Form Site Visits Year O Site Visits Year O Site Visits Year One Site Visit Form

Site Visit Interview Guide OMB NO. 0930-xxxx Expiration Date: xx/xx/xxxx

Site Visit Protocol: August 2012

Public Burden Statement: 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 0930-xxxx.  Public reporting burden for this collection of information is estimated to average 150 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 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 SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland, 20857.

1. Site Visit Overview

SAMHSA HIV MAI TCE Evaluation Site Visit Protocol

Year One

Date(s) of site visit
Grantee name & location
Project name
Partner organizations and locations visited
Participants (full name, credentials, project title and organizational affiliation)

Introduction and Background

The goals of the Minority AIDS Initiative – Targeted Capacity Expansion (MAI-TCE) program are to facilitate the development and expansion of culturally competent and effective integrated behavioral health and primary care, which include HIV services and medical treatment, within 11 of the 12 Metropolitan Statistical Areas (MSAs) and Metropolitan Divisions (MDs) most heavily impacted by HIV/AIDS. The program also supports the integration of behavioral health services (i.e., prevention, treatment, and substance use) into the CDC’s Enhanced Comprehensive HIV Prevention Plans (ECHPP).

Over the life of the project, the evaluation contractor, in support of the cross-site evaluation, will conduct a total of two in-person site visits to each of the 11 MAI-TCE program grantee locations. The goals of these visits are to assess MAI-TCE grantees in terms of program readiness, program implementation, service integration, and program outcomes.

During the site visits, the evaluation contractor will conduct interviews and disseminate a self-assessment tool (Appendix A) to grantee staff. Use of these tools will support the evaluation contractor’s overall efforts to conduct a cross-site evaluation and address issues such as:

• Project implementation, administration, development of the system network, and the continuum of services;

• Challenges, successes, and lessons learned about accessing and integrating HIV care, mental health services, and substance use programming;

• Progress with developing staff and engaging the target community;

• The successes and challenges with data submission requirements;

• Site specific evaluation plans;

• Progress with addressing “cultural competence”¹ in service provision and how it is conceptualized and operationalized by grantees; and,

• Integrating consumer oriented perspectives in programming.

2. Project Overview

This section of the interview will address issues concerning the community in which your organization operates including: (1) who you are providing services to; (2) how your project is designed and administered; and, (3) the physical facilities in which services are provided. Your responses in this section will provide us a broad understanding of your MAI-TCE program, how it is designed to meet the needs of your target population, and will assist with efforts to create accurate logic models for your project.

1. Community Context

1. To get a better understanding of the larger community in which you work, please describe some of the unique socio-economic and cultural characteristics of the community and how these characteristics influence programming for the MAI TCE project. How do these characteristics influence your approach to engaging the community and providing needed services?

Probes:

• Demographic/population trends

• Emerging health and epidemiological trends (especially regarding HIV, mental health and substance use)

• Employment and poverty rates

• Other

2. Please provide some context about the specific population(s) you’re targeting for MAI TCE services.

Probes:

• What is your current population(s) of focus?

• Is this a change from the population(s) discussed in your application?

• If so, what was the rationale for this change?

• What is your goal for the number of persons you intend to contact, the number tested (HIV RT), and the number served for each year of your grant?

• How long have you been working with this population(s)?

• Are there any subpopulations you anticipate also providing services to?

• What are the emerging health needs for this population(s)?

3. Please provide us your understanding of the evolution of HIV, mental health, and substance use programming/services in your community. This may include the evolution of services at the local as well as at the state level. How has programming evolved to address the service needs within your community?

4. Describe some of the challenges or barriers your project has faced with implementing programming in your community and any planning to overcome these challenges.

5. Describe some of the initial successes related to project implementation in your community. To what do you attribute these successes?

1. Project Design, Administration & Program Funding

1. How would you describe the design and objectives of the MAI-TCE project in your city? Has this been formalized and documented in a programmatic mission statement or vision?

Probe:

• How is your project structured to facilitate programming integration in your community?

2. Please describe how you, as the Grantee, are administering the project. Can you provide details on your organizational structure and leadership?

Probes:

• How is leadership involved with coordinating partners and services?

• What sort of reporting structure is in place to monitor project implementation and administration?

• What level of funding is dedicated to project administration?

3. Can you describe the current status of project implementation of your MAI-TCE initiative?

Probes:

• Is it different from planning in the original application?

• What have been the successes of your implementation effort and the challenges?

• Do you anticipate any changes you may wish to make in subsequent years of programming?

4. Can you tell us about the partners you are working with that are part of your programming effort and service continuum.

Probes:

• How many partners are involved in your project network?

• How many MOUs do you have in place?

• Are there any partners that are part of the service continuum but are not formally part of your project team? Who and what service do they provide?

• What services do your partners offer (both formal and informal partners)?

• How are the goals of the MAI-TCE project disseminated to all your partners to bring your programming effort onto “the same page” in terms of the mission of this project and meeting project objectives?

5. In terms of project development and implementation, we are also interested in Grantee efforts to integrate MAI-TCE goals and requirements with ECHPP standards. Please describe your efforts in this area and any progress you have made.

Probes:

• What have been some of the major barriers?

• What have been some of the major successes?

5. Describe some of the ways in which being an ECHPP grantee have assisted or presented challenges in developing this project.

6. In terms of funding, can you describe how you are coordinating MAI-TCE funding with other funding streams (e.g., across programs like Ryan White-funded services; other Federal/State programs)?

Probes:

• What have been some of the major barriers?

• What have been some of the major successes?

• Any future plans for project funding?

5. What have been some of the successes and challenges the project has faced with implementing your project design?

3. Services & Service Model

Note: In this section we will ask about your service model, the services available to your target community, and the goals of your project. From this discussion, we would like to draft a logic model of your project or update the logic model already in existence.

1. Describe each of the major components of your MAI-TCE model.

Probes:

• Which of these components is currently in place?

• Which of these components is currently operating?

• Have these MAI TCE components changed from the original application?

• What were the reasons for these changes?

2. Describe the array of services that currently address your target population’s needs for integrated mental health, substance use and HIV/AIDS services.

Probes:

• Please describe services for prevention/promotion as well as treatment of these health conditions.

3. Describe your organization’s capacity to address the community’s needs for integrated mental health, substance use and HIV/AIDS before the MAI TCE grant.

Probes:

• Please describe services for prevention/promotion as well as treatment of these health conditions.

4. Describe your partnering organizations’ capacities to reach and address the community’s needs for integrated mental health, substance use and HIV/AIDS before the MAI TCE grant.

Probes:

• Please describe services for prevention/promotion as well as treatment of these health conditions.

5. What are the desired outcomes of your project and how are these arranged in terms of the major components of your project you described earlier?

Probes:

• Client and programmatic short-term outcomes

• Client and programmatic intermediate outcomes

• Client and programmatic long-term outcomes

6. What have been some of the successes and challenges the project has faced with implementing your project design and meeting its objectives?

4. Physical Facilities

1. Describe the locations where HIV primary care, mental health and substance use services are offered through the MAI-TCE initiative.

Probes:

• Number of HIV primary care providers?

• Number of mental health providers?

• Number of substance use providers?

• Physical setting of providers.

2. Are any of services being offered by your project located within the same facility? Describe.

Probes:

• If not, in general, how long would it take one to travel between service facilities, by walking, driving or taking public transportation?

• How do the majority of your clients arrive to receive services?

3. In what parts of the city are these services located? How do these locations relate to the location of your target population(s)?

4. What are the hours of the facilities offering services (e.g. 9AM-5PM)? Are there any special urgent care hours in place with any of your partners?

5. On what days do the facilities offer services (e.g. weekdays only)?

6. Do facilities generally have a private reception area where clients can wait to receive services? Describe.

7. What is the average wait time to get an appointment for services?

Probes:

• HIV/AIDS

• Substance use

• Mental health

8. What is the average wait time for clients in hours or minutes when they arrive for an appointment?

Probes:

• HIV/AIDS

• Substance use

• Mental health

9. What is the average length of time a client spends in hours or minutes at your facility when receiving services?

Probes:

• HIV/AIDS

• Substance use

• Mental health

10. Have any new facilities and/or space been added to your continuum of services that were not present before receiving MAI-TCE funding? Please describe.

Probes:

• What type of services were part of the addition to your facilities/space?

• Why were the reasons for adding the new space?

• What were the costs associated with adding additional facilities/spaces?

11. How do the facilities that are part of your network ensure confidentiality in providing services within the community?

12. What are some of the physical characteristics of the MAI-TCE service settings that present barriers to service for clients?

13. What are the characteristics of facilities that facilitate access?

14. Do you or your partners offer transportation services? Describe.

3. System Network

The purpose of the following questions are to gain a better understanding of how your organizational partners operate, how they were selected, the variety of partners in your system, sources of funding, and the larger system in which you and your partners operate.

1. Network Partnerships

Prior to today’s visit, we asked you to complete the table: “MAI-TCE Partner Organizations” (Appendix B). We just have a few follow-up questions.

1. What processes were used to identify and obtain partners for this project?

Probes:

• What were your primary considerations in selecting partners?

• What challenges did you face in identifying and/or obtaining partners, if applicable?

• How, if at all, have you resolved these challenges?

2. Please draw a diagram illustrating your organization and its partners.

Probe:

• Among the relationships you shared, are they formal or informal?

3. Can you share your communication strategy with your partners to promote the goals of the project and monitor programmatic development?

Probes:

• How is communication structured?

• What are the channels of communication with partners and the frequency?

• How often does communication occur?

4. What infrastructure policies or processes are in place to promote communication and relationship development across partnering organizations?

5. How are resources shared across organizations for MAI-TCE?

Probe:

• If yes, describe the policies and process for sharing resources.

6. What funds have been used to leverage other linkages and services for MAI-TCE?

Probe:

• How were these efforts coordinated?

7. Beyond the partners you work with to deliver services, what agencies influence your work?

2. MAI-TCE Funding & Infrastructure Development

1. How have funds been used for infrastructure development around integrating HIV, substance use, and mental health services?

Probes:

• Have the challenges of spending funding for integrating services required you to change your project?

• If yes, please explain.

• What level of funding has been dedicated to building your partner network?

• How do you see this influencing your project’s sustainability?

2. Prior to today’s visit, we asked you to complete the “Funding Table” (Appendices C) indicating your sources of funding. We just have a few follow-up questions.

Probes:

• What are the sources that fund the largest percentage of your service integration efforts?

• Are there any funding sources that you are not currently using but are exploring, to support your service integration efforts?

4. Programmatic & Clinical Services

This section of our interview will help us to understand basic components of your project such as: the services being offered through your MAI-TCE project; how your target population is engaged and how they flow through your continuum of services; and how service information is shared and documented.

1. Outreach & Referral Services

1. Can you describe your efforts to conduct outreach in your community to reach MAI-TCE populations of focus?

Probes:

• Do you have formal outreach goals integrated into your programming effort?

• Who is conducting the outreach and to what end?

• How many FTE’s roughly are devoted to outreach?

• What level of funding is dedicated to conducting outreach?

• How and where is outreach conducted?

• Is HIV testing part of your outreach effort? Describe.

• What have been the successes and challenges with outreach?

2. Describe your system or process for referring behavioral health clients to HIV services.

Probes:

• Are they referred to off-site services, on-site services, or not referred?

• What is your system for tracking whether clients receive the services to which they were referred?

• How do your partners track referrals?

• How, if at all, are appointments confirmed and documented?

• Are you collecting information on reasons why referrals for services are not completed? (Probe: from the clients or the providers?)

3. Describe your system or process for referring HIV positive clients to mental health services?

Probes:

• Are they referred to off-site services, on-site services, or not referred?

• What is your system for tracking whether clients receive the services to which they were referred?

• How do your partners track referrals?

• How, if at all, are appointments confirmed and documented?

• Are you collecting information on reasons why referrals for services are not completed? (Probe: from the clients or the providers?)

4. Describe your system or process for referring HIV positive clients to substance use services?

Probes:

• Are they referred to off-site services, on-site services, or not referred?

• What is your system for tracking whether clients receive the services to which they were referred?

• How do your partners track referrals?

• How, if at all, are appointments confirmed and documented?

• Are you collection information on reasons why referrals for services are not completed?

5. Do you feel that MAI-TCE clients are referred appropriately for needed services (e.g. mental health, substance use, HIV, and other services)?

Probes:

• Why or why not?

• What percentage of the time?

• What can be improved (ask them to provide this answer by each area)?

2. Enrollment & Intake Assessment

1. Please describe your client enrollment and intake assessment process for the MAI-TCE initiative.

Probes:

• How does the enrollment process vary across the partners involved in your project?

• How does the intake process vary across partners?

• Are all clients screened?

• How are these procedures different for non-MAI-TCE clients?

2. How is the intake assessment finalized?

Probes:

• Does the assessment include a full multi-axial diagnostic formulation? If not, why?

• What is the process for confirming multi-axial diagnosis?

• How does the assessment process vary across the partners involved in your project?

2. How are initial assessments updated and by whom?

Probe:

• How does the assessment process vary across the partners involved in your project?

2. How long does it take, in terms of the number of days needed, to complete the enrollment and intake process (across your system of partners)?

2. How are cases linked across referral partners?

3. Care Planning

1. Please describe your current model for client care planning development.

Probes:

• What is the process for care planning review?

• How does care planning vary across partners?

• How is care planning coordinated across the partners?

• Who participates in the development of care planning and how is it finalized?

• What is the timeline for developing and finalizing care plans?

4. Programmatic & Clinical Services

1. Earlier we began discussing some of the emergent services needs of your target population (briefly revisit key points). Let’s revisit some of these needs and the continuum of services available in the community prior to MAI-TCE programming. Describe specifically the linkages between these programs.

Probes:

• Mental health promotion and treatment

• Substance use disorders treatment and prevention

• HIV/AIDS prevention and treatment

• Basic needs such as housing, nutrition/food assistance, public benefits (e.g., TANF, SSI, SSDI, SNAP)

• Other medical and health care

• Other support service needs

2. Please describe how is your project attempts to enhance the continuum of services available in terms of:

Probes:

• Mental health promotion and treatment

• Substance use disorders treatment

• HIV/AIDS prevention and treatment

• Basic needs such as housing, nutrition/food assistance, public benefits (e.g., TANF, SSI, SSDI, SNAP)

• Other medical and health care

• Other support service needs

3. Please describe how clients flow through your system of services, from client outreach to intake to engagement in behavioral health/primary care services:

Probes:

• What strategies do you use to recruit your target population into services?

• How do you determine who is eligible for MAI-TCE grant-funded services?

• How are you determining which clients are being served by this project?

• Are individuals receiving services given a unique identification number? Please explain.

• How are you differentiating those receiving services with MAI-TCE funds, compared to other funds?

• How are you identifying and counting target population individuals in particular?

• Do you and your partners use a unique client identifier across systems? If not, how does identifier vary?

• For how long do you track clients receiving services?

4. Using the MAI-TCE Services Table (Appendix D) as a guide, please share the following information with us (note to interviewer: please ensure that the table has been completed by site):

Probe:

• Please tell us about the clinical services your project offers.

• Please provide an overview of the counseling you provide in relation to HIV rapid testing.

• For persons who test HIV positive, what is the process for transitioning them into regular counseling?

• What type of counseling is provided to those who test negative?

• What is the process for referring/linking persons who test positive to HIV care?

• How do you track the number of people who refuse to take an HIV test?

• How do you track the number of people who receive an HIV test and test negative?

• What case management models/types are being used?

• What instruments are used for mental health screening?

• What instruments are used for mental health and substance use disorders screening? What forms are used and who enters the data?

5. What clinical instruments are you using for conducting screening and other assessments? Who enters the data and verifies assessments?

Probe:

• Mental health?

• Substance use?

6. Considering the unique social and cultural characteristics of your target population, how do you address these characteristics when providing clinical services for your clients? That is, how do the clinical services you provide address issues of culture or other social characteristics?

7. What level of funding is dedicated to providing clinical services?

Probe:

• For mental health?

• For substance use?

• For HIVcare?

8. Is there a method in place to routinely monitor the implementation of clinical services? What QA/QC programs do you have in place for monitoring delivery of clinical services, clinical supervision, and chart reviews?

9. How is your project monitoring and measuring the outcomes of clinical services?

10. How do you describe the service model your project is offering in terms of responding to the needs of your target population and the coordination of services across your partners?

5. Evidenced Based Services

1. In terms of services, we are also interested in Grantee efforts to used evidence-based practices. When we refer to “evidence-based”, we’re referring to SAMHSA’s criteria for defining an intervention as evidence-based. For reference, these criteria are:

• Inclusion in Federal registries of evidence-based interventions

• Reported (with positive effects on the primary targeted outcome) in peer-reviewed journals

• Documented evidence of effectiveness, based on guidelines developed by SAMHSA/CSAP and/or the State. [See appendix for guidelines.]

2. Please describe your efforts in use of evidence-based services prior to the grant and as a result of the grant.

3. What are the challenges or barriers to providing EB services to the populations of focus?

4. What are the successes or facilitators to providing EB services to the populations of focus?

5. If your MAI-TCE project does not offer EB services, what were the main reasons?

6. Now I’d like to ask about the use of evidence-based practices in the table of MAI-TCE services. Thinking about the MAI-TCE funded services that were identified as evidence-based, please discuss the following topics.

• How many of your network’s partners services are based on EBPs?

• What criteria, if any, did you use in determining which evidence-based services to provide?

• What components of the EBP or EBI have you used? For example,

• Are you using the designated protocol/curriculum?

• Have your staff been trained from trainers who are certified in that EBP

• Are you using measures, instruments or forms for this practice?

• How are you measuring fidelity to the EBPs?

7. For the services that were identified as evidence-based, what are the main strengths?

8. For the services that were identified as evidence-based, what are the main limitations?

6. Case Management & Other Services

Prior to today’s visit, we asked you to complete the “MAI-TCE Services Table” (Appendix D) indicating the range of services available to consumers in your community. We just have a few follow-up questions regarding case management services.

1. What case management services are available for individuals with HIV who have substance use and mental health issues?

2. Please describe the process for referring individuals for ancillary services available through case management.

Probes:

• How are services needs determined?

• What is the process for providing a referral and how does this work in your system of partners?

• What are the facilitators and barriers to providing referrals?

• Is there a verification process in place to determine referral follow-through? Describe.

• How does the verification process work across partners?

• What are the strengths and challenges with determining referral follow-through?

3. What are the primary gaps to providing case management and ancillary services for those living with HIV who have substance use and mental health issues? What else should be offered to help with meeting client needs?

4. How are reimbursements, submission of claims, payments by health insurance handled across your continuum of services? How are these efforts coordinated? Does the same apply for submission of claims to Medicare, Medicaid, and/or Ryan White programming?

7. Information Sharing Across Partners

1. Does a protocol exist for sharing client information across providers?

Probes:

• If yes, please describe?

• How are medical records shared across partners for both hard copy records and EMR? Is this a formal or informal process? For formal arrangements, are letters of agreement in place?

• Are there procedures in place to integrate consumer consent to the sharing of information across partners? Is this a formal or informal process?

• Is the protocol implemented consistently?

• Are sharing procedures for sharing formal or informal?

• What are the facilitators to implementation?

• What are the barriers to implementation?

2. For electronic record sharing what IT security parameters are in place to ensure confidentiality and protection of sensitive data?

Probes:

• Do individuals outside the organization have access to electronic health records?

• How are electronic records shared across organizations? Please describe the process.

1. Documentation, Quality Improvement & Service Monitoring

1. With the complexities of the MAI-TCE project and the need to coordinate and share information across partners:

• What sort of documentation process has been put into place to monitor project development?

• What sort of compliance activities are occurring that support maintenance of federal and state regulations (e.g., HIPAA)?

• How is this coordinated across the partners in your project?

2. Describe the chart review process for the organizations providing services through this initiative.

Probes:

• Has maintaining a timely chart documentation process been problematic considering your system of partners and variety of services?

• Is there a system in place to ensure that partners conduct routine chart reviews to ensure completeness and quality?

3. How is service utilization documented and reviewed? How is this coordinated across the partners who are part of your project?

4. What continuous quality improvement measures are in place?

Probes:

• What are the current goals of your continuous quality improvement efforts

• Who monitors quality improvement efforts?

• How are necessary changes implemented?

5. What are the current goals of your continuous quality improvement efforts?

6. What level of funding is dedicated to providing case management services?

5. Staffing

The following questions will help us gain a clearer understanding of your efforts to staff your project, any changes you may have experienced in relation to staffing, and any staff development/training activities since project funding began.

1. Program Staffing

Prior to today’s visit, we sent the table: “Staffing” (Appendix E). Now we just have some follow-up questions about staffing for the MAI-TCE project in particular.

1. Have new or additional staff been hired for the MAI-TCE Program?

2. Who is tasked with hiring staff for the MAI-TCE project?

3. What is the status of staff you intended to hire or utilize for this initiative?

Probes:

• Can you describe staffing at baseline?

• Is your staffing for the project complete?

• If complete, how long did it take to complete the initial hiring for your project?

• If not, what are the reasons for the staffing vacancies?

4. What specific successes have you encountered in hiring or maintaining staff?

5. How many additional hours of staff time (preferably by skill type) have been employed for this project?

Probes:

• What are the most pressing needs in terms of staffing hours?

• Can you describe the number of hours added by staff position type?

6. What specific obstacles have you encountered in hiring or maintaining staff?

Probe:

• Are there any positions that have been particularly difficult to fill?

• Are you currently facing staff shortages?

• If yes, how is this being addressed?

• Have there been any hiring freezes that have affected your ability to hire staff?

7. In terms of staffing diversity and community representation in staffing:

• Do you have any special initiatives in place to promote diversity within your project?

• Has hiring a diverse staff been difficult?

• How does staffing for your project reflect the makeup of the community you serve?

• Can we get a demographic breakdown of staffing for your project?

• What percentage of staff are individuals from the community you serve?

8. How does your agency promote effective communication and information sharing across staff, within your agency?

Probe:

• Describe formal or informal practices that have been instituted that facilitate this.

9. How does your agency promote effective communication and information sharing across project staff from other organizations?

Probe:

• Describe formal or informal practices that have been instituted that facilitate this

2. Staff Development

Prior to today’s visit, we sent the table: “Staff Training and Development” (Appendix F). Now we just have a few follow-up questions.

1. What trainings have project staff received since the grant began?

Probes:

• Who provided these trainings?

• Were they mandatory or voluntary?

• How many staff have been trained?

2. Describe how the trainings have met your needs.

3. Describe how the trainings have not met your needs.

4. What additional staff training is needed to fulfill the goals of the project?

Probe:

• Are these training available?

6. Evaluation

This section of our interview will cover your plans for any site specific or local evaluation you are conducting and your experiences with submission of required programmatic data for the multi-site evaluation.

1. Evaluation Planning & Monitoring

1. What are your local evaluation plans? What instruments are being used? How adapted for the populations of focus?

2. What are the goals, objectives, processes or outcomes you are evaluating?

3. What is the current status of your local evaluation?

4. How are you monitoring progress made toward your goals and objectives? What instruments are being used? How adapted for the populations of focus?

5. How are you sharing information about the project (e.g. results) with staff, partners, stakeholders and consumers?

6. What level of funding has been dedicated for conducting evaluation activities?

7. Describe a few of the barriers and successes the project has experienced with the local evaluation.

8. Describe the main successes the project has experienced with the local evaluation.

2. Programmatic Data Collection

Now we’d like to ask you a few questions about the data collection effort for the multisite evaluation.

1. How are data entered into the TRAC system, across partners?

Probes:

• What sources of data do you use for data entered into TRAC?

• From how many partners will you be receiving TRAC data?

• Who enters data into TRAC for the client level data collection effort?

• Who enters data into TRAC for the IPP portion of the data base?

• What are your quality assurance procedures for entering data into TRAC?

2. What would help improve your ability to work with the TRAC data system?

3. How are data entered into the HIV RT system, across partners?

Probes:

• From how many of your partners will be collecting HIV RT data?

• Who enters data into HIV RT system?

• What are your quality assurance procedures for entering data into HIV RT system?

4. What would help improve your ability to work with the HIV RT data system?

7. Behavioral Health & Primary Care Network Committee

This part of our interview will address the planning and implementation of your Behavioral Health and Primary Care Network Committee. The goal of this section is to get a better understanding of the composition of your Committee, how they are involved in your programming effort, and how the Committee has influenced the development of your project. We will also reference Table 6 in the appendices to make sure we have your most up to date listing of Committee members.

1. Implementation & Activities

1. What is the status of your Behavioral Health and Primary Care Network Committee?

Probes:

• Is the Committee a new structure or part of an existing structure?

• When was the Committee instituted?

• The RFA had specific guidance on the BH/PCNC. To what extent have you been able to fulfill these requirements?

• Is the Committee in development phase or has it been established?

• If established, how many times has the Committee met??

2. Is the Committee representative of the organizations that the MAI-TCE RFA described?

Probe:

• Describe the current Committee membership composition.

• Do you have a Committee roster that you are able to share?

• What have been some of the challenges to getting these organizations to participate in the BHPCNC?

• What have been some of the successes in getting these organizations to participate in the BHPCNC?

3. In terms of creating a Committee that considers diversity and is reflective of the population(s) served:

Probes:

• Can you describe the diversity of Committee members in terms of race, ethnicity, language, age, gender, sexual orientation, HIV status, experience with mental health treatment, substance use treatment, and representation of family members?

• Is the Committee representative of your MAI-TCE target population(s)?

• Are consumer representatives included on the Behavioral Health and Primary Care Network Committee?

• Describe what methods you are currently using, other than the BH/PCNC, to elicit consumer/community input that influences how services are delivered? (Ryan White Planning Council? HIV Prevention Planning Group? Consumer Advisory Board for your organization? Other?)

• In total, how many BH/PCNC members to you have?

• How many of your members represent consumers or family/community members?

4. Describe your Committee recruitment strategies and selection processes.

Probes:

• Did you use different strategies for different members? Describe.

• What, if any barriers or challenges to recruitment did you encounter and how were they overcome?

• How satisfied are you with Committee membership composition? Describe.

5. In terms of the operation of your Committee:

Probes:

• Describe the roles and responsibilities of the Committee members.

• Are there formal leadership positions such as Chair, Co-Chair, etc.?

• Are there formal Committee operating procedures? (Probe: Request meeting schedule, outline governance procedures, leadership development activities, bylaws.)

• Is there a formal Committee vision/goal/mission statement? (Probe: Ask to see written materials.)

• How frequently are Committee meetings held?

• How many members attend occasionally versus almost every meeting?

• What kinds of issues does the Committee discuss?

• What type of orientation is available for new Committee members and who provides this orientation?

• What sort of ongoing orientation is provided?

• Is this formal or informal?

6. Describe the roles and responsibilities the Behavioral Health and Primary Care Network Committee have in integrating the ECHPP into this project?

Probes:

• How successful have they been in integrating behavioral health services into existing ECHPP implementation plans?

7. How is feedback or programmatic inputs from the Committee gathered and utilized?

8. Do you think the Committee has been successful in influencing the development and expansion of integrated care networks within your target population(s) community?

Probes:

• If yes, could you provide a few examples?

• If no, could you please explain the barriers to making project changes using the Committee’s feedback?

9. What are the strengths and challenges of the Committee in terms of performance and fulfilling their role?

Probes:

• For challenges, are there any changes in the structure of the Committee that might improve their effectiveness?

2. Planning & Next Steps

1. What future plans do you have for the BHPC Committee?

Probes:

• What will be continued/done the same in the future?

• What will be done differently from current efforts?

2. What are your plans for retaining current members?

Probes:

• What would be helpful, whether currently available or not, in retaining current members?

3. Are you planning to recruit additional members?

Probes:

• If yes, what roles are you hoping to fill in recruiting additional members?

• If yes, what processes will you use to recruit additional members?

• If no, what are your reasons?

8. Consumer Involvement

This section will cover the role of consumers and family members and their involvement in different components of your MAI TCE project.  When we refer to “consumers and family members,” we are referring to recipients of mental health services, substance use services or HIV/AIDS care, and their family members. [Site visitors see guidance from RFA in the Appendices section]

1. Planning & Implementation

1. During this project year, how did you involve consumers and family members in activities funded by this MAI TCE grant? (Note: consumer involvement in the BHPC Network Committee should be discussed as a separate section of the protocol.)

Describe for each group -- consumers’ & family members’ – their involvement with….

Activities funded by this MAI TCE grant	Please provide 1or 2 examples of consumers’ involvement with these activities. If they were not involved, please write “N/A.”	Please provide 1or 2 examples of family members’ involvement with these activities. If they were not involved, please write “N/A.”
Design of project
Development of project
Implementation of project
Staffing of project
Training of project staff
Evaluation of project
Project administration & governance
Policy development
Cultural competence
Other activity (Specify):___________
Other activity (Specify):___________

2. Does your organization have a Consumer Advisory Board (comprised of consumers only) or Community Advisory Board (comprised of non-consumers as well as consumers)? If so, please describe the CAB’s name, its purpose, mission/vision statement, and composition especially regarding MAI TCE consumers’ involvement and roles in the CAB.

Probes:

• When was the CAB instituted?

• How often do they meet?

• What kinds of issues does the CAB discuss? Can you provide a few examples?

• What kind of input does this board/body have for the MAI TCE project? Describe the process and guidelines for this input.

2. Programmatic Integration of Feedback

1. Describe how, if at all, your organization seeks input or feedback on programs and services from MAI TCE consumers and family members. [If no feedback is sought: What are the reasons for not seeking consumers and family members input or feedback?]

Probes:

• What type of feedback is sought by the organization?

• What is the purpose or rationale for gathering this feedback?

• How is the feedback gathered? (e.g. annual consumer survey, written comments and suggestions collected anonymously boxes)

• What accommodations are made for multiple language needs or literacy levels?

• How often is feedback gathered?

2. How is feedback from MAI TCE consumers and family members used by the organization?

Probes:

• Is it shared with others? With whom and for what purpose?

3. Do you collect feedback from consumers of other services? [If no feedback is sought: What are the reasons for not seeking consumers and family members input or feedback?]

Probes:

• How is this engagement of consumers different from engaging MAI-TCE consumers?

• What type of feedback is sought by the organization?

• What is the purpose or rationale for gathering this feedback?

• How is the feedback gathered? (e.g. annual consumer survey, written comments and suggestions collected anonymously boxes)

• What accommodations are made for multiple language needs or literacy levels?

3. Future Planning & Activities

1. What future plans or activities are being made by your organization to engage MAI TCE consumers and family members?

Probes:

• What is the purpose or rationale for these plans or activities?

• What will be continued/done the same in the future?

• What will be done differently from the current efforts?

9. Cultural Competence

This section will address your conceptualization of cultural competence, planning for integration of cultural competence into your service model, and any current efforts that consider this concept in your service model. Site visitors may refer to the RFA Guidelines on Cultural Competency included in the Appendices of this guide.

1. Conceptualization, Planning & Implementation

1. How, if at all, does your MAI-TCE project define or envision cultural competence? [If not: How, if at all, has your organization addressed cultural competence in the past?]

Probes:

• What steps have been taken to formalize or document this definition or vision?

• How has leadership in your organization been involved in the shaping of this initiative?

• Is there anyone formally in charge of this part of your project?

• What steps have been taken to integrate this view into project implementation?

• How has it been utilized or integrated by partners and the BHPCNC?

3. Have there been any efforts to integrate your definition or vision of cultural competence into the governance or administration of your MAI-TCE project?

Probes:

• Shaping of policy, procedures and/or guidelines?

• Institution and utilization of resources?

4. What current efforts do you have underway to implement your vision in the MAI-TCE project?

Probes:

• Staffing or hiring efforts?

• With the Behavioral Health and Primary Care Network Committee?

• With your network of partners?

• With other community organizations embedded in the community (e.g., churches, advocacy organizations).

5. Do you have any efforts underway to train your staff on cultural competence? What are these training efforts? How many have been held?

Probes:

• Describe these training efforts: what was rationale for offering them? When offered? How many have been held?

• Has such training been offered for others involved with MAI-TCE project -- partners’ staff, BHPCNC, CAB members?

6. Have you worked with staff to integrate cultural competence into MAI-TCE programming? Describe.

7. What percent of your population of focus for the MAI-TCE initiative are more comfortable with a non-English language?

Probes:

• How have the language needs been address in your organization in terms of staff who are skilled bilingual individuals?

• Are they representative of the population(s) being served?

8. How do print materials and other products associated with providing services (e.g., educational materials, outreach materials) address the needs of the target population?

Probes:

• How do they address the language and literacy needs of the target population?

9. In terms of evaluation, what plans are in place to assess your success related to cultural competence? Do you have objective goals, indicators, or milestones you are attempting to meet as part of your planning?

10. What are your plans for the next year as it relates to cultural competence?

10. Project Sustainability

In this section, we will ask you a few questions about your efforts towards project sustainment and how this effort is being coordinated within your project partners and the BHPCNC.

1. Planning & Implementation

1. How does your organization define or approach sustainability? Describe.

Probes:

• How do your partners and the BHPCNC define or approach sustainability?

2. What aspects of the MAI-TCE initiative do you plan to sustain?

Probes:

• What are your current plans to ensure the sustainment of programming efforts initiated under this grant after federal funds end? [Such updates are part of the progress reports to SAMHSA according to the grantee RFA.]

• Do you have plans to maintain consumers and family members’ engagement as part of your sustainability plans?

• Do you have plans to maintain the BHPCNC as part of your sustainability plans?

• Do you have plans to maintain your current partnerships with other organizations?

3. How are your partners involved in sustainability planning efforts?

Probes:

• If so, is revenue sharing part of this plan?

• How are grant dollars leveraged for other funding opportunities?

• Are any agreements formalized?

4. Do your planning efforts consider preparation for Medicaid coverage expansion? (Note, this pertains to coverage expansion for all low-income adults up to 133% of the Federal Poverty Level in 2014?

5. Do you have plans to maintain consumers and family members’ engagement as part of your sustainability plans?

6. How are the Behavioral Health and Primary Care Network Committee involved in your sustainment planning?

11. Appendices

• Appendix A: Grantee Self-Assessment Form

• Appendix B: Table 1 – MAI-TCE Partner Organizations

• Appendix C: Table 2 – Funding Table

• Appendix D: Table 3 - MAI-TCE Services

• Appendix E: Table 4 - Staffing Table

• Appendix F: Table 5 - Staff Training & Development

• Appendix G: Table 6 - Behavioral Health & Primary Care Network Committee Membership Composition

• Appendix H: Consumer and Family Involvement RFA Guidelines

• Appendix I: Cultural Competence RFA Guidelines

Appendix A: SAMHSA MAI-TCE Program

Service Integration Site Self-Assessment Form

Purpose:

The purpose of the form is to develop an understanding of the status of your current project implementation of integrated care. In completing this survey, please consider your site’s status in integrating HIV primary care and behavioral health care (e.g. mental health and substance use). Feel free to consult additional staff at your site as necessary to assist you in completing the form. We will ask you to complete this survey annually throughout the funding period to assess change over time.

General Information:

Date:

Name of Grantee organization:

Name of partner organization completing form:

Location of site (City, State):

Instructions:

For each of the following elements of integrated behavioral health and primary care, please check the one description that best describes your site.

Section 1: Location of Services

1. The type or level of colocation of client care services for behavioral health and primary care at my site is best described as:

□ Consumers go to separate sites for separate behavioral health and primary care services.

□ Multiple services are available at the same site but consumers must go to separate offices.

□ Consumers receive behavioral health and primary care services at the same site and office.

Comments: ________________________________________________________________

Section 2: Staff Policies and Practices

2. Treatment plan(s) for behavioral health and primary care at my site is best described as:

□ Treatment plans are separate and uncoordinated among behavioral health and primary care providers.

□ Treatment plans are separate and coordination is informal and irregular.

□ Treatment plans are separate and coordination occurs on a regular basis.

□ Treatment plans are integrated and coordination among behavioral health and primary care providers occurs on a regular basis.

Comments: ________________________________________________________________

3. The client care team of behavioral health and primary care providers at my site is best described as:

□ Client care team does not exist.

□ Client care team exists and team members’ roles/responsibilities are very unclear.

□ Client care team exists and team members’ roles/responsibilities are unclear.

□ Client care team exists and team members’ roles/responsibilities are clear.

□ Client care team exists and team members’ roles/responsibilities are very clear.

Comments: ________________________________________________________________

4. Multi-disciplinary team meetings of behavioral health and primary care providers occur at my site:

□ Weekly

□ Monthly

□ Quarterly

□ Never

Comments: ________________________________________________________________

5. Communication between behavioral health and primary care providers at my site primarily occurs through: (*For this question, check all that apply)

□ Behavioral health and primary care providers do not exchange information.

□ E-mail

□ Telephone

□ Face-to-face

□ Paper notes

□ Flags or notes in the client’s electronic record

□ Other (specify)

Comments: ________________________________________________________________

6. Providers’ treatment philosophy at my site is best described as:

□ Primary and behavioral health care providers strongly agree on the value of integrated primary and behavioral health care services.

□ Primary and behavioral health care providers agree on the value of integrated primary and behavioral health care services.

□ Primary and behavioral health care providers disagree on the value of integrated primary and behavioral health care services.

□ Primary and behavioral health care providers strongly disagree on the value of integrated primary and behavioral health care services.

Comments: ________________________________________________________________

Section 3: Medical Records Structure and Access System

7. The medical records structure at my site is best described as:

□ Paper-based

□ Electronic (EMR)

□ Partly paper-based and partly electronic

Comments: ________________________________________________________________

8. Primary health care providers’ access to behavioral health care provider records at my site is best described as:

□ Primary care providers do not have access to behavioral health provider records.

□ Primary care providers have limited access to behavioral health provider records.

□ Primary care providers have full access to behavioral health provider records.

Comments: ________________________________________________________________

9. Behavioral health care providers’ access to primary health care provider records at my site is best described as:

□ Behavioral health providers do not have access to primary care provider records.

□ Behavioral health providers have limited access to primary care provider records.

□ Behavioral health providers have full access to primary care provider records.

Comments: ________________________________________________________________

10. Clients’ access to behavioral health care records at my site is best described as:

• Clients do not have access to paper copies of behavioral health records.

• Clients have access to paper copies of behavioral health records upon request only.

• Clients are given paper copies of behavioral health records on a regular basis.

Comments:

________________________________________________________________

11. Clients’ access to primary health care records at my site is best described as:

• Clients do not have access to paper copies of primary care records.

• Clients have access to paper copies of primary care records upon request only.

• Clients are given paper copies of primary care records on a regular basis.

Comments:

________________________________________________________________

12. The following describes clients’ access to a client portal at my site:

• Clients do not have access to a client portal.

• Clients have access to a client portal for behavioral health.

• Clients have access to a client portal for primary care.

• Clients have access to a client portal for behavioral health and primary care.

Comments:

________________________________________________________________

Section 4

13. Please provide any additional comments:

Thank you for your participation!

Appendix B: Table 1 - MAI-TCE Partner Organizations

Describe the partners you are working with for this SAMHSA MAI TCE Project (For example, sub-recipients, sub-contractors, and other partners.)
Name of the organization	Type of organization	Type of relationship between MAI TCE Grantee and this organization	Date when relationship began with this organization	Date when relationship ended with this organization	How the relationship is formalized (e.g., contract, MOU, MOA, letter of support, no documented relationship)	Is this organization currently represented on the BHPC Network Committee?

Appendix C: Table 2 - Funding Sources Table:

For the following table, share the percentage to which the listed funding sources are used to support integrating HIV, substance use, and behavioral health services:

Funding Source	Percentage
SAMHSA MAI-TCE
Other SAMHSA funding
CDC
HRSA
Medicare
Medicaid
State
Local
Private
Other: ____________________
TOTAL	100%

Appendix D: Table 3 - MAI-TCE Services

	Please check the services that your organization provides:	Please check the services that your partner organization(s) provides:	Are services based on evidence-based practices wholly, partially, not at all, don’t know? If yes, please identify the EBP.	Type of service offered
HIV PREVENTION, TESTING, AND MEDICAL CARE
HIV prevention (Specify): ____________________
Rapid HIV testing & counseling
Other HIV testing modality (specify): ______________
HIV Counseling
Medical appointments to address HIV needs
Medical appointments for non-HIV medical needs
HIV/AIDS medication prescriptions
Viral load tests
CD4 cell count tests
Genotyping
CASE MANAGEMENT & SUPPORT SERVICES
Case management
Educational or support groups
Referrals & linkages to non-medical needed services
Housing, food, and other ancillary social assistance services
Care coordination with medical, mental health, and/or substance use treatment providers
Supportive counseling
Transportation assistance
Respite care
Language services
Help accessing health insurance premium and cost sharing assistance (e.g. ADAP, Ryan White services, Medicaid, SSI, Medicare, etc.)
Help finding affordable housing
Other (specify): _____________
SCREENING, PREVENTION, AND TREATMENT FOR MENTAL HEALTH CONDITIONS
MH promotion/prevention of mental illness (Specify): ____________________
Screening
Assessment
Crisis intervention
Individual psychotherapy
Group psychotherapy
Psychiatric assessment and medication management
Neuropsychological screening and testing
Care coordination with medical providers
Grief and loss counseling
Pastoral care
Psychoeducational services related to medical treatment
Other (specify): ________________
SUBSTANCE ABUSE PREVENTION & SUBSTANCE USE DISORDER TREATMENT SERVICES
Substance use prevention
Screening
Substance use screening
Substance use assessment
Assessment
Individual counseling
Group counseling
Care coordination with medical providers
Outpatient treatment (e.g., methadone, Suboxone/buprenorphine)
Inpatient/residential treatment (e.g., detoxification)
Other (specify): ____________________

Appendix E: Table 4 - Staffing

Staff Positions (Include staff position and hrs/week or full-time equivalent/FTE)	Staff name and degree (or “vacant” if applicable)	Hours worked per month	Wage Rates	Changes in staffing since the last site visit (staffing additions and staff replacements)	Add staff member’s start and end dates for time spent on this project
Example: Clinician, 0.75 FTE	Jane Doe, MSW	160	$38.25	Ms. Doe filled a staff vacancy that was left after Mr. Smith left the agency in Jan ’04.
     	     			     
     	     			     
     	     			     
     	     			     

Appendix F: Table 5 - Staff Training & Development

Name and Date(s) and Duration of Training or Staff Development Activity	Purpose of Training	Number and type of staff participating in training (e.g., 3 clinical staff, 2 administrative assistants)	Trainer(s) origin (Organization/affiliation)
Example: HIV and Alcohol Training Mar 19, 2012 9:00 am to 1:00 pm	CME and basic education on HIV and alcohol for frontline staff	3 Case managers	PAETC
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     

Appendix G: Table 6 - Behavioral Health & Primary Care Network Committee Membership Composition

Describe Behavioral Health and Primary Care Network Committee (BH/PCNC) membership composition for this SAMHSA MAI TCE Project
Member name	Committee Role	Name of affiliated organization?	Type of organization?	Date when relationship began with this organization	Date when relationship ended with this organization
	Co-Chair		Public Health Department grantee rep
	Co-Chair		State or local mental health agency
	Co-Chair		State or local substance use agency.
			State Medicaid office
			State and local public housing authority
			Local Health Resources and Services Administration (HRSA) Ryan White Planning Council
			Local primary care and HIV-oriented healthcare organizations
			Local community-based, mental health and substance use provider organizations
			Individuals who are most at risk for or living with HIV/AIDS; and individuals in recovery from mental and/or substance use disorders.

Appendix H: Consumer and family involvement guidance from SAMHSA RFA for grantees (This information is for site visitor’s reference only)

In general, applicant organizations should have experience and a documented history of positive program involvement by recipients of mental health or substance use services and their family members. This involvement should be meaningful and span all aspects of the organization's activities as described below:

• Program Mission. The organization's mission should reflect the value of involving consumers and family members in order to improve outcomes.

• Program Planning. Consumers and family members should be involved in substantial numbers in the conceptualization of initiatives, including identification of community needs, goals and objectives; identification of innovative approaches to address those needs; and development of budgets to be submitted with applications. Approaches should incorporate peer support methods.

• Training and Staffing. Organization staff should have substantive training in, and be familiar with, consumer and family-related issues. Attention should be placed on staffing the initiative with people who are themselves consumers or family members. Such staff should be paid commensurate with their work and in parity with other staff.

• Informed Consent. Recipients of project services should be fully informed of the benefits and risks of services and make a voluntary decision, without threats or coercion, to receive or reject services at any time. SAMHSA Confidentiality and Participant Protection requirements are detailed in SAMHSA GFAs. These requirements and must be addressed in SAMHSA grant applications and adhered to by SAMHSA grantees.

• Rights Protection. Consumer and family members must be fully informed of all of their rights including those related to information disclosure, choice of providers and plans, access to emergency services, participation in treatment decisions, respect and non-discrimination, confidentiality of healthcare information, complaints and appeals, and consumer responsibilities.

• Program Administration, Governance, and Policy Determination. Efforts should be made to hire consumers and family members in key management roles to provide project oversight and guidance. Consumers and family members should sit on all Boards of Directors, Steering Committees and Advisory bodies in meaningful numbers. Such members should be fully trained and compensated for their activities.

• Program Evaluation. Consumers and family members should be integrally involved in designing and carrying out all research and program evaluation activities. These activities include: determining research questions, adapting/selecting data collection instruments and methodologies, conducting surveys, analyzing data, and writing/submitting journal articles.

Appendix I: Cultural Competence: Guidance from SAMHSA RFA for grantees (This information is for site visitor’s reference only)

• Training and Staffing. The staff of the organization should have training in gender/age/cultural competence. Attention should be placed on staffing the initiative with people who are familiar with, or who are themselves members of, the population/community.

• Language. If an organization is providing services to a multi-linguistic population, there should be multi-linguistic resources, including use of skilled bilingual and bicultural individuals whenever a significant percentage of the target population/community is more comfortable with a language other than English.

• Materials. It should be demonstrated that material and products such as audio-visual materials, PSA’s, training guides and print materials to be used in the project are gender/age/culturally appropriate or will be made consistent with the population/community to be served.

• Community Representation. The population/community targeted to receive services should be a planned participant in all phases of program design. There should be an established mechanism to provide members, reflective of the target group to be served, with opportunities to influence and help shape the project’s proposed activities and interventions. A community advisory council or board of directors of the organizations (with legitimate and working agreements) with decision-making authority should be established to affect the course and direction of the proposed project. Members of the targeted group should be represented on the council/board.

• Implementation. There should be objective evidence/indicators in the application that the applicant organization understands the cultural aspects of the community that will contribute to the program’s success and which will avoid pitfalls.

• Evaluation. Program evaluation methods and instrument(s) should be appropriate to the population/community being served. There should be rationale for the use of the evaluation instrument(s) that are chosen, and the rationale should include a discussion of the validity of the instrument(s) in terms of the gender/age/culture of the group(s) targeted. The evaluators should be sensitized to the culture and familiar with the gender/age/culture whenever possible and practical.

1 For the purposes of this evaluation, cultural competence is defined as “a set of congruent behaviors attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency, or those professionals to work effectively in cross-cultural situations.” (Cross, T.L., Bazron, B.J., Dennis, K.W., Issacs, M.R. (1999)).

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