Form Quarterly Report Quarterly Report Quarterly Report

OMB No. 0930-0340

Expiration Date XX/XX/XXXX

Attachment 2: Quarterly Report Format

Primary and Behavioral Health Care Integration

The Primary and Behavioral Health Care Integration (PBHCI) program is a landmark Federal initiative, and SAMHSA requests regular information from each grantee to learn about the innovative and creative approaches you are taking to accomplish PBHCI program goals.  Your quarterly report should either be emailed (preferable) or mailed to your project officer. You can include appendices of press releases or other relevant documents that pertain to the questions in the report. Appendices and materials that are not electronically available can be mailed to your program officer.

Trina Dutta 1 Choke Cherry Road, 6-1076 Rockville MD 20857 Trina.dutta@samhsa.hhs.gov Roxanne Castaneda 1 Choke Cherry Road, 6-1012 Rockville MD 20857 Roxanne.castaneda@samhsa.hhs.gov

Marian K. Scheinholtz 1 Choke Cherry Rd, 6-1009 Rockville, MD 20857 Marian.scheinholtz@samhsa.hhs.gov Tenly Pau 1 Choke Cherry Road, 6-1014 Rockville MD 20857 Tenly.pau@samhsa.hhs.gov

Report items can be answered in brief bullet format and the report should be no longer than 3-5 pages. Reports are due as follows:

Quarterly report due dates are:

• 1^st Quarter: January 31, 2013 covering the time from beginning of your grant to December 31, 2012

• 2^nd Quarter: April 30, 2013 covering the period from January 1, 2013 to March 31, 2013

• 3^rd Quarter: July 31, 2013 covering the period from April 1, 2013 to June 30, 2013

• 4^th Quarter: October 31, 2013 covering the period from July 1, 2013 to September 30, 2013

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 0990-0xxx. Public reporting burden for this collection of information is estimated to average 8 hours 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.

Report Labeling: VERY IMPORTANT!

At top of report, put your grant number, the name of your site and program, the name of the Project Director, and the name of the person to contact about the report (if different than the Project Director).

Label the report for the dates covered and the date submitted.

Put the quarter number and year.

Please label your electronic attachments with something that includes the abbreviated site name, Quarter #, and Year. So a filename might look like ANN ARBOR CMHC 1st QTR 1/31/13

Outline for Report Content

General Instructions—Within each section of your report, include accomplishments and barriers. For barriers, outline the solutions implemented (if the problem was resolved) or your plans for resolution; include detail on any delays in program implementation. For each question, identify technical assistance needed.

1. Describe your efforts across the following dimensions:

   1. Provision of on-site primary care services (by qualified primary care professionals)

   2. Provision of medically necessary referrals (by qualified specialty care professionals or other coordinators of care)

   3. Service as your client’s health home

   4. Meeting your annual targets for enrollment and reassessment. Attach the following TRAC Reports: Number of Consumers Served, Reassessment Interview Rate, NOMs Outcome Measures, and Section H Outcome Measures.

2. Describe your wellness-related education and programming activities. For example, if you spent money on developing a smoking cessation program, describe the activity and the staff involved, program duration, and provide an estimate of the expenditures in direct costs.

3. Describe your efforts in meeting Meaningful Use Standards. For example, if you spent money on submitting at least 40% of prescriptions electronically; receiving structured lab results electronically; sharing a standard continuity of care record between behavioral health providers and physical health providers; or participating in the regional extension center program, describe the activity and the staff involved, program duration, and provide an estimate of the expenditures in direct costs.

4. Describe the infrastructure activities engaged in by your site. For example, if you spent money on redesigning office processes or enhancing workforce development, describe the activity and the staff involved, and provide an estimate of the expenditures in direct costs.

5. Describe your efforts at sustaining PBHCI services. Provide specific details on program revenue (e.g., Medicaid, Medicare, third party billing, etc) and other monetary resources obtained for PBHCI services, as well as plans for securing future funding.¹

6. Detail your progress regarding data collection (e.g., NOMs, Section H, IPP, etc) and the related Continuous Quality Improvement efforts. For each method of data collection, indicate your efforts to monitor, analyze, and/or share the data with relevant parties.

7. Complete and/or update Attachment A, “PBHCI Staffing Profile.” Please include attachments of new staff resumes and copies of any formal correspondence made between your site and SAMHSA about staffing changes.

8. Describe the involvement of consumers and families in your project (e.g., data collection/evaluation activities, Advisory Board Members, wellness coaches, volunteer vs. paid, etc).

9. Describe which clients are eligible to receive PBHCI services through your program.

10. Describe staff involvement in the PBHCI program’s group activities or with the SAMHSA Project Officer. For example, describe involvement in group conference calls, grantee meetings, and site visits and interaction with the Project Officer or CIHS.

11. Provide an update on your program’s progress in realizing the following elements of your Special Terms and Conditions related to health disparities:

    1. Disparities Impact Statement (Access to Services; Service Use; Outcomes – changes in PBHCI outcomes (e.g., blood pressure, cholesterol, etc.) among your identified sub-population(s)

    2. Implementation of policies and procedures to ensure the cultural and linguistic needs of all sub-populations identified in your proposal.

    3. Use of data for outcomes regarding race, ethnicity and LGB or T status, across the following domains: Data collection activities; Program services and activities development and implementation; and Data reporting, including access, service use and outcomes measures.

    4. Adherence to the National Culturally and Linguistically Appropriate Services (CLAS) Standards (diverse cultural health beliefs and practices; preferred languages, including meaningful access by limited English proficient (LEP) persons; and health literacy and other communication needs of all sub-populations within the proposed geographic region.)

Appendix A: PBHCI Staffing Profile
Clinical Discipline	Role	Primary Duties	Level of Effort	PBHCI Funding	Employer
e.g. Nurse Care Manager	Registered Nurse	Assess a client's physical, mental, and social needs; develop an individualized plan of care to meet them, be they small or large, medical or practical (includes making referrals to appropriate services, and coordinating, evaluating, and adjusting them as needed); and ongoing monitoring, advocacy and assistance	0.50 FTE	25%	FQHC Partner
e.g. Peer Support	Wellness Coach	Help clients identify personal reasons for pursuing greater wellness, and to enhance motivation for behavior change using evidence-based strategies; establishes relationships and practices core coaching skills that assist the client in identifying values and desires, transforming them into action, and maintaining lasting change over time	1.0 FTE (increased from 0.50 FTE)	100%	CMHC

1Funds under this program may not be used to supplant financing of health home services that are eligible for payment or reimbursement from third-party payers (i.e., Medicaid or Medicare). Rather, these funds are targeted to coordinate access to and provision of health home services for which there is no current funding source, including services for uninsured populations.