Form SPF-RX

Division of State Programs-Management Reporting Tool (DSP- MRT)

SPF Rx Unique Items DSP-MRT Supplement

OMB No: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Contents

Administration 1

Grantee Information 1

Sub-State Information 1

Subrecipients 1

High-Need Communities 1

Needs Assessment 2

Needs Assessment 2

Accomplishments and Barriers/Challenges 2

Capacity 3

Membership 3

Advisory Council and Other Workgroup Meetings 3

Other Opioid-Specific Workgroup Activities 3

Grantee Funding Resources 4

Other Resources 4

Policies, Regulations, and Laws 4

Data Infrastructure 5

Training and Technical Assistance (TA) 6

Accomplishments and Barriers/Challenges 7

Planning 8

Strategic Plan 8

Accomplishments and Barriers/Challenges 8

Behavioral Health Disparities 9

Disparities Impact Statement (DIS) 9

Population(s) Experiencing the Disparity 9

Focus and Data Gaps 9

Access to Prevention Efforts 9

Use and Reach of Prevention Efforts 9

Outcomes of Prevention Efforts 9

Accomplishments and Barriers/Challenges 9

Implementation 10

Community-Based Social Marketing/Public Education Plan 10

Subrecipient Progress 10

Promising Approaches and Innovations 10

Use of Federal Toolkits/Guidelines 10

Accomplishments and Barriers/Challenges 11

Evaluation 12

Evaluation Plan 12

Evaluation Report 12

Other Document 12

Accomplishments and Barriers/Challenges 12

Sustainability 13

Accomplishments and Barriers/Challenges 13

Note: This document is intended as a supplement to the Division of State Programs- Management Reporting Tool (DSP-MRT) for the Strategic Prevention Framework for Prescription Drugs (SPF Rx) grant program. Please refer to the DSP-MRT document where applicable.

Administration

Grantee Information

See DSP-MRT.

Sub-State Information

See DSP-MRT.

Subrecipients

See DSP-MRT.

High-Need Communities

See DSP-MRT.

Needs Assessment

Needs Assessment

See DSP-MRT.

Please note that a Needs Assessment is not required for SPF Rx.

Accomplishments and Barriers/Challenges

See DSP-MRT.

Capacity

Membership

See DSP-MRT.

Advisory Council and Other Workgroup Meetings

See DSP-MRT.

Other Opioid-Specific Workgroup Activities

Use this section to enter information about opioid-specific workgroups outside of your State/Tribal Epidemiological Outcomes Workgroup (SEOW/TEOW).

Information about SEOW/TEOW is reported in a separate section. The section includes questions regarding leveraging resources, including state-/grantee-level opioid workgroups and grantee-level funding resources.

Item	Response Options
Do you have a state-/grantee-level opioid workgroup?	Yes No
Does your opioid workgroup serve as your SPF-Rx Advisory Council? (This item will only appear if YES is selected for the first item in this section.)	Yes No
Does a state/grantee-wide strategic plan exist addressing opioid issues, including prevention of misuse, treatment, and overdose prevention?	Yes No
Is there an opioid-focused taskforce out of your governor’s office?	Yes No
How has the opioid-focused taskforce out of your governor’s office informed the SPF-Rx project? (This item will only appear if YES is selected for the previous item in this section.)	Free text
Is your SPF-Rx strategic plan integrated into or harmonized with the state/grantee-wide opioid strategic plan? (This item will only appear if YES is selected for the first item in this section.)	Yes No

Item	Response Options
Have you engaged in efforts to coordinate opioid funding streams during this reporting period?	Yes No
Please describe your efforts to coordinate opioid funding streams during this reporting period? (This item will only appear if YES is selected for the previous item in this section.)	Free text

Grantee Funding Resources

See DSP-MRT.

Other Resources

Policies, Regulations, and Laws

Use this section to enter information regarding the existence of policies, regulations, and laws related to prescribing or dispensing opioids in your state, tribal area, or jurisdiction. Once you complete this section, you will only update it if there are any revisions or additional changes related to your policies, regulations, or laws.

Item	Response Options
Indicate if guidelines/regulations currently exist in your state/jurisdiction related to any of the following: Required universal prescriber registration with the PDMP	Yes No
Doctors can assign authorized delegates to access the PDMP	Yes No
Requirements for prescribers to query PDMP before prescribing opioids in certain conditions (e.g., for more than short-term use)	Yes No
Pharmacists have a set time frame for uploading opioid dispensing data	Yes No
If yes, what is the time frame for uploading opioid dispensing data? (This item will only appear if YES is selected in previous item.)	Free text
PDMP patient records and electronic health records are linked in at least one large health care system	Yes No

Item	Response Options
PDMP records are linked with vital records (e.g., deaths)	Yes No
PDMP data can be used for public health surveillance, prevention, and research	Yes No
PDMP produces regular reports that summarize key state or regional statistics of interest	Yes No
PDMP produces unsolicited reports	Yes No
If yes, reports are for which groups? (This item will only appear if YES is selected in previous item.)	Prescribers Dispensers Licensing boards Law enforcement agencies Other group(s) (Specify)
Interstate agreements to share PDMP data	Yes No
Requirements for prescribers to receive training on safe opioid prescribing	Yes No
Limit to dose of opioid prescription (e.g., 90 MME/day) without special approval	Yes No
Limit to the duration of opioid prescription for noncancer patients without special approval	Yes No
Requirements that pain clinics must be regularly certified by the state medical board	Yes No N/A (State does not have pain clinics)
Requirements that pain clinics must be owned and operated by a licensed physician	Yes No N/A (State does not have pain clinics)
Other relevant PDMP guidelines or regulations not captured above?	Free text

Data Infrastructure

Use this section to enter information regarding data infrastructure and related activities.

Item	Response Options
During this reporting period, have you engaged in efforts to:
… Enhance access to PDMP data at the grantee/state level?	Yes No
… Enhance access to PDMP data at the subrecipient level?	Yes No
… Enhance usage of PDMP data at the grantee/state level?	Yes No
… Enhance usage of PDMP data at the subrecipient level?	Yes No
… Enhance the quality of PDMP data collected?	Yes No
… Increase registration for the PDMP?	Yes No
… Increase voluntary PDMP enrollment?	Yes No
… Increase mandatory PDMP enrollment?	Yes No
… Increase timely data upload by pharmacists to the PDMP?	Yes No
… Integrate PDMPs with electronic health records?	Yes No
… Integrate PDMPs with health information exchanges?	Yes No
… Increase reports to prescribers?	Yes No
… Increase reports to dispensers?	Yes No
… Increase reports to licensing boards?	Yes No
Please describe any other efforts to improve data infrastructure that have not been captured.	Free text

Training and Technical Assistance (TA)

See DSP-MRT.

Please note that this section does not include prescriber education trainings, which are reported in the Implementation section of this progress report and the Annual Implementation Instrument.

Accomplishments and Barriers/Challenges

See DSP-MRT.

Planning

Strategic Plan

Ensure that your strategic plan clearly explains how PDMP and/or other epidemiological data were used to identify communities with high rates of prescription drug misuse, focuses on improving PDMP partnerships and access/use of PDMP data, identifies data gaps, and addresses program sustainability.

Item	Response Options
Upload document	Browse
Provide a brief description of your document and, if relevant, any changes made to your document between the previous version and this one.	Free text
Were PDMP data incorporated into your strategic plan?	Yes No

Accomplishments and Barriers/Challenges

See DSP-MRT.

Behavioral Health Disparities

Disparities Impact Statement (DIS)

See DSP-MRT.

Population(s) Experiencing the Disparity

See DSP-MRT.

Focus and Data Gaps

See DSP-MRT.

Access to Prevention Efforts

See DSP-MRT.

Use and Reach of Prevention Efforts

See DSP-MRT.

Outcomes of Prevention Efforts

See DSP-MRT.

Accomplishments and Barriers/Challenges

See DSP-MRT.

Implementation

Use of Federal Toolkits/Guidelines

Federal resources have been developed that can assist grantees in training and increasing capacity around the prevention of opioid misuse and overdose. Please describe how the tools noted below were used.

Item	Response Options
Did the grantee/state use SAMHSA’s Opioid Overdose Prevention Toolkit?	Yes No
How was SAMHSA’s Opioid Overdose Prevention Toolkit used? (This item will only appear if YES is selected for the prior item.	Free text
Did the grantee/state use the CDC’s Guidelines for Prescribing Opioids for Chronic Pain?	Yes No
How were the CDC’s Guidelines for Prescribing Opioids for Chronic Pain used? (This item will only appear if YES is selected for the prior item.	Free text

Subrecipient Progress

See DSP-MRT.

Promising Approaches and Innovations

See DSP-MRT

Community-Based Social Marketing/Public Education Plan

Upload and provide a brief description of your community-based social marketing/public education plan.

Item	Response Options
Upload document	Browse
Provide a brief description of your document and, if relevant, any changes made to your document between the previous version and this one.	Free text

Accomplishments and Barriers/Challenges

See DSP-MRT.

Evaluation

Evaluation Plan

See DSP-MRT.

Evaluation Report

See DSP-MRT.

Other Document

See DSP-MRT.

Accomplishments and Barriers/Challenges

See DSP-MRT.

Sustainability

Accomplishments and Barriers/Challenges

See DSP-MRT.

DSP-MRT for SPF Rx print version