Form 1 RHOP draft PIMS

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 XXXX-XXXX.  Public reporting burden for this collection of information is estimated to average X hours per response, including the time for reviewing instructions, searching existing data sources, 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 HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857.

Federal Office of Rural Health Policy: Rural Health Opioid Program

Community-Based Division Grant Programs

Performance Improvement and Measurement System (PIMS) Database

Section 1: TARGET Population Demographics (applicable to all grantees)

Table Instructions: This table collects demographic information for all individuals within the target population by race, ethnicity, age and insurance status. Please see the definition of “target population” below. The total for each of the following questions should equal the total of the number of individuals in the target population. Please do not leave any sections blank. There should not be a N/A (not applicable) response since the measures are applicable to all grantees. If the number for a particular category is zero (0), please put zero in the appropriate section (e.g., if the total number that is Hispanic or Latino is zero (0), enter zero in that section).

“Opioid Use Disorder” (OUD) is defined as a problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

1. Opioids are often taken in larger amounts or over a longer period than was intended.

2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use.

3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.

4. Craving, or a strong desire or urge to use opioids.

5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.

6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.

7. Important social, occupational, or recreational activities are given up or reduced because of opioid use.

8. Recurrent opioid use in situations in which it is physically hazardous.

9. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

10. Tolerance, as defined by either of the following:

    1. A need for markedly increased amounts of opioids to achieve intoxication or desired effect.

    2. A markedly diminished effect with continued use of the same amount of an opioid.

Note: This criterion is not considered to be met for those taking opioids solely under appropriate medical supervision.

11. Withdrawal, as manifested by either of the following:

    1. The characteristic opioid withdrawal syndrome (refer to Criteria A and B of the criteria set for opioid withdrawal).

    2. Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms.¹

“Target Population” is defined as all individuals identified as having OUD who are residents of and/or who receive direct services in the approved service area. Individuals who were previously identified as having OUD who are now in treatment and recovery are also to be considered members of the target population.

Note: It is expected that each grantee organization will collect baseline data, and then again report at the end of the budget period. If this target population was not identified before the beginning of the project period, then the number for all categories can be zero (0) for baseline data.

Hispanic or Latino Ethnicity

• Column A (Hispanic/Latino): Report the number of persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, broken down by their racial identification and including those Hispanics/Latinos born in the United States. Do not count persons from Portugal, Brazil, or Haiti whose ethnicity is not tied to the Spanish language.

• Column B (Non-Hispanic/Latino): Report the number of all other people except those for whom there are neither racial nor Hispanic/Latino ethnicity data. If a person has chosen a race (described below) but has not made a selection for the Hispanic /non-Hispanic question, the patient is presumed to be non-Hispanic/Latino.

• Column C (Unreported/Refused to Report): Only one cell is available in this column. Report on Line 7, Column C only those patients who left the entire race and Hispanic/Latino ethnicity part of the intake form blank.

People who self-report as Hispanic/Latino but do not separately select a race must be reported on Line 7, Column A as Hispanic/Latino whose race is unreported or refused to report. Health centers may not default these people to “White,” “Native American,” “more than one race,” or any other category.

Race

All people must be classified in one of the racial categories (including a category for persons who are “Unreported/Refused to Report”). This includes individuals who also consider themselves to be Hispanic or Latino. People who self-report race, but do not separately indicate if they are Hispanic or Latino, are presumed to be non-Hispanic/Latino and are to be reported on the appropriate race line in Column B.

People sometimes categorized as “Asian/Other Pacific Islander” in other systems are divided into three separate categories:

• Line 1, Asian: Persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Indonesia, Thailand, or Vietnam

• Line 2a, Native Hawaiian: Persons having origins in any of the original peoples of Hawaii

• Line 2b, Other Pacific Islander: Persons having origins in any of the original peoples of Guam, Samoa, Tonga, Palau, Truk, Yap, Saipan, Kosrae, Ebeye, Pohnpei or other Pacific Islands in Micronesia, Melanesia, or Polynesia

• Line 2, Total Native Hawaiian/Other Pacific Islander: Must equal lines 2a+2b

American Indian/Alaska Native (Line 4): Persons who trace their origins to any of the original peoples of North and South America (including Central America) and who maintain Tribal affiliation or community attachment.

More than one race (Line 6): “More than one race” should not appear as a selection option on your intake form. Use this line only if your system captures multiple races (but not a race and an ethnicity) and the person has chosen two or more races. This is usually done with an intake form that lists the races and tells the person to “check one or more” or “check all that apply.” “More than one race” must not be used as a default for Hispanics/Latinos who do not check a separate race. They are to be reported on Line 7 (Unreported/Refused to Report), as noted above.

1	Line	Number of People in Target Population by Race	Hispanic/Latino (a)		Non-Hispanic/Latino (b)	Unreported/ Refused to Report Ethnicity (c)	Total (d)
	1	Asian
	2a.	Native Hawaiian
	2b.	Other Pacific Islander
	2.	Total Native Hawaiian/Other Pacific Islander (automatically calculated)
	3.	Black/African American
	4.	American Indian/ Alaska Native
	5.	White
	6.	More than one race
	7.	Unreported/Refused to report race
	8.	Total of individuals served (automatically calculated)					Equal to the total of the number of individuals in the target population
2	Line	Number of People in Target Population by Age		Baseline			End of Budget Period
	1.	Children (0-12)
	2.	Adolescents (13-17)
	3.	Adults (18-64)
	4.	Elderly (65 and over)
	5.	Unknown
	6.	Total (automatically calculated)		Equal to the total of the number of individuals in the target population			Equal to the total of the number of individuals in the target population
3	Line	Number of People in Target Population by Insurance Status		Baseline			End of Budget Period
	1.	None/Uninsured
	2.	Dual Eligible (covered by both Medicaid and Medicare)
	3.	Medicaid/CHIP only
	4.	Medicare plus supplemental
	5.	Medicare only
	6.	Other third party
	7.	Unknown
	8.	Total (automatically calculated)		Equal to the total of the number of individuals in the target population			Equal to the total of the number of individuals in the target population

Section 2: Care Coordination (applicable to all grantees)

Table Instructions: This table collects information about an aggregate count of the people identified as having OUD, who were educated on locally available treatment options and support services, as well as an aggregate count of those identified as having OUD, who were also referred to a treatment provider. The total for each of the following questions should equal the total of the number of unique individuals who received only direct services reported in the previous section. Please do not leave any sections blank. There should not be a N/A (not applicable) response since the measures are applicable to all grantees. If the number for a particular category is zero (0), please put zero in the appropriate section.

A “treatment provider” is defined as any health care provider that has been trained and certified in the treatment of opioid use disorder, such as any health care provider that has been trained and certified to prescribe buprenorphine or methadone.

		End of Budget Period
4	Number of individuals screened for OUD
5	Number of individuals, who, after being screened for OUD, were identified as having OUD
6	Number of individuals with OUD who were referred by one provider to another provider for the treatment of OUD
7	Number of individuals with OUD, who, after receiving an initial consultation with a treatment provider, started the treatment process
8	Which of the following care coordination mechanisms/activities have you implemented during this budget year? Select all that apply.*
	Facilitate transitions across settings
	Linkage to community resources
	Patient support and engagement
	Case management
	Create care plans
	Medication management
	Other – specify
	Not applicable

*In the Comment Box, please describe the care coordination mechanisms/activities you implemented during this budget year.

Section 3: Treatment and recovery (applicable to all grantees)

Table Instructions: This table collects information about an aggregate count of the people who have been in treatment/recovery for period of 0-2 months, 3-5 months, 6-12 months and more than one year. This table also collects information about an aggregate count of the people in treatment and recovery who attended 3 or more behavioral counselling sessions in addition to an aggregate count of the people in treatment and recovery who attended 3 or more recovery support activities. The sum of the numbers entered in lines 9 through 14 should equal the number of individuals in the target population as entered in Measure 1 Line 8, Measure 2 Line 6, and Measure 3 Line 8. Please do not leave any sections blank. If a specific measure is not applicable to your project or if accurate data is unavailable, please enter N/A (not applicable). If the number for a particular category is zero (0), please put zero in the appropriate section.

“Without interruption” is defined as a recovery process free of extended periods of relapse, where an individual stops the treatment process agreed upon by themselves and their healthcare provider.

Behavioral counselling sessions are clinical services, either individual or group, that focus on reducing or stopping substance use, skill building, adherence to a recovery plan, and/or social, family, and professional/educational outcomes. Specific forms of behavioral counselling are, but not limited to, cognitive-behavioral therapy, contingency management, motivational enhancement therapy and 12-step facilitation therapy.

Recovery support activities are non-clinical services that are used with treatment to support individuals in their recovery goals. These services are often provided by peers, or others who are already in recovery. Recovery support can include: transportation to and from treatment and recovery-oriented activities, employment or educational supports, specialized living situations, peer-to-peer services, mentoring and coaching, spiritual and faith-based support, parenting education, self-help and support groups, outreach and engagement, staffing drop in centers, clubhouses, respite/crisis services or warm-lines (peer-run listening lines staffed by people in recovery themselves), and education about strategies to promote wellness and recovery.²

		End of Budget Period
9	Number of people in the target population who have been in treatment for 0-2 months without interruption
10	Number of people in the target population who have been in treatment for 3-5 months without interruption
11	Number of people in the target population who have been in treatment for 6-12 months without interruption
12	Number of people in the target population who have been in treatment for more than a year without interruption
13	Number of people in the target population who have not started treatment
14	Number of people in the target population who, upon starting treatment, discontinued the treatment process
15	Number of people in recovery who participated in 3 or more behavioral counselling sessions that were created and/or enhanced during the budget period*
16	Number of people in recovery who participated in 3 or more recovery support activities that were created and/or enhanced during the budget period*

*In the Comment Box, please describe the behavioral counselling and recovery support activities that were created and/or enhanced during the budget period.

Section 4: education and training (applicable to all grantees)

Table Instructions (Measure 17): This table collects information about a count, by age, of the people within the community, who received direct education about the opioid epidemic in an effort to reduce stigma within the community. The total should equal the total of the number of unique individuals who received education. Please do not leave any sections blank. There should not be a N/A (not applicable) response since the measures are applicable to all grantees. If the number for a particular category is zero (0), please put zero in the appropriate section.

“Direct Education” is defined as any method of education that is delivered in-person or via a technological platform in real time. Examples of direct education include classroom-based learning, town hall presentations, individual and group consultations, webinars (live and recorded) and online modules.

Education on the opioid epidemic to reduce stigma within the community may include, but is not limited to, the following topics:

• OUD and addiction as a medical condition

• Methods for treatment of OUD/Locally available treatment options

• Methods for preparing individuals with OUD for treatment

• Methods for referring individuals with OUD to treatment

• Methods for supporting individuals in recovery

• Opioid use prevention

		End of Budget Period
17	Number of community members who received education directly*
	Children (0-12)
	Adolescents (13-17)
	Adults (18-64)
	Elderly (65 and over)
	Unknown
	Total (automatically calculated)	Equal to the total of the number of unique individuals who received education directly

*In the Comment Box, please describe the form(s) of direct education.

Table Instructions (Measure 18): This table collects information about a count of the people within the community, who received indirect education about the opioid epidemic in an effort to reduce stigma within the community. If an accurate number cannot be identified, you may estimate the number of individuals who received indirect education. In the comment box, describe the methods by which people received education indirectly as well as how you determined or estimated the total number of individuals who received education indirectly. Please do not leave any sections blank. There should not be a N/A (not applicable) response since the measures are applicable to all grantees. If the number for a particular category is zero (0), please put zero in the appropriate section.

“Indirect Education” is defined as any method of education that is not delivered in-person or via a technological platform in real time. Examples of indirect education include billboards, flyers, health fairs, mailings/newsletters, and other mass media. Webinars (live and recorded) and online modules are considered direct education and should be reported in the previous section.

		End of Budget Period
18	Number of community members who received education indirectly

*In the Comment Box, please describe the form(s) of indirect education.

Table Instructions (Measure 19): This table collects information about the number of health care providers, by type, that completed the required training and have been waivered to prescribe buprenorphine for the treatment of OUD. The total should equal the number of unique healthcare providers who completed the necessary training and received a waiver. Information about acceptable training programs and requirements to obtain a waiver are below. Please do not leave any sections blank. There should not be a N/A (not applicable) response since the measures are applicable to all grantees. If the number for a particular category is zero (0), please put zero in the appropriate section.

Necessary training required to apply for a Drug Addiction Treatment Act of 2000 (DATA) waiver to prescribe buprenorphine for the treatment of OUD is defined as training, of no fewer than 8 hours for qualifying physicians and no fewer than 24 hours for qualifying nurse practitioners and physician assistants, provided by one of the following organizations: The American Society of Addiction Medicine, American Academy of Addiction Psychiatry, American Medical Association, American Osteopathic Association, American Nurses Credentialing Center, American Psychiatric Association, American³ Association of Nurse Practitioners, American Academy of Physician Assistants, or any other organization that the Secretary of Health and Human Services determines is appropriate.

The Substance Abuse and Mental Health Services Administration (SAMHSA) provides additional information on the process of obtaining a DATA waiver: https://www.samhsa.gov/medication-assisted-treatment/buprenorphine-waiver-management/apply-for-physician-waiver

		Baseline	End of Budget Period
19	Number of healthcare providers within the service area who have completed the necessary training and received a waiver to prescribe buprenorphine*
	Physician
	Physician Assistant
	Nurse Practitioner
	Total (automatically calculated)

*In the Comment Box, please identify the training platform(s) utilized by healthcare providers to complete the necessary training to receive their DATA waiver.

Section 5: Impact (applicable to all grantees)

Table Instructions: This table collects information about the number of non-fatal and fatal overdoses that are attributed to opioids within the project’s service area. Please do not leave any sections blank. There should not be a N/A (not applicable) response since the measures are applicable to all grantees. If the number for a particular category is zero (0), please put zero in the appropriate section.

		Baseline	End of Budget Period
20	Number of non-fatal opioid overdoses in the project’s service area
21	Number of fatal opioid overdoses in the project’s service area

1 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association. All Rights Reserved.

2 https://www.samhsa.gov/treatment/substance-use-disorders

3 https://www.samhsa.gov/medication-assisted-treatment/qualify-nps-pas-waivers

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