Form 2 Attachment C Program Specific Form

Training 02 PERFORMANCE MEASURE Goal: MCH Training Program and Healthy Tomorrows Cultural Responsiveness Level: Grantee Domain: MCH Workforce Development	The percent of MCHB training and Healthy Tomorrows programs that have incorporated cultural and linguistic responsiveness elements into their policies, guidelines, and training.
GOAL	To increase the percentage of MCH Training and Healthy Tomorrows programs that have integrated cultural and linguistic responsiveness into their policies, guidelines, and training, including elements that have been integrated from broader organizational initiatives.

MEASURE	The percent of MCHB training and Healthy Tomorrows programs that have integrated cultural and linguistic responsiveness into their policies, guidelines, and training.

DEFINITIONS	Attached is a checklist of 6 elements that demonstrate cultural and linguistic responsiveness. Please check yes or no to indicate if your MCH Training or Healthy Tomorrows program has met each element. Please keep the completed checklist attached. Cultural and linguistic responsiveness is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations. ‘Culture’ refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. ‘Responsiveness’ implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities. (Adapted from Cross, 1989; cited from National Center for Cultural Competence) Linguistic responsiveness is the capacity of an organization and its personnel to communicate effectively, and convey information in a manner that is easily understood by diverse audiences including persons of limited English proficiency, those who have low literacy skills or are not literate, and individuals with disabilities. Linguistic responsiveness requires organizational and provider capacity to respond effectively to the health literacy needs of populations served. The organization must have policy, structures, practices, procedures, and dedicated resources to support this capacity. (T. Goode and W. Jones, 2004. National Center for Cultural Competence) Cultural and linguistic responsiveness is a process that occurs along a developmental continuum. A culturally and linguistically responsive program is characterized by elements including the following: written strategies for advancing cultural responsiveness; cultural and linguistic responsiveness policies and practices; cultural and linguistic responsiveness knowledge and skills building efforts; research data on populations served according to racial, ethnic, and linguistic groupings; faculty and other instructors are racially and ethnically diverse; faculty and staff participate in professional development activities related to cultural and linguistic responsiveness; and periodic assessment of trainees’ progress in developing cultural and linguistic responsiveness. Note: This form utilizes DGIS Form 10.A for annual performance objective and data reporting.

BENCHMARK DATA SOURCES	Related to the following Healthy People 2030 Objectives: PHI-RO3: Increase the use of core and discipline-specific competencies to drive workforce development PHI-06: Increase the proportion of state public health agencies that use core competencies in continuing education. PHI-07: Increase the proportion of local public health agencies that use core competencies in continuing education

GRANTEE DATA SOURCES	Attached data collection form is to be completed by grantees. There is no existing national data source to measure the extent to which MCHB supported programs have incorporated cultural responsiveness elements into their policies, guidelines, and training.

SIGNIFICANCE	Over the last decade, researchers and policymakers have emphasized the central influence of cultural values and cultural/linguistic barriers: health seeking behavior, access to care, and racial and ethnic disparities. In accordance with these concerns, cultural responsiveness objectives have been: (1) incorporated into the Division of MCH Workforce Development priorities; and (2) in guidance materials related to the MCH Training and Healthy Tomorrows Programs. The Division of MCH Workforce Development provides support to programs that address cultural and linguistic responsiveness through development of curricula, research, learning and practice environments. This performance measure directly relates to MCHB Strategic Plan Objective 3.2: Support training and educational opportunities to create a diverse and culturally responsive MCH workforce, including professionals, community-based workers, and families.

DATA COLLECTION FORM FOR DETAIL SHEET: Training 02 – MCH Training Program and Healthy Tomorrows Cultural Responsiveness

Please indicate if your MCH Training or Healthy Tomorrows program has incorporated the following cultural/linguistic responsiveness elements into your policies, guidelines, and training, including elements that have been integrated from broader organizational initiatives.

Please use the space provided beneath each element to provide additional details or justification. If you selected “No – 0,” please specify any technical assistance needed on the element (500 character limit). If you selected “Yes – 1”), you may provide details on how your program met this element.

Element	Yes 1	No 0
Written Guidelines Strategies for advancing cultural and linguistic responsiveness are integrated into your training or Healthy Tomorrows program’s written plan(s) (e.g., grant application, recruiting plan, placement procedures, monitoring and evaluation plan, human resources, formal agreements, etc.).
Additional details:
Training Cultural and linguistic responsiveness knowledge and skills building are included in training aspects of your program.
Additional details:
Data Research or program information gathering includes the collection and analysis of data on populations served according to racial, ethnic, and linguistic groupings, where appropriate.
Additional details:
Staff/faculty cultural and linguistic diversity MCH Training Program or Healthy Tomorrows staff and faculty reflect cultural and linguistic diversity of the populations served (e.g., program has diverse faculty who work with trainees, program has efforts to recruit cultural and linguistically diverse staff and faculty).
Additional details:
Professional development MCH Training Program or Healthy Tomorrows staff and faculty participate in professional development activities to promote their cultural and linguistic competence.
Additional details:
Measurement of progress A process is in place to assess the progress of MCH Training program or Healthy Tomorrows participants in developing cultural and linguistic responsiveness.
Additional details:

Comments:

Training Form 03

Training 03 PERFORMANCE MEASURE Goal: Healthy Tomorrows Title V Collaboration Level: Grantee Domain: MCH Workforce Development	The degree to which the Healthy Tomorrows Partnership for Children program collaborates with State Title V agencies, other MCH or MCH-related programs.
GOAL	To assure that the Healthy Tomorrows program has collaborative interactions related to professional development, policy development and product development and dissemination with relevant national, state and local MCH programs, agencies and organizations.

MEASURE	The degree to which a Healthy Tomorrows program collaborates with State Title V agencies, and other MCH or MCH-related programs.

DEFINITION	Attached is a list of the 7 elements that describe activities carried out by Healthy Tomorrows programs for or in collaboration with State Title V and other agencies on a scale of 0 to 1 (0=no; 1=yes). Selecting “0” (or “no”) indicates that a Healthy Tomorrows program does not collaborate on an element. Selecting “1” (or “yes”) indicates that a Healthy Tomorrows program does collaborate on an element. If a value of ‘1’ (yes) is selected, provide the number of activities for the element. The total score for this measure will be determined by the sum of those elements noted as ‘1.’ Activity: An activity is a collaborative interaction related to professional development, policy development and product development and dissemination with relevant national, state and local MCH programs, agencies and organizations. An ongoing collaborative activity should be counted as one (1) activity. For example, if you are working with a Title V partner on an ongoing research project on maternal health that includes multiple interactions or meetings, you will count that as one (1) collaborative activity with Title V. Note: This form utilizes DGIS Form 10.A for annual performance objective and data reporting.

BENCHMARK DATA SOURCES	Related to the following Healthy People 2030 Objectives: ECBP-DO9: Increase core clinical prevention and population health education in medical schools. ECBP-D10: Increase core clinical prevention and population health education in nursing schools. ECBP-D11: Increase core clinical prevention and population health education in physician assistant training programs. ECBP-D12: Increase core clinical prevention and population health education in pharmacy schools. ECBP-D13: Increase core clinical prevention and population health education in dental schools. PHI-06: Increase the proportion of state public health agencies that use core competencies in continuing education. PHI-07: Increase the proportion of local public health agencies that use core competencies in continuing education. PHI-DO1: Increase the proportion of tribal public health agencies that use core competencies in continuing education.

GRANTEE DATA SOURCES	The Healthy Tomorrows program completes the attached table which describes the categories of collaborative activity.

SIGNIFICANCE	As a SPRANS grantee, a Healthy Tomorrows program enhances the Title V State block grants that support MCHB Strategic Plan Goal 1: to assure access to high-quality and equitable health services to optimize health and well-being for all MCH populations. Interactive collaboration between a Healthy Tomorrows program and Federal, Tribal, State and local agencies dedicated to improving the health of MCH populations will increase active involvement of many disciplines across public and private sectors and increase the likelihood of success in meeting the goals of relevant stakeholders. This measure will document a Healthy Tomorrows program’s abilities to: collaborate with State Title V and other agencies (at a systems level) to support achievement of the MCHB Strategic Goals and Healthy People 2030 objectives; make the needs of MCH populations more visible to decision-makers and help states achieve best practice standards for their systems of care; internally use these data to assure a full scope of these program elements in all regions.

DATA COLLECTION FORM FOR DETAIL SHEET: Training 03 – Healthy Tomorrows Title V Collaboration

Indicate the degree to which the Healthy Tomorrows program collaborates with State Title V (MCH Block Grant) agencies and other MCH or MCH-related programs^1,2 by entering the following values:

0= Does not collaborate on this element 1= Does collaborate on this element.

If your program does collaborate, provide the total number of activities for the element.

	State Title V Agencies¹			Other MCH-related programs²
Element	0	1	Total number of activities	0	1	Total number of activities
Advisory Committee Examples might include: having representation from State Title V or other MCH program on your advisory committee
Professional Development & Training Examples might include: collaborating with state Title V agency or other MCH program to develop training activity
Policy Development Examples might include: working with State Title V agency to develop and pass legislation
Research, Evaluation, and Quality Improvement Examples might include: working with MCH partners on quality improvement efforts
Product Development Examples might include: participating in a collaborative with MCH partners to develop materials
Dissemination Examples might include: distributing information on Healthy Tomorrows program-specific development, implementation, and impact to local, state, and/or national MCH partners
Sustainability Examples might include: working with state and local MCH representatives to develop and implement plans to increase impact and longevity of programs
Total

¹State Title V programs include State Block Grant funded or supported activities.

²Other MCH-related programs (both MCHB-funded and funded from other sources) include, but are not limited to:

State Health Department
State Adolescent Health
Social Service Agency
Medicaid Agency
Education
Juvenile Justice
Early Intervention
Home Visiting
Professional Organizations/Associations
Family and/or Consumer Group
Self-Advocacy Groups
Foundations
Clinical Program/Hospitals
Local and state division of mental health
Developmental disability agencies
Tribal governments and organizations
School-based programs, including heath centers
City and County Health Departments
Health care organizations
Behavioral health disorder support and advocacy organizations
College/University programs
Faith-based programs
Other programs working with maternal and child health populations

Comments:

Training Form 04

Training 04 PERFORMANCE MEASURE Goal: MCH Training Program Title V Collaboration Level: Grantee Domain: MCH Workforce Development	The degree to which a training program collaborates with State Title V agencies, other MCH or MCH-related programs.
GOAL	To assure that a training program has collaborative interactions related to training, technical assistance, continuing education, and other capacity-building services with relevant national, state and local programs, agencies and organizations.

MEASURE	The degree to which a training program collaborates with State Title V agencies, other MCH or MCH-related programs and other professional organizations.

DEFINITION	Attached is a list of the 6 elements that describe activities carried out by training programs for or in collaboration with State Title V and other agencies. Selecting “0” (or “no”) indicates that a training program does not collaborate on an element. Selecting “1” (or “yes”) indicates that a training program does collaborate on an element. If a value of “1”(yes) is selected, provide the number of activities for the element. The total score for this measure will be determined by the sum of those elements noted as “1.” Activity: An activity is a collaborative interaction related to service, training, continuing education, technical assistance, research, and product development with relevant national, state and local MCH programs, agencies and organizations. An ongoing collaborative activity should be counted as one (1) activity across all categories. For example, if you are working with a Title V partner on an ongoing research project on maternal health that includes multiple interactions or meetings, you will count that as one (1) collaborative activity with Title V. Note: This form utilizes DGIS Form 10.A for annual performance objective and data reporting.

BENCHMARK DATA SOURCES	Related to the following Healthy People 2030 Objectives: ECBP-DO9: Increase core clinical prevention and population health education in medical schools. ECBP-D10: Increase core clinical prevention and population health education in nursing schools. ECBP-D11: Increase core clinical prevention and population health education in physician assistant training programs. ECBP-D12: Increase core clinical prevention and population health education in pharmacy schools. ECBP-D13: Increase core clinical prevention and population health education in dental schools. PHI-06: Increase the proportion of state public health agencies that use core competencies in continuing education. PHI-07: Increase the proportion of local public health agencies that use core competencies in continuing education. PHI-DO1: Increase the proportion of tribal public health agencies that use core competencies in continuing education.

GRANTEE DATA SOURCES	The training program completes the attached table which describes the categories of collaborative activity.

SIGNIFICANCE	As a SPRANS grantee, a training program enhances the Title V State block grants that support the MCHB Strategic Plan Goal 1: to assure access to high-quality and equitable health services to optimize health and well-being for all MCH populations. Interactive collaboration between a training program and Federal, Tribal, State and local agencies dedicated to improving the health of MCH populations will increase active involvement of many disciplines across public and private sectors and increase the likelihood of success in meeting the goals of relevant partners. This measure will document a training program’s abilities to: collaborate with State Title V and other agencies (at a systems level) to support achievement of MCHB Strategic Goals and Healthy People 2030 objectives; make the needs of MCH populations more visible to decision-makers and can help states achieve best practice standards for their systems of care; and internally use these data to assure a full scope of these program elements in all regions.

DATA COLLECTION FORM FOR DETAIL SHEET PM #Training 04 – MCH Training Program Title V Collaboration

Indicate the degree to which your training program collaborates with national, state, local and community-based partners, including State Title V (MCH Block Grant) agencies and other MCH-related programs,² by entering the following values:

0= Does not collaborate on this element 1= Does collaborate on this element.

If your program does collaborate on an element, provide the total number of activities for that element. An ongoing collaborative activity should be counted as one (1) activity. For example, if you are working with a Title V partner on an ongoing research project on maternal health that includes multiple interactions or meetings, you will count that as one (1) activity.

An activity that involves both Title V and other MCH-related Programs can be counted in both categories.

Element	State Title V programs¹			Other MCH-related programs²
Element	0	1	Total number of activities	0	1	Total number of activities
Clinical Service³ Examples might include: Clinics run by the training program and/ or in collaboration with other agencies.
Community Outreach Examples might include: Health education or workshops for community partners.
Continuing Education Examples might include: Webinars, conferences, or other educational events that serve to enhance the knowledge of and/or maintain credentials of practicing MCH professionals. Activities may lead to CE credit, but do not have to. Do not include formal classes or seminars for trainees.
Technical Assistance⁴ Examples might include: Conducting or assisting with needs assessments with State programs, policy development, identifying best practices, organizational capacity building for Title V or other partners, and leading collaborative groups.
Research⁵ Examples might include: Collaborative writing and submission of grants, research teams that include Title V or other MCH-program staff and the training program’s trainees or faculty.
Product Development⁶ Examples might include: Collaborative development of journal articles, training or informational videos, fact sheets, or policy briefs.
Total

¹State Title V programs include State Block Grant funded or supported activities.

²Other MCH-related programs (both MCHB-funded and funded from other sources) include, but are not limited to:

State Health Department
State Adolescent Health
Social Service Agency
Medicaid Agency
Education
Juvenile Justice
Early Intervention
Home Visiting
Professional Organizations/Associations
Family and/or Consumer Group
Self-Advocacy Groups
Foundations
Clinical Program/Hospitals
Local and state division of mental health
Developmental disability agencies
Tribal governments and organizations
School-based programs, including heath centers
City and County Health Departments
Health care organizations
Behavioral health disorder support and advocacy organizations
College/University programs
Faith-based programs
Other national, state, local and community-based programs working with MCH populations

Comments:

³Ongoing collaborations with clinical locations should be counted as one activity (For example: multiple trainees rotate through the same community-based clinical site over the course of the year. This should be counted as one activity.)

⁴Any products that are developed as part of technical assistance should be counted in this section.

⁵Any products that are developed as part of research collaborations should be counted in this section.

⁶Do not count any products that are developed as part of technical assistance or research collaborations.

Training Form 07

Training 07 PERFORMANCE MEASURE Goal: MCH LEAP Program Level: Grantee Domain: MCH Workforce Development	The percent of MCHB LEAP Program graduates who have been engaged in work focused on MCH populations.
GOAL	To increase the percent of graduates of MCH Leadership, Education and Advancement in Undergraduate Pathways (LEAP) Programs who have been/are engaged in work focused on MCH populations.

MEASURE	The percent of MCHB LEAP Program graduates who have been engaged in work focused on MCH populations since graduating from the MCH LEAP Training Program.

DEFINITION	Numerator: Number of LEAP graduates reporting they have been engaged in work focused on MCH populations since graduating from the MCH LEAP Training Program. Denominator: The total number of trainees responding to the survey Units: 100 Text: Percent MCH LEAP trainees are defined as undergraduate students from underserved or underrepresented backgrounds, including trainees from racially and ethnically underrepresented groups who receive education, mentoring, and guidance to increase their interest and entry into MCH public health and related health professions. Former LEAP trainees should complete a follow-up survey 2-years and 5-years after graduating to provide information on post-graduation activities. Trainees should be tracked based on when they graduate from the undergraduate institution. For example, if a LEAP trainee graduates in 2020, 2-year follow-up should be collected and reported to MCHB in 2022 and 5-year follow-up should be collected and reported in 2025. MCH Populations: Includes women, infants and children, adolescents, young adults, and their families including fathers, and children and youth with special health care needs Note: This form utilizes DGIS Form 10.A for annual performance objective and data reporting.

BENCHMARK DATA SOURCES	Related to the following Healthy People 2030 Objectives: AHS-R01: Increase the ability of primary care and behavioral health professionals to provide more high-quality care to patients who need it. AHS-R02: Increase the use to telehealth to improve access to health services. PHI-R02: Expand public health pipeline programs that include service or experiential learning. PHI-R03: Increase use of core and discipline-specific competencies to drive workforce development

GRANTEE DATA SOURCES	Attached data collection form to be completed by grantees. A LEAP program follow-up survey should be used to collect the data for the data collection form. A proposed survey template is provided as an option for grantees to use. On the proposed survey, question number 2 provides former trainee data needed to complete the data collection form.

SIGNIFICANCE	HRSA’s MCHB places special emphasis on improving service delivery to women, children and youth from communities with limited access to comprehensive care. This national performance measure relates directly to MCHB Strategic Plan Goal 3: Strengthen public health capacity and workforce for MCH.

DATA COLLECTION FORM FOR DETAIL SHEET: Training 07 - MCH LEAP Program

MCH Leadership, Education and Advancement in Undergraduate Pathways (LEAP) Program graduates who report working with the maternal and child health population (i.e., women, infants, children, adolescents, young adults, and their families, including and children with special health care needs) 2 years and 5 years after graduating from their MCH LEAP program.

Trainees should be tracked based on when they graduate from the undergraduate institution. For example, if a LEAP trainee graduates in 2020, 2-year follow-up should be collected and reported to MCHB in 2022 and 5-year follow-up should be collected and reported in 2025.

NOTE: Each LEAP trainee should be counted once.

2 YEARS AFTER GRADUATING FROM MCH LEAP PROGRAM

A. The total number of LEAP Trainees that graduated 2 years ago _________

B. The total number of graduates lost to follow-up

_________

C. The total number of respondents (A-B) = denominator

_________

D. Number of respondents who report working with MCH populations

since graduating from the MCH LEAP Training Program _________

E. Percent of respondents who report working with MCH populations

since graduating from the MCH LEAP Training Program _________

5 YEARS AFTER GRADUATING FROM MCH LEAP PROGRAM

A. The total number of LEAP Trainees that graduated 5 years ago _________

B. The total number of graduates lost to follow-up _________

C. The total number of respondents (A-B) = denominator _________

D. Number of respondents who report working with MCH populations

since graduating from the MCH LEAP Training Program _________

E. Percent of respondents who report working with MCH populations

since graduating from the MCH LEAP Training Program _________

Comments:

Proposed Survey Questions

Please answer the following questions to help us understand the impact of the LEAP Training Program on your post-graduation activities. Thank you for taking the time to complete this survey. When you have filled out the entire survey, return it to your LEAP Program Director.

What year did you graduate from the MCH LEAP Training Program? _________

Are you currently enrolled or have you completed a graduate school program that is preparing you to work with MCH populations?

¨ Yes

¨ No

1a. If yes, which graduate programs have you enrolled in or completed?

¨ Medicine (e.g., Pediatric, Ob/Gyn, Primary Care)

¨ Public health

¨ Nutrition

¨ Social work

¨ Nursing

¨ Pediatric dentistry

¨ Psychology

¨ Pediatric occupational/physical therapy

¨ Speech language pathology

¨ Other MCH-related health profession (specify):_____

1b. If yes, did the MCH LEAP Training Program help in your admission to your graduate program?

¨ Yes

¨ No

1c. If yes, did the MCH LEAP Training Program help you be successful in your graduate program?

¨ Yes

¨ No

Have you worked with Maternal and Child Health (MCH) populations since graduating from the MCH LEAP Training Program? (i.e., women, infants and children, adolescents, young adults, and their families, including fathers, and children and youth with special health care needs)

¨ Yes

¨ No

Have you worked with populations that have been historically underserved and/or marginalized since graduating from the MCH LEAP Training Program?

¨ Yes

¨ No

Training Form 08

Training 08 PERFORMANCE MEASURE Goal: MCH LEAP Program Level: Grantee Domain: MCH Workforce Development	The percent of MCH LEAP Program graduates who have been engaged in work with populations that are underserved or have been marginalized.
GOAL	To increase the percent of graduates of MCH Leadership, Education and Advancement in Undergraduate Pathways (LEAP) Programs who have been engaged in work with populations that are underserved or have been marginalized.

MEASURE	The percent of MCH LEAP Program graduates who have been engaged in work with populations that are underserved or have been marginalized since graduating from the MCH LEAP Training Program.

DEFINITION	Numerator: Number of LEAP graduates reporting they have been engaged in work with populations that are underserved or have been marginalized since graduating from the MCH LEAP Training Program. Denominator: The total number of trainees responding to the survey Units: 100 Text: Percent MCH LEAP trainees are defined as undergraduate students from underserved or underrepresented backgrounds, including trainees from racially and ethnically underrepresented groups who receive education, mentoring, and guidance to increase their interest and entry into MCH public health and related fields. Former LEAP trainees should complete a follow-up survey 2-years and 5-years after graduating to provide information on post-graduation activities. Trainees should be tracked based on when they graduate from the undergraduate institution. For example, if a LEAP trainee graduates in 2020, 2-year follow-up should be collected and reported to MCHB in 2022 and 5-year follow-up should be collected and reported in 2025. Populations that are underserved or have been marginalized refers to groups of individuals at higher risk for health disparities by virtue of their race or ethnicity, socioeconomic status, geography, gender, age, disability status, or other risk factors including those associated with sex and gender. Note: This form utilizes DGIS Form 10.A for annual performance objective and data reporting.

BENCHMARK DATA SOURCES	Related to the following Healthy People 2030 Objectives: AHS-R01: Increase the ability of primary care and behavioral health professionals to provide more high-quality care to patients who need it. AHS-R02: Increase the use of telehealth to improve access to health services. PHI-R02: Expand public health pipeline programs that include service or experiential learning. PHI-R03: Increase use of core and discipline-specific competencies to drive workforce development.

GRANTEE DATA SOURCES	Attached data collection form to be completed by grantees. A LEAP program follow-up survey should be used to collect the data for the data collection form. A proposed survey template is provided as an option for grantees to use. On the proposed survey, question number 3 provides former trainee data needed to complete the data collection form.

SIGNIFICANCE	HRSA’s MCHB places special emphasis on improving service delivery to women, children and youth from communities with limited access to comprehensive care. This national performance measure relates directly to MCHB Strategic Plan Goal 3: Strengthen public health capacity and workforce for MCH.

DATA COLLECTION FORM FOR DETAIL SHEET: Training 08 - MCH LEAP Program

MCH Leadership, Education and Advancement in Undergraduate Pathways (LEAP) Program graduates who have worked with populations that are underserved or have been marginalized 2 years and 5 years after graduating from their MCH LEAP program.

NOTE: Each LEAP trainee should be counted once.

2 YEARS AFTER GRADUATING FROM MCH LEAP PROGRAM

A. The total number of LEAP Trainees that graduated, 2 years ago

_________

B. The total number of graduates lost to follow-up

_________

C. The total number of respondents (A-B) = denominator

_________

D. Number of respondents who have worked with populations that have been historically underserved and/or marginalized since graduating from the MCH LEAP Training Program

_________

E. Percent of respondents who have worked with populations that have been historically underserved and/or marginalized since graduating from the MCH LEAP Training Program

_________

5 YEARS AFTER GRADUATING FROM MCH LEAP PROGRAM

A. The total number of LEAP Trainees that graduated 5 years ago

_________

B. The total number of graduates lost to follow-up

_________

C. The total number of respondents (A-B) = denominator

_________

D. Number of respondents who have worked with populations that have been historically underserved and/or marginalized since graduating from the MCH LEAP Training Program

_________

E. Percent of respondents who have worked with populations that have been historically underserved and/or marginalized since graduating from the MCH LEAP Training Program

_________

Comments:

Proposed Survey Questions

What year did you graduate from the MCH LEAP Training Program? _________

Are you currently enrolled or have you completed a graduate school program that is preparing you to work with MCH populations?

¨ Yes

¨ No

1a. If yes, which graduate programs have you enrolled in or completed?

¨ Medicine (e.g., Pediatric, Ob/Gyn, Primary Care)

¨ Public health

¨ Nutrition

¨ Social work

¨ Nursing

¨ Pediatric dentistry

¨ Psychology

¨ Pediatric occupational/physical therapy

¨ Speech language pathology

¨ Other MCH-related health profession (specify):_____

1b. If yes, did the MCH LEAP Training Program help in your admission to your graduate program?

¨ Yes

¨ No

1c. If yes, did the MCH LEAP Training Program help you be successful in your graduate program?

¨ Yes

¨ No

Have you worked with Maternal and Child Health (MCH) populations since graduating from the MCH LEAP Training Program? (i.e., women, infants and children, adolescents, young adults, and their families, including fathers, and children and youth with special health care needs)

¨ Yes

¨ No

Have you worked with populations that have been historically underserved and/or marginalized since graduating from the MCH LEAP Training Program?

¨ Yes

¨ No

Training Form 09

Training 09 PERFORMANCE MEASURE Goal: MCH LEAP Program Level: Grantee Domain: MCH Workforce Development	The percent of LEAP graduates that enter graduate programs preparing them to work with the MCH population.
GOAL	To increase the number of Leadership, Education and Advancement in Undergraduate Pathways (LEAP) graduates that enter graduate programs preparing them to work with the MCH population.

MEASURE	The percent of LEAP graduates that enter graduate programs preparing them to work with the MCH population.

DEFINITION	Numerator: Total number of MCH LEAP trainees enrolled in or who have completed a graduate school program preparing them to work with the MCH population, 2 or 5 years after graduating from the MCH LEAP program. Denominator: Total number of MCH LEAP Trainees who graduated from the MCH LEAP program 2 or 5 years previously. Former LEAP trainees should complete a follow-up survey 2-years and 5-years after graduating to provide information on post-graduation activities. Trainees should be tracked based on when they graduate from the undergraduate institution. For example, if a LEAP trainee graduates in 2020, 2-year follow-up should be collected and reported to MCHB in 2022 and 5-year follow-up should be collected and reported in 2025. Note: This form utilizes DGIS Form 10.A for annual performance objective and data reporting.

BENCHMARK DATA SOURCES	Related to the following Healthy People 2030 Objectives: ECBP-DO9: Increase core clinical prevention and population health education in medical schools. ECBP-D10: Increase core clinical prevention and population health education in nursing schools. ECBP-D11: Increase core clinical prevention and population health education in physician assistant training programs. ECBP-D12: Increase core clinical prevention and population health education in pharmacy schools. ECBP-D13: Increase core clinical prevention and population health education in dental schools. PHI-R03: Increase use of core and discipline-specific competencies to drive workforce development. PHI-06: Increase the proportion of state public health agencies that use core competencies in continuing education. PHI-07: Increase the proportion of local public health agencies that use core competencies in continuing education. PHI-DO1: Increase the proportion of tribal public health agencies that use core competencies in continuing education

GRANTEE DATA SOURCES	Attached data collection form to be completed by grantees. A LEAP program follow-up survey should be used to collect the data for the data collection form. A proposed survey template is provided as an option for grantees to use. On the proposed survey, question number 1 provides former trainee data needed to complete the data collection form.
SIGNIFICANCE	MCHB training programs assist in developing a public health workforce that addresses key MCH issues and fosters field leadership in the MCH arena. This national performance measure relates directly to MCHB Strategic Plan Goal 3: Strengthen public health capacity and workforce for MCH.

DATA COLLECTION FORM FOR DETAIL SHEET: Training 09 – Graduate Program Enrollment

NOTE: Each LEAP trainee should be counted once.

2 YEARS AFTER GRADUATING FROM MCH LEAP PROGRAM

A. The total number of LEAP Trainees that graduated 2 years ago _________

B. The total number of graduates lost to follow-up ________

C. The total number of respondents (A-B) = denominator ________

D. Total number of respondents that are enrolled in or have completed graduate

programs preparing them to work with the MCH population ________

Specify the number of respondents that are enrolled in or have completed the following graduate programs:

Medicine (e.g. Pediatric, Ob/Gyn, Primary Care): _____

Public health: _____

Nutrition: _____

Social work: _____

Nursing: _____

Pediatric dentistry: _____

Psychology: _____

Pediatric occupational/physical therapy: _____

Speech language pathology: _____

Other MCH-related health profession (specify):_____

E. Percent of respondents that are enrolled in or have completed graduate

programs preparing them to work with the MCH population ________

F. Number of LEAP trainees who indicate MCH LEAP Training Program helped in

admission to a graduate program __________

G. Percent of LEAP trainees who indicate MCH LEAP Training Program helped in

admission to a graduate program __________

H. Number of LEAP trainees who indicate MCH LEAP Training Program helped in

being successful in a graduate program __________

I. Percent of LEAP trainees who indicate MCH LEAP Training Program helped in

being successful in a graduate program __________

5 YEARS AFTER GRADUATING FROM MCH LEAP PROGRAM

A. The total number of LEAP Trainees that graduated 5 years ago _________

B. The total number of graduates lost to follow-up ________

C. The total number of respondents (A-B) = denominator ________

D. Number of respondents that are enrolled in or have completed graduate

Programs preparing them work with the MCH population ________

Specify the number of respondents that are enrolled in or have completed the following graduate programs:

Medicine (e.g. Pediatric, Ob/Gyn, Primary Care): _____

Public health: _____

Nutrition: _____

Social work: _____

Nursing: _____

Pediatric dentistry: _____

Psychology: _____

Pediatric occupational/physical therapy: _____

Speech language pathology: _____

Other MCH-related health profession (specify):_____

E. Percent of respondents that are enrolled in or have completed graduate

Programs preparing them work with the MCH population ________

F. Number of LEAP trainees who indicate MCH LEAP Training Program helped in

admission to a graduate program __________

G. Percent of LEAP trainees who indicate MCH LEAP Training Program helped in

admission to a graduate program __________

H. Number of LEAP trainees who indicate MCH LEAP Training Program helped in

being successful in a graduate program __________

Percent of LEAP trainees who indicate MCH LEAP Training Program helped in

being successful in a graduate program ___________

Comments:

Proposed Survey Questions

What year did you graduate from the MCH LEAP Training Program? _________

Are you currently enrolled or have you completed a graduate school program that is preparing you to work with MCH populations?

¨ Yes

¨ No

1a. If yes, which graduate programs have you enrolled in or completed?

¨ Medicine (e.g., Pediatric, Ob/Gyn, Primary Care)

¨ Public health

¨ Nutrition

¨ Social work

¨ Nursing

¨ Pediatric dentistry

¨ Psychology

¨ Pediatric occupational/physical therapy

¨ Speech language pathology

¨ Other MCH-related health profession (specify):_____

1b. If yes, did the MCH LEAP Training Program help in your admission to your graduate program?

¨ Yes

¨ No

1c. If yes, did the MCH LEAP Training Program help you be successful in your graduate program?

¨ Yes

¨ No

Have you worked with Maternal and Child Health (MCH) populations since graduating from the MCH LEAP Training Program? (i.e., women, infants and children, adolescents, young adults, and their families, including fathers, and children and youth with special health care needs)

¨ Yes

¨ No

Have you worked with populations that have been historically underserved and/or marginalized since graduating from the MCH LEAP Training Program?

¨ Yes

¨ No

Training Form 14

Training 14 PERFORMANCE MEASURE Goal: Medium-Term Trainees Skill and Knowledge Level: Grantee Domain: MCH Workforce Development	The percentage of Level I medium-term trainees who report an increase in knowledge and the percentage of Level II medium-term trainees who report an increase in knowledge or skills related to MCH core competencies .
GOAL	To increase the percentage of medium-term trainees (MTT) who report increased knowledge or skills related to MCH core competencies.

MEASURE	The percentage of Level I medium-term trainees who report an increase in knowledge and the percentage of Level II medium-term trainees who report an increase in knowledge or skills related to MCH core competencies.

DEFINITION	Numerator: The number of Level I medium-term trainees who report an increase in knowledge and Level II medium-term trainees who report an increase in knowledge or skills related to MCH core competencies. Denominator: The total number of medium-term trainees responding to the survey. Medium Term trainees: Level I MTT complete 40-149 hours of training. Level II MTT complete 150–299 hours of training. Note: This form utilizes DGIS Form 10.A for annual performance objective and data reporting.

BENCHMARK DATA SOURCES	Related to the following Healthy People 2030 Objectives: ECBP-DO9: Increase core clinical prevention and population health education in medical schools. ECBP-D10: Increase core clinical prevention and population health education in nursing schools. ECBP-D11: Increase core clinical prevention and population health education in physician assistant training programs. ECBP-D12: Increase core clinical prevention and population health education in pharmacy schools. ECBP-D13: Increase core clinical prevention and population health education in dental schools. PHI-06: Increase the proportion of state public health agencies that use core competencies in continuing education. PHI-07: Increase the proportion of local public health agencies that use core competencies in continuing education. PHI-DO1: Increase the proportion of tribal public health agencies that use core competencies in continuing education. MICH-20: Increase the proportion of children and adolescents with special health care needs who have a system of care.

GRANTEE DATA SOURCES	End of training survey is used to collect these data.

SIGNIFICANCE	Medium-Term trainees comprise a significant proportion of training efforts. These trainees impact the provision of care to MCH populations nationally. The impact of this training must be measured and evaluated. This national performance measure relates directly to MCHB Strategic Plan Goal 3: Strengthen public health capacity and workforce for MCH.

TA COLLECTION FORM FOR DETAIL SHEET: Training 14 – Medium-Term Trainees Skill and Knowledge

Level I Medium-Term Trainees - Knowledge

The total number of Level I Medium-Term Trainees (40-149 hours) _______
The total number of Level I MTT lost to follow-up _______
The total number of respondents (A-B) _______
Number of respondents reporting increased knowledge _______
Percentage of respondents reporting increased knowledge _______

Level II Medium-Term Trainees – Knowledge:

The total number of Level II Medium-Term Trainees (150-299 hours) _______
The total number of Level II MTT lost to follow-up _______
The total number of respondents (A-B) _______
Number of respondents reporting increased knowledge _______
Percentage of respondents reporting increased knowledge _______

Level II Medium-Term Trainees - Skills:

The total number of Level II Medium-Term Trainees (150-299 hours) ________
The total number of Level II MTT lost to follow-up ________
The total number of respondents (A-B) ________
Number of respondents reporting increased skills ________
Percentage of respondents reporting increased skills ________

Comments:

Training Form 15

Training 15 PERFORMANCE MEASURE Goal: Consultation and Training for Mental and Behavioral Health Level: Grantee Domain: MCH Workforce Development
GOAL	Increase the availability and accessibility of consultation services to providers caring for individuals with behavioral or mental health conditions.

MEASURE	Number of providers participating in consultation and care coordination support services.

DEFINITION	Total number of providers participating in consultation (teleconsultation and in-person) and care coordination support services provided by the Pediatric Mental Health Care Access (PMHCA) program and the Screening and Treatment for Maternal Mental Health and Substance Use Disorders (MMHSUD) program.

BENCHMARK DATA SOURCES	None

GRANTEE DATA SOURCES	PMHCA and MMHSUD awardees report using the data collection form.

SIGNIFICANCE	Mental and behavioral health issues are prevalent among children and adolescents, and pregnant and postpartum persons in the United States. However, due to shortages in the number of psychiatrists, developmental-behavioral providers, and other behavioral health clinicians, access to mental and behavioral health services is lacking. Research indicates that telehealth can improve access to care, reduce health care costs, improve health outcomes, and address workforce shortages in underserved areas. Telehealth strategies that connect primary care providers with specialty mental and behavioral health care providers can be an effective means of increasing access to mental and behavioral health services for children and pregnant and postpartum persons, especially those living in rural and other underserved areas.

Training 15 Data Collection Form

Instructions

Tab A. Provider Consultation and Training

A.1.i: Select Yes or No to indicate if your program had any enrolled providers during the reporting period.

If select Yes, enter provider counts for “Number enrolled”, as well as “Number participating” and “Number enrolled AND participating” if applicable, by provider type. If there are no providers for a field, enter zero.
- Provider counts may be duplicated across columns (Number enrolled, Number participating, Number enrolled and participating), but not within cells. For example, if a provider is enrolled AND participating during the reporting period, they should be counted in all three columns; the provider would be counted three times across the cells/row, but only once in each column. The "Number of enrolled AND participating” should be less than or equal to both the “Number enrolled” and the “Number participating” in each row.
If select No, enter provider counts for “Number participating”, by provider type. If there are no providers for a field, enter zero.
If a provider contacts the program more than once during the reporting period, they should only be counted once in each applicable column.
If a provider is acting in multiple roles/provider types, categorize them by their primary role as it relates to the encounter. For example, if a family visitor, doula, or social worker is filling the role of a care coordinator/patient navigator, they should be reported as a “Care Coordinator/Patient Navigator”. If a social worker is filling the role of behavioral health clinician and acting as a therapist or counselor, they would be reported in the “Behavioral Health Clinician” category.
Medical Residents should be included in the category for which they are completing their residency. For example, a family medicine resident should be included in “Primary Care Providers (non-specialty), Family Medicine”.
Parents and caregivers are not included in reporting.

A.1.ii.a: Enter the number of provider contacts during the reporting period for each type of contact. Enter an unduplicated count of provider contacts across contact types; if a provider is seeking both consultation and care coordination support, count the provider only under “Both”. Count each provider contact regardless of whether it is about the same patient or if it is the same provider calling in multiple times. If no providers contacted the program, enter zero (0) in the cell.

If a provider contacted the consultation line about a patient, and then called a separate time and received either consultation and/or care coordination support for the same patient, they would be counted as two separate provider contacts. If a provider contacts the consultation line and receives consultation and/or care coordination support about multiple patients, this would be counted as one provider contact.

For PMHCA programs only, consultation can be provided by any member of the PMHCA team and not just the child and adolescent psychiatrist.

A.1.ii.b: Enter the number of consultations and/or referrals provided by the team during the reporting period. Report consultations by consultation type (telehealth vs. in-person). Enter an unduplicated count of consultations provided via telehealth or in person; a consultation should only fall into one of those categories. For referrals, count the total number of referrals given during the reporting period. If there were no consultations and/or referrals, enter zero (0) into the cell.

A.1.ii.c: Select the condition(s) about which providers received consultation (teleconsultation or in-person) or care coordination support services from the program during the reporting period. Select all conditions that apply.

For each selected condition, enter the number of consultation (teleconsultation or in-person) or care coordination contacts for each. Each contact can involve more than one condition.
If the patient has a diagnosed condition, but the provider received consultation about another condition, a different presenting concern, or another reason, count the reason(s) for which the provider received consultation. If the patient does not have a diagnosis, the reason for contact can be a suspected diagnosis, diagnostic impression, presenting concerns/symptoms, suspected concern, or another reason. The condition or conditions selected should be the reason(s) the provider received consultation (teleconsultation or in-person) or care coordination support services. Each contact with the consultation team member can involve more than one condition, however, the conditions should be limited to the primary reasons the provider received consultation and/or care coordination support from the consultation program.
If the condition is not listed, select “Other” and list the condition(s) or reason(s) in “Other- Description”; multiple conditions can be entered, separated by commas. In the “Other” row, indicate the total number of contacts for all combined “Other” conditions that are listed in the “Other-Description”,
Categorize encounters regarding delusions and disorganized thoughts related to postpartum psychosis in “Other” and share more details with HRSA in the non-competing continuation progress report narratives or contacts with the program. Categorize encounters regarding perinatal mood and anxiety disorders in the anxiety category.

A.1.iii: [Measure applies only to PMHCA awardees] Enter the number of consultations and referrals provided during the reporting period, by PMHCA team member type. If no consultations and/or referrals were provided by the PMHCA team member type, enter zero (0).

If a single provider contact results in multiple referral recommendations, each referral should be counted separately. For example, if a team member refers the provider to a mental health counselor for psychotherapy AND provides a referral for an addiction counselor, this would count as two referrals.
If a provider is acting in multiple roles/provider types, categorize them by their primary role as it relates to the encounter. Social workers, counselors etc. working in the role of care coordinator should be counted as care coordinators.
If a team member type is not listed, select “Other” and list the member type(s) in “Other-Description”; multiple team member types can be entered, separated by commas. In the “Other” row, indicate the total number of consultations or referrals provided for all combined “Other” team member types that are listed.
For consultations or referrals provided by an interdisciplinary team, each member of the interdisciplinary team would be counted for consultations or referrals provided.

A.2.i: Enter the number of providers trained during the reporting period, by provider type.

Report unduplicated counts of providers. If a provider attended more than one training conducted by the program during the reporting period, the provider should only be counted once.
If a provider type is not listed, select “Other” and list the member type(s) in “Other-Description”; multiple provider types can be entered, separated by commas. In the “Other” row, indicate the total number of “Other” providers attending training for all combined “Other” provider types.

A.2.ii.: Enter the total number of trainings provided by the program during the reporting period. Report an unduplicated count of trainings.

A.2.ii.a: Enter the number of trainings provided during the reporting period, by topic. Each individual training reported in A.2.ii. should be associated with ONLY ONE topic; the sum of trainings by topic should equal the total number of trainings reported in A.2.ii. Trainings often cover multiple topics; choose the most appropriate training topic to categorize each training provided by the program. If a topic was not covered, enter a zero (0) in that cell.

Continuing Education (CE) is not required to count as a training.
If the primary training topic is not listed, select “Other” and list the topic(s) in “Other-Description”; multiple topics can be entered, separated by commas. In the “Other” row, indicate the total number of trainings held during the reporting period for all combined “Other” topics.

A.2.ii.b: Report the total number of trainings covered by each training mechanism. Each individual training reported in A.2.ii. should be associated with ONLY ONE mechanism; the sum of trainings by mechanism should equal the total number of trainings reported in A.2.ii.

If the training mechanism is not listed, select “Other” and list the mechanism(s) in “Other-Description”; multiple mechanisms can be entered, separated by commas. In the “Other” row, indicate the total number of trainings held during the reporting period for all combined “Other” mechanisms.

Tab B. Individuals Served: Select your program (PMHCA or MMHSUD). PMHCA will complete data entry for Children 0-11 and Adolescents 12-21. MMHSUD will complete data entry for Pregnant or postpartum persons.

B.1: Enter the number of individuals for whom a provider contacted the program for consultation (teleconsultation or in-person) or care coordination support services during the reporting period. Enter an unduplicated count of individuals for whom a provider contacted the program; if a provider contacted the program about an individual multiple times, they should only be counted once. Enter both the total number, as well as the number from rural/underserved areas.

Only include children and adolescents (PMHCA) and pregnant and postpartum persons (MMHSUD) about whom a provider contacted the consultation team/program for consultation or referral. Do not include the entire patient panel of enrolled or participating providers.
Do not count parenting persons or caregivers who contact the program.
Provider zip codes may be used to identify rural or underserved counties. The use of patient zip codes is not required.

B.2: Enter the number of individuals recommended for referral only, treatment only, or both referral and treatment, among those for whom a provider contacted the program for consultation (teleconsultation or in-person) or care coordination support services during the reporting period. If there were no recommendations for referral and/or treatment, enter zero (0) into the cell.

Only include individuals about whom a provider contacted the program for consultation or referral. Do not include the entire patient panel of enrolled or participating providers.

If the provider called in multiple times about the same patient, the outcome of the call (referral, treatment, or both) would be counted separately for each contact.

B.3: [Optional] Enter the numerator and denominator for the percent screened for each applicable measure. If there were no screenings for behavioral or mental health condition, enter zero (0) into the cell.

HRSA strongly encourages programs to report these data if programs are collecting screening data from electronic medical records (EMRs) or electronic health records (EHRs). If programs can’t get EMR or EHR data, programs would add these data by provider report or not report since this measure is optional.
PMHCA
- Numerator: Number of children and adolescents, 0-21 years of age, for whom a provider contacted the mental health team for consultation or referral, who received at least one screening for a behavioral health condition using a standardized validated tool.
- Denominator: Number of children and adolescents, 0-21 years of age, for whom a provider contacted the mental health team for consultation or referral.
MMHSUD
- Numerator: Number of pregnant or postpartum persons, for whom a provider contacted the program for consultation or care coordination support, who received at least one screening for a behavioral health condition (depressions, anxiety, or substance use, separately) using a standardized validated tool.
- Denominator: Number of pregnant or postpartum persons, for whom a provider contacted the program for consultation or care coordination support.

Do not report data when there is only an assumption about whether the patient was screened. If programs cannot ask the provider whether a screening has occurred, then do not report.
Include screens conducted by the provider or practice that is calling for the consultation or referral. A paraprofessional may not be conducting screens but can validate that a screening occurred and report that to the consult line.
Report on screens conducted within the previous 12 months at the time of the consultation/referral call.
HRSA Project Officers will provide examples of validated screening tools.

Definitions:

Enrolled Provider: A provider who has formally registered with the program to facilitate use of consultation (teleconsultation or in-person) or care coordination support services, at the time of reporting. An enrolled provider is currently enrolled with the program even if initial enrollment occurred prior to current reporting period. An enrolled provider may or may not be a participating provider.

Participating Provider: A provider who has contacted the program for consultation (teleconsultation or in-person) or care coordination support services, and who may or may not be an enrolled provider.

Enrolled AND Participating Provider: Refers to the number of enrolled providers (registered) who are participating in the program (contacting the program for consultation or care coordination support services).

Care Coordination Support: In context of MMHSUD/PMHCA, care coordination support means, at minimum, that the program provides resources and referrals to a provider when they contact the program, or to the patient/family when the program works with patients/families directly. In these programs, “care coordination support” is synonymous with “providing resources and referrals”.

Telehealth: is the use of electronic information and telecommunication technologies to support and promote long-distance clinical consultation, patient and professional health-related education, public health and health administration. Permitted telehealth modalities between providers include (but are not limited to): real-time video, telephonic communications, electronic mail (email) with encryption, store-and-forward imaging, and mobile health (mHealth) applications.

Referrals are given to providers (or directly to the patients/families) by the program to introduce specific health providers or services. Recommending “family therapy” without providing a specific provider name or practice would not be considered a referral, but a recommendation for treatment. Referrals are typically provided using resources included in the referral database. Referrals fall under the category of care coordination support in the context of MMHSUD/PMHCA.

Example 1: The PMHCA/MMHSUD program recommends Jonathan Smith, PhD, clinical psychologist specializing in childhood anxiety disorders, address xxxx Main Street, Springfield, TX, phone number xxx-xxx-xxxx, email address [email protected]. This counts as one referral.

Example 2: The PMHCA/MMHSUD program refers the provider or family to a specific mental health counselor or therapist for psychotherapy AND provides a referral for a specific addiction counselor or specific practice. The consultation team member provided 2 referrals.

Example 3: A provider calls into the consultation line regarding a patient experiencing depression. The patient’s family is experiencing housing insecurity, and the provider shares that information for assistance. The consultation team member provides a referral to a behavioral health therapist and to a social worker who specializes in subsidized housing. This counts as 2 referrals.

Training: refers to education programs or sessions that serve to enhance the knowledge and/or maintain the credentials and licensure of professional providers. Training may also serve to enhance the knowledge base of community outreach workers, families, and other members who directly serve the community. Examples of trainings include mental or behavioral health conditions, medication, screening and assessment, treatment modalities, trauma, etc. Conference presentations would be considered training if training was the intent of the presentation. A conference presentation that describes an intervention or program would not be considered training.

In-person training: is any form of training that occurs “in person” and in real time between trainers and participants.
Project ECHO® (Extension for Community Healthcare Outcomes) distance learning cohort: refers to a group of individuals who advance through an educational program together as part of their participation in Project ECHO®. Project ECHO® is a collaborative model of medical education and care management that uses tele-mentoring to share knowledge between specialists and outlying Primary Care Providers (PCPs) with the goals of supporting PCPs in their administration of high-quality, leading-edge care to their patients and improving health outcomes for underserved patients.
ECHO-like distance learning cohort: A technology-enabled educational model, in which a mentor with specialized knowledge provides interactive and case-based guidance to a group of mentees for the purpose of strengthening their skills and knowledge to provide high-quality healthcare. These programs are similar in structure and goals to Project ECHO® but not officially Project ECHO®.
Web-based training: refers to computer-based training that takes place online via the internet. This can include synchronous web-based training that is trainer-led and involves real-time interactions between trainers and trainees; asynchronous web-based training that takes place without real-time instruction, where content is available online, pre-recorded, and trainees can access it at their convenience; or blended web-based training, which involves both real-time interactions between a trainer and trainees and pre-recorded content that can be self-paced according to one’s schedule.
Hybrid (combination of virtual and in-person) training: refers to a training model that involves both in-person and online instruction and activities.

Treatment is the provision, coordination, or management of health care and related services among health care providers. Providers contacting the programs for consultation may or may not be the ones providing the treatment that is recommended by the consulting provider.

Rural/Underserved: HRSA defines rural areas as all counties that are not designated as parts of metropolitan areas (MAs) by the Office of Management and Budget. In addition, HRSA uses Rural Urban Commuting Area Codes to designate rural areas within MAs. This rural definition can be accessed at: https://www.hrsa.gov/rural-health/about-us/what-is-rural.. If the county is not entirely rural or urban, follow the link for “Rural Health Grants Eligibility Analyzer” to determine if a specific site qualifies as rural based on its specific census tract within an otherwise urban county. Underserved areas are defined by the following terms: Any Medically Underserved Area/Population (MUA/P); or a Partially MUA/P. MUA/Ps are accessible through https://data.hrsa.gov/tools/shortage-area/mua-find

Provider Consultation and Training
1. Consultation:
  1. Number and types of providers enrolled for and participating in program consultation (teleconsultation or in-person) and care coordination support services.

Did you have any enrolled providers during the reporting period?  Yes  No

Provider Type		Number enrolled	Number participating	Number enrolled AND participating
Primary Care Providers (non-specialty)	Pediatrician
	Family Medicine
	OB/GYN
	Internal Medicine
	Advanced Practice Nurse/Nurse Practitioner
	Certified Nurse Midwife
	Physician Assistant
Others	Psychiatrist
	Developmental-Behavioral Pediatrician
	Nurse
	Behavioral Health Clinician (e.g. psychologist, therapist, counselor)
	Care Coordinator/ Patient Navigator
	Doula
	Other Specialist Physician, APN/NP, PA (specify type):
	Other (specify type):
Unknown Provider type
Total (will auto-populate)
Total Primary Care (will auto-populate)

Use of program consultation and care coordination support services.
1. Number of provider contacts with the program for consultation (teleconsultation or in-person), care coordination support, or both.

Type of contact	Number of provider contacts with the program for services
Consultation Only
Care Coordination Support Only
Both

Number of consultations and referrals given to providers.

Consultation or referral	Number of consultations or referrals given
Consultations via telehealth
Consultations in-person
Referrals

Please indicate the condition(s) about which providers received consultation (teleconsultation or in-person) or care coordination support services from the program. Select all conditions that apply. Specify the number of contacts for each condition. Each contact can involve more than one condition.

Anxiety disorders
- Number of contacts for this reason _________
Depressive disorders (excluding postpartum depression)
- Number of contacts for this reason _________
Postpartum depression
- Number of contacts for this reason _________
Bipolar and related disorders
- Number of contacts for this reason _________
Attention-Deficit/ Hyperactivity Disorder (ADHD)
- Number of contacts for this reason _________
Autism Spectrum Disorder
- Number of contacts for this reason _________
Disruptive, impulse-control, and conduct disorders
- Number of contacts for this reason _________
Neurodevelopmental disorders (including developmental delay and intellectual disabilities)
- Number of contacts for this reason _________
Feeding and eating disorders
- Number of contacts for this reason _________
Obsessive-compulsive and related disorders
- Number of contacts for this reason _________
Trauma and stressor-related disorders
- Number of contacts for this reason _________
Schizophrenia spectrum and other psychotic disorders
- Number of contacts for this reason _________
Substance-related disorders
- Number of contacts for alcohol _________
- Number of contacts for marijuana _________
- Number of contacts for nicotine _________
- Number of contacts for opioids _________
- Number of contacts for other substance-related disorders _______
Suicidality or self-harm
- Number of contacts for this reason _________
Social and environmental concerns (including violence, unstable housing, language barriers, isolation/lack of social support, food insecurity, transportation, etc.)
- Number of contacts for this reason _________
Other (please specify)___________
- Number of contacts for this reason _________

Number of consultations (teleconsultations and in-person) and referrals provided by each member of the mental health team. [Measure applies only to PMHCA awardees]

Member of mental health team	Number of consultations provided	Number of referrals provided
Psychiatrist
Psychologist
Social Worker
Counselor
Care Coordinator
Other behavioral clinicians
Other (specify type):
Total (will auto-populate)

Training:
1. Number and types of providers trained.

Provider Type		Number Trained
Primary Care Providers (non-specialty)	Pediatrician
	Family Medicine
	OB/GYN
	Internal Medicine
	Advanced Practice Nurse/Nurse Practitioner
	Certified Nurse Midwife
	Physician Assistant
Others	Psychiatrist
	Developmental-Behavioral Pediatrician
	Nurse
	Behavioral Health Clinician (e.g. psychologist, therapist, counselor)
	Care Coordinator/ Patient Navigator
	Doula
	Other Specialist Physician, APN/NP, PA (specify type):
	Other (specify type):
Unknown Provider type
Total Primary Care (will auto-populate)
Total (will auto-populate)

Total number of trainings held ____
1. Topic focus of trainings and number of trainings per topic focus. Select all that apply [Note: Each individual training should be associated with only one topic focus; the sum of trainings for each individual training topic focus should equal the total number of trainings held].:

 Mental or behavioral health conditions-related trainings (e.g., anxiety, depression, substance use disorder, ADHD, OCD, eating disorders, tics, Autism, developmental delay, behavioral dysregulation, etc.) Please include comprehensive trainings that cover medications, screenings, treatments, etc. for specific conditions in this category.