CMHS NOMs Tool_8-16-2022_ Tracked

Form Approved

OMB No. 0930-0285

Expiration Date 03/30/2025

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)

August 2202

Public reporting burden for this collection of information is estimated to average 20 minutes per response if all items are asked of a client/consumer/participant; to the extent that providers already obtain much of this information as part of their ongoing client/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.

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Table of Contents

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RECORD MANAGEMENT

RECORD 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
1a. [IF QUESTION 1 IS BASELINE] Enter the MONTH and YEAR when the client first received services under this grant for this episode of care.
|____|____| / |____|____|____|____| MONTH YEAR

2. birth?ofyear month andthe client’sis What

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

EARY MONTH

3. Was the assessment interview conducted?

Yes	No
3a. [IF QUESTION 3 IS YES] When? |____|____| / |____|____| /|____|____|____|____| MONTH DAY YEAR	3b. [IF QUESTION 3 IS NO]Why not? Choose only one. Not able to obtain consent from proxy Client was impaired or unable to provide consent Client refused this interview Client was not reached for interview Client refused all interviews

4. asW[CHILD ONLY] the respondent the child or the caregiver?

• Child

• Caregiver

BEHAVIORAL HEALTH DIAGNOSES

BEHAVIORAL HEALTH DIAGNOSES information is collected by grantee staff at BASELINE, REASSESSMENT and DISCHARGE, even when an assessment interview is not conducted.

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

• Yes

• No

• DON’T KNOW

1a. leaseP [IF QUESTION 1 IS NO] 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

1b. asW IF QUESTION 1 IS YES][ the screen positive?

• Yes

• No

• DON’T KNOW

2. Did the client have a positive suicide screen?

• Yes

• No

• DON’T KNOW

2a.Was 2 IS YES] QUESTION[IF a suicidal safety plan developed?

• Yes

• No

• DON’T KNOW

2b. Was 2 IS YES]QUESTION[IF access to lethal means assessed?

• Yes

• No

• DON’T KNOW

3. Behavioral Health Diagnoses

Please indicate the client’s current behavioral health diagnoses using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes listed below, as made by a clinician. 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 behavioral from the health diagnosesmental health, Z-codes, and substance use diagnoses below.

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	
MENTAL HEALTH DIAGNOSES	Diagnosed?
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	Diagnosed?
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	
Z codes – Persons with potential health hazards related to socioeconomic and psychosocial circumstances	Diagnosed?
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	
SUBSTANCE USE DIAGNOSES	Diagnosed?
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:

• If an interview WAS conducted, go to Demographic Data.

• If an interview WAS NOT conducted, STOP HERE.

For REASSESSMENT or CLINICAL DISCHARGE:

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

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

DEMOGRAPHIC DATA

DEMOGRAPHIC DATA are only collected at BASELINE. If this is NOT a BASELINE, go to Section A.

1. What do you consider yourself to be? [READ CHOICES.]

• Male

• Female

• Transgender (Male to Female)

• Transgender (Female to Male)

• Gender non-conforming

• OTHER (Specify) ______________________________

• REFUSED

2. Do you think of yourself as…

• Straight or Heterosexual

• Homosexual (Gay Or Lesbian)

• Bisexual

• Queer

• Pansexual

• Questioning

• Asexual

• Something Else? Please Specify ___________________________________

• REFUSED

3. Are you [is your child] Hispanic, Latino/a, or of Spanish origin?

 Yes

 No [SKIP TO QUESTION 4.]

 REFUSED [SKIP TO QUESTION 4.]

3a. [IF QUESTION 3 IS YES] What ethnic group do you [your child] consider yourself [themselves] ? You may indicate more than one.

• Central American

• Cuban

• Dominican

• Mexican

• Puerto Rican

• South American

• OTHER (Specify)________________________

• REFUSED

4. What is your [your child’s] race? You may indicate more than one.

• Black or African American

• White

• American Indian

• Alaska Native

• South Asian

• Chinese

• Filipino

• Japanese

• Korean

• Vietnamese

• Other Asian

• Native Hawaiian

• Guamanian or Chamorro

• Samoan

• Other Pacific Islander

• OTHER (Specify)___________________________

• REFUSED

5. [IF CLIENT 5 YEARS OLD OR OLDER] Do you [does your child] speak a language other than English at home?

• Yes

• No

• NOT APPLICABLE

5a. [IF CLIENT 5 YEARS OLD OR OLDER] [IF QUESTION 5 IS YES] What is this language?

• Spanish

• OTHER (Specify) ____________________________

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

• Yes

• No [GO TO SECTION A.]

• DON’T KNOW [GO TO SECTION A.]

• NOT APPLICABLE [GO TO SECTION A.]

7. [ADULT ONLY] [IF QUESTION 6 IS YES] Are you currently serving on active duty in the Armed Forces, the Reserves, or the National Guard?

• Yes

• No

• REFUSED

• DON’T KNOW

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

2. To provide the best mental health and related services, we need to know how well you were [your child was] able to deal with everyday life during the past 30 [thirty] days. Please indicate your [your child’s] response to each of the following statements:

[READ EACH STATEMENT TO THE CLIENT, FOLLOWED BY RESPONSE OPTIONS OF YES OR NO] OR CAREGIVER

During the past 30 [thirty] days ….	Yes	No	NO RESPONSE / REFUSED
a. I am [my child is] handling daily life.			
b. I am [my child is] able to deal with unexpected events in my [their] life.			
c. I [my child does] get along with friends and other people.			
d. I [my child does] get along with family members.			
e. I do [my child does] well in social situations.			
f. I do [my child does] well in school and/or work.			
g. I have [my child has] had a safe place to live.			

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

During the past 30 [thirty] days, did you [your child] feel …	Yes	No	NO RESPONSE / REFUSED
a. Nervous?			
b. Hopeless?			
c. Restless or fidgety?			
d. So depressed that nothing could cheer you [your child] up?			
e. That everything was an effort?			
f. Worthless?			
g. Bothered by psychological or emotional problems?			

B. STABILITY IN HOUSING

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

	Yes	No	NO RESPONSE / REFUSED
a. Been homeless?			
b. Spent time in a hospital for mental health care?			
c. Spent time in a facility for detox/inpatient treatment for a substance abuse disorder?			
d. Spent time in a correctional facility (e.g., jail, prison, [juvenile] facility)?			
e. Gone to an emergency room for a mental health or emotional problem?			
f. Been satisfied with the conditions of your living space?			

2. In the past 30 [thirty] days, where have you [has your child] 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 [is 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? [SELECT ONLY ONE]

   • 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? [SELECT ONLY ONE]

   • 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 [thirty] days, did you have enough money to meet your [your child’s] needs?

   • Yes

   • No

   • NO RESPONSE/REFUSED

D. CRIME AND CRIMINAL JUSTICE STATUS

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

	Yes	No	NO RESPONSE / REFUSED
a. Been arrested?			
b. Spent time in jail or a correctional facility or been on 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.

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

E. PERCEPTION OF CARE

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

[READ EACH STATEMENT TO THE CLIENT OR CAREGIVER, FOLLOWED BY RESPONSE OPTIONS OF YES OR NO]

Statement	Yes	No	NO RESPONSE/ REFUSED
Staff here believe that I [my child] can grow, change, and recover.			
I [my child] felt free to complain.			
I [my child] was given information about my [my child’s] rights.			
Staff encouraged me [my child] to take responsibility for how I [they] live my [their] life.			
Staff told me [my child] what side effects to watch out for.			
Staff respected my [my child’s] wishes about who is and who is not to be given information about my [my child’s] treatment.			
Staff were sensitive to my [my child’s] cultural background (e.g., race, religion, language).			
Staff helped me [my child] obtain the information I [my child] needed so that I [my child] could take charge of managing my [their] illness.			
I [my child] was encouraged to use consumer-run programs (support groups, drop-in centers, crisis phone line, etc.).			
I [my child] felt comfortable asking questions about my [their] treatment and medication.			
I [my child], not staff, decided my [my child’s] treatment goals.			
I [my child] like[s] the services received here.			
I [my child] would still get services from this agency if there were other choices.			
I [my child] would recommend this agency to a friend or family member.			

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

2. Indicate which grantee staff administered section E to the client 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 [your child’s] mental health provider(s) over the past 30 [thirty] days.

[READ EACH STATEMENT TO THE CLIENT OR CAREGIVER, FOLLOWED BY RESPONSE OPTIONS OF YES OR NO]

Statement	Yes	No	NO RESPONSE/ REFUSED
I am [my child is] happy with my [their] friendships.			
I have [my child has] people with whom I [they] can do enjoyable things.			
I feel [my child feels] that I [they] belong in the community.			
In a crisis, I [my child] would have the support needed from family or friends.			
I have [my child has] family or friends that are supportive of my [their] recovery.			
I [my child] generally accomplish]es[ what I [they] set out to do.			

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

BASELINE ASSESSMENT, stop now – the interview is completed.

REASSESSMENT interview or CLINICAL DISCHARGE – go to Section H.

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

BASELINE interview – go to Section G for your program and then stop.

REASSESSMENT interview or CLINICAL DISCHARGE interview:
go to Section G for your program, and then to Section H.

G. PROGRAM-SPECIFIC QUESTIONS

You are NOT responsible for collecting data on ALL Section G questions. Only complete the Section G which is specific to your program.

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. ASSISTED OUTPATIENT TREATMENT HYPERLINK \l "_G1._ASSISTED_OUTPATIENT" 

LAW ENFORCEMENT AND BEHAVIORAL HEALTH PARNTERSHIPS FOR EARLY DIVERSION HYPERLINK \l "_G2._LAW_ENFORCEMENT" 

PROMOTING THE INTEGRATION OF PRIMARY AND BEHAVIORAL HEALTH CARE HYPERLINK \l "_G3._PROMOTING_THE" 

MINORITY AIDS – SERVICE INTEGRATION HYPERLINK \l "_G4._MINORITY_AIDS" 

HEALTHY TRANSITIONS HYPERLINK \l "_G5._HEALTHY_TRANSITIONS" 

ASSERTIVE COMMUNITY TREATMENT HYPERLINK \l "_G6._ASSERTIVE_COMMUNITY" 

CLINICAL HIGH RISK FOR PSYCHOSIS HYPERLINK \l "_G7._CLINICAL_HIGH" 

CERTIFIED COMMUNITY BEHAVIORAL HEALTH CLINICS HYPERLINK \l "_G7._CERTIFIED_COMMUNITY" 

NATIONAL CHILD TRAUMATIC STRESS INITIATIVE – CATEGORY 3 HYPERLINK \l "_G9._NATIONAL_CHILD"

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