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16 <br /> INDICATOR Lead Status Status Status Status <br /> Agency October 2015 January 2016 April 2016 July 2016 <br /> 3.2.1 CRC Ongoing On-going On-going On-going <br /> Promotion of referrals to <br /> the model of PACE programs <br /> medical homes <br /> 3.2.2 CRC, UNC On-going On-going On-going <br /> Expansion of hospitals <br /> hospital <br /> transition <br /> programs— <br /> decline in <br /> hospital <br /> readmission <br /> rates <br /> 3.3.1 OCDoA/AT/ Two workshops Healthy Ideas Plans for free <br /> Older adults Cardinal held on impact program Depression <br /> educated on Innovations of substance expanded Screenings in the <br /> mental health /Wellness use on older through Senior Centers in <br /> and substance adults. Cardinal involvement of late fall 2016 <br /> abuse issues Innovations held Project EngAGE <br /> Mental Health volunteers <br /> First Aid course <br /> at Seymour <br /> Center in June. <br /> Mental health <br /> education <br /> provided in <br /> Project EngAGE <br /> curriculum. <br /> h3.3.3 OCDoA/AT 5 Project Free Memory On-going On-going <br /> Access to free EngAGE Health <br /> MH and SA volunteers Screenings <br /> screening, trained in offered as part <br /> referrals, and Healthy IDEAS in of the National <br /> brief counseling September to Memory <br /> services promote Screening day at <br /> expanded at depression both Sr Ctrs. <br /> Senior Centers identification, Educational <br /> referral, and tools shared at <br /> intervention event <br /> 3.3.4 Cardinal <br /> MH needs of Innovations <br /> long-term care —/OCDoA <br /> residents <br /> identified and <br />