Form PDWS

Now Is the Time (NITT) - Healthy Transition (HT) Evaluation

Attachment 5_Project Director Web Surveys

Project Director Web Survey

OMB: 0930-0360

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OMB No. 0930-XXXX

Expiration Date XX/XX/XXXX

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-xxxx. Public reporting burden for this collection of information is estimated to average 20 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 5: Project Director Web Surveys

Project Director Web Survey: Time 1

*NOTE*

Bracketed content in bold and CAPS is filled in prior to administration

Bracketed content in bold and italics are instructions for the respondent

Comments identified with *NOTE* describe how items are intended to be programmed or other types of explanation for reader or evaluation team, rather than respondents

PART I. Personal Information Module

Name: [FILL]

Name of organization/program: [FILL]

Brief description of type of organization/program: [FILL]

Job title: [FILL]

Brief description of the job/responsibilities: [FILL]

Brief description of their job/responsibilities related to youth and young adults if not apparent from above: [FILL]

Main geographic location of work site [if not working from office/clinic, what is the geographic location of the work they do]: [FILL]

List certifications [provide examples relevant to locality derived from personnel section of application]:

How many years of experience do you have in _________________________? [Fill in appropriate role based on type of instrument being administered]

___ 0-6 months ___> 6-12 months ___ > 1 to 3 years ___ > 3 to 5 years ____ > 5 years

How long have you been at your present job?

___ 0-6 months ___> 6-12 months ___ > 1 to 3 years ___ > 3 to 5 years ____ > 5 years

Gender: Female _____ Male _____ Other ______

Race/ethnicity Note: Please answer BOTH Questions 9 & 10 about Hispanic Origin and Race. For this questionnaire, origins are not races:

Hispanic Origin: [select one]

Is this person Hispanic, Latino or of Spanish origin?

_____ Yes _____ No

Race: What is the person’s race [Select one or more]

_____ Black/African American _____ Asian

_____ Native American/Indigenous _____ Pacific Islander

_____ White/Caucasian _____Mixed-Racial- Specify: _________________

______Other Race- Specify: _________________

Highest Degree Status: [select one]

____No high school diploma or equivalent ____Bachelor’s degree

____High School diploma or equivalent ____Master’s degree

____Some college, but no degree ____Doctoral degree

____Associate’s degree ____Other degree (specify):_______________

Do you work in an educational, behavioral health, or human service profession? Y ___ N ___

Discipline/Profession [select all that apply]:

____Addictions Counseling ____Social Work ___Nurse Practitioner

____Other Counseling ____Physician’s Assistant ___Administration

____Education ____Medicine: Primary Care ___Unemployed

____Vocational Rehabilitation ____Medicine: Psychiatry ___Student

____Criminal Justice ____Medicine: Other ___Other (specify)

____Psychology ____Nurse _______________________

How many years of experience do you have in _________________________? [Fill in appropriate role based on type of instrument being administered]

___ 0-6 months ___> 6-12 months ___ > 1 to 3 years ___ > 3 to 5 years ____ > 5 years

How long have you been at your present job?

___ 0-6 months ___> 6-12 months ___ > 1 to 3 years ___ > 3 to 5 years ____ > 5 years

PART II. Documentation Updates

Since our last Document Review request [FILL IN DATE OF DOCUMENT REQUEST #1] which of the following types of documentation related to STATE policies related to the target Y & YA population for your NITT-HT Initiative have been changed or updated? Documents related to [check all that apply]:

Transition planning while in adolescent care (e.g., DSS, mental health services)?

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Grandfathering of eligibility, or any extension of child/adolescent services beyond the upper age limit?

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Any interagency agreements that involve sharing responsibility about youth in transition?

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Policies requiring preparation of adolescents in care for independent living?

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Any policies around youth in care who will not meet eligibility requirements?

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Principles calling for assurance of smooth transitions to adult system or specific means for assuring transitions?

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Other

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Since our last Document Review request [FILL IN DATE OF DOCUMENT REQUEST #1] any documented changes to the organization of child and adult services related to the target Y & YA population for your NITT-HT initiative? Y ___ N ___

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Since our last Document Review request [FILL IN DATE OF DOCUMENT REQUEST #1] which of the following types of NITT-HT Initiative documents have been changed or updated? Documents related to [check all that apply]:

Logic Model

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Strategic Plan(s)

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Action Plan(s)

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Policies and Procedures

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Workforce Development Plan

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Quality Assurance/Improvement Plans

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Financial or sustainability plans?

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Practice Guidelines

If YES, these changes were for [check all that apply]:

Core staff [i.e., staff primarily responsible for planning and case management with NITT-HT youth who complete the Core Staff Survey]?
Other professional, non-peer staff?
Professional or paraprofessional peer staff?

Did the NITT-HT Initiative contribute to making these documented policy updates and changes?

Y ___ N ___

Manuals

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Plans for addressing needs/disparities related to special subpopulations of NITT-HT youth (e.g., ethnic, sexual identity/orientation, homeless, other minority or at risk groups?).

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

PART III. Information on Service Array and Funding Sources

Below, please do the following: 1) indicate which of the different types of services listed are typically delivered to NITT-HT youth in your grantee communities; 2) using drop down menus the different sources of funding for each, up to a maximum of 4; and 3) each funding source selected, indicate the APPROXIMATE amount of funding for the service provided by the source.

If there is only one funding source for a given service, select that funding source in the first drop down menu, and select “None” in the remaining dropdown menus; if there are two funding sources, select the largest in the first dropdown, the second largest in the second, and “None” in the remaining menus, and so forth.
If there are more than four funding sources for a given service, select the three largest sources of funding, and indicate one of each in the first three drop down lists; and in the fourth, select “multiple sources”.

*NOTE: In the programmed instrument, below each of the services in the first “Services” checkbox list below, four drop down menus will contain selections from the second, “Funding Sources” drop down menu list, one for each source of funding to be identified. Beside each funding source drop down menu, the respondent will indicate in a second, “Funding Percentages” drop down menu list the proportion of overall funding for the service provided by that source [see example below]*

*EXAMPLE:*

*NOTE: array continues, one for each service check box in sample table above *

Services Check Box List [select all that apply]:

Mental Health Service
Vocational Rehabilitation Service
Education or Special Education Service
Substance Abuse Service
Developmental Disability Service
Housing Service
Independent Living Service
Delinquency Rehabilitation Service
Child Welfare Services
Child Protection Service
Public Safety Service
Medical Health Service
Recreation Service
Flex funding (i.e., funds to be used for individualized needs of youth as they arise)
Other ________________________________________________________________

Funding Sources Drop Down Menu List [*NOTE: these lists appear in four DROP DOWN MENUS in sample table above below each check box, as explained above*]:

NITT-HT grant
Other federal grant
Medicaid
Other federal funding source
State grant
Other state agency funding
Local mental health authority/Care management entity
Local education authority/school district
Private insurance or out of pocket
Other: ______________________________________________________________
Multiple sources
None

Project Director Web Survey: Time 2

PART I. Personal Information Module *NOTE: ONLY administer this if Project Director was hired since Project Director Interview #1*

PART II. Documentation Updates

Since our last Document Review request [FILL IN DATE OF DOCUMENT REQUEST #2] which of the following types of documentation related to STATE policies related to the target Y & YA population for your NITT-HT Initiative have been changed or updated? Documents related to [check all that apply]:

Transition planning while in adolescent care (e.g., DSS, mental health services)?

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Grandfathering of eligibility, or any extension of child/adolescent services beyond the upper age limit?

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Any interagency agreements that involve sharing responsibility about youth in transition?

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Policies requiring preparation of adolescents in care for independent living?

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Any policies around youth in care who will not meet eligibility requirements?

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Principles calling for assurance of smooth transitions to adult system or specific means for assuring transitions?

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Other

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Since our last Document Review request [FILL IN DATE OF DOCUMENT REQUEST #2] any documented changes to the organization of child and adult services related to the target Y & YA population for your NITT-HT initiative? Y ___ N ___

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Since our last Document Review request [FILL IN DATE OF DOCUMENT REQUEST #2] which of the following types of NITT-HT Initiative documents have been changed or updated? Documents related to [check all that apply]:

Logic Model

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Strategic Plan(s)

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Action Plan(s)

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Policies and Procedures

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Workforce Development Plan

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Quality Assurance/Improvement Plans

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Financial or sustainability plans?

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Practice Guidelines

If YES, these changes were for [check all that apply]:

Core staff [i.e., staff primarily responsible for planning and case management with NITT-HT youth who complete the Core Staff Survey]?
Other professional, non-peer staff?
Professional or paraprofessional peer staff?

Did the NITT-HT Initiative contribute to making these documented policy updates and changes?

Y ___ N ___

Manuals

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Plans for addressing needs/disparities related to special subpopulations of NITT-HT youth (e.g., ethnic, sexual identity/orientation, homeless, other minority or at risk groups?).

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ____

PART III. Questions on Healthy Transitions Practices

INSTRUCTIONS

Please describe briefly the practices that were either initiated or significantly adapted to support the goals of the NITT grant. In other words, these practices were NOT implemented prior to the NITT-HT grant or were implemented very differently than they have been after the grant was received. These could be any of the practices identified in prior interviews, including evidence-based practices or other services. But they should all be practices: a) initiated or significantly adapted following the grant award; b) initiated or adapted using resources from the grant.

You may identify UP TO 6 practices for youth with serious mental health conditions served by NITT-HT other than those specifically designed for youth with early episode psychosis (these will be asked about separately). If there are more than 6 practices that are new or significantly adapted, identify the practices currently serving the most youth and young adults.

You are encouraged to use practices identified in the Services & Supports Inventory conducted earlier during the initiative, around the time of the Site Visit (These practices were listed in the invitation to this survey; you can also contact your Project Liaison for this list). If there have been substantial changes in practices implemented since the Services & Supports Inventory was conducted though, you may change these responses. Again, if there are more than 6 practices, please identify the six serving the most youth in NITT-HT, and please omit practices for Y & YA with early episode psychosis.

New or Significantly Adapted Practices for Y & YA other than those for early psychosis (up to SIX):

New NITT-HT Practice #1: __________________________________________

New NITT-HT Practice #2: __________________________________________

New NITT-HT Practice #3: __________________________________________

New NITT-HT Practice #4: __________________________________________

New NITT-HT Practice #5: __________________________________________

New NITT-HT Practice #6: __________________________________________

Now identify UP TO 4 practices other than those listed above that are specifically designed for youth with early episode psychosis. Again, you are encouraged to identify the same practices as those identified in the Services & Supports Inventory, unless there have been major changes since the Services & Supports Inventory was conducted.

New or Adapted NITT-HT Practices specifically designed for Y & YA with early psychosis (up to FOUR):

New NITT-HT Practice #7: __________________________________________

New NITT-HT Practice #8: __________________________________________

New NITT-HT Practice #9: __________________________________________

New NITT-HT Practice #10: _________________________________________

Of the 10 practices listed above, which is MOST widely used for Y & YAs in your NITT-HT Initiative?: _________________________________________________________

We will refer to the practices listed above in the rest of this survey as

the “Healthy Transitions” practices

HEALTHY TRANSTIION PRACTICE IMPLEMENTATION AND SUSTAINABILITY

Next you will be asked some questions about your state’s implementation of specific Healthy Transitions Practices. Respond regarding the Healthy Transitions initiated/adapted practice that is most widely used with youth and young adults served by the initiative (the one you identified above). Please press “Next” to continue.

1. Which statement below most accurately describes funding for the Healthy Transitions practice specified? This would include costs associated with direct service, supervision, and overhead.

Note: This question does not refer to Healthy Transitions start-up costs.

No components of services are reimbursable
Some costs are covered
Most costs are covered
Services pays for itself (e.g. all costs covered adequately, or finding of covered components compensates for non-covered components)
Service pays for itself and reimbursement rates attractive relative to competing non-EBP services.

{PROGRAMMER NOTES} Format as single choice, radio buttons

2A. Is training specific to this Healthy Transitions practice available within your state?

{PROGRAMMER NOTES} Format as single choice, radio buttons. IF Question 2A=YES, ASK 2B, ELSE SKIP TO 3.

2B. Do any of the statements below accurately describe the specified Healthy Transitions practice’s ongoing training, supervision and consultation for the practice program leader and clinical staff?

If there is variability among sites, please consider the average training support across sites.

2B1. Initial didactic (classroom-based) training in the practice provided to clinicians

2B2. Initial agency consultation regarding implementation strategies

2B3. Ongoing training (e.g., “boosters”) for practitioners to reinforce application of the practice

2B4. Ongoing on site supervision for practitioners from supervisors, coaches, or outside consultants

2B5. Ongoing administrative consultation for program administrators until the practice is incorporated into routine work flow

{PROGRAMMER NOTES}. Format as a grid; single choice, radio buttons

3. Which one of the statements below best describes state regulations, policies and procedures to identify and remove any barriers to the Healthy Transitions practice implementation?

Examples of supportive state policies:

State ties Healthy Transitions practice delivery to contracts.
State ties Healthy Transitions practice to licensing/ certification/ regulation.

Examples of state policies that might create barriers:

State develops a fiscal model or clinical guidelines that directly conflict with Healthy Transitions practice model (e.g. insufficient staffing ratio for Individual Placement and Support).
State licensing or certification directly interfere with a program’s ability to implement the Healthy Transitions practice.

Virtually all state policies and regulations impacting this practice act as barriers
On balance, state policies that create barriers outweigh policies that support/promote this practice
SMHA policies that are support/promote this practice are approximately equally balanced by policies that create barriers
On balance, state policies that support/promote this practice outweigh policies that create barriers
Virtually all state policies and regulations impacting this practice support/promote the practice

{PROGRAMMER NOTES} Format as single choice, radio buttons.

4A. Does your agency have a system of conducting ongoing fidelity reviews by trained reviewers for this Healthy Transitions practice?

{PROGRAMMER NOTES} Format as single choice, radio buttons. IF 4A=YES, ASK 4B, ELSE SKIP TO 5.

4B. To the best of your knowledge, dwhich characteristics below describe the measurement of this EBP’s fidelity in Healthy Transitions programs?

4B 1. Practice fidelity is measured at defined intervals

4B 2. Fidelity assessment is measured by independent state or contracted agency staff, not by the program itself

4B 3. Fidelity is measured a minimum of annually

4B 4. Fidelity performance data is given to programs and used for purposes of quality improvement

4B 5. Fidelity performance data is reviewed by the state and/or the local mental health agency

4B 6. The state routinely uses fidelity performance data for purposes of quality improvement, to identify and respond to high and low performers

4B 7. The fidelity performance data is made public (e.g. website, published in newspaper, etc.)

{PROGRAMMER NOTES} Format as a grid; single choice, radio buttons

5A. Does your agency have a mechanism in place for collecting and using youth and young adult outcome data for this Healthy Transitions practice?

{PROGRAMMER NOTES} Format as single choice, radio buttons. IF 5A=YES, ASK 5B, ELSE SKIP TO NEXT SECTION.

5B. Do any of the statements below describe how youth and young adult outcomes are measured and used for this Healthy Transitions practice? If outcome measurement is variable among sites, consider the typical site.

5B 1. The outcome measures have documented reliability/validity, or indicators are nationally developed/recognized

5B 2. Youth and young adult outcomes are measured every 6 months at a minimum

5B 3. Youth and young adult outcome data is used routinely to develop reports on agency performance

5B 4. Youth and young adult specific outcome data are given to programs and practitioners to support clinical decision making and treatment planning

5B 5. Agency performance data related to outcomes are given to programs and used for purposes of quality improvement

5B 6. Agency performance data related to outcomes are reviewed by the state and/or the local mental health agency

5B 7. The state routinely uses agency outcome-oriented performance data for purposes of quality improvement; performance data trigger state action. Client outcome data is used as a mechanism for identification and response to high and low performers

5B 8. The aggregate agency outcome performance data is made public (e.g. website, published in newspaper, etc.)

{PROGRAMMER NOTES} Format as a grid; single choice, radio buttons

Project Director Web Survey: Time 3

PART I. Personal Information Module *NOTE: ONLY administer this if Project Director was hired since Project Director Interview #2*

PART II. Documentation Updates

Since our last Document Review request [FILL IN DATE OF DOCUMENT REQUEST #3] which of the following types of documentation related to STATE policies related to the target Y & YA population for your NITT-HT Initiative have been changed or updated? Documents related to [check all that apply]:

Transition planning while in adolescent care (e.g., DSS, mental health services)?

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Grandfathering of eligibility, or any extension of child/adolescent services beyond the upper age limit?

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Any interagency agreements that involve sharing responsibility about youth in transition?

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Policies requiring preparation of adolescents in care for independent living?

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Any policies around youth in care who will not meet eligibility requirements?

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Principles calling for assurance of smooth transitions to adult system or specific means for assuring transitions?

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Other

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Since our last Document Review request [FILL IN DATE OF DOCUMENT REQUEST #3]any documented changes to the organization of child and adult services related to the target Y & YA population for your NITT-HT initiative? Y ___ N ___

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Since our last Document Review request [FILL IN DATE OF DOCUMENT REQUEST #3]which of the following types of NITT-HT Initiative documents have been changed or updated? Documents related to [check all that apply]:

Logic Model

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Strategic Plan(s)

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Action Plan(s)

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Policies and Procedures

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Workforce Development Plan

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Quality Assurance/Improvement Plans

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Financial or sustainability plans?

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Practice Guidelines

If YES, these changes were for [check all that apply]:

Core staff [i.e., staff primarily responsible for planning and case management with NITT-HT youth who complete the Core Staff Survey]?
Other professional, non-peer staff?
Professional or paraprofessional peer staff?

Did the NITT-HT Initiative contribute to making these documented policy updates and changes?

Y ___ N ___

Manuals

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

Plans for addressing needs/disparities related to special subpopulations of NITT-HT youth (e.g., ethnic, sexual identity/orientation, homeless, other minority or at risk groups?).

If YES, did the NITT-HT Initiative contribute to making these documented policy updates and changes? Y ___ N ___

PART III. Questions on Sustainability