Form 3 Rural Communities Opioid Response Program – MAT Access

OMB Number: 0906-0044
Expiration Date: XX/XX/202X

RCORP-MAT Access Measures (Draft –
Pending OMB Approval)
SERVICE AREA AND CONSORTIUM
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1

Measure Instructions
Identify the number and types of
partner organizations
participating in the RCORP-MAT
Access project

Measure
• Hospital - Critical Access Hospital (CAH)
• Hospital - Small Rural (49 beds or
less, non-CAH) or other (e.g., Sole
Community, Rural Referral Center,
etc.)
• Emergency medical services entity
• Federally Qualified Health Center (FQHC)
• HIV and HCV prevention, testing, or
treatment organization
• First responder – Law enforcement/ EMT
• Criminal justice entity (e.g., Court system,
Prison, Probation and parole)
• Local or state health department
• Mental and behavioral health
organization, practice, or
provider
• Primary care practice or provider
• Rural Health Clinic
• Ryan White HIV/AIDS clinic
• Substance abuse treatment provider
– Methadone clinic
• Substance abuse treatment provider
– Opioid treatment program (OTP non-methadone)
• Substance abuse treatment provider
– Other
• Recovery Community Organization (RCO)
• Maternal, Infant, and Early Childhood
organization
• Pharmacy
• Faith-based organization
• Community Based Organization
• Single State Agency (SSA)
• State Office of Rural Health (SORH)
• Tribe/Tribal organization
• Maternal, Infant, and Early
Childhood Home Visiting Program
local implementation agency
• Research / Academic Organization
• School system
• Other agency or organization, Type
1- Specify:
• Other agency or organization, Type
2- Specify

OMB Number: 0906-0044
Expiration Date: XX/XX/202X

RCORP-MAT Access Measures (Draft –
Pending OMB Approval)

2

Select the option that best
describes your project’s service
area

3

Please report the total number
of people that live in the
project’s rural service area.

4

Please report the total
unduplicated number of service
delivery sites within applicant
organization and any partner
organization in the target rural
service area offering at least one
prevention, treatment and/or
recovery service within the
current
reporting period.
For each of the following
services, please report the total
number of service delivery sites
within the applicant
organization and any partner
organization in the target rural
service area that offered that
service within the current
reporting period. If no service
delivery sites offered the service,
please input 0.
Report the total unduplicated
number of service delivery sites
within the applicant
organization and any partner
organization in the target rural
service area offering at least one
harm reduction service within
the
current reporting period.
For each of the following harm
reduction services, please report
the total number of service
delivery sites within the
applicant organization and any
partner organization in the
target rural service area that
offered that service within the
current reporting period. If no
service delivery sites offered the

5

6

7

•

Other agency or organization, Type 3Specify

•
•
•
•
•
•

Single County
Multiple Counties
State
Multiple States
National
Total population in the project’s rural
service area

•

Total number of unduplicated service
delivery sites offering at least one
prevention, treatment and/or recovery
service

•
•
•

Prevention services
Screening and/or assessment services
Medication-Assisted Treatment (with
or without psychosocial)
SUD/OUD treatment other than MAT
Infectious disease testing (i.e., HIV or HCV)
Recovery support services
Mental health treatment
Other - specify

•
•
•
•
•
•

Total number of unduplicated
service delivery sites offering
at least one harm reduction
service

•
•
•
•
•
•

Naloxone access
Syringe services
Fentanyl test strips
Safe smoking kits
Sex worker services
Other - specify

OMB Number: 0906-0044
Expiration Date: XX/XX/202X

RCORP-MAT Access Measures (Draft –
Pending OMB Approval)
service, please input 0.

8

For each service listed, select
whether it was newly established
with or without RCORP- MAT
Access funds, expanded with or
without RCORP-MAT Access
funds, remained the same, or did
not exist in the current reporting
period (dropdown).

9

Please report the number and
type of MAT access points
established and/or supported by
RCORP-MAT Access funding
during this current reporting
period

Prevention service (any except naloxone)
Naloxone access
Screening and/or assessment service
MAT (with or without psychosocial therapy)
SUD/OUD treatment other than MAT
Mental health treatment
Infectious disease testing (i.e., HIV or HCV)
Recovery support services (any)
Harm reduction services (any except
naloxone)
• Other – please specify
________Correctional Facility
•
•
•
•
•
•
•
•
•

________Federally Qualified Health Center
(FQHC)
________Health Clinic (not an FQHC or Rural
Health Clinic)
________Hospital (not including emergency
rooms)
________Emergency Department
________Mobile Unit
________Outpatient Substance Use Treatment
________Parole and Reentry Agency
________Pharmacy
________Primary Care Practice
________Rural Health Clinic
________Other-please specify

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11

NOTE: Sustainability measures
only reported in final reporting
period of the grant (Sept. 2024)
Will MAT services be sustained
after the RCORP MAT Access
grant ends?
If you selected yes, how will the
activity or activities be
sustained? (check all that apply)

•
•
•

•
•
•
•
•

Yes

No

Absorption of services or other means of
in- kind support
Reimbursement by third party payers
RCORP grant funding
HRSA grant funding (not including
RCORP grants)
Other grant funding (not including
HRSA and RCORP grant funding)

OMB Number: 0906-0044
Expiration Date: XX/XX/202X

RCORP-MAT Access Measures (Draft –
Pending OMB Approval)
•
•
•
•
•
•
•

Fees
Applying for an 11-15 waiver
Changing Medicaid formularies
Increasing insurance reimbursement (both
costs covered and new insurance payers)
Becoming a line item in a state or local
budget
Creating certification/licensing programs
to facilitate workforce payments (e.g.,
peer recovery specialists)
Other: please describe (text box)

DIRECT SERVICES
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Measure Instructions
Measure
Please report the total number of Total number of individuals screened for SUD
individuals
who have been screened for
substance use disorder (SUD) in
the current reporting
period.
Please report the total number of Total number of individuals who screened
individuals who screened
positive for SUD
positive for SUD, or at risk for
overuse/misuse, in the current
reporting period.

OMB Number: 0906-0044
Expiration Date: XX/XX/202X

RCORP-MAT Access Measures (Draft –
Pending OMB Approval)
14

Please report the total number of Total number of individuals who were
individuals who were screened
screened for mental health disorder
for mental health disorders using
an age-appropriate standardized
tool

15

Please report the total number of Total number of individuals who were tested
individuals who were tested for for HIV/AIDS
HIV/AIDS

16

Please report the total number of Total number of individuals who were tested
individuals who were tested for for HCV
HCV

OMB Number: 0906-0044
Expiration Date: XX/XX/202X

RCORP-MAT Access Measures (Draft –
Pending OMB Approval)
17

Please report the total number of Total number of individuals who received
individuals who received recovery recovery support services
support services in
the current reporting period.

18

Please report the number of
individuals who were referred to
treatment and/or support
services.

19

For each MAT access point type
you established and/or supported
during this reporting period,
report the total number of
patients who received MAT
services at each site.

Total number of individuals who were referred
to treatment and/or support services _____
• Number of individuals who were referred to
SUD treatment
• Number of individuals referred to childcare
services
• Number of individuals referred to
employment services
• Number of individuals referred to recovery
housing services
• Number of individuals referred to
prenatal/postpartum care services
• Number of individuals referred to
transportation to treatment
• Number of individuals referred to traumainformed services
• • Other – specify
________Correctional Facility
________Federally Qualified Health Center
(FQHC)
________Health Clinic (not an FQHC or Rural
Health Clinic)
________Hospital (not including emergency
rooms)
________Emergency Department
________Mobile Unit
________Outpatient Substance Use Treatment
________Parole and Reentry Agency
________Pharmacy
________Primary Care Practice

OMB Number: 0906-0044
Expiration Date: XX/XX/202X

RCORP-MAT Access Measures (Draft –
Pending OMB Approval)
________Rural Health Clinic
________Other-please specify
20

21

Please report the total number of
patients who have received MAT
(including medication AND
psychosocial therapy) for a period
of three months or more without
interruption
What MAT medications (drug
name and form) have you
prescribed/distributed through
your organization or at least one
partner in your HRSA-designated
rural service area during the
current reporting period? (select
all that apply)

Number of patients who have received MAT for
three months or more without interruption

[ ] Acamprosate (delayed-release tablets)
[ ] Buprenorphine, sublingual tablets (e.g.,
Subutex)
[ ] Buprenorphine, extended-release
subcutaneous injection (e.g., Sublocade)
[ ] Buprenorphine, implant for subdermal
administration (e.g., Probuphine)
[ ] Buprenorphine with Naloxone, sublingual
film (e.g., Suboxone film, Cassipa)
[ ] Buprenorphine with Naloxone, buccal film
(e.g., Bunavail)
[ ] Buprenorphine with Naloxone, sublingual
tablets (e.g., Zubsolv)
[ ] Disulfiram
[ ] Methadone, oral tablets (e.g., Dolophine)
[ ] Methadone, oral concentrate (e.g.,
Methadose)
[ ] Naltrexone, oral tablets (e.g., ReVia,
Depade)
[ ] Naltrexone, extended-release injection
(e.g., Vivitrol)
[ ] Other (please specify): _
[ ] None of the above

OMB Number: 0906-0044
Expiration Date: XX/XX/202X

RCORP-MAT Access Measures (Draft)

DEMOGRAPHICS
These tables collect demographic information for all individuals who have received direct services for
SUD/OUD use disorder, within the current reporting period in the project’s rural service area. The total
number of each sub-section should equal the total number of individuals who have received direct
services within the current reporting period. Each sub-section should total to the same amount. Please
do not leave any sections blank or use N/A (not applicable) since the measures are applicable to all
RCORP grantees providing direct services. If the number for a particular category is zero (0), please put
zero in the appropriate section (e.g., if the total number that is Hispanic or Latino is zero (0), enter zero
in that section). If data are incomplete or have other limitations, please enter the data you have,
indicate the data have limitations, and explain those limitations in the comments box below.

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22

Measure Instructions
Please report the number of
individuals
served, by ethnicity, during the
current reporting period.

23

Please report the number of
individuals served, by race, during
the current reporting period.

24

Please report the number of
individuals served, by age, during
the current reporting period.

25

Please report the number of
individuals served, by
insurance status, during the
current reporting period.

Measure
• Hispanic or Latino
• Not Hispanic or Latino
• Unknown
• Total
• American Indian or Alaska Native
• Asian
• Black or African American
• Native Hawaiian or Other Pacific
Islander
• White
• More than one race
• Unknown
• Total
• 0-12
• 13-17
• 18-24
• 25-34
• 35-44
• 45-54
• 55-64
• 65 and over
• Total
• Self-pay
• None/Uninsured
• Dual Eligible (covered by both
Medicaid and
Medicare)
• Medicaid/CHIP only
• Medicare only
• Medicare plus supplemental
• TriCARE
• Other third party (e.g., privately
insured)

OMB Number: 0906-0044
Expiration Date: XX/XX/202X

RCORP-MAT Access Measures (Draft)
•
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27

Unknown
Total

Please report the number of
• Male
individuals served, by sex, during the • Female
• Unknown
current reporting period
• Total
Please report the number of
• LGBTQI+
individuals served, by LGBTQI+,
• Non-LGBTQI+
during the current reporting period • Unknown
• • Total
WORKFORCE

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Measure Instructions
Measure
Please report the total number of
• Total number of unduplicated
providers (i.e., individuals) within
unduplicated providers within the
the applicant organization and
applicant organization and any
any partner organization who
partner organization who provided
provided SUD/OUD treatment
SUD/OUD treatment services,
services, behavioral health
behavioral health services, and/or
services, and/or recovery
recovery support services in the
support services in the target
target rural service area in the
rural service area in the current
current reporting period. Of the
reporting period.
total number of providers, please
• Total number of providers newly
also report how many were newly
hired with RCORP-MAT Access
hired with grant funds (e.g., their
grant funds
salary was paid for in full or in
part with RCORP-MAT Access grant
funds) during the current reporting
period.
Total number of providers (i.e.,
Please report the total number of
individuals) who have a DATA waiver
providers (i.e., individuals) within
the applicant organization and any
partner organization who have a
DATA waiver to prescribe
buprenorphine-containing products
for
medication-assisted treatment (MAT)
within the target rural service area
Please report the total number of
• Total number of providers (i.e.,
providers
individuals) who have prescribed
medications used to treat OUD
(i.e. individuals) within the applicant
organization and any partner
• Total number of providers (i.e.,
organization who have prescribed
individuals) who have prescribed
medications used to treat
medications used to treat AUD
OUD and/or AUD during the current
reporting period.

OMB Number: 0906-0044
Expiration Date: XX/XX/202X

RCORP-MAT Access Measures (Draft)
31

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Please report the total number of
• Total Number of Providers
providers (i.e., individuals) within
• Number of Medical Providers
the applicant organization and any
• Number of Non-Medical Counseling
partner organization who have
Staff
provided SUD/OUD treatment
services, including MAT, during the • Number of Peer
Recovery Support
current reporting period in the target
Specialists
rural service area. Of those
providers, please specify how many • Other – specify
were medical providers, nonmedical counseling staff, peer
recovery support specialists, or other
(specify).
Report the total number of SUD
• Number of ACES trainings
and/or mental health disorder
• Number of contingency management
trainings conducted in the current trainings
reporting period as a result of RCORP • Number of behavioral therapy
funding in the target rural service
trainings
area. For each topic area, please
• Number of mental health first aid
provide the number of trainings in
trainings
each category.
• Number of Naloxone trainings
• Number of Opioid prescribing
guidelines trainings
• Number of school-based evidencebased practices trainings
• Number of stigma reduction trainings
• Number of trauma-informed
evidence-based practices trainings
• Other - specify
Please report the percentage of MAT Percentage of MAT services currently
service costs (including medication, covered through reimbursement or
psychosocial therapy, and wrapother non-grant funding sources
around services) covered through
reimbursement (e.g. by Medicaid,
Medicare, private insurance) or
other non- grant funding sources
during the past 6- months:
• Numerator: all costs associated
with MAT services that were
reimbursed or paid for by other
non-grant funding sources.
• Denominator: total costs
associated with MAT services.

OMB Number: 0906-0044
Expiration Date: XX/XX/202X

RCORP-MAT Access Measures (Draft)

PREVALENCE
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Measure Instructions
Measure
Using the following scale, please
• Significantly increased
indicate the degree to which non- • Increased
fatal overdoses have changed within • Decreased
the current reporting period.
• Significantly Decreased
• No change
Using the following scale, please
• Significantly increased
indicate the degree to which fatal • Increased
overdoses have changed within the • Decreased
current reporting period.
• Significantly Decreased
• No change
Public Burden Statement: The purpose of this data collection is to provide data on each Rural Communities Opioid
Response Program initiative to enable HRSA to provide aggregate program data required by Congress under the
Government Performance and Results Act of 1993. 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 OMB control number. The OMB
control number for this project is 0906-0044 and it is valid until XX/XX/202X. Public reporting burden for this collection
of information is estimated to average 1.63 hours per response, including the time for reviewing instructions,
searching existing data sources, and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or
[email protected].