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Behavioral Health is Essential To Health • Prevention Works • Treatment is Effective • People Recover
FY 2012
Block Grant Reporting Section
CFDA 93.958 (Mental Health)
R e d u c i n g t h e i m p a c t o f s u b s t a n c e a b u s e a n d m e n t a l i l l n e s s o n A m e r i c a ’s c o m m u n i t i e s .
·
Table of Contents
A.
B.
C.
D.
E.
Introduction
Implementation Report
State Agency Expenditure Report
Population and Services Report
Performance Indicators and Accomplishments
Section A. Introduction
Title XIX, Part B, Subpart III of the Public Health Service Act (42 U.S.C. 300x-52(a)) requires
the Secretary of the Department of Health and Human Services, acting through the Administrator
of the Substance Abuse and Mental Health Services Administration (SAMHSA), to determine
the extent to which States and Jurisdictions have implemented the State plan for the prior fiscal
year. The purpose of the Annual Report is to provide information to assist the Secretary in
making this determination.
States and jurisdictions are requested to prepare and submit their reports for the last completed
fiscal year in the format provided in this guidance. The report will address the purposes for
which the MHBG and SABG funds were expended, the recipients of grant funds, and the
authorized activities and services purchased with such funds. Particular attention should be
given to the progress made toward accomplishing the goals and performance indicators identified
in the States’ and Jurisdictions’ plans.
All States are required to prepare and submit their respective reports utilizing SAMHSA’s Web
Block Grant Application System (BGAS). This report must be received by SAMHSA not later
than December 1 in order for State or Jurisdiction to receive a grant for the subsequent Federal
fiscal year. If the due date falls on a weekend or Federal holiday, the report will be due on the
next business day. The following schedule provides specific due dates for annual reports:
2013
Plan and Repor t Receipt Dates
Plan Receipt Planning Per iod Repor t
Date
Receipt Date
9/01/2011
10/01/2011 –
12/01/2011
06/30/2013
12/01/2012
2014
04/01/2013
Application for
Feder al fiscal year
2012
07/01/2013 06/30/2015
2015
2016
2017
12/01/2013
12/01/2014
04/01/2015
07/01/2015 –
06/30/2017
12/01/2015
12/01/2016
Repor t Per iod
10/01/2010 09/30/2011
07/01/2011 06/30/2012
07/01/2012 –
06/30/2013
07/01/2013 –
06/30/2014
07/01/2014 –
06/30/2015
07/01/2015 06/30/2016
States are required to complete the Reporting Document. The reporting Document is comprised
of the following sections:
Section B: Implementation Report - In this first section, States are required to provide a brief
review of the extent to which their respective plans were implemented, the progress towards the
priorities and goals identified in the Block Grant application. The report should also include a
brief review of areas that the State identified in Block Grant Application as needing
improvement and changes that the State and Jurisdiction would propose to achieve the goals
established for the priorities.
Section C: State Agency Expenditure Report - In this section, States should provide information
regarding expenditures for authorized activities and services for mental health (and substance
abuse prevention, and substance abuse treatment if submitting combined report).
Section D: Populations and Services Report - In this section, States and Jurisdictions must
provide specific information regarding the number of individuals that were served with MHSBG
funds. In addition, States and Jurisdictions should provide specific information regarding the
services these individuals received.
Section E: Performance Indicators and Accomplishments - In this section of the report, States
and Jurisdictions are required to complete the Performance Indicator tables. Performance
indicators should be reported using the table format provided in this document. The purpose of
the performance indicator tables is to show progress made over time as measured by SAMHSA’s
National Outcome Measures (NOMS) for mental health services as well as any State- or
Jurisdiction-selected performance indicators.
B. Implementation Report
Table 1: As part of the planning section, States identified their priorities in addition to the joint
planning areas and the statutorily required priorities. This table should be filled out for all
priority areas that the State will focus on during the planning period. The same table will be
used to capture progress reporting.
Table 1
Report Year(s):
State Identifier:
State Priorities
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Add more priority areas as needed
At the end of each priority area, States and Jurisdictions should clearly indicate whether or not
the particular goal identified in the State plan for the prior State fiscal year was “achieved” or
“not achieved.” If a target was “not achieved,” a detailed explanation must be provided.
Table 2, Priority Area by Goal, Strategy, and Performance Indicator, should be completed for
each priority areas identified by States and Jurisdictions in their respective State plans and for
which fiscal resources were expended during the prior State fiscal year.
Table 2
Report Year(s):
State Identifier:
Priority Area:
Goal:
Strategy: (use as many lines as needed for each strategy)
Performance Indicator:
Description of Collecting and Measuring Changes in Performance Indicator:
Report of Progress toward goal attainment in prior State Fiscal Year:
____ Achieved
_____ Not Achieved (if not achieved, explain why)
Changes Proposed to Meet Goal
C. Expenditure Reports
Mental Health Services Block Grant Spending
States and Jurisdictions should provide information regarding MHBG and State general revenue
funds expended for authorized activities to prevent and treat mental illness. Please complete the
tables described below: Please Note: Data for all tables contained in the Uniform
Reporting System (URS) will continue to be submitted into the URS data base maintained
by the URS Contractor.
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•
•
•
•
•
•
•
Table 3A and 3B (URS Tables 5A and 5B). Profile of Clients by Type of Funding
Support. Table 3A and 3B is to provides the number of Female and Male clients by race
and by ethnicity that have: Medicaid Only, Non-Medicaid Sources, Both Medicaid and
Non-Medicaid, and Status not available.
Table 4 (URS Table 7). Profile of Mental Health Service Expenditures and Sources of
Funding. Table 4 is to provide information on Mental Health Expenditures and Sources
of Funding. This includes funding from Medicaid, the MHSBG. Other federal funding
sources, state, local and other funds.
Table 5 (NEW). MHSBG Expenditures By Service. Table 5 is to be used to provide
information on MHSBG spending by unduplicated individual and specific services.
Table 6 (NEW) Primary Prevention Expenditures Checklist. This table provides a
description of MHSBG Block Grant expenditures on primary prevention strategies
funded by State Mental Health Authority.
Table 7(URS Table 8). Profile Of Community Mental Health Block Grant Expenditures
For Non-Direct Service Activities. Table 7 is used to describe the use of MHSBG funds
for non-direct service activities that are sponsored, or conducted by the State Mental
Health Authority
Table 8(URS Table 10). – Statewide Entity Inventory. This table provides a description
of the recipients of MHSBG funds including intermediaries, e.g., administrative service
organizations, and other organizations which provided mental health services during the
prior State fiscal year. The table has been amended to include recipients of SAPTBG
funds for those states submitting one application.
Table 9 (NEW) - Maintenance of Effort for State Expenditures on Mental Health
Services. This table provides a description of all State non-Federal expenditures for
authorized activities to prevent and treat mental illness during each State fiscal year.
Table 10 (NEW) – Report and Set-aside for Children’s Mental Health Services. This
table provides a description of non-Federal funds expended for children’s mental health
services during each State fiscal year (SFY).
Table 3A. (URS Table 5A) Profile of Clients by Type of
Funding Support
This table provides a summary of clients by Medicaid coverage. Since the focus of the reporting is on clients of the public mental health service delivery system,
this table focuses on the clientele serviced by public programs that are funded or operated by the State Mental Health Authority. Persons are to be counted in the
Medicaid row if they received a service reimbursable through Medicaid.
Please note that the same person may be served in both Medicaid and Non-Medicaid programs during the same reporting period.
Table 3A
Report Year:
State Identifier:
Total
Female
Male
Not
Available
Total
American Indian or Alaska
Native
Not
Female
Male
Available
Asian
Female
Male
Not
Available
Black or African American
Not
Female
Male
Available
Medicaid (only
Medicaid)
Non-Medicaid
Sources (only)
People Served
by Both
Medicaid and
Non-Medicaid
Sources
Medicaid
Status Not
Available
Total Served
Comments on
Data (for Age):
Comments on
Data (for
Gender):
Comments on
Data (Overall):
Each row should have a unique (unduplicated) count of clients: (1) Medicaid Only, (2) Non-Medicaid Only, (3) Both Medicaid and Other Sources funded their
treatment, and (4) Medicaid Status Not Available.
If a state is unable to unduplicate between people whose care is paid for by Medicaid only or Medicaid and other funds, then all data should be reported into the
'People Served by Both Medicaid and Non-Medicaid Sources' and the 'People Served by Both includes people with any Medicaid' check box should be checked.
(continued on next page)
Table 3A
(Con’t)
Report Year:
State
Identifier:
Native Hawaiian or
Other Pacific Islander
Femal
e
Medicaid
(only
Medicaid)
Non-Medicaid
Sources
(only)
People
Served by
Both Medicaid
and NonMedicaid
Sources
Medicaid
Status Not
Available
Total Served
Male
Not
Availa
ble
Hispanic * use only if data
for Table 5b are not
available.
White
Femal
e
Male
Not
Availa
ble
Femal
e
Male
Not
Availa
ble
More Than One Race
Reported
Femal
e
Male
Not
Availa
ble
Race Not Available
Femal
e
Male
Not
Availa
ble
Table 3B. (URS Table 5B) Profile of Clients by Type of
Funding Support
Of the total persons covered by Medicaid, please indicate the gender and number of persons who are Hispanic/Latino or not Hispanic/Latino. Total
persons covered by Medicaid would be the total indicated in Table 3A.
Please note that the same person may be served in both Medicaid and Non-Medicaid programs during the same reporting
period.
Table 3B.
Report Year:
State Identifier:
Not Hispanic or Latino
Female
Male
Not
Available
Hispanic or Latino
Female
Male
Not
Available
Hispanic or Latino Origin
Unknown
Female
Male
Not
Available
Total
Female
Male
Not
Available
Total
Medicaid Only
Non-Medicaid Only
People Served by
Both Medicaid and
Non-Medicaid
Sources
Medicaid Status
Unknown
Total Served
Comments on Data
(for Age):
Comments on Data
(for Gender):
Comments on Data
(Overall):
Each row should have a unique (unduplicated) count of clients: (1) Medicaid Only, (2) Non-Medicaid Only, (3) Both Medicaid and Other Sources funded
their treatment, and (4) Medicaid Status Unknown.
Table 4 (URS Table 7): Profile of Mental Health Service Expenditures and Sources of Funding
This table describes expenditures for public mental health services provided or funded by the State mental health agency by source of
funding.
Table 4
Report Year:
State Identifier:
State Agency Expenditure Report
(Include ONLY funds expended by the executive branch agency administering the SAPT Block Grants and the CMHS Block Grant*)
Source of Funds
ACTIVITY
(See instr uctions for using Row 1.)
1.
Substance Abuse Pr evention**
and Tr eatment
2.
Pr imar y Pr evention
3.
Tuber culosis Ser vices
4.
HIV Ear ly Inter vention
Ser vices
5.
State Hospital
6. Other 24 Hour Car e
7. Ambulator y/Community Non-24
Hour Car e
8. Administr ation (excluding
pr ogr am / pr ovider level
9. Subtotal (Rows 1, 2, 3, 4, and 8)
10. Subtotal (Rows 5, 6, 7, and 8)
11. Total
A.
Substance Abuse
Block Gr ant
B.
Mental Health
Block Gr ant.
Block Gr ant
C. Medicaid
(Feder al, State,
and local)
D. Other Feder al
Funds (e.g., ACF
(TANF), CDC,
CMS (Medicar e)
SAMHSA, etc.)
E. State funds
F. Local funds
(excluding local
Medicaid)
G. Other
* States and Jurisdictions may utilize a single table to report expenditures for the SAPT and CMHS Block Grants if a State or Jurisdiction submits a single report to
SAMHSA**Prevention other than Primary Prevention
Table 5 (NEW): MHSBG Expenditures by Service
Table 5
Report Year:
State Identifier:
Service
Prevention and Wellness
Screening, Brief Intervention and Referral to Treatment (SBIRT)
Brief Motivational Interviewing
Screening and Brief Intervention for Tobacco Cessation
Parent Training
Facilitated Referral
Relapse Prevention/Wellness Recovery Support
Warm Line
Engagement Services
Assessment
Specialized Evaluations
Service Planning
Consumer/Family Education
Outreach
Outpatient Services
Individual Evidenced Based Therapies
Group Therapy
Family Therapy
Multi-family counseling
Consultation with Caregivers
Medication Services
Medication management
Pharmacotherapy
Laboratory Services
Community Support Services
MHSBG Block Grant Expenditures by Service
Unduplicated Individuals
Units
Expenditures
Table 5
Report Year:
State Identifier:
Service
Parent/Caregiver Support
Skill Building
Case management
Continuing care
Behavior management
Supported employment
Permanent supportive housing
Recovery housing
Therapeutic mentoring
Traditional healing services
Recovery Support Services
Peer Support
Recovery Support Coaching
Recovery Support Center Services
Supports for Self Directed Care
Other Supports
Personal care
Homemaker
Respite
Supported education
Transportation
Assisted Living
Recreational services
Trained Behavioral Health Interpreters
Interactive Communication Technology Devices
Intensive Support Services
Substance Abuse Intensive Outpatient (IOP)
Partial hospital
Assertive Community Treatment
Intensive home based services
MHSBG Block Grant Expenditures by Service
Unduplicated Individuals
Units
Expenditures
Table 5
Report Year:
State Identifier:
Service
Multi-systemic Therapy
Intensive Case Management
Out of Home Residential Services
Crisis residential/stabilization
Adult Substance Abuse Residential
Adult Mental Health Residential
Youth Substance Abuse Residential
Children's Residential Mental Health
Therapeutic foster care
Acute Intensive Services
Mobile crisis
Peer based crisis services
Urgent care
23 hr. observation bed
Inpatient detoxification
24/7 crisis hotline
Other (please list)
MHSBG Block Grant Expenditures by Service
Unduplicated Individuals
Units
Expenditures
Table 6 (NEW): Primary Prevention Expenditure Checklist
*Please lit all sources, if possible (e.g.., Centers for Disease Control and Prevention, Block Grant, foundations, etc.)
Table 6
Report Year:
State Identifier:
Strategy
A.
IOM Target
Primary Prevention Expenditures Checklist
B.
C.
MHSBG Block Grant
Other Federal
D.
State
E.
Local
F. Other
1. Infor mation Dissemination
Universal
$
$
$
$
$
Selected
$
$
$
$
$
Indicated
$
$
$
$
$
Unspecified
$
$
$
$
$
Universal
$
$
$
$
$
Selected
$
$
$
$
$
Indicated
$
$
$
$
$
Unspecified
$
$
$
$
$
Universal
$
$
$
$
$
Selected
$
$
$
$
$
Indicated
$
$
$
$
$
Unspecified
$
$
$
$
$
Universal
$
$
$
$
$
Selected
$
$
$
$
$
Indicated
$
$
$
$
$
Unspecified
$
$
$
$
$
2. Education
3. Alter natives
4. Pr oblem Identification and Refer r al
5. Community-Based Pr ocesses
6. Envir onmental
7. Section 1926-Tobacco
8. Other
Universal
$
$
$
$
$
Selected
$
$
$
$
$
Indicated
$
$
$
$
$
Unspecified
$
$
$
$
$
Universal
$
$
$
$
$
Selected
$
$
$
$
$
Indicated
$
$
$
$
$
Unspecified
$
$
$
$
$
Universal
$
$
$
$
$
Selected
$
$
$
$
$
Indicated
$
$
$
$
$
Unspecified
$
$
$
$
$
Universal
$
$
$
$
$
Selected
$
$
$
$
$
Indicated
$
$
$
$
$
Unspecified
$
$
$
$
$
Table 7 (URS Table 8): Profile of Community Mental Health Block Grant Expenditures for Non-Direct Service Activities
This table is used to describe the use of CMHS BG funds for non-direct service activities that are sponsored, or conducted, by the State Mental
Health Authority.
PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!
Table 7
Report Year:
State Identifier:
Profile of Community Mental Health Block Grant Expenditures for Non-Direct Service Activities
Service
Estimated Total Block Grant
MHA Technical Assistance Activities
MHA Planning Council Activities
MHA Administration
MHA Data Collection/Reporting
MHA Activities Other Than Those Above
Total Non-Direct Services
Comments on Data:
Instructions:
1. States should only report on the expenditures of the CMHBG by the SMHA or programs that they directly contract with.
2. States should not report on expenditures by programs more than one-level down from the State in funding: e.g., if a state provides CMHBG
funds to county mental health authorities, which in turn contract with private, not-for-profit mental health providers, only the expenditures by
the SMHA and the county mental health authorities should be reported in this table.
Table 8 (URS Table 10). Statewide Entity Inventory
Table 88
Report Year:
State Identifier:
Entity Inventory
State
A
Entity
Number
Total
ISATS
ID (for
SABG)
Area
Served
(Statewide
or SubState
Planning
Area)
Provider/Program
Name
Street
Address
City
State
Zip
$
$
$
B
Prevention
(other than
primary
prevention)
and
Treatment
Services
$
$
$
Source of Funds
SAPT Block Grant
B
D
E
Pregnant
Primary
Early
Women
Prevention Intervention
and
Services for
Women
HIV
with
Dependent
Children
$
$
$
$
$
$
$
$
$
CMHS Block Grant
F
G
Adults with
Children with a
serious mental
serious
illness
emotional
disturbance
$
$
$
$
$
$
Table 9 (NEW). Maintenance of Effort for State Expenditures on Mental Health Services
Table 9:
Report Year:
State Identifier:
Total Expenditures for SMHA _____
Period
Expenditures
B1 (2009) + B2 (2010)
2
A
SFY 2009
(1)
SFY 2010
(2)
SFY 2011
(3)
B
C
Are the expenditure amounts reported in Column B “actual” expenditures for the State fiscal years involved?
FY 2009
FY 2010
FY 2011
Yes_____
Yes_____
Yes_____
No_____
No_____
No_____
If estimated expenditures are provided, please indicate when “actual” expenditure data will be submitted to SAMHSA:
___/___/_________
mm/dd/yyyy
Table 10(NEW): Report on Set-Aside for Children’s Mental Health Services
Table 10:
Report Year:
State Identifier:
Actual SFY 2008
State Expenditures for Mental Health Services
Actual SFY 2012
Actual SFY 2013
States are required to not spend less than the amount expended in FY 2008. This is a change from the previous year, when the
baseline for the state expenditures was 1994.
D. Populations and Services Report
States are requested to provide information regarding individuals that are served by the state
mental health authority for FY 2011 using Tables 11 through 15.
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•
•
•
•
•
Table 11 (URS Table 1). Profile of the State Population by Diagnosis. Table 11 provides
the number of Adults with SMI and Children with SED in the reporting year and in three
years forward.
Table 12 (URS Table 12) . State Mental Health Agency Profile. Table 12 provides the
Populations covered in State hospitals and Community program in age categories; 0-3, 417 and 18 and above.
Table 13A and 13B (URS Tables 2A and 2B) Profile of Persons Served, All Programs by
Age, Gender and Race/Ethnicity. Table 13 provides an aggregate profile of unduplicated
persons in the reporting year. The reporting year should be the latest state fiscal year for
which data are available. This profile is based on a client receiving services in programs
provided or funded by the state mental health agency. The client profile takes into
account all institutional and community services for all such programs. States are to
provide this information on all programs by age, gender, race/ethnicity.
Table 14 (URS Table 3). Profile Of Persons Served In The Community Mental Health
Settings, State Psychiatric Hospitals And Other Settings. Table 14 provides an aggregate
profile of unduplicated persons in the reporting year for services funded through the
MHSBG. The reporting year should be the latest state fiscal year for which data are
available. This profile is based on a client receiving services in programs provided or
funded by the MHSBG. The client profile takes into account all institutional and
community services for all such programs. States are to provide this information on all
programs by age, gender, race/ethnicity.
Tables 15A,15B and 15C (NEW, URS Tables 14A and 14B). Profile of Persons With
SMI/SED Served By Age, Gender And Race/Ethnicity. Tables 15A, B and Crequest
counts for persons with SMI or SED using the definitions provided by the CMHS. Tables
15A, B and C included individuals receiving services in programs provided or funded by
the state mental health agency. These tables count only clients who meet the CMHS
definition of SMI or SED. States should report using the Federal Definitions of SMI and
SED if they can report them, if not, please report using your state’s definitions of SMI
and SED and provide information in these tables describing your state’s definition.
Table 16 (URS Table 5). Profile of Client Turnover. Table 16 requests information
regarding the profile of client turnover in various out of home settings (e.g. state
hospitals, inpatient psychiatric hospitals, residential treatment centers). Information
collected by this table requests admissions, discharges, and length of stay.
Table 11 (URS Table 1). Profile of the State
Population by Diagnosis
This table summarizes the estimates of adults residing within the State with serious mental illness (SMI)
and children residing within the state with serious emotional disturbances (SED). The table calls for
estimates for two time periods, one for the report year and one for three years into the future. CMHS will
provide this data to States based on the standardized methodology developed and published in the
Federal Register and the State level estimates for both adults with SMI and children with SED.
Table 11
Report Year:
State Identifier:
Current Report Year
Adults with Serious Mental Illness (SMI)
Children with Serious Emotional Disturbances (SED)
Note: This Table will be completed for the States by CMHS.
Table 12 (URS Table 12): State Mental Health Agency Profile
Three Years Forward
The purpose of this profile is to obtain information that provides a context for the data provided in the tables. This profile covers the
populations served, services for which the state mental health agency is responsible, data reporting capacities, especially related to
duplication of numbers served as well as certain summary administrative information.
PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!
Table 12
Report Year:
State Identifier:
Populations Served
1
Which of the following populations receive services operated or funded by the state mental health agency? Please
indicate if they are included in the data provided in the tables. (Check all that apply.)
Populations Covered
State Hospitals
Community Programs
Included in Data
State Hospitals
Community
Programs
1. Aged 0 to 3
2. Aged 4 to 17
3. Adults Aged 18 and over
4. Forensics
Comments on Data:
2
Do all of the adults and children served through the state mental health agency meet the Federal definitions of
serious mental illness and serious emotional disturbances?
2.a.
If no, please indicate the percentage of persons served for the reporting period who met the federal definitions of serious
mental illness and serious emotional disturbance?
Percent of adults meeting Federal definition of SMI:
Percentage of children/adolescents meeting Federal definition of SED
2.a.1
2.a.2
3
Co-Occurring Mental Health and Substance Abuse:
3.a.
What percentage of persons served by the SMHA for the reporting period have a dual diagnosis of mental illness and
substance abuse?
3.a.1
Percentage of adults served by the SMHA who also have a diagnosis of substance abuse problem:
3.a.2.
3.b.
Percentage of children/adolescents served by the SMHA who also have a diagnosis of substance abuse
problem:
What percentage of persons served for the reporting period who met the Federal definitions of adults with SMI and
children/adolescents with SED have a dual diagnosis of mental illness and substance abuse.
3.b.1
Percentage of adults meeting Federal definition of SMI who also have a diagnosis of substance abuse
problem:
3.b.2.
Percentage of children/adolescents meeting the Federal definition of SED who also have a diagnosis of
substance abuse problem:
3b.3
4
Please describe how you calculate
and count the number of persons
with co-occurring disorders
State Mental Health Agency Responsibilities
a. Medicaid: Does the State Mental Health Agency have any of the following responsibilities for mental health services
provided through Medicaid? (Check All that Apply)
1. State Medicaid Operating
Agency
2. Setting Standards
3. Quality Improvement/Program Compliance
4. Resolving Consumer Complaints
5. Licensing
6. Sanctions
7. Other
b. Managed Care (Mental Health Managed Care
4.b.1
4.b.2
4.b.3
4.b.4
4.b.5
4.b.6
4.b.7
4.b.8
4.b.9
5
Are Data for
these programs
reported on
URS Tables?
Does the State have a Medicaid Managed Care initiative?
Does the State Mental Health Agency have any responsibilities for mental health
services provided through Medicaid Managed Care?
If yes, please check the responsibilities the SMHA has:
Direct contractual responsibility and oversight of the MCOs or BHOs
Setting Standards for mental health services
Coordination with state health and Medicaid agencies
Resolving mental health consumer complaints
Input in contract development
Performance monitoring
Other
Data Reporting: Please describe the extent to which your information systems allows the generation of
unduplicated client counts between different parts of your mental health system. Please respond in particular for
Table 2, which requires unduplicated counts of clients served across your entire mental health system.
Are the data reporting in the
tables?
5.a.
5.b.
5.c.
5.d.
Unduplicated :counted once even if they were served in both State hospitals and community
programs and if they were served in community mental health agencies responsible for
different geographic or programmatic areas.
Duplicated: across state hospital and community programs
Duplicated: within community programs
Duplicated: Between Child and Adult Agencies
5.e.
Plans for Unduplication: If you are not currently able to provide unduplicated client counts across all
parts of your mental health system, please describe your plans to get unduplicated client counts by the
end of your Data Infrastructure Grant.
6
Summary Administrative Data
6.a.
6.b.
6.c.
6.d.
6.e.
6.f.
Report Year
State Identifier
Summary Information on Data Submitted by SMHA:
Year being reported: From:
Person Responsible for Submission
Contact Phone Number:
Contact Address
6.g.
E-mail:
to
Table 13A (URS Table 2A). Profile of Persons Served, All Programs by Age, Gender and Race/Ethnicity
This table provides an aggregate profile of persons in the reporting year. The reporting year should be the latest state fiscal year for which data
are available. This profile is based on a client receiving services in programs provided or funded by the state mental health agency. The client
profile takes into account all institutional and community services for all such programs. Please provide unduplicated counts if possible.
Please report the data under the categories listed - "Total" are calculated automatically.
Table 2.
Report Year:
State Identifier:
Total
Female
Male
Not
Availa
ble
Total
American Indian or Alaska
Native
Female
Male
Not
Availabl
e
Asian
Female
Black or African American
Male
Not
Availabl
e
Female
Male
Not
Availabl
e
0-17 years
18-24 years
25-44 years
45-64 years
65+ years
Total
Pregnant
Women
Are these numbers unduplicated?
Comments on Data (for Age):
Comments on Data (for
Gender):
Comments on Data (for Race/Ethnicity):
Comments on Data (Overall):
(continued on next page)
Table 13A.
Report Year:
State Identifier:
Native Hawaiian or Other
Pacific Islander
Female
Male
Not
Availab
le
White
Hispanic * use only if data for
Table 2b are not available.
Female
Male
Not
Availab
le
Female
Male
Not
Availab
le
0-17 years
18-24 years
25-44 years
45-64 years
65+ years
Total
Pregnant
Women
Table 13B (URS Table 2B). Profile of Persons Served, All Programs by Age, Gender and
Race/Ethnicity
More Than One Race
Reported
Female
Male
Not
Availabl
e
Race Not
Available
Femal
Male
e
Not
Availabl
e
Of the total persons served, please indicate the age, gender and the number of persons who are
Hispanic/Latino or not Hispanic/Latino. Total persons served would be the total as indicated in Table 2A.
Please report the data under the categories listed - "Total" are calculated automatically.
Table 13B.
Report Year:
State Identifier:
Not Hispanic or Latino
Female
Male
Not
Available
Hispanic or Latino
Female
Male
Not
Available
Hispanic or Latino Origin
Not Available
Female
Male
Not
Available
Total
Female
Male
0-17 years
18-24 years
25-44 years
45-64 years
65+ years
Total
Pregnant Women
Comments on Data
(for Age):
Comments on Data
(for Gender):
Comments on Data
(for Race/Ethnicity):
Comments on Data
(Overall):
Table 14 (URS Table 3). Profile of Persons served in the community mental health setting, State Psychiatric Hospitals and
Other Settings
Not
Available
Total
This table provides a profile for the clients that received public funded mental health services in community mental health
settings, in state psychiatric hospitals, in other psychiatric inpatient programs, and in residential treatment centers for children.
Table 14
Report Year:
State
Identifier:
Age 0-17
Table 14
Service Setting
Female
Male
Age 18-20
Not
Available
Female
Male
Age 21-64
Not
Available
Female
Male
Age 65+
Not
Available
Female
Male
Not
Available
Community
Mental
Health
Programs
State
Psychiatric
Hospitals
Other
Psychiatric
Inpatient
Residential
Treatment
Centers
(continued on next page)
Table 14 (cont.) Profile of Persons served in the community mental health setting, State Psychiatric Hospitals and Other Settings
Table 14
Report Year:
State Identifier:
Age Not Available
Table 14
Service Setting
Female
Male
Total
Not Available
Female
Male
Not Available
Total
Community Mental Health
Programs
State Psychiatric Hospitals
Other Psychiatric Inpatient
Residential Treatment Centers
Comments on Data (for Age):
Comments on Data (for Gender):
Comments on Data (Overall):
Note: Clients can be duplicated between Rows: e.g., The same client may be served in both state psychiatric hospitals and community mental health centers during
the same year and thus would be reported in counts for both rows.
Instructions:
1
2
3
4
5
6
States that have county psychiatric hospitals that serves as surrogate state hospitals should report persons served in such settings as receiving services in state hospitals.
If forensic hospitals are part of the state mental health agency system include them.
Persons who receive non-inpatient care in state psychiatric hospitals should be included in the Community MH Program Row
Persons who receive inpatient psychiatric care through a private provider or medical provider licensed and/or contracted through the SMHA should be counted in the "Other
Psychiatric Inpatient" row. Persons who receive Medicaid funded inpatient services through a provider that is not licensed or contracted by the SMHA should not be counted here.
A person who is served in both community settings and inpatient settings should be included in both rows
RTC: CMHS has a standardized definition of RTC for Children: “An organization, not licensed as a psychiatric hospital, whose primary purpose is the provision of individually
planned programs of mental health treatment services in conjunction with residential care for children and youth primarily 17 years old and younger. It has a clinical program that
is directed by a psychiatrist, psychologist, social worker, or psychiatric nurse who has a master’s degree or doctorate. The primary reason for the admission of the clients is mental
illness that can be classified by DSM-IV codes-other than the codes for mental retardation, developmental disorders, and substance-related disorders such as drug abuse and
alcoholism (unless these are co-occurring with a mental illness).”
Table 15A (NEW) Profile of Persons with SMI/SED Served by Age, Gender and Race/Ethnicity
This table provides a profile for the clients that received public funded mental health services in community mental health
settings, in state psychiatric hospitals, in other psychiatric inpatient programs, and in residential treatment centers for children.
PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!
Table 15A
Report Year:
State
Identifier:
Age 0-17
Table 15A
Service Setting
Female
Male
Age 18-20
Not Available
Female
Male
Age 21-64
Not Available
Female
Male
Not Available
Community
Mental
Health
Programs
State
Psychiatric
Hospitals
Other
Psychiatric
Inpatient
Residential
Treatment
Centers
(continued on next page)
Table 15A (cont.) Profile of Persons served in the community mental health setting, State Psychiatric Hospitals and Other Settings
Table 15A
Report Year:
State Identifier:
Age 65+
Table 15A
Service Setting
Female
Male
Age Not Available
Not
Available
Female
Male
Not
Available
Total
Female
Male
Not
Available
Total
Community Mental Health
Programs
State Psychiatric Hospitals
Other Psychiatric Inpatient
Residential Treatment Centers
Comments on Data (for Age):
Comments on Data (for Gender):
Comments on Data (Overall):
Note: Clients can be duplicated between Rows: e.g., The same client may be served in both state psychiatric hospitals and community mental health centers during the same year and thus
would be reported in counts for both rows.
Instructions:
1
States that have county psychiatric hospitals that serve as surrogate state hospitals should report persons served in such settings as receiving services in state hospitals.
2
If forensic hospitals are part of the state mental health agency system include them.
3
Persons who receive non-inpatient care in state psychiatric hospitals should be included in the Community MH Program Row
Persons who receive inpatient psychiatric care through a private provider or medical provider licensed and/or contracted through the SMHA should be counted in the "Other Psychiatric
Inpatient" row. Persons who receive Medicaid funded inpatient services through a provider that is not licensed or contracted by the SMHA should not be counted here.
4
5
6
A person who is served in both community settings and inpatient settings should be included in both rows
RTC: CMHS has a standardized definition of RTC for Children: “An organization, not licensed as a psychiatric hospital, whose primary purpose is the provision of individually planned
programs of mental health treatment services in conjunction with residential care for children and youth primarily 17 years old and younger. It has a clinical program that is directed by a
psychiatrist, psychologist, social worker, or psychiatric nurse who has a master’s degree or doctorate. The primary reason for the admission of the clients is mental illness that can be classified
by DSM-IV codes-other than the codes for mental retardation, developmental disorders, and substance-related disorders such as drug abuse and alcoholism (unless these are co-occurring with a
mental illness).”
Table 15B (URS Table 14A). Profile of Persons with SMI/SED served by Age,
Gender and Race/Ethnicity
This is a developmental table similar to Table 2A. and 2B. This table requests counts for persons with SMI or SED using the definitions provided
by the CMHS. Table 2A. and 2B. included all clients served by publicly operated or funded programs. This table counts only clients who meet
the CMHS definition of SMI or SED. For many states, this table may be the same as Tables 2A. and 2B. For 2007, states should report using
the Federal Definitions of SMI and SED if they can report them, if not, please report using your state’s definitions of SMI and SED and provide
information below describing your state’s definition.
Please report the data under the categories listed - "Total" are calculated automatically.
Table 15B
Report Year:
State
Identifier:
Total
Femal
e
Male
Not
Availa
ble
American Indian or
Alaska Native
Total
Fem
ale
Mal
e
Not
Availa
ble
Asian
Fema
le
Male
Black or African
American
Not
Availa
ble
Femal
e
Male
Not
Availa
ble
0-12 Years
13-17 years
18-20 years
21-64 years
65-74 years
75+ years
Not
Available
Total
Comments on Data (for Age):
Comments on Data (for Gender):
Comments on Data (for Race/Ethnicity):
Comments on Data (Overall):
(contin
ued on
next
page)
Table 15B.
Report Year:
Native Hawaiian or
Other Pacific
Islander
Fem Mal
Not
ale
e
Availa
ble
State
Identifier:
White
Hispanic *use only if data
for Table 14b are not
available
Femal
e
Male
Not
Availa
ble
Femal
e
Male
Not
Availa
ble
More Than One Race
Reported
Fema
le
Male
Not
Availa
ble
Race Not Available
Femal
e
0-12 Years
13-17 years
18-20 years
21-64 years
65-74 years
75+ years
Not
Available
Total
1. State Definitions Match the Federal Definitions:
Yes
No
Adults with SMI, if No describe or attach state definition:
Yes
No
Diagnoses included in state SMI definition:
Yes
No
Children with SED, if No describe or attach state definition:
Yes
No
Diagnoses included in State SED definition:
Male
Not
Availa
ble
Table 15C (URS Table 14B). Profile of Persons with SMI/SED served by Age, Gender
and Race/Ethnicity
Of the total persons served, please indicate the age, gender and the number of persons who meet the Federal definition of SMI and SED and who are Hispanic/Latino or
not Hispanic/Latino. The total persons served who meet the Federal definition of SMI or SED should be the total as indicated in Table 14A.
Please report the data under the categories listed - "Total" are calculated automatically.
Table 15C
Report Year:
State Identifier:
Not Hispanic or Latino
Female
0 - 12 Years
13 - 17 years
18 - 20 years
21-64 years
65-74 years
75+ years
Not Available
Total
Comments on Data (for Age):
Comments on Data (for Gender):
Comments on Data (for
Race/Ethnicity):
Comments on Data (Overall):
Male
Not
Available
Hispanic or Latino
Female
Male
Not
Available
Hispanic or Latino Origin
Not Available
Female
Male
Not
Available
Total
Female
Male
Not
Available
Total
Table 16 (URS Table 5): Profile of Client Turnover
PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!
Table 16.
Report Year:
State Identifier:
Profile of Service Utilization
State Hospitals
Children (0 to 17 years)
Adults (18 yrs and over)
Age Not Available
Other Psychiatric Inpatient
Children (0 to 17 years)
Adults (18 yrs and over)
Age Not Available
Residential Tx Centers
Children (0 to 17 years)
Adults (18 yrs and over)
Age Not Available
Community Programs
Children (0 to 17 years)
Adults (18 yrs and over)
Age Not Available
Comments on Data (State
Hospital):
Comments on Data (Other
Inpatient):
Comments on Data (Residential
Treatment):
Comments on Data (Community
Programs):
Comments on Data (Overall):
Total Served at
Beginning of
Year
(unduplicated)
Admissions
During the
year
(duplicated)
Discharges
During the
year
(duplicated)
Length of Stay (in
Days): Discharged
Patients
For Clients in
Facility for Less
Than 1 Year:
Average Length of
Stay (in Days):
Residents at end
of year
Average
(Mean)
Average
(Mean)
Median
Median
For Clients in Facility
More Than 1 Year:
Average Length of Stay
(in Days): Residents at
end of year
Average
(Mean)
Median
E.
Performance Data and Outcomes
•
•
•
•
•
•
•
•
Table 17 (URS Table 17). Profile of Adults with Serious Mental Illnesses Receiving
Specific Services During the Year. Table 17 provides the number of unduplicated Adults
with SMI receiving family psychoeducation, integrated treatment for co-occurring
disorders, illness self-management and medication management.
Table 18A (URS Table 4). Profile of Adult Clients By Employment Status. Table 18A
describes the status of adults clients served in the report year by the public mental health
system in terms of employment status. The focus is on employment for the working age
population, recognizing, however, that there are clients who are disabled, retired or who
homemakers, care-givers, are etc and not a part of the workforce. These persons should
be reported in the “Not in Labor Force” category. This category has two subcategories:
retired and other. (The totals of these two categories should equal the number in the row
for “Not in Labor Force”). Unemployed refers to persons who are looking for work but
have not found employment. Data should be reported for clients in non-institutional
settings at time of discharge or last evaluation.
Table 18B (URS Table 4A). Profile Of Adult Clients By Employment Status: By Primary
Diagnosis Reported. Table 18B request information on the status of adult clients served
in the report year by the public mental health system in terms of employment status by
primary diagnosis reported.
Table 19 (URS Table 15). Living Situation Profile. Table 19 requests information
regarding the number of Individuals in Each Living Situation as collected by the most
recent assessment in the reporting period. Specifically, information is collected on the
individual’s last known living situation. Living situations include, but are not limited to:
private residence, foster care, residential care, jail/correctional facility, homeless shelter
and other.
Table 20 (URS Table 19B). Profile of Change in School Attendance. Table 20 measures
the change in days attended over time. Information requested includes information on
suspensions, expelled, and changes in the school attendance.
Table 21 (URS Table 9). Social Connectedness and Improved Functioning. Table 21
requests states to provide information for youth and adults regarding Social
Connectedness. In addition, States are requested to provide information on functional
domains that provide a general sense of an individual’s ability to develop and maintain
relationships, cope with challenges and a sense of community belonging.
Table 22A (URS Table 11). Summary Profile of Client Evaluation of Care. Table 22A
requests information that evaluates the “experience” of care for individuals that
participate in the public mental health system. Specifically, the evaluation focuses on
several areas including: access, quality and the appropriateness of services, participation
in treatment planning and general satisfaction with services. Please provide unduplicated
counts, if possible. This table provides an aggregate profile of persons served in the
reporting year. The reporting year should be the latest state fiscal year for which data are
available. This profile is based on a client's last known Living Situation.
Table 22B (URS Table 11A). Consumer Evaluation of Care By Consumer
Characteristics: Race/Ethnicity.
•
•
•
•
•
Table 23 (URS Table 19A). Profile Of Criminal Justice Or Juvenile Justice Involvement.
Table 23 requests information to measure the change in Arrests over time.
Table 24 (URS Table 16). Profile of Adults With Serious Mental Illnesses And Children
With Serious Emotional Disturbances Receiving Specific Services. Table 24 requests
information regarding the number and demographics of individuals that are receiving
specific evidenced-based services. In addition, the table requests information on if and
how states monitor the fidelity for the evidenced based services.
Table 25A (URS Table 20A). Profile of Non-Forensic (Voluntary and Civil-Involuntary)
Patients Readmission to Any State Psychiatric Inpatient Hospital Within 30/180 Days of
Discharge. Table 25A provides the total number of discharges within the year, the
number of readmissions within 30-days and 180-days and the percent readmitted by age,
gender, race, and ethnicity.
Table 25B (URS Table 20B). Profile of Forensic Patients Readmission to Any State
Psychiatric Inpatient Hospital Within 30/180 Days of Discharge. Table 25B provides the
total number of discharges within the year, the number of readmissions within 30-days
and 180-days and the percent readmitted by age, gender, race, and ethnicity.
Table 26 (URS Table 21). Profile of Non-Forensic (Voluntary and Civil-Involuntary
Patients) Readmission to Any Psychiatric Inpatient Care Unit (State Operated or Other
Psychiatric Inpatient Unit) within 30/180 Days of Discharge This Table provides the
total number of discharges from inpatient care units w/I the year, the number of
readmissions w/I 30-days and 180-days and the percent readmitted by age, gender, race,
and ethnicity..
Table 17 (URS Table 17): Profile of Adults with Serious Mental Illnesses Receiving Specific Services
During The Year:
Table 17.
Report Year:
State Identifier:
ADULTS WITH SERIOUS MENTAL
ILLNESS
Receiving Family
Psychoeducation
Receiving Integrated
Treatment for Cooccurring Disorders
(MH/SA)
Receiving
Illness Self
Management
Yes
Yes
Yes
Receiving
Medication
Management
Age
18-20
21-64
65-74
75+
Not Available
TOTAL
Gender
Female
Male
Not Available
Race
American Indian/ Alaska Native
Asian
Black/African American
Hawaiian/Pacific Islander
White
Hispanic*
More than one race
Unknown
Hispanic/Latino Origin
Hispanic/Latino Origin
Non Hispanic/Latino
Hispanic origin not available
Do You monitor fidelity
for this service?
No
No
No
Yes
No
IF YES,
What fidelity measure do you use?
Who measures fidelity?
How often is fidelity measured?
Yes
No
Yes
No
Yes
Is the SAMHSA EBP Toolkit used to guide EBP Implementation?
Have staff been specifically trained to implement the EBP?
* Hispanic is part of the total served.
Comments on Data (overall):
Comments on Data (Family Psychoeducation):
Comments on Data (Integrated Treatment for Co-occurring Disorders):
Comments on Data (Illness Self Management):
Comments on Data (Medication Management):
* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as a Ethnic Origin are not available
No
Yes
No
Table 18A (URS Table 4) Profile of Adult Clients by Employment
Status
This table describes the status of adults clients served in the report year by the public mental health system in terms of employment status. The focus is on employment for the
working age population, recognizing, however, that there are clients who are disabled, retired or who are homemakers, care-givers, etc and not a part of the workforce. These persons
should be reported in the “Not in Labor Force” category. This category has two subcategories: retired and other. (The totals of these two categories should equal the number in the
row for “Not in Labor Force”). Unemployed refers to persons who are looking for work but have not found employment. Data should be reported for clients in non-institutional
settings at time of discharge or last evaluation.
PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!
Table 18A
Report Year:
State Identifier:
18-20
Adults Served
Employed:
Competitively
Employed Full or
Part Time (includes
Supported
Employment)
Female
Male
21-64
Not
Available
Female
Unemployed
Not In Labor
Force: Retired,
Sheltered
Employment,
Sheltered
Workshops, Other
(homemaker,
student, volunteer,
disabled, etc.)
Not Available
Total
How Often Does your State Measure Employment Status?
What populations are included:
Comments on Data
(for Age):
Comments on Data
(for Gender):
Comments on Data
(Overall):
Male
65+
Not
Available
Female
Male
Not
Available
Age Not Available
Not
Female Male Available
Total
Female
Male
Not
Available
Total
Table 18B (URS Table 4A) Optional Profile of Adult Clients by Employment Status: by Primary
Diagnosis Reported
The workgroup exploring employment found that the primary diagnosis of consumers results in major differences in employment status. The workgroup
has recommended that we explore the ability of states to report employment by primary diagnosis and the impact of diagnosis on employment. The
workgroup recommended 5 diagnostic clusters for reporting.
PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR
CELLS!
Table 18B
Report Year:
State Identifier:
Clients
Primary Diagnosis
Schizophrenia & Related Disorders
(295)
Bipolar and Mood Disorders (296,
300.4, 301.11, 301.13, 311)
Other Psychoses (297, 298)
All Other Diagnoses
No Dx and Deferred DX (799.9,
V71.09)
Diagnosis Total
Comments on Data (for Diagnosis):
Employed:
Competitively
Employed Full or Part
Time (includes
Supported
Employment)
Unemployed
Not In Labor Force:
Retired, Sheltered
Employment,
Sheltered Workshops,
Other (homemaker,
student, volunteer,
disabled, etc.)
Employment Status
Not Available
Total
Table 19 (URS Table 15). Living
Situation Profile:
Number of Clients in Each Living Situation as Collected by the Most Recent Assessment in the Reporting Period
All Mental Health Programs by Age, Gender, and Race/Ethnicity
Please provide unduplicated counts, if possible. This table provides an aggregate profile of persons served in the reporting year. The reporting year should be the latest
state fiscal year for which data are available. This profile is based on a client's last known Living Situation.
PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!
Table 18
Report Year:
State Identifier:
Private
Residence
Foster
Home
Residential
Care
Crisis
Residence
Children's
Residential
Treatment
Institutional
Setting
Jail/
Correctional
Facility
Homeless/
Shelter
Other
NA
0-17
18-64
65 +
Not Available
TOTAL
Female
Male
Not Available
TOTAL
American Indian/Alaska Native
Asian
Black/African American
Hawaiian/Pacific Islander
White/Caucasian
Hispanic *
More than One Race Reported
Race/Ethnicity Not Available
TOTAL
(continued on next page)
Total
Table 19 (cont.) Living Situation
Profile:
Number of Clients in Each Living Situation as Collected by the Most Recent Assessment in the Reporting Period
All Mental Health Programs by Age, Gender, and Race/Ethnicity
Please provide unduplicated counts, if possible. This table provides an aggregate profile of persons served in the reporting year. The reporting year should be the latest state
fiscal year for which data are available. This profile is based on a client's last known Living Situation.
PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!
Please report the data under the Living Situation categories listed - "Total" are calculated automatically.
Table 18
Report Year:
State Identifier:
Private
Residence
Foster
Home
Residential
Care
Crisis
Residence
Hispanic or Latino Origin
Non Hispanic or Latino Origin
Hispanic or Latino Origin Not Available
TOTAL
Comments on Data:
How Often Does your State Measure Living
Situation?
* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as an Ethnic Origin are not available
Children's
Residential
Treatment
Institutional
Setting
Jail/
Correctional
Facility
Homeless/
Shelter
Other
NA
Total
Table 20 (URS Table 19B). Profile of Change in School Attendance
PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!
1. This is a developmental measure. To assist in the development process, we are asking states to report information on the school attendance outcomes of
mental health consumers with their December 2007 MHBG submission.
2. The SAMHSA National Outcome Measure for School Attendance measures the change in days attended over time. The DIG Outcomes Workgroup pilot
tested 3 consumer self-report items that can be used to provide this information. If your state has used the 3 Consumer Self-Report items on School
Attendance, you may report them here.
3. If your SMHA has data on School Attendance from alternatives sources, you may also report that here. If you only have data for School attendance for
consumers in this year, please report that in the T2 columns. If you can calculate the change in Attendance from T1 to T2, please use all these columns.
4. Please complete the check boxes at the bottom of the table to help explain the data sources that you used to complete this table.
5. Please tell us anything else that would help us to understand your indicator (e.g., list survey or MIS questions; describe linking methodology and data
sources; specify time period for criminal justice involvement; explain whether treatment data are collected).
Table 19b. Profile of Change in School Attendance
Time period in which services were received:
State:
For Consumers in Service for at least 12 months
T1
"T1" Prior 12 months
(more than 1 year
ago)
#
# Not
No
Res
Susp
Susp
pon
ende
ende
se
d or
d or
Expe
Expel
lled
led
Total
Gender
Male
Female
Gender NA
Age
Under 18
T2
"T2" Most Recent 12
months
(this year)
No
# Not
#
Res
Susp Suspe
pons
nded
ende
e
or
d or
Expell
Expe
ed
lled
T1 to T2 Change
If Suspended at T1
(Prior 12 Months)
# with
an
Expell
ed or
Susp
ended
in T2
#
with
No
Susp
ensio
n or
Expul
sion
at T2
No
Resp
onse
Impact of Services
If Not Suspended at
T1 (Prior 12 Months)
# with
an
Expel
led or
Susp
ende
d in
T2
#
with
No
Susp
ensio
n or
Expu
lsion
at T2
No
Resp
onse
Over the last 12 months, the number of
days my child was in school have
#
Gre
ater
(Imp
rove
d)
#
Sta
yed
the
Sa
me
#
Few
er
days
(gott
en
wors
e)
#
Not
Appl
icabl
e
No
resp
ons
e
Total
Resp
onse
s
Table 20. Profile of Change in School Attendance (Con’t) –
For Consumers Who Began Mental Health Services during the past 12 months
T1
T2
"T1" 12 months prior
to beginning services
Total
Gender
Male
Female
Gender NA
Age
Under 18
#
Susp
ende
d or
Expe
lled
# Not
Susp
ende
d or
Expel
led
No
Res
pon
se
0
0
0
T1 to T2 Change
"T2" Since Beginning
Services
(this year)
#
# Not
No
Susp Suspe
Res
ende
nded
pons
d or
or
e
Expe
Expell
lled
ed
0
0
If Suspended at T1
(Prior 12 Months)
# with
an
Expell
ed or
Susp
ended
in T2
0
0
#
with
No
Susp
ensio
n or
Expul
sion
at T2
0
No
Resp
onse
0
Impact of Services
If Not Suspended at
T1
(Prior 12 Months)
# with
#
No
an
with
Resp
Expel
No
onse
led or Susp
Susp
ensio
ende
n or
d in
Expu
T2
lsion
at T2
0
0
0
Since starting to receive MH Services, the
number of days my child was in school have
#
Gre
ater
(Imp
rove
d)
#
Sta
yed
the
Sa
me
#
Few
er
days
(gott
en
wors
e)
#
Not
Appl
icabl
e
No
resp
ons
e
Total
Resp
onse
s
0
0
0
0
0
0
0
0
0
0
See Page 2 for additional Questions about the source of this data.
Source of School
Attendance Information
1) Consumer survey
(recommended items)
4) State Education Department
2) Other Survey: Please send us items
3) Mental health MIS
5) Local Schools/Education Agencies
6) Other (specify)
Measure of School
Attendance
1) School Attendance
2) Other: (Specify)
Mental health programs
include:
1) Children with SED
only
2) Other Children (specify)
Region for which data are
reported:
1) The whole state
2) Less than the whole state (please describe)
3)
Both.
What is the Total Number of Persons Surveyed or for whom School Attendance Data Are
Reported
Child/Adolescents
1. If data is from a survey, What is the total Number of people from which the sample was drawn?
2. What was your sample size? (How many individuals were selected for the sample)?
3. How many survey Contacts were made? (surveys to valid phone numbers or addresses)
4. How many surveys were completed? (survey forms returned or calls completed) If data source was not a Survey, How many persons were data available for?
5. What was your response rate? (number of Completed surveys divided by number of Contacts):
State Comments/Notes
Table 21 (URS Table 9): SAMHSA NOMs: SOCIAL CONNECTEDNESS AND IMPROVED
FUNCTIONING
PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS
AND/OR CELLS!
Table 9: NOMS Social Connectedness & Functioning
Report Year (Year Survey was Conducted):
State Identifier:
Adult Consumer Survey Results:
Number of Positive
Responses
Responses
Percent Positive
(calculated)
Number of Positive
Responses
Responses
Percent Positive
(calculated)
1. Social Connectedness
2. Functioning
Child/Adolescent Consumer Survey Results:
3. Social Connectedness
4. Functioning
Comments on Data:
Adult Social Connectedness and Functioning Measures
1. Did you use the recommended new Social Connectedness Questions? Yes No
2: Did you use the recommended new Functioning Domain Questions? Yes No
Measure used
Measure used
3. Did you collect these as part of your MHSIP Adult Consumer Survey? Yes No
If No, what source did you use?
Child/Family Social Connectedness and Functioning Measures
4: Did you use the recommended new Social Connectedness Questions? Yes No
5: Did you use the recommended new Functioning Domain Questions? Yes No
6. Did you collect these as part of your YSS-F Survey? Yes No
If No, what source did you use?
Recommended Scoring Rules
Please use the same rules for reporting Social connectedness and Functioning Domain scores as for calculating
Measure used
Measure used
other Consumer Survey Domain scores for Table 11: E.g.:
1. Recode ratings of “not applicable” as missing values.
2. Exclude respondents with more than 1/3rd of the items in that domain missing.
3. Calculate the mean of the items for each respondent.
4. FOR ADULTS: calculate the percent of scores less than 2.5. (percent agree and strongly agree).
5. FOR YSS-F: calculate the percent of scores greater than 3.5. (percent agree and strongly agree).
Items to Score in the Functioning Domain:
Adult MHSIP Functioning Domain:
1 I do things that are more meaningful to me.
2 I am better able to take care of my needs.
3 I am better able to handle things when they go wrong.
4 I am better able to do things that I want to do.
5 My Symptoms are not bothering me as much (this question already is part of the MHSIP Adult Survey)
YSS-F Functioning Domain Items:
1 My child is better able to do things he or she wants to do.
2 My child is better at handling daily life. (existing YSS-F Survey item)
3 My child gets along better with family members. (existing YSS-F Survey item)
4 My child gets along better with friends and other people. (existing YSS-F Survey item)
5 My child is doing better in school and/or work. (existing YSS-F Survey item)
6 My child is better able to cope when things go wrong. (existing YSS-F Survey item)
Items to Score in the Social Connectedness Domain:
Adult MHSIP Social Connectedness Domain:
1 I am happy with the friendships I
have.
2 I have people with whom I can do enjoyable things.
3 I feel I belong in my community.
4 In a crisis, I would have the support I need from family or friends.
YSS-F Social Connectedness Domain Items:
1 I know people who will listen and understand me when I need to talk
2 I have people that I am comfortable talking with about my child's problems.
3 In a crisis, I would have the support I need from family or friends.
4 I have people with whom I can do enjoyable things
Table 22A (URS Table 11): Summary Profile of Client Evaluation
of Care
PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS
AND/OR CELLS!
Table 22.
Report Year (Year Survey was Conducted):
State Identifier:
Adult Consumer Survey Results:
Number of
Positive
Responses
Responses
Confidence Interval*
Responses
Confidence Interval*
1. Reporting Positively About Access.
2. Reporting Positively About Quality and Appropriateness for Adults
3. Reporting Positively About Outcomes.
4. Adults Reporting on Participation In Treatment Planning.
5. Adults Positively about General Satisfaction with Services.
Child/Adolescent Consumer Survey Results:
1. Reporting Positively About Access.
Number of
Positive
Responses
2. Reporting Positively about General Satisfaction for Children.
3. Reporting Positively about Outcomes for Children.
4. Family Members Reporting on Participation In Treatment Planning for their Children
5. Family Members Reporting High Cultural Sensitivity of Staff.
Please enter the number of persons responding positively to the questions and the number of total
responses within each group. Percent positive will be calculated from these data.
* Please report Confidence Intervals at the 95% level. See directions below regarding the calculation of confidence
intervals.
Comments on
Data:
Adult Consumer Surveys
1. Was the Official 28 Item MHSIP Adult Outpatient Consumer Survey Used?
1.a. If no, which version:
1. Original 40 Item Version
2. 21-Item Version
3. State Variation of MHSIP
4. Other Consumer Survey
1.b. If other, please attach instrument used.
1.c. Did you use any translations of the MHSIP into another language?
2. Other Language:
Adult Survey Approach:
2. Populations covered in survey? (Note all surveys should cover all regions of state)
2.a. If a sample was used, what sample methodology was used?
4. Other Sample:
Adult Consumer Surveys (Continued)
2.b Do you survey only people currently in services, or do you also Survey Persons no longer in service?
3. Please Describe the populations included in your sample: (e.g., all adults, only adults with SMI, etc.)
3.4 Other: describe: (for example, if you survey anyone served in the last 3 months, describe that here):
4. Methodology of collecting data? (Check all that apply)
Self-Administered
Phone
Mail
Interview
Face-to-face
Web-Based
4.b. Who administered the Survey? (Check all that apply)
6. Other: describe:
5. Are Responses Anonymous, Confidential and/or Linked to other Patient Databases?
6. Sample Size and Response Rate
6a. How many Surveys were Attempted (sent out or calls initiated)?
6.b How many survey Contacts were made? (surveys to valid phone numbers or addresses)
6.c How many surveys were completed? (survey forms returned or calls completed)
6.d. What was your response rate? (number of Completed surveys divided by number of Contacts)
6.e. If you receive "blank" surveys back from consumers (surveys with no responses on them), did you count these survey's as
"completed" for the calculation of response rates?
7. Who Conducted the Survey
7.a. SMHA Conducted or contracted for the Survey (survey done at state level)
7.b. Local Mental Health Providers/County mental health providers conducted or contracted for the survey
(survey was done at the local or regional level)
7.c. Other: Describe:
* Report Confidence Intervals at the 95% confidence level
Note: The confidence interval is the plus-or-minus figure usually reported in newspaper or television opinion poll results. For
example, if you use a confidence interval of 4 and 47% percent of your sample picks an answer you can be "sure" that if you had
asked the question of the entire relevant population between 43% (47-4) and 51% (47+4) would have picked that answer.
The confidence level tells you how sure you can be. It is expressed as a percentage and represents how often the true percentage
of the population who would pick an answer lies within the confidence interval. The 95% confidence level means you can be 95%
certain; the 99% confidence level means you can be 99% certain. Most researchers use the 95% confidence level.
When you put the confidence level and the confidence interval together, you can say that you are 95% sure that the true
percentage of the population is between 43% and 51%. (From www.surveysystem.com)
Child/Family Consumer Surveys
1. Was the MHSIP Children/Family Survey (YSS-F) Used?
If No, what survey did you use?
If no, please attach instrument used.
1.c. Did you use any translations of the Child MHSIP into another language?
2. Other Language:
Child Survey Approach:
2. Populations covered in survey? (Note all surveys should cover all regions of state)
2.a. If a sample was used, what sample methodology was used?
4. Other Sample:
2.b Do you survey only people currently in services, or do you also Survey Persons no longer in service?
2a. If yes to 2, please describe how your survey persons no longer receiving services.
3. Please Describe the populations included in your sample: (e.g., all children, only children with SED, etc.)
3.4 Other: describe: (for example, if you survey anyone served in the last 3 months, describe that here):
4. Methodology of collecting data? (Check all that apply)
Self-Administered
Interview
Phone
Mail
Face-to-face
Web-based
4.b. Who administered the Survey? (Check all that apply)
6. Other: describe:
5. Are Responses Anonymous, Confidential and/or Linked to other Patient Databases?
6. Sample Size and Response Rate
6a. How many Surveys were Attempted (sent out or calls initiated)?
6.b How many survey Contacts were made? (surveys to valid phone numbers or addresses)
6.c How many surveys were completed? (survey forms returned or calls completed)
6.d. What was your response rate? (number of Completed surveys divided by number of Contacts)
6.e. If you receive "blank" surveys back from consumers (surveys with no responses on them), did you count
these survey's as "completed" for the calculation of response rates?
7. Who Conducted the Survey
7.a. SMHA Conducted or contracted for the Survey (survey done at state level)
7.b. Local Mental Health Providers/County mental health providers conducted or contracted for the survey
(survey was done at the local or regional level)
7.c. Other: Describe:
Table 25A (URS Table 20A). Profile of Non-Forensic (Voluntary and Civil-Involuntary) Patients
Readmission to Any State Psychiatric Inpatient Hospital Within 30/180 Days of Discharge
Table 20A.
Report Year:
State Identifier:
Total number
of Discharges
in Year
Number of Readmissions
to ANY STATE Hospital
within
30 days
TOTAL
0
180 days
0
Percent Readmitted
30 days
0
Age
0-12
13-17
18-20
21-64
65-74
75+
Not Available
Gender
Female
Male
Gender Not Available
Race
American Indian/ Alaska Native
Asian
Black/African American
Hawaiian/Pacific Islander
White
Hispanic*
More than one race
Race Not Available
Hispanic/Latino Origin
Hispanic/Latino Origin
Non Hispanic/Latino
Hispanic/Latino Origin Not
Available
Are Forensic Patients Included?
Comments on Data:
* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as a Ethnic Origin are not available
180 days
Table 25B (URS Table 20B). Profile of Forensic Patients Readmission to Any State Psychiatric
Inpatient Hospital Within 30/180 Days of Discharge
Table 20B.
Report Year:
State Identifier:
Total number
of Discharges
in Year
Number of Readmissions
to ANY STATE Hospital
within
30 days
TOTAL
0
180 days
0
Percent Readmitted
30 days
0
Age
0-12
13-17
18-20
21-64
65-74
75+
Not Available
Gender
Female
Male
Gender Not Available
Race
American Indian/ Alaska Native
Asian
Black/African American
Hawaiian/Pacific Islander
White
Hispanic*
More than one race
Race Not Available
Hispanic/Latino Origin
Hispanic/Latino Origin
Non Hispanic/Latino
Hispanic/Latino Origin Not
Available
Comments on Data:
* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as a Ethnic Origin are not available
180 days
Table 26 (URS Table 21). Profile of Non-Forensic (Voluntary and Civil-Involuntary Patients)
Readmission to Any Psychiatric Inpatient Care Unit (State Operated or Other Psychiatric Inpatient
Unit) Within 30/180 Days of Discharge
Table 21.
Report Year:
State Identifier:
Total number
of
Discharges in
Year
Number of Readmissions to ANY
Psychiatric Inpatient Care Unit
Hospital within
30 days
TOTAL
0
180 days
0
Percent Readmitted
30 days
0
Age
0-12
13-17
18-20
21-64
65-74
75+
Not Available
Gender
Female
Male
Gender Not Available
Race
American Indian/ Alaska Native
Asian
Black/African American
Hawaiian/Pacific Islander
White
Hispanic*
More than one race
Race Not Available
Hispanic/Latino Origin
Hispanic/Latino Origin
Non Hispanic/Latino
Hispanic/Latino Origin Not Available
1. Does this table include readmission from state psychiatric hospitals?
2. Are Forensic Patients Included?
Comments on Data:
* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as a Ethnic Origin are not available
180 days
| File Type | application/pdf |
| File Title | Block Grant Application |
| Author | USER |
| File Modified | 2011-06-16 |
| File Created | 2011-06-16 |