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pdfOMB No. 0930-0285
Expiration Date 5/21/2013
Transformation Accountability (TRAC)
Center for Mental Health Services
NOMs Client-Level Measures for Discretionary
Programs Providing Direct Services
SERVICES TOOL
For Adult Programs
CMHS
Center for Mental Health Services
SAMHSA
March 2011
Version 7
Public reporting burden for this collection of information is estimated to average 30 minutes per
response if all items are asked of a consumer/participant; to the extent that providers already obtain
much of this information as part of their ongoing consumer/participant intake or follow-up, less time
will be required. Send comments regarding this burden estimate or any other aspect of this collection
of information to SAMHSA Reports Clearance Officer, Room 7-1045, 1 Choke Cherry Road,
Rockville, MD 20857. 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
control number for this project is 0930-0285.
RECORD MANAGEMENT
Consumer ID
|____|____|____|____|____|____|____|____|____|____|____|
Grant ID (Grant/Contract/Cooperative Agreement) |____|____|____|____|____|____|____|____|____|____|
Site ID
|____|____|____|____|____|____|____|____|____|____|
1. Assessment
Baseline Assessment
6-Month Reassessment
24-Month Reassessment
42-Month Reassessment
60-Month Reassessment
12-Month Reassessment
30-Month Reassessment
48-Month Reassessment
66-Month Reassessment
18-Month Reassessment
36-Month Reassessment
54-Month Reassessment
Clinical Discharge
2. Interview Conducted?
Yes
No
[GO TO 3]
2a. Why was the interview not conducted? Choose only one.
[PLEASE MARK YOUR ANSWER UNDER THE COLUMN RELATING TO THE ASSESSMENT TYPE]
Consumer refused interview
Baseline
Assessment
Clinical
Discharge
Reassessments
Not able to obtain consent from proxy
Consumer was impaired/unable to provide
consent
[IF THIS
ANSWER IS
SELECTED, GO
TO SECTION H
(if applicable) or I]
[IF THIS
ANSWER IS
SELECTED, GO
TO SECTION H (if
applicable) or J]
Consumer cannot be reached for interview
Staff previously indicated “Administrative data
only” or “No data” would be submitted
[IF THIS IS A CLINICAL DISCHARGE GO TO 2c]
1
RECORD MANAGEMENT (Continued)
2b. What data will be submitted for the next reassessment?
Interview data (all sections)
Administrative data only [Record Management, Sections H (if applicable), then I or J, &K] – will not attempt
any subsequent interviews.
No data – will only provide discharge status [Record Management & Section J] when discharged.
[GO TO 3]
2c. [CLINICAL DISCHARGE ONLY] What data will be submitted for this Clinical Discharge?
Administrative data only [Record Management and Sections H (if applicable), then J, & K]
No data – will only provide discharge status [Record Management & Section J]
3. When was the interview conducted or attempted?
[REASSESSMENTS AND CLINICAL DISCHARGE: IF ANSWERED “CONSUMER CANNOT BE
REACHED FOR INTERVIEW” IN 2a, GO TO INSTRUCTIONS BELOW 4]
|____|____| / |____|____| / |____|____|____|____|
MONTH
DAY
YEAR
[IF THIS IS A BASELINE GO TO 4, ALL OTHERS GO TO INSTRUCTIONS BELOW]
4. When did the consumer first receive services under the grant for this episode of care?
|____|____| / |____|____|____|____|
MONTH
YEAR
[IF THIS IS A BASELINE, GO TO SECTION A.]
[FOR ALL REASSESSMENTS:
IF AN INTERVIEW WAS CONDUCTED, GO TO SECTION B.]
IF AN INTERVIEW WAS NOT CONDUCTED, GO TO SECTION H (IF APPLICABLE), THEN
SECTION I AND K.]
[FOR A CLINICAL DISCHARGE:
IF AN INTERVIEW WAS CONDUCTED, GO TO SECTION B.]
IF AN INTERVIEW WAS NOT CONDUCTED, GO TO SECTION H (IF APPLICABLE), THEN
SECTION J AND K.]
2
A.
DEMOGRAPHIC DATA
[SECTION A IS ONLY COLLECTED AT BASELINE. IF THIS IS NOT A BASELINE, GO TO SECTION B.]
1.
What is your gender?
2.
MALE
FEMALE
TRANSGENDER
OTHER (SPECIFY) _____________________________________
REFUSED
Are you Hispanic or Latino?
YES
NO
REFUSED
[GO TO 3]
[GO TO 3]
[IF YES] What ethnic group do you consider yourself? Please answer yes or no for each of the
following. You may say yes to more than one.
YES NO
REFUSED
Central American
Cuban
Dominican
Mexican
Puerto Rican
South American
OTHER
[IF YES, SPECIFY BELOW]
(SPECIFY) ______________________________
3.
What race do you consider yourself? Please answer yes or no for each of the following. You may say yes
to more than one.
YES
NO REFUSED
Black or African American
Asian
Native Hawaiian or other Pacific Islander
Alaska Native
White
American Indian
4.
What is your month and year of birth?
|____|____| / |____|____|____|____|
MONTH
YEAR
REFUSED
[STOP HERE IF THE BASELINE INTERVIEW WAS NOT CONDUCTED AND THE DEMOGRAPHIC DATA
WAS OBTAINED FROM RECORDS. ALL OTHERS CONTINUE.]
3
B.
FUNCTIONING
1.
How would you rate your overall health right now?
2.
Excellent
Very Good
Good
Fair
Poor
REFUSED
DON’T KNOW
In order to provide the best possible mental health and related services, we need to know what you think
about how well you were able to deal with your everyday life during the past 30 days. Please indicate
your disagreement/agreement with each of the following statements.
[READ EACH STATEMENT FOLLOWED BY THE RESPONSE OPTIONS TO THE CONSUMER.]
Undecided
Agree
Strongly
Agree
REFUSED
a. I deal effectively with daily problems.
b. I am able to control my life.
c. I am able to deal with crisis.
d. I am getting along with my family.
e. I do well in social situations.
f.
I do well in school and/or work.
g. My housing situation is satisfactory.
h. My symptoms are not bothering me.
NOT
APPLICABLE
Disagree
RESPONSE OPTIONS
Strongly
Disagree
STATEMENT
4
B.
FUNCTIONING (Continued)
3.
The following questions ask about how you have been feeling during the past 30 days. For each question,
please indicate how often you had this feeling.
[READ EACH QUESTION FOLLOWED BY THE RESPONSE OPTIONS TO THE CONSUMER.]
Most
of the Time
Some of the
Time
A Little of
the Time
None of the
Time
REFUSED
DON’T
KNOW
RESPONSE OPTIONS
All of the
Time
QUESTION
a. nervous?
b. hopeless?
c. restless or fidgety?
d. so depressed that nothing could cheer you up?
e. that everything was an effort?
f. worthless?
During the past 30 days, about how often did you
feel …
5
B.
FUNCTIONING (Continued)
4.
The following questions relate to your experience with alcohol, cigarettes, and other drugs. Some of the
substances we’ll talk about are prescribed by a doctor (like pain medications). But I will only record
those if you have taken them for reasons or in doses other than prescribed.
[READ EACH QUESTION FOLLOWED BY THE RESPONSE OPTIONS TO THE CONSUMER.]
Once or
Twice
Weekly
Daily or
Almost
Daily
REFUSED
DON’T
KNOW
RESPONSE OPTIONS
Never
QUESTION
b1. [IF B >= ONCE OR TWICE, AND RESPONDENT
MALE], How many times in the past 30 days have you
had five or more drinks in a day? [CLARIFY IF
NEEDED: A standard drink (e.g., 12 oz beer, 5 oz
wine, 1.5 oz liquor)].
b2. [IF B >= ONCE OR TWICE, AND RESPONDENT
NOT MALE], How many times in the past 30 days
have you had four or more drinks in a day?
[CLARIFY IF NEEDED: A standard drink (e.g., 12 oz
beer, 5 oz wine, 1.5 oz liquor)].
c. cannabis (marijuana, pot, grass, hash, etc.)?
d. cocaine (coke, crack, etc.)?
e. prescription stimulants (Ritalin, Concerta, Dexedrine,
Adderall, diet pills, etc.)?
f.
methamphetamine (speed, crystal meth, ice, etc.)?
g. inhalants (nitrous oxide, glue, gas, paint thinner, etc.)?
h. sedatives or sleeping pills (Valium, Serepax, Ativan,
Librium, Xanax, Rohypnol, GHB, etc.)?
In the past 30 days, how often have you used…
a. tobacco products (cigarettes, chewing tobacco, cigars,
etc.)?
b. alcoholic beverages (beer, wine, liquor, etc.)?
i.
hallucinogens (LSD, acid, mushrooms, PCP, Special
K, ecstasy, etc.)?
j.
street opioids (heroin, opium, etc.)?
k. prescription opioids (fentanyl, oxycodone [OxyContin,
Percocet], hydrocodone [Vicodin], methadone,
buprenorphine, etc.)?
l.
other – specify:
6
B.
FUNCTIONING (Continued)
[OPTIONAL: GAF SCORE REPORTED BY GRANTEE STAFF AT PROJ ECT’S DISCRETION.]
DATE GAF WAS ADMINISTERED:
|____|____| / |____|____| /|____|____|____|____|
MONTH
DAY
YEAR
WHAT WAS THE CONSUMER’S SCORE?
GAF =
|____|____|____|
7
C.
STABILITY IN HOUSING
1.
In the past 30 days how many …
Number of
Nights/
Times
REFUSED
DON’T
KNOW
|____|____|
|____|____|
a.
nights have you been homeless?
b.
nights have you spent in a hospital for mental health care?
c.
nights have you spent in a facility for detox/inpatient or
residential substance abuse treatment?
|____|____|
d.
nights have you spent in correctional facility including jail, or
prison?
|____|____|
[ADD UP THE TOTAL NUMBER OF NIGHTS SPENT HOMELESS, IN
HOSPITAL FOR MENTAL HEALTH CARE, IN DETOX/INPATIENT OR
RESIDENTIAL SUBSTANCE ABUSE TREATMENT, OR IN A
CORRECTIONAL FACILITY. (ITEMS A-D, CANNOT EXCEED 30
NIGHTS)]
e.
times have you gone to an emergency room for a psychiatric or
emotional problem?
|____|____|
|____|____|
[IF 1A, 1B, 1C, OR 1D IS 16 OR MORE NIGHTS, GO TO SECTION D.]
2.
In the past 30 days, where have you been living most of the time?
[DO NOT READ RESPONSE OPTIONS TO THE CONSUMER. SELECT ONLY ONE.]
OWNED OR RENTED HOUSE, APARTMENT, TRAILER, ROOM
SOMEONE ELSE’S HOUSE, APARTMENT, TRAILER, ROOM
HOMELESS (SHELTER, STREET/OUTDOORS, PARK)
GROUP HOME
ADULT FOSTER CARE
TRANSITIONAL LIVING FACILITY
HOSPITAL (MEDICAL)
HOSPITAL (PSYCHIATRIC)
DETOX/INPATIENT OR RESIDENTIAL SUBSTANCE ABUSE TREATMENT FACILITY
CORRECTIONAL FACILITY (JAIL/PRISON)
NURSING HOME
VA HOSPITAL
VETERAN’S HOME
MILITARY BASE
OTHER HOUSED (SPECIFY) _______________________________________________
REFUSED
DON’T KNOW
8
D.
EDUCATION AND EMPLOYMENT
1.
Are you currently enrolled in school or a job training program?
[IF ENROLLED] Is that full time or part time?
2.
What is the highest level of education you have finished, whether or not you received a degree?
3.
LESS THAN 12TH GRADE
12TH GRADE/HIGH SCHOOL DIPLOMA/EQUIVALENT (GED)
VOC/TECH DIPLOMA
SOME COLLEGE OR UNIVERSITY
BACHELOR’S DEGREE (BA, BS)
GRADUATE WORK/GRADUATE DEGREE
REFUSED
DON’T KNOW
Are you currently employed? [CLARIFY BY FOCUSING ON STATUS DURING MOST OF THE
PREVIOUS WEEK, DETERMINING WHETHER CONSUMER WORKED AT ALL OR HAD A
REGULAR J OB BUT WAS OFF WORK.]
3a.
NOT ENROLLED
ENROLLED, FULL TIME
ENROLLED, PART TIME
OTHER (SPECIFY)______________
REFUSED
DON’T KNOW
EMPLOYED FULL TIME (35+ HOURS PER WEEK, OR WOULD HAVE BEEN)
EMPLOYED PART TIME
UNEMPLOYED, LOOKING FOR WORK
UNEMPLOYED, DISABLED
UNEMPLOYED, VOLUNTEER WORK
UNEMPLOYED, RETIRED
UNEMPLOYED, NOT LOOKING FOR WORK
OTHER (SPECIFY) ___________
REFUSED
DON’T KNOW
[IF EMPLOYED]
•
•
•
1
Ar e you paid at or above the minimum wage 1?
Ar e your wages paid dir ectly to you by your employer ?
Could anyone have applied for this job?
For information on Federal minimum wage go to http://www.dol.gov/esa/whd/flsa/.
Yes
No
REFUSED
DON’T KNOW
9
E.
CRIME AND CRIMINAL JUSTICE STATUS
1.
In the past 30 days, how many times have you been arrested?
|____|____| TIMES
REFUSED
DON’T KNOW
[IF THIS IS A BASELINE, GO TO SECTION G. OTHERWISE, GO TO SECTION F.]
10
F.
PERCEPTION OF CARE
[SECTION F IS NOT COLLECTED AT BASELINE. FOR BASELINE INTERVIEWS, GO TO SECTION G.]
1.
In order to provide the best possible mental health and related services, we need to know what you think
about the services you received during the past 30 days, the people who provided it, and the results.
Please indicate your disagreement/agreement with each of the following statements.
[READ EACH STATEMENT FOLLOWED BY THE RESPONSE OPTIONS TO THE CONSUMER.]
Undecided
Agree
Strongly
Agree
REFUSED
a. Staff here believe that I can grow, change and
recover.
b. I felt free to complain.
c. I was given information about my rights.
d. Staff encouraged me to take responsibility for
how I live my life.
e. Staff told me what side effects to watch out for.
k. I, not staff, decided my treatment goals.
l.
m. If I had other choices, I would still get services
from this agency.
n. I would recommend this agency to a friend or
family member.
f.
Staff respected my wishes about who is and who
is not to be given information about my
treatment.
g. Staff were sensitive to my cultural background
(race, religion, language, etc.)
h. Staff helped me obtain the information I needed
so that I could take charge of managing my
illness.
i. I was encouraged to use consumer run programs
(support groups, drop-in centers, crisis phone
line, etc.)
j. I felt comfortable asking questions about my
treatment and medication.
I like the services I received here.
11
NOT
APPLICABLE
Disagree
RESPONSE OPTIONS
Strongly
Disagree
STATEMENT
F.
PERCEPTION OF CARE (Continued)
2.
[INDICATE WHO ADMINISTERED SECTION F - PERCEPTION OF CARE TO THE
RESPONDENT FOR THIS INTERVIEW.]
ADMINISTRATIVE STAFF
CARE COORDINATOR
CASE MANAGER
CLINICIAN PROVIDING DIRECT SERVICES
CLINICIAN NOT PROVIDING SERVICES
CONSUMER PEER
DATA COLLECTOR
EVALUATOR
FAMILY ADVOCATE
RESEARCH ASSISTANT STAFF
SELF-ADMINISTERED
OTHER (SPECIFY) ____________________________
12
G.
SOCIAL CONNECTEDNESS
1.
Please indicate your disagreement/agreement with each of the following statements. Please answer for
relationships with persons other than your mental health provider(s) over the past 30 days.
[READ EACH STATEMENT FOLLOWED BY THE RESPONSE OPTIONS TO THE CONSUMER.]
Disagree
Undecided
Agree
Strongly
Agree
REFUSED
RESPONSE OPTIONS
Strongly
Disagree
STATEMENT
a. I am happy with the friendships I have.
b. I have people with whom I can do enjoyable things.
c. I feel I belong in my community.
d. In a crisis, I would have the support I need from
family or friends.
IF YOUR PROGRAM DOES NOT REQUIRE SECTION H:
[IF THIS IS A BASELINE INTERVIEW, STOP NOW. THE INTERVIEW IS COMPLETE.]
[IF THIS IS A REASSESSMENT INTERVIEW, PLEASE GO TO SECTION I THEN K.]
[IF THIS IS A CLINICAL DISCHARGE INTERVIEW, PLEASE GO TO SECTION J THEN K.]
IF YOUR PROGRAM DOES REQUIRE SECTION H:
[IF THIS IS A BASELINE INTERVIEW, PLEASE PROCEED TO SECTION H THEN STOP. THE
INTERVIEW WILL BE COMPLETE.]
[IF THIS IS A REASSESSMENT INTERVIEW, PROCEED TO SECTION H, THEN I AND K.]
[IF THIS IS A CLINICAL DISCHARGE INTERVIEW, PROCEED TO SECTION H, SKIP SECTION I,
AND GO TO SECTION J AND K.]
13
H.
PROGRAM SPECIFIC QUESTIONS
SOME PROGRAMS HAVE PROGRAM SPECIFIC DATA THAT IS SUBMITTED TO TRAC. CMHS
WILL LET YOU KNOW IF YOU ARE REQUIRED TO DO SECTION H, AND YOU WILL HAVE A
SEPARATE SECTION H FORM.
FOR A LIST OF PROGRAMS THAT HAVE PROGRAM SPECIFIC DATA, SEE APPENDIX A OF
THE NOMS CLIENT-LEVEL MEASURES FOR DISCRETIONARY PROGRAMS PROVIDING
DIRECT SERVICES QUESTION-BY-QUESTION INSTRUCTION GUIDE FOR ADULT
PROGRAMS.
14
I.
REASSESSMENT STATUS
[SECTION I IS REPORTED BY GRANTEE STAFF AT REASSESSMENT.]
1.
Have you or other grant staff had contact with the consumer within 90 days of the last encounter?
2.
Yes
No
Is the consumer still receiving services from your project?
Yes
No
GO TO SECTION K.
15
J.
CLINICAL DISCHARGE STATUS
[SECTION J IS REPORTED BY GRANTEE STAFF ABOUT THE CONSUMER AT CLINICAL DISCHARGE]
1.
On what date was the consumer discharged?
|____|____| / |____|____|____|____|
MONTH
YEAR
2.
What is the consumer’s discharge status?
Mutually agreed cessation of treatment
Withdrew from/refused treatment
No contact within 90 days of last encounter
Clinically referred out
Death
Other (Specify) __________________________________
IF A DISCHARGE INTERVIEW WAS CONDUCTED, CONTINUE TO SECTION K.
IF A DISCHARGE INTERVIEW WAS NOT CONDUCTED:
•
IF STAFF PREVIOUSLY INDICATED “ADMINISTRATIVE DATA ONLY” WOULD BE SUBMITTED,
CONTINUE TO SECTION K.
•
IF STAFF PREVIOUSLY INDICATED “NO DATA” WOULD BE SUBMITTED, STOP HERE.
16
K.
SERVICES RECEIVED
[SECTION K IS REPORTED BY GRANTEE STAFF AT REASSESSMENT AND DISCHARGE UNLESS STAFF
PREVIOUSLY INDICATED “NO DATA” WOULD BE SUBMITTED]
1.
On what date did the consumer last receive services?
|____|____| / |____|____|____|____|
MONTH
YEAR
[IDENTIFY ALL OF THE SERVICES YOUR PROJECT PROVIDED TO THE CONSUMER SINCE HIS/HER
LAST NOMS INTERVIEW; THIS INCLUDES CMHS-FUNDED AND NON-FUNDED SERVICES.]
Core Services
1.
2.
3.
4.
5.
Screening
Assessment
Treatment Planning or Review
Psychopharmacological Services
Mental Health Services
Yes
Provided
No
[IF YES, PLEASE ESTIMATE HOW FREQUENTLY MENTAL HEALTH SERVICES WERE
DELIVERED.]
Number of times ____ _ per
Day
Week
Month
Year
6.
7.
8.
9.
Yes
No
Co-Occurring Services
Case Management
Trauma-specific Services
Was the Consumer referred to another provider for any of the above core services?
Yes No
Support Services
1. Medical Care
2. Employment Services
3. Family Services
4. Child Care
5. Transportation
6. Education Services
7. Housing Support
8. Social Recreational Activities
9. Consumer Operated Services
10. HIV Testing
Yes
Provided
No
11. Was the consumer referred to another provider for any of the above support services?
Yes No
17
| File Type | application/pdf |
| File Title | CMHS NOMs Adult Client-level Measures for Discretionary Programs Providing Services |
| Subject | record Management, demographic data, functioning, stability in housing, education and employment, crime and criminal justice sta |
| Author | TRAC |
| File Modified | 2011-03-18 |
| File Created | 2010-03-22 |