Form 6 NHSC Behavioral Health Checklist

Bureau of Health Workforce

U.S. Department of Health and Human Services Health Resources and Services Administration

NHSC COMPREHENSIVE BEHAVIORAL HEALTH SERVICES CHECKLIST

Attach all signed affiliation agreements for any service elements not provided onsite.

**Only NHSC Site Administrators are permitted to submit certification documents**

Name of Site

Address

Section I. Core Comprehensive Behavioral Health Service Elements The following three sets of services must be provided onsite; these services cannot be offered through affiliation.	Provided Onsite (Select One) Yes No
Screening and Assessment: Screening is the practice of determining the presence of risk factors, early behaviors, and biomarkers which enables early identification of behavioral health disorders (e.g., warning signs for suicide, substance abuse, depression) and early access to care. Assessment is a structured clinical examination that analyzes patient bio-psych-social information to evaluate a behavioral health complaint.
Treatment Plan: A formalized, written document that details a patient's current clinical symptoms, diagnosis, and outlines the therapeutic strategies and goals that will assist the patient in reducing clinical symptoms and overcoming his or her behavioral health issues. The plan also identifies, where indicated, clinical care needs and treatment(s) to be provided by affiliated health and behavioral health care providers and settings.
Care Coordination: Care Coordination is the practice of navigating and integrating the efforts primary care, specialty health care and social service providers to support a patient’s health, wellness and independence.

Section II. Additional Comprehensive Behavioral Health Service Elements

The following four sets of services may be provided onsite or through formal affiliation. Signed affiliation agreements must be uploaded to the BHW Program Portal for any services not provided onsite.

Provided Onsite

(Select One)

Yes No

1. Diagnosis: The practice of determining a patient’s emotional, socio-emotional, behavioral or mental symptoms as a diagnosable disorder in accordance with the Diagnostic and Statistical Manual of Mental Disorders (DSM; most current edition) and International Classification of Disease (ICD; most current edition).

2. Therapeutic Services(including, but not limited to, psychiatric medication prescribing and management, chronic disease management, and Substance Use Disorder Treatment): Broad range of evidence-based or promising behavioral health practice(s) with the primary goal of reducing or ameliorating behavioral health symptoms, improve functioning, and restore/maintain a patient’s health (e.g., individual, family, and group psychotherapy/ counseling; psychopharmacology; and short/long-term hospitalization).

1. Psychiatric Medication Prescribing and Management

2. Substance Use Disorder Treatment

3. Short/long-term hospitalization

Other (Please list) _________________________________________________
Other (Please list)___________________________________________________

3. Crisis/Emergency Services (including, but not limited to, 24-hour crisis call access): The method(s) used to offer immediate, short-term help to individuals who experience an event that produces emotional, mental, physical, and behavioral distress or problems. In some instances, a crisis may constitute an imminent threat or danger to self, to others, or grave disability. (Note: generic hotline, hospital emergency room referral, or 911 is not sufficient).

4. Consultative Services: The practice of collaborating with health care and other social service providers (e.g., education, child welfare, and housing) to identify the biological, psychological, medical and social causes of behavioral health distress, to determine treatment approach(s), and to improve patient functioning.

5. Case Management: The practice of assisting and supporting patients in developing their skills to gain access to needed health care, housing, employment, social, educational and other services essential to meeting basic human needs and consistent with their health care treatment, symptom management, recovery and independent functioning.

Section III. Affiliation Agreements for Off-Site Behavioral Health Services For each of the services under Section II that are provided off-site, a formal affiliation agreement(s) must be uploaded to the BHW Program Portal. Under this section, the NHSC-approved site must provide basic information for each entity with which a formal affiliation is in place.
Affiliated Entity: Address: Services Covered Under Affiliation: Date Affiliation Agreement Executed: Services available under this agreement are offered to all without regard for the ability to pay? Yes □ No □	Affiliated Entity: Address: Services Covered Under Affiliation: Date Affiliation Agreement Executed: Services available under this agreement are offered to all without regard for the ability to pay? Yes □ No □
Affiliated Entity: Address: Services Covered Under Affiliation: Date Affiliation Agreement Executed: Services available under this agreement are offered to all without regard for the ability to pay? Yes □ No □	Affiliated Entity: Address: Services Covered Under Affiliation: Date Affiliation Agreement Executed: Services available under this agreement are offered to all without regard for the ability to pay? Yes □ No □

Section IV. Certification of Compliance with Behavioral Health Clinical Practice Requirements Certify that the behavioral health site adheres to the clinical practice requirements for behavioral health providers under the NHSC and supports NHSC participants in meeting their obligation related to the clinical practice requirements.	Site Meets Criteria (Select One) Yes No
Fulltime: The site offers employment opportunities that adhere to the NHSC definition of full-time clinical practice. Full-time clinical practice for behavioral health providers means a minimum of 40 hours/week, for a minimum of 45 weeks/service year. At least 32 hours/week are spent providing patient care at the approved service site(s). Of the minimum 32 hours spent providing patient care, no more than 8 hours/week may be spent in a teaching capacity. The remaining 8 hours/week are spent providing patient care at the approved site(s), providing patient care in alternative settings (e.g., hospitals, nursing homes, shelters) as directed by the approved site(s), and as an extension of care at the approved site, or performing clinical-related administrative activities.
Half-time: The site offers employment opportunities that adhere to the NHSC definition of half-time clinical practice. Half-time clinical practice for behavioral health providers means a minimum of 20 hours/week, for a minimum of 45 weeks/service year. At least 16 hours/week are spent providing patient care at the approved service site(s). Of the minimum 16 hours spent providing patient care, no more than 4 hours/week may be spent in a teaching capacity. The remaining 4 hours/week are spent providing patient care at the approved site(s), providing patient care in alternative settings (e.g., hospitals, nursing homes, shelters) as directed by the approved site(s), and as an extension of care at the approved site, or performing clinical-related administrative activities.

Section V. Site Certification:

By signing below, the NHSC Site Administrator is affirming the truthfulness and accuracy of the information in this document.

I, _______________________________, hereby certify that the information provided above, and all supporting information, is true and accurate. I understand that this information is subject to verification by the NHSC.

Signature Date

OFFICIAL NHSC USE ONLY
Recommended By:	Certified	Not Certified
Comments: