stanly county, NC - monarch's certified community behavioral health clinic in stanly county, NC will increase the depth and breadth of mental health and substance use disorder services in rural north carolina through care management, strengthened collaborations with established partners, and extended education and outreach to incarcerated individuals at the stanly county detention center. Monarch projects IT will serve 3,750 unduplicated individuals during the lifetime of this four-year CCBHC-IA project. Monarch's population of focus for this CCBHC improvement and advancement 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 stanly county, north carolina. Project name: monarch's certified community behavioral health clinic in stanly county, NC goal 1: monarch will implement strategies and services that contribute to the mental and physical health and wellness of CCBHC patients. Goal 2: monarch will use evidence-based screenings, assessments and surveys to determine patient risk and coordinate appropriate support. Goal 3: monarch will address the critical behavioral health needs of stanly county residents by expanding community education, outreach and partnerships. Goal 4: monarch will complete technology-based enhancements to support care delivery and care coordination for patients. OBJ. 1-a: by september 29, 2026, monarch will provide patient follow up by nurse care manager or peer support within 7 days of discharge from inpatient hospital care, with 50% of patients (estimated N = 100 patients) receiving contact. OBJ. 1-B: by september 29, 2026, monarch will incorporate occupational therapy services specific to MH/SUD with 85% of patients with documented need forsupport receiving internal referrals. OBJ. 2-a: by september 29, 2026, monarch will complete comprehensive clinical assessments on 80% of patients seeking services at the stanly county CCBHC. OBJ. 2-B: by september 29, 2026, using social determinants of health surveys, monarch will identify patients experiencing barriers to treatment and enroll at least 50% of those identified patients into targeted care management services. OBJ. 3-a: by september 29, 2026, monarch will educate a minimum of 300 community members on mental health and substance use disorder-related topics through six (6) community events. OBJ. 3-B: by september 29, 2026, monarch's CCBHC staff will expand community outreach to the general stanly county population, and to targeted populations including veterans, the hispanic community, the lgbtq population and incarcerated individuals at the stanly county detention center through 10 documented contacts per month and reaching an estimated 400 people. OBJ. 3-C: by september 29, 2026, monarch will 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) to facilitate care coordination/referrals for people served, completing 15 cooperative agreements in the grant period. OBJ. 4-a: by september 29, 2026, monarch will engage in north carolina's health information exchange - NC healthconnex - to share and access healthcare information and evolve population health capacities during the four-year CCBHC-IA grant period. OBJ. 4-B: by september 29, 2026, monarch will integrate health record and information with the medisked care coordination suite to enhance care coordination for CCBHC patients.