Form Quarterly Report Quarterly Report Quarterly Report

OMB No. 0930-0xxx

Expiration Date: xx/xx/xx

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 0930-0xxx.  Public reporting burden for this collection of information is estimated to average 8 hours 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.

RECOMMENDED REPORT OUTLINE

Section I: Grantee Information

Name of CSAT Government Project Officer:

Federal Grantee Number:

Project Name:

Name of the Grantee Organization:

Project Director:

Project Coordinator:

Start Date for Grant:

End Date of Grant:

Current Date:

Evaluator:

Office and Project Site Address:

Date/s Report Completed:

Program Length of Stay:

Program Number of Children Allowed to Reside in Residential Treatment with Mother:

Instructions:

All questions refer to the period of performance from the start date of the grant to the end date of the grant. Please use data from your local evaluation and Government Performance and Results Act (GPRA) reporting to respond to questions where possible, keeping the dates of service consistent. Provide data with respect to your population(s) of focus, including sub-populations (e.g., race, ethnicity, federally recognized tribe, language, and socioeconomic characteristics). Please note the attachment with guidelines for reporting race and ethnicity. Please also indicate the source of the data (e.g., from your GPRA data, state or epidemiological data, provider records). The report can discuss the population of focus and its relationship to your geographic catchment area and other relevant factors.

Section II: Women

Data sources used (e.g., locally designed instruments, screening and/or assessment tools, case notes, GPRA, local evaluation data): __________

Time period reported __________

1. Number of pregnant and postpartum women who entered the program, by pregnancy status (i.e. trimester or postpartum) at intake.
   
   a. First Trimester __________
   b. Second Trimester __________
   c. Third Trimester __________

d. Postpartum __________

2. Number of women enrolled in program who delivered infants. __________

3. Number of women served through the program by age and race/ethnicity.

Age of Woman	Race/Ethnicity
	Hispanic or Latino	AI/AN	Asian	Black or African American	Nat. Hawaiian or Other Pacific Islander	White
12-17
18-25
More than 26 years of age

4. Number of mothers screened for Fetal Alcohol Syndrome (FASD).

_________ Number screened positive ________

5. Number of children screened with Fetal Alcohol Syndrome (FASD).

_________ Number of children screened positive ______

6. Number of women who screened positive for depression, anxiety, and other mental disorders.
   
   Positive Screen __________

7. Number of women who self-reported for depression, anxiety, and other mental disorders.

Self-Report __________

8. Number of women who used tobacco by pregnancy status (i.e., trimester or postpartum).

a. First Trimester __________
b. Second Trimester __________
c. Third Trimester __________

d. Postpartum __________

9. Number of women who used alcohol by pregnancy status (i.e., trimester or postpartum).

a. First Trimester __________
b. Second Trimester __________
c. Third Trimester __________

d. Postpartum __________

10. Number of women who used illicit substances other than alcohol by pregnancy status (i.e., trimester or postpartum).

a. First Trimester __________
b. Second Trimester __________
c. Third Trimester __________

d. Postpartum __________

What instrument do you use to assess illicit substances use? _______________________________

11. Number of women discharged by Length of Stay and Treatment Status.

Length of Stay	Completed Treatment	Terminated Treatment
<30 days
31-60 days
61-90 days
91-120 days
121-150 days
151-180 days
More than 180 days

12. Number of women discharged by Type of Living Arrangement and Treatment Status.

Living Arrangement	Completed Treatment	Terminated Treatment
Returned to home
Living with relatives
Shelter
Homeless
Unknown

13. Number of women in residential treatment who received trauma-informed care and pregnancy status (i.e., trimester or postpartum).
    
    a. First Trimester __________
    b. Second Trimester __________
    c. Third Trimester __________

d. Postpartum __________

Section III: Children

Data sources used __________

Time period reported __________

14. Number of children to whom the mother had given birth at time of intake by age, gender, and racial/ethnic origin:

Age of Children	Gender		Race/Ethnicity
Birth to 3	Male	Female	Hispanic or Latino	AI/AN	Asian	Black or African Am.	Nat. Hawaiian. or OPI	White
Ages 4-6
Ages 7-10
Ages 11-17

15. Number of children born to women after admission into the program, by gender and by race/ethnic origin.

Age of Children	Gender		Race/Ethnicity
Birth to 3	Male	Female	Hispanic or Latino	AI/AN	Asian	Black or African Am.	Nat. Hawaiian. or OPI	White
Ages 4-6
Ages 7-10
Ages 11-17

16. Number of children who resided with their mothers (excluding children born during the program), by age, gender, and race/ethnicity.

Age of Children	Gender		Race/Ethnicity
Birth to 3	Male	Female	Hispanic or Latino	AI/AN	Asian	Black or African Am.	Nat. Hawaiian. or OPI	White
Ages 4-6
Ages 7-10
Ages 11-17

17. Number of children who did not reside with mothers but received services in the program; by age, gender, and race/ethnicity.

Age of Children	Gender		Race/Ethnicity
Birth to 3	Male	Female	Hispanic or Latino	AI/AN	Asian	Black or African Am.	Nat. Hawaiian. or OPI	White
Ages 4-6
Ages 7-10
Ages 11-17

18. Number of children receiving medication assisted treatment (MAT). _________

19. Number of children removed from the mother’s custody. _________

20. Number of children reunified with their mothers during treatment. _________

21. Number of children with open reunification cases for mother. _________

22. Number of children reunified with their fathers. _________

23. Number of children with open reunification cases for father. _________

24. Number of children screened for Fetal Alcohol Syndrome (FASD). _________

25. Number of children diagnosed with FASD. _________

26. Number of children served in residence who use/d tobacco. _________

Section IV: Fathers and Other Adults

Data sources used __________

Time period reported __________

27. Number of fathers and other supportive male adults who received services from the program, by racial and ethnic origin.

Supportive Male	Race/Ethnicity
	Hispanic or Latino	AI/AN	Asian	Black or African American	Nat. Hawaiian or Other Pacific Islander	White
Biological Father
Father Figure
Other Supportive Male

28. Number of other supportive female adults (e.g., grandmothers, aunts) who received services from the program, by racial and ethnic origin.

Supportive Female	Race/Ethnicity
	Hispanic or Latino	AI/AN	Asian	Black or African American	Nat. Hawaiian or Other Pacific Islander	White
Grandmother
Aunt
Sister
Other Supportive Female

29. How many fathers, father figures or other supportive male adults reported having experienced trauma? __________

How is this information collected? ________________________________________

30. How many fathers, father figures, or other supportive adults are addicted (have substance use disorders) to drugs or alcohol? __________

How is this information collected? ________________________________________

31. Number of other adults screened for Fetal Alcohol Syndrome (FASD). __________

32. Number of other adults diagnosed with Fetal Alcohol Syndrome (FASD). __________

33. Number of family members who use tobacco:

1. Biological mothers __________

2. Biological fathers __________

3. Grandparents __________

4. Father figures __________

5. Siblings __________

6. Mentors __________

7. Other supportive adults __________

Section V: Core Services and Evidence-based Practices (EBPs)

Data sources used __________

Time period reported __________

Core services include: intensive case management, child care, mental health services, substance use treatment, relapse prevention, psycho-education groups with family members to build a bridge for when the client returns, support groups for families and multi-family groups.

Evidence-based practices are services, practices, and techniques that have been tested and shown to be effective. EBPs include: celebrating families, nurturing families, seeking safety, TREM, beyond trauma, others as approved in RFA response.

Services to engage children and family members who do not live in residential center: family case management, outreach, home visits, bring children to facility to spend weekend or overnight with mother, family night activities, work with foster families who may resist reunification, family therapy over the phone, “Understanding Dads” programs to help mothers value the fathers’ roles and help fathers understand the value of co-parenting.

33. Which of the following core services were delivered by the residential services provider on-site to pregnant or postpartum women, their children, fathers of children, and other adult family members, family groups (indicate types of participants)? Please indicate which services are third party reimbursable.

Core Service	Delivered On-site (Y/N)	Third Party Reimbursable (Y/N)
Women
Intensive Case Management
Child Care
Mental Health Services
Relapse Prevention
Psycho-Education Groups
Multi-Family Groups
Support Group for Family
Trauma-Informed Care
Other – specify
Fathers, Partners, Others
Outreach
Father-initiative program
Staff Specific for Fathers
Others

33. Which of the following core services were delivered by providers in the system of care (but not the residential services provider) to pregnant or postpartum women, their children, fathers, and other adult family members? Please indicate which services are third party reimbursable.

Core Service	Delivered Off-site (Y/N)	Third Party Reimbursable (Y/N)
Women
Intensive Case Management
Child Care
Mental Health Services
Relapse Prevention
Psycho-Education Groups
Multi-Family Groups
Support Group for Family
Trauma-Informed Care
Other – specify
Fathers, Partners, Others
Outreach
Father-initiative program
Staff Specific for Fathers
Others

33. Which of the following supplemental/recovery support services were provided onsite and/or in the community? Please indicate which of the following are third party reimbursable.

Women

Service	Delivered On-site (Y/N)	Delivered in the Community (Y/N)	Third Party Reimbursable (Y/N)
Outreach, engagement, pre-treatment
Detoxification
SA education, treatment, relapse prevention
Medical, dental, other health services
Postpartum health care including medication needs
Parenting education and intervention
Home management and life skills training
HIV/AIDS, hepatitis testing, treatment, and related issues
Employment readiness; job training
GED and other education services
Peer-to-peer recovery support; mentoring, coaching
Transportation and other wrap-around services

Children

Service	Delivered On-site (Y/N)	Delivered in the Community (Y/N)	Third Party Reimbursable (Y/N)
Screening and development diagnostic assessments of infants at birth through developmental trajectories of children
Prevention assessment and interventions related to mental, emotional, and behavioral wellness
Mental health care that includes trauma-informed system assessments, interventions, and skill building services
Developmental services (e.g., child care, counseling, play and art therapy, occupational, speech, and physical therapy)
Primary and pediatric health care services including immunization, treatment of environmental effects of parental SA, or neglect
Social services, including financial supports and health care benefits
Educational and recreational services

Family, including Fathers, Partners, and Other Supportive Adults

Service	Delivered On-site (Y/N)	Delivered in the Community (Y/N)	Third Party Reimbursable (Y/N)
Family-focused programs to support family strengthening and reunification, including parenting education and interventions, and social or recreational activities
Alcohol and drug education and referral services for substance use treatment
Mental health promotion and assessment, prevention and treatment services in a trauma-informed context.
Social services, including home visiting, education, vocational, employment, financial, and health care services.

Case Management

Service	Delivered On-site (Y/N)	Delivered in the Community (Y/N)	Third Party Reimbursable (Y/N)
Coordination and integration of services and support with navigating systems of care to implement individualized and family service plans.
Assess and monitor the extent to which required services were provided and are appropriate for women, children, and family members.
Discharge planning and follow-up care for mother and children.
Assistance with community reintegration, before and after discharge, including referrals to appropriate services and resources.
Connection to safe, stable, and affordable housing that can be sustained over time.

33. Number of pregnant and postpartum women, fathers, and other adult family members who received parenting classes or instruction and number of hours provided.

Recipient of Parenting Classes	# Receiving Parenting Classes	# of Hours of Parenting Classes Received
Pregnant Mother
Postpartum Mother
Father
Other Adult Family Member
Other Supportive Adult

33. Number of pregnant and postpartum women, fathers, and other adult family members who received family therapy and number of hours of family therapy provided.

Recipient of Family Therapy	# Receiving Family Therapy	# of Hours of Family Therapy Received
Pregnant Mother
Postpartum Mother
Father
Other Adult Family Member
Other Supportive Adult

33. Number of pregnant and postpartum women, fathers, and other adult family members who received substance abuse education/treatment, and number of hours of education provided.

Recipient of Substance Abuse Education/Treatment	# Receiving SA Education/Treatment	# of Hours of SA Education/Treatment
Pregnant Mother
Postpartum Mother
Father
Other Adult Family Member
Other Supportive Adult

33. Please briefly describe efforts to incorporate trauma-informed approaches into treatment service delivery.

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

33. Number of women and other family members and supporters who received or were referred for trauma-informed care.

Recipient of Trauma-Informed Care Services	# Receiving Onsite Trauma Informed Care Services	# Receiving Referral for Trauma Informed Care Services
Pregnant Mother
Postpartum Mother
Father
Other Adult Family Member
Other Supportive Adult

Please briefly describe the type/s of interventions received.

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Evidence-Based Practices (EBPs)

41. Number of women who received the following types of evidence-based services (EBPs) and practices by pregnancy status (i.e., pregnant and postpartum):

EBPs Service	Pregnant	Postpartum
Screening
Assessment
Intervention
- Type
- Type
- Type

41. Briefly describe the EBPs that were used for each population of focus (e.g., mothers, older children, and fathers). Include any modifications the program made, the reasons for the modifications.

Population	EBP Used	Modification/s
Mothers
Children Residing in Program
Children not in Residence
Fathers
Other Supportive Adults

Please briefly describe the impact of the modifications of the EBPs on the populations of focus.

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

41. Please briefly describe how the EBPs will help address disparities in subpopulations while retaining fidelity to choose practice demographics (e.g., race, ethnicity, gender, age, sexual identity, disability)?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

41. Please briefly describe how you are defining and operationalizing family/youth/other family member involvement in the implementation of the EBPs.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Barriers Encountered Working Between Systems of Care

45. What barriers did you encounter working between systems of care (i.e., transportation, aftercare hand offs, available workforce for referrals)?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

45. How were you able to overcome these barriers?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

45. Please describe the step by step process for enrolling women into treatment after detox.
    
    

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

45. What barriers, if any, did you experience with CPS/Foster Care Systems?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

45. What strategies did you use to address the barriers experienced with CPS/Foster Care systems?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Section VI: Staffing

Data sources used __________

Time period reported __________

45. Number and types of direct staff associated with the project.

Staff Title	Total	# Hired for Project	# Located On-site
Project Manager/ Women’s Coordinator
Case Manager/ Child’s Coordinator
Family Case Manager
Transportation Coordinator
Master’s Level Clinician
Nurse Manager
Administrative Assistant
Personal Care Coordinator
Cook/House Manager
Day Care Worker

45. Labor hours and wage rates (this information will be kept confidential) for staff involved with PPW, by type of staff. See above. What is listed below is staff who are not on site.

Staff Title	Average Labor Hours per Week	Average Wage Rate
Project Manager/ Women’s Coordinator
Case Manager/ Child’s Coordinator
Family Case Manager
Transportation Coordinator
Master’s Level Clinician
Nurse Manager
Administrative Assistant
Personal Care Coordinator
Cook/House Manager
Day Care Worker
Clinical Director
Project Director
Intake Coordinator
IT Director
HR Coordinator
Finance Director/Accounting
Billing Manager

45. Number of staff who received training, by type of training and number of hours. Type of currently employed staff trained in providing each EBP.

EBPs Service	Type of Staff Trained	# of Staff Trained	# of Hours of Training
Screening
Assessment
Intervention
- Type
- Type
- Type

45. Type and number of currently employed staff who train other local staff on how to provide each EBP.

EBPs Service	Type of Staff Providing Training	# of Persons Trained	# of Hours of Training Provided
Screening
Assessment
Intervention
- Type
- Type
- Type

45. Please include the total cost of training for staff. __________

46. Please include other direct costs (e.g., rent, utilities, supplies). __________

Section VII: Process Questions

Data sources used __________

Time period reported __________

45. Please briefly discuss ways in which the program addressed the needs of your population(s) of focus, including sub-populations (e.g., race, ethnicity, federally recognized tribe, language, socioeconomic characteristics). The answer may discuss the population of focus and its relationship to your geographic catchment area and other relevant factors.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

45. Please briefly describe the primary achievements of the grant.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

45. Please briefly describe the major impediments you encountered and how each were addressed.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

45. What activities most promoted positive outcomes with women? Fathers? Other Adult Family Members?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

45. What strategies have been successful in engaging mothers and family members in services outside of the residential facility?  What were the biggest successes?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

45. What activities were used to promote collaboration with system of care grantees or other federal initiatives made the single largest impact?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

45. How is your program using data to promote service improvement?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

45. How did your program use data to promote community engagement?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

45. What additional comments do you have about the impact of your program on your community and the system of care?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

45. What factors and approaches do you think led to meaningful and relevant results (e.g., meeting target numbers, providing access to a system of care)?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

45. What other funding sources have been used for the residential treatment and ancillary services (e.g., Medicaid, State funds)? What percentage of these funds supported residential treatment and what percentage supported ancillary services?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

45. What policies most impacted reimbursement for services?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

45. How are you planning to sustain services beyond the grant? What changes to the program do you anticipate in order to maintain the program? For example, for what additional funding are you hoping to apply (e.g., State or Federal grants)? To what extent do you expect that resources such as Medicaid, health care exchanges, State funds, and private donations will assist in sustaining your programs?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

45. What other program or facilities sources have been used for treatment and ancillary services (e.g., Health Homes, Federally Qualified Health Centers, etc.)? What percentage of women received services or were treated at Health Homes or FQHCs? Note: Numbers should be unduplicated.

Services Site	Served	Percent
Health Home
FQHC