Form Follow Up Intervie Follow Up Intervie Follow Up Interview Guide

OMB No. 0930-0336

Expiration Date: 06/30/2016

MINORITY AIDS INITIATIVE CONTINUUM OF CARE (CoC)

EVALUATION

PROJECT STAFF SEMI-STRUCTURED INTERVIEW GUIDE – FOLLOW-UP

CONDUCTED BY:

TBD

Date(s) of site visit (MM/DD/YYYY)
Grantee organization name
Location
Grantee ID #
Project name
Partner organizations and locations visited
Participants (full name, credentials, project title and organizational affiliation)
Site Visitors (full name, credentials, project title and organizational affiliation)

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 0930-0xxx.  Public reporting burden for this collection of information is estimated to average 120 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, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20857.

1. Site Visit Overview

Introduction and Background

The purpose of SAMHSA’s Minority AIDS Initiative HIV Continuum of Care (MAI-CoC) program, which currently funds the MAI-CoC grantees, is to integrate behavioral health treatment, prevention, and HIV and Hepatitis medical care services for racial/ethnic minority populations at high risk for behavioral health disorders who are also at high risk for or living with HIV and/or Hepatitis. Other priority populations include men who have sex with men (MSM), bisexual men, transgender persons, and persons with substance use disorders. This program is primarily intended for substance use disorder (SUD) treatment and community mental health care providers to provide coordinated and integrated services through the co-location and/or integration of behavioral health treatment and HIV medical care.

The goals of the MAI-CoC program are to: 1) increase HIV and Hepatitis testing among behavioral health clients who are unaware of their HIV and Hepatitis status; 2) increase diagnoses of HIV and Hepatitis among behavioral health clients; 3) increase the number of clients who are linked to HIV and Hepatitis medical care; 4) increase the number of behavioral health clients who are retained in HIV and Hepatitis medical care; 5) increase the number of behavioral health clients who are receiving antiretroviral therapy (ART); 6) improve the adherence to behavioral treatment and ART; 7) increase the number of behavioral health clients who have sustained (HIV) viral suppression; and 8) increase adherence and retention in behavioral health (both substance use and mental disorders) treatment.

In support of this program, Abt Associates is conducting interviews with MAI-CoC grantees to gather contextual information on programming efforts. Through the second round of interviews with MAI-CoC grantees, SAMHSA hopes to continue to gain insight into the successes and challenges of implementing your grantee project and providing HIV, Hepatitis, behavioral health, and primary care services to historically underserved and high-risk populations. Although we will take detailed notes, we would also like to ask if we may record the interview to verify our notes from the interview. The information you share with us will support our overall effort to assess the performance of MAI-CoC grantees in meeting their programmatic objectives and our evaluation’s efforts to:

1. Assess the impact of the SAMHSA-funded HIV programs in reducing behavioral health disorders and HIV infections; increasing access to SUD and mental disorder treatment and care; improving behavioral and mental health outcomes; and reducing HIV-related disparities;

2. Describe the different integrated behavioral health and medical program models; and

3. Determine which program types or models are most effective in improving behavioral health and clinical outcomes.

Similar to our last round of visits with MAI-CoC grantees, this protocol includes general questions about: 1) the context of the communities in which your organization operates and 2) the programmatic and clinical services designed to support the MAI-CoC initiative. We have also included questions related to the CIHS Standard Framework Indicators to help us understand grantee approaches to integration of services to prevent and treat substance use and mental health disorders, HIV, and Hepatitis.

Prior to our site visit, we asked that you please update the tables in the appendices and send them back to the team that will be visiting your project. These tables are intended to collect consistent information across sites and will be discussed in the sections that address Community Context (Section 2.1), Staffing and Staff Development (Section 2.3) and Programmatic and Clinical services (Section 3). We also requested that you provide an organizational chart to facilitate discussion of the Organizational Structure (Section 2.2). These materials will be referred to during the site visit interview.

2. Project Overview

   1. Community Context

The following section includes follow-up questions about the community in which you provide services. During the first site visit we gained an understanding of the larger context in which your organization operates. We are interested in hearing about any significant changes since our previous site visit. Probes are provided for some of the questions to facilitate dialogue and promote clarity for major questions.

1. Since our last visit, have any of the unique socio-economic and cultural characteristics of the community in which your organization operates changed? If so, please describe the changes and how these changes have influenced programming for the MAI-CoC project?

Probes:

• Have these changes influenced the demographic/population characteristics within the community

in which your organization operates?

• What other unique factors or community characteristics are related to any changes described (i.e., prominent cultural beliefs, prominent health or mental health issues, substance dependence issues, rural or urban populations, etc)?

2. In the last visit, it was described that…

[Note: Site visitor should include a brief description of information provided during the previous site visit.]

Since our last visit, have there been any changes to risk and protective factors prevalent in the community where your organization operates? By risk and protective factors, we mean community-level characteristics and/or health and epidemiological trends that impact the prevalence of HIV among the population, such as rates among men who have sex with men, rates of drug use and dependence, poverty, educational attainment, etc. If there have been any changes please describe them and how these changes have influenced programming for the MAI-CoC project.

Probes:

• What are the driving forces behind the changes referenced?

• Have there been any changes to your target population’s access to health insurance or free or reduced-priced community services?

[Note: Site visitor should describe information provided during the previous site visit.]

3. Since our last visit, have there been any changes to the mix of services widely available in the community where your MAI-CoC project operates?

[Note: Site visitor should describe information provided during the previous site visit.]

• Substance use disorder (SUD) treatment

• Substance abuse prevention

• Mental health disorder treatment

• Prevention of mental health disorders

• HIV prevention and testing

• HIV pre-exposure prophylaxis (PrEP)

• HIV post-exposure prophylaxis (PEP)

• Primary care for persons living with or at risk for HIV

• Hepatitis prevention and testing

• Primary care for persons with or at risk for Hepatitis

4. Since our last visit, have there been any changes to the following services in terms of accessibility in the community where your MAI-CoC project operates?

[Note: Site visitor should describe information provided during the previous site visit.]

• Substance use disorder (SUD) treatment

• Substance abuse prevention

• Mental health disorder treatment

• Prevention of mental health disorders

• HIV prevention and testing

• HIV pre-exposure prophylaxis (PrEP)

• HIV post-exposure prophylaxis (PEP)

• Primary care for persons living with or at risk for HIV

• Hepatitis prevention and testing

• Primary care for persons with or at risk for Hepatitis

Probes:

• Public transportation issues in your locale?

• Payment challenges for individuals with low socioeconomic status (SES)?

• Lack of knowledge in the community regarding available services?

5. Since our last visit, have there been any changes to your organization’s population(s) of focus?

Probes:

• If different than in the past, what has prompted changes?

• If so, how have these changes influenced MAI-CoC programming at your organization?

6. Since our last visit, have there been any changes in the ways your organization engages with the community? If different than in the past, what has prompted these changes?

Probes:

• Membership in community leadership groups

• Existence of organizational community advisory board

• Established presence/sponsorship of community events

• Existence of memoranda of understanding (MOUs) with other organizations

Next, I would like to ask about your organization’s history of providing services.

7. Since our last visit, have there been any changes to the services your organization provides from the following services for Hepatitis, HIV, mental health conditions, and substance use disorders (SUD)? If there are changes can you please describe them and the reasons for these changes? Please refer to Appendix A to note these changes.

[Note: Site visitor should describe information provided during the previous site visit.]

Services:

• Vaccination for Hepatitis A and B

• Prevention information and resources

• Screening and testing

• Medical care – for HIV, including Antiretroviral therapy (ART)

• Referrals and other services

Probes:

• Have any of these services increased or decreased since the previous site visit? If so, please specify which ones and the reasons for these changes.

• Have any services been added or ended since the previous site visit? If so, please specify which ones, the year they began (or ended), and the reasons for these changes.

• Any other changes to these services? If so, please specify which ones and the reasons for these changes.

8. Since our last site visit, have there been any changes to the provision of any other services that we have not previously discussed?

Probes:

• Have you added or reduced any other services that are part of your service continuum?

• Have you altered the way in which any of these services are delivered as a result of your experiences?

2. Organizational Structure

In this next section of the guide we will discuss the structure of your organization as well as that of the MAI-CoC project, and where the MAI-CoC project fits within your organization. In this follow-up visit we are interested in hearing about any significant changes since our previous site visit. We will discuss any changes that may have occurred with the lines of authority for project administration and how communications flow within your MAI-CoC project. We would also like to follow-up with you concerning any changes in staff since our last visit. For a detailed staffing table, please refer to Appendix B.

If the organizational chart was not received prior to the site visit, ask questions 1-3.

If the organizational chart was received, use questions 1-3 to probe for missing or unclear details.

1. Since our last visit, have there been any changes in your overall organizational structure?

[If grantee reports ‘yes,’ ask the following questions:]

1. What would an updated schematic representation of your organizational structure look like?

2. Have there been any changes to your MAI-CoC service project’s situation or structure, within your overall organization?

Probes:

• Can you provide an updated organizational chart of your organization?

• Within the organizational chart, can you show us where your MAI-CoC project currently sits?

2. Since the last site visit, what are the revised lines of authority and communication within the overall organization?

3. Since the last site visit, what are the lines of authority and communication within your MAI-CoC project?

Probes:

• How do the lines of authority and communication currently relate to the organizational and programmatic diagram we are asking you to provide?

• Who does the MAI-CoC Project Director currently report to?

3. Staffing & Staff Development

This section of the guide will help us review any changes that may have occurred to the staffing structure within the organization and your MAI-CoC project since our last site visit. This will help us to understand any updates to the certifications and credentials that your staff holds, and trainings that they undergo, which enable them to provide services within your organization and MAI-CoC project.

1. Since our last visit, have there been any changes to your MAI-CoC staffing structure? Please note the number of staff you have for the MAI-CoC project. (Please refer to Appendix B.)

[Note: Site visitor should describe information and appendices provided during the previous site visit.]

2. What is your approximate average caseload for direct services staff? Please specify caseload by staff position (e.g., case managers, therapists/counselors, peer recovery specialists).

   1. What percentage of your staff has specific professional degrees, licensure or certification in the direct services they provide?

   2. What certification is required of your service providers who are involved in the MAI-CoC Project? Has this certification requirement changed since our previous visit? Please describe all changes in detail, by staff position.

3. What training or staff development is currently required for staff working with MAI-CoC Project? (Please refer to Appendix C).

[Note: Site visitor should describe information and appendices provided during previous site visit.]

1. Since our previous visit, what trainings have project staff received?

Probes:

• Who provided these trainings?

• Were they mandatory or voluntary?

• How many staff have been trained?

4. Is this a change in your original approach or planning for staff development/training?

5. Describe how the trainings have met your project needs.

7. Describe how the trainings have not met your project needs.

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

Probe:

• Are these needed trainings available?

• What, if any, barriers are there to getting access to these trainings? How can these barriers be addressed?

3. Programmatic & Clinical Services

   1. Services & Service Model

This section explores the services that are offered within your organization as a whole for your MAI-CoC project. It also seeks to update our understanding of the approach that you employ to deliver services and the process of engaging clients in care.

1. During our last visit, you described your organization’s MAI-CoC care/service delivery approach as follows.

[Note: Site visitor to provide a brief of what was shared by the grantee.]

Since our previous visit, have there been any changes to your care/service delivery approach?

1. What changes occurred to the core components of that approach?

2. How do these changes help meet the requirements of the RFA?

1. Have there been any changes to the types of services your organization employs to deliver MAI-CoC services? (Please refer to Appendix D.)

Probes:

• Have there been any changes to the services provided in-house/ by your organization at one of your sites?

• Have there been any changes to the services your organization co-located at another site?

• Have there been any changes to the services provided off-site/ by another community organization or provider at their own site(s)?

• Have there been any changes to the services provided by another community organization or provider co-located at one of your sites?

3. Have there been any changes to the services your organization offers overall, outside of MAI-CoC services?

4. Have there been any changes to who is eligible to receive services at your organization?

Probes:

• What, if any, financial supports are in place to help low-income clients receive services?

• What changes have occurred since our previous visit?

2. Outreach, Referral, and Enrollment into Services

The purpose of this section is to continue developing our understanding of the flow of clients in and out of your MAI-CoC project. For this section of the guide, we’d like to discuss what, if any, updates have occurred since our previous visit in terms of your MAI-CoC project’s outreach efforts, referral and linkage processes, and your project’s partnerships with other organizations.

1. We’d like to hear about significant changes to your approach and procedures for different services, since our previous site visit. Have any changes occurred for your MAI-CoC project in how your organization…

• …defines and conducts “engagement?”

• …defines and conducts “recruitment?”

• …defines and conducts “enrollment?”

• …defines and conducts an “intake?”

• …defines and conducts a “discharge” or “disenrollment?”

• Have any changes occurred in the types of discharges you employ for your MAI-CoC project?

1. For this next question, describe any significant changes to project outreach strategies since our previous site visit. Have any changes occurred with your MAI-CoC project outreach strategies…

• …within your organization?

• …to external community service providers and partners?

• …to the larger community in which your program is located?

2. Have any changes occurred with how your organization uses social media (e.g., Facebook, Twitter, Linked In, Instagram, Google+, Yelp, etc.) and other forms of internet or digital communications (e.g., blogs, e-mail newsletters, etc.)?

1. Last time we visited, you provided us an overview of your enrollment process…

[Note: Site visitor to provide a brief of what was shared during the prior site visit.]

Have any changes occurred in terms of:

1. How you assign client IDs for MAI-CoC clients?

   1. Can a client have more than one ID?

2. How you track clients to link applicable data across systems?

3. Your use of an EHR system, especially for MAI-CoC clients?

4. Are all enrollees completing SAIS GPRA and RHHT forms even if RHT/RHHT services are not received?

5. How you track clients in order to complete a discharge?

Next, we’d like to hear about any updates to your referral and linkage processes.

3. Please describe any changes to your referral and linkage methods and procedures related to your MAI-CoC services that may have occurred since our last visit. (Please refer to Appendix D - MAI-CoC Services.)

   1. Has your definition of a referral changed? If yes, how have they changed and what prompted these changes?

   2. Has your referral process changed? If yes, how have they changed and what prompted these changes?

Probes:

• Are referrals made by your staff for your MAI-CoC clients to receive services?

• Are referrals from other providers received by your MAI-CoC project?

3. Has your definition and process for a “linkage” changed?

4. During our prior visit, you mentioned the following information concerning the referral and linkage methods and procedures used among providers who are internal or within your organization?

[Note: Site visitor to provide a brief of what was shared by the grantee during the prior visit.]

Have there been any changes to these methods and procedures?

Probes:

• Initiation of referral

• Confirmation of client connection (or linkage) to referred service provider

• Method and type of client record sharing (e.g., paper, medical record sharing, other electronic method). If using a medical record system – what type?

5. During our prior visit, you shared the following information with us concerning the referral and linkage methods and procedures used among providers external or outside of your organization?

[Note: Site visitor to provide a brief of what was shared by the grantee during the prior visit.]

Have there been any changes to any of the following methods and procedures?

Probes:

• Initiation of referral

• Confirmation of client connection (or linkage) to referred service provider

• Method and type of client record sharing (e.g., paper, medical record sharing, other electronic method). If using a medical record system – what type?

Next, we’d like to hear about any updates concerning your partnerships with external organizations.

4. Have any updates occurred with the service partnerships mentioned during our prior visit? (Please refer to Appendix D.)

   1. Have there been any changes with any community organizations or off-site agency components your organization partners with to provide services to clients (e.g., primary care, SUD, mental health services, housing/public assistance, other)?

   2. Have there been any changes in the frequency of how often you meet with your partners?

   3. Have there been any changes to the specific services your service partners provide to MAI-CoC clients? (Please refer to Appendix D.)

3. Service/Care Coordination & Integration

This section of the guide follows-up on our understanding of the coordination of care between your behavioral health and primary care providers, as well as integration of services offered or coordinated by your MAI-CoC project. The following questions will help us continue developing our understanding of how your organization coordinates your care approach and integrates care at the organizational level.

1. During our prior visit, you provided us the following information on the location of your behavioral health and primary care providers treating your MAI-CoC clients.

[Note: Site visitor to provide a brief of what was shared by the grantee during the prior visit.]

What has changed in terms of the following:

1. Facilities and practice spaces?

2. Mechanisms for ensuring the client sees all providers that are part of their continuum of care?

1. [If the grantee reported the sharing of client information between behavioral health and primary care providers:] Have any changes occurred in the mechanisms your organization uses for sharing client records between behavioral health and primary care providers?

   1. If yes, please describe the changes that have occurred in how records are shared with both internal providers and external providers.

   2. [If the grantee reported using an EHR during the prior visit:] Do you still share access to a common electronic health records (EHR) system?

2. During our prior visit, you shared the following information concerning how clients are referred, tracked, and/or “shared” between behavioral health and primary care providers? What has changed since our last site visit?

[Note: Site visitor should provide a brief of information shared during the prior visit.]

4. Since our prior visit, what has changed in how verbal, written and electronic communication occurs between behavioral health and primary care providers serving your MAI-CoC clients? Please describe.

[Note: Site visitor should provide a brief of information shared during the prior visit and ask the sub-questions below as needed.]

1. Have there been any changes with how meetings or verbal communications are conducted between behavioral health and primary care providers serving your MAI-CoC clients? Have there been any changes in terms of:

• The general purpose of these meetings?

• The information exchanged?

• The outcomes of these meetings?

• Who is involved?

• The typical duration of these meetings?

4.1.1 Have there been any changes to the frequency of these meetings or verbal communications? If so, how frequently are these meetings currently being held?

• Less than once per month

• About once per month

• Once per month or more often

• Other: _____________

1. Have there been any changes to other channels of communications/contacts made between behavioral health and primary care providers serving your MAI-CoC clients? If so, please provide details on these changes in terms of:

• The mode (e.g., telephone, email, etc)?

• The general purpose?

• The information exchanged?

• The outcomes of these communications?

• Who is involved?

• The typical duration?

1. Have there been any changes to how often these communications occur?

• Less than once per month

• About once per month

• Once per month or more often

• Other: _____________

2. If verbal and/or written communication still occurs, have there been changes to the nature of the discussion since our last site visit (i.e., what information is usually exchanged)?

 Diagnoses confirmation

 Treatment planning

 Ongoing regular coordination of care

 Other: _________________

5. During our last visit, the following was shared concerning how care is coordinated and information exchanged with external service providers/partners to ensure the fidelity of care for clients engaged in services.

[Note: Site visitor should provide a brief of information shared during the prior visit.]

What changes have occurred in terms of:

• Shared EHR system?

• Meetings to discuss shared clients? Has the frequency of these meetings changed?

• What other ways is care coordinated with external providers?

1. Have there been any changes in terms of:

• The general purpose of these meetings?

• The information exchanged?

• The outcomes of these meetings?

• Who is involved?

• The typical duration of these meetings?

6. Please describe any changes since the prior visit to the defined roles within your organized care teams involving both behavioral health and primary care providers. If changes have occurred, what prompted those changes?

   1. What changes have occurred regarding the facilitators and barriers reported in our prior visit?

   2. What are the barriers to further integration?

4. Funding for Integrated Services

Since the last site visit, we want to hear about changes to the sources of funding your organization receives for integrated services. (Please refer to Appendix E.)

[Note: Site visitor to provide a brief of what was shared by the grantee during the prior visit.]

1. What changes have occurred to the funding sources?

2. What funding sources have begun or ended since the last site visit?

3. Are there any funding sources that you are not currently using but are exploring, to support your service integration efforts? If yes, please describe.

5. Project successes and challenges

Finally, we ask that you reflect on your main project-related successes and challenges to date.

1. What have been the project successes to date? Please describe.

2. What have been the project challenges to date? Have you tried to address them? Please describe these challenges and related efforts to address them.

3. Is there anything else about the project that you would like to share with us?

4. Appendices

   1. Appendix A: Table 1 - Organization’s History of Providing Services for HIV, Hepatitis, Mental Health Conditions, and Substance Use Disorders

If no changes have been made to services for Hepatitis, HIV, mental health conditions and substance use since the previous site visit, please add an “X” to the line below:

There have been no changes to the provision of services listed in Appendix A/Table 1 since the last site visit.

If there have been changes to the services since the last site visit, please record the following changes:

• For services that have increased since the previous site visit, please enter “increased”

• For services that have decreased since the previous site visit, please enter “decreased”

• For services that have been newly added since the last site visit, please note the year when your organization started to provide them.

• For services that have ended since the last site visit, please note the year when your organization stopped providing them.

• If any other changes have occurred to these services, please enter notes about these changes in the table.

Services	Please enter changes to these services for HEPATITIS	Please enter changes to these services for HIV	Please enter changes to these services for MENTAL HEALTH CONDITIONS	Please enter changes to these services for SUBSTANCE USE DISORDERS
Hepatitis A Vaccination		--	--	--
Hepatitis B Vaccination		--	--	--
Prevention Information & Resources
Screening & Testing
Medical Care For HIV, include Antiretroviral Therapy (ART)
Referrals & Other Services

2. Appendix B: Table 2 – Staffing

Please complete and return Table 2: Staffing, before the site visit. Updates should reflect any changes that have occurred since the last site visit.

Staff Positions (Enter each position separately. If you have four clinicians working on the project you would have four “clinician” lines in this column))	Degree/ Licensure/ Certification	Changes in staffing (staffing additions and staff replacements)
Example: Clinician, 0.75 FTE	LICSW	Ms. Doe filled a staff vacancy that was left after Mr. Smith left the agency in Oct. ‘15

3. Appendix C: Table 3 – Staff Training & Development

Please complete and return Table 3: Staff Training & Development, before the site visit. Updates should reflect any changes that have occurred since the last site visit.

Please specify the number of unduplicated staff persons who received MAI-CoC grant-funded training to date: _________

Name of Training or Staff Development Activity	Date(s)	Duration (in number of hours)	Purpose of Training	Number and type of staff participating in training (e.g., 3 clinical staff, 2 administrative assistants)
Example: HIV and Alcohol Training	Mar. 19, 2015	4 hours	CME and basic education on HIV and alcohol for frontline staff	3 Case managers

4. Appendix D: Table 4 – MAI-CoC Services

This section focuses on the services funded by this specific SAMHSA grant. DO NOT include other services provided by your organization and/or your partners if the services were not provided with this SAMHSA grant funding. Please check all services that apply and enter details where requested. Please complete and return Table 4: MAI-CoC Services, before the site visit.

		Please check the services that your organization provides in-house with this SAMHSA grant funding:	Please check the services that your organization co-locates at another site with this SAMHSA grant funding:	Please check the services that your partner organization(s) provides at their own site with this SAMHSA grant funding:	Please check the services that your partner organization(s) co-locates at your site with this SAMHSA grant funding	Please check the services that your organization refers out to another organization:	Are services based on evidence-based practices wholly, partially, not at all, don’t know? If yes, please specify.
HIV SERVICES
Outreach
HIV Prevention Information & Resources
HIV Prevention Education
Pre-Exposure Prophylaxis (PrEP) Services
Post-Exposure Prophylaxis (PEP) Services
Other HIV Prevention (specify): _______________
Rapid HIV Testing & Pre/Post Counseling
Other HIV Testing Modality (specify): ______________
HIV Counseling
Primary Care for HIV- related Issues
Antiretroviral Therapy (ART)
HIV/AIDS Medication Prescriptions
Viral Load Tests
CD4 Cell Count Tests
Genotyping
Other HIV-related Services (specify): _______________
HEPATITIS SERVICES
Hepatitis A Vaccination
Hepatitis B Vaccination
Other Hepatitis Prevention (specify): _______________
Rapid Hepatitis Testing
Other Hepatitis Testing (specify): _______________
Hepatitis Medical Care
Referrals for Other Services
MEDICAL SERVICES
Medical Care for Non- HIV or non-Hepatitis needs
Medical Screenings
Other Medical Services (Specify) ____________
CASE MANAGEMENT & SUPPORT SERVICES
Education / Employment Services
Individual Services Coordination (including Case Management)
Referrals & Linkages to Needed Services
Food, and Other Ancillary Social Assistance Services
Care Coordination
Transportation Assistance
Family Services
Child Care
Language Services
Help Accessing Health Insurance Premium & Cost Sharing Assistance (e.g., ADAP, Ryan White Services, Medicaid, SSI, Medicare, etc.)
Help Finding Affordable Housing
Supportive Transitional Drug-free Housing Services
Other (specify): __________
MENTAL HEALTH SERVICES
Outreach
Screening (specify tool): ____
Assessment (specify tool): ____
Treatment/ Recovery Planning
Crisis Intervention
Individual Counseling
Group Counseling
Family/Marriage Counseling
Outpatient
Intensive Outpatient
Day Treatment
Support Groups (specify): ________________________
Assessment
Pharmacological Interventions
Neuropsychological Screening and Testing
Grief and Loss Counseling
Trauma Services, such as Trauma-Focused Cognitive Behavior Therapy (TF-CBT)
Trauma Informed Care
Mental Health Promotion/ Prevention of Mental Illness (specify):________________
Recovery Support
Continuing Care
Aftercare
Spiritual Support
Self-Help
Other (specify): _______________________
SUBSTANCE USE DISORDER SERVICES
Outreach
Substance Abuse Prevention Education (specify): ________________________
Screening, Brief Intervention and Referral to Treatment (SBIRT)
Substance Use Disorder Screening (specify tool): ____
Substance Use Disorder Assessment (specify tool): ____
Treatment/Recovery Planning
Individual Counseling
Group Counseling
Medication Assisted Treatment (e.g. Methadone, Suboxone/ Buprenorphine, Naltrexone, Vivitrol, Acomprosate)
Outpatient
Intensive Outpatient
Day Treatment
Withdrawal Management (detoxification)
Recovery Support
Self-Help
Continuing Care
Relapse Prevention
Spiritual Support
Aftercare
Other (specify): ________________________
PEER SUPPORT SERVICES
Peer Coaching or Mentoring
Housing Support
Alcohol and Drug-Free Social Activities
Information and Referral
Other Recovery Support Services (specify): _________
OTHER SERVICES NOT LISTED ABOVE
Other (specify): ________________________
Other (specify): ________________________
Other (specify): _______________________

5. Appendix E: Table 4 - Funding Sources

For the following table, share the percentage to which the listed funding sources are used to support integrating HIV, Hepatitis, substance use, and mental health (behavioral health) services. Updates should reflect any changes that have occurred since the last site visit. Please complete and return Table 4: Funding Sources Table, before the site visit.

Funding Source	Percentage
SAMHSA MAI-CoC
Other SAMHSA Funding
CDC
HRSA
Medicare
Medicaid
State
Local
Private Please specify source(s): ____________________
Other: ___________________________________
TOTAL	100%