To: Area DirectorsError! Bookmark not Web viewpr. o. grammatic. data, and . ... The Managing Entity...

Program Guidance for Contract Deliverables Managing Entity NAMEExhibit A, Appendix 1

Reporting Template for Substance Abuse and Mental Health (SAMH)

Integrated Block Grant

Florida Department of Children and FamiliesSubstance Abuse and Mental Health Services

Instructions

The Department of Children and Families’ Substance Abuse and Mental Health office requires the following report for statewide Block Grant reporting to the Substance Abuse and Mental Health Services Administration (SAMHSA).

Please submit a completed report to your Regional Contract Manager.

2Prepared By: SAMH Program Office

Last Update: April 11, 2014

Insert Name of ME

Managing Entity (ME)

Semi-Annual Substance Abuse Prevention and Treatment

Block Grant (SAPTBG) and Community Mental Health Block Grant (CMHBG) Compliance Report

Year-End Report Report Period: July 1, 2013 through June 30, 2014



For Department Use Only:

Date Received from ME:

_______/________/________

Date Submitted by ME:

_______/_______/_______

Name & Phone # of Assigned ME Staff Member Responsible for Report Submission:

___________________

(Name of ME)

System Monitoring Performance Indicators (2014 Block Grant Annual Report Table 3)

Performance Indicator Required Narrative DescriptionDescribe routine monthly data collection processes within your network; continuous quality improvement activities, technical assistanceCompliance with System of Care Report: Managing Entity needs assessment; Performance Improvement activities; strategic plan

Describe analysis to improve care coordination and access to serviceDescribe efforts to build relationships with Federally Qualified Health Centers (FQHCs)

Describe child welfare activities related to data integration; child assessment, and technical assistanceDescribe the use of information technology, within your network.Describe activities to reintegrate individuals discharged from SMHTF; and community supports e.g. supportive housingDiscuss wraparound community services provided e.g. peer support

Describe your network activities to monitor treatment planning to ensure cultural competence and trauma assessments.Describe your network process for the selection of EBP and diversion from criminal justice activities.Describe your network methodology for monitoring wait list to ensure services are provided timely to priority populations



Complete for SAPT BG:Activity A. Treatment B. Prevention C. Total

1. Planning, coordination, needs assessment $ $ $2. Quality Assurance3. Training (post employment)4. Education (pre-employment)5. Program Development6. Research and Evaluation7. Information Systems8. Total

(SAPT 10) This table is intended to capture the count of persons with both initial and subsequent admissions to an episode of care. Level of Care Number of Admissions Number of Persons Served Mean Cost of Services Median Cost of Services Standard Deviation of CostDetoxificationHospital InpatientFree-Standing ResidentialRehabilitation/ResidentialHospital InpatientShort-term (up to 30 days)Long-term (over 30 days)Ambulatory (Outpatient)OutpatientIntensive OutpatientDetoxificationOpioid Replacement TherapyOpioid Replacement TherapyORT Outpatient

(CMH 5) Complete for CMH non-direct service activities Service ExpendituresTechnical Assistance Activities

- Description$

Data Collection/Reporting- Description

Other activities- Description

Total5

Prepared By: SAMH Program OfficeLast Update: April 11, 2014

Comments:

Section I : Report of ME SAPTBG 20% Set-Aside Fund Expenditures and Recipients by CSAP Prevention Strategy for SA Primary Prevention Programs

The Managing Entity (ME) is required to ensure the expenditure of no less than its designated allocation amount of the SAPTBG 20% Prevention Set-Aside Funding that is detailed in the Schedule of Funds. This amount is detailed in the following OCAs - MSA25, MSC27, MSCPP, and MSC80 (see table below for descriptions) for the provision of substance abuse primary prevention services. The ME agrees to ensure the maintenance of adequate provider records, including consumer records with individual consumer prevention outcomes, programmatic data, and fiscal records to provide full details of such recipients, activities, and expenditures for SAPTBG monitoring, reporting, and audit purposes, in accordance with the requirements of the SAPTBG, as contained in 45 C.F.R., pt. 96. See definitions section for description of CSAP Prevention Strategies.

A. List Name of ME Staff, Position Title, and Phone No. Who is Responsible for SAPTBG Prevention Compliance, Monitoring, and Quality Mgt. (Information required)

Below is a table of the SAMH Budget Office expenditure OCAs for substance abuse – adult and children. Specific appropriation OCAs are included.

State Program Component (SPC) Grouping

Expenditure OCA

OCA Title

Substance Abuse - Adult MSA25 Prevention Services

Substance Abuse - Children MSC25 Prevention Services

Substance Abuse - Adult MSA70 Adult Substance Abuse Projects

Substance Abuse - Children MSC80 Projects Informed Families of Florida

Substance Abuse - Children MSCPP Prevention Partnership Grant (PPG)

Report of Grant Expenditures to be Completed at Year-End for Period of July 1, 2013 – June 30, 2014: (Required)

(1a)Information

Dissemination

(2a)Education

(3a)Alternatives

(4a)Problem

Identificationand Referral

(5a)Community-

Based Process

(6a)Environmental

(7a)Combined

Total $

Child SA $ $ $ $ $ $ $

Adult SA $ $ $ $ $ $ $

Total SA $ $ $ $ $ $ $

B. List all other ME funds in SFY 2012-2013 for SA Primary Prevention by source (Federal/State). (Required)



(Information required)

$ $ $ $ $ $ $

SA PRIMARY PREVENTION RECIPIENTS TARGETED BY CHILD/ADULT PRIMARY HIGH RISK FACTOR:

Comprehensive primary prevention programs should give priority to target population sub-groups that are at risk of developing a pattern of substance abuse. Programs should include activities and services provided in a variety of settings, that address specific risk factors, and that may be broken down by age, race/ethnicity, gender, and other characteristics of the population being served. (Summary of Significant Federal Funding Requirements, SAMHSA, 45 CFR Part 96, March 31, 1993).

SABG Table 9 – Prevention Strategy Report

C. Recipient Groups Targeted to be Served Check () recipient groups to be served in non-treatment services provided by ME or contract agency staff through Substance Abuse Primary Prevention Programs to individual and group recipients, by Recipient Age and Primary High Risk Factor.

Column A (Risks) Column B (Strategies) Column C (Providers)

Children of Substance Abusers [1]

Pregnant Women / Teens [2]

Drop-Outs [3]

Violent and Delinquent Behavior [4]

Mental Health Problems [5]

Economically Disadvantaged [6]

Physically Disabled [7]

Abuse Victims [8]

Already Using Substances [9]

Homeless and/or Runaway Youth [10]

Other, Specify [11]

CSAP PREVENTION: NUMBER OF PERSONS SERVED SA PREVENTION PROGRAMS



D. Annual Report of Persons Served: (All totals must equal)

Age Total Single Services

Recurring Services

Race, Ethnicity, and Gender Total Single Services

Recurring Services

*Note:

The same “Total” is repeated for description of the population served by:

o Ageo Raceo Ethnicityo Gender

Single Services:

Single Services are those services that are provided to an individual in a single session such as a group presentation or community event.

Recurring Services:

Recurring Services are those services that are provided to an individual through a continuing multi-session event such as participation in an evidence-based curriculum.

0-4 American Indian/Alaska Native

5-9 Asian

10-11 Black/African American

12 Native Hawaiian/Other Pacific Islander

13 White

14 More than One Race

15 Unknown

16 Total*

17 Not Hispanic or Latino

18-20 Hispanic or Latino

21-24 Total*

25-44 Male

45-64 Female

65+ Total*

Total*

SAPTBG PRIMARY PREVENTION NUMBER OF CONSUMERS SERVED BY PROGRAM STRATEGY: See definitions of CSAP Prevention Strategies.

Number of Consumers:



InformationDissemination

Education Alternatives ProblemIdentificationand Referral

Community-Based Process

Environmental CombinedTotal

Expenditures

Child SA

Adult SA

Total SA

SABG Table 5a – Primary Prevention Expenditures Checklist

IOM Target SAPT Block Grant Other Federal State Local Other

1. Information Dissemination Universal $ $ $ $ $

Selected $ $ $ $ $

Indicated $ $ $ $ $

Unspecified $ $ $ $ $

2. Education Universal $ $ $ $ $

Selected $ $ $ $ $

Indicated $ $ $ $ $


3. Alternatives Universal $ $ $ $ $

Selected $ $ $ $ $

Indicated $ $ $ $ $


4. Problem Identification and Referral Universal $ $ $ $ $

Selected $ $ $ $ $

Indicated $ $ $ $ $


5. Community-Based Services Universal $ $ $ $ $

Selected $ $ $ $ $

Indicated $ $ $ $ $


6. Environmental Universal $ $ $ $ $

Selected $ $ $ $ $



IOM Target SAPT Block Grant Other Federal State Local Other

Indicated $ $ $ $ $


7. Section 1926-Tobacco Universal $ $ $ $ $

Selected $ $ $ $ $

Indicated $ $ $ $ $


8. Other Universal $ $ $ $ $

Selected $ $ $ $ $

Indicated $ $ $ $ $


Suicide Prevention Universal $ $ $ $ $

Selected $ $ $ $ $

Indicated $ $ $ $ $


Total $ $ $ $ $

Section II: Managing Entity and Network Service Providers SAPTBG Primary Prevention Strategies and Activities Checklist

A. SA PRIMARY PREVENTION PROGRAM DEFINITION AND STRATEGIES FOR PURPOSES OF SA PREVENTION AND TREATMENT BLOCK GRANT Substance Abuse Primary Prevention Programs are those directed at individuals who do not require treatment for substance abuse. Such programs are aimed at educating and counseling individuals on such substance abuse and providing for designated non-treatment activities to reduce the risk of abuse. Early intervention activities may not be counted towards the required 20% Primary Prevention Program Set-Aside in the new Block Grant regulations, nor may primary prevention services include any activity designed to determine if a person is in need of treatment . Check () all activities and methods supported for applicable SAPTBG expenditures.



(1) Information Dissemination: This strategy provides awareness and knowledge of the nature and extent of alcohol, tobacco, and drug use, abuse and addiction and their effects on individuals, families and communities. It also provides knowledge and awareness of available prevention programs and services. Information dissemination is characterized by one-way communication from the source to the audience, with limited contact between the two. Examples include:

Clearinghouse/information resource center(s); Resource directories;Media campaigns; Brochures;Radio/TV public service announcements; Speaking engagements;Health fairs/other health promotion, e.g., conferences, meetings, seminars;Information lines/Hot lines; and Other (Specify):______________________

(2) Education: This strategy involves two-way communication and is distinguished from the Information Dissemination strategy by the fact that interaction between the educator/facilitator and the participants is the basis of its activities. Activities under this strategy aim to affect critical life and social skills, including decision-making, refusal skills, critical analysis (e.g. of media messages) and systematic judgment abilities. Examples include:

Ongoing classroom and/or small group sessions (all ages);Parenting and family management classes; Mentors;Peer leader/helper programs;Education programs for youth groups; Children of substance abusers groups;Preschool ATOD prevention programs; andOther (Specify):______________________

(3) Alternatives: This strategy provides for the participation of the target populations in activities that exclude alcohol, tobacco, and other drug use. The assumption is that constructive and healthy activities offset the attraction to, or otherwise meet the needs usually filled by alcohol, tobacco and other drugs and would, therefore, minimize or obviate resort to the latter. Examples include:

Drug free dances and parties; Outward Bound;Youth/adult leadership activities; Recreation activities;Community drop-in centers; Community service activities; and Other (Specify):______________________

(4) Problem Identification and Referral: This strategy aims at identification of those youth who have indulged in illegal/age-inappropriate use of tobacco or alcohol and those individuals who have indulged in the first use of illicit drugs in order to assess if their behavior can be reversed through education. It should be noted, however, that this strategy does not include any activity designed to determine if a person is in need of treatment. Examples include:

Marketing Only of Employee Assistance Programs; (SAMH policy prohibits the payment of federal or state funds through UCR or Non-UCR funding to support EA Programs)Student assistance programs; Other (Specify):______________________

(5) Community-Based Process: This strategy aims to enhance the ability of the community to more effectively provide prevention and treatment services for alcohol, tobacco and other drug abuse disorders. Activities in this strategy include organizing, planning, enhancing efficiency and effectiveness of services implementation, inter-agency collaboration, coalition building and networking. Examples include:

Community and volunteer training, e.g., neighborhood action training,Impacted training (key people in the system), staff/officials training;

Systematic planning; Community team-building;Multi-agency coordination and collaboration/coalition;Accessing services and funding; and Other (Specify):_____________________

(6) Environmental: This strategy establishes or changes written and unwritten community standards, codes and attitudes, thereby influencing incidence and prevalence of alcohol, tobacco and other drugs used in the general population. This strategy is divided into two subcategories to permit distinction between activities which center on legal and regulatory initiatives and those that relate to service and action-oriented initiatives. Examples include:



Promoting establishment/review of alcohol/tobacco/other drug policies in schools;Guidance and technical assistance to communities to monitor and maximize local enforcement procedures governing availability and distribution of alcohol, tobacco and other drug use;Modifying alcohol and tobacco advertising practices;Product pricing strategies; and Other (Specify):______________________

Section III: SAPTBG Primary Prevention Program Staff and Written Program Plan

A. SAPTBG PREVENTION PROVIDER AGENCY NAME, STRATEGIES UTILIZED AND CONTRACT AMOUNT: (Required)

SAPTBG Primary Prevention Providers Strategies Utilized Contract Amount

B. WRITTEN PROGRAM PLAN for CONSULTATION AND EDUCATION SERVICES (Required)

In order to strengthen SAPT Block Grant planning and accountability for the 20% Set-Aside for Substance Abuse Primary Prevention Services, the ME is requested to provide a brief summary below of Written Program Plan highlights pertaining to substance abuse populations, objectives, and activities. This Plan should specify substance abuse populations that will be targeted in the coming fiscal year (including those High-Risk groups identified) and evidence-based programs to be implemented. This Plan should include activities and services in each of the six Substance Abuse Primary Prevention Strategies.1. Please provide a brief summary below of Written Plan highlights pertaining to substance abuse at risk target populations, objectives, and activities. (Required)

CSAP PREVENTION FORM P2: NUMBER OF SAMHSA National Registry of Evidence-based Programs and Practices (NREPP) IMPLEMENTED THROUGH ME AND CONTRACT AGENCIES THROUGH SAPTBG FUNDING

B1. Report of No. of Programs Provided & No. of Consumers Served:

Provide a listing of the number of SAPTBG programs provided, and the number of consumers served, through evidence–based substance abuse prevention programs that are listed on the SAMHSA NREPP. NREPP web address is <http://www.nrepp.samhsa.gov/>.



http://www.nrepp.samhsa.gov/

Name of NREPP Evidence-BasedSubstance Abuse Prevention Program Implemented

WITH IDENTIFICATION OF FACILITATING STAFF MEMBER(S) AND COUNTY AND HOST AGENCY LOCATION WHERE PROGRAM

HAS BEEN PROVIDED*

Universal Population:No. of Times Program Was

Provided toUniversal Populations

andNo. of Consumers

Served

Selective Population:No. of Times Program Was

Provided to Selective Populations and

No. of Consumers Served

Indicated Population:No. of Times Program Was

Provided to Indicated Populations and

No. of Consumers Served

Total

# of Times Program Provided

# of Consumers

Served


# of Consumers

Served


# of Consumers

Served

# of Times Programs Provided

Unduplicated# of Consumers

Served

Section IV: Priority Admission Preference for Pregnant Women and Women with Dependent Children (PWWDC)

PWWDCState Base Expenditures YTD People Served YTD

A. List Name of ME Staff, Position Title, and Phone No. Who is Responsible for SAPTBG PWWDC Services Compliance, Monitoring, and Quality Management:

Section V: Injecting Drug Use (IDU) Programs and Services

Please list providers that reached 90% capacity.

A. List Name of ME Staff, Position Title, and Phone No. Who is Responsible for SAPTBG IDU Services Compliance, Monitoring, and Quality Management

B. Describe your ME’s policies and practices that ensure that all ME and contract agency staff provide IDU consumer admission within 14 days of request for services, or if at capacity, within 120 days of request for services, and provision of interim services within 48 hours of request for services.



SABG Table 3 SA Block Grant Expenditures by ServiceService Unduplicated Individuals Unit Type Unit Quantity SABG Expenditures

1st 6 months 2nd 6 months

1st 6 months

2nd 6 months 1st 6 months 2nd 6 months


Healthcare Home/Physical Health

General and specialized outpatient medical servicesAcute Primary care

General Health Screens, Tests and ImmunizationsComprehensive Care Management

Care coordination and Health PromotionComprehensive Transitional Care

Individual and Family SupportReferral to Community ServicesPrevention

Prevention Including Promotion

Screening, Brief Intervention and Referral to Treatment

Brief Motivational Interviews

Screening and Brief Intervention for Tobacco Cessation

Parent Training

Facilitated Referrals

Relapse Prevention/Wellness Recovery Support

Warm Line

Substance Abuse Primary Prevention



Service Unduplicated Individuals Unit Type Unit Quantity SABG Expenditures


1st 6 months



Classroom and/or small group sessions (Education)Media campaigns (Information Dissemination) Media campaigns (Information Dissemination)

Systematic Planning/Coalition and Community Team Building(Community Based Process)Parenting and family management (Education)Education programs for youth groups (Education)Community Service Activities (Alternatives)Student Assistance Programs (Problem Identification and Referral)Employee Assistance programs (Problem Identification and Referral)Community Team Building (Community Based Process)

Promoting the establishment or review of alcohol, tobacco, and drug use policies (Environmental)

Engagement Services

Assessment

Specialized Evaluations (Psychological and Neurological)

Service Planning (including crisis planning)

Consumer/Family Education

Outreach





1st 6 months



Outpatient Services

Individual evidenced based therapies

Group therapy

Family therapy

Multi-family therapy

Consultation to Caregivers

Medication Services

Medication management

Pharmacotherapy (including MAT)

Laboratory services

Community Support (Rehabilitative)Parent/Caregiver Support

Skill building (social, daily living, cognitive)

Case management

Behavior management

Supported employment

Permanent supported housingRecovery housing

Therapeutic mentoring

Traditional healing services

Recovery Supports

Peer Support

Recovery Support Coaching

Recovery Support Center Services

Supports for Self Directed CareOther Supports (Habilitative)





1st 6 months



Personal care

Homemaker

Respite

Supported Education

Transportation

Assisted living services

Recreational services

Trained behavioral health interpretersInteractive communication technology devicesIntensive Support Services

Substance abuse intensive outpatient (IOP)Partial hospital

Assertive Community Treatment

Intensive home based services

Multi-systemic therapy

Intensive Case Management

Out of Home Residential Services

Crisis residential/stabilizationClinically Managed 24 Hour Care (SA)

Clinically Managed Medium Intensity Care (SA)Adult Substance Abuse Residential

Adult Mental Health ResidentialYouth Substance Abuse Residential ServicesChildren's Residential Mental Health Services





1st 6 months



Therapeutic foster care

Acute Intensive Services

Mobile crisis

Peer based crisis services

Urgent care

23 hr. observation bed

Medically Monitored Intensive Inpatient (SA)24/7 crisis hotline services

Other (please list)

A. List Name of ME Staff, Position Title, and Phone No. Who is Responsible for SAPTBG Priority Admission Compliance, Monitoring, and Quality Mgt.

B. Describe your ME adult and child program policies and practices assuring priority admission preference for all substance abuse individuals who meet federally defined special population criteria in all ME programs and contract agencies. Describe the ME’s contract management and monitoring, training, technical assistance, and quality management practices that ensure that all ME and contract agency direct services staff provide Priority Admission Preference for all pregnant injecting drug users, pregnant women, and injecting drug users.

C. Document evidence of satisfactory efforts of the ME and contract agencies to advertise and publicize priority admission policies in the current fiscal year assuring admission to all pregnant injecting drug users, pregnant women, and injecting drug users.

Section VI: Universal TB Screening, Testing, Referral & Case Management Services, & Health Department MOA

A. List Name of ME Staff, Position Title, and Phone No. Who is Responsible for SAPTBG TB Services Compliance, Monitoring, and Quality Management

B. Describe the ME’s adult and child substance abuse universal TB screening policies. Describe the ME’s contract management and monitoring, training, technical assistance, and quality



management practices that ensure that all ME and contract agency direct services staff provide universal TB screening for all adult and child substance abuse consumers. Indicate the specific type of screening services that are provided by direct services staff and indicate the standard location for documentation in each consumer’s record for program monitoring and audit purposes in compliance with Ch. 65D-30.004(9) F.A.C.

C. Describe the ME’s adult and child substance abuse policies related to TB Testing, Referral, and Case Management or Community Support Services for individuals identified as high-risk for TB. Describe the ME’s contract management and monitoring, training, technical assistance, and quality management practices that ensure that all ME and contract agency direct services staff provide appropriate TB Testing, Referral and Case Management or Community Support Services for individuals identified as high-risk for TB. Indicate the specific criteria for TB Testing and Referral Services and the standard location for documentation in each consumer’s record for program monitoring and audit purposes.

D. Do providers have a current Memorandum of Agreement with the local health department pertaining to TB Services in place? Yes No

If “No”, please describe your ME’s strategy to address this:

Section VII: HIV Programs and Services

Required To be completed only by the following programs that receive specialized funding for HIV:

A. List Name of ME Staff, Position Title, and Phone No. Who is Responsible for SAPTBG HIV Services Compliance, Monitoring, and Quality Mgt. (Required)

MEs and contract agencies that receive SAPTBG HIV Set-Aside Funds are required to provide HIV Early Intervention Services to substance abuse treatment clients who are at risk for HIV disease. These services are defined in the SAPTBG regulations as listed below. Of the number of substance abuse treatment clients who have received the designated HIV Early Intervention Services, and the number of hours provided of HIV Early Intervention Services in each of these services.

Providers receiving HIV Set-Aside Funds:

Provider Funding

B. For MEs: Describe the ME’s adult and child substance abuse policies for HIV referral, pre-test counseling, testing , and post-test counseling services. Describe the ME’s contract management and monitoring, training, technical assistance, and quality management practices that ensure that all ME and contract agency direct services staff provide appropriate HIV pre-test counseling, testing, post test counseling, and referral for all adult and child substance abuse consumers. Indicate the standard location for documentation in the consumer’s record for program monitoring and audit purposes.



C. Provide a listing of the number of substance abuse treatment clients served with HIV/AIDS-related services and the number of hours of these HIV/AIDS -related services provided to clients enrolled in substance abuse treatment services in the following four areas of service: This information is required and must be reported here.

First Six Months Reportof SA Treatment

Clients Served andHours of HIV/AIDS-Related Services

Provided:July 1, 20__ to Dec. 31, 20__

Second Six Months Reportof SA Treatment


Provided:Jan. 1, 20__ to June 30, 20__

Combined First and Second Six Months Reports

of Unduplicated SA Treatment Clients Served and

Hours of HIV/AIDS-Related Services Provided:

July 1, 20__ to June 30, 20__

TYPE OF SERVICE No. of Clients Served

Units Provided No. of ClientsServed


Units Provided

1) Appropriate pretest counseling for HIV and AIDS.

2) Testing individuals with respect to such HIV/AIDS disease, including tests to confirm the presence of the disease, tests to diagnose the extent of the deficiency in the immune system, and tests to provide information on appropriate therapeutic measures for preventing and treating the deterioration of the immune system and for prevention and treating conditions arising from the disease.

3) Appropriate post-test counseling.

4) Total # of HIV infected individuals who tested positive and referred into treatment and care during the reporting period.

5.) Total # of HIV tests conducted. This number may include multiple tests administered per individual client during the reporting period.

6.) Total number of HIV tests conducted that were positive for HIV.



First Six Months Reportof SA Treatment


Provided:July 1, 20__ to Dec. 31, 20__

Second Six Months Reportof SA Treatment


Provided:Jan. 1, 20__ to June 30, 20__

Combined First and Second Six Months Reports

of Unduplicated SA Treatment Clients Served and

Hours of HIV/AIDS-Related Services Provided:

July 1, 20__ to June 30, 20__

TYPE OF SERVICE No. of Clients Served



Units Provided

7.) Total # of individuals who tested positive for HIV, but who were unaware of their HIV infection status prior to testing.

TOTAL

HIVExpenditures YTD People Served YTD Units Provided YTD

Section VIII: Report of ME CMHBG Fund Expenditures and Recipients of MH Programs

The Managing Entity (ME) is required to ensure the expenditure of no less than its designated allocation amount of the MH BG 10% Set-Aside Funding for serious emotional Disturbance (SED) children that is detailed in the Schedule of Funds. This amount is detailed in the following OCAs MHC01, MHC09, MHC18, MHC25, for the provision of community mental health block grant services. The ME agrees to ensure the maintenance of adequate provider records, including consumer records with individual consumer outcomes, programmatic data, and fiscal records to provide full details of such recipients, activities, and expenditures for CMHBG monitoring, reporting, and audit purposes, in accordance with the requirements of the CMHBG, as contained in 45 CFR, Part 96, and as highlighted in the Summary of Significant Federal Funding Requirements.

Below is a table of the SAMH Budget Office expenditure OCAs for mental health – adults and children.


Expenditure OCA OCA Title

Mental Health – Children MHC01 24 Hour Care (Non-Hospitization) Residential




Expenditure OCA OCA Title

Mental Health – Children MHC09 Ambulatory/Community Non-24 Hour Care

Mental Health – Children MHC18 CSU, Baker Act, Inpatient Crisis Services

Mental Health – Children MHC25 Prevention Services

Report of Expenditures by Service Type: (Required)Prevention Engagement

ServicesOutpatient

ServicesMedication

ServicesCommunity

SupportRecovery Supports

Other Supports (Habilitative)

Intensive Support Services

Out of Home Residential

Services


Other

Child MH $ $ $ $ $ $ $ $ $ $ $

Adult MH $ $ $ $ $ $ $ $ $ $ $

Total MH $ $ $ $ $ $ $ $ $ $ $

B. List all other ME funds by source (Federal/State). (Required)

$ $ $ $ $ $ $

NUMBER OF PERSONS SERVED IN ME AND CONTRACT AGENCY CMHBG PROGRAMS

C. Annual Report of Persons Served (All totals must equal):


Recurring Services


Recurring Services

*Note:



0-4 American Indian/Alaska Native

5-9 Asian

10-11 Black/African American

12 Native Hawaiian/Other Pacific Islander




Recurring Services


Recurring Services

*Note:



Single Services:


Recurring Services:


Single Services:


Recurring Services:


13 White

14 More than One Race

15 Unknown

16 Total*

17 Not Hispanic or Latino

18-20 Hispanic or Latino

21-24 Total*

25-44 Male

45-64Female

65+ Total*

Total*

E1. Number of Consumers:

MHBG Table 3 – MH Block Grant Expenditures by Service

Table 3 is to be used to report MHBG Expenditures by unduplicated individual and specific services.

Service Unduplicated Individuals Unit Type Unit Quantity MHBG Expenditures

1st 6 months 2nd 6 months 1st 6 months 2nd 6 months 1st 6 months 2nd 6 months 1st 6 months 2nd 6 months

Healthcare Home/Physical Health

General and specialized outpatient medical servicesAcute Primary care

General Health Screens, Tests and ImmunizationsComprehensive Care Management

Care coordination and Health Promotion





Comprehensive Transitional Care

Individual and Family Support

Referral to Community Services

Prevention and Wellness

Screening, Brief Intervention and Referral to Treatment (SBIRT)Brief Motivational Interviewing

Screening and Brief Intervention for Tobacco CessationParent Training

Facilitated Referral

Relapse Prevention/Wellness Recovery Support

Warm Line

Engagement Services

Assessment

Specialized Evaluations

Service Planning

Consumer/Family Education

Outreach

Outpatient Services

Individual Evidenced Based Therapies

Group Therapy

Family Therapy

Multi-family counseling

Consultation with Caregivers

Medication Services

Medication management

Pharmacotherapy

Laboratory Services

Community Support Services

Parent/Caregiver Support

Skill Building

Case management





Continuing care

Behavior management

Supported employment

Permanent supportive housing

Recovery housing

Therapeutic mentoring

Traditional healing services

Recovery Support Services

Peer Support

Recovery Support Coaching

Recovery Support Center Services

Supports for Self Directed Care

Other Supports

Personal care

Homemaker

Respite

Supported education

Transportation

Assisted Living

Recreational services

Trained Behavioral Health Interpreters

Interactive Communication Technology Devices

Intensive Support Services

Substance Abuse Intensive Outpatient (IOP)

Partial hospital

Assertive Community Treatment

Intensive home based services

Multi-systemic Therapy

Intensive Case Management

Out of Home Residential Services

Crisis residential/stabilization

Adult Substance Abuse Residential





Adult Mental Health Residential

Youth Substance Abuse Residential

Children's Residential Mental Health

Therapeutic foster care


Mobile crisis

Peer based crisis services

Urgent care

23 hr. observation bed

Inpatient detoxification

24/7 crisis hotline

Other (please list)

MHBG Table 4 – Set – Aside for Children’s Mental Health

States and Jurisdictions are required not to spend less than the amount expended in FY 2008. (CFDA 93.958, 2014)

State Base – MH SED Expenditures YTD People Served YTD

MHBG Table 8a and 8b – Profile of Clients by Type of Funding Support

Total American Indian or Alaska Native Asian Black or African American

Female MaleNot

Available Total Female MaleNot

Available Female MaleNot


AvailableMedicaid (only Medicaid) 0 0 0 0Non-Medicaid Sources (only) 0 0 0 0People Served by Both Medicaid and Non-Medicaid Sources 0 0 0 0



Medicaid Status Not Available 0 0 0 0

Total Served 0 0 0 0 0 0 0 0 0 0 0 0 0

Native Hawaiian or Other Pacific Islander White

Hispanic * use only if data for Table 5b are not available. More Than One Race Reported Race Not Available

Female MaleNot





AvailableMedicaid (only Medicaid)Non-Medicaid Sources (only)People Served by Both Medicaid and Non-Medicaid SourcesMedicaid Status Not Available

Total Served 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Section IX: CMHBG Staff and Written Program Plan

A. CMHBG PROVIDER AGENCY NAMES: (Required)

B. WRITTEN PROGRAM PLAN for CONSULTATION AND EDUCATION SERVICES

In order to strengthen CMHBG Block Grant planning and accountability, the ME is requested to provide a brief summary below of Written Program Plan highlights pertaining to mental health populations, objectives, and activities. This Plan should specify mental health populations that will be targeted in the coming fiscal year (including those High-Risk groups and evidence-based programs to be implemented. This Plan should include trainings and services in addition to information provided in previous sections. Please provide a brief summary below of Written Plan highlights pertaining to at risk target populations, objectives, and activities. (Required)

CMHBG FORM P2: NUMBER OF EVIDENCE-BASED PROGRAMS IMPLEMENTED THROUGH ME ANDCONTRACT AGENCIES THROUGH CMHBG FUNDING



B1. No. of Programs Provided & No. of Consumers:

Provide a listing of the number of CMHBG programs provided, and the number of consumers served, through evidence–based programs that are listed on the SAMHSA National Registry of Evidence-based Programs and Practices (NREPP). NREPP web address is <http://www.nrepp.samhsa.gov/>.

Name of NREPP Evidence-BasedProgram Implemented

WITH IDENTIFICATION OF FACILITATING STAFF MEMBER(S) AND COUNTY AND

HOST AGENCY LOCATION WHERE PROGRAM HAS BEEN PROVIDED*

No. of Times Program Was Provided and

No. of ConsumersServed


# of Consumers Served



http://www.nrepp.samhsa.gov/

The National Outcome Measures (NOMS serve as performance targets for State and Federally funded initiatives and programs for substance abuse prevention and mental health promotion, early intervention, and treatment services. Please complete the Outcome section with ME responses.

National Outcome Measures (NOMS) - Florida General Appropriation Act (GAA)

Program Type Measures Description Outcome

Children's Mental Health Services

Average annual days seriously emotionally disturbed (SED) children (excluding those in juvenile justice facilities) spend in the communityPercent of children with mental illness restored to competency and recommended to proceed with a judicial hearing

Percent of children with emotional disturbances who improve their level of functioning

Percent of children with serious emotional disturbances who improve their level of functioning.

Percent of children with emotional disturbance (ED) who live in a stable housing environment

Percent of children with serious emotional disturbance (SED) who live in a stable housing environment

Percent of children at risk of emotional disturbance who live in a stable housing environment

Adult Community Mental Health Services

Average annual days worked for pay for adults with severe and persistent mental illness

Percent of adults with serious mental illness who are competitively employed.

Percent of adults with severe and persistent mental illnesses who live in stable housing environment.

Percent of adults in forensic involvement who live in stable housing environment.

Percent of adults in mental health crisis who live in stable housing environment.

Child SA Prevention, Evaluation and Treatment Services

Percent of children who successfully complete substance abuse treatment services.

Percent change in the number of children arrested 30 days prior to admission versus 30 days prior to discharge.

Percent of children with substance abuse who live in a stable housing environment at the time of discharge.

Adult SA Prevention, Eval and Trt Svcs

Percentage change in clients who are employed from admission to discharge.

Percent change in the number of adults arrested 30 days prior to admission versus 30 days prior to discharge.

Percent of adults who successfully complete substance abuse treatment services.

Percent of adults with substance abuse who live in a stable housing environment at the time of discharge.



The undersigned persons hereby attest to the accuracy and completeness of the information provided in this report:

A1. ME Director Name (Printed) _____________ Signature Date

A2. ME Finance Officer Name (Printed) Signature Date

We would appreciate your report submissions with original signatures through electronic submission.

Please ensure that the document is sent as a Microsoft Word file.



Section VIII: SAMH Review (For Department Use Only)

Position Title Name ofDepartment Staff

Date Reviewed

Corrective Action Recommended?

If “Yes”, describe actions needed and follow-up planned or implemented.



To: Area DirectorsError! Bookmark not Web viewpr. o. grammatic. data, and . ... The Managing Entity...

Documents

Transcript of To: Area DirectorsError! Bookmark not Web viewpr. o. grammatic. data, and . ... The Managing Entity...