Form 7 RCORP NAS DRAFT PIMS Measures FINAL 07092024

RCORP-Neonatal Abstinence Syndrome (FY23) (Draft-Pending OMB Approval)

SERVICE AREA AND CONSORTIUM

1	Identify the number and types of consortium members participating in the RCORP-Neonatal Abstinence Syndrome 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 State
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-NAS funds The total unduplicated number of service delivery sites within the consortium in the target rural service area that were expanded with RCORP-NAS 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- NAS funds, expanded with or without RCORP-NAS 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) Behavioral health crisis intervention services Suicide prevention services Other – please specify
9	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
10	NOTE: Sustainability measures only reported in final reporting period of the grant Will the consortium as a unit and/or at least one key consortium activity be sustained after the RCORP grant ends?	Yes No
11	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
12	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)

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. Each demographic sub-section should total to the same amount. In addition, the total number for each demographic sub-section should equal the total number of individuals who have received direct services reported within the current reporting period. 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
13	Please report the number of individuals served, by ethnicity, during the current reporting period.	Hispanic or Latino Not Hispanic or Latino Unknown Total
14	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
15	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
16	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
17	Please report the number of individuals served, by sex, during the current reporting period.	Male Female Unknown Total
18	Please report the number of individuals served, by LGBTQI+, during the current reporting period.	LGBTQI+ Non-LGBTQI+ Unknown Total

DIRECT SERVICES

#	Measure Instructions	Measure
19	Please report the total number of infants who have been screened for Neonatal Abstinence Syndrome (NAS)	Number of infants screened for NAS
20	Please report the total number of infants who have been screened positive for Neonatal Abstinence Syndrome (NAS)	Number of infants screened positive for NAS
21	Of those that screened positive, please report the total number of infants who were referred to NAS specific services	Number of infants who were referred to NAS specific services
22	Of the infants screened positive for SUD, please report the total number of infants who have been diagnosed for substance use disorder (SUD) during the current reporting period.	Number of infants diagnosed for SUD
23	Please report the total number of infants born with Neonatal Abstinence Syndrome (NAS)/Neonatal Opioid Withdrawal (NOW) Syndrome-related symptoms in the project service area.	Number of NAS/NOW-related births in the project’s service area.
24	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)
25	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)

26	Please report the total number of patients diagnosed with SUD who were also screened for clinical depression using an age appropriate standardized tool.	Number of patients with an SUD diagnosis who were screened for depression
27	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
28	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
29	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
30	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
31	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
32	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
33	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.	Percentage of MAT services currently covered through reimbursement or other non-grant funding sources

Denominator: total costs associated with MAT services.

WORKFORCE

#	Measure Instructions	Measure
34	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-NAS 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-NAS grant funds
35	Please report the total number of unduplicated providers within the consortium who screened, diagnosed, and/or treated infants with NAS during 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-NAS grant funds) during the current reporting period.	Total number of unduplicated providers # of providers who screened infants for NAS # of providers who diagnosed infants for NAS # of providers who treated infants for NAS Total number of providers newly hired with RCORP-NAS grant funds
36	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)
37	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
38	Please report the total number of providers, paraprofessional staff, and community members (non-providers) within the consortium who participated	Mental health first aid trainings Naloxone trainings Opioid prescribing guidelines trainings

in direct substance use disorder education and training activities as a result of RCORP funding.

Stigma reduction trainings Contingency Management Trauma – specific evidence based practices 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.