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23 <br />INDICATOR <br />Lead Agency <br />Status <br />Status <br />Status <br />Status <br />October 2013 <br />January 2014 <br />April 2014 <br />July 2014 <br />3.2.1 <br />CRC <br />New PACE <br />On -going <br />Promotion of the <br />program <br />promotion and <br />model of medical <br />opened in <br />referral. <br />homes <br />December <br />2013 that will <br />serve older <br />adults in <br />southern OC <br />3.2.2 <br />CRC <br />UNC continues <br />Ongoing <br />Expansion of <br />to enroll <br />hospital <br />participants <br />transition <br />into various <br />programs — <br />care transitions <br />decline in <br />programs <br />hospital <br />readmission <br />rates <br />3.3.1 <br />OCDoA /AT/ <br />No action this <br />Older adults <br />Cardinal <br />year. Move to <br />educated on <br />Innovations <br />Year 3 <br />mental health <br />and substance <br />abuse issues <br />3.3.2 <br />OCDOA/ <br />Physicians will <br />No action this <br />Healthy IDEAS <br />Wellness <br />be notified in <br />year. Move to <br />materials sent to <br />Feb 2014. <br />Year 3 <br />primary care <br />Implementation <br />practices <br />Plan <br />3.3.3 <br />OCDoA /AT <br />On -going <br />On -going <br />On -going <br />On -going <br />Access to free <br />MH and SA <br />screening, <br />referrals, and <br />brief counseling <br />services <br />expanded at <br />Senior Centers <br />3.3.4 <br />Cardinal <br />No action this <br />MH needs of <br />Innovations — <br />year. Move to <br />long -term care <br />/OCDoA <br />Year 3. <br />residents <br />identified and <br />