6 (Revised) Attachment C_RCORP-CABH Measures -Proposed Revision

RCORP-Child and Adolescent Behavioral Health Measures

SERVICE AREA AND CONSORTIUM
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Measure Instructions

Measure

1

Identify the number and types of
consortium members
participating in the RCORP-Child
and Adolescent Behavioral
Health project

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OMB Control Number: 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 1-

Burden Estimate (# of hours –
0.00 format)

RCORP-Child and Adolescent Behavioral Health Measures

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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.

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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:

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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-CABH
funds
• The total unduplicated number of
service delivery sites within the
consortium in the target rural
service area that were expanded
with RCORP-CABH funds

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Specify:
Other agency or organization, Type
2- Specify
Other agency or organization, Type 3Specify
Single County
Multiple Counties
State
Multiple States
Total population in the project’s rural
service area

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

• Prevention services (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

If no service delivery site offered the
service, please input 0.
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Report the total unduplicated
number of service delivery sites
within the consortium in the
target rural service area offering
OMB Control Number: 0906-0044
Expiration Date: 8/31/2027

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

RCORP-Child and Adolescent Behavioral Health Measures
at least one harm reduction
service within the current
reporting period.
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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 RCORP- Child
and Adolescent Behavioral
Health funds, expanded with or
without RCORP- Child and
Adolescent Behavioral Health
funds, remained the same, or did
not exist in the current reporting
period (dropdown).

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

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

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NOTE: Sustainability measures
only reported in final reporting
period of the grant (August
2027)
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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Consortium as a unit

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At least one key consortium activity

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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

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OMB Control Number: 0906-0044
Expiration Date: 8/31/2027

No

RCORP-Child and Adolescent Behavioral Health Measures

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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)

DIRECT SERVICES
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Measure Instructions

12

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

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Measure

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Please report the total number of Number of individuals with a positive screen
individuals with a positive screen and/or an SUD diagnosis who were referred
and/or diagnosis of substance
to SUD treatment
use disorder (SUD) who were
referred to SUD treatment during
the current reporting period.

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

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Please report the total number of
individuals who screened positive
and/or were diagnosed with a
mental health disorder in the
current reporting period.
Please report the total number of
individuals who screened positive
and/or had a mental health
disorder diagnosis who were
referred to mental health

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OMB Control Number: 0906-0044
Expiration Date: 8/31/2027

Total number of individuals with a positive
screen and/or diagnosed with a mental health
disorder
Number of individuals who screened positive
and/or had a mental health disorder diagnosis
who were referred to mental health treatment

Burden Estimate (# of hours
– 0.00 format)

RCORP-Child and Adolescent Behavioral Health Measures
treatment during the current
reporting period.
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Please report the total number of
individuals who screened positive
and/or were diagnosed with a cooccurring substance use AND a
mental health disorder during the
current reporting period.
Please report the total number of
individuals who were tested for
HIV/AIDS
Please report the total number of
individuals who were tested for
HCV

Total number of individuals who screened
positive and/or were diagnosed with a cooccurring substance use AND a mental health
disorder

Total number of individuals who were
tested for HIV/AIDS
Total number of individuals who were tested
for HCV

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

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Please report the number of
Total number of individuals who were referred
individuals who were referred to to support services _____
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
• Other – specify

OMB Control Number: 0906-0044
Expiration Date: 8/31/2027

RCORP-Child and Adolescent Behavioral Health Measures
23

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.

OMB Control Number: 0906-0044
Expiration Date: 8/31/2027

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

RCORP-Child and Adolescent Behavioral Health Measures

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

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Measure Instructions

Measure

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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.

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

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OMB Control Number: 0906-0044
Expiration Date: 8/31/2027

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
Under 5
5-12
13-17
18 and over
Total

Self-pay
None/Uninsured
Dual Eligible (covered by both
Medicaid and
Medicare)
Medicaid/CHIP only
Medicare only
Medicare plus supplemental
TriCARE
Other third party (e.g., privately

Burden Estimate (# of hours –
0.00 format)

RCORP-Child and Adolescent Behavioral Health Measures

insured)
Unknown
Total
Male
Female
Unknown
Total
LGBTQI+
Non-LGBTQI+
Unknown
Total

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Please report the number of
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individuals served, by sex, during the •
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current reporting period
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Please report the number of
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individuals served, by LGBTQI+,
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during the current reporting period •
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WORKFORCE

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Measure Instructions

Measure

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Please report the total number of
unduplicated providers within the
consortium who provided
SUD/OUD treatment services,
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-CABH grant funds)
during the current reporting period.
Please report the total number of
providers (i.e., individuals) within the
consortium who have prescribed
medications used to treat
OUD and/or AUD during the current
reporting period.

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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
OMB Control Number: 0906-0044
Expiration Date: 8/31/2027

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Total number of unduplicated
providers (i.e., individuals) within
the consortium who provided
SUD/OUD treatment services,
behavioral health services,
and/or recovery support services
in the target rural service area in
the current reporting period.
Total number of providers newly
hired with RCORP-Behavioral
Health Care Support grant funds

• Total number of providers (i.e.,
individuals) who have prescribed
medications used to treat OUD
• Total number of providers (i.e.,
individuals) who have prescribed
medications used to treat AUD
• Number of Medical Providers
• Number of Non-Medical Counseling
Staff
• Number of Peer
Recovery Support
Specialists
• Other – specify
• Total Number of Providers

Burden Estimate (# of hours –
0.00 format)

RCORP-Child and Adolescent Behavioral Health Measures
support specialists, or other
(specify).
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Please report the total number of
providers (i.e., individuals) within the
consortium who have provided
mental health treatment services
during the current reporting period
in the target rural service area. Of
those providers, please specify how
many were medical providers, nonmedical counseling staff, peer
recovery support specialists, or other
(specify).
Please report the total number of
providers (i.e., individuals) within the
consortium who have provided
recovery support services during the
current reporting period in the target
rural service area

Report the total number of SUD
and/or mental health disorder
trainings conducted in the current
reporting period as a result of RCORP
funding in the target rural service
area. For each topic area, please
provide the number of trainings in
each category.

OMB Control Number: 0906-0044
Expiration Date: 8/31/2027

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

• Number of Medical Providers
• Number of Non-Medical
Counseling Staff
• Number of Peer Recovery Support
Specialists
• Other – specify
• Total Number of Providers
• Number of ACES trainings
• Number of contingency
management trainings
• Number of behavioral therapy
trainings
• Number of mental health first aid
trainings
• Number of Naloxone trainings
• Number of Opioid prescribing
guidelines trainings
• Number of school-based evidencebased practices trainings
• Number of stigma reduction
trainings
• Number of trauma-informed
evidence-based practices trainings
• Other - specify

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/508-resources for the HRSA digital
accessibility statement.

OMB Control Number: 0906-0044
Expiration Date: 8/31/2027