Form 5 RCORP Overdose Response FINAL 07092024

RCORP Overdose response DRAFT PIMS Measures

Rural Communities Opioid Response Program (RCORP) Performance Measures

Service Area and Consortium

	Measure Name	Instructions and Answer Options	Burden Estimate (# of hours – 0.00 format)
1	Service Area	Please select the option that best describes your project’s service area: Single county Multiple counties State Multiple states
2	States/ Territories	Identify the State(s)/Territories included in the project service area. Select from the 'States/Territories' drop-down and then click on the 'Add' button and repeat if needed.
3	Total population in the project’s service area	Please report the number of people that live in the project’s service area
4	Will the consortium as a unit and/or at least one key consortium activity be sustained after the RCORP grant ends?	Yes No
5	If you selected yes in previous sub-section, what will sustain? (check all that apply)	Consortium as a unit At least one key consortium activity
6	If you selected “At least one key consortium activity” in the previous sub-section how will the activity or activities be sustained? (check all that apply)	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) Fees Applying for an 1115 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)
7	For each of the following services, please report the following within the current reporting period: The total unduplicated number of service delivery sites within the consortium in the target rural service area The total unduplicated number of service delivery sites within the consortium in the target rural service area that were newly established with RCORP-Overdose Response funds The total unduplicated number of service delivery sites within the consortium in the target rural service area that were expanded with RCORP-Overdose funds. If no service delivery site offered the service, please input 0.	Prevention services (not including naloxone) 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 Behavioral health crisis intervention services Suicide prevention services Other – specify

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. Each demographic sub-section should total to the same amount. In addition, the total number for each demographic sub-section should equal the total number of individuals who have received direct services reported within the current reporting period. 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.

	Measure Name	Instructions and Answer Options
8	Number of People Served by Ethnicity	Please report the number of people served, by ethnicity, during the past 12-months. Hispanic or Latino Not Hispanic or Latino Unknown Total
9	Number of People Served by Race	Please report the number of people served, by race, during the past 12-months. American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White More than one race Unknown Total
10	Number of People Served by Age	Please report the number of people served, by age, during the past 12-months. 0-12 13-17 18-24 25-34 35-44 45-54 55-64 65 and over Total
11	Please report the number of individuals served, by LGBTQI+, during the current reporting period	LGBTQI+ Non-LGBTQI+ Unknown Total
12	Number of People Served by Sex	Please report the number of people served, by sex, during the past 12-months. Male Female Unknown Total
13	Number of People Served by Insurance Status	Please report the number of people served, by insurance status, during the past 12-months. 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) Unknown Total

Direct Services & Activities

	Measure Name	Instructions and Answer Options
14	Number of individuals screened for SUD	Please report the total number of individuals who have been screened for substance use disorder (SUD) in the past 12-months.
15	Number of patients with a positive screen for alcohol or substance use	Please report the total number of patients who screened positive for alcohol or substance overuse/misuse, or at risk for overuse/misuse, in the past 12-months. If known, please specify the number of patients who screened positive for specific SUD. While patients could screen positive for multiple SUDs, each sub category should not exceed the total. Total number of patients who screened positive for alcohol or substance use Number of patients who screened positive for alcohol overuse/misuse (or at risk of this) Number of patients who screened positive for opioid overuse/misuse (or at risk of this) Number of patients who screened positive for psychostimulant overuse/misuse (or at risk of this) Number of patients who screened positive for other substance overuse/misuse (or at risk of this)
16	Number of patients with a diagnosis of SUD who were referred to treatment	Please report the total number of patients with a diagnosis of substance use disorder (SUD) who were referred for SUD treatment during the past 12-months.
17	Number of patients who were tested for HIV/AIDS	Please report the total number of patients who were also tested for HIV/AIDS during the past 12-months.
18	Number of patients who were tested for HCV	Please report the total number of patients who were also tested for the Hepatitis C Virus (HCV) during the past 12-months.
19	Please report the number of individuals who were referred to support services.	Total number of individuals who were referred to support services _____ 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 food/meal programs Number of individuals referred to prenatal/postpartum care services Number of individuals referred to housing services Number of individuals referred to legal services Number of individuals referred to transportation to treatment Number of individuals referred to trauma-informed services Number of individuals referred to academic support Other – specify
20	Number of patients who have received MAT (medication-assisted treatment)	Please report the total number of patients who have received medication assisted treatment (MAT) only or MAT with psychosocial therapy within the past 12-months. Number of patients who received MAT AND psychosocial therapy in the past 12 months Number of patients who received MAT ONLY in the past 12 months
21	Number of patients who have received MAT for 3 months or more without interruption	Please report the total number of patients who have received MAT (including both medication AND psychosocial therapy) for a period of 3 months or more without interruption in the past 12 months.
22	Please report the total number of individuals who received recovery support services in the past 12-months	Number of individuals who received recovery support services

Workforce

	Measure Name	Instructions and Answer Options
23	Please report the total number of unduplicated providers who provided SUD/OUD treatment services, mental/behavioral health services, and/or recovery support services in the target rural service area in the current reporting period. Of the total number of providers, please also report how many were newly hired with grant funds (e.g., their salary was paid for in full or in part with RCORP-Overdose Response grant funds) during the current reporting period.	Please report the total number of unduplicated providers who provided SUD/OUD treatment services, mental/behavioral health services, and/or recovery support services in the target rural service area in the current reporting period. Of the total number of providers, please also report how many were newly hired with grant funds (e.g., their salary was paid for in full or in part with RCORP-Overdose Response grant funds) during the current reporting period. Total number of unduplicated providers (i.e., individuals) within the consortium who provided SUD/OUD treatment services, mental/behavioral health services, and/or recovery support services in the target rural service area Total number of providers newly hired with RCORP-Overdose Response grant funds
24	Number of providers who provided SUD/OUD treatment services, including MAT	Please report the total number of providers (i.e., individuals who have provided SUD/OUD treatment services, including MAT, during the past six months in the target rural service area
25	Number of providers who have provided medications used to treat OUD	Please report the total number of providers who have prescribed medications used to treat OUD during the past 12 months.
26	Number of participants who received SUD education or training	Please report the total number of providers, paraprofessional staff, and community members (non-providers) who participated in direct substance use disorder education or training activities within the past 12 -months as a result of RCORP funding. For each topic area, please provide the number of participants in each category. Mental health first aid Naloxone training Opioid prescribing guidelines Stigma reductio Contingency management Trauma-specific evidence-based practices Other Type 1:

Public Burden Statement: The purpose of this activity is to collect information on Rural Communities Opioid Response Program grantees to provide HRSA with information on grant activities funded under this program. 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 0906-XXXX and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit (42 U.S.C. 912). Data will remain private to the extent permitted by the law. Public reporting burden for this collection of information is estimated to average approximately 1 hour and 22 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or [email protected].  Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.