Form 28 FY2018 Expanding Access to Quality SUD-MH IBHS Progress

The Health Center Program Application Forms

FY2018 Expanding Access to Quality SUD-MH IBHS Progress Reporting

FY 2018 Expanding Access to Quality SUD-MH/IBHS Progress Reporting

OMB: 0915-0285

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FY2018 Expanding Access to Quality Substance Use Disorder and

Mental Health Services (SUD-MH)/Integrated Behavioral Health Services (IBHS) Progress Reporting


OMB No.: 0915-0285. Expiration Date: XX/XX/20XX

  1. SUD-MH/IBHS Staffing Positions by Major Service Category

Enter the number of FTEs hired or contracted by your health center to expand access to SUD and/or MH services from 9/1/2018 to the end of the current reporting period. Report only the ongoing FTEs supported by SUD-MH supplemental funding. For example, if you hired a 1.0 FTE clinical social worker and increased a .5 FTE case manager to full time using SUD-MH funding, you would report 1.0 FTE under clinical social worker and .5 FTE under Case Manager.

Behavioral Health (SUD and MH)

Hired

Contracted

Psychiatrists



Licensed Clinical Psychologists



Licensed Clinical Social Workers



Other Licensed Mental Health Provider (e.g., psychiatric social workers, psychiatric nurse practitioners, family therapists)



Other Mental Health Staff (e.g., unlicensed individuals, including “certified” individuals, who provide counseling, treatment, or support to mental health providers)



Substance Use Disorder Providers



Physicians

Hired

Contracted

Family Physicians



General Practitioners



Internist



Obstetrician/Gynecologist



Pediatricians



Other Specialty Physicians and Sub-Specialists (e.g., Emergency Medicine, Addiction Medicine, Pain Medicine, Infectious Disease)



Nurse Practitioners, Physician Assistants, and Certified Nurse Midwives

Hired

Contracted

Nurse Practitioners



Physician Assistants



Certified Nurse Midwives



Medical

Hired

Contracted

Nurses



Other Medical Personnel (e.g. medical assistants, nurse aides)



Laboratory Personnel



Pharmacy

Hired

Contracted

Pharmacy Personnel



Enabling Services

Hired

Contracted

Case Managers



Patient/Community Education Specialists



Outreach Workers



Transportation Staff



Eligibility Assistance Workers



Interpretation Staff



Community Health Workers



Other Enabling Services Staff (e.g., staff who support outreach, care coordination, transportation)



Professional Services

Hired

Contracted

Other Professional Health Services Staff (e.g., physical therapists, occupational therapists, acupuncturists)



SUBTOTAL



TOTAL (Hired and Contracted)



  1. Substance Use Disorder (SUD) Services

Enter total patients and visits from 9/1/2018 to the end of the current reporting period. Report all patients and visits, regardless of funding source (do not limit responses to activities supported by SUD-MH funding).

2a.

Number of unduplicated patients receiving SUD services.



2b.

Number of visits of patients receiving SUD services.



  1. Mental Health (MH) Services

Enter total patients and visits from 9/1/2018 to the end of the current reporting period. Report all patients and visits, regardless of funding source (do not limit responses to activities supported by SUD-MH funding).

3a.

Number of unduplicated patients receiving MH services.



3b.

Number of visits of patients receiving MH services.



3c.

Number of unduplicated patients who are receiving Screening, Brief Intervention, and Referral to Treatment (SBIRT) services.



3d.

Number of visits for SBIRT services.



3e.

Number of patients aged 12 years and older who were screened for depression with a follow-up plan documented on the date of the positive screen.




  1. Opioid Use Disorder (OUD) Services

Enter total patients and providers from 9/1/2018 to the end of the current reporting period. Report all patients and providers, regardless of funding source (do not limit responses to activities supported by SUD-MH funding). Enter only numbers.

4a.

Number of patients who are receiving MAT for opioid use disorder (OUD) from a physician, certified nurse practitioner, or physician assistant with a Drug Addiction Treatment Act of 2000 (DATA) waiver working on behalf of the heath center.


4b.

Number of providers who have obtained DATA waiver for OUD medication-assisted treatment.



  1. Telehealth

Respond below regarding your use of telehealth to provide SUD and/o MH services. Report on all telehealth services, regardless of funding source (do not limit responses to activities supported by SUD-MH funding. Enter Yes or No.

5a.

Are you using telehealth to provide SUD services?


5b.

Are you using telehealth to provide MH services?



6.    Issues and Barriers

What new or ongoing issues/barriers have you encountered in implementing the activities supported with the SUD-MH supplemental funding over the past four months?










Required field; Minimum 500 characters up to 2500 characters (1 page)

7.    Successes and Lessons Learned

What new or ongoing success and/or lessons learned have you experienced in implementing the activities supported with the SUD-MH supplemental funding over the past four months?










Required field; Minimum 500 characters up to 2500 characters (1 page)


Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) deliver comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. The Health Center Program application forms provide essential information to HRSA staff and objective review committee panels for application evaluation; funding recommendation and approval; designation; and monitoring. The OMB control number for this information collection is 0915-0285 and it is valid until XX/XX/XXXX. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). Public reporting burden for this collection of information is estimated to average 1 hour 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 14N136B, Rockville, Maryland, 20857 or [email protected].


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorPena, Maria-Thelma (HRSA)
File Modified0000-00-00
File Created2021-01-14

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