Form 1 STATE IMPLEMENTATION GRANT PROGRAM QUESTIONNAIRE

OMB Control Number 0915-0335

Expiration Date XX/XX/201X

ATTACHMENT H:

STATE IMPLEMENTATION GRANT PROGRAM QUESTIONNAIRE

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 0915-0335. Public reporting burden for this collection of information is estimated to average .75 hour 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 10‑29, Rockville, MD, Maryland, 20857

State Implementation Grant Questionnaire

Insight Policy Research developed this questionnaire for the Evaluation of the Combating Autism Act Initiative (CAAI). The purpose of the questionnaire is to gather information that can be summarized across all State Implementation Grants, in order to provide MCHB with a collective snapshot of the States’ CAAI-related efforts and accomplishments.

The questionnaire asks about SIG-funded activities and outcomes in the following areas:

• Increasing awareness of ASD among professionals and the public

• Training professionals and families

• Reducing barriers to ASD screening and diagnostic evaluation

• Improving systems of care for children and youth with ASD and other DD

• Infrastructure building

Insight will synthesize the information gathered through this questionnaire with information from grantee progress reports and semi-structured interviews, and the results will be presented in a summary evaluation report for MCHB.

Section I: Increasing Awareness of ASD

In the table on the following page, please identify any ASD-related materials that have been developed and/or disseminated as part of your grant in order to raise awareness of ASD and other DD. Examples may include customized versions of CDC “Learn the Signs, Act Early” materials, or original materials developed for parents, pediatricians, early childhood educators, etc.

In column A, please list each unique resource material developed or disseminated. Examples may include fact sheets, websites, and brochures. If a product is translated into multiple languages, list each translation separately.

In column B, briefly describe the topic addressed in each product (e.g., Early signs and symptoms of ASD, Resources for transition age youth with ASD).

In column C, please indicate the medium for each product (e.g., hard copy, website, downloadable pdf).

In column D, for each product, please indicate the number distributed (for hard copy materials, CDs, DVDs), or the number of website views or hits, if this information is available.

Informational Resources for Increasing Awareness of ASD and other DD
A Resource Material	B Topic	C Medium	D Number distributed

Section II: Training

Please document any ASD-related trainings that have been supported in full or in part by your grant.

In column A, please indicate the target audience for each ASD/DD- related training.

In column B, briefly describe the general topic or topics covered during training (e.g., screening tools, family-centered, community-based medical home, issues pertaining to transition age youth).

In column C, please indicate the mode of delivery (e.g., in-person, webinar, CD/DVD).

In column D, please indicate the approximate number reached, if these data are available (e.g. number of pediatric practices, number of public health nurses, or number of families).

Training Activities
A Target audience	B Topic of Training	C Mode of delivery	D Number trained

Section III: Monitoring ASD screening and diagnostic evaluation

Please complete the table below to indicate what kinds of monitoring activities are currently in place within your State.

In column A, please indicate the scope of the monitoring activities (e.g., is it Statewide or does it include selected practices, communities, or a selected subpopulation of health care consumers?).

In column B, please indicate how often data are collected.

In column C, please indicate whether or not data on changes over time are available and if so, document any results.

Monitoring Access to Screening and Diagnostic Services
	A Population covered	B Frequency of data collection	C Measured changes
Rates of screening at 18 and 24 months
Average age of confirmed ASD diagnosis or rule-out
Time between screening and diagnosis
Time between diagnosis and enrollment in intervention services

Section IV: Improving Systems of Care

The following questions are aimed at assessing your State’s efforts to improve systems of care for children and youth with ASD and other DD. The questions focus on the following components of a comprehensive, coordinated system of services*:

(1) partnerships between professionals and families of children and youth with ASD;

(2) access to a culturally competent family-centered medical home which coordinates care with pediatric subspecialties and community-based services;

(3) access to adequate health insurance and financing of services;

(4) community services organized for easy use by families, and

(5) transition to adult health care.

* There are no questions in this section pertaining to early and continuous screening for ASD and other developmental disabilities, as data on this indicator are being collected elsewhere.

Promoting family involvement and partnerships between professionals and families

For each of the following items, please place a checkmark in column B if this is an activity that your States has undertaken in association with your grant.

In column C, please report any outputs associated with that activity.

A Activity	B (Check if yes)	C Outputs
Does your project team include any family members of CSHCNs?		If yes, how many family members have been involved in these activities to date?
Does your project team engage family members of CSHCN in any of the following: Strategic planning Program planning Materials development Training of MCH providers
Are any family members compensated for their time and expenses?		If yes, how many are compensated?
Has your project team provided any providers or health care practices with technical assistance pertaining to family-centered care?		If yes, how many providers or practices have received technical assistance?

Access to a culturally competent family-centered medical home

1. Have any SIG funds been used to support the training of medical practices in the medical home model for ASD and other DD?

• No

• Yes; If yes:

How many medical practices have participated in such trainings?

2. Has your SIG team disseminated validated tools such as the Medical Home Index to practice sites?

• No

• Yes; If yes:

What tools were disseminated?

How many providers or practices received the tools?

3. Has your State used any SIG funds to provide social service agencies, families and other appropriate community-based organizations with lists of medical home sites?

• No

• Yes; If yes:

How many families have received such lists?

How many agencies or organizations received such lists?

1. Have your SIG funds supported any efforts to convene with partners to address gaps in insurance coverage and other financing of services for ASD and other DD?

• No

• Yes; If yes, please mark the partners with which you have worked to address gaps in coverage:

• Medicaid

• State insurance commissioners

• Health insurance companies/managed care organizations

• Provider organizations (e.g., hospitals, physician groups)

• Health purchasers (e.g. employers, unions, and other employee-related organizations)

• Families

• Advocacy groups

• Policymakers

• Community-based organizations

• Education

• Other partners

2. Has your State provided families with training on financing needed services for CYSHCN?

• No

• Yes; If yes, how many families have participated?

3. Has your State worked with medical associations and insurance providers to review coding and reimbursement coverage for CYSHCN?

• No

• Yes; If yes:

How many associations and providers have you reached?

Access to adequate health insurance and financing of services

1. Has your SIG funding helped support any efforts to ensure that all families and children with special health care needs are aware of community-based support services for which they are eligible, and know how to access those services?

• No

• Yes; If yes:

How many families have been reached through these efforts? (Please provide your best estimate. If no data are available on number of families reached, enter Not Available.)

2. Has your SIG funding supported any efforts to measure satisfaction of families with the array of available community-based services for children and youth with ASD and other DD, and the delivery of such services?

• No

• Yes

3. Has your SIG funding helped support training for care coordinators in your State?

• No

• Yes; If yes, how many care coordinators have been trained?

How many families have received care coordination services through the State?

Community services organized for easy use by families*

*These items are based on the Ease of Use Framework developed by the National Center for Ease of Use of Community Based Services, available at http://www.communitybasedservices.org/

Services for Transition-Age Youth

(1) Did your SIG funding help support any of the following:

• Training of medical practices on transition care for youths with ASD

  • If yes, how many practices were reached?

• Training families on how to support the transition to adulthood for youth with ASD

  • If yes, how many families were trained?

• Developing materials or delivering information for youth with ASD to help them navigate the transition to adult health care and employment or educational opportunities.

  • If yes, how many youths were reached?

(2) Have SIG funds supported any efforts to assist families in finding adult medical practices that accept youth with ASD/DD and provide the full range of care and care coordination?

• How many families have received such assistance?

Infrastructure Development

For a network analysis of your grant program we ask you to complete the Network Diagram on the following page.

1. Enter the names of all organizations you, the grantee, consider partners in the implementation of grant activities.

2. Indicate the frequency of communication between the grantee and each partner. Communication can be either by telephone, email, or written reports, but the content of the communication must be regarding grant activities. Use the codes described below.

If communication between the grantee and the partners is at least:	Indicate this level by drawing the following type of line:
Weekly	(single thick line)
Twice a month	(double thin lines)
Monthly	(single thin line)
Quarterly	(dashed line)
Twice a year	(dotted line)
Yearly	(no line)

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