Form Financial Benchmar Financial Benchmar Financial Benchmarking Tool

Attachment 7

OMB No. 0930-03xx

Expiration Date: xx/xx/xx

CHILDREN’S MENTAL HEALTH INITIATIVE

NATIONAL EVALUATION

Financial benchmarking tool

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 0930-03xx.  Public reporting burden for this collection of information is estimated to average 40 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, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20857.

Attachment 7a

CMHI SOC Evaluation: Financial Benchmarking Tool

Overview

Evaluation Question. What are the uses of funds for children’s mental health and how do they change over the life of the grant in all or selected jurisdictions?

The special benchmarking study will analyze the uses of Mental Health Authority (MHA) and Medicaid funds for services in jurisdictions that are able and willing to provide these data. The purpose of the study is to examine variation in actual utilization and expenditures across these funding sources by state. Benchmarking information may be used to document reductions in the use of high cost services in order to illustrate the business case for children’s system of care (SOC).

This data will be collected from grantees who volunteer to participate in the data collection effort following the financial mapping interview.

Data Collection Instruments. The benchmarking study will collect data on access, utilization, and cost of children’s mental health services in states or counties that volunteer to participate. The National Evaluation Team (NET) has drafted two data requests, one for the Mental Health Authority and one for the Medicaid agency. The data request specifies information needed on enrollment (Medicaid only), number of children using services, units of service, and expenditures by service category. The NET has developed standard definitions for levels of care to promote consistency in reporting across states in order to accurately compare states’ rates of access, utilization, and cost for intensive services like inpatient, residential, and emergency care and community based services like traditional outpatient and rehabilitative, system of care, and supportive services.

The draft MHA and Medicaid Data Collection Tools are included. Both tools use the same service categories but some of the questions are customized to the Medicaid environment.

Analysis. The spending level analysis will include: (1) rates of spending per capita, (2) rates of utilization, (3) performance on specified indicators, and (4) the proportion of funds contributed by different sources. The NET will calculate penetration rates for traditional mental health services, including inpatient days, residential days, emergency room, and outpatient services; as well as penetration rates for services often included in systems of care, including high fidelity wraparound (service planning and intensive care coordination), psychosocial rehabilitation, and support services. For service categories using consistent units of service, the NET will calculate units of service used per 1000 members (for Medicaid) and per population in the specific geographical area (for Mental Health Authority services). The NET will compare 30-day readmission rates for inpatient care, an indicator related to service quality. The NET will also analyze relative spending for the different levels of care as well as rates of expenditure per 1000 members and per population overall and by level of care. The NET will make comparisons across states and counties and, for the first cohort, within states and counties over time. This analysis may show spending patterns that indicate shifts in costs as states move toward expanded provision of system of care and community based services. Such investments in community care may result in reduced use of inpatient and residential treatment services. The savings from reduced use of these expensive levels of care may contribute to or cover the costs of the additional community services. The NET will include states and counties in the same analysis, but will note the population in each geographical area. In past analyses, the NET has found that many states are smaller in population than some of the larger counties. Therefore, there is not a strong justification for analyzing them separately.

Attachment 7b

INFORMED CONSENT

Since this data will be collected from grantees who volunteer to participate, consent is implied. However, participants will be given a choice to stop participating in this data collection effort at any time during the process.

Attachment 7c

OMB No. xxxx-xxxx

Expiration Date: xx/xx/201x

CHILDREN’S MENTAL HEALTH INITIATIVE

NATIONAL SYSTEM OF CARE EXPANSION EVALUATION

Evaluation Benchmarking Data Collection Instrument

mental health Authority Version

INTRODUCTION

Thank you for volunteering to participate in this data collection effort. By gathering both Mental Health Authority (MHA) and Medicaid utilization and spending data, the National Evaluation Team (NET) is trying to describe the two primary funding streams for your children’s mental health system.

CONFIDENTIALITY/INFORMED CONSENT

By volunteering to participate, you are providing your consent to participate. However, you have the right to stop participating in this data collection effort at any time so please inform us if you want to stop participating in this data collection effort at any time. As indicated in our invitation, the goal of this special study is to provide comparisons between participating states and counties. For this reason, the summary statistics you provide on your state’s utilization and cost of children’s mental health services will be shared publicly. However, no data will be provided in a form that identifies any specific individual. In addition, we will not report any category where the number of clients reported is 9 or fewer to prevent the possibility of a specific individual to be identified.

INSTRUCTIONS

Thank you for participating in this project. This Data Collection Instrument is for your Mental Health Authority. The NET has submitted a similar instrument to your state’s Medicaid agency. By gathering both MHA and Medicaid utilization and spending data, the NET is trying to describe the two primary funding streams for your children’s mental health system. The NET recognizes that agencies other than the MHA and Medicaid may also expend significant funds on children’s mental health. However, those funding sources are outside the domain of this study.

Please provide your data in the spaces allotted on the attached sheets. The NET may call you to clarify any items whose interpretation is uncertain. When you have provided as much data as you can, please email the form to _________(email address of contact person). If you have any questions, or if you are unable to submit your data by __________(date), please call ______ (name of contact person) at _____ (phone number), or e-mail at ______. Thank you. If you have any questions, or if you are unable to submit your data by __________(date), please call _____ (name of contact person) at ____ (phone number), or e-mail at ______. Thank you.

Definitions: For your reference, The NET has provided definitions of the categories of service for which The NET are requesting data at the end of this instrument.

Mental Health Authority

Respondent
Job Title					Agency Name
County or State
Phone			Fax				E-mail

Please answer as many questions as possible for children’s mental health services funded by your Mental Health Authority. This Mental Health Authority Data Collection Instrument requests data on expenditures and utilization for services that are your agency’s fiscal responsibility, recognizing that this will probably include some expenditure that are matched by Medicaid. Utilization and cost data where the state match is the fiscal responsibility of the Medicaid Agency (from a budget perspective) have been requested directly from your Medicaid agency. You may not be able to provide data for all the questions. If you can only answer the most general question in a given section, but cannot respond to the more specific questions, please provide any responses that you are able to; your data will still be very helpful to us.

Please provide data on all children, age 0 through 17, and for all young adults, age 18 through 21. If you are reporting on a different age range, please enter the age range here. If the data are for a different age range for any individual indicator, please specify in your response.

Age Range Covered in your response
Youngest Age	Years	Oldest Age	Years

For each indicator, provide data for the most recent year available. Please indicate here the Start Date and End Date of the Year ____________ for which you are reporting most or all data If you are reporting data for a different year for any individual indicator, note that in the column to the right of the data.

Period Covered in your response
Start Date	Mo/Day/Year	End Date	Mo/Day/Year

For all questions that request the number of children served, please provide unduplicated counts. If you are aware of minor duplications, you may use the Comments section at the end of this Instrument to let us know what causes them. If any of the numbers you are providing are estimates, please use the same Comments area to let us know what technique(s) you used to develop them.

Total Number of Children Receiving Services				#			Year
1.	a.	How many children received any mental health service from the Mental Health Authority within the reporting year.
1.		Please provide the number of children in each of the following demographic categories:
	b.	Age	birth - 6
			7 - 12
			13 - 17
			18 - 21
	c.	Gender	Male
			Female
	d.	Race/Ethnicity	Non-Hispanic White
			Non-Hispanic Black or African American
			Hispanic or Latino
			Asian
			American Indian or Alaska Native
			Native Hawaiian or Other Pacific Islander
			Other (specify)
2.	a.	Does the number of children reported in item 1.a. include children who were eligible for Medicaid?		Yes		No
	b.	If yes, please specify the number of Medicaid eligible children who are included:
	c.	To be eligible for funding by your MHA, must a child meet Serious Emotional Disturbance (SED) criteria?		Yes		No
		Other criteria? (please describe in comments section)		Yes		No
	d.	Are you reporting here on any children whose mental health services are wholly funded by Medicaid?		Yes		No
		If yes, how many?

Financial			$	Year
3.	a.	Total expenditures by your Mental Health Authority for mental health services to the children reported in item 1.a.	$

INPATIENT CARE - psychiatric treatment in a specialized unit of a general hospital, a psychiatric hospital, or a state hospital.				#		Year
4.	a.	Number of children who experienced MHA-funded psychiatric inpatient treatment.
4.	b.	Total number of days spent in MHA-funded inpatient hospital settings by children reported in 4.a.
	c.	Total number of psychiatric inpatient admissions experienced by children reported in 4.a.
	d.	Total MHA expenditures for inpatient care for the children reported in 4.a.		$
	e.	Number of children reported in 4.a. who were readmitted to MHA-funded inpatient care within 30 days from discharge.
	f.	Please specify the type(s) of inpatient care included in the data provided above:
		State hospital (Y/N)		Yes		No
		Private psychiatric hospital (Y/N)		Yes		No
		General hospital with psychiatric unit (Y/N)		Yes		No
		Other (specify)
		Note: If possible, report Psychiatric Residential Treatment Facility services as non-hospital 24-hour care, even if your state considers this service to be an inpatient level of care. If it is not possible to separate PRTF care from hospital inpatient care, specify this in the ‘other’ category

OTHER (NON-HOSPITAL) 24-HOUR CARE - group homes, residential treatment centers, or therapeutic foster care			#	Year
5.	a.	Number of children who received care in 24-hour non-hospital-based mental health treatment. Note: If possible, report Psychiatric Residential Treatment Facility services as non-hospital 24-hour care, even if your state considers this service to be an inpatient level of care
	b.	Total number of days spent in these 24-hour non-hospital-based mental health treatment facilities by children reported in 5.a.
	c.	Total MHA expenditures for other (non-hospital) 24-Hour Care for children reported in 5.a.	$
	d.	Please specify what care is included in these numbers (i.e., types of facilities).

COMMUNITY BASED SERVICES: LESS THAN 24-HOUR CARE			#		Year
6.	Partial Hospitalization - part day acute hospital therapeutic services
	a.	Number of children who received MHA-funded partial hospitalization services.
	b.	Total number of days of partial hospitalization services delivered to children reported in 6.a. Indicate unit of measurement, if other than one day. _________
	c.	Total MHA expenditures for partial hospitalization services for children reported in 6.a.
7.	Emergency Department Services – psychiatric care in hospital emergency departments Note: report specialized psychiatric crisis services in item 13.
	a.	Number of children who received MHA-funded emergency department services for mental health diagnoses.
	b.	Number of MHA funded mental health emergency department visits by children reported in 7.a. Indicate unit of measurement, if other than visit. _________
	c.	Total MHA expenditures for mental health emergency department services for children reported in 7.a.	$
8.	Outpatient Services - provided by a clinic, hospital, or independent practitioner. Include psychiatry.
	a.	Total number of children who received MHA-funded outpatient care.
	b.	Total number of outpatient visits by children reported in 8.a. Indicate unit of measurement, if other than one visit. ________
	c.	Total MHA expenditures for outpatient care for children reported in 8.a.	$
9.	Primary Care Mental Health Services - mental health screening and treatment provided by primary care clinicians
	a.	Total number of children who received MHA funded outpatient mental health screening and/or treatment provided by primary care clinicians.
	b.	Total number of outpatient mental health visits that were delivered by primary care clinicians for children reported in 9.a. Indicate unit of measurement, if other than one visit. _________
	c.	Total MHA expenditures for primary care mental health outpatient care received by children reported in 9.a.
10.	Case Management Services - traditional case management, often provided by state or county staff. If case management is part of the system of care service planning process and is held to high fidelity wraparound principles, report in item 11. (See definitions for further information, or call DMA for clarification.)
	a.	Number of children who received MHA-funded Case Management services.
	b.	Number of units of Case Management service delivered to children reported in 10.a. Indicate unit of measurement. _________
	c.	Total MHA expenditures for Case Management services delivered to children reported in 10.a.		$

SYSTEM OF CARE, REHABILITATIVE AND SUPPORTIVE MENTAL HEALTH SERVICES					#	Year
11.	System of Care Planning Services - includes wraparound planning and intensive care coordination services
	a.		Number of children who received MHA-funded wraparound planning and/or intensive care coordination services for mental health.
	b.		Number of mental health wraparound planning services delivered to children reported in 11.a. Indicate unit of measurement. _________ (If multiple units of service are included in this category, omit this item.)
	c.		Total MHA expenditures for mental health wraparound planning services delivered to children reported in 11.a.
12.	Psycho-social Rehab Services - includes home-based and community-based services, peer/family services, day treatment, and other rehabilitative mental health services (see definitions for examples)
	a.		Number of children who received MHA-funded psychosocial rehabilitative mental health services
	b.		Number of psychosocial rehabilitative mental health services delivered to children reported in 12.a. Indicate unit of measurement. _________ (If multiple units of service are included in this category, omit this item.)
	c.		Total MHA expenditures for psychosocial rehabilitative mental health services for children reported in 12.a.		$
13.		Psychiatric Crisis Services - includes psychiatric crisis intervention, mobile crisis intervention, crisis stabilization beds, and crisis stabilization programs (Note: report emergency department care in item 7)
		a.		Number of children who received MHA- funded psychiatric crisis services for mental health.
		b.		Number of units of mental health psychiatric crisis services delivered to children reported in 13.a. Indicate unit of measurement. _________ (If multiple units of service are included in this category, omit this item.)
		c.		Total MHA expenditures for mental health psychiatric crisis services to children reported in 13.a.	$
14.		Other Services - all MHA-funded services that are not specified above, including any unique services the MHA offers that do not fit into standard categories
		a.		Please list the services included in this section:
		b.		Number of children who received other MHA-funded services.
		c.		Number of units of MHA funded Other Service encounters delivered to children reported in 14.b. Indicate unit of measurement. _________ (If multiple units of service are included in this category, omit this item.)
		d.		Total MHA expenditures for other MHA-funded services to children reported in 14.b.	$

Comments

Item #	Comment (add additional lines as needed)

Thank you again for participating in this project. Please email your completed form to:

___________________________________________

CMHI Evaluation: Service Category Definitions

CMHI Evaluation Service Categories	Definition	Examples
Psychiatric Inpatient	Psychiatric inpatient treatment in a specialized unit of a general hospital, a psychiatric hospital, a state hospital
Non-hospital 24 hour care	Group homes, residential treatment centers, therapeutic foster care	Residential treatment programs, therapeutic group homes, therapeutic foster care, therapeutic overnight camps or wilderness programs, supportive housing, independent living
Ambulatory Mental Health Services: Partial Hospitalization	Partial hospitalization, part-day acute therapeutic services	Partial hospitalization, hospital intensive outpatient services
Ambulatory Mental Health Services: Traditional Outpatient Mental Health Care	Traditional outpatient mental health care provided by a clinic or an independent practitioner, including psychiatry	Diagnostic and evaluation services; individual, family and group counseling; medication management; and professional consultations. May also include psychoeducation for youth and/or family and specialized forms of outpatient treatment such as CBT and trauma-informed.
Ambulatory Mental Health Services: Psychotropic Medication	Medications prescribed to treat psychiatric conditions	Note: medication prescribing and monitoring is part of the outpatient service category
Ambulatory Mental Health Services: Traditional Case Management	Traditional case management, often provided by state or county agency staff. Not held to high fidelity to wraparound principles	Case management, targeted case management
System of Care Services: Wraparound Planning	Care planning activities conducted with fidelity to wraparound principles, including comprehensive biopsychosocial assessment and family-directed, youth-guided service planning with a team of service providers and family identified team members. Assists older youth and family to plan and transition to adult services.	Wraparound planning, biopsychosocial assessment, service planning, targeted case management if provided with high fidelity to wraparound principles
System of Care Services: Intensive Care Coordination	Care coordination conducted with fidelity to wraparound principles. Assists youth and family to access and coordinate needed services, and supports them in doing so independently. May be provided by trained or certified peers.	Care coordination including by certified peers or family partners, intensive case management
System of Care Services: Flexible Funding	Funds provided for goods or services otherwise not covered by a state program which are necessary to assist youth and families reach service goals
System of Care Services: Outreach	Activities to identify youth and families who are potentially eligible for system of care services, provide education about the program, and engage them in services. May be conducted by a Family Organization and/or by others.
Psychosocial Rehab: Home-based and Community-Based Mental Health Services	Services designed to address mental health problems in a child’s home or community setting	Behavioral management services, behavior management consultation and training, behavioral/therapeutic aides, intensive home-based services, Multi-Systemic Therapy
Psychosocial Rehab: Peer/Family Support	Organized peer supports for youth and/or families other than formal case management. May be billed as psychosocial rehabilitation.
Psychosocial Rehab: Day treatment and other rehabilitative services	Activities that promote psychosocial rehabilitation and reintegration into the community.	Day treatment, therapeutic afterschool programs or child care, community support, activity therapies, vocational training, recreational activities
Psychiatric crisis services	Specialized team interventions, often provided on a mobile basis to stabilize children experiencing mental health crises. Available 24/7. May include short-term crisis stabilization residential care for individuals who do not need to be hospitalized	Crisis intervention teams, mobile crisis intervention, crisis stabilization beds, crisis stabilization programs
Support Services: Respite Care	Out of home or in-home care for a youth with SED that is not required by the youth’s condition, but is for the purpose of providing respite for the youth’s primary caretakers.	Stays in residential programs or in-home care and supervision
Support Services: Other	Any other supportive services designed to support youth with SED and their families	Supportive services provided by non-peers, informal supports, self-help groups, family preservation services, recreational activities
Support Services: Transportation
MH Services Provided by Medical Organizations: Emergency Department	Psychiatric Care in ED
MH Services Provided by Medical Organizations: Primary care mental health services	Mental health screening and treatment provided by primary care clinicians	Screening, and evaluation and management for a mental health diagnosis

Attachment 7d

OMB No. xxxx-xxxx

Expiration Date: xx/xx/201x

CHILDREN’S MENTAL HEALTH INITIATIVE

NATIONAL SYSTEM OF CARE EXPANSION EVALUATION

Evaluation Benchmarking Data Collection Instrument

Medicaid Agency Version

INTRODUCTION

Thank you for volunteering to participate in this data collection effort. By gathering both Mental Health Authority (MHA) and Medicaid utilization and spending data, The NET is trying to describe the two primary funding streams for your children’s mental health system.

CONFIDENTIALITY/INFORMED CONSENT

By volunteering to participate, you are providing your consent to participate. However, you have the right to stop participating in this data collection effort at any time so please inform us if you want to stop participating in this data collection effort at any time. As indicated in our invitation, the goal of this special study is to provide comparisons between participating states and counties. For this reason, the summary statistics you provide on your state’s utilization and cost of children’s mental health services will be shared publicly. However, no data will be provided in a form that identifies any specific individual. In addition, we will not report any category where the number of clients reported is 9 or fewer to prevent the possibility of a specific individual to be identified.

INSTRUCTIONS

Thank you for participating in this project. This Data collection instrument is for children’s Medicaid mental health services. The Mental Health Authority in your state has received a parallel Instrument. The National Evaluation Team (NET) is seeking all children’s mental health expenditures by your Medicaid agency (i.e., where Medicaid pays for the state match), both Federal and State contributions. Please be aware that the NET is separately requesting data from the Mental Health Authority for those Medicaid eligible services for which they provide the state match. By gathering both Medicaid and MHA utilization and spending data, the NET seeks to describe the two primary funding streams for your children’s mental health system. The NET recognize that agencies other than the MHA and Medicaid may expend significant funds on child mental health, but those sources of state funds are outside the domain of this study.

Please provide your data in the spaces allotted on the attached sheets. The NET may call you to clarify any items whose interpretation is uncertain. When you have provided as much data as you can, please email the form to _________(email address of contact person). If you have any questions, or if you are unable to submit your data by __________(date), please call ______ (name of contact person) at _____ (phone number), or e-mail at ______. Thank you. If you have any questions, or if you are unable to submit your data by __________(date), please call _____ (name of contact person) at ____ (phone number), or e-mail at ______. Thank you.

Definitions: For your reference, the NET has provided definitions of the categories of service for which the NET is requesting data at the end of this instrument.

Medicaid Agency

Respondent
Job Title					Agency Name
County or State
Phone			Fax				E-mail

Please answer as many questions as possible for children’s mental health services funded by Medicaid. The NET is separately requesting Mental Health Authority spending and utilization data. You may not be able to provide data for all the questions. If you can only answer the most general question in a given section, but cannot respond to the more specific questions, please provide any responses that you are able to; your data will still be very helpful to us.

Please provide data on all children, age 0 through 17, and for all young adults, age 18 through 21. If you are reporting on a different age range, please indicate that age range here. If the data are for a different age range for any individual indicator, please specify in your response.

Age Range Covered in your response
Youngest Age	Years	Oldest Age	Years

For each indicator, provide data for the most recent year available. Please indicate here the Start Date and End Date of the Year for which you are reporting most or all data. . If you are reporting data for a different year for any individual indicator, note that in the column to the right of the data.

Period Covered in your response
Start Date	Mo/Day/Year	End Date	Mo/Day/Year

For all questions that request the number of children served, please provide unduplicated counts. If you are aware of minor duplications, you may use the Comments section at the end of this Instrument to let us know what causes them. If any of the numbers you are providing are estimates, please use the same Comments area to let us know what technique(s) you used to develop them.

When providing expenditure figures, please include Federal, State and local contributions. Do not include spending for services that would be reported by your Mental Health Authority.

Enrollment/Eligibility			#		Year
I.	a.	How many children were enrolled in Medicaid (whether or not they received any mental health service) during the reporting year?
	b.	How is the Medicaid enrollment number provided above calculated? (please check one below)
		Average Monthly Enrollment
		Total number enrolled in Medicaid during the year
		Other (specify in comments section)
	c.	How many children were enrolled in the following eligibility categories?
		Disabled
		Foster Care
		Income Eligible – Medicaid
		Income Eligible – SCHIP
		All Other
II.	a.	Do you enroll Medicaid eligible children in Medicaid managed care (e.g., HMOs or MCOs)?	Yes		No
	b.	If yes, how many Medicaid children are enrolled in managed care? (Please specify total member months.)
	c.	Are any children’s mental health services included (carved into) the managed care benefit?	Yes		No
	d.	If yes, what children’s mental health services are included? (Please specify)
	e.	Are you providing any data on children’s mental health services provided under managed care arrangements?	Yes		No
	f.	If yes, what data elements include services for children in managed care?

Total Number of Children Receiving Services				#	Year
1.	a.	Total number of children who received any Medicaid mental health service within the reporting year.
	b.	Please provide the number of children who received any Medicaid mental health service in each of the following demographic categories:
		Age	Birth – 6
			7 – 12
			13 – 17
			18 – 21
		Gender	Male
			Female
	c.	Race/Ethnicity	Non-Hispanic White
			Non-Hispanic Black or African American
			Hispanic or Latino
			Asian
			American Indian or Alaska Native
			Native Hawaiian or Other Pacific Islander
			Other (specify)

Financial			$	Year
2.	a.	Total Medicaid expenditures for the mental health services provided to the children reported in question 1a.	$

INPATIENT CARE - Psychiatric inpatient treatment in a specialized unit of a general hospital, a psychiatric hospital, or a state hospital				#			Year
3.	a.	Number of children who experienced Medicaid-funded psychiatric hospitalizations.
	b.	Number of days of inpatient psychiatric care paid for the children reported in 3.a.
	c.	Number of inpatient psychiatric admissions of the children reported in 3.a.
	d.	Total Medicaid expenditures for inpatient psychiatric care for the children reported in item 3.a.		$
4.	a.	Number of inpatient psychiatric discharges of the children reported in 3.a.
	b.	Number of children reported in item 4.a. who were readmitted to inpatient psychiatric care at any facility within 30 days from discharge.
5.	a.	Please specify the type(s) of inpatient care included in the numbers above:
		State hospital (Y/N)		Yes		No
		Private psychiatric hospital (Y/N)		Yes		No
		General hospital with psychiatric unit (Y/N)		Yes		No
		Other (specify)
		Note: If possible, report Psychiatric Residential Treatment Facility services as non-hospital 24-hour care, even if your state considers this service to be an inpatient level of care. If it is not possible to separate PRTF care from hospital inpatient care, specify this in the ‘other’ category.

OTHER (NON-HOSPITAL) 24-HOUR CARE - group homes, psychiatric residential treatment centers, therapeutic foster care			#	Year
6.	a.	Number of children who received Medicaid-funded care in 24-hour non-hospital-based mental health treatment facilities. Note: If possible, report Psychiatric Residential Treatment Facility services in this category, even if your state considers this service to be an inpatient level of care.
	b.	Total number of Medicaid-funded days spent in these 24-hour non-hospital-based mental health treatment facilities by children reported in 6.a.
	c.	Total Medicaid expenditures for Other (non-hospital) 24-Hour Care for children reported in 6.a.	$
	d.	Please specify the types of residential programs/facilities reported in 6. a-c.

COMMUNITY BASED SERVICES: LESS THAN 24-HOUR CARE							#	Year
7.		Partial Hospitalization – part day acute hospital therapeutic services
		a.		Total number of children who received Medicaid funded partial hospitalization services.
		b.		Total days of Medicaid funded partial hospitalization services received by children reported in 7.a. Indicate unit of measurement, if other than one day. _________
		c.		Total Medicaid expenditures for partial hospitalization services received by children reported in 7.a.
8.		Emergency Department Services – psychiatric care in hospital emergency departments. Note: report specialized psychiatric crisis services in item 14.
		a.		Number of children who received Medicaid funded emergency department services for mental health.
		b.		Number of Medicaid funded mental health emergency department visits received by children reported in 8.a. Indicate unit of measurement, if other than visit. _________
		c.		Total Medicaid expenditures for mental health emergency department services for children reported in 8.a.		$
			Outpatient Mental Health Services: provided by a clinic, hospital, or independent practitioner. Include psychiatry.
			a.		Total number of children who received Medicaid funded outpatient care.
			b.		Total number of Medicaid paid outpatient visits received by children reported in 9.a. Indicate unit of measurement, if other than one visit. _________
			c.		Total Medicaid expenditures for outpatient care received by children reported in 9.a.	$
			Primary Care Mental Health Services – mental health screening and treatment provided by primary care clinicians
			a.		Total number of children who received Medicaid funded outpatient mental health screening provided by primary care clinicians.
			b.		Total number of children who received Medicaid paid outpatient visits with primary care clinicians to treat mental health diagnoses. Indicate unit of measurement, if other than one visit. _________
			c.		Total Medicaid primary care visits for mental health screening and/or treatment for children reported in 10a and 10b. Indicate unit of measurement, if other than one visit. _________
			d.		Total Medicaid expenditures for primary care mental health screening and outpatient care reported in 8.a. and 8.b.	$
			Case Management Services - traditional case management, such as that provided by state or county staff. If case management is part of the system of care service planning process and is held to high fidelity wraparound principles, report in item 12. (See definitions for further information, or call DMA for clarification.)			#		Year
			a.		Total number of children who received Medicaid-funded Case Management services.
			b.		Total number of units of Case Management service delivered to children reported in 11.a. Indicate unit of measurement. _________ (If multiple units of service are included in this category, omit this item.)
			c.		Total Medicaid expenditures for Case Management services delivered to children reported in 11.a.	$

SYSTEM OF CARE PLANNING, REHABILITATIVE AND SUPPORTIVE MENTAL HEALTH SERVICES			#	Year
	System of Care Planning Services - includes wraparound planning and intensive care coordination services
	a.	Number of children who received Medicaid-funded wraparound planning and intensive care coordination services for mental health.
	b.	Number of units of Medicaid funded mental health wraparound planning and intensive care coordination services delivered to children reported in 12.a. Indicate unit of measurement. _________ (If multiple units of service are included in this category, omit this item.)
	c.	Total Medicaid expenditures for mental health wraparound planning and intensive care coordination services for children reported in 12.a.	$
	Psychosocial Rehab Services - includes home-based and community-based services, peer/family services, day treatment, and other rehabilitative mental health services (see definitions for examples)
	a.	Specify the number of children who received Medicaid-funded psychosocial rehabilitative mental health services.
	b.	Number of units of Medicaid psychosocial rehabilitative mental health services delivered to children reported in 13.a. Indicate unit of measurement. _________ (If multiple units of service are included in this category, omit this item.)
	c.	Total Medicaid expenditures for psychosocial rehabilitative mental health services for children reported in 13.a.	$
	Psychiatric Crisis Services - includes psychiatric crisis intervention, mobile crisis intervention, crisis stabilization beds and crisis stabilization programs. (Note: report emergency department care in item 8.)
	a.	Number of children who received Medicaid funded psychiatric crisis services for mental health.
	b.	Number of units of Medicaid funded mental health psychiatric crisis services delivered to children reported in 14.a. Indicate unit of measurement. _________ (If multiple units of service are included in this category, omit this item.)
	c.	Total Medicaid expenditures for mental health psychiatric crisis services to children reported in 14.a.	$
	Other Medicaid funded services - all services that are not specified above, including any unique Medicaid services that do not fit into standard categories		#	Year
	a.	Please list the services included in this section:
	b.	Number of children who received other Medicaid-funded mental health services listed in 15.a.
	c.	Number of units of other Medicaid-funded service encounters delivered to children reported in 15.b. Indicate unit of measurement. _________ (If multiple units of service are included in this category, omit this item.)
	d.	Total Medicaid expenditures for other mental health services delivered to children reported in 15.b.	$

Comments

Item #	Comment (add additional lines as needed)

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CMHI Evaluation: Service Category Definitions

CMHI Evaluation Service Categories	Definition	Examples
Psychiatric Inpatient	Psychiatric inpatient treatment in a specialized unit of a general hospital, a psychiatric hospital, a state hospital
Non-hospital 24 hour care	Group homes, residential treatment centers, therapeutic foster care	Residential treatment programs, therapeutic group homes, therapeutic foster care, therapeutic overnight camps or wilderness programs, supportive housing, independent living)
Partial hospitalization	Part-day acute therapeutic services	Partial hospitalization, and hospital intensive outpatient services.
Emergency Department	Psychiatric Care in ED
Outpatient Mental Health Care	Traditional outpatient mental health care provided by a clinic or an independent practitioner, including psychiatry	Diagnostic and evaluation services, individual, family and group counseling, medication management, and professional consultations. May also include psychoeducation for youth and/or family, and specialized forms of outpatient treatment such as CBT, and trauma-informed.
Primary care mental health services	Mental health screening and treatment provided by primary care clinicians	Screening, and evaluation and management for a mental health diagnosis
Case Management (Traditional)	Traditional case management, often provided by state or county agency staff. Not held to high fidelity to wrapround principles	Case management, targeted case management
System of Care Services
System of Care Services: Wraparound Planning	Care planning activities conducted with fidelity to wraparound principles, including comprehensive biopsychosocial assessment and family directed youth guided service planning with a team of service providers and family identified team members. Assists older youth and family to plan and transition to adult services.	Wraparound planning, biopsychosocial assessment, service planning, targeted case management if provided with high fidelity to wraparound principles
System of Care Services: Intensive Care Coordination	Care coordination conducted with fidelity to wraparound principles. Assists youth and family to access and coordinate needed services, and supports them in doing so independently. May be provided by trained or certified peers.	Care coordination including by certified peers or family partners, intensive case management
Psycho-social rehabilitation
Psycho-social Rehab: Home-based and Community-Based Mental Health Services	Services designed to address mental health problems in a child’s home or community setting	Behavioral management services, behavior management consultation/ and training, behavioral/ therapeutic aides, intensive home-based services, and Multi-Systemic Therapy
Psycho-social Rehab: Peer/Family Support	Organized peer supports for youth and/or families other than formal case management. May be billed as psychosocial rehabilitation
Psycho-social Rehab: Day treatment and other rehabilitative services	Activities that promote psychosocial rehabilitation and reintegration into the community.	Day treatment, therapeutic afterschool programs or child care, community support, activity therapies, vocational training, and recreational activities.
Psychiatric crisis services	Specialized team interventions, often provided on a mobile basis to stabilize children experiencing mental health crises. Available 24/7. May include Short term crisis stabilization residential care for individuals who do not need to be hospitalized	Crisis intervention teams, mobile crisis intervention, crisis stabilization beds, crisis stabilization programs
Other Mental Health Services
Respite Care	Out of home or in-home care for a youth with SED which is not required by the youth’s condition, but is for the purpose of providing respite for the youth’s primary caretakers.	Stays in residential programs or in-home care and supervision
Other Support Services:	Any other supportive services designed to support youth with SED and their families	Supportive services provided by non-peers, Informal supports, self-help groups, family preservation services, or recreational activities
Flexible Funding	Funds provided for goods or services otherwise not covered by a state program which are necessary to assist youth and families reach service goals

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Attachment 7: Financial Benchmarking