5 (Revised) Attachment F_RCORP-Overdose Response Measures - Proposed

RCORP OVERDOSE RESPONSE PIMS Measures

RCORP-Overdose Response Program
Please note: Throughout this document there are references to “consortium.” The legacy RCORP grant programs
require grantees to establish formal partnerships and consortiums and were kept in due to consistency purposes. The
RCORP-Overdose Response grant does not have this requirement. Therefore, some questions were slightly changed in
the Salesforce platform for RCORP-Overdose Response grantees to account for this difference across programs.

Service Area and Consortium
1

Measure Name

Service Area

Instructions and Answer Options

2

States/ Territories

3

Total population in the
project’s service area
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)

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.
Please report the number of people that live in the project’s service area

4

5

6

Please select the option that best describes your project’s service area:
o Single county
o Multiple counties
o State
o Multiple states

•
•

Yes
No

•
•

Consortium as a unit
At least one key consortium activity

•
•
•
•
•

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)

•
•
•
•
•
•

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

RCORP OVERDOSE RESPONSE PIMS MEASURES

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.

•

Other: please describe (text box)

•
•
•
•
•
•
•
•
•
•

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.

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

RCORP OVERDOSE RESPONSE PIMS MEASURES

8

Measure Name

Number of People Served by
Ethnicity

9

Number of People Served by
Race

10

Number of People Served by
Age

11

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

12

13

Number of People Served by
Sex

Number of People Served by
Insurance Status

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

Instructions and Answer Options

Please report the number of people served, by ethnicity, during the past 12months.
• Hispanic or Latino
• Not Hispanic or Latino
• Unknown
• Total
Please report the number of people served, by race, during the past 12months.
• American Indian or Alaska Native
• Asian
• Black or African American
• Native Hawaiian or Other Pacific Islander
• White
• More than one race
• Unknown
• Total
Please report the number of people served, by age, during the past 12months.
• 0-12
• 13-17
• 18-24
• 25-34
• 35-44
• 45-54
• 55-64
• 65 and over
• Total
• LGBTQI+
• Non-LGBTQI+
• Unknown
• Total
Please report the number of people served, by sex, during the past 12months.
• Male
• Female
• Unknown
• Total
Please report the number of people served, by insurance status, during the
past 12-months.
• Self-pay
• None/Uninsured

RCORP OVERDOSE RESPONSE PIMS MEASURES
•
•
•
•
•
•
•
•

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

14

15

16

17

Measure Name

Instructions and Answer Options

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.

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.

Number of patients with a
diagnosis of SUD who were
referred to treatment

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)
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.

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

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

RCORP OVERDOSE RESPONSE PIMS MEASURES
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 _____
o Number of individuals referred to childcare services
o Number of individuals referred to employment services
o Number of individuals referred to recovery housing services
o Number of individuals referred to food/meal programs
o Number of individuals referred to prenatal/postpartum care
services
o Number of individuals referred to housing services
o Number of individuals referred to legal services
o Number of individuals referred to transportation to treatment
o Number of individuals referred to trauma-informed services
o Number of individuals referred to academic support
o Other – specify

20

Number of patients who have
received MAT (medicationassisted 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
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
OMB #: 0906-0044
Expiration Date: 8/31/2027

Instructions and Answer Options
•

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 RCORPOverdose 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

RCORP OVERDOSE RESPONSE PIMS MEASURES

24
25

26

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.
Number of providers who
provided SUD/OUD treatment
services, including MAT
Number of providers who have
provided medications used to
treat OUD

Number of participants who
received SUD education or
training

•

services in the target rural service area
Total number of providers newly hired with RCORP-Overdose
Response grant funds

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
Please report the total number of providers who have
prescribed medications used to treat OUD during the
past 12 months.

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