6 NHSC Comprehensive Behavioral Health Services Checklist

OMB Number: 0915-0127

Expiration Date: xx/xx/xxxx

APPENDIX E: NATIONAL HEALTH SERVICE CORPS COMPREHENSIVE BEHAVIORAL HEALTH SERVICES CHECKLIST

**Only National Health Service Corps Site Administrators are permitted to submit certification documents**

Site Name
Address

Section I. Core Comprehensive Behavioral Health Service Elements

National Health Service Corps-approved Comprehensive Primary Behavioral Health Service sites must upload documentation demonstrating that Core Comprehensive Behavioral Health Services are provided on-site. Core service elements must be provided on-site; these services cannot be offered in-network, through referral, affiliation, or contract.

Service	Check the box and upload supporting documentation for each Core service provided on-site
1. Screening and Assessment: Screening is the practice of determining the presence of risk factors, early behaviors, and biomarkers which enables early identification of behavioral health disorders (e.g., warning signs for suicide, substance abuse, depression) and early access to care. Assessment is a structured clinical examination that analyzes patient bio-psych-social information to evaluate a behavioral health complaint.
2. Treatment Plan: A formalized, written document that details a patient's current clinical symptoms, diagnosis, and outlines the therapeutic strategies and goals that will assist the patient in reducing clinical symptoms and overcoming his or her behavioral health issues. The plan also identifies, where indicated, clinical care needs and treatment(s) to be provided by affiliated health and behavioral health care providers and settings.
3. Care Coordination: Care Coordination is the practice of navigating and integrating the efforts primary care, specialty health care and social service providers to support a patient’s health, wellness, and independence.

Section II. Additional Comprehensive Behavioral Health Service Elements (Non-Core Elements)

National Health Service Corps-approved Comprehensive Primary Behavioral/Mental Health Service sites must upload documentation demonstrating patient access to non-core service elements, which may be provided on-site, in-network, through referral, affiliation, or contract. Acceptable documentation includes: affiliation agreements; memorandums of understanding/agreement; contracts; letters of referral; letters of support/commitment; or referral and follow-up policy.

Service	Select On-site or Off-site and upload supporting documentation
	Provided On-site	Provided Off-site
1. Diagnosis: The practice of determining a patient’s emotional, socio-emotional, behavioral, or mental symptoms as a diagnosable disorder in accordance with the Diagnostic and Statistical Manual of Mental Disorders (DSM; most current edition) and International Classification of Disease (ICD; most current edition).	☐	☐
2. Therapeutic Services (including, but not limited to, psychiatric medication prescribing and management, chronic disease management, and Substance Use Disorder Treatment): Broad range of evidence-based or promising behavioral health practice(s) with the primary goal of reducing or ameliorating behavioral health symptoms, improve functioning, and restore/maintain a patient’s health (e.g., individual, family, and group psychotherapy/ counseling; psychopharmacology; and short/long-term hospitalization).	☐	☐
Psychiatric Medication Prescribing and Management Substance Use Disorder Treatment Short/long-term hospitalization Other (Please list) Other (Please list)	☐ ☐ ☐ ☐ ☐	☐ ☐ ☐ ☐ ☐
3. Crisis/Emergency Services (including, but not limited to, 24-hour crisis call access): The method(s) used to offer immediate, short-term help to individuals who experience an event that produces emotional, mental, physical, and behavioral distress or problems. In some instances, a crisis may constitute an imminent threat or danger to self, to others, or grave disability. (Note: generic hotline, hospital emergency room referral, or 911 is not sufficient).	☐	☐
4. Consultative Services: The practice of collaborating with health care and other social service providers (e.g., education, child welfare, and housing) to identify the biological, psychological, medical, and social causes of behavioral health distress, to determine treatment approach(s), and to improve patient functioning.	☐	☐
5. Case Management: The practice of assisting and supporting patients in developing their skills to gain access to needed health care, housing, employment, social, educational, and other services essential to meeting basic human needs and consistent with their health care treatment, symptom management, recovery, and independent functioning.	☐	☐

Section III. Off-Site Behavioral Health Service Details

Under this section, the National Health Service Corps-approved site must provide basic information for each entity that supports access to non-core behavioral health services.

Provider			Provider
Address			Address
Services Offered			Services Offered

Provider			Provider
Address			Address
Services Offered			Services Offered

Section IV. Certification of Compliance with Behavioral Health Clinical Practice Requirements

Certify that the behavioral health site adheres to the clinical practice requirements for behavioral health providers under the National Health Service Corps and supports National Health Service Corps participants in meeting their obligation related to the clinical practice requirements. Refer to the appropriate NHSC Application and Program Guidance for a detailed definition of Full-Time or Half-Time Clinical Practice.

	Provided On-site	Not Provided On-site
Full-time: The site offers employment opportunities that adhere to the National Health Service Corps definition of full-time clinical practice.	☐	☐
Half-time: The site offers employment opportunities that adhere to the National Health Service Corps definition of half-time clinical practice.	☐	☐

Section V. Site Certification:

By signing below, you (the National Health Service Corps Site Administrator) are affirming the truthfulness and accuracy of the information in this document.

I, , hereby certify that the information provided above, and all supporting information, is true and accurate. I understand that this information is subject to verification by the National Health Service Corps.

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Signature Date

Certified	Not Certified
☐	☐

OFFICIAL NATIONAL HEALTH SERVICE CORPS USE ONLY

Recommended By:

COMMENTS

Public Burden Statement: The purpose of this information collection is to obtain information through the National Health Service Corps Loan Repayment Program that is used to assess a Loan Repayment Program applicant’s eligibility and qualifications for the Loan Repayment Program, or for NHSC Site Application and Recertification purposes. Clinicians interested in participating in the National Health Service Corps Loan Repayment Program must submit an application to the National Health Service Corps. 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 information collection is 0915-0127 and it is valid until xx/xx/xxxx. This information collection is required to obtain or retain a benefit (Section 333 [254f] (a)(1) of the Public Health Service Act). The information is protected by the Privacy Act, but it may be disclosed outside the U.S. Department of Health and Human Services, as permitted by the Privacy Act and Freedom of Information Act, to Congress, the National Archives, and the Government Accountability Office, and pursuant to court order and various routine uses as described in the System of Record Notice 09-15-0037. Public reporting burden for this collection of information is estimated to average approximately 30 minutes 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 14N39, Rockville, Maryland, 20857 or [email protected].