Form Financial Mapping Financial Mapping Financial Mapping Interview

Attachment 6

OMB No. 0930-03xx

Expiration Date: xx/xx/xx

CHILDREN’S MENTAL HEALTH INITIATIVE

NATIONAL SYSTEM OF CARE EXPANSION EVALUATION

Financial Mapping Interview Protocol

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 0930-03xx.  Public reporting burden for this collection of information is estimated to average 150 minutes per respondent, 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 2-1057, Rockville, Maryland, 20857.

Attachment 6a

CMHI SOC Evaluation: Financial Mapping Interview Protocol

Overview

Evaluation Question. What funding sources are used to support the SOC expansion efforts and how do they change over time?

The National Evaluation Team (NET) will review documents and interview key informants to collect data necessary to map the funding streams covering children’s mental health services, including any blending or braiding of funds. In addition, the team will identify any eligibility criteria for the specific service types. This information will be collected twice for three grantee cohorts to identify the funding sources used in Year 1 or Year 2, and how it changed two years later. The purpose of financial mapping is to document the primary public funding sources being used to implement and expand systems of care over the life of the expansion planning and implementation grants. Measuring changes over time in target populations, funding streams, services, and eligibility will document grantees’ ability to implement sustainable expansion strategies and help identify what strategies are most successful. Please note: the NET does not expect to collect data on actual service budgets or expenditures in this component of the evaluation.

In addition to the financial mapping information, the NET will also explore the ability of Medicaid and Mental Health agencies to share data and/or track shared clients. This information will help the team to identify states that have effective information systems and may be interested in participating in the benchmarking component of this evaluation.

Data Collection Instruments. The NET will use two data collection approaches in this component of the evaluation: document review and key informant interviews. We will review grantee information and additional requested documents, as well as the websites of state Medicaid agencies, state or county Mental Health agencies, and tribal authorities to collect as much preliminary information as possible and to become familiar with the terminology used in each state’s mental health service system. This review will be used to prepopulate a list of children’s mental health services which will be sent to respondents at least a week before the interview for clarification and correction. This corrected list will be incorporated into the interview tool and provide the basis for gathering data on eligibility and financing of these services. Customizing the interview tool for each state will allow interviews to focus on validation of information, clarification of information, and filling in any gaps.

The NET has drafted interview schedules for the following five organizations. Each interview covers the same general topics but is customized to the particular scope of each organization.

• Mental Health Authority

• Medicaid Agency

• Tribal Health Authority

• Mental Health Provider Trade Association (will not be conducted for interviews with tribal grantees)

• Family/Youth Organization

This packet includes these draft interview schedules. The Mental Health Provider Trade Association interview is more limited in scope and focuses on any limitations on how public payers are using SOC services and whether commercial payers are buying any. The Family/Youth Organization interview focuses on the scope of services provided by the organization and how they are financed.

This interview will be conducted twice. From the first year interview and document analysis, the NET will map baseline funding for children’s mental health services. The subsequent interview, conducted two years later, will identify changes. The same interview will be conducted for the adult division of the mental health agency if the system of care (SOC) is serving young adults ages 18 or older. In addition, the Medicaid agency will also be interviewed about its provision of children’s mental health services.

After MHA, Medicaid and tribal interviews, key information will be summarized and sent back to respondents for verification and correction, if necessary. Once validated, this information will provide the basis for baseline analysis. In addition, this information will be the starting point for interviews two years later, when respondents will be asked to identify any changes in services provided, eligibility standards, sources of financing, and availability across the state, county or tribal territory.

Analysis. The financial map will identify (1) the continuum of children’s mental health services and for each service: (2) any applicable income or clinical eligibility standards, and (3) sources of funds (funding agency or agencies, which could include juvenile justice, child welfare, and education sources).

The NET’s specific focus will be to identify changes in the structure of financing between the baseline year and two years later, and the impact of these changes on behavioral health services for children in the jurisdiction. The map will also document any relevant expansion of benefits to broaden coverage or geographic availability for services that may be introduced as part of the SOC, such as wraparound planning, intensive care coordination, family and youth peer-support, and flexible funds.

Attachment 6b

INFORMED CONSENT

These interviews will be conducted with grantee representatives over the phone. Thus, information about the purpose and scope of the evaluation will be shared at the beginning of the interview over the phone. The respondent will be asked if he/she understands the information shared and voluntarily agrees to respond to the questions. Thus, a verbal consent will be acquired over the phone.

Attachment 6c

OMB No. xxxx-xxxx

Expiration Date: xx/xx/201x

CHILDREN’S MENTAL HEALTH INITIATIVE

NATIONAL SYSTEM OF CARE EXPANSION EVALUATION

Draft financial Mapping Survey

mental health Agency Version

INTRODUCTION

Thank you for your willingness to participate in this interview. The goals of this interview are to:

• Acquire and verify information about key services in the state’s mental health service system for children and how they have changed over the grant period, specifically:

  • Service eligibility criteria

  • Funding sources

• Identify any additional services introduced as part of the state’s SOC, any changes in eligibility criteria for these services or how children’s MH and SOC services are funded.

CONFIDENTIALITY/INFORMED CONSENT

The National Evaluation team is conducting an evaluation of system of care expansion grantees on behalf of the Substance Abuse and Mental Health Services Administration (SAMSHA).

We will be asking you to share information about various topics related to funding of system of care implementation and expansion.

This session will last approximately 90 to 120 minutes.

Your participation is completely voluntary, and you have the right to stop at any time or to refuse to answer any question.

Your responses to these questions will be kept confidential and will not be shared outside of the evaluation team. In any of our reports, aggregate data will be used to summarize the findings.

[OBTAIN INFORMED VERBAL CONSENT]

We would like to record this interview so that we can be sure to accurately capture your responses. A recording would only be reviewed by a few National Evaluation staff members.

[OBTAIN VERBAL CONSENT TO RECORD SESSION]

INSTRUCTIONS

The interviewer will ask you several questions. Please ask for clarification and provide as accurate information as possible.

Date of Interview: _____________ Interviewer’s Initials: ___________

Agency/Organization Name: ________________________________________________

Name & Position of Interviewee: _________________________________________

Name & Position of Interviewee: _________________________________________

Name & Position of Interviewee: _________________________________________

Date of interview: __________ Interviewer’s Initials: _________

Our initial set of questions concerns the full scope of children’s mental health services provided by your agency.

1. What funding sources does your agency use to pay for children’s mental health services?

(for example, MH Block Grant, State General Fund, special taxes, county contribution, Medicaid and other)

Funding Source	Y/N	Comments
MH Block Grant
State General Fund
Earmarked tax revenue (specify)
County contribution
Medicaid
Other, specify:

2. How are the children’s mental health services your agency pays for organized and delivered?

(for example, fund a Community Mental Health Center for catchment area, network of contracted providers, use of a lead community provider, public (state or county) operated clinics, and other)

3. The table below shows the children’s mental health services that you have previously identified as those provided, purchased or financed by your state’s Mental Health Authority. We will be using this service list in our subsequent questions. Do you have any additions or corrections to make to this list?

Service Table 1: State MHA Services
CMHI Evaluation Service Category/ Service Name	State MHA or Medicaid Department/ Service Name
Psychiatric Inpatient Care
State Hospital
Community or Psychiatric Hospital
Non-Hospital 24 Hour Care
Residential Treatment Programs
Therapeutic Foster Care
Ambulatory Mental Health Services
Partial Hospital
Traditional Outpatient Mental Health Care
Psychotropic Medications
Traditional Case Management
Crisis Intervention
Psychiatric Crisis Intervention
Mobile Crisis Services
Crisis Stabilization (up to 72 hours)
Telephonic Crisis Services
System of Care Services
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Outreach
Psychosocial Rehabilitation
Home and Community Based Services
Peer Services
Day Treatment
Other
Supportive Services
Respite
Transportation
Other
MH Services Provided by Medical Organizations
Hospital Emergency Services
Primary Care Mental Health Services

4. What are the eligibility criteria for each of the children’s mental health services provided by your agency? Probes: eligibility criteria might be based on income, clinical condition, or other factors

Service Table 2: MHA Eligibility Criteria
State MHA or Medicaid Department/ Service Name	Income Y – Yes% FPL N - No	Clinical Y - Yes 1 - SED 2 - Other N - No	Other Describe
Psychiatric Inpatient Care
State Hospital
Community or Psychiatric Hospital
Non-Hospital 24 Hour Care
Residential Treatment Programs
Therapeutic Foster Care
Ambulatory Mental Health Services
Partial Hospital
Traditional Outpatient Mental Health Care
Psychotropic Medications
Traditional Case Management
Crisis Intervention
Psychiatric Crisis Intervention
Mobile Crisis Services
Crisis Stabilization (up to 72 hours)
Telephonic Crisis Services
System of Care Services
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Outreach
Psychosocial Rehabilitation
Home and Community Based Services
Peer Services
Day Treatment
Other
Supportive Services
Respite
Transportation
Other
MH Services Provided by Medical Organizations
Hospital Emergency Services
Primary Care Mental Health Services

5a. What are the MHA funding sources for each type of service?

Service Table 3: State MHA Funding Sources
State Service Name	State General Funds	Medicaid Federal Match	County Funds	Other (specify)
Psychiatric Inpatient Care
State Hospital
Community or Psychiatric Hospital
Non-Hospital 24 Hour Care
Residential Treatment Programs
Therapeutic Foster Care
Ambulatory Mental Health Services
Partial Hospital
Traditional Outpatient Mental Health Care
Psychotropic Medications
Traditional Case Management
Crisis Intervention
Psychiatric Crisis Intervention
Mobile Crisis Services
Crisis Stabilization (up to 72 hours)
Telephonic Crisis Services
System of Care Services
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Outreach
Psychosocial Rehabilitation
Home and Community Based Services
Peer Services
Day Treatment
Other
Supportive Services
Respite
Transportation
Other
MH Services Provided by Medical Organizations
Hospital Emergency Services
Primary Care Mental Health Services

5b. Do any other public entities cover part of the cost of these children’s mental health services? (e.g., the Medicaid, child welfare, or juvenile justice agencies or schools)? If yes, who are the other payers and what types of costs do they cover (e.g., treatment component, room and board, education)?

Service Table 4: Other Funding Sources
State Service Name	Federal Funded (Specify grant name)	Other Agency CW – child welfare Sch – schools JJ – juvenile justice	Other	Notes
Psychiatric Inpatient Care
State Hospital
Community or Psychiatric Hospital
Non-Hospital 24 Hour Care
Residential Treatment Programs
Therapeutic Foster Care
Ambulatory Mental Health Services
Partial Hospital
Traditional Outpatient Mental Health Care
Psychotropic Medications
Traditional Case Management
Crisis Intervention
Psychiatric Crisis Intervention
Mobile Crisis Services
Crisis Stabilization (up to 72 hours)
Telephonic Crisis Services
System of Care Services
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Outreach
Psychosocial Rehabilitation
Home and Community Based Services
Peer Services
Day Treatment
Other
Supportive Services
Respite
Transportation
Other
MH Services Provided by Medical Organizations
Hospital Emergency Services
Primary Care Mental Health Services

6. Are fees charged to participating families for any of these services? If so, for what services? Do you use a sliding scale?

Service Table 5: Self Pay
State Service Name	Self-pay? Y – Yes N- No	Sliding Fee Scale? Y – Yes N- No	Notes
Psychiatric Inpatient Care
State Hospital
Community or Psychiatric Hospital
Non-Hospital 24 Hour Care
Residential Treatment Programs
Therapeutic Foster Care
Ambulatory Mental Health Services
Partial Hospital
Traditional Outpatient Mental Health Care
Psychotropic Medications
Traditional Case Management
Crisis Intervention
Psychiatric Crisis Intervention
Mobile Crisis Services
Crisis Stabilization (up to 72 hours)
Telephonic Crisis Services
System of Care Services
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Outreach
Psychosocial Rehabilitation
Home and Community Based Services
Peer Services
Day Treatment
Other
Supportive Services
Respite
Transportation
Other
MH Services Provided by Medical Organizations
Hospital Emergency Services
Primary Care Mental Health Services

Our next set of questions pertains to Mental Health Authority services designated for or primarily used by children with SED.

6. How does your agency’s definition for Serious Emotional Disturbance (SED) compare to SAMHSA’s definition? (eg, more or less restrictive in terms of age, specified diagnoses or level of functioning, or substantially comparable.)

SAMHSA’s Definition of Serious Emotional Disturbance (SED)

Federal Register: Volume 58, Number 96. Pages 29422-29425

The CMHS definition is that children with “serious emotional disturbance” are persons:

1. From birth up to age 18

2. Who currently or at any time during the past year have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within the current DSM

3. That resulted in functional impairment, which substantially interferes with or limits the child's role or functioning in family, school, or community activities (p.29425).

Mental disorders are those listed in DSM-III-R or their ICD-9-CM equivalent (and subsequent revisions) Those of biological etiology are included and DSM-III-R `V' codes, substance use, and developmental disorders are excluded.

“Functional impairment is defined as difficulties that substantially interfere with or limit a child or adolescent from achieving or maintaining one or more developmentally-appropriate social, behavioral, cognitive, communicative, or adaptive skills. Functional impairments of episodic, recurrent, and continuous duration are included unless they are temporary and expected responses to stressful events in their environment. Children who would have met functional impairment criteria during the referenced year without the benefit of treatment or other support services are included in this definition….” (p. 29425).

6. Who is authorized to determine whether a child has SED? ( Probes: Provider clinician, state or county clinician, summary assessment submitted to State/County, other)

6. Have you ever received a report from Medicaid on the use or cost of Medicaid services by children with SED? If so, how were these children identified? Probes: matched client IDs, defined SED by diagnoses or claims, have a marker in the Medicaid system that identifies clients with SED

For this part of the evaluation, we are focusing on some of the core services needed by children with SED in a system of care. These include wraparound planning, intensive care coordination, flexible funding, family peer services and youth peer services. We recognize that you may not provide all these services or may include additional services when thinking about systems of care. The next set of questions addresses how these five services fit into the overall service system for children with SED.

6. First, we’d like to confirm that we correctly understand the population of focus your current CMHI grant. Can you review this description and let us know if anything needs to be corrected? (Note: we will summarize this from our review of grant documents using such categories as age, region, clinical criteria, functional criteria, use of certain type of service (eg. inpatient, residential), referral source, child welfare status, juvenile justice status, other)

[Insert state/county specific description here}

6. Who authorizes children to receive wraparound planning, intensive care coordination, flexible funding and family or youth peer services?

Service Table 6: System of Care Service Eligibility
System of Care Services	Provider clinician	State or county clinician	Summary assessment submitted to state/county	Other (specify)
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Family Peer Services
Youth Peer Services

6. Are specific tools used to make this determination? (If so, please specify)

Service Table 7: Tools
System of Care Services	Eligibility Determination Tool
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Family Peer Services
Youth Peer Services

6. What kinds of provider organizations deliver these services?

Service Table 8: Providers
System of Care Services	Provider Type
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Family Peer Services
Youth Peer Services

6. Are these services available statewide? Would you say they are available in 75% to 100% of the state, 50%-75% of the state, 25%-50% of the state or less than 25% of the state?

Service Table 9: Statewideness
System of Care Services	Statewide? 1-Statewide 2 – 50-75% of State 3 – 25-50% of State 4 – 0-25% of State
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Family Peer Services
Youth Peer Services

6. Are there plans for funding these services from other sources in the future? (eg. secure funding from Medicaid, Child Welfare, Juvenile Justice, other )

Service Table 10: Future Funding Plans
System of Care Services	Planned Sources for Future Funding
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Family Peer Services
Youth Peer Services (specify)
Other services

Finally, we would like your thoughts about the factors in your state likely to be relevant to generating sustainable funding for statewide SOC services.

6. What are the main barriers to funding the system of care services on a statewide basis? (probe: what agencies are responsible for addressing these barriers?)

6. Now that we have discussed the barriers, what factors in your state are facilitating the funding of the system of care services on a statewide basis? (probe: what agencies or other entities are involved?)

Closing Comments

6. What else can you tell us to help us understand the Mental Health Authority’s contribution to financing SOC or related services for children with SED and their families in your state?

We plan to summarize the information you have provided and give you a chance to review it to be sure we correctly understand your state’s financing. Thank you very much for your help.

End of Instrument:

Thank you for participating in the financial mapping portion of the National Systems of Care Expansion Evaluation.

Attachment 6d

OMB No. xxxx-xxxx

Expiration Date: xx/xx/201x

CHILDREN’S MENTAL HEALTH INITIATIVE

NATIONAL SYSTEM OF CARE EXPANSION EVALUATION

Draft financial Mapping Survey

medicaid Agency Version

INTRODUCTION

Thank you for your willingness to participate in this interview. The goals of this interview are to:

• Acquire and verify information about key services in the state’s mental health service system for children and how they have changed over the grant period, specifically:

  • Service eligibility criteria

  • Funding sources

• Identify any additional services introduced as part of the state’s SOC, any changes in eligibility criteria for SOC services or how children’s MH and SOC services are funded.

CONFIDENTIALITY/INFORMED CONSENT

The National Evaluation team is conducting an evaluation of system of care expansion grantees on behalf of the Substance Abuse and Mental Health Services Administration (SAMSHA).

We will be asking you to share information about various topics related to funding of system of care implementation and expansion.

This session will last approximately 90 to 120 minutes.

Your participation is completely voluntary, and you have the right to stop at any time or to refuse to answer any question.

Your responses to these questions will be kept confidential and will not be shared outside of the evaluation team. In any of our reports, aggregate data will be used to summarize the findings.

[OBTAIN INFORMED VERBAL CONSENT]

We would like to record this interview so that we can be sure to accurately capture your responses. A recording would only be reviewed by a few National Evaluation staff members.

[OBTAIN VERBAL CONSENT TO RECORD SESSION]

INSTRUCTIONS

The interviewer will ask you several questions. Please ask for clarification and provide as accurate information as possible.

Date of Interview: _____________ Interviewer’s Initials: ___________

Agency/Organization Name: ________________________________________________

Name & Position of Interviewee: _________________________________________

Name & Position of Interviewee: _________________________________________

Name & Position of Interviewee: _________________________________________

Date of interview: __________ Interviewer’s Initials: _________

Our initial set of questions concerns the full scope of your state’s Medicaid and SCHIP program and its children’s mental health services.

1. The table below shows the Medicaid eligibility criteria you previously reviewed. Do you have any additions or corrections? (This will have been prepopulated and submitted to the respondent prior to the interview for review and correction.)

Eligibility Category	Ages 0-1 (% of Federal Poverty Levels)	Ages 2-5 (% of Federal Poverty Levels)	Ages 6-19 (% of Federal Poverty Levels)
Medicaid eligibility criteria: ages 0-5 _______%Federal Poverty Level ages 6-19 __________%FPL
Medicaid expansion eligibility:
SCHIP eligibility criteria:
Other category (specify)

2. Does your state use Managed Care Organizations (MCO) or Managed Behavioral Health Organizations (MBHO) for children enrolled in Medicaid or SCHIP? What children’s eligibility categories are included in these managed care programs and what children’s eligibility categories are excluded? What geographies are included and what geographies are excluded?

Managed Care Type	Used? Y- Yes N- No	Eligibility Categories Included	Eligibility Categories Excluded	Geographic Areas Included	Geographic Areas Excluded
MCOs
MBHOs
Other

3. Approximately what share of Medicaid/SCHIP enrolled children are enrolled in MCOs and MBHOs in your state?

Managed Care Type	Share of children enrolled 1-more than 75% 2 – 50-75% 3 – 25-50% 4 – 0-25%
MCOs
MBHOs
Other

4. The table below shows the Medicaid children’s mental health services that you have previously identified. We will be using this service list in our subsequent questions. Do you have any additions or corrections to make to this list?

Service Table 1: State Medicaid Services
CMHI Evaluation Service Category/ Service Name	State Medicaid Department/ Service Name
Psychiatric Inpatient Care
State Hospital
Community or Psychiatric Hospital
Non-Hospital 24 Hour Care
Residential Treatment Programs
Therapeutic Foster Care
Ambulatory Mental Health Services
Partial Hospital
Traditional Outpatient Mental Health Care
Psychotropic Medications
Traditional Case Management
Crisis Intervention
Psychiatric Crisis Intervention
Mobile Crisis Services
Crisis Stabilization (up to 72 hours)
Telephonic Crisis Services
System of Care Services
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Outreach
Psychosocial Rehabilitation
Home and Community Based Services
Peer Services
Day Treatment
Other
Supportive Services
Respite
Transportation
Other
MH Services Provided by Medical Organizations
Hospital Emergency Services
Primary Care Mental Health Services

5. Are any of these services carved out of Medicaid or SCHIP managed care plans? Please specify.

Service Table 2: Managed Care Status
CMHI Evaluation Service Category/ Service Name	Carved Out of MCO? Y-Yes N- No	Carved Out of MBHO? Y-Yes N- No
Psychiatric Inpatient Care
State Hospital
Community or Psychiatric Hospital
Non-Hospital 24 Hour Care
Residential Treatment Programs
Therapeutic Foster Care
Ambulatory Mental Health Services
Partial Hospital
Traditional Outpatient Mental Health Care
Psychotropic Medications
Traditional Case Management
Crisis Intervention
Psychiatric Crisis Intervention
Mobile Crisis Services
Crisis Stabilization (up to 72 hours)
Telephonic Crisis Services
System of Care Services
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Outreach
Psychosocial Rehabilitation
Home and Community Based Services
Peer Services
Day Treatment
Other
Supportive Services
Respite
Transportation
Other
MH Services Provided by Medical Organizations
Hospital Emergency Services
Primary Care Mental Health Services

6. Are there clinical or other authorization or eligibility criteria for these services?

Service Table 3: Eligibility Criteria
State MHA or Medicaid Department/ Service Name	Clinical Y - Yes 1 - SED 2 - Other N - No	Other Describe
Psychiatric Inpatient Care
State Hospital
Community or Psychiatric Hospital
Non-Hospital 24 Hour Care
Residential Treatment Programs
Therapeutic Foster Care
Ambulatory Mental Health Services
Partial Hospital
Traditional Outpatient Mental Health Care
Psychotropic Medications
Traditional Case Management
Crisis Intervention
Psychiatric Crisis Intervention
Mobile Crisis Services
Crisis Stabilization (up to 72 hours)
Telephonic Crisis Services
System of Care Services
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Outreach
Psychosocial Rehabilitation
Home and Community Based Services
Peer Services
Day Treatment
Other
Supportive Services
Respite
Transportation
Other
MH Services Provided by Medical Organizations
Hospital Emergency Services
Primary Care Mental Health Services

7. Does Medicaid share funding for any of these services with other public entities (such as the mental health, child welfare, or juvenile justice agencies or schools)? Who are the other payers and what types of costs do they cover (e.g., room and board, education)?

Service Table 4: Non-Medicaid Funding Sources
State Service Name	Federal (specify source)	State (specify source)	County (specify source)	Grant Funded (specify source)	Other (specify source)	Notes
Psychiatric Inpatient Care
State Hospital
Community or Psychiatric Hospital
Non-Hospital 24 Hour Care
Residential Treatment Programs
Therapeutic Foster Care
Ambulatory Mental Health Services
Partial Hospital
Traditional Outpatient Mental Health Care
Psychotropic Medications
Traditional Case Management
Crisis Intervention
Psychiatric Crisis Intervention
Mobile Crisis Services
Crisis Stabilization (up to 72 hours)
Telephonic Crisis Services
System of Care Services
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Outreach
Psychosocial Rehabilitation
Home and Community Based Services
Peer Services
Day Treatment
Other
Supportive Services
Respite
Transportation
Other
MH Services Provided by Medical Organizations
Hospital Emergency Services
Primary Care Mental Health Services

8. Are fees charged to participating families for any of these services? If so, for what services and how much?

Service Table 5: Self-Pay
State Service Name	Self-pay? Y – Yes N- No	Amount of copay $ or %	Notes
Psychiatric Inpatient Care
State Hospital
Community or Psychiatric Hospital
Non-Hospital 24 Hour Care
Residential Treatment Programs
Therapeutic Foster Care
Ambulatory Mental Health Services
Partial Hospital
Traditional Outpatient Mental Health Care
Psychotropic Medications
Traditional Case Management
Crisis Intervention
Psychiatric Crisis Intervention
Mobile Crisis Services
Crisis Stabilization (up to 72 hours)
Telephonic Crisis Services
System of Care Services
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Outreach
Psychosocial Rehabilitation
Home and Community Based Services
Peer Services
Day Treatment
Other
Supportive Services
Respite
Transportation
Other
MH Services Provided by Medical Organizations
Hospital Emergency Services
Primary Care Mental Health Services

Our next set of questions pertains to any Medicaid mental health services designated for or primarily used by children with Serious Emotional Disturbance (SED).

9. Does Medicaid use a specific definition for Serious Emotional Disturbance (SED) in connection with any mental health services? Y _____ N _____

9.a. If yes, How is it defined?

SED Definition: _______________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

9.b. If yes, to which services does it pertain?

Service Table 6: SED Services
State Service Name	SED Qualification? Y-Yes N-No	Comments
Psychiatric Inpatient Care
State Hospital
Community or Psychiatric Hospital
Non-Hospital 24 Hour Care
Residential Treatment Programs
Therapeutic Foster Care
Ambulatory Mental Health Services
Partial Hospital
Traditional Outpatient Mental Health Care
Psychotropic Medications
Traditional Case Management
Crisis Intervention
Psychiatric Crisis Intervention
Mobile Crisis Services
Crisis Stabilization (up to 72 hours)
Telephonic Crisis Services
System of Care Services
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Outreach
Psychosocial Rehabilitation
Home and Community Based Services
Peer Services
Day Treatment
Other
Supportive Services
Respite
Transportation
Other
MH Services Provided by Medical Organizations
Hospital Emergency Services
Primary Care Mental Health Services

10. (If applicable) What process is used to determine whether a child has SED? Are there tools used to assess SED? (If so, please specify)

SED Determination Process: ________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

SED Tools: _______________________________________________________________________________

11. What kinds of providers deliver Medicaid children’s mental health services?

• child/family choice of any willing provider_______________________________________

• use of a lead agency _________________________________________________________

• public (state or county) offices ________________________________________________

• other specify ______________________________________________________________

__________________________________________________________________________________________________________________________________________________

12. Does your agency have a method of generating information on the service utilization and cost of Medicaid enrolled children with SED? Probes: matched client IDs, defined SED by diagnoses or claims, have a marker in the Medicaid system that identifies clients with SED

For this part of the evaluation, we are focusing on some of the core services needed by children with SED in a system of care. These include wraparound planning, intensive care coordination, flexible funding, family peer services and youth peer services. We recognize that Medicaid may not cover all these services or may include additional services when thinking about systems of care. The next set of questions addresses how these five services fit into the overall service system for children with SED.

13. For any of these services covered by Medicaid, what Medicaid option is used to finance them?

Service Table 7: Medicaid Option
System of Care Services	State Plan Service Y- Yes N-No	Medicaid Managed Care Waiver Y- Yes N-No	Medicaid Home & Community Based Waiver Y- Yes N-No	Other Medicaid Waiver (specify)
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Family Peer Services
Youth Peer Services

14. Who authorizes children to receive wraparound planning, intensive care coordination, flexible funding and family or youth peer services?

Service Table 8: System of Care Service Eligibility
System of Care Services	Provider clinical	State or county clinician	Summary assessment submitted to state/county	Other (specify)
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Family Peer Services
Youth Peer Services

15. Are specific tools used to make this determination? (If so, please specify)

Service Table 9: Tools
System of Care Services	Eligibility Determination Tool
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Family Peer Services
Youth Peer Services

16. What kinds of provider organizations deliver these services?

Service Table 10: Providers
System of Care Services	Provider Type
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Family Peer Services
Youth Peer Services

17. Are these services available statewide? Would you say they are available in 75% to 100% of the state, 50%-75% of the state, 25%-50% of the state or less than 25% of the state?

Service Table 11: Statewideness
System of Care Services	Statewide? 1-Statewide 2 – 50-75% of State 3 – 25-50% of State 4 – 0-25% of State
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Family Peer Services
Youth Peer Services

18. Which SOC services could potentially be funded by Medicaid either under your current state plan or through a state plan amendment? Are there plans for using Medicaid to fund any of these services in the future?

Service Table 12: Future Funding Plans
System of Care Services	Potential for Medicaid funding Y-Yes N-No	Plans for Future Funding
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Family Peer Services
Youth Peer Services (specify)
Other services

Finally, we would like your thoughts about the factors in your state likely to be relevant to generating sustainable funding for statewide SOC services.

6. What are the main barriers to funding the system of care services on a statewide basis? (probe: what agencies are responsible for addressing these barriers?)

6. Now that we have discussed the barriers, what factors in your state are facilitating the funding of the system of care services on a statewide basis? (probe: what agencies or other entities are involved?

Closing Comments

6. What else can you tell us to help us understand Medicaid’s contribution to financing SOC or related services for children with SED in your state?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

We plan to summarize the information you have provided and give you a chance to review it to be sure we correctly understand your state’s financing. Thank you very much for your help.

End of Instrument:

Thank you for participating in the financial mapping portion of the National Systems of Care Expansion Evaluation.

Attachment 6e

OMB No. xxxx-xxxx

Expiration Date: xx/xx/201x

CHILDREN’S MENTAL HEALTH INITIATIVE

NATIONAL SYSTEM OF CARE EXPANSION EVALUATION

Draft financial Mapping Survey

mental health provider trade association Version

INTRODUCTION

Thank you for your willingness to participate in this interview. The goals of this interview are to:

• Acquire and verify information about key services in the state’s mental health service system for children and how they have changed over the grant period, specifically:

  • Service eligibility criteria

  • Funding sources

• Identify any additional services introduced as part of the state’s SOC, any changes in eligibility criteria for SOC services or how children’s MH and SOC services are funded.

CONFIDENTIALITY/INFORMED CONSENT

The National Evaluation team is conducting an evaluation of system of care expansion grantees on behalf of the Substance Abuse and Mental Health Services Administration (SAMSHA).

We will be asking you to share information about various topics related to funding of system of care implementation and expansion.

This session will last approximately 60 to 90 minutes.

Your participation is completely voluntary, and you have the right to stop at any time or to refuse to answer any question.

Your responses to these questions will be kept confidential and will not be shared outside of the evaluation team. In any of our reports, aggregate data will be used to summarize the findings.

[OBTAIN INFORMED VERBAL CONSENT]

We would like to record this interview so that we can be sure to accurately capture your responses. A recording would only be reviewed by a few National Evaluation staff members.

[OBTAIN VERBAL CONSENT TO RECORD SESSION]

INSTRUCTIONS

The interviewer will ask you several questions. Please ask for clarification and provide as accurate information as possible.

Date of Interview: _____________ Interviewer’s Initials: ___________

Agency/Organization Name: ________________________________________________

Name & Position of Interviewee: _________________________________________

Name & Position of Interviewee: _________________________________________

Name & Position of Interviewee: _________________________________________

Date of interview: __________ Interviewer’s Initials: _________

Our initial set of questions concerns the scope of children’s public mental health services provided in your state.

1. We have interviewed the Medicaid and Mental Health Authority in your state/county to develop this list of the children’s mental health services they purchase or provide. Which of these children’s mental health services do your members provide?

Service Table 1: State MHA & Medicaid Services
CMHI Evaluation Service Category/ Service Name	State MHA & Medicaid Department/ Service Name	Provided by Trade Assn Members? Y-Yes N-No
Psychiatric Inpatient Care
State Hospital
Community or Psychiatric Hospital
Non-Hospital 24 Hour Care
Residential Treatment Programs
Therapeutic Foster Care
Ambulatory Mental Health Services
Partial Hospital
Traditional Outpatient Mental Health Care
Psychotropic Medications
Traditional Case Management
Crisis Intervention
Psychiatric Crisis Intervention
Mobile Crisis Services
Crisis Stabilization (up to 72 hours)
Telephonic Crisis Services
System of Care Services
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Outreach
Psychosocial Rehabilitation
Home and Community Based Services
Peer Services
Day Treatment
Other
Supportive Services
Respite
Other
Transportation
MH Services Provided by Medical Organizations
Hospital Emergency Services
Primary Care Mental Health Services

2. The following table indicates the eligibility criteria for these services.[Note: the income and clinical eligibility criteria will be populated from our interviews with the state Medicaid and Mental Health agencies.] Are there any barriers for eligible children to receive these services? Please describe.

Service Table 2: MHA Eligibility Criteria
State MHA or Medicaid Department/ Service Name	Income Y – Yes % FPL N - No	Clinical Y - Yes 1 - SED 2 - Other N - No	Barriers Describe
Psychiatric Inpatient Care
State Hospital
Community or Psychiatric Hospital
Non-Hospital 24 Hour Care
Residential Treatment Programs
Therapeutic Foster Care
Ambulatory Mental Health Services
Partial Hospital
Traditional Outpatient Mental Health Care
Psychotropic Medications
Traditional Case Management
Crisis Intervention
Psychiatric Crisis Intervention
Mobile Crisis Services
Crisis Stabilization (up to 72 hours)
Telephonic Crisis Services
System of Care Services
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Outreach
Psychosocial Rehabilitation
Home and Community Based Services
Peer Services
Day Treatment
Other
Supportive Services
Respite
Other
Transportation
MH Services Provided by Medical Organizations
Hospital Emergency Services
Primary Care Mental Health Services

3. What agencies or other entities pay for each of these services? What is the method of payment (cost reimbursement or grant, unit rate, class rate, case rate)?

Service Table 3: Funding Sources

Service Category/Service Name

Funding Sources

Method of Payment CR-Cost reimbursement U – unit rate C – class rate CA – Case rate

Medicaid

State Mental Health Authority

County Mental Health Authority

Grant (specify)

Other (specify)

Psychiatric Inpatient Care

State Hospital

Community or Psychiatric Hospital

Non-Hospital 24 Hour Care

Residential Treatment Programs

Therapeutic Foster Care

Ambulatory Mental Health Services

Partial Hospital

Traditional Outpatient Mental Health Care

Psychotropic Medications

Traditional Case Management

Crisis Intervention

Psychiatric Crisis Intervention

Mobile Crisis Services

Crisis Stabilization (up to 72 hours)

Telephonic Crisis Services

System of Care Services

Wraparound Planning

Intensive Care Coordination

Flexible Funding

Outreach

Psychosocial Rehabilitation

Home and Community Based Services

Peer Services

Day Treatment

Other

Supportive Services

Respite

Other

Transportation

MH Services Provided by Medical Organizations

Hospital Emergency Services

Primary Care Mental Health Services

4. Are fees charged to participating families for any of these services? If so, for what services? Do your members use sliding fee scales? Are co-pays charged to families for any of these services? If so, for what services? Approximately what percentage of co-pays are collected?

Service Table 4: Self Pay
State Service Name	Self-pay? Y – Yes N- No	Sliding Fee Scale? Y – Yes N- No	Co-pays? Y-Yes N-No	Approximate percentage of co-pays collected 1-> 75% 2- 50%-75% 3- 25%-50% 4- < 25%
Psychiatric Inpatient Care
State Hospital
Community or Psychiatric Hospital
Non-Hospital 24 Hour Care
Residential Treatment Programs
Therapeutic Foster Care
Ambulatory Mental Health Services
Partial Hospital
Traditional Outpatient Mental Health Care
Psychotropic Medications
Traditional Case Management
Crisis Intervention
Psychiatric Crisis Intervention
Mobile Crisis Services
Crisis Stabilization (up to 72 hours)
Telephonic Crisis Services
System of Care Services
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Outreach
Psychosocial Rehabilitation
Home and Community Based Services
Peer Services
Day Treatment
Other
Supportive Services
Respite
Other
Transportation
MH Services Provided by Medical Organizations
Hospital Emergency Services
Primary Care Mental Health Services

Our next set of questions pertains to Medicaid or Mental Health Authority services designated for or primarily used by children with Serious Emotional Disturbance (SED).

5. Which Medicaid or Mental Health Authority services, if any, are designated for children with Serious Emotional Disturbance (SED)?

6. If applicable, what process is used to determine whether a child has SED? Who is authorized to determine whether a child has SED? (Probes: Provider clinician, state or county clinician, summary assessment submitted to State/County, other. What is the role of providers in determination of SED status?)

Service Table 5: SED Services
State Service Name	SED? Y – Yes N- No	Authority for Determination of Eligibility	Notes
Psychiatric Inpatient Care
State Hospital
Community or Psychiatric Hospital
Non-Hospital 24 Hour Care
Residential Treatment Programs
Therapeutic Foster Care
Ambulatory Mental Health Services
Partial Hospital
Traditional Outpatient Mental Health Care
Psychotropic Medications
Traditional Case Management
Crisis Intervention
Psychiatric Crisis Intervention
Mobile Crisis Services
Crisis Stabilization (up to 72 hours)
Telephonic Crisis Services
System of Care Services
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Outreach
Psychosocial Rehabilitation
Home and Community Based Services
Peer Services
Day Treatment
Other
Supportive Services
Respite
Other
Transportation
MH Services Provided by Medical Organizations
Hospital Emergency Services
Primary Care Mental Health Services

7. Do families have a choice of providers for these (SED) services? (Please describe range and availability of family choices)

For this part of the evaluation, we are focusing on some of the core services needed by children with SED in a system of care. These include wraparound planning, intensive care coordination, flexible funding, family peer services and youth peer services. We recognize that you may not provide all these services or may include additional services when thinking about systems of care. The next set of questions addresses how these five services fit into the overall service system for children with SED.

8. What is your understanding of the definition of the population of focus for the state’s CMHI grant?

SOC population of focus definition:

9. Who authorizes children to receive wraparound planning, intensive care coordination, flexible funding and family or youth peer services? (Skip if this question has been answered above.)

Service Table 6: System of Care Service Eligibility
System of Care Services	Provider clinical	State or county clinician	Summary assessment submitted to state/county	Other (specify)
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Family Peer Services
Youth Peer Services

10. Are specific tools used to make this determination? (If so, please specify) (Skip if this question has been answered above.)

Service Table 7: Tools
System of Care Services	Eligibility Determination Tool
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Family Peer Services
Youth Peer Services

11. Which of these services are provided by your members?

Service Table 8: Providers
System of Care Services	Provider Type
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Family Peer Services
Youth Peer Services

12. Do private insurers pay for any of these services? Which services? What method is used to pay for them (unit rate, case rate, other)? For what circumstances or conditions are they authorized?

Service Table 9: Private Insurance Coverage
System of Care Services	Covered? Y-yes N-no	Payment method U- unit rate CA – Case rate	Reasons for authorization
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Family Peer Services
Youth Peer Services

13. Are these services available statewide to children enrolled in Medicaid? Would you say they are available in 75% to 100% of the state, 50%-75% of the state, 25%-50% of the state or less than 25% of the state?

Service Table 10: Statewideness
System of Care Services	Statewide? 1-Statewide 2 – 50-75% of State 3 – 25-50% of State 4 – 0-25% of State
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Family Peer Services
Youth Peer Services

14. What promising options for future funding of these services do you see?

Service Table 11: Future Funding Options
System of Care Services	Options for Future Funding
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Family Peer Services
Youth Peer Services (specify)
Other services

Finally, we would like your thoughts about the factors in your state likely to be relevant to generating sustainable funding for statewide SOC services.

15. What are the main barriers to funding the system of care services on a statewide basis? (probe: what agencies are responsible for addressing these barriers?)

16. Now that we have discussed the barriers, what factors in your state are facilitating the funding of the system of care services on a statewide basis? (probe: what agencies or other entities are involved?

Closing Comments

17. What else can you tell us to help us understand providers’ perspective on financing SOC or related services for children with SED in your state?

We plan to summarize the information you have provided and give you a chance to review it to be sure we correctly understand your organization’s financing. Thank you very much for your help.

End of Instrument:

Thank you for participating in the financial mapping portion of the National Systems of Care Expansion Evaluation.

Attachment 6f

OMB No. 0930-xxxx

Expiration Date xx/xx/20xx

CHILDREN’S MENTAL HEALTH INITIATIVE

NATIONAL SYSTEM OF CARE EXPANSION EVALUATION

Draft financial Mapping Survey

youth and family organization Version

INTRODUCTION

Thank you for your willingness to participate in this interview. The goals of this interview are to:

• Acquire and verify information about key services in the state’s mental health service system for children and how they have changed over the grant period, specifically:

  • Service eligibility criteria

  • Funding sources

• Identify any additional services introduced as part of the state’s SOC, any changes in eligibility criteria for SOC services or how children’s MH and SOC services are funded.

CONFIDENTIALITY/INFORMED CONSENT

The National Evaluation team is conducting an evaluation of system of care expansion grantees on behalf of the Substance Abuse and Mental Health Services Administration (SAMSHA).

We will be asking you to share information about various topics related to funding of system of care implementation and expansion.

This session will last approximately 60 to 90 minutes.

Your participation is completely voluntary, and you have the right to stop at any time or to refuse to answer any question.

Your responses to these questions will be kept confidential and will not be shared outside of the evaluation team. In any of our reports, aggregate data will be used to summarize the findings.

[OBTAIN INFORMED VERBAL CONSENT]

We would like to record this interview so that we can be sure to accurately capture your responses. A recording would only be reviewed by a few National Evaluation staff members.

[OBTAIN VERBAL CONSENT TO RECORD SESSION]

INSTRUCTIONS

The interviewer will ask you several questions. Please ask for clarification and provide as accurate information as possible.

Date of Interview: _____________ Interviewer’s Initials: ___________

Agency/Organization Name: ________________________________________________

Name & Position of Interviewee: _________________________________________

Name & Position of Interviewee: _________________________________________

Name & Position of Interviewee: _________________________________________

Date of interview: __________ Interviewer’s Initials: _________

Our initial set of questions focuses on the scope of services your organization provides, both as part of [program name of system of care program] and any additional services you may provide.

1. What services does your organization deliver to children with mental health problems and their families? Are any of these services delivered by certified peers?

(Note: we expect that each organization will deliver only a few of these services.)

Service Type	Peers Certified? Y- Yes N-No	Service Description (if needed)
Outreach
Support groups
Information and referral
Advocacy
Parent peer support
Parent peer care coordination
Youth peer support
Other (specify)
Other (specify)

2. What are the eligibility criteria for the SOC services you provide? Are any of your organization’s services designated only for children with Serious Emotional Disturbance (SED)? (Record in table below)

Service Type	Target Population			Other eligibility criteria (if needed)
	All children	SED only	Other
Outreach
Support groups
Information and referral
Advocacy
Parent peer support
Parent peer care coordination
Youth peer support
Other (specify)
Other (specify)

3. What other functions or activities related to the system of care does your organization perform? (e.g., social marketing, evaluation, advisory group participation)

_______________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Our next set of questions concerns the financing for the services you provide.

4. What agencies or other entities pay for each of these services?  When a payer covers only part of the cost of the service, what do they pay for?  How does your organization finance the balance of the cost?

Service Type	Funding Source						Source of balance of funds
	CMHI Grant	Medicaid	Mental Health Agency	Other Grant	Other (specify)	Other (specify)
	F-full cost S- shared cost
Outreach
Informal Peer support (support groups, etc.)
Information and referral
Advocacy
Family Peer support
Family Peer care coordination
Youth Peer Support
Other (specify)
Other (specify)
Balance of program costs

5. a. Are participating families charged a fee for any of these services?  If so, for what services? Do you use a sliding scale?

b. Do private insurers pay for any of these services?  Which services?  For what kind of conditions or circumstances?

Service Type	Funding Sufficiency		Private Insurance? Y-yes No-No	Conditions or Circumstances when covered
	Self pay? Y- Yes N-No	Sliding Fee Scale Y- Yes N-No
Outreach
Informal Peer support (support groups, etc.)
Information and referral
Advocacy
Family Peer support
Family Peer care coordination
Youth Peer Support
Other (specify)
Other (specify)
Balance of program costs

6. Please list any additional sources of funding for your organization’s operations. 

7. a. Are these funding sources sufficient to maintain your operations? Please rate the current sufficiency of funding sources for each of the services you provide. Rate sufficiency on a scale from 1 to 4 where 1 is not all sufficient and 4 is wholly sufficient.

2. Approximately what percentage of your current funding sources for each service are sustainable? (Less than 25%; 25% to 50%; 50% to 75%; 75% or more.)

Service Type	Sufficiency for current operations	Sustainability
	1 is not at all sufficient. 4 wholly sufficient	1-> 75% 2- 50%-75% 3- 25%-50% 4- < 25%
Outreach
Informal Peer support (support groups, etc.)
Information and referral
Advocacy
Family Peer support
Family Peer care coordination
Youth Peer Support
Other (specify)
Other (specify)
Balance of program costs

Finally, we would like your thoughts about the factors in your state likely to be relevant to generating sustainable funding for statewide SOC services.

8. What are the main barriers to funding the system of care services on a statewide basis? (probe: what agencies are responsible for addressing these barriers?)

9. Now that we have discussed the barriers, what factors in your state are facilitating the funding of the system of care services on a statewide basis? (probe: what agencies or other entities are involved?

Closing Comments

11. What else can you tell us to help us understand the youth and family perspective on financing your organization’s services, or other SOC or mental health services for children in your state?

We plan to summarize the information you have provided and give you a chance to review it to be sure we correctly understand your organization’s financing. Thank you very much for your help.

End of Instrument:

Thank you for participating in the financial mapping portion of the National Systems of Care Expansion Evaluation.

Attachment 6g

OMB No. xxxx-xxxx

Expiration Date: xx/xx/201x

CHILDREN’S MENTAL HEALTH INITIATIVE

NATIONAL SYSTEM OF CARE EXPANSION EVALUATION

Draft financial Mapping Survey

Tribal version

INTRODUCTION

Thank you for your willingness to participate in this interview. The goals of this interview are to:

• Acquire and verify information about key services in the Tribal mental health service system for children and how they have changed over the grant period, specifically:

  • Service eligibility criteria

  • Funding sources

• Identify any additional services introduced as part of the state’s SOC, any changes in eligibility criteria for SOC services or how children’s MH and SOC services are funded.

CONFIDENTIALITY/INFORMED CONSENT

The National Evaluation team is conducting an evaluation of system of care expansion grantees on behalf of the Substance Abuse and Mental Health Services Administration (SAMSHA).

We will be asking you to share information about various topics related to funding of system of care implementation and expansion.

This session will last approximately 60 to 90 minutes.

Your participation is completely voluntary, and you have the right to stop at any time or to refuse to answer any question.

Your responses to these questions will be kept confidential and will not be shared outside of the evaluation team. In any of our reports, aggregate data will be used to summarize the findings.

[OBTAIN INFORMED VERBAL CONSENT]

We would like to record this interview so that we can be sure to accurately capture your responses. A recording would only be reviewed by a few National Evaluation staff members.

[OBTAIN VERBAL CONSENT TO RECORD SESSION]

INSTRUCTIONS

The interviewer will ask you several questions. Please ask for clarification and provide as accurate information as possible.

Date of Interview: _____________ Interviewer’s Initials: ___________

Agency/Organization Name: ________________________________________________

Name & Position of Interviewee: _________________________________________

Name & Position of Interviewee: _________________________________________

Name & Position of Interviewee: _________________________________________

Date of interview: __________ Interviewer’s Initials: _________

Our initial set of questions concerns the scope of children’s public mental health services provided by your tribe and the state and/or county.

1. The following table that you provided for us previously lists the children’s mental health services provided by your tribe, and the Medicaid or the Mental Health Authority services most often used by children in your tribe. Do you have any corrections or additions to make?

Service Table 1: State Tribal and Other Public Services
CMHI Evaluation Service Category/ Service Name	Provided by Tribe? Y-Yes N-No	State MHA & Medicaid Department/ Service Name
Psychiatric Inpatient Care
State Hospital
Community or Psychiatric Hospital
Non-Hospital 24 Hour Care
Residential Treatment Programs
Therapeutic Foster Care
Ambulatory Mental Health Services
Partial Hospital
Traditional Outpatient Mental Health Care
Psychotropic Medications
Traditional Case Management
Crisis Intervention
Psychiatric Crisis Intervention
Mobile Crisis Services
Crisis Stabilization (up to 72 hours)
Telephonic Crisis Services
System of Care Services
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Outreach
Psychosocial Rehabilitation
Home and Community Based Services
Peer Services
Day Treatment
Other
Supportive Services
Respite
Other
Transportation
MH Services Provided by Medical Organizations
Hospital Emergency Services
Primary Care Mental Health Services

2. How are tribal-funded children’s mental health services organized and delivered?

(provided by Indian Health Service clinic or health center, purchased from specialty providers, other)

3. What are the eligibility criteria for tribal mental health services?

Service Table 2: MHA Eligibility Criteria
Tribe Name/ Service Name	Income Y – Yes % FPL N - No	Clinical Y - Yes 1 - SED 2 - Other N – No	Other Describe
Psychiatric Inpatient Care
State Hospital
Community or Psychiatric Hospital
Non-Hospital 24 Hour Care
Residential Treatment Programs
Therapeutic Foster Care
Ambulatory Mental Health Services
Partial Hospital
Traditional Outpatient Mental Health Care
Psychotropic Medications
Traditional Case Management
Crisis Intervention
Psychiatric Crisis Intervention
Mobile Crisis Services
Crisis Stabilization (up to 72 hours)
Telephonic Crisis Services
System of Care Services
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Outreach
Psychosocial Rehabilitation
Home and Community Based Services
Peer Services
Day Treatment
Other
Supportive Services
Respite
Other
Transportation
MH Services Provided by Medical Organizations
Hospital Emergency Services
Primary Care Mental Health Services

4. What agencies or other entities provide funding or pay for each of these services? What is the method of payment (cost reimbursement or grant, unit rate, class rate, case rate)?

Service Table 3: Funding Sources

Service Category/Service Name

Funding Sources

Method of Payment

Dept. of the Interior IHS

Other Tribal Funds

Medi-caid

State Mental Health Authority

County Mental Health Authority

Grant (specify)

Other (specify)

CR-Cost reimbursement U – unit rate C – class rate CA – Case rate

Psychiatric Inpatient Care

State Hospital

Community or Psychiatric Hospital

Non-Hospital 24 Hour Care

Residential Treatment Programs

Therapeutic Foster Care

Ambulatory Mental Health Services

Partial Hospital

Traditional Outpatient Mental Health Care

Psychotropic Medications

Traditional Case Management

Crisis Intervention

Psychiatric Crisis Intervention

Mobile Crisis Services

Crisis Stabilization (up to 72 hours)

Telephonic Crisis Services

System of Care Services

Wraparound Planning

Intensive Care Coordination

Flexible Funding

Outreach

Psychosocial Rehabilitation

Home and Community Based Services

Peer Services

Day Treatment

Other

Supportive Services

Respite

Other

Transportation

MH Services Provided by Medical Organizations

Hospital Emergency Services

Primary Care Mental Health Services

5. Are fees charged to participating families for any of these services? If so, for what services? Are sliding fee scales used? Are co-pays charged to families for any of these services? If so, for what services? Approximately what percentage of co-pays are collected?

Service Table 4: Self Pay
State Service Name	Self-pay? Y – Yes N- No	Sliding Fee Scale? Y – Yes N- No	Co-pays? Y-Yes N-No	Approximate percentage of co-pays collected 1-> 75% 2- 50%-75% 3- 25%-50% 4- < 25%
Psychiatric Inpatient Care
State Hospital
Community or Psychiatric Hospital
Non-Hospital 24 Hour Care
Residential Treatment Programs
Therapeutic Foster Care
Ambulatory Mental Health Services
Partial Hospital
Traditional Outpatient Mental Health Care
Psychotropic Medications
Traditional Case Management
Crisis Intervention
Psychiatric Crisis Intervention
Mobile Crisis Services
Crisis Stabilization (up to 72 hours)
Telephonic Crisis Services
System of Care Services
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Outreach
Psychosocial Rehabilitation
Home and Community Based Services
Peer Services
Day Treatment
Other
Supportive Services
Respite
Other
Transportation
MH Services Provided by Medical Organizations
Hospital Emergency Services
Primary Care Mental Health Services

6. The following is a list of the other public services that you identified are frequently used by the children in your tribe. Have the children in your tribe who are eligible for these services experienced any barriers to receiving them? Please describe.

Service Table 5: Barriers to Service
Tribe Name/ Service Name	Barriers Describe
Psychiatric Inpatient Care
State Hospital
Community or Psychiatric Hospital
Non-Hospital 24 Hour Care
Residential Treatment Programs
Therapeutic Foster Care
Ambulatory Mental Health Services
Partial Hospital
Traditional Outpatient Mental Health Care
Psychotropic Medications
Traditional Case Management
Crisis Intervention
Psychiatric Crisis Intervention
Mobile Crisis Services
Crisis Stabilization (up to 72 hours)
Telephonic Crisis Services
System of Care Services
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Outreach
Psychosocial Rehabilitation
Home and Community Based Services
Peer Services
Day Treatment
Other
Supportive Services
Respite
Other
Transportation
MH Services Provided by Medical Organizations
Hospital Emergency Services
Primary Care Mental Health Services

Our next set of questions pertains to any Tribal services designated for or primarily used by children with Serious Emotional Disturbance (SED).

7. Are any tribal services designated for children with Serious Emotional Disturbance (SED)? If so, which services?

8. Does the tribe have any role in determining whether a child has SED? If yes, please describe.

Service Table 6: SED Services
State Service Name	SED? Y – Yes N- No	Authority for Determination of Eligibility	Notes
Psychiatric Inpatient Care
State Hospital
Community or Psychiatric Hospital
Non-Hospital 24 Hour Care
Residential Treatment Programs
Therapeutic Foster Care
Ambulatory Mental Health Services
Partial Hospital
Traditional Outpatient Mental Health Care
Psychotropic Medications
Traditional Case Management
Crisis Intervention
Psychiatric Crisis Intervention
Mobile Crisis Services
Crisis Stabilization (up to 72 hours)
Telephonic Crisis Services
System of Care Services
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Outreach
Psychosocial Rehabilitation
Home and Community Based Services
Peer Services
Day Treatment
Other
Supportive Services
Respite
Other
Transportation
MH Services Provided by Medical Organizations
Hospital Emergency Services
Primary Care Mental Health Services

For this part of the evaluation, we are focusing on some of the core services needed by children with SED in a system of care. These include wraparound planning, intensive care coordination, flexible funding, family peer services and youth peer services. We recognize that you may not provide all these services or may include additional services when thinking about systems of care. The next set of questions addresses how these five services fit into the overall service system for children with SED.

9. First, we’d like to confirm our understanding of who the population of focus is for your current CMHI grant. Can you review this description and let us know if anything needs to be corrected? (Note: we will summarize this from our review of grant documents using such categories as age, region, clinical criteria, functional criteria, use of certain type of service (eg. inpatient, residential), referral source, child welfare status, juvenile justice status, other)

[Insert tribe specific description here}

10. Who authorizes children to receive wraparound planning, intensive care coordination, flexible funding and family or youth peer services?

Service Table 7: System of Care Service Eligibility
System of Care Services	Provider clinician	State or county clinician	Summary assessment submitted to state/county	Other (specify)
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Family Peer Services
Youth Peer Services

11. Are specific tools used to make this determination? (If so, please specify)

Service Table 8: Tools
System of Care Services	Eligibility Determination Tool
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Family Peer Services
Youth Peer Services

12. Which of these services are provided by the tribe?

Service Table 9: Tribal Services
System of Care Services	Provider Type
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Family Peer Services
Youth Peer Services

11. Do private insurers pay for any of these services? Which services? What method is used to pay for them (unit rate, case rate, other)? For what circumstances or conditions are they authorized?

Service Table 10: Private Insurance Coverage
System of Care Services	Covered? Y-yes N-no	Payment method U- unit rate CA – Case rate	Reasons for authorization
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Family Peer Services
Youth Peer Services

11. Are these services available to the all eligible children in the tribe? Would you say they are available in 75% to 100% of eligible children, 50%-75%, 25%-50% or less than 25% of eligible children in the tribe?

Service Table 11: Extent of Access to Tribe
System of Care Services	Percent of eligible children? 1 - > 75% 2 – 50-75% 3 – 25-50% 4 – 0-25%
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Family Peer Services
Youth Peer Services

11. Do you see any promising options for future funding of these services?

Service Table 12: Future Funding Options
System of Care Services	Options for Future Funding
Wraparound Planning
Intensive Care Coordination
Flexible Funding
Family Peer Services
Youth Peer Services (specify)
Other services

Finally, we would like your thoughts about the factors in your state likely to be relevant to generating sustainable funding for tribal SOC services.

11. What are the main barriers to funding the system of care services to all children in the tribe who need them? (probe: what agencies are responsible for addressing these barriers?)

11. Now that we have discussed the barriers, what factors are facilitating the funding of the system of care services throughout your tribe? (probe: what agencies or other entities are involved?

Closing Comments

11. What else can you tell us to help us understand your tribe’s perspective on financing SOC or related services for children with SED in your state?

We plan to summarize the information you have provided and give you a chance to review it to be sure we correctly understand your organization’s financing. Thank you very much for your help.

End of Instrument:

Thank you for participating in the financial mapping portion of the National Systems of Care Expansion Evaluation.

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Attachment 6: Financial Mapping