Attachment A.4 (2014 N-MHSS CATI Questionnaire)
2014 NATIONAL MENTAL HEALTH SERVICES SURVEY – CATI QUESTIONNAIRE
Hello Hello, my name is [fill INTERVIEWER NAME] and I am calling concerning the Federal Government’s survey of mental health service providers called the National Mental Health Services Survey. N-MHSS is sponsored by SAMHSA, the Substance Abuse and Mental Health Services Administration.
GetDir May I speak with [fill DIRECTOR NAME] regarding this facility’s 2014 N-MHSS?
USE UpdateInfo TAB TO ENTER A DIFFERENT PHONE NUMBER
<1> SPEAKING WITH FACILITY DIRECTOR/APPROPRIATE PERSON [goto Intro]
<2> CONNECTED TO FACILITY DIRECTOR/APPROPRIATE PERSON [goto Hello2]
<3> FACILITY DIRECTOR NOT AVAILABLE [goto Callback]
<4> ANSWERING MACHINE [goto Message_Q]
<5> WRONG NUMBER [goto Sorry]
Sorry I’m sorry. Thank you for your time.
Hello2 Hello, my name is [fill INTERVIEWER NAME] and I am calling concerning the Federal Government’s survey of mental health treatment service providers called the National Mental Health Services Survey. The N-MHSS is sponsored by SAMHSA, the Substance Abuse and Mental Health Services Administration.
[goto Intro]
Intro Recently you were mailed a letter from Dr. Peter J. Delany at SAMHSA. This letter requested the participation of your facility in the 2014 N-MHSS. We are calling at this time to complete the survey. Is this a good time?
<1> YES, CONTINUE [goto Confirm2]
<2> SCHEDULE CALLBACK AT CONVENIENT TIME [goto Callback]
<3> COMPLETING ON THE WEB [Thanks]
<4> NO LONGER PROVIDES MENTAL HEALTH SERVICES [goto A1a]
<5> NEVER PROVIDED MENTAL HEALTH SERVICES [goto A1a]
<6> DUPLICATE FACILITY [goto Duplicate]
<7> MERGED WITH ANOTHER FACILITY [goto Merged]
<8> FACILITY CLOSED/NO LONGER EXISTS [goto Thanks2]
<9> WRONG NUMBER [goto Sorry]
Confirm2 I will be asking you questions about [fill FACILITY NAME] located at
[fill address 1]
[fill address 2]
[fill City],
[fill State]
[fill zip]
IF NOT CORRECT USE THE UpdateInfo TAB TO UPDATE FACILITY INFORMATION
[goto a1]
RE3 Who could answer facility-specific questions such as which types of mental health treatment services are offered at this facility?
RE4 Could I speak with [fill CONTACT NAME]?
<1> YES [goto RE5]
<2> NOT AVAILABLE – INTERVIEWER: Thank you, I will call back. [goto Callback]
<3> CONNECTED TO ANSWERING MACHINE [goto Message_Q]
RE5 Hello, my name is [fill INTERVIEWER NAME] and I am calling on behalf of the Federal Government’s survey of mental health treatment service providers called the National Mental Health Services Survey. This survey is sponsored by SAMHSA, the Substance Abuse and Mental Health Services Administration. I have a few questions I’d like to ask you.
<1> YES, CONTINUE [goto A1]
<2> NO, NOT A CONVENIENT TIME [goto Callback]
<3> NO, WILL COMPLETE ON WEB [goto Thanks]
Duplicate Which facility is a duplicate of this one?
PRESS ENTER TO CHOOSE FROM LIST OR TO ENTER FACILITY INFO [choose from list of facilities or goto MainFacility]
Merged Which facility was this one merged with?
PRESS ENTER TO CHOOSE FROM LIST OR TO ENTER FACILITY INFO [choose from list of facilities or goto MainFacility]
MainFacility May I have the name, address and phone number of the facility?
<1> CONTINUE
PhoneNumber Please give me the telephone number, area code first.
[goto Thanks]
Message_Q ***QUESTIONNAIRE CALL MESSAGE***
DID YOU LEAVE THE MESSAGE?
<1> YES
<0> NO
Thanks Thank you so much for your time. Your responses are very important to the study and we look forward to receiving your completed questionnaire.
Thanks2 Thank you for your time.
A: FACILITY CHARACTERISTICS
A1 (INTRO)
First, I will ask you about the characteristics of the mental health treatment facility, [fill FACILITY NAME] located at [fill LOCATION ADDRESS].
Please answer the next questions referring only to this mental health facility.
<1> CONTINUE TO A1a
A1 Does this facility, at [fill LOCATION ADDRESS], offer:
|
YES |
NO |
Mental health intake |
(1) |
(0) |
Mental health diagnostic evaluation |
(1) |
(0) |
Mental health information and referral (also includes emergency programs that provide services in person or by telephone) |
(1) |
(0) |
*Mental health treatment (interventions such as therapy or psychotropic medication that treat a person’s mental health problem or condition, reduce symptoms, and improve behavioral functioning and outcomes) |
(1) |
(0) |
Substance abuse treatment |
(1) |
(0) |
Administrative services |
(1) |
(0) |
A2 PROGRAMMING CHECK: “YES” to mental health treatment in question A1 (option 4)?
<1> YES
<0> NO [goto C1]
*A3 What levels of care are offered at this facility, at [fill LOCATION ADDRESS], for mental health treatment?
|
YES |
NO |
24-hour hospital inpatient care |
(1) |
(0) |
24-hour residential care |
(1) |
(0) |
Less than 24-hour partial hospitalization |
(1) |
(0) |
Less than 24-hour outpatient care |
(1) |
(0) |
*A4 Which ONE category best describes this facility, at [fill LOCATION ADDRESS]?
PROBE: For definitions of facility types, log on to: http://info.nmhss.org
INTERVIEWER: Code one only
<1> Psychiatric hospital [goto A6]
<2> Separate inpatient psychiatric unit of a general hospital (consider this psychiatric unit as the relevant “facility” for the purpose of this survey) [goto A6]
<3> Residential treatment center for children only [goto A6]
<4> Residential treatment center for adults only [goto A6]
<5> Other residential treatment setting [goto a6]
<6> Veterans Administration medical center (VAMC)/facility [goto A6]
<7> Community mental health center [goto A6]
<8> Outpatient mental health facility
<9> Multi-setting mental health facility (non-hospital residential plus outpatient or partial hospitalization)
<10> Other (SPECIFY) [specify] END WITH //
A5 Is this facility a solo practice or small group practice?
<1> YES
<0> NO [goto A6]
A5a Is this facility licensed or accredited as a mental health clinic or mental health center?
PROBE: Do not count the licenses or credentials of individual practitioners.
<1> YES
<0> NO [goto C4]
A6 Is this facility a Federally Qualified Health Center (FQHC)?
PROBE: FQHCs include: (1) all organizations that receive grants under Section 330 of the Public Health Service Act; and (2) other organizations that have not received grants to date, but have met the requirements to receive grants under Section 330 according to U.S. Department of Health and Human Services.
<1> YES
<0> NO
A7 What is the primary treatment focus of this facility, at [fill LOCATION ADDRESS]?
PROBE: Separate psychiatric units in a general hospital should answer for just their unit and NOT for the entire hospital.
INTERVIEWER: CODE ONE ONLY
<1> Mental health treatment
<2> Substance abuse treatment [goto C4]
<3> Mix of mental health and substance abuse treatment (neither is primary)
<4> General health care
<5> Other service focus (SPECIFY) [specify] END WITH //
A8 Is this facility a jail, prison, or detention center that provides treatment exclusively for incarcerated persons or juvenile detainees?
<1> YES [goto C4]
<0> NO
*A9 Is this facility operated by:
INTERVIEWER: CODE ONE ONLY
<1> A private for-profit organization [goto A10]
<2> A private non-profit organization [goto A10]
<3> A public agency or department
*A9a Which public agency or department?
INTERVIEWER: CODE ONE ONLY
<1> State mental health authority (SMHA)
<2> Other state government agency or department (e.g., Department of Health)
<3> Regional/district authority or local, county, or municipal government
<4> Tribal government
<5> Department of Veterans Affairs
<6> Indian Health Service
<7> OTHER (SPECIFY) [specify] END WITH //
A10 Is this facility affiliated with a religious organization?
<1> YES
<0> NO
*A11 Which of these mental health treatment approaches are offered at this facility, at [fill LOCATION ADDRESS]?
PROBE: For definitions of treatment approaches, log on to : http://info.nmhss.org |
YES |
NO |
Activity therapy |
(1) |
(0) |
Behavior modification |
(1) |
(0) |
Cognitive/behavioral therapy |
(1) |
(0) |
Couples/family therapy |
(1) |
(0) |
Electroconvulsive therapy |
(1) |
(0) |
Group therapy |
(1) |
(0) |
Individual psychotherapy |
(1) |
(0) |
Integrated dual disorders treatment |
(1) |
(0) |
Psychotropic medication |
(1) |
(0) |
Telemedicine therapy |
(1) |
(0) |
Other (SPECIFY) [specify] END WITH // |
(1) |
(0) |
*A12 Which of these supportive services and practices are offered at this facility, at [fill LOCATION ADDRESS]?
PROBE: For definitions of supportive practices, log on to : http://info.nmhss.org |
YES |
NO |
Assertive community treatment |
(1) |
(0) |
Case management |
(1) |
(0) |
Chronic disease/illness management (CDM) |
(1) |
(0) |
Consumer-run (peer support) services |
(1) |
(0) |
Court ordered outpatient treatment |
(1) |
(0) |
Education services |
(1) |
(0) |
Family psychoeducation |
(1) |
(0) |
Housing services |
(1) |
(0) |
Illness management and recovery (IMR) |
(1) |
(0) |
Legal advocacy |
(1) |
(0) |
Nicotine replacement therapy |
(1) |
(0) |
Non-nicotine smoking/tobacco cessation medications (by prescription) |
(1) |
(0) |
Psychiatric emergency walk-in services |
(1) |
(0) |
Psychosocial rehabilitation services |
(1) |
(0) |
Screening for tobacco use |
(1) |
(0) |
Suicide prevention services |
(1) |
(0) |
Supported employment |
(1) |
(0) |
Supported housing |
(1) |
(0) |
Therapeutic foster care |
(1) |
(0) |
Tobacco cessation counseling |
(1) |
(0) |
Vocational rehabilitation services |
(1) |
(0) |
Other (SPECIFY) [specify] END WITH // |
(1) |
(0) |
*A13 What age groups are accepted for treatment at this facility?
|
YES |
NO |
Children (17 or younger) |
(1) |
(0) |
Young adults (18-25) |
(1) |
(0) |
Adults (26-64) |
(1) |
(0) |
Seniors (65 or older) |
(1) |
(0) |
*A14 Does this facility offer a mental health treatment program or group designed exclusively for:
PROBE: If you treat these clients for mental health, but do not have a specifically tailored program or group for them, respond “NO.”
|
YES |
NO |
Children with serious emotional disturbance (SED) |
(1) |
(0) |
Adults with serious mental illness (SMI) |
(1) |
(0) |
Seniors or older adults |
(1) |
(0) |
Persons with Alzheimer’s or dementia |
(1) |
(0) |
Persons with co-occurring mental and substance use disorders |
(1) |
(0) |
Persons with eating disorders |
(1) |
(0) |
Persons with HIV or AIDS |
(1) |
(0) |
Persons with post-traumatic stress disorder (PTSD) |
(1) |
(0) |
Veterans |
(1) |
(0) |
Active duty military |
(1) |
(0) |
Members of military families |
(1) |
(0) |
Persons with traumatic brain injury (TBI) |
(1) |
(0) |
Lesbian, gay, bisexual, or transgender clients (LGBT) |
(1) |
(0) |
Forensic clients (referred from the court/judicial system) |
(1) |
(0) |
Other special program (SPECIFY) [specify] END WITH // |
(1) |
(0) |
*A15 Does this facility offer a crisis intervention team that handles acute mental health issues at this facility and/or off-site?
<1> YES
<0> NO
*A16 Does this facility offer mental health treatment services for the hearing-impaired?
<1> YES
<0> NO
*A17 Does this facility provide mental health treatment services in a language other than English at [fill LOCATION ADDRESS]?
<1> YES
<0> NO, only English [goto A18]
*A17a Do staff provide mental health treatment services in Spanish at this facility?
<1> YES
<0> NO
A17b Do staff at this facility provide mental health treatment services in any other languages?
<1> YES
<0> NO [goto A18]
*A17c In what other languages do staff provide mental health treatment services at this facility?
PROBE: Do not count languages provided only by on-call interpreters.
INTERVIEWER: CODE ALL THAT APPLY
American Indian or Alaska Native:
<1> Hopi
<2> Lakota
<3> Navajo
<4> Ojibwa
<5> Yupik
<6> Other Native American Indian or Alaska Native Language (SPECIFY) [specify] END WITH //
Other Languages:
<7> Arabic
<8> Any Chinese Language
<9> Creole
<10> French
<11> German
<12> Greek
<13> Hmong
<14> Italian
<15> Japanese
<16> Korean
<17> Polish
<18> Portuguese
<19> Russian
<20> Tagalog
<21> Vietnamese
<22> Any Other Language (SPECIFY) [specify] END WITH //
A18 Which of these quality assurance practices are part of this facility’s standard operating procedures?
|
YES |
NO |
Monitoring continuing education requirements for professional staff |
(1) |
(0) |
Regularly scheduled case review with a supervisor |
(1) |
(0) |
Regularly scheduled case review by an appointed quality review committee |
(1) |
(0) |
Client/patient outcome follow-up after discharge |
(1) |
(0) |
Periodic utilization review |
(1) |
(0) |
Periodic client/patient satisfaction surveys |
(1) |
(0) |
*A19 Which statement(s) below BEST describe(s) this facility’s smoking policy for clients?
INTERVIEWER: CODE ONE ONLY
<1> Not permitted to smoke anywhere outside or within any building
<2> Permitted in designated outdoor area(s)
<3> Permitted anywhere outside
<4> Permitted in designated indoor area(s)
<5> Permitted anywhere inside
<6> Permitted anywhere without restriction
A20 In the 12-month period beginning May 1, 2013, and ending April 30, 2014, have staff at this facility used seclusion or restraint with clients?
<1> YES
<0> NO [goto A21]
A20a In the 12-month period beginning May 1, 2013, and ending April 30, 2014, has your facility adopted any initiatives to reduce the use of seclusion or restraint?
<1> YES
<0> NO
A21 For each of the following functions, please indicate if staff members routinely use computer or electronic resources, paper only, or a combination of both to complete the function.
Function |
Computer/ Electronic Only |
Paper Only |
Both Electronic and Paper |
N/A |
Intake |
(1) |
(2) |
(3) |
(0) |
Scheduling appointments |
(1) |
(2) |
(3) |
(0) |
Assessment/evaluation |
(1) |
(2) |
(3) |
(0) |
Treatment plan |
(1) |
(2) |
(3) |
(0) |
Discharge |
(1) |
(2) |
(3) |
(0) |
Referrals |
(1) |
(2) |
(3) |
(0) |
Issue/receive lab results |
(1) |
(2) |
(3) |
(0) |
Billing |
(1) |
(2) |
(3) |
(0) |
Client progress monitoring |
(1) |
(2) |
(3) |
(0) |
Prescribing/dispensing medication |
(1) |
(2) |
(3) |
(0) |
Checking medication interactions |
(1) |
(2) |
(3) |
(0) |
Health records |
(1) |
(2) |
(3) |
(0) |
Collaboration with a client’s other providers (such as primary care provider) |
(1) |
(2) |
(3) |
(0) |
Client or family satisfaction surveys |
(1) |
(2) |
(3) |
(0) |
*A22 Does this facility use a sliding fee scale?
<1> YES
<0> NO [goto A23]
A22a Do you want the availability of a sliding fee scale published in SAMHSA’s online Behavioral Health Treatment Services Locator?
PROBE: The Locator will explain that sliding fee scales are based on income and other factors.
<1> YES
<0> NO
*A23 Does this facility offer treatment at no charge to clients who cannot afford to pay?
<1> YES
<0> NO [goto A24]
A23a Do you want the availability of free care for eligible clients published in SAMHSA’s online Behavioral Health Treatment Services Locator?
PROBE: The Locator will inform potential clients to call the facility for information on eligibility.
<1> YES
<0> NO
*A24 Which of the following types of client payments, insurance, or funding are accepted by this facility for mental health treatment services?
|
YES |
NO |
DON’T KNOW |
Cash or self-payment |
(1) |
(0) |
(d) |
Private health insurance |
(1) |
(0) |
(d) |
Medicare |
(1) |
(0) |
(d) |
Medicaid |
(1) |
(0) |
(d) |
State-financed health insurance plan other than Medicaid |
(1) |
(0) |
(d) |
State mental health agency (or equivalent) funds |
(1) |
(0) |
(d) |
State welfare or child and family services agency funds |
(1) |
(0) |
(d) |
State corrections or juvenile justice agency funds |
(1) |
(0) |
(d) |
State education agency funds |
(1) |
(0) |
(d) |
Other state government funds |
(1) |
(0) |
(d) |
County or local government funds |
(1) |
(0) |
(d) |
Community Service Block Grants |
(1) |
(0) |
(d) |
Community Mental Health Block Grants |
(1) |
(0) |
(d) |
Federal military insurance (such as TRICARE) |
(1) |
(0) |
(d) |
U.S. Department of Veterans Affairs funds |
(1) |
(0) |
(d) |
IHS/638 contract care funds |
(1) |
(0) |
(d) |
Other (SPECIFY) [specify] END WITH // |
(1) |
(0) |
(d) |
A25 From which of these organizations does this facility have licensing, certification, or accreditation?
PROBE: Do not include personal-level credentials or general business licenses such as a food service license.
|
YES |
NO |
State mental health authority |
(1) |
(0) |
State substance abuse agency |
(1) |
(0) |
State department of health |
(1) |
(0) |
Hospital licensing authority |
(1) |
(0) |
The Joint Commission (JC) |
(1) |
(0) |
Commission on Accreditation of Rehabilitation Facilities (CARF) |
(1) |
(0) |
Council on Accreditation (COA) |
(1) |
(0) |
Department of Family and Children’s Services |
(1) |
(0) |
Medicare |
(1) |
(0) |
Medicaid |
(1) |
(0) |
Other national, state, or local organization (SPECIFY) [specify] END WITH // |
(1) |
(0) |
*A26 What telephone number(s) should a potential client call to schedule an intake appointment?
NUMERIC INTAKE TELEPHONE NUMBER(S):
1. | | | | - | | | | - | | | | |
(RANGE) (RANGE) (RANGE)
2. | | | | - | | | | - | | | | |
(RANGE) (RANGE) (RANGE)
ALPHA-NUMERIC INTAKE TELEPHONE NUMBER(S):
1. | | | | - | | | | - | | | | |
(RANGE) (RANGE) (RANGE)
2. | | | | - | | | | - | | | | |
(RANGE) (RANGE) (RANGE)
B: CLIENT/PATIENT COUNT INFORMATION
The next questions ask about the number of clients/patients treated at this facility on specific dates. Questions will ask for either a single day count, a one-month count, or a 12-month count, which will be specified in that question.
Include ALL (clients/patients) receiving mental health treatment services in your counts, even if a mental health disorder is a secondary diagnosis or has not yet been formally determined.
B1 Although reporting for only the clients/patients treated at this facility is preferred, we realize that may not be possible. Will the client/patient counts reported in this questionnaire include…
<1> Only this facility [goto B3]
<2> This facility plus others [goto B2]
<3> Another facility in the organization will report client counts for this facility
B1a What is the name and phone number of the facility that will report your client count?
INTERVIEWER: After recording the facility name and telephone number in B1a, SKIP TO C1
FACILITY NAME
TELEPHONE NUMBER:
| | | | - | | | | - | | | | |
(RANGE) (RANGE) (RANGE)
B2 I am looking at a screen that shows the other facilities currently linked to this facility in our database. Please tell me which facilities will be included in the client counts you will report and I will record them here.
READ IF ADDITIONAL FACILITIES DO NOT APPEAR ON DISPLAY SCREEN: Please tell me the name, address, telephone number, and facility email address for each additional facility that will be included in the client counts you report. Also what level of care does the facility offer; 24‑hour hospital inpatient care, 24-hour residential care, and/or less than 24 hour outpatient mental health treatment (including partial hospitalization) at that location?
FACILITY NAME:
ADDRESS:
CITY:
STATE:
ZIP:
PHONE:
FACILITY EMAIL ADDRESS:
LEVEL(S) OF CARE OFFERED:
|
YES |
NO |
Hospital Inpatient |
(1) |
(0) |
Residential |
(1) |
(0) |
Outpatient |
(1) |
(0) |
<1> RECORD ADDITIONAL FACILITY
<2> FINISHED RECORDING FACILITIES, CONTINUE WITH B3
24-HOUR HOSPITAL INPATIENT COUNTS
B3 On April 30, 2014, did any patients receive 24‑hour hospital inpatient mental health treatment at [FILL this facility/these facilities], at [FILL this location/these locations]?
<1> YES [goto B3a]
<0> NO [goto B4]
B3a On April 30, 2014, how many patients received 24‑hour hospital inpatient mental health treatment at [FILL this facility/these facilities]?
PROBE: Do NOT count family members, friends, or other non-treatment patients.
| | | | | TOTAL hospital inpatients [goto B3b]
B3b (INTRO)
For each of the following categories, please provide a breakdown of the [fill B3a] Hospital Inpatients reported in the previous question. Use either numbers or percents, whichever is more convenient.
INTERVIEWER: IF NUMBERS ARE USED—EACH CATEGORY TOTAL SHOULD EQUAL THE NUMBER REPORTED IN THE B3a TOTAL BOX
IF PERCENTS ARE USED—EACH CATEGORY TOTAL SHOULD EQUAL 100%
<1> PREFERS NUMBERS [goto IPSexTotM]
<2> PREFERS PERCENTAGES [goto IPSexPerM]
B3b (GENDER)
Of the [fill B3a] patients that received 24-hour hospital inpatient mental health treatment services on April 30, 2014, how many were male patients?
[IPSexTotM]
OR
[IPSexPerM]
Of the [fill B3a] patients that received 24-hour hospital inpatient mental health treatment services on April 30, 2014, how many were female patients?
[IPSexTotF]
OR
[IPSexPerF]
B3b (AGE)
Of the [fill B3a] patients that received 24-hour hospital inpatient mental health treatment services on April 30, 2014, how many were 17 years old or younger?
[IPAgeTot017]
OR
[IPAgePer017]
Of the [fill B3a] patients that received 24-hour hospital inpatient mental health treatment services on April 30, 2014, how many were between the ages of 18 to 64?
[IPAgeTot1864]
OR
[IPAgePer1864]
Of the [fill B3a] patients that received 24-hour hospital inpatient mental health treatment services on April 30, 2014, how many were 65 years old or older?
[goto IPAgeTot65]
OR
[goto IPAgePer65]
B3b (ETHNICITY)
Of the [fill B3a] patients that received 24-hour hospital inpatient mental health treatment services on April 30, 2014, how many were Hispanic or Latino?
[IPEthTotHisp]
OR
[IPEthPerHisp]
Of the [fill B3a] patients that received 24-hour hospital inpatient mental health treatment services on April 30, 2014, how many were not Hispanic or Latino?
[IPEthTotNonHisp]
OR
[IPEthPerNonHisp]
Of the [fill B3a] patients that received 24-hour hospital inpatient mental health treatment services on April 30, 2014, how many were of unknown ethnicity or not collected?
[IPEthTotUnk]
OR
[IPEthPerUnk]
B3b (RACE)
Of the [fill B3a] patients that received 24-hour hospital inpatient mental health treatment services on April 30, 2014, how many were American Indian or Alaska Native?
[IPRaceTotIndian]
OR
[IPRacePerIndian]
Of the [fill B3a] patients that received 24-hour hospital inpatient mental health treatment services on April 30, 2014, how many were Asian?
[IPRaceTotAsian]
OR
[IPRaceTotAsian]
Of the [fill B3a] patients that received 24-hour hospital inpatient mental health treatment services on April 30, 2014, how many were black or African American?
[IPRaceTotBlk]
OR
[IPRacePerBlk]
Of the [fill B3a] patients that received 24-hour hospital inpatient mental health treatment services on April 30, 2014, how many were Native Hawaiian or other Pacific Islander?
[IPRaceTotHawPac]
OR
[IPRacePerHawPac]
Of the [fill B3a] patients that received 24-hour hospital inpatient mental health treatment services on April 30, 2014, how many were white?
[IPRaceTotWhit]
OR
[IPRacePerWhit]
Of the [fill B3a] patients that received 24-hour hospital inpatient mental health treatment services on April 30, 2014, how many were two or more races?
[IPRaceTotMR]
OR
[IPRacePerMR]
Of the [fill B3a] patients that received 24-hour hospital inpatient mental health treatment services on April 30, 2014, for how many were of unknown race or not collected?
[IPRaceTotUnk]
OR
[IPRacePerUnk]
B3b (LEGAL STATUS)
Of the [fill B3a] patients that received 24-hour hospital inpatient mental health treatment services on April 30, 2014, how many had a legal status of voluntary?
[IPLegalTotVol]
OR
[IPLegalTPerVol]
Of the [fill B3a] patients that received 24-hour hospital inpatient mental health treatment services on April 30, 2014, how many had a legal status of involuntary, non-forensic?
[IPLegalTotNonForen]
OR
[IPLegalPerNonForen]
Of the [fill B3a] patients that received 24-hour hospital inpatient mental health treatment services on April 30, 2014, how many had a legal status of involuntary, forensic?
[IPLegalTotForen]
OR
[IPLegalPerForen]
B3c On April 30, 2014, how many hospital inpatient beds at this facility were specifically designated for providing mental health treatment?
| | | | | NUMBER OF BEDS
<0> IF NONE
24-HOUR RESIDENTIAL (NON-HOSPITAL) CLIENT COUNTS
B4 On April 30, 2014, did any clients receive 24-hour residential mental health treatment at [FILL this facility/these facilities], at [FILL this location/these locations]?
<1> YES [goto B4a]
<0> NO [goto B5]
B4a On April 30, 2014, how many clients received 24‑hour residential mental health treatment at [FILL this facility/these facilities]?
PROBE: Do NOT count family members, friends, or other non-treatment patients.
| | | | | TOTAL RESIDENTIAL CLIENTS [goto B4b]
B4b (INTRO)
For each of the following categories, please provide a breakdown of the [fill B4a] Hospital Inpatients reported in the previous question. Use either numbers or percents, whichever is more convenient.
INTERVIEWER: IF NUMBERS ARE USED—EACH CATEGORY TOTAL SHOULD EQUAL THE NUMBER REPORTED IN THE B4a TOTAL BOX
IF PERCENTS ARE USED—EACH CATEGORY TOTAL SHOULD EQUAL 100%
<1> PREFERS NUMBERS [goto RCSexTotM]
<2> PREFERS PERCENTAGES [goto RCSexPerM]
B4b (GENDER)
Of the [fill B4a] clients that received 24-hour residential mental health treatment services on April 30, 2014, how many were male clients?
[RCSexTotM]
OR
[RCSexPerM]
Of the [fill B4a] clients that received 24-hour residential mental health treatment services on April 30, 2014, how many were female clients?
[RCSexTotF]
OR
[RCSexPerF]
B4b (AGE)
Of the [fill B4a] clients that received 24-hour residential mental health treatment services on April 30, 2014, how many were 17 years old or younger?
[RCAgeTot017]
OR
[RCAgePer017]
Of the [fill B4a] clients that received 24-hour residential mental health treatment services on April 30, 2014, how many were between the ages of 18 to 64?
[RCAgeTot1864]
OR
[RCAgePer1864]
Of the [fill B4a] clients that received 24-hour residential mental health treatment services on April 30, 2014, how many were 65 years old or older?
[RCAgeTot65]
OR
[RCAgePer65]
B4b (ETHNICITY)
Of the [fill B4a] clients that received 24-hour residential mental health treatment services on April 30, 2014, how many were Hispanic or Latino?
[RCEthTotHisp]
OR
[RCEthPerHisp]
Of the [fill B4a] clients that received 24-hour residential mental health treatment services on April 30, 2014, how many were not Hispanic or Latino?
[RCEthTotNonHisp]
OR
[RCEthPerNonHisp]
Of the [fill B4a] clients that received 24-hour residential mental health treatment services on April 30, 2014, for how many were of unknown ethnicity or not collected?
[RCEthTotUnk]
OR
[RCEthPerUnk]
B4b (RACE)
Of the [fill B4a] clients that received 24-hour residential mental health treatment services on April 30, 2014, how many were American Indian or Alaska Native?
[RCRaceTotIndian]
OR
[RCRacePerIndian]
Of the [fill B4a] clients that received 24-hour residential mental health treatment services on April 30, 2014, how many were Asian?
[RCRaceTotAsian]
OR
[RCRacePerAsian]
Of the [fill B4a] clients that received 24-hour residential mental health treatment services on April 30, 2014, how many were black or African American?
[RCRaceTotBlk]
OR
[RCRacePerBlk]
Of the [fill B4a] clients that received 24-hour residential mental health treatment services on April 30, 2014, how many were Native Hawaiian or other Pacific Islander?
[RCRaceTotHawPac]
OR
[RCRacePerHawPac]
Of the [fill B4a] clients that received 24-hour residential mental health treatment services on April 30, 2014, how many were white?
[RCRaceTotWhit]
OR
[RCRacePerWhit]
Of the [fill B4a] clients that received 24-hour residential mental health treatment services on April 30, 2014, how many were two or more races?
[RCRaceTotMR]
OR
[IPRacePerMR]
Of the [fill B4a] clients that received 24-hour residential mental health treatment services on April 30, 2014, how many were of unknown race or not collected?
[RCRaceTotUnk]
OR
[RCRacePerUnk]
B4b (LEGAL STATUS)
Of the [fill B4a] clients that received 24-hour residential mental health treatment services on April 30, 2014, how many had a legal status of voluntary?
[RCLegalTotVol]
OR
[RCLegalTPerVol]
Of the [fill B4a] clients that received 24-hour residential mental health treatment services on April 30, 2014, how many had a legal status of involuntary, non-forensic?
[RCLegalTotNonForen]
OR
[RCLegalPerNonForen]
Of the [fill B4a] clients that received 24-hour residential mental health treatment services on April 30, 2014, how many had a legal status of involuntary, forensic?
[RCLegalTotForen]
OR
[RCLegalPerForen
B4c On April 30, 2014, how many residential beds at this facility were specifically designated for providing mental health treatment?
| | | | | NUMBER OF BEDS
<0> IF NONE
LESS THAN 24-HOUR OUTPATIENT CLIENT COUNTS
B5 During the month of April 2014, did any clients receive less than 24-hour outpatient mental health treatment at [FILL this facility/these facilities], at [FILL this location/these locations]? Also include partial hospitalization clients.
<1> YES [goto B5a]
<0> NO [goto B6]
B5a During the month of April 2014, how many clients received outpatient mental health treatment at [FILL this facility/these facilities]?
READ: Only include those seen at this facility at least once during the month of April, and who were still enrolled in treatment on April 30, 2014.
PROBE: Do NOT count family members, friends, or other non-treatment clients
| | | | | TOTAL OUTPATIENT CLIENTS [goto B5b]
B5b (INTRO)
For each of the following categories, please provide a breakdown of the [fill B5a] Outpatient Clients reported in the previous question. Use either numbers or percents, whichever is more convenient.
INTERVIEWER: IF NUMBERS ARE USED—EACH CATEGORY TOTAL SHOULD EQUAL THE NUMBER REPORTED IN THE B5a TOTAL BOX
IF PERCENTS ARE USED—EACH CATEGORY TOTAL SHOULD EQUAL 100%
<1> PREFERS NUMBERS [goto OPSexTotM]
<2> PREFERS PERCENTAGES [goto OPSexPerM]
B5b (GENDER)
Of the [fill B5a] clients that received less than 24-hour outpatient mental health treatment services during the month of April 2014, how many were male clients?
[OPSexTotM]
OR
[OPSexPerM]
Of the [fill B5a] clients that received less than 24-hour outpatient mental health treatment services during the month of April 2014, how many were female clients?
[OPSexTotF]
OR
[OPSexPerF]
B5b (AGE)
Of the [fill B5a] clients that received less than 24-hour outpatient mental health treatment services during the month of April 2014, how many were 17 years old or younger?
[OPAgeTot017]
OR
[OPAgePer017]
Of the [fill B5a] clients that received less than 24-hour outpatient mental health treatment services during the month of April 2014, how many were between the ages of 18 to 64?
[OPAgeTot1864]
OR
[OPAgePer1864]
Of the [fill B5a] clients that received less than 24-hour outpatient mental health treatment services during the month of April 2014, how many were 65 years old or older?
[OPAgeTot65]
OR
[OPAgePer65]
B5b (ETHNICITY)
Of the [fill B5a] clients that received less than 24-hour outpatient mental health treatment services during the month of April 2014, how many were Hispanic or Latino?
[OPEthTotHisp]
OR
[OPEthPerHisp]
Of the [fill B5a] clients that received less than 24-hour outpatient mental health treatment services during the month of April 2014, how many were not Hispanic or Latino?
[OPEthTotNonHisp]
OR
[OPEthPerNonHisp]
Of the [fill B5a] clients that received less than 24-hour outpatient mental health treatment services during the month of April 2014, how many were of unknown ethnicity or not collected?
[OPEthTotUnk]
OR
[OPEthPerUnk]
B5b (RACE)
Of the [fill B5a] clients that received less than 24-hour outpatient mental health treatment services during the month of April 2014, how many were American Indian or Alaska Native?
[OPRaceTotIndian]
OR
[OPRacePerIndian]
Of the [fill B5a] clients that received less than 24-hour outpatient mental health treatment services during the month of April 2014, how many were Asian?
[OPRaceTotAsian]
OR
[OPRacePerAsian]
Of the [fill B5a] clients that received less than 24-hour outpatient mental health treatment services during the month of April 2014, how many were black or African American?
[OPRaceTotBlk]
OR
[OPRacePerBlk]
Of the [fill B5a] clients that received less than 24-hour outpatient mental health treatment services during the month of April 2014, how many were Native Hawaiian or other Pacific Islander?
[OPRaceTotHawPac]
OR
[OPRacePerHawPac]
Of the [fill B5a] clients that received less than 24-hour outpatient mental health treatment services during the month of April 2014, how many were white?
[OPRaceTotWhit]
OR
[OPRacePerWhit]
Of the [fill B5a] clients that received less than 24-hour outpatient mental health treatment services during the month of April 2014, how many were two or more races?
[OPRaceTotMR]
OR
[OPRacePerMR]
Of the [fill B5a] clients that received less than 24-hour outpatient mental health treatment services during the month of April 2014, how many were of unknown race or not collected?
[OPRaceTotUnk]
OR
[OPRacePerUnk]
B5b (LEGAL STATUS)
Of the [fill B5a] clients that received less than 24-hour outpatient mental health treatment services during the month of April 2014, how many had a legal status of voluntary?
[OPLegalTotVol]
OR
[OPLegalTPerVol]
Of the [fill B5a] clients that received less than 24-hour outpatient mental health treatment services during the month of April 2014, how many had a legal status of involuntary, non-forensic?
[OPLegalTotNonForen]
OR
[OPLegalPerNonForen]
Of the [fill B5a] clients that received less than 24-hour outpatient mental health treatment services during the month of April 2014, how many had a legal status of involuntary, forensic?
[OPLegalTotForen]
OR
[OPLegalPerForen]
B6 (INTRO)
Please think about all of the mental health treatment care settings when answering the next questions, including 24-hour hospital inpatient, 24-hour residential (non-hospital), and less than 24-hour outpatient, including partial hospitalization.
B6 On April 30, 2014, approximately what percent of the mental health treatment clients enrolled at [FILL this facility/these facilities] had diagnosed co-occurring mental and substance use disorders?
| | | | PERCENT WITH CO-OCCURRING DIAGNOSIS
<0> IF NONE
B7 In the 12-month period of May 1, 2013 through April 30, 2014, how many mental health treatment admissions, readmissions, and incoming transfers did this facility have? Exclude returns from unauthorized absence, such as escape, AWOL, or elopement.
IF DATA FOR THIS TIME PERIOD ARE NOT AVAILABLE, PROBE: Use the most recent 12‑month period for which data are available
FOR OUTPATIENT CLIENTS, PROBE: Consider each initiation to a course of treatment as an admission. Count admissions into treatment, not individual treatment visits
WHEN A MENTAL HEALTH DISORDER IS A SECONDARY DIAGNOSIS, PROBE: Count all admissions where clients received mental health treatment.
| | | | NUMBER OF MENTAL HEALTH TREATMENT
ADMISSIONS IN 12‑MONTH PERIOD
<0> IF NONE
B8 What percent of the [fill B7] admissions just reported were military veterans? Please give your best estimate.
| | | | PERCENT MILITARY VETERANS
<0> IF NONE
C: GENERAL INFORMATION
C1 If eligible, does this facility want to be listed in SAMHSA’s online Behavioral Health Treatment Services Locator?
PROBE: The Locator can be found at http://findtreatment.samhsa.gov
<1> YES
<0> NO
C2 Does this facility have a website or web page with information about the facility’s mental health treatment programs?
<1> YES
<0> NO [goto C3]
*C2a What is this facility’s website address?
READ: PLEASE TELL ME THE ADDRESS EXACTLY AS IT SHOULD BE ENTERED IN ORDER TO ACCESS YOUR SITE.
<1> RECORD
C3 Does this facility have a National Provider Identifier (NPI) number?
PROBE: Do not include the NPI numbers of individual practitioners and of groups of practitioners.
<1> YES
<0> NO [goto C4]
C3a What is the NPI number for this facility?
PROBE: If the facility has more than one NPI number, please tell me only the primary number.
<1> RECORD NPI NUMBER
C4. I would like to confirm your contact information.
PROBE: This information will only be used if we need to contact you about your responses. It will not be published.
First I need to record how we should address you.
Is it Ms., Mrs., Mr., Dr., or something else?
INTERVIEWER: CODE ONE ONLY
<1> Ms.
<2> Mrs.
<3> Mr.
<4> Dr.
<5> Other (SPECIFY) [specify] END WITH //
IF KNOWN, RECORD WITHOUT ASKING. IF NOT KNOWN, READ: Could you please spell your first and last name for me?
NAME:_____________________________________
What is your title?
TITLE:______________________________________
What is the best telephone number to reach you?
PHONE NUMBER
(| | | | - | | | | - | | | | |
Area Code Extension
What is your fax number?
FAX NUMBER
(| | | | - | | | | - | | | | |
Area Code Extension
What is your email address?
EMAIL ADDRESS:________________________________
What is your facility’s email address?
FACILITY EMAIL ADDRESS:________________________
THANK YOU
Those are all the questions that I have. Thank you very much for your participation.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | 2014 N-MHSS CATI Screener |
| Subject | CATI |
| Author | Ryan McInerney |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |