Form CMHS NOMS Data Col CMHS NOMS Data Col CMHS NOMS Data Collection Tool

Mental Health Client/Consumer Outcome Measures and Infrastructure, Prevention and Promotion Indicators

Attachment A-NOMS Data Collection Tool

CMHS NOMS Data Collection Tool

OMB: 0930-0285

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ATTACHMENT A

Form Approved

OMB No. 0930-0285

Expiration Date 02/28/2022

Substance Abuse and Mental Health Services Administration (SAMHSA)

Center for Mental Health Services (CMHS)

National Outcome Measures (NOMs) Client-Level Measures for Discretionary Programs Providing Direct Services

SERVICES TOOL

SAMHSA’s Performance Accountability and Reporting System (SPARS)

May 2021

Public reporting burden for this collection of information is estimated to average 40 minutes per response if all items are asked of a consumer/participant; to the extent that providers already obtain much of this information as part of their ongoing consumer/participant intake or follow-up, less time will be required. Send comments regarding this burden estimate, or any other aspect of this collection of information, to the Substance Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, Room 15E57B, 5600 Fishers Lane, Rockville, MD 20857. 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 Office of Management and Budget (OMB) control number. The control number for this project is 0930-0285.

Table of Contents






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RECORDS MANAGEMENT

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

Client ID |____|____|____|____|____|____|____|____|____|____|____|

Grant ID |____|____|____|____|____|____|____|____|____|____|____|

Site ID |____|____|____|____|____|____|____|____|____|____|

  1. Indicate Assessment Type:

    Baseline Assessment

    Reassessment (3-month or 6-month)

    Clinical Discharge Assessment

    Enter the MONTH and YEAR when the consumer first received services under this grant for this episode of care.



     

    |____|____| / |____|____|____|____|
    MONTH YEAR


     

  2. Was the assessment interview conducted?

Yes

No

When?

|____|____| / |____|____| / |____|____|____|____|
MONTH DAY YEAR

Why not? Choose only one.

 Not able to obtain consent from proxy

 Client/consumer was impaired or unable to provide consent

 Client/consumer refused this interview

 Client/consumer was not reached for interview

 Client/consumer refused all interviews


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



Child

Caregiver



DEMOGRAPHIC DATA

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

Shape1 Male

Shape2 Female

Shape3 Transgender (Male to Female)

Shape4 Transgender (Female to Male)

Shape5 Gender non-conforming

Shape6 Other (Specify)______________________________

Shape7 Refused

  1. Do you think of yourself as…

Shape8 Straight Or Heterosexual

Shape9 Homosexual (Gay Or Lesbian)

Shape10 Bisexual

Shape11 Queer

Shape12 Pansexual

Shape13 Questioning

Shape14 Asexual

Shape15 Something Else? Please Specify ___________________________________

Shape16 Refused

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

 Yes

 No [GO TO 4.]

 Refused [GO TO 4.]


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

Shape17 Central American

Shape18 Cuban

Shape19 Dominican

Shape20 Mexican

Shape21 Puerto Rican

Shape22 South American

Shape23 Other (Specify)_____________

Shape24 Refused





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

    Race





    Shape25 Black or African American

    Shape26 White







    Shape27 American Indian







    Shape28 Alaska Native







    Shape29 South Asian







    Shape30 Chinese







    Shape31 Filipino

    Shape32 Japanese

    Shape33 Korean

    Shape34 Vietnamese

    Shape35 Other Asian

    Shape36 Native Hawaiian

    Shape37 Guamanian or Chamorro

    Shape38 Samoan

    Shape39 Other Pacific Islander

    Shape40 Other (Specify)___________________






  2. 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 ___________

  1. What is your month and year of birth?

|____|____| / |____|____|____|____|

Month Year


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

  • Yes

  • No

  • Don’t know

  • Not applicable


  1. [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


Stop here if a BASELINE ASSESSMENT interview was not conducted.


BEHAVIORAL HEALTH DIAGNOSES – This section should be completed by a licensed clinician

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


  • Yes

  • No

  • Don’t know


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

  • Don’t know


  1. Did the client/consumer have a positive suicidal screen?

  • Yes

  • No

  • Don’t know


If Yes, was a suicidal safety plan developed?

  • Yes

  • No

  • Don’t know


If Yes, was access to lethal means assessed?

  • Yes

  • No

  • Don’t know


  1. Behavioral Health Diagnoses [This data is reported by Grantee Program Staff]

Please indicate the client/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 mental health diagnoses. If there are any co-occurring disorders, you may select up to three substance use disorders.

If no mental health diagnosis, select reason:

  • No clinician assessment

  • 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_______________________________________)

MENTAL HEALTH DIAGNOSES

 Diagnosed?

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


F20 – Schizophrenia

F21 – Schizotypal disorder

F22 – Delusional disorder

F23 – Brief psychotic disorder

F24 – Shared psychotic disorder

F25 – Schizoaffective disorders

F28 – Other psychotic disorder not due to a substance or

known physiological condition

F29 – Unspecified psychosis not due to a substance or

known physiological condition

Mood [affective] disorders]


F30 – Manic episode

F31 – Bipolar disorder

F32 – Major depressive disorder, single episode

F33 – Major depressive disorder, recurrent

F34 – Persistent mood [affective] disorders

F39 – Unspecified mood [affective] disorder

Phobic Anxiety and Other Anxiety Disorders


F40 – Phobic anxiety disorders

F40.00 – Agoraphobia, unspecified

F40.01 – Agoraphobia with panic disorder

F40.02 – Agoraphobia without panic disorder

F40.1 – Social phobias (Social anxiety disorder)

F40.10 – Social phobia, unspecified

F40.11 – Social phobia, generalized

F40.2 – Specific (isolated) phobias

F41 – Other anxiety disorders

F41.0 – Panic disorder

F41.1 – Generalized anxiety disorder

Obsessive-compulsive disorders


F42 – Obsessive-compulsive disorder

F42.2 – Obsessive-compulsive disorder with mixed obsessional thoughts and acts

F42.3 – Hoarding disorder

F42.4 – Excoriation (skin-picking) disorder

F42.8 – Other obsessive-compulsive disorder

F42.9 – Obsessive-compulsive disorder, unspecified

Reaction to severe stress and adjustment disorders


F43 – Acute stress disorder; reaction to severe stress, and

adjustment disorders

F43.10 – Post traumatic stress disorder, unspecified

F43.2 – Adjustment disorders

F44 – Dissociative and conversion disorders

F44.81 – Dissociative identity disorder

F45 – Somatoform disorders

F45.22 – Body dysmorphic disorder

F48 – Other non-psychotic mental disorders

Behavioral syndromes associated with physiological disturbances and physical factors


F50 – Eating disorders

F51 – Sleep disorders not due to a substance or known

physiological condition

Disorders of adult personality and behavior


F60.0 – Paranoid personality disorder

F60.1 – Schizoid personality disorder

F60.2 – Antisocial personality disorder

F60.3 – Borderline personality disorder

F60.4 – Histrionic personality disorder

F60.5 – Obsessive-compulsive personality disorder

F60.6 – Avoidant personality disorder

F60.7 – Dependent personality disorder

F60.8 – Other specific personality disorders

F60.9 – Personality disorder, unspecified

F63.3 – Trichotillomania

F70–F79 – Intellectual disabilities

F80–F89 – Pervasive and specific developmental disorders

Behavioral and emotional disorders with onset usually occurring in childhood and adolescence


F90 – Attention-deficit hyperactivity disorders

F91 – Conduct disorders

F93 – Emotional disorders with onset specific to childhood

F93.0 – Separation anxiety disorder of childhood

F94 – Disorders of social functioning with onset specific to

childhood or adolescence

F94.0 – Selective mutism

F94.1 – Reactive attachment disorder of childhood

F94.2 – Disinhibited attachment disorder of childhood

F95 – Tic disorder

F98 – Other behavioral and emotional disorders with onset

usually occurring in childhood and adolescence

F99 – Unspecified mental disorder

Z codes – Persons with potential health hazards related to socioeconomic and psychosocial circumstances


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

Z65 – Problems related to other psychosocial

circumstances


SUBSTANCE USE DIAGNOSES

 Diagnosed?

Alcohol related disorders

 

F10.10 – Alcohol abuse, uncomplicated

F10.11 – Alcohol abuse, in remission

F10.20 – Alcohol dependence, uncomplicated

F10.21 – Alcohol dependence, in remission

F10.9 – Alcohol use, unspecified

Opioid related disorders

 

F11.10 – Opioid abuse, uncomplicated,

F11.11 – Opioid abuse, in remission

F11.20 – Opioid dependence, uncomplicated

F11.21 – Opioid dependence, in remission

F11.9 – Opioid use, unspecified

Cannabis related disorders

 

F12.10 – Cannabis abuse, uncomplicated

F12.11 – Cannabis abuse, in remission

F12.20 – Cannabis dependence, uncomplicated

F12.21 – Cannabis dependence, in remission

F12.9 – Cannabis use, unspecified

Sedative, hypnotic, or anxiolytic related disorders

 

F13.10 – Sedative, hypnotic, or anxiolytic abuse, uncomplicated

F13.11 – Sedative, hypnotic, or anxiolytic abuse, in remission

F13.20 – Sedative, hypnotic, or anxiolytic dependence, uncomplicated

F13.21 – Sedative, hypnotic, or anxiolytic dependence, in remission

F13.9 – Sedative, hypnotic, or anxiolytic-related use, unspecified

Cocaine related disorders

 

F14.10 – Cocaine abuse, uncomplicated

F14.11 – Cocaine abuse, in remission

F14.20 – Cocaine dependence, uncomplicated

F14.21 – Cocaine dependence, in remission

F14.9 – Cocaine use, unspecified

Other stimulant related disorders

 

F15.10 – Other stimulant abuse, uncomplicated

F15.11 – Other stimulant abuse, in remission

F15.20 – Other stimulant dependence, uncomplicated

F15.21 – Other stimulant dependence, in remission

F15.9 – Other stimulant use, unspecified

Hallucinogen related disorders

 

F16.10 – Hallucinogen abuse, uncomplicated

F16.11 – Hallucinogen abuse, in remission

F16.20 – Hallucinogen dependence, uncomplicated

F16.21 – Hallucinogen dependence, in remission

F16.9 – Hallucinogen use, unspecified

Inhalant related disorders

 

F18.10 – Inhalant abuse, uncomplicated

F18.11 – Inhalant abuse, in remission

F18.20 – Inhalant dependence, uncomplicated

F18.21 – Inhalant dependence, in remission

F18.9 – Inhalant use, unspecified

Other psychoactive substance related disorders

 

F19.10 – Other psychoactive substance abuse, uncomplicated

F19.11 – Other psychoactive substance abuse, in remission

F19.20 – Other psychoactive substance dependence, uncomplicated

F19.21 – Other psychoactive substance dependence, in remission

F19.9 – Other psychoactive substance use, unspecified

Nicotine dependence

 

F17.20 – Nicotine dependence, unspecified

F17.21 – Nicotine dependence, cigarettes



For BASELINE and REASSESSMENT:

  • If an interview WAS conducted, go to Section A.

  • If an interview WAS NOT conducted go to Section H.

For a CLINICAL DISCHARGE:

  • If an interview WAS conducted, go to Section A.

  • If an interview WAS NOT conducted, go to Section H.





A. FUNCTIONING

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

 Excellent

 Very Good

 Good

 Fair

Poor

No response/refused

  1. To provide the best mental health and related services, we need to know how well you [your child] were able to deal with everyday life during the past thirty days. Please indicate your [your child’s] response to each of the following statements:

    During the past 30 days ….

    Yes

    No

    No Response/Refused

    2.a. I am [my child is] handling daily life.

    2.b. I am [my child is] able to deal with unexpected events in my life.

    2.c. I [my child does] get along with friends and other people.

    2.d. I [my child does] get along with family members.

    2.e. I [my child does] do well in social situations.

    2.f. I [my child does] do well in school and/or work.

    2.g. I do [my child does] have had a safe place to live.

  2. The following questions ask about how you [your child] has been feeling during the past 30 days. Please indicate your response to each question:

During the past 30 days, did you [your child] feel

Yes

No

No Response /Refused

3.a. Nervous?

3.b. Hopeless?

3.c. Restless or fidgety?

3.d. So depressed that nothing could cheer you [your child] up?

3.e. That everything was an effort?

3.f. Worthless?

3.g. Bothered by psychological or emotional problems?


















B. STABILITY IN HOUSING


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

Yes

No

No Response/Refused

  1. Been homeless

  1. Spent time in a hospital for mental health care

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

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

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

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

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

[Do not read response options to the client. Select only one.]

    • Private residence

    • Foster home

    • Residential care

    • Crisis residence

    • Residential treatment center

    • Institutional setting

    • Jail/correctional facility

    • Homeless/shelter

    • Other (SPECIFY)

    • Don’t know


C. EDUCATION AND EMPLOYMENT

    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 12TH GRADE

      • 12TH 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

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

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

      • Employed, part-time

      • Unemployed –but looking for work

      • Not Employed, NOT looking for work

      • Not working due to a disability

      • Retired, not working

      • Other (SPECIFY)

      • Refused

      • Don’t know

    4. In the past 30 days , did you …

Statement

Yes

No

No response or Refused

4.a. Have you enough money to meet your [your child’s] needs?


___________________________
1
For information on federal minimum wage, go to https://www.dol.gov/general/topic/wages


D. CRIME AND CRIMINAL JUSTICE STATUS

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

Statement

Yes

No

No response/refused

D.1.a. Been arrested?

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



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

Statement

Yes

No

No response/refused

D.2.a. Been arrested?

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


If this is a BASELINE assessment, go to Section F.



If this is a REASSESSMENT or a CLINICAL DISCHARGE assessment, go to Section E.



E. PERCEPTION OF CARE

Go to Section F if this is a BASELINE assessment

Section E data is collected only for the REASSESSMENT interview and the CLINICAL DISCHARGE assessment.

  1. In order to provide the best possible mental health and related services, we need to know what you [your child] thinks about the services you received during the past 30 days, the people who provided it, and the results. Please indicate your disagreement/agreement with each of the following statements.

[Read each statement to the client/consumer, followed by the response options]

Statement




yes

No

No response / Refused

  1. Staff here believe that I [my child] can grow, change, and recover.

  1. I [my child] felt free to complain.

  1. I [my child] was given information about my rights.

  1. Staff encouraged me [my child] to take responsibility for how I live my life.

  1. Staff told me [my child] what side effects to watch out for.

  1. Staff respected my [my child’s] wishes about who is and who is not to be given information about my treatment.

  1. Staff were sensitive to my [my child’s] cultural background (e.g., race, religion, language).

  1. Staff helped me [my child] obtain the information I [my child] needed so that I [my child] could take charge of managing my [his/her] illness.

  1. I [my child] was encouraged to use consumer-run programs (support groups, drop-in centers, crisis phone line, etc.).

  1. I [my child] felt comfortable asking questions about my treatment and medication.

  1. I, not staff, decided my treatment goals.

  1. I [my child] like[s] the services received here.

  1. I [my child] would still get services from this agency if there were other choices.

  1. I would recommend this agency to a friend or family member.

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)



F. SOCIAL CONNECTEDNESS

    1. Please indicate YES or NO for each of the following statements. Please answer for relationships with persons other than your mental health provider(s) over the past 30 days.

[Read each statement to the client/consumer, followed by the response options]

STATEMENT




Yes

No

No response / Refused

  1. I [my child is] am happy with my [their] friendships.




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

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

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

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

f. I [my child] generally accomplishes what I [they] set out to do.


Shape41 If your program does not require Section G and this is a …

  1. BASELINE ASSESSMENT, stop now – the interview is completed

  2. REASSESSMENT interview – go to Section H.

  3. CLINICAL DISCHARGE interview assessments go to Section H.



IF YOUR PROGRAM DOES REQUIRE SECTION G, and this is a …

  1. BASELINE interview – go to Section G and then stop. The interview has been completed.

  2. REASSESSMENT interview: go to Section G, and then to Section H.

  3. CLINICAL DISCHARGE interview – go to Section G, and then Section H.


G. PROGRAM-SPECIFIC QUESTIONS

You are not responsible for collecting data on all Section G questions. Your GPO will provide guidance on which specific Section G questions you are to complete. If you have any questions, please contact your GPO.




G1. PROGRAM-SPECIFIC QUESTIONS: ASSISTED OUTPATIENT TREATMENT

Question 1 should be asked of the client/consumer at BASELINE, REASSESSMENT, and CLINICAL DISCHARGE.

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

    • Yes

    • No

    • Refused

    • Not applicable


Question 2 should be answered by grantee staff at REASSESSMENT and CLINICAL DISCHARGE.


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


  • Yes

  • No

  • Refused

  • Not applicable



If this is a BASELINE assessment, stop here.

If this is a REASSESSMENT, go to Sections H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.



G2. PROGRAM-SPECIFIC QUESTIONS: LAW ENFORCEMENT AND BEHAVIORAL HEALTH PARNTERSHIPS FOR EARLY DIVERSION

Questions 1 and 2 should be answered by grantee at

BASELINE, REASSESSMENT, and CLINICAL DISCHARGE.

1. Was the consumer referred to mental health services?

YES NO

 

    1. [IF YES] Did they receive mental health services?

YES NO OTHER

 

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

YES NO

 

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

YES NO OTHER

 


Question 3 should be answered by the client/consumer only at REASSESSMENT and CLINICAL DISCHARGE.

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

  • Yes

  • No

  • No response

  • Refused



If this is a BASELINE assessment, stop here.

If this is a REASSESSMENT, go to Section H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.


G3. PROGRAM-SPECIFIC QUESTIONS: PROMOTING THE INTEGRATION OF PRIMARY AND BEHAVIORAL HEALTH CARE

Questions should be answered by the client/consumer at BASELINE, REASSESSMENT, and CLINICAL DISCHARGE.


1. In the past 30 days, have you ….

Yes

No

Refused

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

|

b. Been hospitalized overnight for a physical healthcare problem?

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

Program-Specific Health Items

  1. Health measurements (Report Quarterly)

    a.

    Systolic blood pressure

     

    mmHg

    b.

    Diastolic blood pressure

     

    mmHg

    c.

    Weight

     

    kg

    d.

    Height

     

    cm

    f.

    Breath CO for smoking status

     

    ppm

  2. Blood test results (Report at Baseline, Reassessment, & Clinical Discharge). For b or c, please choose one only.

a. Date of blood draw: |____|____| / |____|____| / |____|____|____|____|
MONTH DAY YEAR

b.

Fasting plasma glucose

 

mg/dL

c.

HgBA1c

 

%

d.

Total Cholesterol

 

mg/dL

e.

LDL Cholesterol

 

mg/dL


If this is a BASELINE assessment, stop here.

If this is a REASSESSMENT, go to Section H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.




G4. PROGRAM-SPECIFIC QUESTIONS: MINORITY AIDS – SERVICE INTEGRATION

Questions should be asked by grantee staff at BASELINE, REASSESSMENT, and CLINICAL DISCHARGE



1a. Did the program provide an HIV test?

  • Yes

  • No [SKIP TO G1b.]

  • REFUSED [SKIP TO G1b.]

  • DON’T KNOW [SKIP TO G1b.]

[IF YES] What was the result?

  • Positive

  • Negative [SKIP TO G1b.]

  • Indeterminate [SKIP TO G1b.]

  • REFUSED [SKIP TO G1b.]

  • DON’T KNOW [SKIP TO G1b.]

[IF CONSUMER SCREENED POSITIVE] Were you connected to HIV treatment services?

  • Yes

  • No

  • REFUSED

  • DON’T KNOW

1b. Did the program provide a Hepatitis B (HBV) test?

  • Yes

  • No [SKIP TO G1c.]

  • REFUSED [SKIP TO G1c.]

  • DON’T KNOW [SKIP TO G1c.]

[IF YES] What was the result?

  • Positive

  • Negative [SKIP TO G1c.]

  • Indeterminate [SKIP TO G1c.]

  • REFUSED [SKIP TO G1c.]

  • DON’T KNOW [SKIP TO G1c.]

[IF CONSUMER SCREENED POSITIVE] Were you connected to HBV treatment services?

  • Yes

  • No

  • REFUSED

  • DON’T KNOW

1c. Did the program provide a Hepatitis C (HCV) test?

  • Yes

  • No [SKIP TO G2a.]

  • REFUSED [SKIP TO G2a.]

  • DON’T KNOW [SKIP TO G2a.]

[IF YES] What was the result?

  • Positive

  • Negative [SKIP TO G2a.]

  • Indeterminate [SKIP TO G2a.]

  • REFUSED [SKIP TO G2a.]

  • DON’T KNOW [SKIP TO G2a.]

[IF CONSUMER SCREENED POSITIVE] Were you connected to HCV treatment services?

  • Yes

  • No

  • REFUSED

  • DON’T KNOW


2a. [If HIV STATUS IS POSITIVE] Did you receive a referral form from [INSERT GRANTEE NAME] to medical care?

  • Yes

  • No

  • REFUSED

  • DON’T KNOW


2b. Have you been prescribed an Antiretroviral Medication (ART)?

  • Yes

  • No

  • REFUSED

  • DON’T KNOW


[FOR CONSUMERS WHO REPORT BEING PRESCRIBED AN ART] In the past 30 days, how often have you taken your ART as prescribed to you?

  • Always

  • Usually

  • Sometimes

  • Rarely

  • Never

  • Refused

  • DON’T KNOW

  • NOT APPLICABLE


Shape42

If this is a BASELINE assessment, stop here.


If this is a REASSESSMENT, go to Section H.


If this is a CLINICAL DISCHARGE assessment, go to Section H.


[IF THE PRESCRIPTION WAS GIVEN FOR THE FIRST TIME AT THIS APPOINTMENT, SELECT NOT APPLICABLE.]



Shape43 G5. PROGRAM-SPECIFIC QUESTIONS: HEALTHY TRANSITIONS

Questions should be answered by grantee staff at BASELINE, REASSESSMENT and CLINICAL DISCHARGE.

1. Was the consumer referred to mental health services?

YES NO

 

      1. [IF YES] Did they receive mental health services?

YES NO OTHER

 

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

YES NO

 

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

YES NO OTHER

 


If this is a BASELINE assessment, stop here.

If this is a REASSESSMENT, go to Section H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.


G6. PROGRAM-SPECIFIC QUESTIONS: ASSERTIVE COMMUNITY TREATMENT


Shape44

Questions 1 and 2 should be answered by the consumer/client at REASSESSMENT and CLINICAL DISCHARGE

  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

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

  • Yes

  • No

  • Refused

  • Not applicable


If this is a BASELINE assessment, stop here.

If this is a REASSESSMENT, go to Section H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.



G7. PROGRAM-SPECIFIC QUESTIONS: CLINICAL HIGH RISK FOR PSYCHOSIS

Question 1 should be answered by grantee staff at REASSESSMENT and CLINICAL DISCHARGE.

  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.

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


If this is a BASELINE assessment, stop here.

If this is a REASSESSMENT, go to Section H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.


G8 PROGRAM-SPECIFIC QUESTIONS: CERTIFIED COMMUNITY BEHAVIORAL HEALTH CLINICS

Program specific health items are reported by Grantee Staff about the client/consumer at BASELINE, REASSESSMENT, and CLINICAL DISCHARGE.

    1. During the past 30 days, did the client/consumer receive the following services?

      • Crisis mental health services _____ Yes _____ No

      • Screening, assessment, diagnosis _____ Yes _____ No

      • Patient-centered treatment planning _____ Yes _____ No

      • Outpatient mental health services _____ Yes _____ No

      • Physical health screening/monitoring _____ Yes _____ No

      • Targeted case management _____ Yes _____ No

      • Psychiatric rehabilitation services _____ Yes _____ No

      • Peer support services _____ Yes _____ No

      • Family psychoeducation and support _____ Yes _____ No

      • Services for veterans and military members _____ Yes _____ No

    2. Health measurements: (Report quarterly)

a.

Systolic blood pressure

 

mmHg

b.

Diastolic blood pressure

 

mmHg

c.

Weight

 

kg

d.

Height

 

cm



If this is a BASELINE assessment, stop here.

If this is a REASSESSMENT, go to Section H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.


























Shape45 G9 PROGRAM-SPECIFIC QUESTIONS: NATIONAL CHILD TRAUMATIC STRESS INITIATIVE – CATEGORY 3

Questions should be answered by the client/consumer or caregiver REASSESSMENT,

and CLINICAL DISCHARGE.



Read each statement below to the client/consumer or caregiver and note the responses.

STATEMENT 





Yes

No

No response

Not applicable

1. As a result of treatment and services received, my [my child’s] trauma and/or loss experiences were identified and addressed.

2. As a result of treatment and services received for trauma and/or loss experiences, my [my child’s] problem behaviors/symptoms have decreased.


If this is a REASSESSMENT, go to Section H.

If this is a CLINICAL DISCHARGE assessment, go to Section H.



H. SERVICES RECEIVED AND CLINICAL DISCHARGE STATUS

Question 1 is reported by Grantee Staff about the client/consumer at REASSESSMENT and CLINICAL DISCHARGE only.


  1. On what date did the consumer last receive services?


|___|___| / |___|___|___|___|

MONTH YEAR

Identify all the services your grant project provided to the client/consumer during their participation in the program. This includes grant-funded and non-grant funded services.

Core Services

Provided

UNKNOWN

SERVICE
NOT AVAILABLE

Yes

No

  1. Screening

  1. Assessment

  1. Treatment Planning or Review

  1. Psychopharmacological Services

  1. Mental Health Services









  1. Co-occurring Services

  1. Case Management

  1. Trauma-specific Services

  1. Was the consumer referred to another provider for any of the above core services?


Support Services

Provided

UNKNOWN

SERVICE
NOT AVAILABLE

Yes

No

  1. Medical Care

  1. Employment Services

  1. Family Services

  1. Child Care

  1. Transportation

  1. Education Services

  1. Housing Support

  1. Social Recreational Activities

  1. Consumer-Operated Services

  1. HIV Testing

  1. Was the consumer referred to another provider for any of the above support services?

Shape46

Questions 2 and 3 are reported by Grantee Staff about the client/consumer at CLINICAL DISCHARGE only




  1. On what date was the consumer discharged?

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

  1. What is the consumer’s discharge status?

Mutually agreed cessation of treatment

      • Withdrew from/refused treatment

No contact within 90 days of last encounter

Clinically referred out

Death

Other (Specify)



Page 1 of 49


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleCMHS NOMs Client-Level Services Tool for Adults
SubjectCMHS NOMs Client-Level Services Tool for Adults revised March 2019
AuthorSubstance Abuse and Mental Health Services Administration
File Modified0000-00-00
File Created2022-08-17

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