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

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

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)
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.
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.
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.
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].