NOMS Table of Changes

ATTACHMENT C: Proposed Changes to NOMS Services [Please note that this tool has been merged to include both adult and children questions]

Current Tool

Changed

Notes

RECORD MANAGE-MENT

[RECORD MANAGEMENT IS REPORTED BY GRANTEE STAFF AT BASELINE, REASSESSMENT, AND DISCHARGE, REGARDLESS OF WHETHER AN INTERVIEW IS CONDUCTED.]

Records Management information is collected by Grantee Staff at BASELINE, REASSESSMENT, and DISCHARGE, even when an assessment interview is not conducted.

Language is simplified.

• Reassessment

Which 6-month reassessment?

[ENTER 06 FOR A 6-MONTH, 12 FOR A 12-MONTH, 18 FOR AN 18-MONTH ASSESSMENT, ETC.]

• Reassessment (3-month or 6-month)

Added 3-month reassessment.

Skip to 4. For Adults

3. Was the respondent the child or caregiver?

• Child

• Caregiver

For children, was the respondent the child or the caregiver?

• Child

• Caregiver

Simplified the question

The Behavioral Health Diagnoses section was switched with Demographic Data section. Demographic Data comes first, followed by the Behavioral Health Diagnoses section. If an interview is not conducted, it will end with the demographic data section.

Demographic Data

[SECTION A IS ONLY COLLECTED AT BASELINE. IF THIS IS NOT A BASELINE, GO TO SECTION B.]

Removed since Demographic Data will be the first section to complete after Records Management.

1. What is your gender?

 MALE

 FEMALE

 TRANSGENDER

 OTHER (SPECIFY) ______________________

 REFUSED

1. What do you consider yourself to be? [Read choices]

Male

Female

Transgender (Male to Female) Transgender (Feale to Male)

Gender Non-conforming

Other (specify _____________________

Refused

2. Do you think of yourself as …

O Straight or Heterosexual

O Homosexual (Gay or Lesbian)O Bisexual

O Queer

O Pansexual

O Questioning

O Asexual

O Something else? ________________

O Refused

Gender question was expanded to include additional categories per workgroup input and to align with CSAT questions.

2. Are you Hispanic or Latino?

3. Are you Hispanic, Latino/a, or of Spanish origin?

O Yes

O No

O Refused

Latino/a is the preferred term and also changed to align with CSAT.

[IF YES] What ethnic group do you consider yourself? Please answer yes or no for each of the following. You may say yes to more than one.

Ethnic Group YES NO REFUSED

Central American 

Cuban 

Dominican 

Mexican 

Puerto Rican 

South American 

OTHER 

[IF YES, SPECIFY BELOW.]

(SPECIFY)

[IF YES] What ethnic group do you consider yourself? You may indicate more than one.

Ethnic Group

Central American 

Cuban 

Dominican O

Mexican 

Puerto Rican 

South American 

OTHER 

Refused O

3. What race do you consider yourself? Please answer yes or no for each of the following. You may say yes to more than one.

Race YES NO REFUSED

Alaska Native 

American Indian 

Asian 

Black or African American 

Native Hawaiian or other Pacific Islander 

White 

4. What is your race? You may indicate more than one.

Race

Black or African American 

White 

American Indian O

Alaska Native 

South Asian 

Chinese 

Filipino 

Japanese 

Korean 

Vietnamese 

Other Asian O

Native Hawaiian 

Guamanian or Chamorro 

Samoan 

Other Pacific Islander O

Other (specify ) O

Per the work group, race categories were expanded and aligned with CSAT.

Language access question is not in the current version.

5. Do you speak a language other than English at home? (5 years old or older)

• Yes

• No

IF YES, what is this language (5 years old or older)

• Spanish

• Other ________

Per the HHS Office of Minority Health, these questions are part of demographic data collection. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=53

What is your month and year of birth?

Demographic Data

Section B. Military Family and Deployment was removed and two questions were added at the end of the Demographic Data section.

7. [ADULT ONLY] Have you ever served in the Armed Forces, the Reserves, or the National Guard?

• Yes

• No

• Don’t know

• Not applicable

AND

7. [ADULT ONLY] Are you currently serving on active duty in the Armed Forces, the Reserves, or the National Guard?

• Yes

• No

• Refused

• Don’t Know

These two questions were added to the end of the demographic data section, eliminating section b, making the tool shorter and more streamlined. The question on whether a client has served in active duty role is for adults only. Adults would be the only person who would serve.

Behavioral Health Diagnosis section should be completed by a licensed clinician. Licensed clinicians can diagnose clients/consumers. Licensed clinicians are the only staff members administering this section of the NOM tool.

Behavioral Health Diagnoses

In Section B. Violence and Trauma, lists these questions

7. Have you ever experienced violence or trauma in any setting (including community or school violence; domestic violence; physical, psychological, or sexual maltreatment/assault within or outside of the family; natural disaster; terrorism; neglect; or traumatic grief)?

• YES

• NO [GO TO 11.]

• REFUSED [GO TO 11.]

• DON’T KNOW [GO TO 11.]

7. Did any of these experiences feel so frightening, horrible, or upsetting that in the past and/or present you:

1. Have had nightmares about it or thought about it when you did not want to?

2. Tried hard not to think about it or went out of your way to avoid situations that remind you of it?

3. Were constantly on guard, watchful, or easily startled?

4. Felt numb and detached from others, activities, or your surroundings?

Due to lack of space, the choices for each of the question 10a-10d were Yes, No, Refused, and Don’t Know.

7. In the past 30 days, how often have you been hit, kicked, slapped, or otherwise physically hurt?

• Never

• Once

• A few times

• More than a few times

• REFUSED

• DON’T KNOW

Question 9 was moved to Section A. Functioning.

These new trauma questions were added at the beginning of the behavioral health diagnoses section.

1. Was the client/consumer screened or assessed by your program for trauma-related experiences:

• Yes

• No

If “no”, please select why:

• No time during interview

• No training around trauma screening/disclosure

• No institutional/organizational policy around screening.

• No referral network and/or infrastructure for trauma services currently available

• Other

If screened/assessed, was the screen positive?

• Yes

• No

Per the workgroup, instead of asking trauma questions, the questions are worded to see if trauma was screened by the program.

Questions 10 and 11 were deleted. There was concern that if asked and adverse effects occurred, it could be detrimental to the client.

Behavioral Health Diagnoses

Please indicate the consumer’s current behavioral health diagnoses using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes listed below. Please note that some substance use disorder ICD-10-CM codes have been crosswalked to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) descriptors. Select up to three diagnoses. For each diagnosis selected, please indicate whether it is primary, secondary, or tertiary, if known. Only one diagnosis can be primary, only one can be secondary, and only one can be tertiary.

The substance use disorder diagnoses are listed first, followed by mental health diagnoses. There are sub-categories among the substance use disorders and none for mental health. Primary, secondary, and tertiary radio buttons are included for each diagnosis.

The mental health diagnoses are listed first, with sub-categories, followed by substance use diagnoses. The diagnoses are aligned with the most current version of the ICD-10. Radio buttons for primary, secondary or tertiary were removed

1Per workgroup input.

Behavioral Health Diagnoses

These questions were moved from the Zero Suicide program specific questions as part of the behavioral health diagnoses section, right after the trauma questions.

2. Did the individual have a positive suicidal screen?

• Yes

• No

• Don’t know

• Refused

If Yes, was a suicidal safety plan developed?

• Yes

• No

• Don’t know

• Refused

If Yes, was access to lethal means assessed?

• Yes

• No

• Don’t know

• Refused

These questions were added per Center leadership instead of asking direct questions related to suicide in the program specific guidance. These questions will also be asked of every grant program.

Behavioral Health Diagnoses

Several categories for mental health diagnoses were expanded, to include more commonly selected diagnoses.

These are the categories for mental health diagnoses (with specific conditions under each one, but not listed here for space issues):

• Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders

• Mood [affective] disorders

• Phobic anxiety and other anxiety disorders

• Obsessive-compulsive disorders

• Reaction to severe stress and adjustment disorders

• Behavioral syndromes associated with psychological disturbances and physical factors

• Disorders of adult personality and behavior

These categories were added per CMHS leadership.

Behavioral Health Diagnoses

This was not in the original tool.

Right before the list of diagnostic codes, a question is added:

If no mental health diagnosis, select reason:

• Clinician was not available to assess

• High risk factors requiring intervention and not yet meeting criteria for a DSM/ICD diagnosis

• Only met criteria for a “Z “code

 Other (please specify_______________________________________)

Z codes were also added at the end of the diagnostic code list. They are:

• Z55 – Problems related to education and literacy

• Z56 – Problems related to employment and unemployed

• Z57 – Occupational exposure to risk factors

• Z59 – Problems related to housing and economic circumstances

• Z60 – Problems related to social environment

• Z62 – Problems related to upbringing

• Z63 – Other problems related to primary support group, including family circumstances

• Z64 – Problems related to certain psychological circumstances

These additional questions and Z codes were included to ensure complete data collection. The selected Z codes are related to the social determinants of health, which are being encouraged by Medicaid providers to begin collecting.

Behavioral Health Diagnoses

The substance use disorder diagnoses are listed first, followed by mental health diagnoses. There are sub-categories among the substance use disorders and none for mental health. Primary, secondary, and tertiary radio buttons are included for each diagnosis.

The mental health diagnoses are listed first, with sub-categories, followed by substance use diagnoses. The diagnoses are aligned with the most current version of the ICD-10. Radio buttons for primary, secondary or tertiary were removed.

Per workgroup input.

FUNCTIONING

1. How would you rate your or your child’s overall health right now?

• Excellent

• Very Good

• Good

• Fair

• Poor

• REFUSED

• DON’T KNOW

1. How would you rate your [your child’s] overall mental health right now?

• Excellent

• Very Good

• Good

• Fair

• Poor

• Refused

The choices “refused” and “don’t know” were removed. Also, the question was reworded to address the overall mental health, not physical health.

Question on how well you (or your child) were able to deal with everyday life during the past thirty days and the question about how you have been feeling during the past 30 days uses a Likert scale.

These questions were reduced and have answer choices of Yes, No, or No response/refused.

Likert scale changed to be more concise and clearer for grantees to answer and reduce the amount of time needed for the grantee to read the possible responses.

These following questions are in Section B. Functioning:

• In the last 4 weeks how would you rate your quality of life? (very poor, poor, neither good or poor, good, very good, refused, don’t know)

• In the last 4 weeks do you have enough energy for everyday life? (not at all, a little, moderately, mostly, completely, refused, don’t know)

The answer choices are very dissatisfied, dissatisfied, neither satisfied or dissatisfied, satisfied, very satisfied, refused, don’t know for the following questions: In the last 4 weeks…

• How satisfied are you with your ability to perform your daily living activities?

• How satisfied are you with your health?

• How satisfied are you with yourself?

• How satisfied are you with your personal relationships?

All of these questions are deleted.

Per workgroup

6. The following questions relate to your experience with alcohol, cigarettes, and other drugs. Some of the substances we’ll talk about are prescribed by a doctor (like pain medications). In the past 30 days, how often have you used …

All of the questions in this section are deleted.

Data was not used and deletion reduces grantee burden. Per workgroup

Global Assessment of Functioning Score

Deleted.

The GAF is no longer used in clinical assessments.

MILITARY AND FAMILY DEPLOYMENT

7b. have you ever been deployed to a combat zone?

• Yes

• No

• Refused

• Don’t know

If yes (list of combat zones and wars).

8. Is anyone in your family or someone close to you currently serving on active duty in or retired/separated from the Armed Forces, the Reserves or the National Guard?

These questions are deleted.

Data was not used, and deletion reduces grantee burden.

STABILITY IN HOUSING

In the past 30 days, how many …

1. Nights have you been homeless

2. Nights have you spent in a hospital for mental health care?

3. Nights have you spent in a facility for detox/inpatient or residential substance abuse treatment?

4. Nights have you spent in correctional facility including jail or prison?

5. Times you have gone to an emergency room for a psychiatric or emotional problem?

These questions include # of nights, refused, don’t know.

In the past 30 days, have you [your child] …

1. been homeless

2. spent time in a hospital for mental health care

3. Spent time in a facility for detox/inpatient treatment for a substance abuse disorder

4. Spent time in a correctional facility (e.g. jail, prison, juvenile facility)

5. Gone to an emergency room for a mental health or emotional problem

6. Been satisfied with the conditions of your living space.

Responses choices are now Yes, No, or No Response/Refused.

Streamlined questions based on GPO workgroup feedback.

3. In the past 30 days, where have you been living most of the time?

• OWNED OR RENTED HOUSE, APARTMENT, TRAILER, ROOM

• SOMEONE ELSE’S HOUSE, APARTMENT, TRAILER, ROOM

• HOMELESS (SHELTER, STREET/OUTDOORS, PARK)

• GROUP HOME

• ADULT FOSTER CARE

• TRANSITIONAL LIVING FACILITY

• HOSPITAL (MEDICAL)

• HOSPITAL (PSYCHIATRIC)

• DETOX/INPATIENT OR RESIDENTIAL SUBSTANCE ABUSE TREATMENT FACILITY

• CORRECTIONAL FACILITY (JAIL/PRISON)

• NURSING HOME

• VA HOSPITAL

• VETERAN’S HOME

• MILITARY BASE

• OTHER HOUSED (SPECIFY) ________

• REFUSED

• DON’T KNOW

In the last 4 weeks … how satisfied are you with the conditions of you living place? (very dissatisfied, dissatisfied, neither dissatisfied or satisfied, satisfied, very satisfied)

2. In the past 30 days, where have you been living most of the time?

• Private residence

• Foster home

• Residential care

• Crisis residence

• Residential treatment center

• Institutional setting

• Jail/correctional facility

• Homeless/shelter

• Other (SPECIFY)_________________

• Don’t know

Streamlined questions based on GPO workgroup feedback.

Reduced number of responses = reduced grantee burden.

EDUCATION AND EMPLOYMENT

1. Are you currently enrolled in school or a job training program?

[IF ENROLLED] Is that full time or part time?

• NOT ENROLLED

• ENROLLED, FULL TIME

• ENROLLED, PART TIME

• OTHER (SPECIFY) _________

• REFUSED

• DON’T KNOW

2. What is the highest level of education you have finished, whether or not you received a degree?

• LESS THAN 12^TH GRADE

• 12^TH GRADE/HIGH SCHOOL DIPLOMA/EQUIVALENT (GED)

• VOCATIONAL/TECHNICAL (VOC/TECH) DIPLOMA

• SOME COLLEGE OR UNIVERSITY

• BACHELOR’S DEGREE (BA, BS)

• GRADUATE WORK/GRADUATE DEGREE

• REFUSED

• DON’T KNOW

1. Are you [your child] currently enrolled in school or a job training program?

• Yes

• No

• No response/refused

2. [ADULT ONLY] – What is the highest level of education you have finished, whether or not you received a degree?

• LESS THAN 12^TH GRADE

• 12^TH GRADE/HIGH SCHOOL DIPLOMA/EQUIVALENT (GED)

• VOCATIONAL/TECHNICAL (VOC/TECH) DIPLOMA

• SOME COLLEGE OR UNIVERSITY

• BACHELOR’S DEGREE (BA, BS)

• GRADUATE WORK/GRADUATE DEGREE

• REFUSED

• DON’T KNOW

These questions were modified child or adult, made it more streamlined.

The “Are you currently employed” question remains the same (no change). However, the subsequent questions (see below) were removed.

3a. [IF EMPLOYED.] Employment Status. Choices are Yes, No, Refused, Don't know

• Are you paid at or above the minimum wage?

• Are your wages paid directly to you by your employer?

• Could anyone have applied for this job?

3a questions are deleted.

Per workgroup input.

3. 1. [ADULT ONLY) - Are you currently employed?

      1. Employed full-time (35+ HOURS per week)

      2. Employed, part-time

      3. Unemployed, but looking for work

      4. Unemployed, not looking for work

      5. Unemployed, not working due to a disability

      6. Unemployed, not working, retired

      7. Other (SPECIFY)

      8. Refused

      9. Don’t know

1. [ADULT ONLY) - Are you currently employed?

   • Employed full-time (35+ HOURS per week)

   • Employed, part-time

   • Unemployed, but looking for work

   • Not looking for work

   • Disable, not working

   • Retired, not working

   • Other (SPECIFY)

   • Refused

   • Don’t know

Took out the word “unemployed” for certain answer choices per feedback from CBHSQ.

4. In the past 30 days, did you … 4.a. Have you enough money to meet your needs? Answer choices are not at all, a little, moderately, mostly, completely, refused, don’t know.

4. In the past 30 days, did you … 4.a. Have you enough money to meet your [your child’s] needs? Answer choices are yes, no, no response, n/a.

Likert scale changed to be more concise and clearer for grantees to answer. Reduces grantee burden

CRIME AND CRIMINAL JUSTICE STATUS

1. In the past 30 days, how many times have you been arrested?

| | |

TIMES

• REFUSED

• DON’T KNOW

1. [ADULT ONLY] In the past 30 days, have you …

D.1.a. Been arrested? (Yes, no, no response, n/a)

D.1.b. Spent time in a jail or correctional facility or

on probation? (Yes, no, no response, n/a)

2. [CHILD ONLY] In the past 30 days, have you …

D.2.a. Been arrested? (Yes, no, no response, n/a)

D.2.b. Spent time in a jail or been on juvenile

probation? (Yes, no, no response, n/a)

Questions expanded and broken out for adult and child. Number of times arrested was removed – data was never used.

PERCEPTION OF CARE

Questions 1a. – 1n remain the same. The answer choices are Strongly Disagree, Disagree, Undecided, Agree, Strongly Agree, Refused, and Not applicable.

Questions 1a – 1n remain the same. The answer choices are changed to Yes, No, or No Response/Refused. .

Likert scale changed to be more concise and clearer for grantees to answer. Reduced grantee burden.

2. [INDICATE WHO ADMINISTERED SECTION F, PERCEPTION OF CARE, TO THE REPSONDENT FOR THIS INTERVIEW.]

• ADMINISTRATIVE STAFF

• CARE COORDINATOR

• CASE MANAGER

• CLINICIAN PROVIDING DIRECT SERVICES

• CLINICIAN NOT PROVIDING SERVICES

• CONSUMER PEER

• DATA COLLECTOR

• EVALUATOR

• FAMILY ADVOCATE

• RESEARCH ASSISTANT STAFF

• SELF-ADMINISTERED

• OTHER (SPECIFY) ___________________

Indicate who administered Section F to the client/consumer for this interview:

• Administrative staff

• Care coordinator

• Case manager

• Clinician providing direct services

• Clinician not providing direct services

• Consumer/peer

• Data collector/evaluator

• Family advocate

• Other (SPECIFY) _______________

Evaluator and research assistant staff choices were removed.

SOCIAL CONNECTEDNESS

Please answer for relationships with persons other than your mental health provider(s) over the past 30 days.

Response options are: Strongly Disagree, Disagree, Undecided, Agree, Strongly Agree, and Refused.

1a. I am happy with the friendships I have.

1b. I have people with whom I can do enjoyable things.

1c. I feel I belong in my community.

1d. In a crisis, I would have the support I need from family or friends.

1e. I have family or friends that are supportive of my recovery.

1f. I generally accomplish what I set out to do.

Please answer for relationships with persons other than your mental health provider(s) over the past 30 days.

Response options are: Yes, No, or No Response/Refused.

1a. I [my child] am happy with the friendships I have.

1b. I have [my child has] people with whom I can do enjoyable things.

1c. I feel [my child feels] that I [they] belong in the community.

1d. In a crisis, I [my child] would have the support I need from family or friends.

1e. I have [my child has] family or friends that are supportive of my recovery.

1f. I [my child] generally accomplish what I set out to do.

Combined child and adult questions. Likert scale changed to be more concise and clearer for grantees to answer.

Section H – Health Data and Program-specific questions

Program-specific questions for Assisted Outpatient Treatment, Partnerships for Early Diversion, PIPBHC, Minority AIDS – Service Integration, Healthy Transitions, Assertive Community Treatment, Clinical High Risk for Psychosis, CCBHC, NCTSI-Category 3, CMHI, Zero Suicide

Is now Section G. Program specific questions have been reduced from 12 to 10 programs (deleted questions for Zero Suicide and CMHI)

Reduce grantee burden

Reassessment Status

Deleted

Data is asked in other sections of the tool. Section was deleted.

Clinical Discharge Status and Services Received

Now is Section H. No changes to questions

Not applicable.

G1

Assisted Outpatient Treatment

(AOT)

[QUESTION 1 SHOULD BE ANSWERED BY THE CONSUMER AT BASELINE, REASSESSMENT, AND CLINICAL DISCHARGE.]

Directions are outlined in a box to help grantees distinguish directions from the rest of the Section G questions.

Language is simplified.

1. In the past 30 days, how often have you taken all of your psychiatric medication(s) as prescribed to you?

• Always

• Usually

• Sometimes

• Rarely

• Never

• REFUSED

• DON’T KNOW

• NOT APPLICABLE

2. In the past 30 days, have you taken your psychiatric medication(s) as prescribed to you?

• Yes

• No

• No Response/Refused

Likert scale simplified to ease grantee and client burden.

[QUESTION 2 SHOULD BE REPORTED BY GRANTEE STAFF ABOUT THE CONSUMER AT REASSESSMENT AND CLINICAL DISCHARGE.]

Directions are outlined in a box to help grantees distinguish directions from the rest of the Section G questions.

Language is simplified.

2. In the past 30 days, how compliant has the consumer been with their treatment plan?

• Not compliant

• Minimally compliant

• Moderately compliant

• Highly compliant

• Fully compliant

• DON’T KNOW

• NOT APPLICABLE

3. In the past 30 days, have you followed your treatment plan?

• Yes

• No

• No Response/Refused

Likert scale simplified to ease grantee and client burden.

Directions listed in bold at the end of H1.

Directions are outlined in a box to help grantees distinguish when Section G tool should be administered (baseline, reassessment, and clinical discharge).

Language is simplified.

G2

Law Enforcement and Behavioral Health Partnership for Early Diversion

(EarlyDiv)

[QUESTIONS 1 AND 2 SHOULD BE REPORTED BY GRANTEE STAFF AT BASELINE, REASSESSMENT, AND CLINICAL DISCHARGE.]

Directions are outlined in a box to help grantees distinguish directions from the rest of the Section G questions.

Language is simplified.

1. Did the consumer screen positive for a mental health disorder?

 Consumer screened positive

 Consumer screened negative

 Consumer was not screened

Deleted in proposed tool.

Question was deleted to better suit program needs.

[IF CONSUMER WAS REFERRED TO SERVICES] Did they receive the following services?

Mental health services

YES NO



1. Was the consumer referred to mental health services?

YES NO



Answer scale simplified to ease grantee and client burden.

1. 2. [IF CONSUMER WAS REFERRED TO SERVICES] Did they receive the following services?

Mental health services

YES NO DON’T KNOW NOT APPLICABLE





[IF YES] Did they receive mental health services?

 Yes

 No

 Other

Question was streamlined to be clearer and more concise.

2. Did the consumer screen positive for a substance use disorder?

 Consumer screened positive

 Consumer screened negative

 Consumer was not screened

Deleted in proposed tool.

Question was deleted to better suit program needs.

1. [IF CONSUMER SCREENED POSITIVE] Was the consumer referred to the following type of services?

YES NO

Substance use disorder services  

2.Was the consumer referred to substance use disorder services?

YES NO



Question was deleted to better suit program needs.

1. [IF CONSUMER WAS REFERRED TO SERVICES] Did they receive the following services?

Substance use disorder services

YES NO DON’T KNOW NOT APPLICABLE



[IF YES] Did they receive substance use disorder services?

 Yes

 No

 Other

Question was deleted to better suit program needs.

Directions in current tool were not clear and difficult to read.

Directions are outlined in a box to help grantees distinguish when Section G tool should be administered (reassessment and clinical discharge).

Directions added to Question 3 on when to administer tool.

3. Please indicate the degree to which you agree or disagree with the following statement:

Receiving community-based services through the [INSERT GRANTEE NAME] program has helped me to avoid further contact with the police and the criminal justice system.

• Strongly Disagree

• Disagree

• Undecided

• Agree

• Strongly Agree

• REFUSED

• DON’T KNOW

4. Has this program helped you avoid further contact with the police and criminal justice system?

• Yes

• No

• No response/Refused

Question streamlined to be clearer and more concise.

Directions listed in bold at the end of H2.

Directions are outlined in a box to help grantees distinguish when Section G tool should be administered (baseline, reassessment, and clinical discharge).

Language is simplified.

[QUESTION 1 SHOULD BE ANSWERED BY THE CONSUMER AT BASELINE, REASSESSMENT, AND CLINICAL DISCHARGE.]

Directions are outlined in a box to help grantees distinguish directions from the rest of the Section G questions.

Language is simplified.

G3:

Promoting The Integration of Primary and Behavioral Health Care

(PIPBHC)

1. In the past 30 days, how many times have you (fill in number)…

a. Been to the emergency room for a physical healthcare problem?

2. Been hospitalized overnight for a physical healthcare

problem?

[REPORT NUMBER OF NIGHTS HOSPITALIZED.]

|___|___| # OF DAYS

REFUSED DON’T KNOW NOT APPLICABLE

The same questions (1a and 1b) are asked in the proposed tool. The answer options have changed.

Yes	No	No Response/Refused
|		
		

Question was retained in the proposed tool. However, answer options were changed to Yes, No, or Refused.

Program staff needed to know if a client had been hospitalized or hospitalized overnight within the last 30 days. Staff do not need to know the frequency of hospital entry.

[QUESTION 2 SHOULD BE REPORTED BY GRANTEE STAFF AT BASELINE, REASSESSMENT, AND CLINICAL DISCHARGE.]

Deleted in proposed tool.

Directions were not needed as question was deleted.

2. Please indicate which type of funding source(s) was (were)/will be used to pay for the services provided to this consumer since their last interview. (Check all that apply):

• Current SAMHSA grant funding

• Other federal grant funding

• State funding

• Consumer’s private insurance

• Medicaid/Medicare

• Other (Specify): ____________________

Deleted in proposed tool.

Information on funding sources is not used by program staff.

Question in current version asks for grantee staff to measure a client’s wait circumference and report data (in centimeters).

Deleted in proposed tool.

Measuring waist circumference added burden to grantees. The data collected was not sued in CMHS’s data analysis. Finally, CMHS medical advisers also agreed that this measure was not needed to provide care to clients.

Question in current version asks for grantee staff to measure a client’s wait circumference and report data (in centimeters).

Deleted in proposed tool.

Grantees found this measure to be burdensome. The grantees also do not believe this is a helpful measure for client success.

^{Did patient successfully fast for 8 hours prior to providing the blood sample?}

Deleted in proposed tool.

Fasting data is not used by CMHS in data analysis. Finally, CMHS medical advisers also agreed that this measure was not needed to provide care to clients.

Question in current version asks for grantee staff to determine a client’s HDL cholesterol via a blood test and report data (in milligrams per deciliter).

Deleted in proposed tool.

Collecting HDL cholesterol data added burden to grantees. The data collected was not sued in CMHS’s data analysis. Finally, CMHS medical advisers also agreed that this measure was not needed to provide care to clients.

Question in current version asks for grantee staff to determine a client’s Triglycerides level via a blood test and report data (in milligrams per deciliter).

Deleted in proposed tool.

Collecting blood Triglycerides data added burden to grantees. The data collected was not sued in CMHS’s data analysis. Finally, CMHS medical advisers also agreed that this measure was not needed to provide care to clients.

Directions listed in bold at the end of H3.

Directions are outlined in a box to help grantees distinguish when Section G tool should be administered (baseline, reassessment, and clinical discharge).

Language is simplified.

Directions listed in bold at the end of H3.

Directions are outlined in a box to help grantees distinguish when Section G tool should be administered (baseline, reassessment, and clinical discharge).

Language is simplified.

G4: Minority-AIDS

[QUESTIONS 1 AND 2 SHOULD BE REPORTED BY GRANTEE STAFF AT BASELINE, REASSESSMENT, AND CLINICAL DISCHARGE.]

Directions are outlined in a box to help grantees distinguish directions from the rest of the Section G questions.

Language is simplified.

[QUESTIONS 1 AND 2 SHOULD BE ANSWERED BY THE CONSUMER AT BASELINE, REASSESSMENT, AND CLINICAL DISCHARGE.]

Directions listed in bold at the end of H4.

Directions are outlined in a box to help grantees distinguish when Section G tool should be administered (baseline, reassessment, and clinical discharge).

Language is simplified.

G5:

Healthy Transitions

(HTI)

[QUESTIONS 1 AND 2 SHOULD BE REPORTED BY GRANTEE STAFF AT BASELINE, REASSESSMENT, AND CLINICAL DISCHARGE.]

Directions are outlined in a box to help grantees distinguish directions from the rest of the Section G questions.

Language is simplified.

2. Did the consumer screen positive for a mental health disorder?

 Consumer screened positive

 Consumer screened negative

 Consumer was not screened

Deleted in proposed tool.

Question was deleted to better suit program needs.

IF CONSUMER WAS REFERRED TO SERVICES] Did they receive the following services?

YES NO

Mental health services   

1. Was the consumer referred to mental health services?

YES NO



Answer scale simplified to ease grantee and client burden.

a. [IF CONSUMER WAS REFERRED TO SERVICES] Did they receive the following services?

Mental health services

YES NO DON’T KNOW NOT APPLICABLE

   

[IF YES] Did they receive mental health services?

 Yes

 No

 Other

Answer scale simplified to ease grantee and client burden.

2. Did the consumer screen positive for a substance use disorder?

 Consumer screened positive

 Consumer screened negative

 Consumer was not screened

Deleted in proposed tool.

Question was deleted to better suit program needs.

1. [IF CONSUMER SCREENED POSITIVE] Was the consumer referred to the following type of services?

YES NO

Substance use disorder services  

2.Was the consumer referred to substance use disorder services?

YES NO



Questions changed to be more concise and clearer for grantees to complete.

1. [IF CONSUMER WAS REFERRED TO SERVICES] Did they receive the following services?

Substance use disorder services

YES NO DON’T KNOW NOT APPLICABLE



[IF YES] Did they receive substance use disorder services?

 Yes

 No

 Other

Answer scale changed to be more concise and clearer for grantees to complete.

Directions in current tool were not clear and difficult to read.

Directions are outlined in a box to help grantees distinguish when Section G tool should be administered (reassessment and clinical discharge).

Directions added to Question 3 on when to administer tool.

CMHI and Zero Suicide no longer use Section H6 (now Section G6) for program-specific data collection in the proposed tool.

G6:

Assertive Community Treatment

(ACT)

[QUESTION 1 SHOULD BE ANSWERED BY THE CONSUMER AT BASELINE, REASSESSMENT, AND CLINICAL DISCHARGE.]

Directions are outlined in a box to help grantees distinguish directions from the rest of the Section G questions.

Language is simplified.

1. In the past 30 days:

a. How many times have you thought about killing yourself?

1. How many times did you attempt to kill yourself?

Number of Times	REFUSED	DON’T KNOW
|____|____|		
|____|____|		

Deleted in proposed tool.

Question was not needed by program staff.

[QUESTION 2 SHOULD BE ANSWERED BY THE CONSUMER AT REASSESSMENT AND CLINICAL DISCHARGE.]

1. How often does a member of your team interact with you?

• Several times a day

• Almost every day

• A few times a week

• About once a week

• A few times a month

• About once a month

• Less than once per month

• REFUSED

• DON’T KNOW

1. How often does a member of your team interact with you?

• At least daily

• At least weekly

• At least monthly

• Never

• REFUSED

• DON’T KNOW

Likert scale was modified to be more concise and clearer.

Question added to new tool.

2. If I need to talk with someone on my team, I know who to call.

• Yes

• No

• Refused

• Not applicable

Question added to understand if client understand how to contact their care team. Question was requested by program staff and aligns with the goals of the program.

No directions listed at the end of Section H5

Directions are outlined in a box to help grantees distinguish when Section G tool should be administered (baseline, reassessment, and clinical discharge).

Language is simplified.

[QUESTIONS 1 AND 2 SHOULD BE REPORTED BY GRANTEE STAFF AT REASSESSMENT AND CLINICAL DISCHARGE.]

Directions are outlined in a box to help grantees distinguish when Section G tool should be administered (reassessment, and clinical discharge).

Language is simplified.

G7:

Clinical High Risk for Psychosis

(CHR-P)

QUESTION 2 SHOULD BE ANSWERED BY THE CONSUMER AT BASELINE, REASSESSMENT, AND CLINICAL DISCHARGE IF THEY ARE CURRENTLY ENROLLED IN SCHOOL.]

Deleted in proposed tool.

Direction not needed as question was deleted.

1. Has the consumer experienced a first-episode of psychosis (FEP) since their last interview?

• Yes

• No

• DON’T KNOW

a. [IF YES] Please indicate the approximate date that the consumer initially experienced the FEP.

|___|___| / |___|___|___|___|
MONTH YEAR

b. [IF YES] Was the consumer referred to FEP services?

• Yes

• No

• DON’T KNOW

[IF CONSUMER WAS REFERRED TO FEP SERVICES] Please indicate the date that the consumer first received FEP services/treatment.

|___|___| / |___|___|___|___| DON’T KNOW
MONTH YEAR 

1. Has the consumer experienced an episode of psychosis since their last interview?

• Yes

• No

• DON’T KNOW

a.[IF YES] Please indicate the approximate date that the consumer initially experienced psychosis.

|___|___| / |___|___|___|___|
MONTH YEAR

b. [IF YES] Was the consumer referred to services?

• Yes

• No

• DON’T KNOW

[IF CONSUMER WAS REFERRED] Please indicate the date that the consumer received services/treatment.

|___|___| / |___|___|___|___| MONTH YEAR

DON’T KNOW



Client was previously asked If they had a first episode of psychosis. Program staff no longer needed to know when the first-episode of psychosis occurred. Staff need to know if psychosis occurred.

3. [IF THE CONSUMER INDICATED THAT THEY WERE ENROLLED IN SCHOOL] During the past 30 days of school, how many days were you absent for any reason?

|___|___| # OF DAYS REFUSED DON’T KNOW NOT APPLICABLE

Deleted in proposed tool.

Education information is already collected in Demographics Section of NOMS tool.

No directions listed at the end of Section H5

Directions are outlined in a box to help grantees distinguish when Section G tool should be administered (baseline, reassessment, and clinical discharge).

Language is simplified.

G8:

Certified Community Behavioral Health Clinics-Expansion Grant

(CCBHC-E)

[PROGRAM-SPECIFIC HEALTH ITEMS ARE REPORTED BY THE GRANTEE ABOUT THE CONSUMER.]

Directions are outlined in a box to help grantees distinguish directions from the rest of the Section G questions.

Language is simplified.

Question in current version asks for grantee staff to measure a client’s wait circumference and report data (in centimeters).

Deleted in proposed tool.

Grantees found this measure to be burdensome. The grantees also do not believe this is a helpful measure for client success.

No directions listed at the end of Section H8.

Directions are outlined in a box to help grantees distinguish when Section G tool should be administered (baseline, reassessment, and clinical discharge).

Language is simplified.

G9:

National Child Traumatic Stress Imitative – Category 3

(NTCSI-Cat-3)

{Questions should be answered by the client/consumer or caregiver BASELINE, REASSESSMENT, and CLINICAL DISCHARGE.}

Directions are outlined in a box to help grantees distinguish directions from the rest of the Section G questions.

Language is simplified.

[CHILD ONLY} As a result of treatment and services received, I [my child has] have shown improvement in daily life, such as in school or interacting with family or friends.

• Yes

• No

• Refused

• Not applicable

Deleted in proposed tool.

Question was not related to program-specific goals.

No directions listed at the end of Section H5.

Directions are outlined in a box to help grantees distinguish when Section G tool should be administered (reassessment, and clinical discharge).

Language is simplified.