Form 1 Rural Communities Opioid Response Program-Implementation

RCORP Measures

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 0906-0044 and is valid until 03/31/2025. Public reporting burden for this collection of information is estimated to average 1.24 hours per response, including the time for reviewing instructions, searching existing data sources, 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 HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857.

Green = new measure

Yellow = revised measure

SERVICE AREA AND CONSORTIUM

#	Measure Instructions	Measure
1	Identify the number and types of medical organizations and agencies in your consortium.	Hospital - Critical Access Hospital (CAH) Hospital - Small Rural (49 beds or less, non-CAH) Hospital - Other (e.g., Sole Community, Rural Referral Center, etc.) Emergency medical services entity Federally Qualified Health Center (FQHC) FQHC Look-alike Local or state health department Mental and behavioral health organization, practice, or provider Primary care practice or provider Rural Health Clinic Ryan White HIV/AIDS clinic Substance abuse treatment provider – Methadone clinic Substance abuse treatment provider – Opioid treatment program (OTP) Substance abuse treatment provider – Other Other medical agency or organization, Type 1- Specify: Other medical agency or organization, Type 2- Specify Other medical agency or organization, Type 3- Specify
2	Identify the number and types of social service and non-medical organizations and agencies in the consortium	Community-based organization Cooperative extension system office Criminal justice entity – Law enforcement Criminal justice entity – Court system Criminal justice entity - Prison Criminal justice entity – Probation and parole Faith-based organization Healthy Start site HIV and HCV prevention organization Maternal, Infant, and Early Childhood Home Visiting Program local implementation agency Poison Control Center Primary Care Association (PCA) Primary Care Organization (PCO) Recovery Community Organization (RCO) Research / Academic Organization School system Single State Agency (SSA) State Office of Rural Health (SORH) Tribe/Tribal organization Other social service and non-medical agency or organization, Type 1- Specify Other social service and non-medical agency or organization, Type 2- Specify Other social service and non-medical agency or organization, Type 3- specify
3	Select the option that best describes your project’s service area	Single County Multiple Counties State Multiple States National
4	Please report the total number of people that live in the project’s rural service area.	Total population in the project’s rural service area
5	Please report the total number of consortium meetings conducted in the current reporting period in which the majority (>75%) of members participated.	Total number of consortium meetings conducted in the current reporting period
6	Please report the total unduplicated number of service delivery sites within the consortium in the target rural service area offering at least one prevention, treatment and/or recovery service within the current reporting period.	Total number of unduplicated service delivery sites offering at least one prevention, treatment and/or recovery service
7	For each of the following services, please report the total number of service delivery sites within the consortium in the target rural service area that offered that service within the current reporting period. If no service delivery sites offered the service, please input 0.	Prevention services (not including naloxone) Screening and/or assessment services Medication-Assisted Treatment (with or without psychosocial) SUD/OUD treatment other than MAT Infectious disease testing (i.e., HIV or HCV) Recovery support services Mental health treatment Other - specify
8	Report the total unduplicated number of service delivery sites within the consortium in the target rural service area offering at least one harm reduction service within the current reporting period.	Total number of unduplicated service delivery sites offering at least one harm reduction service
9	For each of the following harm reduction services, please report the total number of service delivery sites within the consortium in the target rural service area that offered that service within the current reporting period. If no service delivery sites offered the service, please input 0.	Naloxone access Syringe services Fentanyl test strips Safe smoking kits Sex worker services Other - specify
10	For each service listed, select whether it was newly established with or without RCORP-Implementation Support funds, expanded with or without RCORP-Implementation funds, remained the same, or did not exist in the current reporting period (dropdown).	Prevention service (any except naloxone) Screening and/or assessment service MAT (with or without psychosocial therapy) SUD/OUD treatment other than MAT Mental health treatment Infectious disease testing (i.e., HIV or HCV) Recovery support services (any) Harm reduction services (any) Other – please specify
11	NOTE: Sustainability measures only reported in final reporting period of the grant (Sept. 2024) Will the consortium as a unit and/or at least one key consortium activity be sustained after the RCORP grant ends?	Yes No
12	If you selected yes in previous sub-section, what will sustain? (check all that apply)	Consortium as a unit At least one key consortium activity
13	If you selected “At least one key consortium activity” in the previous sub-section how will the activity or activities be sustained? (check all that apply)	Absorption of services or other means of in-kind support Reimbursement by third party payers RCORP grant funding HRSA grant funding (not including RCORP grants) Other grant funding (not including HRSA and RCORP grant funding) Fees Applying for an 11-15 waiver Changing Medicaid formularies Increasing insurance reimbursement (both costs covered and new insurance payers) Becoming a line item in a state or local budget Creating certification/licensing programs to facilitate workforce payments (e.g., peer recovery specialists) Other: please describe (text box)

DEMOGRAPHICS

These tables collect demographic information for all individuals who have received direct services for SUD/OUD use disorder, within the current reporting period in the project’s rural service area. The total number of each sub-section should equal the total number of individuals who have received direct services within the current reporting period. Each sub-section should total to the same amount. Please do not leave any sections blank or use N/A (not applicable) since the measures are applicable to all RCORP grantees providing direct services. If the number for a particular category is zero (0), please put zero in the appropriate section (e.g., if the total number that is Hispanic or Latino is zero (0), enter zero in that section). If data are incomplete or have other limitations, please enter the data you have, indicate the data have limitations, and explain those limitations in the comments box below.

#	Measure Instructions	Measure
14	Please report the number of individuals served, by ethnicity, during the current reporting period.	Hispanic or Latino Not Hispanic or Latino Unknown Total
15	Please report the number of individuals served, by race, during the current reporting period.	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White More than one race Unknown Total
16	Please report the number of individuals served, by age, during the current reporting period.	0-12 13-17 18-24 25-34 35-44 45-54 55-64 65 and over Total
17	Please report the number of individuals served, by insurance status, during the current reporting period.	Self-pay None/Uninsured Dual Eligible (covered by both Medicaid and Medicare) Medicaid/CHIP only Medicare only Medicare plus supplemental TriCARE Other third party (e.g., privately insured) Unknown Total

DIRECT SERVICES

#	Measure Instructions	Measure
18	Please report the total number of individuals who have been screened for substance use disorder (SUD) in the current reporting period.	Number of individuals screened for SUD
19	Please report the total number of individuals who screened positive for SUD, or at risk for overuse/misuse, in the current reporting period. If known, please specify the number of individuals who screened positive for specific substances. While individuals could screen positive for multiple substances, each subcategory should not exceed the total.	Total number of individuals who screened positive for alcohol or substance use Number of individuals who screened positive for alcohol overuse/misuse (or at risk for this) Number of individuals who screened positive for opioid overuse/misuse (or at risk of this) Number of individuals who screened positive for psychostimulant overuse/misuse (or at risk of this) Number of individuals who screened positive for other substance overuse/misuse (or at risk of this) (specify)
20	Please report the total number of individuals diagnosed with substance use disorder (SUD) in the current reporting period. If known, please specify the number of individuals who were diagnosed for specific SUDs. While individuals could be diagnosed with multiple SUDs, each subcategory should not exceed the total.	Total number of individuals diagnosed with an SUD Number of individuals diagnosed with alcohol use disorder Number of individuals diagnosed with opioid use disorder Number of individuals diagnosed with psychostimulant use disorder Number of individuals diagnosed with other SUD (specify)
21	Please report the total number of patients diagnosed with SUD who were also screened for clinical depression using an age appropriate standardized tool	Patients with an SUD diagnosis who were screened for depression
22	Please report the total number of patients diagnosed with SUD who were tested for HIV/AIDS	Patients with an SUD diagnosis who were tested for HIV/AIDS
23	Please report the total number of patients diagnosed with SUD who were tested for HCV	Patients with an SUD diagnosis who were tested for HCV
24	Please report the total number of patients diagnosed with SUD who were referred to SUD treatment	Patients with an SUD diagnosis who were referred to treatment
25	Please report the total number of individuals who received recovery support services in the current reporting period.	Number of individuals who received recovery support services
26	Please report the number of patients diagnosed with SUD who were referred to support services.	Number of patients with a diagnosis of SUD who were referred to support services: Childcare Employment services Prenatal/postpartum care services Recovery housing Transportation to treatment Other - specify
27	Please report the total number of patients who have received MAT only or MAT with psychosocial therapy	Number of patients who received MAT AND psychosocial therapy Number of patients who received MAT ONLY
28	Please report the total number of patients who have received MAT (including medication AND psychosocial therapy) for a period of three months or more without interruption	Number of patients who have received MAT for three months or more without interruption

WORKFORCE

#	Measure Instructions	Measure
29	Please report the total number of unduplicated providers within the consortium who provided SUD/OUD treatment services, mental/behavioral health services, and/or recovery support services in the target rural service area in the current reporting period. Of the total number of providers, please also report how many were newly hired with grant funds (e.g., their salary was paid for in full or in part with RCORP-Implementation grant funds) during the current reporting period.	Total number of unduplicated providers (i.e., individuals) within the consortium who provided SUD/OUD treatment services, mental/behavioral health services, and/or recovery support services in the target rural service area Total number of providers newly hired with RCORP-Implementation grant funds
30	Please report the total number of providers (i.e., individuals) within the consortium who have a DATA waiver to prescribe buprenorphine-containing products for medication-assisted treatment (MAT) within the target rural service area	Total number of providers (i.e., individuals) who have a DATA waiver (note: no FTE required)
31	Please report the total number of providers (i.e. individuals) within the consortium who have prescribed medications used to treat OUD during the current reporting period.	Total number of providers (i.e., individuals) who have prescribed medications used to treat OUD (note: no FTE required)
32	Please report the total number of providers (i.e., individuals) within the consortium who have provided SUD/OUD treatment services, including MAT, during the current reporting period in the target rural service area. Of those providers, please specify how many were medical providers, non-medical counseling staff, peer recovery support specialists, or other (specify).	Total Number of Providers Number of Medical Providers Number of Non-Medical Counseling Staff Number of Peer Recovery Support Specialists Other – specify
33	Please report the total number of providers, paraprofessional staff, and community members (non-providers) who participated in direct substance use disorder education and training activities as a result of RCORP funding.	Mental health first aid trainings Naloxone trainings Opioid prescribing guidelines trainings Stigma reduction trainings Other - specify

OTHER

#	Measure Instructions	Measure
34	Among the drug types listed, please rank in order the top three drug types that currently pose the greatest concern to the health and well-being of your service area	Alcohol Methamphetamine Fentanyl and Fentanyl Analogs (i.e. synthetic opioids) Heroin Prescription opioids Marijuana Benzodiazepines
35	Among the drug types listed, please rank in order the top three drug types that your service area has the least capacity to treat.	Alcohol Methamphetamine Fentanyl and Fentanyl Analogs (i.e. synthetic opioids) Heroin Prescription opioids Marijuana Benzodiazepines
36	Among the problem areas listed, please rank in order the top three problem areas that currently pose the greatest concern to the health and well-being of your HRSA-designated rural service area.	Drug-related bacterial infections (e.g., infectious endocarditis) Drug-related HIV infection Drug-related viral Hepatitis (A, B, C) Fatal and non-fatal overdoses (all drugs) Neonatal Abstinence Syndrome Opioid poisonings among children aged 1-4 years
37	Among the problem areas listed, please rank in order the top three problem areas that your HRSA-designated rural service area has the least capacity to address.	Drug-related bacterial infections (e.g., infectious endocarditis) Drug-related HIV infection Drug-related viral Hepatitis (A, B, C) Fatal and non-fatal overdoses (all drugs) Neonatal Abstinence Syndrome Opioid poisonings among children aged 1-4 years
38	Among the populations listed, please rank in order the top three population that are currently most at risk for a substance use disorder within your HRSA-designated rural service area.	People of color People of Hispanic or Latino ethnicity People whose native language is not English Adolescents Emerging adults Women People who identify as LGBTQI+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex) People who are unhoused or homeless People with criminal justice involvement People with low income/socioeconomic status Pregnant or post-partum women People with disabilities Veterans Tribal populations Other (specify)
39	Among the populations listed, please rank in order the top five populations at risk for an SUD that your HRSA-designated rural service area has the least capacity to address.	People of color People of Hispanic or Latino ethnicity People whose native language is not English Adolescents Emerging adults Women People who identify as LGBTQI+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex) People who are unhoused or homeless People with criminal justice involvement People with low income/socioeconomic status Pregnant or post-partum women People with disabilities Veterans Tribal populations Other (specify)
40	Please rank the top five populations that are most vulnerable to health disparities among people with and without SUD within your service area.	People of color People of Hispanic or Latino ethnicity People whose native language is not English Adolescents Emerging adults Women People who identify as LGBTQI+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex) People who are unhoused or homeless People with criminal justice involvement People with low income/socioeconomic status Pregnant or post-partum women People with disabilities Veterans Tribal populations Other (specify)
41	Please rank the top five populations that are vulnerable to health disparities among people with and without SUD in your service area that you have had challenges in engaging or providing services.	People of color People of Hispanic or Latino ethnicity People whose native language is not English Adolescents Emerging adults Women People who identify as LGBTQI+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex) People who are unhoused or homeless People with criminal justice involvement People with low income/socioeconomic status Pregnant or post-partum women People with disabilities Veterans Tribal populations Other (specify)
42	Among the social determinants of health listed, please rank in order the top five areas that are pose the greatest threat to the health and well-being of your HRSA-designated rural service area.	Child maltreatment Community violence Criminality Developmental Disabilities Domestic violence Juvenile delinquency Homelessness Poverty Suicide Unemployment Other (specify)
43	Among the social determinants of health listed, please rank in order the top five areas that your HRSA-designated rural service area has the least capacity to address.	Child maltreatment Community violence Criminality Developmental Disabilities Domestic violence Juvenile delinquency Homelessness Poverty Suicide Unemployment Other (specify)
44	Please rate the degree to which the following pose challenges to your service system and those you are actively trying to address.	Care coordination between mental health, substance use, and other healthcare providers Infrastructure for data sharing Partnerships between local, state and federal funders and licensing bodies Affordability Third party reimbursement Stigma - Among community members Stigma - Among service providers Service capacity - Mental health services Service capacity – recovery services Service capacity - SUD services Service capacity - Services treating co-occurring mental health and SUDs Workforce capacity - Mental health providers Workforce capacity - SUD providers Workforce capacity - Providers treating co-occurring mental health and substance use disorders Wrap-around services for individuals with co-occurring mental health and substance use disorders Other (please specify) None of the above
45	Is your consortium currently utilizing telehealth/telemedicine as part of your RCORP project?	Yes No
46	If yes, please provide a 2-3 sentence overview of how your consortium is leveraging telehealth/telemedicine to implement your project
47	If applicable, select the types of services your consortium is currently using telehealth/telemedicine for (select all that apply)	Case management Group therapy Individual counseling Intake and assessments Prescribing MAT Recovery services, including meetings with peer support workers Other (specify)
48	If applicable, select the telehealth platform types your consortium is currently using (select all that apply)	Audio-only telehealth Mobile/app-based health services (e.g., My Strength, text messages, text alerts) Store-and-forward communication (e.g., Health Lens, online patient portal) Video conferencing (e.g., Zoom, Doxy.me) Other (specify)
49	Select the challenges your consortium has experienced in trying to implement telehealth (select all that apply)	Billing and reimbursement challenges Concerns about sustainability of reimbursement Discomfort with technology Expensive equipment Internet/cell phone minute costs for staff Lack of cellular connections Lack of reliable broadband access Privacy concerns/HIPAA compliance concerns Staff discomfort with telehealth services (e.g., too impersonal) Other (specify) None of the above
50	Select the challenges patients/clients served by your consortium have experienced with telehealth (select all that apply)	Discomfort with technology Discomfort with telehealth services (e.g., too impersonal) Expensive equipment needed to access telehealth Internet/cell phone minute costs Lack of internet or cellular connections Privacy concerns Other (specify) None of the above
51	Please report the percentage of MAT service costs (including medication, psychosocial therapy, and wrap-around services) covered through reimbursement (e.g. by Medicaid, Medicare, private insurance) or other non-grant funding sources during the past 6-months: • Numerator: all costs associated with MAT services that were reimbursed or paid for by other non-grant funding sources. • Denominator: total costs associated with MAT services.	Percentage of MAT services currently covered through reimbursement or other non-grant funding sources

OMB No. 0906-0044

Expires: 03/31/2025