Attachment E MH and SA Collection Form

OMB No. 0930-0277

Expiration Date: 05/31/2009

The CMHS Jail Diversion

Targeted Capacity Expansion Initiative

Mental Health and Substance Abuse Service Use

Data Collection Form

final version – revised MAY 2006

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is 0930-0277.  Public reporting burden for this collection of information is estimated to average 1,373 hours per client per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

INSTRUCTIONS:

Complete one form (page 3) per program participant per provider. Broad treatment categories are required (i.e. 0100, 0200, 0300, etc.). Alternatively, specific treatment categories within the broad categories may instead be recorded. Use one line per treatment episode for Emergency Room (ER), psychiatric inpatient/hospital, residential treatment/community living arrangements and detoxification. All other treatment codes should be listed only once.

Always indicate treatment code, date treatment began, date treatment ended, and number of days OR number of visits/times to date as well as number of hours, if available. Whether days or times/visits are required depends on the treatment category (see specific instructions under each TREATMENT CODE category on pages 4 and 5). If episode is incomplete, enter date treatment ended as 99/99/99. Data should be collected for 6 months post-baseline for all major service providers and one year post-baseline for hospitalizations and ER use.

NOTE THE FOLLOWING:

• If the following services were received as part of an overarching service package (e.g., Assertive Community Treatment (ACT), psychiatric inpatient/hospital, intensive outpatient treatment), record the overarching service code ONLY:

• Individual therapy – any focus

• Group therapy – any focus

• Medication Management/Monitoring

• Case Management

• Any vocational/rehabilitation

• Any community support

EXAMPLES:

1. Records indicate that a program participant received the following outpatient services from a service provider:

• Hour-long individual therapy sessions with an unknown focus from October 18, 2002 to November 17, 2002 (attended 3 sessions) and again from January 4, 2003 to February 20, 2003 (attended 4 sessions).

• Group therapy, substance abuse focus every week for 1.5 hours from October 20, 2002 to March 15, 2003 (attended 13 sessions).

Two coding options exist:

1. Code: 0400; Date Tx Began: 10/18/02; Date Tx Ended: 03/15/03; #Visits/Times: 20; Hours: 27

2. Code: 0405; Date Tx Began: 10/18/02; Date Tx Ended: 02/20/03; #Visits/Times: 7; Hours: 7

Code: 0407: Date Tx Began: 10/20/02; Date Tx Ended: 03/15/03; #Visits/Times: 13; Hours: 20

2. Records indicate that a program participant was hospitalized on the following occasions:

• November 18, 2002 to November 26, 2002

• January 18, 2003 to January 30, 2003

One coding option exists:

1. Code: 0300; Date Tx Began: 11/18/02; Date Tx Ended: 11/26/02; # Days: 9

Code: 0300; Date Tx Began: 1/18/03; Date Tx Ended: 01/30/03; # Days: 13

R ETURN THIS PAGE TO TAPA CENTER

Date of Baseline Interview: __ __/ __ __/ __ __ __ __ Subject ID: ___ ___- ___ ___ ___ ___ ___

(Site Code) (Prog#) (Subject ID#)

Provider Agency/Organization:______________________________________________________

[*Be sure to complete one form per program participant PER PROVIDER.] Total # Hours

[Round up to

the nearest

whole hour.

Date Tx Ended Leave blank

[Enter 99/99/99 # Days OR if unknown]

Code Specify Date Tx Began if still in treatment] Visits/Times

[CHECK ONE] __ Days

___ ___ ___ ___ ______________________ __ __/__ __/__ __ __ __/__ __/__ __ ___ ___ ___ __Visits/Times ___ ___ ___

__Days

___ ___ ___ ___ ______________________ __ __/__ __/__ __ __ __/__ __/__ __ ___ ___ ___ __Visits/Times ___ ___ ___

__Days

___ ___ ___ ___ ______________________ __ __/__ __/__ __ __ __/__ __/__ __ ___ ___ ___ __Visits/Times ___ ___ ___

__Days

___ ___ ___ ___ ______________________ __ __/__ __/__ __ __ __/__ __/__ __ ___ ___ ___ __Visits/Times ___ ___ ___

__Days

___ ___ ___ ___ ______________________ __ __/__ __/__ __ __ __/__ __/__ __ ___ ___ ___ __Visits/Times ___ ___ ___

__Days

___ ___ ___ ___ ______________________ __ __/__ __/__ __ __ __/__ __/__ __ ___ ___ ___ __Visits/Times ___ ___ ___

__Days

___ ___ ___ ___ ______________________ __ __/__ __/__ __ __ __/__ __/__ __ ___ ___ ___ __Visits/Times ___ ___ ___

__Days

___ ___ ___ ___ ______________________ __ __/__ __/__ __ __ __/__ __/__ __ ___ ___ ___ __Visits/Times ___ ___ ___

__Days

___ ___ ___ ___ ______________________ __ __/__ __/__ __ __ __/__ __/__ __ ___ ___ ___ __Visits/Times ___ ___ ___

TREATMENT CODES:

0100 = Emergency Room

(Use one line per episode, include start and end date and total number of days. Collect data on all episodes for 1 year post-baseline.)

0200 = Other Crisis Services

(List total number of times used--and total number of hours, if known--within time period; start date= first day of first time used and end date = last day of last time used.)

0201 = Mobile crisis services

0202 = Crisis Stabilization Unit

0203 = Crisis residential/respite care

0204 = Other, specify _____________

0205 = Other, specify _____________

0300 = Psychiatric Inpatient/Hospital

(Use one line per episode, include start and end date and total number of days. Collect data on all episodes for 1 year post-baseline.)

0400 = Outpatient (excluding Case Management)

(List total number of times/visits--and total number of hours if known—within time period; start date = first time/visit, end date = last time/ visit.)

0401 = Individual or family therapy, mental health focus

0402 = Individual or family therapy, substance abuse focus

0403 = Individual or family therapy, mental health & substance

abuse focus

0404 = Individual or family therapy, other focus, specify

____________

0405 = Individual or family therapy, focus unknown

0406 = Group therapy/specialty groups, mental health

0407 = Group therapy/specialty groups, substance abuse

0408 = Group therapy/specialty groups, mental health &

substance abuse

0409 = Group therapy/specialty groups, other focus, specify

____________

0410 = Group therapy/specialty groups, focus unknown

0411 = Intensive outpatient treatment/day treatment/partial

hospitalization, mental health

0412 = Intensive outpatient treatment/day treatment/partial

hospitalization, substance abuse

0413 = Intensive outpatient treatment/day treatment/partial

hospitalization, mental health & substance abuse

0414 = Intensive outpatient treatment/day treatment/partial

hospitalization, focus unknown

0415 = Other, specify _________________

0416 = Other, specify _________________

0500 = Case Management

(List total number of times/visits--and total number of hours if known—within time period; start date = first time/visit, end date = time/ visit.)

0501 = Case management

0502 = Intensive case management

0503 = Assertive Community Treatment (ACT)

0504 = Other, specify _______________

0505 = Other, specify _______________

0600 = Medication Management/ Monitoring

(List total number of times/visits--and total number of hours if known--within time period; start date = first time/visit, end date = last time/ visit.)

0700 = Residential Treatment/ Community Living Arrangements

(Use one line per episode, include start and end date and total number of days.)

0701 = Supported housing/living

0702 = Group home, community residence

0703 = Adult home/living facility

0704 = Residential (substance abuse) treatment

0705 = Halfway house (criminal justice)

0706 = Other, specify _____________

0707 = Other, specify _____________

0800 = Detoxification

(Use one line per episode, include start and end date and total number of days.)

0900 = Vocational/Rehabilitation

(List total number of times/visits--and total number of hours if known--within time period; start date = first time/visit, end date = last time/ visit.)

0901 = Psychosocial rehabilitation

0902 = Consumer-operated/ peer-run services

0903 = Supported employment

0904 = Vocational counseling

0905 = Supported education

0906 = Other, specify _________________

0907 = Other, specify _________________

1000 = Community Support

(List total number of times/visits--and total number of hours if known--within time period; start date = first time/visit, end date = last time/ visit.)

1001 = Homeless outreach

1002 = Legal or consumer advocacy

1003 = Representative payee services

1004 = Family psychoeducation

1005 = Other, specify _______________

1006 = Other, specify _______________

1100 = Jail Services

(List total number of times/visits--and total number of hours if known--within time period; start date = first time/visit, end date = last time/ visit.)

Service Use Data Collection Form Final Version – May 2006

The TAPA Center