Form 1 FINAL RCORP Performance Measures_Rev

OMB Number (0906-XXXX)
Expiration date (XX/XX/202X)

Rural Communities Opioid Response Program (RCORP) Performance Measures

Instrument Information

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 0906-XXXX.  Public reporting burden for this collection of information is estimated to average 5.66 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.

Note: It is expected that each grantee organization will collect and report data bi-annually.

Measures & Definitions

SECTION 1: TARGET POPULATION DEMOGRAPHICS (applicable to all RCORP grantees providing direct services (e.g. not applicable for RCORP-Planning grantees)

Table Instructions: This table collects demographic information for all individuals who have received direct services for substance use disorder (SUD) or opioid use disorder (OUD) funded by the Rural Communities Opioid Response Program (RCORP) in the rural project service area.

Please do not leave any sections blank or use N/A (not applicable) since the measures are applicable to all RCORP grantees providing direct services. 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).

Hispanic or Latino Ethnicity

• 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.

• 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.

• Unknown: Report on only individuals who did not provide information regarding their race or ethnicity.

Race

All people must be classified in one of the racial categories (including a category for persons who are “Unknown”). 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.

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

• 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

• Native Hawaiian: Persons having origins in any of the original peoples of Hawaii

• 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

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: 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. “More than one race” must not be used as a default for Hispanics/Latinos who do not check a separate race.

A	Number of people served by ethnicity:
	Hispanic or Latino
	Not Hispanic or Latino
	Unknown
	Total (equal to the total of the number of individuals who received direct services)	(Automatically calculated by system)
B	Number of people served by race:
	American Indian or Alaska Native
	Asian
	Black or African American
	Native Hawaiian or Other Pacific Islander
	White
	More than one race
	Unknown
	Total (equal to the total of the number of individuals who received direct services)	(Automatically calculated by system)
C	Number of people served, by age group:
	Children (0-12)
	Adolescents (13-17)
	Adults (18-64)
	Elderly (65 and over)
	Unknown
	Total (equal to the total of the number of individuals who received direct services)	(Automatically calculated by system)
D	Number of people by insurance status:
	Self-pay
	None/Uninsured
	Dual Eligible (covered by both Medicaid and Medicare)
	Medicaid/CHIP only
	Medicare only
	Medicare plus supplemental
	TriCARE
	Other third party (e.g., privately insured)
	Unknown
	Total (equal to the total of the number of unique individuals who received direct services)	(Automatically calculated by system)

SECTION 2: RCORP Core Measures

Measures are applicable to Planning, Implementation, MAT-Expansion, or Centers of Excellence awardees as indicated in the far right columns. An asterisk/* means a measure is optional or reported only as applicable.

	Measure	Definition	Planning	Implementation	MAT-Expansion	Centers of Excellence
1 Core	Total population in the project’s service area	Please report the total number of individuals in your project’s service area. NOTE: This is not necessarily the number of people who availed themselves of your services but the number of people in the project’s service area.	P	I	M	C
2 Core	Number of individuals screened for SUD in the project’s service area	Please report the total number of individuals in your project’s service area who have been screened for substance use disorder (SUD), including OUD, by a health care provider in the past 6-months. Include screenings using evidence-based screening tools such as the CAGE, MAST, DAST, or screening methods such as SBIRT: Screening Brief Intervention, and Referral to Treatment or provider-developed screening questions.		I	M	C
3 Core	Number of non-fatal opioid overdoses in the project’s service area	Please report the total number of non-fatal overdoses from opioid poisoning in your project’s service area in the past 6-months. Include all types (e.g., accidental, intentional, undetermined).	P	I	M	C
4 Core	Number of fatal opioid overdoses in the project’s service area	Please report the total number of fatal overdoses from opioid poisoning in your project’s service area in the past 6-months. Include cases where opioids are the underlying or contributing cause of death and include all types (e.g., accidental, intentional, undetermined).	P	I	M	C
5 Core	Number of healthcare providers within the project’s service area who have a DATA waiver	Please report the total number of healthcare providers within the service area who have a Data Treatment Act 2000 (DATA) waiver to prescribe buprenorphine-containing products for medication assisted treatment (MAT). Additionally, please report the total number of health care providers within your consortium who have a DATA Waiver. Please specify by provider type: Physicians (MD/DOs, including internal medicine, family medicine, pediatrics, and other specialties) Psychiatrists (i.e. physician in the specialty of psychiatry) Physician Assistants Nurse practitioners Clinical nurse specialists Certified nurse-midwives Certified registered nurse anesthetists	P	I	M	C

SECTION 3: RCORP Program-Specific Activity Measures

Program-Specific Activity Measures are applicable to Planning, Implementation, MAT-Expansion, or Centers of Excellence awardees as indicated in the table in the far right columns. An asterisk/* means a measure is optional or reported if/as applicable.

	Measure	Definition	P	I	MAT	CoE
6	Identify the types and number of organizations in the consortium	Please report the types and number of member organizations in your consortium: Health care providers: ____ Critical access hospitals or other hospitals ____ Emergency medical services entities ____ Federally qualified health centers (FQHCs) ____ FQHC Look-alikes ____ Local or state health departments ____ Mental and behavioral health organizations, practices, and providers ____ Methadone Center ____ Opioid treatment programs (OTPs) ____ Primary care practices and providers ____ Rural health clinics ____ Ryan White HIV/AIDS clinics ____ Sole community hospitals ____ Substance abuse treatment providers ____Other medical agencies and organizations (Please specify) Other organizations: ____ Community-based organizations ____ Cooperative extension system offices ____ Criminal justice (e.g., probation and parole) ____ Faith-based organizations ____ Healthy Start sites ____ HIV and HCV prevention organizations ____ Law enforcement ____ Maternal, infant, and Early Childhood Home Visiting Program local implementation agencies ____ Poison control centers ____ Primary Care Associations ____ Primary Care Organizations ____ Prisons ____ School systems ____ Single state agencies (SSAs) ____ State Offices of Rural Health (SORHs) ____ Tribes/Tribal Organizations ____ Other social service and non-medical agencies and organizations (Please specify)	P	I	M	C
7	Define your service area	Please select the option that best describes your project’s service area: multiple states, state, multiple counties, single county, partial county (census tract(s) within counties). Identify the State(s) included in the project service area	P	I	M
8	Indicate the total number of consortium meetings conducted in the past 6-months	Please report the total number of consortium meetings conducted in the past 6-months in which the majority of consortium members (>75%) participated. NOTE: Meeting types may include: face-to-face, via teleconference, or via webinar. Consortium members are those that signed MOU, MOA, or letters of commitment.	P	I
9	Please check any/all activities included in your program	Please indicate the types of activities included in your program during the past 6-months as a result of RCORP funding: Creating subcommittees DATA Waiver/MAT trainings Hosting town halls, focus groups (or other community education/outreach) Naloxone training/distribution Overdose reversal reporting Provider usage of Prescription Drug Monitoring Program (PDMP) data Telehealth Training on prescribing guidelines Other (please specify)	P
10	Will the consortium continue to operate after the Federal grant funding period?	Please indicate if the consortium and/or activities of the consortium will continue to operate after the Federal grant period of performance by choosing one of the options below: Yes, the consortium and/or activities of the consortium are expected to operate after the period of performance. No, the consortium is not expected to continue after the period of performance.	P
11	Select funding sources for sustainability	Please indicate the type(s) of sources of funding for sustainability using the following categories (please check all that apply) and amount for each, if applicable: Contractual Services Fees charged to individuals for services Foundations Fundraising/ Monetary donations In-kind contributions (defined as donations of anything other than money, including goods or services/time.) Membership Fees/Dues None Other Federal grants (non-HRSA) Other HRSA grants (non-RCORP) Program Revenue RCORP MAT-Expansion RCORP-Implementation Reimbursement from third-party payers (e.g. private insurance, Medicare, Medicaid) State grants Other – specify type	P	I

12	Number of patients with a positive screen for alcohol or substance use	Please report the total number of patients who screened positive for alcohol, opioid, or other substance overuse/misuse, or at risk for overuse/misuse, in the past 6-months. Including: Number of patients who screened positive for alcohol overuse/misuse (or at risk of this) Number of patients who screened positive for opioid overuse/misuse (or at risk of this) Number of patients who screened positive for other substance overuse/misuse (or at risk of this)		I	M	C
13	Number of patients diagnosed with SUD	Please provide the total number of patients diagnosed with substance use disorder in the past 6-months. Including: Number of patients diagnosed with alcohol use disorder Number of patients diagnosed with opioid use disorder (OUD) Number of patients diagnosed with other substance use disorders (SUD)		I	M	C
14	Number of patients with a diagnosis of SUD who were also screened for depression	Please report the total number of patients diagnosed with substance use disorder who were also screened for clinical depression/substance-induced mental disorders using an age appropriate standardized tool such as the Patient Health Questionnaire 9 (PHQ-9) during the past 6-months.		I	M
15	Number of patients with a diagnosis of SUD who were tested for HIV/AIDS and HCV	Please report the total number of patients with a diagnosis of substance use disorder who were also tested for HIV/AIDS and Hepatitis C Virus (HCV) during the past 6-months.		I		C
16	Number of patients with a diagnosis of SUD who were referred to treatment	Please report the total number of patients with a diagnosis of substance use disorder (SUD) were also referred for SUD treatment during the past 6-months.		I	M	C
17	Number of unduplicated patients who have received MAT	Please report the total number of unduplicated patients who have received medication assisted treatment within the past 6-months: Number of unduplicated patients who received MAT (including both medication AND psychosocial therapy) in the past 6-months. Number of unduplicated patients who received MAT (medication ONLY) in the past 6-months.		I	M	C
18	Number of unduplicated patients who have received MAT for 3 months or more without interruption	Please report the total number of unduplicated patients who have received MAT (including both medication AND psychosocial therapy) for a period of 3 months or more without interruption in the past 6 months.		I	M	C
19	Number of eligible providers without a DATA waiver	Please report the total number and full-time equivalent (FTE) of providers within your consortium who are eligible for the Data Treatment Act 2000 (DATA) waiver but have not yet completed the necessary training to receive a waiver. Please specify by provider type: Physicians (MD/DOs, including internal medicine, family medicine, pediatrics, and other specialties) Psychiatrists (i.e. physician in the specialty of psychiatry) Physician assistants Nurse practitioners Clinical nurse specialists Certified nurse-midwives Certified registered nurse anesthetists Other (Please specify) NOTE: This is the full list of provider types eligible to receive the DATA waiver at this time. If policy changes, we may use this response option to gather additional eligible providers.		I	M	C
20	Number of providers who have provided MAT	Please report the total number and full-time equivalent (FTE) of providers within your consortium who have prescribed medications that are used to treat OUD in the past 6-months, by provider type. These medications can include Buprenorphine, Suboxone, Methadone, Naltrexone (extended-release injectable), Naltrexone (oral). Physicians (MD/DOs, including internal medicine, family medicine, pediatrics, and other specialties) Psychiatrists (i.e. physician in the specialty of psychiatry) Physician assistants Nurse practitioners Clinical nurse specialists Certified nurse-midwives Certified nurse anesthetists Other		I	M	C
21	Number of providers, paraprofessionals, and community members (non-providers) who received general SUD education or training	Please report the total number of providers, paraprofessional staff, and community members (non-providers) who participated in direct substance use disorder education or training activities within the past 6-months as a result of RCORP funding. For each topic area, please provide the number of participants in each category: Providers, paraprofessional staff (e.g. peer support staff, care managers, care navigators, other recovery support staff) and community members (neither providers nor paraprofessional staff). Mental health first aid Naloxone training Prescribing guidelines Stigma reduction Other (specify) NOTE: In PIMS, there will be 3 boxes per training/educational activity – one to report the number of providers, one for paraprofessionals/support staff, and another to report the number of community members (non-providers) who attended the training.	P	I	M	C
22	Number of patients with a diagnosis of SUD who were referred to support services	Please report the total number of patients with a diagnosis of SUD who were referred to support services within the past 6-months, by type of service: Childcare Employment services Prenatal/postpartum care services Recovery housing Transportation to treatment Other (please specify)		I	M	C
23	Number of FTE currently providing SUD/OUD treatment services	Please report the total number of full time equivalent (FTE) providers within your consortium currently implementing SUD/OUD services, including MAT, in support of the RCORP project either directly or through contract(s). Please specify by provider type: Physicians (MD/DOs, including internal medicine, family medicine, pediatrics, and other specialties) Psychiatrists (i.e. physician in the specialty of psychiatry) Clinical psychologists Counseling psychologists Licensed professional counselors Licensed clinical social workers Nurse practitioners Clinical nurse specialist Psychiatric nurse specialists Marriage and family therapists SUD counselors Registered nurses Certified nurse-midwives Certified registered nurse anesthetists Pharmacists Physician assistants Peer support specialists Other (please specify)		I	M
24	Percentage of MAT services currently covered through reimbursement or other non-grant funding sources	Please report the percentage of MAT services (including medication, psychosocial therapy, and wrap-around services) currently covered through reimbursement or other non-grant funding sources at the application organization: Numerator: all costs associated with medication assisted treatment services currently reimbursed through non-federal funding sources (e.g. by Medicaid, Medicare, private insurance, or other non-federal funding). Denominator: all costs associated with medication assisted treatment services NOTE: RCORP-MAT Expansion funds should not be included in the numerator of reimbursed costs, only in the denominator of all costs associated with medication assisted treatment services.			M
25	Incidence of NAS-related births in the project’s service area	OPTIONAL MEASURE: Please report the total number of infants born with Neonatal Abstinence Syndrome(NAS)/Neonatal Opioid Withdrawal (NOW) Syndrome-related symptoms in the project service area in the past 6-months		*	*

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