Form 8 RCORP –Impact PIMS

D RAFT – RCORP-Impact Program

OMB Number: 0906-0044

Expiration Date: XX/XX/XXXX

Measure #	Category	Measure	Responses
PART 1: Project Overview
1	Project Overview	Identify the number and types of medical organizations and agencies in your network.	Hospitals Critical Access Hospital (CAH) Small Rural Hospital (49 beds or less, non-CAH) Medium/Large Rural Hospital (50 beds or more, non-CAH) Urban Hospital (non-CAH) Rural Emergency Hospital (non-CAH) Other Hospital (non-CAH), specify: Primary Care Rural Health Clinic Federally Qualified Health Center (FQHC) or FQHC Look-alike Other primary care practice or provider (non-RHC, non-FQHC): Specify Behavioral Health Organization Methadone clinic Opioid treatment program Certified Community Behavioral Health Clinic Other mental and behavioral health organization: specify Other Medical Emergency medical services entity Local or state health department Ryan White HIV/AIDS clinic Other medical agency or organization, Type 1 Specify: Other medical agency or organization, Type 2 Specify Other medical agency or organization, Type 3 Specify Total
2	Project Overview	Identify the number and types of social service and non-medical organizations and agencies in the network.	Criminal Justice Law Enforcement Court System Prison Probation and parole Other Criminal Justice organization: specify Youth-focused Healthy Start site Maternal, Infant, and Early Childhood Home Visiting Program local implementation agency School system Other youth-focused organization: specify Behavioral health (non-medical) Recovery Community Organization (RCO) Single State Agency (SSA) Other behavioral health (non-medical) organization: specify Other Social Service Faith-based organization Poison Control Center Primary Care Association (PCA) Primary Care Organization (PCO) Research / Academic Organization State Office of Rural Health (SORH) Tribe/Tribal organization Other social service and non-medical agency or organization, Type 1- Specify Other social service and non-medical agency or organization, Type 2- Specify Other social service and non-medical agency or organization, Type 3- specify Total
3	Project Overview	Select the County(ies) and State(es) included in your service area.	Drop down with states/counties
4	Project Overview	Please report the total number of people that live in the project’s rural service area	Total population in the project’s rural service area
5.	Project Overview	Please report the total number of unique service delivery sites supported by RCORP-Impact funds	Total Service Delivery Sites
Part 2: Service Delivery Site-Specific Information
Section A: Behavioral Health Treatment and Recovery Service Delivery Sites
For each unique service delivery site supported by RCORP-Impact funds, report the following.
6.	Access	Site Name	Site Name
7	Access	Physical Address where treatment and recovery services are being provided.	Address
8	Access	CMS Certification Number (CCN)	CCN
9	Access	Site Type	Brick and mortar Mobile unit Other (Specify)
10	Access	Are telehealth services provided at this site?	Yes No
11	Access	If telehealth services are provided at this site, is it a spoke or a hub?	Spoke (receiving telehealth) Hub (originating telehealth)
12	Access	Organization Type	Hospitals Critical Access Hospital (CAH) Small Rural Hospital (49 beds or less, non-CAH) Medium/Large Rural Hospital (50 beds or more, non-CAH) Urban Hospital (non-CAH) Rural Emergency Hospital (non-CAH) Other Hospital (non-CAH), specify: Primary Care Rural Health Clinic Federally Qualified Health Center (FQHC) or FQHC Look-alike Other primary care practice or provider (non-RHC, non-FQHC): Specify Behavioral health organization Methadone clinic Opioid treatment program Certified Community Behavioral Health Clinic Other mental and behavioral health organization: specify Other Medical Emergency medical services entity Local or state health department Ryan White HIV/AIDS clinic Other medical agency or organization, Type 1 Specify: Other medical agency or organization, Type 2 Specify Other medical agency or organization, Type 3 Specify Criminal Justice Law Enforcement Court System Prison Probation and parole Other Criminal Justice organization: specify Youth-focused Healthy Start site Maternal, Infant, and Early Childhood Home Visiting Program local implementation agency School system Other youth-focused organization: specify Behavioral health (non-medical) Recovery Community Organization (RCO) Single State Agency (SSA) Other behavioral health (non-medical) organization: specify Other Social Service Faith-based organization Poison Control Center Primary Care Association (PCA) Primary Care Organization (PCO) Research / Academic Organization State Office of Rural Health (SORH) Tribe/Tribal organization Other social service and non-medical agency or organization, Specify Specify Organization Type
Section B: Services offered at each unique service delivery site
For each service provided at this site, report the following. List of service options: Prevention Evidence-based prevention services SUD screening and/or assessment Naloxone distribution SUD Treatment MOUD Contingency Management Psychosocial therapy for SUD Other SUD treatment (Specify) Mental Health Treatment Psychosocial therapy for mental health Medication management for mental health Other mental health treatment (specify) Recovery Recovery housing Peer recovery support specialist services Recovery support groups Other recovery support services (specify) Social Support Services Childcare Employment services Transportation to treatment Other transportation services (specify) Food access Housing support Tutoring/educational assistance Other (specify)
13	Capacity	Was the service newly established or newly expanded with RCORP-Impact funds in the reporting period?	Newly established with RCORP-Impact funds Newly expanded with RCORP-Impact funds Remained the same Does not exist
14	Capacity	Total number of individuals receiving the RCORP-Impact supported service at each site in the reporting period	# individuals receiving prevention # of individuals receiving SUD treatment # of individuals receiving mental health treatment # of individuals receiving recovery # of individuals receiving social support services Total
15	Capacity	Total number of individuals newly receiving the RCORP-Impact supported service at each site for the first time in this reporting period	# individuals receiving prevention # of individuals receiving SUD treatment # of individuals receiving mental health treatment # of individuals receiving recovery # of individuals receiving social support services Total
16	Capacity	Number of children/adolescents ages 5-17 receiving the service at each site in the reporting period.	# individuals receiving prevention # of individuals receiving SUD treatment # of individuals receiving mental health treatment # of individuals receiving recovery # of individuals receiving social support services Total
17		Number of children/adolescents ages 5-17 newly receiving the service at each site for the first time in this reporting period.	# individuals receiving prevention # of individuals receiving SUD treatment # of individuals receiving mental health treatment # of individuals receiving recovery # of individuals receiving social support services Total
Note that the following four measures are for Treatment and Recovery services only. These measures are mutually exclusive. Please only count individuals in ONE category.
18	Health Outcomes	Total number of individuals retained 3-6 months in the service, as of the end of the reporting period.	# individuals retained for SUD treatment services # of individuals retained for mental health treatment services # of individuals retained for recovery services Total #
19	Health Outcomes	Total number of individuals retained 6+ months in the service, as of the end of the reporting period.	# individuals retained for SUD treatment services # of individuals retained for mental health treatment services # of individuals retained for recovery services Total #
20	Health Outcomes	Total number of individuals successfully discharged from the service, as of the end of the reporting period	# individuals successfully discharged from SUD treatment services # of individuals successfully discharged from mental health treatment services # of individuals successfully discharged from recovery services Total #
21	Health Outcomes	Total number of individuals who left service for other reasons (not successfully discharged), as of the end of the period of performance.	# individuals left SUD treatment services # of individuals left mental health treatment services # of individuals left recovery services Total #
Part 3: Provider-Specific Information
22		How many providers are being supported by RCORP-Impact funding? Include providers who are providing direct or non-direct services to individuals	# providers
23	Capacity	Provider name or other unique identifier (if preferred).	Name/Unique Identifier
24	Capacity	Provider/Specialty Type (select best option)	Addiction Medicine Specialist Family Nurse Practitioner Licensed Clinical Alcohol and Drug Abuse Specialist Licensed Clinical Social Worker Licensed Marriage and Family Therapist Licensed Professional Counselor Mental Health Nurse Practitioner Peer Recovery Support Specialist Primary Care Physician Psychologist Psychiatrist Other (Specify):
25	Capacity	Was the provider newly hired in the reporting period to provide direct patient care?	Yes No
26	Capacity	Was the provider newly hired in the reporting period to provide non-direct patient care?	Yes No
27	Capacity	If newly hired, was the provider hired through a loan repayment program?	National Health Service Corps Nurse Corps Loan Repayment Program Pediatric Specialty Loan Repayment Program Substance Use Disorder Treatment and Recovery Loan Repayment Program Other (specify):
28	Capacity	Does the provider offer MOUD?	Yes No
29	Capacity	Has the provider newly expanded their scope of practice to include MOUD or other SUD treatment services during the reporting period?	Expanded to include MOUD Expanded to include other (non-MOUD) treatment services Expanded to include BOTH MOUD and other SUD treatment services None.
30	Capacity	Which direct care services does the provider provide? (select all that apply)	Prevention SUD Screening and/or Assessment Naloxone distribution Other prevention: specify SUD Treatment MOUD Contingency Management Psychosocial therapy for SUD Other SUD treatment (Specify) Mental Health Treatment Psychotherapy for mental health Medication management for mental health Other mental health treatment (specify) Recovery Recovery housing Peer Recovery Support Specialist services Recovery support groups Other Recovery support services (specify) Not Applicable/Non-Direct Services
31	Capacity	Number of months the provider has been supported by RCORP-Impact to provide direct care during the reporting period?	# months, 12 or less.
32	Capacity	If less than 12, is this provider still supported with RCORP-Impact funds?	Yes No
33	Capacity	How long has the provider been supported through RCORP-Impact funds to provide non-direct care during the reporting period, (ie, nurse manager, etc)	# months, 12 months or less
Part 4: Consolidated Project Data Information
34	Capacity	How many doses of Naloxone have you purchased and distributed using RCORP-Impact funds? If you are not using RCORP-Impact funds to purchase and distribute Naloxone, enter 0.	# Doses Naloxone purchased # Doses Naloxone distributed
35	Capacity	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.	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
36	Health Outcomes	Total number of individuals diagnosed with substance use disorder (SUD) in the current reporting period.	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) Total
37	Capacity	Total number of individuals diagnosed with SUD who were referred to SUD treatment	Individuals with an SUD diagnosis who were referred to treatment
38	Health Outcomes	Total number of individuals diagnosed with SUD and initiated SUD treatment	Patients with an SUD diagnosis who initiated treatment immediately in the same location where they received the diagnosis. Patients with an SUD diagnosis who were referred to treatment and later initiated SUD treatment.
39	Capacity	Please report the total number of providers, paraprofessional staff, and community members (non-providers) who participated in direct substance use disorder education and training activities as a result of RCORP-Impact funding.	Mental health first aid trainings Naloxone trainings Opioid prescribing guidelines trainings Training and certifying peer recovery specialists Other - specify
40	Access	Please report the number of individuals served, by age, during the current reporting period. Count each individual only once. The total individuals should equal the total number of individuals served, from measure	0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85 and over Total
41	Access	Please report the number of individuals served, by insurance status, during the current reporting period. Count each individual only once. The total individuals should equal the total number of individuals served, from measure	Insurance through a current or former employer or union Insurance purchased directly from an insurance company Medicare, for people 65 and older, or people with certain disabilities Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability TRICARE or other military healthcare VA (enrolled for VA healthcare) Indian Health Service Any other type of health insurance or health coverage plan No health insurance coverage Health insurance coverage status unknown Total
42	Sustainability	Please report the percentage of billable MOUD service costs (including medication, psychosocial therapy, and wrap-around services) covered through reimbursement (e.g. by Medicaid, Medicare, private insurance) during the reporting period.	% of billable MOUD services covered through reimbursement.
43	Sustainability	Please report the costs associated with the provision of MOUD services that were reimbursed	Numerator: all costs associated with MOUD services that were reimbursed
44	Sustainability	Please report the total costs associated with the provision of MOUD services	Denominator: total costs associated with MOUD services
Part 5: Sustainability (Only reported in the final reporting period of the grant)
45	Sustainability	Will the network as a unit and/or at least one key network activity be sustained after the RCORP grant ends?	Yes No
46	Sustainability	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
47	Sustainability	If you selected “At least one key network 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) Applying for an 11-15 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)

Public Burden Statement: The purpose of this data collection is to provide data on each Rural Communities Opioid Response Program initiative to enable HRSA to provide aggregate program data required by Congress under the Government Performance and Results Act of 1993. 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 project is 0906-0044 and it is valid until XXXXXXXX. Public reporting burden for this collection of information is estimated to average 1.15 hours 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 13N82, Rockville, Maryland, 20857 or [email protected].