MHBG Reporting

FY16 17 MHBG Reporting.pdf

Community MH Services BG and SAPT BG Application Guidance and Instructions FY 2016-2017

MHBG Reporting

OMB: 0930-0168

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0930-0168 can be found here:

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Block Grant Reporting Section
FY 2016
FY2017

CFDA 93.958
(Mental Health)

U.S. Department of Health and Human Services
Substance Abuse and Mental Health Services Administration

101

Table of Contents

A. Introduction
B. Implementation Report
MHBG Table 1 Priority Area and Annual Performance Indicators – Progress Report
C. State Agency Expenditure Reports
MHBG Table 2 (URS Table 7) State Agency Expenditure Report
MHBG Table 3 MHBG Expenditures by Service
MHBG Table 4 Set-aside for Children’s Mental Health Services
MHBG Table 5 (URS Table 8) Profile Of Mental Health Block Grant Expenditures for
Non-Direct Service Activities.
MHBG Table 6 (URS Table 10) – Statewide Entity Inventory
MHBG Table 7 Maintenance of Effort for Statewide Expenditures on Mental Health
Services
D. Population and Services Reports
MHBG Table 8A and MHBG Table 8b Profile of Clients by Type of Funding Support
(URS Tables 5A and 5B)
MHBG Table 9 (URS Table 1) Profile of the State Population by Diagnosis.
MHBG Table 10 (URS Table 12) State Mental Health Agency Profile.
MHBG Table 11A and MHBG Table 11B (URS Tables 2A and 2B) Profile of Persons
Served, All Programs by Age, Gender and Race/Ethnicity
MHBG Table 12 (URS Table 3) Profile of Persons Served In the Community Mental
Health Settings, State Psychiatric Hospitals and Other Settings
MHBG Tables 13A, 13B and 13C (NEW, URS Tables 14A and 14B) Profile of Persons
with SMI/SED Served By Age, Gender and Race/Ethnicity
MHBG Table 14 (URS Table 5) Profile of Client Turnover; Performance Indicators and
Accomplishments
E: Performance Indicators and Accomplishments
MHBG Table 15 (URS Table 17) Profile of Adults with Serious Mental Illnesses
Receiving Specific Services during the Year
MHBG Table 16A (URS Table 4) Profile of Adult Clients by Employment Status
MHBG Table 16B (URS Table 4A) Profile of Adult Clients by Employment Status: By
Primary Diagnosis Reported

102

MHBG Table 17 (URS Table 15) Living Situation Profile
MHBG Table 18 (URS Table 19B) Profile of Change in School Attendance
MHBG Table 19 (URS Table 9) Social Connectedness and Improved Functioning
MHBG Table 20A (URS Table 11) Summary Profile of Client Evaluation of Care
MHBG Table 20B (URS Table 11A) Consumer Evaluation of Care by Consumer
Characteristics: Race/Ethnicity
MHBG Table 21 (URS Table 19A) Profile of Criminal Justice or Juvenile Justice
Involvement
MHBG Table 22 (URS Table 16) Profile of Adults with Serious Mental Illnesses and
Children with Serious Emotional Disturbances Receiving Specific Services
MHBG Table 23A (URS Table 20A) Profile of Non-Forensic (Voluntary and CivilInvoluntary) Patients Readmission to Any State Psychiatric Inpatient Hospital within
30/180 Days of Discharge
MHBG Table 23B (URS Table 20B) Profile of Forensic Patients Readmission to Any
State Psychiatric Inpatient Hospital within 30/180 Days of Discharge
MHBG Table 24 (URS Table 21) Profile of Non-Forensic (Voluntary and CivilInvoluntary Patients) Readmission to Any Psychiatric Inpatient Care Unit (State Operated
or Other Psychiatric Inpatient Unit) within 30/180 Days of Discharge

103

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 State
Fiscal Year (SFY) in the format provided in this guidance. The report will address the purposes for
which the MHBG were expended, the recipients of grant funds, and the authorized activities
conducted 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 and Jurisdictions 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 the State or Jurisdiction to receive its next grant. If
the due date falls on a weekend or Federal holiday, the report will be due on the next business day.
The following schedule includes specific due dates for annual reports:

FY for which the state
is applying for funds
2016

2017

Due Dates for MH and Combined BG Components
Application
Plan
Planning Period
Due
Due
9/1/2015
Yes
7/1/15 – 6/30/17

9/1/2016

No*

Updates only

MHBG Report
Due
12/1/2015
Report year is Last
Completed SFY
12/1/2016
Report year is Last
Completed SFY

States and Jurisdictions are required to complete the Reporting Document. The Reporting Document
is comprised of the following sections:
Section B: Implementation Report - In this section, States and Jurisdictions 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 plan covering the last completed fiscal year. The
report should also include a brief review of areas that the State or Jurisdiction identified in that Block
Grant Plan as needing improvement and changes that the State or Jurisdiction would propose to
achieve the goals established for the priorities.
Section C: State Agency Expenditure Reports - In this section, States and Jurisdictions should
provide information regarding expenditures for authorized activities and services for mental health.

104

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 MHBG 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 Jurisdictionselected performance indicators.

105

B. Implementation Report
The information States and Jurisdictions entered into the performance indicator tables (Plan Table 1)
in the planning section of the 2016/2017 Behavioral Health Assessment and Plan will automatically
populate cells 1 – 6 in the progress report tables below. States and Jurisdictions are required to
indicate whether each first-year performance target/outcome measurement identified in the
2016/2017 Plan was “Achieved” or “Not Achieved” in Cell 7, Report of Progress toward goal
attainment. If a target was not achieved, a detailed explanation must be provided as well as the
remedial steps proposed to meet the target.
MHBG Table 1 - Priority Area and Annual Performance Indicators – Progress Report
Priority Areas and Annual Performance Indicators
2. Priority Type (SAP, SAT, MHP, MHS):
1. Priority Area:
3. Population(s) (SMI, SED, PWWDC, IVDUs, HIV EIS, TB, OTHER):
4. Goal of the priority area:

5. Strategies to attain the goal:
6. Annual Performance Indicators/objectives to measure goal success:
Indicator #1:
a)

Baseline measurement (Initial data collected prior to the first-year target/outcome):

b) First-year target/outcome measurement (Progress – end of SFY 2016):
c) Second-year target/outcome measurement (Final – end of SFY 2017):
d)

Data source:

e) Description of data:
f)

Data issues/caveats that affect outcome measures:

7. Report of Progress toward Goal Attainment:
First-year Target:

____ Achieved

_____ Not Achieved (If not achieved, explain why.)

Reason why target was not achieved, and changes proposed to meet target:

106

C. State Agency Expenditure Reports
States and Jurisdictions should provide information regarding MHBG and State funds expended for
authorized activities to prevent and treat mental illness during the last completed State fiscal year
(SFY). 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. Please complete the tables described below.
MHBG Table 2 (URS Table 7) - State Agency Expenditure Report. MHBG Table 2 provides
information on Mental Health Expenditures and Sources of Funding. This includes funding from
Medicaid, the MHBG and other federal funding sources, state, local and other funds.
MHBG Table 3 - MHBG Expenditures by Service MHBG. Table 3 is to be used to report MHBG
expenditures by unduplicated individual and specific services.
MHBG Table 4 - Set-aside for Children’s Mental Health Service. This table provides a report of
state-wide expenditures for children’s mental health services during the last completed State fiscal
year (SFY).
MHBG Table 5 (URS Table 8) - Profile of Mental Health Block Grant Expenditures for Non-Direct
Service Activities. MHBG Table 5 is used to report expenditures of MHBG funds for non-direct
service activities that are funded or conducted by the State Mental Health Authority during the last
completed State fiscal year (SFY).
MHBG Table 6 (URS Table 10) - Statewide Entity Inventory. This table reports payments to
recipients of MHBG funds including intermediaries, e.g., administrative service organizations, and
other organizations which provided mental health services during the last completed State fiscal year.
MHBG Table 7 - Maintenance of Effort for Statewide Expenditures for Mental Health Service.
This table reports expenditures of all statewide non-Federal expenditures for authorized activities to
prevent and treat mental illness during the last completed State fiscal year (SFY).

107

MHBG Table 2 (URS Table 7) - MHBG State Agency Expenditure Report
This table describes expenditures for public mental health services provided or funded by the State
mental health agency by source of funding. Include ONLY funds expended by the executive
branch agency administering the MH Block Grant.
MHBG State Agency Expenditures Report
MHBG Table 2
Report Period- From:

To:

State Identifier:
Source of Funds
ACTIVITY
(See instructions for using Row
1.)

A.
Substance
Abuse Block
Grant

B.
Mental
Health
Block
Grant.

C. Medicaid
(Federal,
State, and
local)

D. Other
Federal Funds
(e.g., ACF
(TANF), CDC,
CMS
(Medicare)
SAMHSA, etc.)

E. State
funds

F. Local
funds
(excluding
local
Medicaid)

G.
Other

Substance Abuse
Prevention and Treatment

Pregnant Women
and Women with
Dependent Children

All Other

Primary Prevention*

EBP for Early Intervention
(5 percent)

Tuberculosis Services

HIV Early Intervention
Services

State Hospital

6. Other 24 Hour Care

7. Ambulatory/Community Non24 Hour Care

8. Administration (excluding
program / provider level

9. Total

* States may only use MH Block Grant funds to provide primary prevention services to the priority populations of adults

with serious mental illness and children with serious emotional disturbance.

108

MHBG Table 3 (Requested) - MH Block Grant Expenditures by Service
Table 3 is to be used to report MHBG expenditures by unduplicated individual and specific services.
MHBG Block Grant Expenditures by Service
MHBG Table 3
State Identifier:
Report Period-

From:

To:
Service

Unduplicated
Individuals

Unit
Type

Unit
Quantity

MHBG
Expenditures

Healthcare Home/Physical Health
General and specialized outpatient medical services
Acute Primary care
General Health Screens, Tests and Immunizations
Comprehensive Care Management
Care coordination and Health Promotion
Comprehensive Transitional Care
Individual and Family Support
Referral to Community Services
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
Parent/Caregiver Support
Skill Building
Case management

109

MHBG Block Grant Expenditures by Service
MHBG Table 3
State Identifier:
Report Period-

From:

To:
Service

Unduplicated
Individuals

Unit
Type

Unit
Quantity

MHBG
Expenditures

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
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

110

MHBG Block Grant Expenditures by Service
MHBG Table 3
State Identifier:
Report Period-

From:

To:
Service

Unduplicated
Individuals

Unit
Type

Unit
Quantity

MHBG
Expenditures

Other (please list)

111

MHBG Table 4 Set-Aside for Children’s Mental Health Services
States and Jurisdictions are required not to spend less than the amount expended in FY 2008.
Statewide Expenditures for Children’s Mental Health Services
MHBG Table 4:
State Identifier:
Report Period: From:
To:
Actual SFY 2008
Actual SFY 2015

112

MHBG Table 5 (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 MHBG 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!
MHBG Table 5
State Identifier:
Report Period- From:

Profile of Community Mental Health Block Grant Expenditures for Non-Direct Service Activities
To:

Service

Expenditures

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:

MHBG Table 6 (URS Table 10) Statewide Entity Inventory
Statewide Entity Inventory
MHBG Table 6
State Identifier:
Report Period- From:

To:
A

Entity
Number

Total

I-SATS
ID (for
SABG)

Area
Served
(Statewide
or SubState
Planning
Area)

Provider/Program
Name

Street
Address

City

State

Zip

Total
Block
Grant
Funds

$
$
$

Source of Funds
SA Block Grant
B
D
E

B
Prevention
(other than
primary
prevention)
and
Treatment
Services
$
$
$

MH Block Grant
G

Pregnant
Women and
Women
with
Dependent
Children

Primary
Prevention

Early
Intervention
Services for
HIV

Adults
with
serious
mental
illness

Children with a
serious emotional
disturbance

Non-Direct
Service
Activities

$
$
$

114

MHBG Table 7 Maintenance of Effort for State Expenditures on Mental Health Services
Maintenance of Effort for State Expenditures on Mental Health Services
MHBG Table 7:
State Identifier:
Report Year:
Total Expenditures for State _____
Period

Expenditures

B1 (2013) + B2 (2014)
2

A
SFY 2013
(1)
SFY 2014
(2)
SFY 2015
(3)

Are the expenditure amounts reported in Column B “actual” expenditures for the fiscal years
involved?
Yes

SFY 2013
SFY 2014
SFY 2015
If any estimated expenditures are provided, please indicate when “actual” expenditure data will be
submitted to SAMHSA:
___/___/_____
mm/dd/yyyy

D. Populations and Services Report
States and Jurisdictions are requested to provide information regarding individuals that are served by
the state mental health authority using MHBG Tables 8 through 14.
MHBG Table 8A and 8b Profile of Clients by Type of Funding Support MHBG Tables 8A and 8B
provide 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.
MHBG Table 9 (URS Table 1) Profile of the State Population by Diagnosis MHBG Table 9
provides the number of Adults with SMI and Children with SED in the reporting year and in three
years forward.
MHBG Table 10 (URS Table 12) State Mental Health Agency Profile MHBG Table 10 provides the
Populations covered in State hospitals and Community program in age categories; 0-3, 4-17 and 18
and above.
MHBG Tables 11A and 11B (URS Tables 2A and 2B) Profile of Persons Served, All Programs by
Age, Gender and Race/Ethnicity MHBG Tables 11A and 11B provide 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 and Jurisdictions are to provide this information on
all programs by age, gender, race/ethnicity.
MHBG Table 12 (URS Table 3) Profile of Persons Served In the Community Mental Health Settings,
State Psychiatric Hospitals and Other Settings MHBG Table 12 provides an aggregate profile of
unduplicated persons in the reporting year for services funded through the MHBG. 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 MHBG. The client profile takes into
account all institutional and community services for all such programs. States and Jurisdictions are
to provide this information on all programs by age, gender, race, and ethnicity.
MHBG Tables 13A,13 B and 13C (URS Tables 14A and 14B) Profile of Persons with SMI/SED
Served By Age, Gender and Race/Ethnicity MHBG Tables 13A, 13B and 13C request counts for
persons with SMI or SED using the definitions provided by the CMHS. MHBG Tables 13A, 13B and
13C 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
and Jurisdictions should report using the Federal Definitions of SMI and SED if they can report
them, if not, please report using the state’s definitions of SMI and SED and provide information in
these tables describing your state’s definition.
MHBG Table 14 (URS Table 6) Profile of Client Turnover MHBG Table 14 requests information
regarding the profile of client turnover in various out-of-home settings (e.g. state hospitals, inpatient
116

psychiatric hospitals, residential treatment centers). Information collected by this table requests
admissions, discharges, and length of stay.

117

MHBG Table 8A. Profile of Clients by Type of Funding Support (URS
Table 5A)
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.

MHBG Table 8A
Report Period- From:
State Identifier:

To:

Total
Female

Male

American Indian or Alaska Native
Not
Available

Total

Female

Male

Not Available

Asian
Female

Male

Black or African American
Not Available

Female

Male

Not 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.

MHBG Table
8A (Con’t)
Report
Period- From:
To:
State
Identifier:
Native Hawaiian or Other
Pacific Islander
Female

Male

Medicaid
(only
Medicaid)
NonMedicaid
Sources
(only)
People
Served by
Both
Medicaid and
NonMedicaid
Sources
Medicaid
Status Not
Available
Total Served

(continued on next page)

Not
Available

Hispanic * use only if data for
MHBG Table 3b are not
available.

White

Female

Male

Not
Available

Female

Male

Not
Available

More Than One Race
Reported
Female

Male

Not
Available

Race Not Available

Female

Male

Not
Available

MHBG Table 8B. (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 MHBG Table 8A.

Please note that the same person may be served in both Medicaid and Non-Medicaid programs during the same reporting period.
MHBG Table 8B.
Report Period- From
State Identifier:

To:

Not Hispanic or Latino
Female

Male

Not
Available

Hispanic or Latino
Female

Ma
l

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 NonMedicaid 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.

120

MHBG Table 9 (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.
MHBG Table 9
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.

Three Years Forward

MHBG Table 10 (URS Table 12): State Mental Health Agency Profile

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!
MHBG Table 10
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:

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?

2.a.1

Percent of adults meeting Federal definition of SMI:

2.a.2

Percentage of children/adolescents meeting Federal definition of SED

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?

122

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.

3b.3

Percentage of children/adolescents meeting the Federal definition of SED who also have a diagnosis of
substance abuse problem:
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

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

4.b.6
4.b.7
4.b.8

Coordination with state health and Medicaid agencies
Resolving mental health consumer complaints
Input in contract development
Performance monitoring

4.b.9

Other

Are Data for
these programs
reported on URS
Tables?

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 MHBG 11a and
MHBG 11b, which require unduplicated counts of clients served across your entire mental health system.

123

Are the data reporting in the
tables?
5.a.

5.b.
5.c.
5.d.
5.e.

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
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.

Summary Administrative Data

6.a.

Report Year

6.b.

State Identifier
Summary Information on Data Submitted by SMHA:

6.c.

Year being reported: From:

6.d.

Person Responsible for Submission

6.e.

Contact Phone Number:

6.f.

Contact Address

6.g.

E-mail:

124

MHBG Table 11A (URS Table 2A). Profile of Persons Served, All Programs by Age, Gender, 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.
MHBG Table
11A.
Report Year:
State Identifier:
Total
Female

Male

Not
Availab
le

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)

MHBG Table
11A.
Report Year:
State Identifier:

Native Hawaiian or Other
Pacific Islander
Female

Male

Not
Availabl
e

White

Hispanic * use only if data for

More Than One Race Reported

MHBG Table 11b are not
available.

Female

Male

Not
Availabl
e

Female

Male

Not
Availabl
e

Female

Male

Not
Availabl
e

Race Not
Available
Female

Male

0-17 years
18-24 years
25-44 years
45-64 years
65+ years
Total
Pregnant
Women

126

Not
Availabl
e

MHBG Table 11B (URS Table 2B). Profile of Persons Served, All Programs by Age, Gender and
Race/Ethnicity
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 MHBG Table 11A.
Please report the data under the categories listed - "Total" are calculated automatically.
MHBG Table 11B.
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

Not
Available

Total

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 Ethnicity):
Comments on Data
(Overall):

127

MHBG Table 12 (URS Table 3). Profile of Persons served in tCommunity Mental Health Settings, State Psychiatric Hospitals and
OtherSettings
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.

MHBG Table
12
Report Year:
State
Identifier:
MHBG Table
12
Service Setting

Age 0-17
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)

128

MHBG Table 12 (cont.) Profile of Persons served in Community Mental Health Settings, State Psychiatric Hospitals and Other Settings
Table 12
Report Year:
State Identifier:
Age Not Available
Table 12
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

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).”

129

Table 13A 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!
MHBG Table
13A
Report Year:
State
Identifier:
MHBG Table
13A
Service Setting

Age 0-17
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)

130

MHBG Table 13A (cont.) Profile of Persons served in the community mental health setting, State Psychiatric Hospitals and Other Settings
MHBG Table 13A
Report Year:
State Identifier:
Age 65+
MHBG Table 13A
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.

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.

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).”

131

MHBG Table 13B (URS Table 14A). Profile of Persons with SMI/SED served by Age,
Gender and Race/Ethnicity
This is a developmental table similar to MHBG Tables 11a and 11b (URS Table 2A. and 2B). This table requests counts for persons with SMI or SED using the
definitions provided by the CMHS. MHBG Table 11A and 11B (URS 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 MHBG Tables 11 A and 11B (URS Table
2A. and 2B). For 2013, 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.
MHBG Table
13B
Report Year:
State
Identifier:
Total
Female

Male

Not
Available

American Indian or
Alaska Native
Total

Female

Male

Not
Available

Asian
Female

Male

Black or African American
Not
Available

Female

Male

Not
Available

Native Hawaiian or Other
Pacific Islander
Female

Male

Not
Available

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):

(continued on next page)

132

(

MHBG Table
13B.
Report Year:
State
Identifier:
Hispanic *use only if data
for MHBG Table 13c are
not available

White
Female

Male

Not
Available

More Than One Race
Reported
Female

Male

Not
Available

Race Not Available
Female

Male

Not Available

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

Children with SED, if No describe or attach state definition:

Yes

Diagnoses included in State SED definition:

Diagnoses included in state SMI definition:

133

MHBG Table 13C (URS Table 14B). Profile of Persons with SMI/SED served by Age, Gender
and 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 MHBG Table 13b.

Please report the data under the categories listed - "Total" are calculated automatically.
MHBG Table 13C
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

Not
Available

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):

134

Total

MHBG Table 14 (URS Table 6): Profile of Client Turnover

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!
MHBG Table 14.
Report Year:
State Identifier:

Profile of Service Utilization

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)

Median

For Clients in Facility More
Than 1 Year: Average
Length of Stay (in Days):
Residents at end of year
Average
(Mean)

Median

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):

135

E. Performance Data and Outcomes
MHBG Table 15 (URS Table 17) Profile of Adults with Serious Mental Illnesses Receiving Specific
Services during the Year MHBG Table 15 provides the number of unduplicated Adults with SMI
receiving family psycho education, integrated treatment for co-occurring disorders, illness selfmanagement and medication management.
MHBG Table 16A (URS Table 4) Profile of Adult Clients by Employment Status MHBG Table 16A
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, caregivers, 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.
MHBG Table 16B (URS Table 4A) Profile of Adult Clients by Employment Status, by Primary
Diagnosis Reported MHBG Table 16B 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.
MHBG Table 17 (URS Table 15) Living Situation Profile MHBG Table 17 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.
MHBG Table 18 (URS Table 19B) Profile of Change in School Attendance MHBG Table 18
measures the change in days attended over time. Information requested includes information on
suspensions, expelled, and changes in the school attendance.
MHBG Table 19 (URS Table 9) Social Connectedness and Improved Functioning MHBG Table 19
requests states and jurisdictions 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.
MHBG Table 20A (URS Table 11) Summary Profile of Client Evaluation of Care MHBG Table
20A 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.
MHBG Table 20B (URS Table 11A) Consumer Evaluation of Care by Consumer Characteristics:
Race/Ethnicity
MHBG Table 21 (URS Table 19A) Profile of Criminal Justice or Juvenile Justice Involvement
MHBG Table 21 requests information to measure the change in Arrests over time.
MHBG Table 22 (URS Table 16) Profile of Adults with Serious Mental Illnesses and Children with
Serious Emotional Disturbances Receiving Specific Services MHBG Table 22 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 and Jurisdictions monitor
the fidelity for the evidenced based services.
MHBG Table 23A (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
MHBG Table 23A 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.
MHBG Table 23B (URS Table 20B) Profile of Forensic Patients Readmission to Any State
Psychiatric Inpatient Hospital within 30/180 Days of Discharge MHBG Table 23B 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.
MHBG Table 24 (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 MHBG Table 24 provides the total number of
discharges from inpatient care units w/I the year, the number of readmissions w/I 30-days and 180days and the percent readmitted by age, gender, race, and ethnicity.

137

MHBG Table 15 (URS Table 17): Profile of Adults with Serious Mental Illnesses Receiving Specific Services
During The Year:

MHBG Table 15
Report Year:
State Identifier:
ADULTS WITH SERIOUS MENTAL
ILLNESS
Receiving Family
Psychoeducation

Receiving Integrated
Treatment for Co-occurring
Disorders (MH/SA)

Receiving
Illness Self
Management

Receiving Medication
Management

Age

18-20
21-64
65-74
75+
Not Available
TOTAL
Gender
Female
Male
Not Available
Ethnicity
Hispanic/Latino Origin
Non Hispanic/Latino
Hispanic origin not available
Race
American Indian/ Alaska Native
Asian
Black/African American
Hawaiian/Pacific Islander
White
Hispanic*
More than one race
Unknown

Do You monitor fidelity
for this service?

Yes

IF YES,
What fidelity measure do you use?
Who measures fidelity?
How often is fidelity measured?
Is the SAMHSA EBP Toolkit used to guide EBP Implementation?

138

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

139

MHBG Table 16A (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!
MHBG Table 16 A
Report Year:
State Identifier:
18-20
Adults Served
Employed:
Competitively
Employed Full or
Part Time (includes
Supported
Employment)

Female

Male

21-64
Not
Available

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):

Female

Male

65+
Not
Available

Female

Male

Not
Available

Age Not Available
Not
Female Male Available

Total
Female

Male

Not
Available

Total

MHBG Table 16B (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!
MHBG Table 10020
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

MHBG Table 17 (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!

MHBG 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

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

MHBG Table 17 (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.
MHBG Table 17
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

Total

Table 18 (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
State:

Time period in which services were received:

For Consumers in Service for at least 12 months

"T1" Prior 12 months
(more than 1 year ago)

"T2" Most Recent 12 months
(this year)

T1 to T2 Change

# Not
# Not
# Suspended Suspended or
No
# Suspended Suspended or
or Expelled
Expelled
Expelled
Response or Expelled

Total

If Suspended at T1 (Prior 12 Months)

No
Response

Impact of Services

If Not Suspended at T1 (Prior 12 Months)

# with an
# with No
# with an
# with No
Expelled or
Suspension
Expelled or Suspension
Suspended in or Expulsion
Suspended in or Expulsion
T2
at T2
No Response
T2
at T2

No
Response

Over the last 12 months, the number of days my child was in school have

# Greater # Stayed
(Improved) the Same

# Fewer days
(gotten
# Not
worse)
Applicable

No
response

Total
Responses
0

Gender
Male

Female

Gender NA

Age
Under 18

For Consumers Who Began Mental Health Services during the past 12 month

"T1" 12 months prior to beginning
services

"T2" Since Beginning Services
(this year)

T1 to T2 Change

# Not
# Not
# Suspended Suspended or
No
# Suspended Suspended or
or Expelled
Expelled
Response or Expelled
Expelled

Total

No
Response

Impact of Services

If Not Suspended at T1
(Prior 12 Months)

If Suspended at T1 (Prior 12 Months)

# with an
# with No
# with an
# with No
Expelled or
Suspension
Expelled or Suspension
Suspended in or Expulsion
Suspended in or Expulsion
T2
at T2
T2
at T2
No Response

Since starting to receive MH Services, the number of days my child was in
school have

No
Response
0

# Greater # Stayed
(Improved) the Same

# Fewer days
(gotten
# Not
worse)
Applicable

No
response

Total
Responses
0

Gender
Male

Female

Gender NA

Age
Under 18

See Page 2 for additional Questions about the source of this data.
Source of School Attendance Information

Measure of School Attendance

Mental health programs include:
Region for which data are reported:

1) Consumer survey (recommended items)

2) Other Survey: Please send us items

3) Mental health MIS

4) State Education Department

5) Local Schools/Education Agencies

6) Other (specify)

1) School Attendance

1) Children with SED only
1) The whole state

2) Other: (Specify)

2) Other Children (specify)

3) Both.

2) Less than the whole state (please describe)

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):

MHBG Table 19 (URS Table 9): SOCIAL CONNECTEDNESS AND IMPROVED FUNCTIONING

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS
AND/OR CELLS!
MHBG Table 19: 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

Measure used

2: Did you use the recommended new Functioning Domain Questions? Yes No

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?

Measure used
Measure used

Recommended Scoring Rules
Please use the same rules for reporting Social connectedness and Functioning Domain scores as for calculating
other Consumer Survey Domain scores for Table MHBG Table
20a: 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).

146

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

MHBG Table 20A (URS Table 11): Summary Profile of Client
Evaluation of Care

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR
CELLS!
MHBG Table 20A
Report Year (Year Survey was Conducted):
State Identifier:
Number of
Positive
Responses

Adult Consumer Survey Results:

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:

Number of
Positive
Responses

1. Reporting Positively About Access.
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.
1.
2.
3.
4.
1.b.
1.c.

If no, which version:
Original 40 Item Version
21-Item Version
State Variation of MHSIP
Other Consumer Survey
If other, please attach instrument used.
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)

148

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

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:
* Report Confidence Intervals at the 95% confidence level

149

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:

150

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?

151

MHBG Table 20b (URS Table 11A) Consumer Evaluation of Care by Consumer Characteristics: (Optional Table by Race/Ethnicity.)

PLEASE DO NOT ADD, DELETE OR MOVE ROWS, COLUMNS AND/OR CELLS!
Table 20b.
Report Year:
State Identifier:

Adult Consumer Survey Results:
*State used the 2 question version for
Hispanic Origin

Indicators
Adult Consumer
Survey Results:
1. Reporting Positively
About Access.

Total

# Positive

Responses

American Indian or
Alaska Native

# Positive

Please check the appropriate box on the left. The "Totals" formula will automatically adjust to account for which method your state used to ask about
Hispanic Origin/Status

Yes

Asian

Responses

# Positive

Responses

Black or African American

# Positive

Responses

Native Hawaiian or Other
Pacific Islander

# Positive

Responses

White

# Positive

Responses

More than One Race
Reported

# Positive

Responses

Other/ Not Available

# Positive

Responses

Hispanic Origin*

# Positive

Responses

2. Reporting Positively
About Quality and
Appropriateness.
3. Reporting Positively
About Outcomes.
4. Reporting Positively
about Participation in
Treatment Planning
5. Reporting Positively
about General
Satisfaction
6. Social Connectedness
7. Functioning

Child/Adolescent Family Survey Results:
*State used the 2 question version for
Hispanic Origin

Indicators
Child/Adolescent
Family Survey Results:

Total

# Positive

Responses

Yes

American Indian or
Alaska Native

# Positive

Please check the appropriate box on the left. The "Totals" formula will automatically adjust to account for which method your state used to ask about
Hispanic Origin/Status

Responses

Asian

# Positive

Responses

Black or African American

# Positive

Responses

Native Hawaiian or Other
Pacific Islander

# Positive

Responses

White

# Positive

Responses

More than One Race
Reported

# Positive

Responses

Other/ Not Available

# Positive

Reporting Positively
About Access.
Reporting Positively
About General
Satisfaction
Reporting Positively
About Outcomes.
Reporting Positively
Participation in Treatment
Planning for their
Children.
Reporting Positively
About Cultural Sensitivity
of Staff.

6. Social Connectedness
7. Functioning

Comments on Data:

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.

Responses

Hispanic Origin*

# Positive

Responses

MHBG Table 21 (URS Table 19a) Profile of Criminal Justice or Juvenile Justice Involvement:

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 arrest histories of mental health consumers with their December 2007 MHBG submission.
2. The SAMHSA National Outcome Measure for Criminal Justice measures the change in Arrests 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 criminal justice, you may report them here.
3. If your SMHA has data on Arrest records from alternatives sources, you may also report that here. If you only have data for arrests for consumers in this year, please report that in the T2 columns. If you can calculate the change
in Arrests from T1 to T2, please use all those 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).

State:

Time period in which services were received:

For Consumers in Service for at least 12 months
T1

"T1" Prior 12 months
(more than 1 year ago)

"T2" Most Recent 12 months
(this year)

Not
Arrested

Arrested

No
Response

T1 to T2 Change

Not
Arrested

Arrested

If Arrested at T1 (Prior 12 Months)

No
Response

# with an
Arrest in T2

# with No
Arrest at T2

Assessment of the Impact of Services
Over the last 12 months, my encounters with the police have…

If Not Arrested at T1 (Prior 12 Months)

No
Response

# with an
Arrest in T2

# with No
Arrest at T2

# Reduced
(fewer
# Stayed
#
encounters) the Same Increased

No
Response

# Not
Applicable

No
Response

Total
Responses

Total

Total Children/Youth (under age 18)

Male

Female
Gender NA
Total Adults (age 18 and over)
Male
Female
Gender NA

0
0
0

0
0
0
0

For Consumers Who Began Mental Health Services during the past 12 months
T1

"T1" 12 months prior to beginning
services

"T2" Since Beginning Services
(this year)

Not
Arrested

Arrested

Total
Total Children/Youth (under age 18)
Male
Female
Gender NA
Total Adults (age 18 and over)
Male
Female
Gender NA

No
Response

T1 to T2 Change

Not
Arrested

Arrested

If Arrested at T1 (Prior 12 Months)

No
Response

# with an
Arrest in T2

# with No
Arrest at T2

Assessment of the Impact of Services
Since starting to receive MH Services, my encounters with the police have…

If Not Arrested at T1 (Prior 12 Months)

No
Response

# with an
Arrest in T2

# with No
Arrest at T2

# Reduced
(fewer
# Stayed
#
encounters) the Same Increased

No
Response

# Not
Applicable

No
Response

Total
Responses

0
0
0
0

153

154

MHBG Table 23A (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

MHBG Table 23A.

Report Year:
State Identifier:
Total number of
Discharges in
Year

Number of Readmissions to
ANY STATE Hospital within

30 days

TOTAL

180 days

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

Percent Readmitted

30 days

180 days

MHBG Table 23B (URS Table 20B). Profile of Forensic Patients Readmission to Any State Psychiatric
Inpatient Hospital Within 30/180 Days of Discharge

MHBG Table 23B.

Report Year:
State Identifier:
Total number
of Discharges
in Year

Number of Readmissions to
ANY STATE Hospital within

30 days

TOTAL

180 days

Percent Readmitted

30 days

180 days

* Hispanic: Only use the "Hispanic" row under Race if data for Hispanic as a Ethnic Origin are not available

157

MHBG Table 24 (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
MHBG Table 24.

Report Year:
State Identifier:
Total number
of Discharges
in Year

Number of Readmissions to ANY
Psychiatric Inpatient Care Unit
Hospital within
30 days

TOTAL

Percent Readmitted

180 days

30 days

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

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File Modified	2015-05-07
File Created	2015-05-07