1c NAS Measures

FY23 RCORP-Neonatal Abstinence Syndrome Program

SERVICE AREA AND CONSORTIUM

OMB #: 0906-0044
Expiration Date: 8/31/2027

FY23 RCORP-Neonatal Abstinence Syndrome Program
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Identify the number and types of
consortium members participating in the
RCORP-Neonatal Abstinence Syndrome
project

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OMB #: 0906-0044
Expiration Date: 8/31/2027

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 1Specify:
Other agency or organization, Type 2Specify
Other agency or organization, Type 3Specify

FY23 RCORP-Neonatal Abstinence Syndrome Program
2

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

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Please report the total number of people
that live in the project’s rural service area.
Please report the total unduplicated number
of service delivery sites within the
Consortium 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 following within the current
reporting period:

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

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• 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-NAS funds
• The total unduplicated number of service
delivery sites within the consortium in the
target rural service area that were expanded
with RCORP-NAS funds
If no service delivery site offered the service, please
input 0.

OMB #: 0906-0044
Expiration Date: 8/31/2027

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Single County
Multiple Counties
State
Multiple State

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

FY23 RCORP-Neonatal Abstinence Syndrome Program

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Report the total unduplicated number of
service delivery sites within the consortium
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 consortium
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.
For each service listed, select whether it was
newly established with or without RCORPNAS funds, expanded with or without
RCORP-NAS funds, remained the same, or
did not exist in the current reporting period
(dropdown).

Please report the number of individuals
who were referred to support services.

OMB #: 0906-0044
Expiration Date: 8/31/2027

Total number of unduplicated service delivery
sites offering at least one harm reduction
service
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Naloxone access
Syringe services
Fentanyl test strips
Safe smoking kits
Sex worker services
Other - specify

• Prevention service (any except naloxone)
• 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)
• Behavioral health crisis intervention services
• Suicide prevention services
• Other – please specify
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 traumainformed services
• Number of individuals referred to academic
support

FY23 RCORP-Neonatal Abstinence Syndrome Program
Other – specify

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NOTE: Sustainability measures only
reported in final reporting period of the
grant
Will the consortium as a unit and/or at least
one key consortium activity be sustained
after the RCORP grant ends?
If you selected yes in previous sub-section,
what will sustain? (check all that apply)
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)

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Yes
No

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Consortium as a unit
At least one key consortium activity
Absorption of services or other means of inkind 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)

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OMB #: 0906-0044
Expiration Date: 8/31/2027

FY23 RCORP-Neonatal Abstinence Syndrome Program
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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)

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

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

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

OMB #: 0906-0044
Expiration Date: 8/31/2027

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

FY23 RCORP-Neonatal Abstinence Syndrome Program
16

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

OMB #: 0906-0044
Expiration Date: 8/31/2027

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Self-pay
None/Uninsured

FY23 RCORP-Neonatal Abstinence Syndrome Program

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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
Male
Female
Unknown
Total

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LGBTQI+
Non-LGBTQI+
Unknown
Total

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

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

DIRECT SERVICES
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Measure Instructions
Please report the total number of infants who
have been screened for Neonatal Abstinence
Syndrome (NAS)

Measure
Number of infants screened for NAS

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Please report the total number of infants who
have been screened positive for Neonatal
Abstinence Syndrome (NAS)

Number of infants screened positive for NAS

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Of those that screened positive, please report Number of infants who were referred to NAS
the total number of infants who were referred specific services
to NAS specific services

OMB #: 0906-0044
Expiration Date: 8/31/2027

FY23 RCORP-Neonatal Abstinence Syndrome Program
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Of the infants screened positive for SUD,
please report the total number of infants who
have been diagnosed for substance use
disorder (SUD) during the current reporting
period.
Please report the total number of infants
born with Neonatal Abstinence Syndrome
(NAS)/Neonatal Opioid Withdrawal (NOW)
Syndrome-related symptoms in the project
service area.
Please report the total number of individuals
who screened positive for SUD, or at risk for
overuse/misuse, in the current reporting
period. If known, please specify the number
of individuals who screened positive for
specific substances. While individuals could
screen positive for multiple substances, each
subcategory should not exceed the total.

Number of infants diagnosed for SUD

Number of NAS/NOW-related births in the
project’s service area.

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Please report the total number of individuals
diagnosed with substance use disorder
(SUD) in the current reporting period. If
known, please specify the number of
individuals who were diagnosed for specific
SUDs. While individuals could be diagnosed
with multiple SUDs, each subcategory
should not exceed the total.

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OMB #: 0906-0044
Expiration Date: 8/31/2027

Total number of individuals who screened
positive for alcohol or substance use
Number of individuals who screened
positive for alcohol overuse/misuse (or at
risk for this)
Number of individuals who screened
positive for opioid overuse/misuse (or at
risk of this)
Number of individuals who screened
positive for psychostimulant
overuse/misuse (or at risk of this)
Number of individuals who screened
positive for other substance
overuse/misuse (or at risk of this)
(specify)
Total number of individuals diagnosed with
an SUD
Number of individuals diagnosed with
alcohol use disorder
Number of individuals diagnosed with
opioid use disorder
Number of individuals diagnosed with
psychostimulant use disorder
Number of individuals diagnosed with other
SUD (specify)

FY23 RCORP-Neonatal Abstinence Syndrome Program

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Please report the total number of patients
diagnosed with SUD who were also screened
for clinical depression using an age
appropriate standardized tool.
Please report the total number of patients
diagnosed with SUD who were tested for
HIV/AIDS.
Please report the total number of patients
diagnosed with SUD who were tested for
HCV.
Please report the total number of patients
diagnosed with SUD who were referred to
SUD treatment.
Please report the total number of individuals
who received recovery support services in
the current reporting period.
Please report the total number of patients
who have received MAT only or MAT with
psychosocial therapy.
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.
Please report the percentage of MAT service
costs (including medication, psychosocial
therapy, and wrap-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.

OMB #: 0906-0044
Expiration Date: 8/31/2027

Number of patients with an SUD diagnosis who
were screened for depression
Patients with an SUD diagnosis who were
tested for HIV/AIDS
Patients with an SUD diagnosis who were
tested for HCV
Patients with an SUD diagnosis who were
referred to treatment
Number of individuals who received recovery
support services
Number of patients who received MAT AND
psychosocial therapy
• Number of patients who received MAT
ONLY
Number of patients who have received MAT for
three months or more without interruption
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Percentage of MAT services currently covered
through reimbursement or other non-grant
funding sources

FY23 RCORP-Neonatal Abstinence Syndrome Program
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Denominator: total costs associated
with MAT services.

WORKFORCE
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Measure Instructions
Please report the total number of
unduplicated providers within the
consortium 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-NAS grant funds) during
the current reporting period.
Please report the total number of
unduplicated providers within the
consortium who screened, diagnosed,
and/or treated infants with NAS during
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-NAS grant funds)
during the current reporting period.

Measure
• 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-NAS grant funds

Please report the total number of providers
(i.e. individuals) within the consortium who
have prescribed medications used to treat
OUD during the current reporting period.
Please report the total number of providers
(i.e., individuals) within the consortium who
have provided SUD/OUD treatment services,
including MAT, during the current reporting
period in the target rural service area. Of
those providers, please specify how many
were medical providers, non-medical
counseling staff, peer recovery support
specialists, or other (specify).

Total number of providers (i.e., individuals)
who have prescribed medications used to treat
OUD (note: no FTE required)

OMB #: 0906-0044
Expiration Date: 8/31/2027

Total number of unduplicated providers
# of providers who screened infants for
NAS
# of providers who diagnosed infants
for NAS
# of providers who treated infants for
NAS

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Total number of providers newly hired
with RCORP-NAS grant funds

Total Number of Providers
Number of Medical Providers
Number of Non-Medical Counseling Staff
Number of Peer Recovery Support
Specialists
Other – specify

FY23 RCORP-Neonatal Abstinence Syndrome Program
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Please report the total number of providers,
paraprofessional staff, and community
members (non-providers) within the
consortium who participated

OMB #: 0906-0044
Expiration Date: 8/31/2027

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Mental health first aid trainings
Naloxone trainings
Opioid prescribing guidelines trainings

FY23 RCORP-Neonatal Abstinence Syndrome Program

in direct substance use disorder education
and training activities as a result of RCORP
funding.

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Stigma reduction trainings
Contingency Management
Trauma – specific evidence based practices
Other - specify

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 0906-0044 and it is valid until 8/31/2027. 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 14NWH04,
Rockville, Maryland, 20857 or [email protected]. Please see https://www.hrsa.gov/about/508resources for the HRSA digital accessibility statement.

OMB #: 0906-0044
Expiration Date: 8/31/2027