Form 6 RCORP CABH DRAFT PIMS Measures FINAL 07092024

RCORP-Child and Adolescent Behavioral Health Measures

(Draft – Pending OMB Approval)

SERVICE AREA AND CONSORTIUM

#	Measure Instructions	Measure	Burden Estimate (# of hours – 0.00 format)
1	Identify the number and types of consortium members participating in the RCORP-Child and Adolescent Behavioral Health project	Hospital - Critical Access Hospital (CAH) Hospital - Small Rural (49 beds or less, non-CAH) or other (e.g., Sole Community, Rural Referral Center, etc.) Emergency medical services entity Federally Qualified Health Center (FQHC) HIV and HCV prevention, testing, or treatment organization First responder – Law enforcement/ EMT Criminal justice entity (e.g., Court system, Prison, Probation and parole) 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 - non-methadone) Substance abuse treatment provider – Other Recovery Community Organization (RCO) Maternal, Infant, and Early Childhood organization Pharmacy Faith-based organization Community Based Organization Single State Agency (SSA) State Office of Rural Health (SORH) Tribe/Tribal organization Maternal, Infant, and Early Childhood Home Visiting Program local implementation agency Research / Academic Organization School system Other agency or organization, Type 1- Specify: Other agency or organization, Type 2- Specify Other agency or organization, Type 3- Specify
2	Select the option that best describes your project’s service area	Single County Multiple Counties State Multiple States
3	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
4	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
5	For each of the following services, please report the following within the current reporting period: The total unduplicated number of service delivery sites within the consortium in the target rural service area The total unduplicated number of service delivery sites within the consortium in the target rural service area that were newly established with RCORP-CABH funds The total unduplicated number of service delivery sites within the consortium in the target rural service area that were expanded with RCORP-CABH funds If no service delivery site 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 Behavioral health crisis intervention services Suicide prevention services Other – specify
6	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
7	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
8	For each service listed, select whether it was newly established with or without RCORP- Child and Adolescent Behavioral Health funds, expanded with or without RCORP- Child and Adolescent Behavioral Health funds, remained the same, or did not exist in the current reporting period (dropdown).	Prevention service (any except naloxone) Naloxone access 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 except naloxone) Behavioral health crisis intervention services Suicide prevention services Smoking cessation treatment Other – please specify
9	NOTE: Sustainability measures only reported in final reporting period of the grant (August 2027) Will the consortium as a unit and/or at least one key consortium activity be sustained after the RCORP grant ends?	Yes No
10	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
11	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 1115 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)

DIRECT SERVICES

#	Measure Instructions	Measure	Burden Estimate (# of hours – 0.00 format)
12	Please report the total number of individuals who have been screened for substance use disorder (SUD) in the current reporting period.	Total number of individuals screened for SUD
13	Please report the total number of individuals who screened positive for SUD, or at risk for overuse/misuse, in the current reporting period.	Total number of individuals who screened positive for SUD
14	Please report the total number of individuals with a positive screen and/or diagnosis of substance use disorder (SUD) who were referred to SUD treatment during the current reporting period.	Number of individuals with a positive screen and/or an SUD diagnosis who were referred to SUD treatment
15	Please report the total number of individuals who were screened for mental health disorders using an age-appropriate standardized tool	Total number of individuals who were screened for mental health disorder
16	Please report the total number of individuals who screened positive and/or were diagnosed with a mental health disorder in the current reporting period.	Total number of individuals with a positive screen and/or diagnosed with a mental health disorder
17	Please report the total number of individuals who screened positive and/or had a mental health disorder diagnosis who were referred to mental health treatment during the current reporting period.	Number of individuals who screened positive and/or had a mental health disorder diagnosis who were referred to mental health treatment
18	Please report the total number of individuals who screened positive and/or were diagnosed with a co-occurring substance use AND a mental health disorder during the current reporting period.	Total number of individuals who screened positive and/or were diagnosed with a co-occurring substance use AND a mental health disorder
19	Please report the total number of individuals who were tested for HIV/AIDS	Total number of individuals who were tested for HIV/AIDS
20	Please report the total number of individuals who were tested for HCV	Total number of individuals who were tested for HCV
21	Please report the total number of individuals who received recovery support services in the current reporting period.	Total number of individuals who received recovery support services
22	Please report the number of individuals who were referred to support services.	Total number of individuals who were referred to support services _____ Number of individuals referred to childcare services Number of individuals referred to employment services Number of individuals referred to recovery housing services Number of individuals referred to food/meal programs Number of individuals referred to prenatal/postpartum care services Number of individuals referred to housing services Number of individuals referred to legal services Number of individuals referred to transportation to treatment Number of individuals referred to trauma-informed services Number of individuals referred to academic support Other – specify
23	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

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	Burden Estimate (# of hours – 0.00 format)
24	Please report the number of individuals served, by ethnicity, during the current reporting period.	Hispanic or Latino Not Hispanic or Latino Unknown Total
25	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
26	Please report the number of individuals served, by age, during the current reporting period.	Under 5 5-12 13-17 18 and over Total
27	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
28	Please report the number of individuals served, by sex, during the current reporting period	Male Female Unknown Total
29	Please report the number of individuals served, by LGBTQI+, during the current reporting period	LGBTQI+ • Non-LGBTQI+ • Unknown Total

WORKFORCE

#	Measure Instructions	Measure	Burden Estimate (# of hours – 0.00 format)
30	Please report the total number of unduplicated providers within the consortium who provided SUD/OUD treatment services, 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-CABH grant funds) during the current reporting period.	Total number of unduplicated providers (i.e., individuals) within the consortium who provided SUD/OUD treatment services, behavioral health services, and/or recovery support services in the target rural service area in the current reporting period. Total number of providers newly hired with RCORP-Behavioral Health Care Support grant funds
31	Please report the total number of providers (i.e., individuals) within the consortium who have prescribed medications used to treat OUD and/or AUD during the current reporting period.	Total number of providers (i.e., individuals) who have prescribed medications used to treat OUD Total number of providers (i.e., individuals) who have prescribed medications used to treat AUD
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).	Number of Medical Providers Number of Non-Medical Counseling Staff Number of Peer Recovery Support Specialists Other – specify Total Number of Providers
33	Please report the total number of providers (i.e., individuals) within the consortium who have provided mental health treatment services 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).	Number of Medical Providers Number of Non-Medical Counseling Staff Number of Peer Recovery Support Specialists Other – specify Total Number of Providers
34	Please report the total number of providers (i.e., individuals) within the consortium who have provided recovery support services during the current reporting period in the target rural service area	Number of Medical Providers Number of Non-Medical Counseling Staff Number of Peer Recovery Support Specialists Other – specify Total Number of Providers
35	Report the total number of SUD and/or mental health disorder trainings conducted in the current reporting period as a result of RCORP funding in the target rural service area. For each topic area, please provide the number of trainings in each category.	Number of ACES trainings • Number of contingency management trainings • Number of behavioral therapy trainings • Number of mental health first aid trainings • Number of Naloxone trainings • Number of Opioid prescribing guidelines trainings • Number of school-based evidence-based practices trainings • Number of stigma reduction trainings • Number of trauma-informed evidence-based practices trainings • Other - specify

Public Burden Statement: The purpose of this activity is to collect information on Rural Communities Opioid Response Program grantees to provide HRSA with information on grant activities funded under this program. 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 information collection is 0906-XXXX and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit (42 U.S.C. 912). Data will remain private to the extent permitted by the law. Public reporting burden for this collection of information is estimated to average approximately 1 hour and 22 minutes 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or paperwork@hrsa.gov.  Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.