Form Self-Assessment_Pa Self-Assessment_Part_1_and_2

Attachment 3: Evidence-Based Practice (EBP) Self-Assessment Part 1
& Part 2

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

1

Welcome to the Evaluation of SAMHSA’s Cooperative Agreements to Benefit
Homeless Individuals (CABHI) Program

OMB No. 0930-0339
Expiration Date: 1/31/2017

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 09300339. Public reporting burden for this collection of information is estimated to average 35 minutes per respondent, per
year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, 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 SAMHSA Reports
Clearance Officer, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20857.

Evidence-Based Practice (EBP) Self-Assessment Part 1

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

2

Instructions

The Evaluation of SAMHSA's Cooperative Agreements to Benefit Homeless Individuals (CABHI)
Program is interested in learning more about the primary evidence-based practices (EBPs) being
implemented by CABHI grant projects. Because some projects are implementing multiple EBPs,
each grant Project Director has identified the PRIMARY EBPs (up to 3) for their CABHI project.
PRIMARY EBPs are defined as those that are received by the largest number of consumers or
clients served by the CABHI project.
This survey seeks general information about implementation of the primary EBP(s) being received
by your CABHI project consumers or clients, and about factors that may serve as barriers or
facilitators to implementation fidelity within projects, such as readiness to implement the EBP,
leadership, funding, training and supervision, quality improvement, and outcomes. Some of the
questions are focused on the grantee agency or the overall CABHI project, and others are focused
on the provider implementing the EBP, which may or may not be different from the grantee agency.
The focus is identified within each of the questions.
Clicking "next" at the bottom of every page moves you to the next set of questions and saves your
answers to that page. Once you have begun the survey, you may go back and modify your
responses at any time. If you are unable to complete the survey, you can return to complete it at a
later date using the same link in the invitation email. The survey will continue where you left off.
Click "next" below to begin taking this survey!

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

3

Grantee Information

2. Please indicate the SAMHSA Homeless project you are
responding for below. If needed, this information is included in
the email that provided the link to this survey.
(Select from drop down list)

6

Project:

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

4

Respondent Information

3. Please indicate your role(s) in the SAMHSA homeless project? (check all that apply)
c Project Director
d
e
f
g

Other 

c Project Manager/Coordinator
d
e
f
g

c Program Manager
d
e
f
g
c Local Evaluator
d
e
f
g

c Mental Health Clinician/Treatment Provider/Supervisor
d
e
f
g

c Substance Abuse Counselor/Treatment Provider/Supervisor
d
e
f
g

c Integrated Treatment Provider (Mental Health and Substance Abuse)
d
e
f
g
c Trauma Specialist
d
e
f
g
c Case Manager
d
e
f
g

c Benefits Specialist
d
e
f
g

c Peer Specialist/Consumer
d
e
f
g
c Vocation Specialist
d
e
f
g
c Housing Specialist
d
e
f
g

c Education Specialist
d
e
f
g

c Other (please specify below)
d
e
f
g

5
6  

4. What is the name of your agency/organization?
5
Other 

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

6  

5

5. What is your agency's role(s) in the SAMHSA homeless project? (check all that apply)
c Grantee agency
d
e
f
g

c Administrative/project coordination/oversight
d
e
f
g
c Research/evaluation
d
e
f
g

c Substance abuse treatment provider
d
e
f
g
c Mental health treatment provider
d
e
f
g

c Integrated treatment provider (mental health and substance abuse)
d
e
f
g
c Housing provider
d
e
f
g

Other 

c Shelter
d
e
f
g

c Case management provider
d
e
f
g

c Medical care provider (primary or specialized)
d
e
f
g
c Benefits assistance provider
d
e
f
g
c Education provider
d
e
f
g

c Employment or job training provider
d
e
f
g

c Veterans Administration services provider
d
e
f
g
c Justice/criminal justice provider
d
e
f
g

c Child and family services provider
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

6

EBP Information

Please answer the following questions for PRIMARY EBP you were asked to respond on for your grant project. 

6. Please indicate the EBP you are responding on
below.
(Select from drop down list)

6

EBP

Other (please specify EBP below if not in drop down list) 

5
6

Other 

7. Was this EBP proposed for implementation in your site's SAMHSA grant application?

j Yes
k
l
m
n
j No
k
l
m
n

8. What percentage of SAMHSA homeless project consumers or clients have received this
EBP over the course of the project to date?
j 0%
k
l
m
n

Other 
j 1­25%
k
l
m
n

j 26­50%
k
l
m
n
j 51­75%
k
l
m
n

j 76­100%
k
l
m
n

9. How is this EBP provided and is it paid for with SAMHSA homeless grant funds? (check
all that apply)
c Provided by grantee, paid for by the grant
d
e
f
g
c Provided by grantee, paid for in­kind
d
e
f
g

c Provided through linkage/referral, paid for by the grant
d
e
f
g
Yes 

c Provided through linkage/referral, paid for in­kind
d
e
f
g

Comments 

5

6

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

7

10. Where is this EBP provided? (check all that apply)
c Street
d
e
f
g

Yes 
c Jail or prison
d
e
f
g

c Hospital
d
e
f
g
c Shelter
d
e
f
g

c Drop­in center
d
e
f
g

c Residential treatment facility
d
e
f
g

c Transitional housing (other than residential treatment; including safe haven, three quarter or halfway house)
d
e
f
g
c Permanent housing
d
e
f
g

c Outpatient treatment center
d
e
f
g

c SAMHSA homeless project offices/grantee administration offices
d
e
f
g

Yes  Other (please specify below) 
c
d
e
f
g

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

8

Target Population

11. Which target populations have received this EBP through your SAMHSA homeless
Yes 
project
to date? (check all that apply)

c Individuals with Mental Health Disorders only
d
e
f
g

c Individuals with Substance Abuse/Dependence Disorders only
d
e
f
g

c Individuals with Co­Occurring Mental Health and Substance Use Disorders
d
e
f
g
c Veterans
d
e
f
g

c Youth (under 18 years old)
d
e
f
g
c Young adults (ages 18­21)
d
e
f
g
c Older adults (55 and over)
d
e
f
g

Yes 
c Undocumented immigrants
d
e
f
g

c Criminal Justice (e.g., Individuals previously incarcerated, in reentry/diversion programs or on probation/adjudication)
d
e
f
g

c Families
d
e
f
g

c Persons at risk or living with HIV/AIDS
d
e
f
g
c Chronic public inebriates
d
e
f
g

c Domestic violence victims
d
e
f
g

c Lesbian, gay, bisexual, transgender, questioning individuals and allies (LGBTQ/LGBTQA)
d
e
f
g
c Pregnant individuals
d
e
f
g

c Developmentally or physically disabled individuals
d
e
f
g
c None of the above specifically targeted
d
e
f
g
Other 
c Other (please specify below)
d
e
f
g

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

9

12. Which homeless populations have received this EBP through your SAMHSA homeless
project to date? (check all that apply)
c At risk of becoming homeless
d
e
f
g
c Acute (first time) homeless
d
e
f
g
Other 
c Episodically homeless
d
e
f
g
c Chronically homeless
d
e
f
g

c Homeless, not specified
d
e
f
g

c Other (please specify below)
d
e
f
g

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

10

Readiness to Implement EBP & Leadership

13. Why was this EBP selected by your SAMHSA homeless project? (check all that apply)
c Fit with the population(s) served
d
e
f
g

c Fit with overall organizational philosophy
d
e
f
g
c Already had the practice in place
d
e
f
g

c Outcomes aligned with program goals
d
e
f
g
c Required by SAMHSA grant
d
e
f
g

c Other (please specify below)
d
e
f
g

5

6  

14. What is the total length of experience the implementing agency has:
implementing this EBP as part of the SAMHSA homeless 

implementing this EBP overall (i.e. total length of 

project?

experience implementing)?

Less than one year

j
k
l
m
n

j
k
l
m
n

1­2 years

j
k
l
m
n

j
k
l
m
n

3­4 years

j
k
l
m
n

j
k
l
m
n

5 or more years

j
k
l
m
n

j
k
l
m
n

15. Which of the following best describes the current stage of implementation of this EBP
for SAMHSA homeless project consumers or clients?
j Preparation (e.g., hiring staff, conducting initial training, creating new operational polices & procedures, developing/finalizing strategic 
k
l
m
n
implementation plan) 

j Early Implementation (e.g., referrals, screening & assessments occurring, services are underway)
k
l
m
n

j Full Implementation (e.g., staff skillful in service delivery, new policies & procedures are routine, practice is fully integrated into 
k
l
m
n
agency/program) 

j Sustainability (e.g., sustainability plan developed & underway, continuous staff training & funding secured for future, outcomes used for 
k
l
m
n
program improvement) 

j Other (please specify below) 
k
l
m
n

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

11

16. How does the implementing agency demonstrate the priority it places on this EBP?
(check all that apply)
c There is an agency plan to implement the EBP
d
e
f
g
c Leadership frequently talks about the EBP
d
e
f
g

c Recruitment/selection of staff to implement the EBP (e.g., adequate number/types of staff)
d
e
f
g
c Allocation of funding/other resources for the EBP
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  
Other 

17. Does the implementing agency have a formal plan to guide implementation of this
EBP?

j Yes
k
l
m
n
j No
k
l
m
n

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

12

18. Which of the following is true of the implementing agency's implementation plan?
(check all that apply)
c It is a written document
d
e
f
g

c It is discussed at staff meetings or at meetings devoted to the plan
d
e
f
g
c All project staff are fully aware of the plan
d
e
f
g

c It has specific short­ and long­term objectives regarding EBP implementation
d
e
f
g

c It identifies strategies for stakeholder outreach/consensus building for the EBP
d
e
f
g
c It identifies sources of funding for the EBP
d
e
f
g

c It identifies training resources for EBP implementation
d
e
f
g

c It identifies strategies for EBP implementation and outcomes evaluation
d
e
f
g
c Other (please specify below) 
d
e
f
g

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

13

19. Within the implementing agency, how supportive is leadership of this EBP's
implementation?
j Extremely supportive
k
l
m
n

j Somewhat supportive
k
l
m
n
j Not at all supportive
k
l
m
n

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

14

20.
At what leadership level(s) within the agency is this support demonstrated? (check all
Other 
that apply)

c Executive Management (e.g., agency executive director)
d
e
f
g
c Program Management
d
e
f
g

c Clinical/Front Line Supervisors
d
e
f
g
c Other (please specify below)
d
e
f
g

5
Other 

6  

21. How is this support demonstrated? (check all that apply)
c Leadership is actively involved in EBP implementation
d
e
f
g

c Barriers that impede implementation or effectiveness are addressed
d
e
f
g

c Support exists for coaching/active supervision of staff directly implementing EBP
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

22. Has a staff person at the implementing agency been assigned to lead implementation
of the EBP?

j Yes
k
l
m
n
j No
k
l
m
n

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

15

23. What percent of his/her time is dedicated to leading the EBP's implementation?
j 100%
k
l
m
n

j 76­99%
k
l
m
n
j 51­75%
k
l
m
n
j 25­50%
k
l
m
n

j less than 25%
k
l
m
n

24. Which of the following is true for the staff person leading implementation of this EBP?
(check all that apply)
c S/he has the necessary authority to lead implementation
d
e
f
g
c S/he has adequate training/expertise in the EBP
d
e
f
g

c S/he has a good relationship with staff directly implementing the EBP
d
e
f
g

c His/her leadership of EBP implementation is perceived positively by others
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

25. Would you say the implementing agency’s interest in this EBP is:
j Limited to this SAMHSA­funded grant project only
k
l
m
n
j Extends beyond this project
k
l
m
n

j Other (please specify below)
k
l
m
n

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

16

26. Does the implementing agency have any explicit policies that SUPPORT
Other 

implementation of this EBP?
j No
k
l
m
n

j Yes (please explain below)
k
l
m
n

5

6  
No 

27. Does the implementing agency have any explicit policies that serve as BARRIERS to
implementation of this EBP?
j No
k
l
m
n

j Yes (please explain below)
k
l
m
n

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

17

28. Are there any state or local regulations or policies (e.g., from the mental health or
substance abuse authority) that SUPPORT implementation of this EBP?
j No
k
l
m
n

j Yes (please explain below)
k
l
m
n

5

6  

29. Are there any state or local regulations or policies that serve as BARRIERS to
implementation of this EBP?
j No
k
l
m
n

j Yes (please explain below)
k
l
m
n

5

6  

30. Are there state or local standards that have to be followed in implementing the EBP
(e.g., specific implementation guidelines related to staffing, fidelity checks, satisfaction
surveys, etc.)?
j No
k
l
m
n

j Yes (please explain below)
k
l
m
n

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

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Other 

31. How are these state or local standards established and enforced?
j Contracting
k
l
m
n
j Licensing
k
l
m
n

j Other (please specify below)
k
l
m
n

5

6  

32. Which of the following consequences may occur for not meeting these state or local
standards? (check all that apply)
c Corrective action plan
d
e
f
g

c Financial consequences
d
e
f
g

c Other (please specify below)
d
e
f
g

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

19

Funding
Other 

33. How is this EBP funded? (check all that apply)
c Medicaid (fee­for­service, Managed Care, Waiver, etc.)
d
e
f
g
c State agency funding (please specify below)
d
e
f
g
c SAMHSA homeless grant funds
d
e
f
g
c Other (please specify below)
d
e
f
g
c Don't know
d
e
f
g

If "state agency funding" or "other" indicated above, please specify below 

5

6

34. How have start up or conversion costs associated with this EBP (e.g., lost productivity
for training, hiring staff before clients enrolled, changing medical records and/or computer
systems, etc.) been financed?
j Costs were covered within the implementing agency’s own operating budget
k
l
m
n

j There was a discreet funding source that covered all costs (please specify below)
k
l
m
n

j There was a discreet funding source that covered some costs (please specify below)
k
l
m
n

j Don’t know
k
l
m
n

Specify discreet funding source as indicated above 

5

6

35. Which of the following best describes the financing for this EBP?
j No components of service are reimbursable
k
l
m
n
j Most costs are reimbursable
k
l
m
n

j Some costs are reimbursable
k
l
m
n

j Service pays for itself (i.e. all costs covered adequately, or funding of covered components compensates for non­covered components)
k
l
m
n
j Service pays for itself and reimbursement rates are attractive relative to competing non­EBP services
k
l
m
n

j Don’t know
k
l
m
n

36. Is there a plan to continue the EBP once SAMHSA homeless funding has ended?
j No
k
l
m
n

j Yes
k
l
m
n

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

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Other 

37. Why will the EBP not be continued after SAMHSA homeless funding ends? (check all
that apply)
c Plan not developed yet but intend to continue the EBP
d
e
f
g
c Insufficient funding
d
e
f
g

c Lack of support from partnering agencies
d
e
f
g
c Too many barriers to implementation
d
e
f
g

c Insufficient numbers of eligible consumers or clients
d
e
f
g
c Model was not viewed as successful
d
e
f
g
c Other (please specify below)
d
e
f
g

Other 

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

21

38. How will the EBP be continued/funded once SAMHSA homeless funding ends? (check
all that apply)
c With Medicaid funding
d
e
f
g

c With state funding (please specify below)
d
e
f
g

c With county/local funding (please specify below)
d
e
f
g
c With federal funding (please specify below)
d
e
f
g

c With philanthropic funding (please specify below)
d
e
f
g
c With other funding (please specify below)
d
e
f
g

Please specify source of funding as indicated above 

5

Other 

6

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

22

Hiring, Training & Supervision

39. Did the implementing agency receive expert advice/consultation regarding strategies
to support implementation of this EBP?
j No
k
l
m
n

j Yes, initially only
k
l
m
n

j Yes, initially & ongoing
k
l
m
n

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

23

40. Who received this consultation? (check all that apply)
c Agency Administrators
d
e
f
g

c Program Directors/Supervisors
d
e
f
g
c Other (please specify below)
d
e
f
g

5

Other 

6  

41. Who supported/funded this consultation? (check all that apply)
c SAMHSA (through homeless grant funds)
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

42. Who provided this consultation?
5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

24

43. Did staff selection/recruitment include attention to ensuring staff have the pre­requisite
skills and/or credentials required by this EBP?
Yes 

j Yes
k
l
m
n
j No
k
l
m
n

44. Was skills training provided to practitioners to support implementation of this EBP?
j Yes, initial training provided only
k
l
m
n

j Yes, both initial & refresher training provided
k
l
m
n
j No
k
l
m
n

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

25

Yes  Which of the following was true of the initial skills training that was provided? (check
45.

all that apply)
c Trainer was an expert who is experienced or certified in the EBP
d
e
f
g
c Training comprehensively addressed all elements of the EBP
d
e
f
g

c Active learning strategies were used (e.g., role play, group work, feedback)
d
e
f
g
c Teaching aides (e.g., worksheets, manuals, handouts) were used
d
e
f
g

c A SAMHSA Took Kit was utilized or referenced as part of the training
d
e
f
g
c None of the above
d
e
f
g

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

26

46. If refresher training is made available to reinforce application of this EBP and to help
staff deal with emerging practice issues, how often is it offered?
j Refresher training is not offered
k
l
m
n
j Monthly or more frequently
k
l
m
n
j Quarterly
k
l
m
n
j Annually
k
l
m
n

j Only as needed/requested
k
l
m
n
Other 

47. Which of the following training methods have been used? (check all that apply)
c Computer assisted training
d
e
f
g

c In­person training workshops
d
e
f
g

c Staff provided with training materials to “self­teach”
d
e
f
g
c Staff observe/shadow experienced staff person(s)
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

48. Does all staff implementing this EBP receive the same training?

j Yes
k
l
m
n

j No (please explain below)
k
l
m
n

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

27

49. Do all practitioners delivering this EBP receive ongoing supervision and oversight?

j Yes
k
l
m
n
j No
k
l
m
n

Other 

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

28

50. Which of the following is true of the supervision provided? (check all that apply)
c Practitioners receive structured face­to­face supervision on a weekly basis
d
e
f
g

c Practitioners receive supervision, but less than weekly (please specify frequency below)
d
e
f
g
c Supervision is provided by a practitioner experienced in this EBP
d
e
f
g

c Supervision includes observation of EBP implementation, coaching & feedback
d
e
f
g
c Supervision is provided but is not specific to the practice
d
e
f
g
c Other (please specify below)
d
e
f
g

If supervision provided less than weekly or "Other" indicated, please specify below 

5

6

51. Is there support/buy­in for implementation of this EBP among practitioners?

j Yes
k
l
m
n
j No
k
l
m
n

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

29

 Other 

52. Which of the following is true with regard to how practitioners demonstrate
support/buy­in? (check all that apply)
c Practitioners voice support for the EBP
d
e
f
g

c Practitioners can describe how they’ve used the EBP
d
e
f
g

c Practitioners can describe how the EBP benefits/helps clients
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

30

Fidelity/Outcomes Monitoring & Performance Improvement

53. Are all consumers or clients screened to determine whether they qualify for receiving
this EBP using standardized tools or admission criteria?

j Yes
k
l
m
n
j No
k
l
m
n

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

31

54. Why are consumers or clients not screened to determine whether they qualify for the
EBP? (check all that apply)
c All clients receive the intervention
d
e
f
g

c No standardized tool or admission criteria available
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

32

55. To date, how many consumers or clients participated in this EBP during the grant
period? (if you are not certain of the exact amount, please provide your best estimate)
5
6  

56. How many consumers or clients were eligible to participate during the grant period? (if
you are not certain of the exact amount, please provide your best estimate)
5
6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

33

57. How is fidelity to this EBP monitored? (check all that apply)
c We do not monitor fidelity to this EBP
d
e
f
g

c Regular use of a standardized fidelity tool/checklist (please specify below)
d
e
f
g
c Direct observation
d
e
f
g
c Document review
d
e
f
g

c Focus groups or interviews with program consumers or clients
d
e
f
g
c Key informant interviews
d
e
f
g

c Tape/video recorded sessions/groups
d
e
f
g
c Other (please specify below)
d
e
f
g

If standardized tool/checklist used or "Other" indicated above, please specify 

5

6

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

34

58. How often is fidelity data collected/assessed for this EBP?
j Ongoing
k
l
m
n

j Every six months
k
l
m
n
j Annually
k
l
m
n

j Other (please specify below)
k
l
m
n

5

6  

59. Who conducts fidelity assessments for this EBP? (check all that apply)
c Staff internal to implementing agency
d
e
f
g

c Staff external to implementing agency
d
e
f
g
c Grant project evaluator
d
e
f
g
c Consultant
d
e
f
g

c Other (please specify below)
d
e
f
g

5

6  

60. When was the last fidelity assessment done and what were the results? (If you are not
certain, please provide your best estimate)
Date conducted:
Measure used:
Score/results:

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

35

61. Which of the following is true regarding the use of fidelity performance data? (check all
that apply)
c Data is shared with project staff
d
e
f
g

c Data is shared with internal advisory groups, board members, etc.
d
e
f
g
c Data is shared publicly via the web, agency annual reports, etc.
d
e
f
g
c Data is used for quality improvement
d
e
f
g

c Implementation adjustments have been made based on fidelity data
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

62. To what degree have the core components of this EBP been implemented to fidelity so
far?
j Low – Less than 50% of components implemented to fidelity
k
l
m
n
j Moderate – 50­80% of components implemented to fidelity
k
l
m
n
j High – 81­100% of components implemented to fidelity
k
l
m
n
j NA
k
l
m
n

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

36

63. Why has this EBP been implemented with moderate to low fidelity so far?
j All components planned but not yet fully implemented
k
l
m
n
j Some components were purposefully modified
k
l
m
n
j NA
k
l
m
n

j Other (please describe below)
k
l
m
n

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

37

64. Please describe how and why this EBP was modified (e.g., why certain components
were not implemented or revised or new components added)
5

6  

65. Are there any plans to maintain fidelity to this EBP after the grant period ends?
j No
k
l
m
n

j Yes (please describe below)
k
l
m
n

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

38

66. Do you anticipate any BARRIERS to maintaining fidelity of this EBP after the grant
period ends?
j No
k
l
m
n

j Yes (please describe below)
k
l
m
n

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

39

67. Are outcome data (e.g. changes in client functioning, access to treatment,
housing/homeless status) related to this EBP collected?

j Yes
k
l
m
n
j No
k
l
m
n

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

40

68. How are the outcome data used? (Check all that apply)
c Data are shared with practitioners to help them track/monitor client progress.
d
e
f
g

c Data are shared with agency leadership to help inform implementation of the EBP.
d
e
f
g

c Data are shared with stakeholders to solicit support (e.g. additional funding/resources) for EBP implementation.
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

41

Overall Barriers/Facilitators

69. Overall, what factors have served as BARRIERS to implementation of this EBP during
this project (i.e. have hindered successful implementation)? (check all that apply)
c Lack of a clear strategic plan for implementing the EBP
d
e
f
g
c Inadequate financing for the EBP
d
e
f
g

c Limited staff time/staff resources for EBP implementation
d
e
f
g
c Staff turnover
d
e
f
g

c Lack of on­going training, supervision, and consultation on the EBP
d
e
f
g
c Lack of positive practitioner attitudes toward the EBP
d
e
f
g
c Lack of prior experience with this EBP
d
e
f
g

c Lack of prior experience with other EBPs
d
e
f
g
c State or local policy/regulations
d
e
f
g

c Grantee or partner agency policies or practices
d
e
f
g

c Lack of support for implementation from key leaders at grantee or partner agency
d
e
f
g
c Lack of support for implementation from key external stakeholders
d
e
f
g
c No barriers encountered
d
e
f
g

c Other (please specify below)
d
e
f
g

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

42

70. Overall, what factors have served as FACILITATORS to implementation of this EBP
during this project (i.e. have helped with successful implementation)? (check all that apply)
c Clear strategic plan for implementing the EBP
d
e
f
g
c Adequate financing for the EBP
d
e
f
g

c Adequate allocation of staff time/staff resources for EBP implementation
d
e
f
g
c Access to on­going training, supervision, and consultation on the EBP
d
e
f
g
c Positive practitioner attitudes toward the EBP
d
e
f
g
c Prior experience with this EBP
d
e
f
g

c Prior experience with other EBPs
d
e
f
g

c Supportive state or local policy/regulations
d
e
f
g

c Supportive grantee or partner agency policies or practices
d
e
f
g

c Support for implementation from key leaders at grantee or partner agency
d
e
f
g
c Support for implementation from key external stakeholders
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

43

Survey (Part I) Completed!

Thank you for your time in completing this survey! 
If you received instructions to also complete Part II of this survey, please follow the appropriate link in the email you 
received to complete Part II. 

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

44

Welcome to the Evaluation of SAMHSA’s Cooperative Agreements to Benefit
Homeless Individuals (CABHI) Program

OMB No. 0930-0339
Expiration Date: 1/31/2017

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 09300339. Public reporting burden for this collection of information is estimated to average 15 minutes per respondent, per
year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, 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 SAMHSA Reports
Clearance Officer, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20857.

Evidence-Based Practice (EBP) Self-Assessment Part 2
Assertive Community Treatment (ACT)/Intensive Case
Management (ICM)

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

45

Instructions

You have been asked to complete this part of the survey because your CABHI project is
implementing the Assertive Community Treatment (ACT) or Intensive Case Management (ICM)
model.
This survey seeks additional information to confirm the extent to which this EBP is being
implemented, degree of implementation fidelity, and specific modifications that may have been made
for use by local SAMHSA homeless projects.
Clicking "next" at the bottom of every page moves you to the next set of questions and saves your
answers to that page. Once you have begun the survey, you may go back and modify your
responses at any time. If you are unable to complete the survey, you can return to complete it at a
later date using the same link in the invitation email. The survey will continue where you left off.
Click "next" below to begin taking this survey!

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

46

Grantee Information

1. Please indicate the SAMHSA Homeless project you are
responding for below. If needed, this information is included in
the email that provided the link to this survey.
(Select from drop down list)

6

Project:

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

47

Respondent Information

2. Please indicate your role(s) in the SAMHSA homeless project? (check all that apply)
c Project Director
d
e
f
g

c Project Manager/Coordinator
d
e
f
g
c Program Manager
d
e
f
g
c Local Evaluator
d
e
f
g

c Mental Health Clinician/Treatment Provider/Supervisor
d
e
f
g

c Substance Abuse Counselor/Treatment Provider/Supervisor
d
e
f
g

c Integrated Treatment Provider (Mental Health and Substance Abuse)
d
e
f
g
c Trauma Specialist
d
e
f
g
c Case Manager
d
e
f
g

c Benefits Specialist
d
e
f
g

c Peer Specialist/Consumer
d
e
f
g
c Vocation Specialist
d
e
f
g
c Housing Specialist
d
e
f
g

c Education Specialist
d
e
f
g

c Other (please specify below)
d
e
f
g

5
6  

3. What is the name of your agency/organization?
5
6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

48

4. What is your agency's role(s) in the SAMHSA homeless project? (check all that apply)
c Grantee agency
d
e
f
g

c Administrative/project coordination/oversight
d
e
f
g
c Research/evaluation
d
e
f
g

c Substance abuse treatment provider
d
e
f
g
c Mental health treatment provider
d
e
f
g

c Integrated treatment provider (mental health and substance abuse)
d
e
f
g
c Housing provider
d
e
f
g
c Shelter
d
e
f
g

c Case management provider
d
e
f
g

c Medical care provider (primary or specialized)
d
e
f
g
c Benefits assistance provider
d
e
f
g
c Education provider
d
e
f
g

c Employment or job training provider
d
e
f
g

c Veterans Administration services provider
d
e
f
g
c Justice/criminal justice provider
d
e
f
g

c Child and family services provider
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

49

ACT/ICM Questions

5. What is the average caseload size of consumers or clients per ACT/ICM team member or
staff?
j 50 or more
k
l
m
n
j 35 to 49
k
l
m
n
j 21 to 34
k
l
m
n
j 11 to 20
k
l
m
n

j 10 or fewer
k
l
m
n
Other 

6. Are ACT/ICM consumers or clients assigned to the caseload of one staff member who is
their primary contact /service provider, or are they assigned to the team and team
members work with all consumers or clients?
j Staff members carry individual caseloads
k
l
m
n

j Staff members work with all consumers or clients (i.e. consumers or clients are assigned to the team)
k
l
m
n
j Other (please specify below) 
k
l
m
n

7. In a typical 2­week period, what percentage of consumers or clients has face­to­face
contact with more than one ACT/ICM team member or staff?
j 90% ­ 100%
k
l
m
n
j 64 ­ 89%
k
l
m
n
j 37 ­ 63%
k
l
m
n
j 11 ­ 36%
k
l
m
n
j 0 ­ 10%
k
l
m
n

8. How often do the ACT team/ICM staff members meet as a full group to review services
provided to consumers or clients?
j At least 4 days/week
k
l
m
n

j At least 2 days/week but less than 4 times/week
k
l
m
n
j 1 day per week
k
l
m
n

j At least twice per month but less than 1day/ week
k
l
m
n
j Once per month or less
k
l
m
n

j Staff do not meet as a full group to discuss consumers or clients
k
l
m
n

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50

9. Are all consumers or clients reviewed at each ACT/ICM team/staff meeting?
j Yes, each consumer or client is reviewed at each meeting, even if briefly
k
l
m
n
j No, each consumer or client is not discussed each time staff meet
k
l
m
n

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51

10. Does the ACT team leader/ICM supervisor provide direct services to consumers or
clients?

j Yes
k
l
m
n
j No
k
l
m
n

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52

11. What percentage of the ACT team leader/ICM supervisor’s time is devoted to direct
services?
j Over 50% of the time
k
l
m
n
j 25­ 50% of the time
k
l
m
n

j Less than 25% of the time or routinely as back­up
k
l
m
n

j No regular percentage; only on rare occasions as back­up
k
l
m
n

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

53

12. What is the total number of staff positions on the ACT team/in the ICM program?
Number of staff positions

13. Please provide the following information to help determine what the staff turnover rate
has been for the program: (if you do not know the exact numbers, please provide your
best estimate)
Number of months 
team/program in existence:
Number of staff who have 
left since program began:

14. Which of the following best represents ACT team/ICM program staffing capacity over
the past 12 months?
j Operated at 95% or more of full staffing
k
l
m
n
j Operated at 80­94% of full staffing
k
l
m
n
j Operated at 65­79% of full staffing
k
l
m
n
j Operated at 50­64% of full staffing
k
l
m
n

j Operated at less than 50% of full staffing
k
l
m
n

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54

15. How many consumers or clients are served by the ACT team/ICM program?
Number served
Other 

16. Is a psychiatrist assigned to work with the ACT team/ICM program?
j No
k
l
m
n

j Yes (specify the number of full­time equivalent (FTE) psychiatrists assigned)
k
l
m
n

5
6  

17. Is a nurse assigned to work with the ACT team/ICM program?
j No
k
l
m
n

j Yes (specify the number of full­time equivalent (FTE) nurses assigned)
k
l
m
n

5
Other 

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

55

18. Is a substance abuse specialist assigned to work with the ACT team/ICM program?
j No
k
l
m
n

j Yes (specify the number of full­time equivalent (FTE) substance abuse specialists assigned)
k
l
m
n

5
6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

56

19. How much training or clinical experience are assigned substance abuse specialists
required to have? (check all that apply)
c At least one year of substance abuse treatment training
d
e
f
g

c Less than one year of substance abuse treatment training
d
e
f
g

c At least one year of supervised clinical substance abuse treatment experience
d
e
f
g

c Less than one year of supervised clinical substance abuse treatment experience
d
e
f
g

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57

20. Is a vocational specialist assigned to work with the ACT team/ICM program?
j No
k
l
m
n

j Yes (specify the number of full­time equivalent (FTE) vocational specialists assigned)
k
l
m
n

5
6  

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58

21. Are assigned vocational specialists required to have at least one year of
training/experience in vocational rehabilitation and support?

j Yes
k
l
m
n
j No
k
l
m
n

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59

22. Is a housing specialist assigned to work with the ACT team/ICM program?
j No
k
l
m
n

j Yes (specify the number of full­time equivalent (FTE) housing specialists assigned)
k
l
m
n

5
6  

23. How many full­time equivalent (FTE) staff does the ACT team/ICM program have?
j At least 10 FTE staff
k
l
m
n
j 7.5­ 9.9 FTE staff
k
l
m
n
j 5.0­ 7.4 FTE staff
k
l
m
n
j 2.5­ 4.9 FTE staff
k
l
m
n

j Less than 2.5 FTE staff
k
l
m
n

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60

24. Are any of the following used as formal admission criteria by the ACT team/ICM
program to screen potential consumers or clients?
Yes

No

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Homelessness

j
k
l
m
n

j
k
l
m
n

Involvement with the 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Diagnosis of serious mental 
illness
Diagnosis of co­occurring 
substance use disorder
Pattern of frequent hospital 
admissions
Other 
Frequent use of emergency 
services
Consumers discharged from 
long­term hospitalization

criminal justice system
Not adhering to 
medications as prescribed
Not benefitting from usual 
mental health services (e.g. 
day treatment)
Other (please specify 
below)
If 'Other' indicated above, please specify below 

5

6

25. Do all consumers or clients served by the program meet the admission criteria you
indicated in your response to the previous question?
j Yes, all cases comply with this admission criteria
k
l
m
n

j Sometimes we accept consumers or clients who do not meet these criteria
k
l
m
n
j We accept most referrals
k
l
m
n

j There are no formal admission criteria for the program
k
l
m
n

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

61

26. On average, how many new consumers or clients has the ACT team/ICM program
taken on during the last six months of operation?
j 6 or fewer per month
k
l
m
n
j 7­9 per month
k
l
m
n

j 10­12 per month
k
l
m
n
j 13­15 per month
k
l
m
n

j 16 or more per month
k
l
m
n

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

62

27. Which of the following services are delivered to ACT team/ICM program consumers or
clients directly by program staff, and which are delivered by another department or
agency? (check all that apply)
Directly by ACT team/ICM program 

By other department/agency

NA

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Housing support

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Substance abuse treatment

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Employment or other 

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

staff
Medication prescription, 
administration, monitoring, 
and documentation
Counseling/individual 
supportive therapy

rehabilitative services (e.g., 
Activities of Daily 
Living/ADLs)

28. What is the ACT team/ICM program staff role in providing 24 hour emergency services?
j Provides 24 hour crisis coverage directly (i.e. a staff member is on­call at all times)
k
l
m
n

j Provides back­up support to emergency/on­call service (e.g., crisis program is called first, makes decision about need for direct ACT/ICM 
k
l
m
n
program involvement) 

j Is available by phone, mostly in consulting role
k
l
m
n

j Emergency service has program­generated protocol to follow for program consumers or clients
k
l
m
n
j Has no responsibility for handling crises after hours
k
l
m
n
j Other (please specify below)
k
l
m
n

5

6  

29. How often is ACT team/ICM program staff involved in the decision to admit consumers
or clients for psychiatric hospitalization?
j Staff are involved in 95% or more of admissions
k
l
m
n
j Staff are involved in 65­94% of admissions
k
l
m
n
j Staff are involved in 35­64% of admissions
k
l
m
n
j Staff are involved in 5­34% of admissions
k
l
m
n

j Staff are involved in less than 5% of admissions
k
l
m
n

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

63

30. When consumers or clients are hospitalized for psychiatric or substance abuse
reasons, how often are ACT team/ICM program staff involved with discharge planning?
j At least 95% of the time
k
l
m
n
j 65­94% of the time
k
l
m
n
j 35­64% of the time
k
l
m
n
j 5­34% of the time
k
l
m
n

Yes 

j Less than 5% of the time
k
l
m
n

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

64

31. Which of the following happens when an ACT/ICM consumer or client’s need for
services is reduced?
j They continue to be served on a time­unlimited basis
k
l
m
n

j They are discharged because they have graduated from services
k
l
m
n

j They are stepped down to less intensive services (Please describe below)
k
l
m
n
j Other (please describe below)
k
l
m
n

If stepped down or 'Other', please describe below 

5

6

32. What percentage of consumers or clients is expected to graduate from the ACT
team/ICM program within the next 12 months of operation?
j Less than 5%
k
l
m
n
j 5­17 %
k
l
m
n

j 18­37%
k
l
m
n
j 38­90%
k
l
m
n

j More than 90%
k
l
m
n

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

65

33. What percentage of face­to­face contacts with program consumers or clients occur in
the community (vs. in an office setting)?
j 80% or more
k
l
m
n
j 60­79%
k
l
m
n
j 40­59%
k
l
m
n
j 20­39%
k
l
m
n

j Less than 20%
k
l
m
n

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

66

34. Please estimate the number of consumers or clients who dropped out of ACT team/ICM
program services over the last 12 months of operation for the following reasons (do not
include those who graduated because their services needs were reduced):
# who refused services
# who cannot be located
# who have been closed 
because staff determined 
they could not serve them
# who dropped out for other 
reasons

35. What happens if a consumer or client continually refuses or does not comply with (e.g.,
misses appointments for) ACT team/ICM program services? (check all that apply)
c They are immediately discharged from the ACT team/ICM program
d
e
f
g

c Staff attempt to engage through street outreach and legal mechanisms (e.g., probation/parole, hospital commitment) but may eventually 
d
e
f
g
discharge 

c After initial attempt to engage, staff focus on most motivated consumers or clients
d
e
f
g

c Staff attempt to engage using assertive techniques (street outreach, legal mechanisms) as much as possible
d
e
f
g
c Staff consistently use assertive techniques to keep consumers involved in services
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

36. What methods do ACT team/ICM program staff use to keep consumers or clients
involved in services? (check all that apply)
c Outpatient commitment
d
e
f
g

c Representative payee services
d
e
f
g

c Contacts with probation/parole
d
e
f
g

c Street/Shelter outreach after enrollment
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

67

37. On average, how much face­to­face time do ACT team/ICM program staff have with
consumers or clients per week?
j 2 hours/week or more
k
l
m
n
j 85­119 minutes/week
k
l
m
n
j 50­84 minutes/week
k
l
m
n
j 15­49 minutes/week
k
l
m
n

j Less than 15 minutes/week
k
l
m
n

38. On average, how many face­to­face contacts do ACT team/ICM program staff have with
consumers or clients per week?
j 4 or more contacts/week
k
l
m
n
j 2­3 contacts/week
k
l
m
n
j 1­2 contacts/week
k
l
m
n

j Less than 1 contact/week
k
l
m
n

39. For each consumer or client who has a support system in the community, on average
how many contacts per month do ACT team/ICM program staff have with family, landlord,
employer, or other informal support network members?
j 4 or more contacts/month
k
l
m
n
j 2­3 contacts/month
k
l
m
n
j 1­2 contacts/month
k
l
m
n

j Less than 1 contact/month
k
l
m
n

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

68

40. How much formal individual substance abuse counseling do consumers or clients
with substance use disorders receive from ACT team/ICM program staff?
j 24 minutes or more/week
k
l
m
n

j Less than 24 minutes/week
k
l
m
n

j Staff integrates some substance abuse counseling into regular client contact, but no formal counseling
k
l
m
n
j Staff occasionally addresses substance abuse concerns with clients, but no formal counseling
k
l
m
n
j No direct substance abuse counseling provided
k
l
m
n

41. Of the consumers or clients with substance use disorders, what percentage attend at
least one substance abuse treatment group per month that is run by ACT team/ICM
program staff?
j 50% or more
k
l
m
n
j 35­49%
k
l
m
n
j 20­34%
k
l
m
n
j 5­19%
k
l
m
n

j Less than 5%
k
l
m
n

42. Which of the following principles and approaches does the ACT team/ICM program use
to treat consumers or clients with substance use issues? (check all that apply)
c Confrontation
d
e
f
g

c Mandated abstinence
d
e
f
g

c Reduction of use (i.e. harm reduction)
d
e
f
g

c Stage wise approach (e.g., stages of change)
d
e
f
g
c Referrals to inpatient rehab
d
e
f
g

c Referrals to detox ­ only when medically necessary
d
e
f
g
c Referrals to detox for other purposes
d
e
f
g
c Referrals to AA, NA, etc.
d
e
f
g

c Other (please specify below)
d
e
f
g

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

69

43. How are consumers or clients involved as ACT team/ICM program staff members?
(check all that apply)
c As full­time paid employees
d
e
f
g

c As part­time paid employees
d
e
f
g
c As volunteers
d
e
f
g

c As full professional team members/staff
d
e
f
g

c As case managers with reduced responsibilities
d
e
f
g
c As aides to the team/program staff
d
e
f
g

c In consumer­ or client­specific roles (e.g., self­help)
d
e
f
g
c Not at all
d
e
f
g

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

70

44. Were any of the following components of the ACT/ICM model difficult to implement?
Yes

No

Small caseload size (10:1)

j
k
l
m
n

j
k
l
m
n

Team approach

j
k
l
m
n

j
k
l
m
n

Frequent program meetings 

j
k
l
m
n

j
k
l
m
n

Practicing program lead

j
k
l
m
n

j
k
l
m
n

Continuity of staffing

j
k
l
m
n

j
k
l
m
n

Operating at full staff 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Explicit admission criteria

j
k
l
m
n

j
k
l
m
n

Low intake rate

j
k
l
m
n

j
k
l
m
n

Full responsibility of the 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Time­unlimited services

j
k
l
m
n

j
k
l
m
n

Services delivered in 

j
k
l
m
n

j
k
l
m
n

No dropout policy

j
k
l
m
n

j
k
l
m
n

Assertive engagement 

j
k
l
m
n

j
k
l
m
n

High intensity of services

j
k
l
m
n

j
k
l
m
n

High frequency of contacts

j
k
l
m
n

j
k
l
m
n

Working with consumers' 

j
k
l
m
n

j
k
l
m
n

to review each consumer or 
client

capacity
1 FTE psychiatrist on staff 
per 100 consumers or 
clients
2 FTE nurses on staff per 
100 consumers or clients
2 substance use specialists 
on staff per 100 consumers 
or clients
2 vocational specialists on 
staff per 100 consumers or 
clients
Program size (appropriate # 
of FTE staff)

ACT team/ICM program for 
treatment services
24 hour responsibility for 
crisis services
Responsibility for hospital 
admission
Responsibility for hospital 
discharge planning

community (vs. office based 
settings)

mechanisms used

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

71

informal support system
Direct provision of 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

individualized substance 
abuse treatment
Co­occurring disorder 
treatment groups provided
Co­occurring disorder 
model used
Consumers provide direct 
services
Other (please specify 
below)
If 'Other' indicated above, please specify below 

5

6

45. Did your agency make any adjustments or modifications to the ACT/ICM model?
j No
k
l
m
n

j Yes (please describe below)
k
l
m
n

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

72

46. Were any of the following types of evidence­based service interventions fully
imbedded within your implementation of the ACT/ICM model?
Yes

No

Motivational Interviewing

j
k
l
m
n

j
k
l
m
n

Cognitive Behavioral 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Peer Support

j
k
l
m
n

j
k
l
m
n

Strengths­Based Case 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Therapy (CBT)
Motivational Enhancement 
Therapy (MET)

Management/Approach
SSI/DI Outreach, Access & 
Recovery (SOAR)
Trauma­Specific 
Intervention (please specify 
below)
Other (please specify 
below)
If 'Trauma­Specific Intervention or 'Other' indicated above, please specify below: 

5

6

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

73

Survey Completed!

Thank you for your time in completing this survey! 

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

74

Welcome to the Evaluation of SAMHSA’s Cooperative Agreements to Benefit
Homeless Individuals (CABHI) Program

OMB No. 0930-0339
Expiration Date: 1/31/2017

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 09300339. Public reporting burden for this collection of information is estimated to average 15 minutes per respondent, per
year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, 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 SAMHSA Reports
Clearance Officer, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20857.

Evidence-Based Practice (EBP) Self-Assessment Part 2
Critical Time Intervention (CTI)

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

75

Instructions

You have been asked to complete this part of the survey because your CABHI project is
implementing the Critical Time Intervention (CTI) model.
This survey seeks additional information to confirm the extent to which this EBP is being
implemented, degree of implementation fidelity, and specific modifications that may have been made
for use by local SAMHSA homeless projects.
Clicking "next" at the bottom of every page moves you to the next set of questions and saves your
answers to that page. Once you have begun the survey, you may go back and modify your
responses at any time. If you are unable to complete the survey, you can return to complete it at a
later date using the same link in the invitation email. The survey will continue where you left off.
Click "next" below to begin taking this survey!

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

76

Grantee Information

1. Please indicate the SAMHSA Homeless project you are
responding for below.
(Select from drop down list)

6

Project:

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

77

Respondent Information

2. Please indicate your role(s) in the SAMHSA homeless project? (check all that apply)
c Project Director
d
e
f
g

c Project Manager/Coordinator
d
e
f
g
c Program Manager
d
e
f
g
c Local Evaluator
d
e
f
g

c Mental Health Clinician/Treatment Provider/Supervisor
d
e
f
g

c Substance Abuse Counselor/Treatment Provider/Supervisor
d
e
f
g

c Integrated Treatment Provider (Mental Health and Substance Abuse)
d
e
f
g
c Trauma Specialist
d
e
f
g
c Case Manager
d
e
f
g

c Benefits Specialist
d
e
f
g

c Peer Specialist/Consumer
d
e
f
g
c Vocation Specialist
d
e
f
g
c Housing Specialist
d
e
f
g

c Education Specialist
d
e
f
g

c Other (please specify below)
d
e
f
g

5
6  
Yes 

3. What is the name of your agency/organization?
5
6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

78

4. What is your agency's role(s) in the SAMHSA homeless project? (check all that apply)
c Grantee agency
d
e
f
g

c Administrative/project coordination/oversight
d
e
f
g
c Research/evaluation
d
e
f
g

c Substance abuse treatment provider
d
e
f
g
c Mental health treatment provider
d
e
f
g

c Integrated treatment provider (mental health and substance abuse)
d
e
f
g
c Housing provider
d
e
f
g

Other 

c Shelter
d
e
f
g

c Case management provider
d
e
f
g

c Medical care provider (primary or specialized)
d
e
f
g
c Benefits assistance provider
d
e
f
g
c Education provider
d
e
f
g

c Employment or job training provider
d
e
f
g

c Veterans Administration services provider
d
e
f
g
c Justice/criminal justice provider
d
e
f
g

c Child and family services provider
d
e
f
g
c Other (please specify)
d
e
f
g

Other 

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

79

CTI Questions

5. Where are consumers or clients who receive CTI services transitioning from? (check all
that apply)
c Hospital
d
e
f
g
c Shelter
d
e
f
g

c Housing setting (e.g., residential, transitional housing) (please specify below)
d
e
f
g
c Streets
d
e
f
g
Other 
c Prison
d
e
f
g
c Jail
d
e
f
g

c Other
d
e
f
g

If 'Housing Setting" or 'Other' selected above, please specify below 

5

6

6. Where are consumers or clients who receive CTI services transitioning to? (check all
that apply)
c Transitional housing
d
e
f
g
c Permanent housing
d
e
f
g

c Other (please specify below)
d
e
f
g

5

6  

7. In what type of setting is the CTI program based?
j Drop­in center
k
l
m
n
j Shelter
k
l
m
n

j Mental health inpatient unit
k
l
m
n
j Other (please specify below)
k
l
m
n

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

80

8. What staff members comprise the CTI team? (check all that apply)
Other 

c Psychiatrist
d
e
f
g

c Nurse
d
e
f
g

c Team leader /coordinator
d
e
f
g

c Housing case manager or specialist(s)
d
e
f
g
c CTI case managers/workers
d
e
f
g

c Other (please specify below)
d
e
f
g

5

6  

9. If a team leader/coordinator was indicated for the previous question, please specify
his/her credentials (e.g., MSW). Otherwise enter 'NA'.
5
6  

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81

10. What is the average consumer or client caseload size per CTI worker?
j More than 50
k
l
m
n
j 35 to 50
k
l
m
n
j 21 to 34
k
l
m
n
j 15 to 20
k
l
m
n

j 10 or fewer
k
l
m
n
Other 

11. Do CTI staff meet as a team to discuss consumer or client needs and care?

j Yes
k
l
m
n
j No
k
l
m
n

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82

12. How often are team meetings held?
j Weekly
k
l
m
n

j Bi­weekly
k
l
m
n

Other 

j Monthly
k
l
m
n

j Only as needed
k
l
m
n

j Other (please specify below)
k
l
m
n

5
6  

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83

13. How often are each CTI consumer or client's needs and care reviewed and discussed
by CTI program staff?
Other 

j Weekly
k
l
m
n

j Bi­Weekly
k
l
m
n
j Monthly
k
l
m
n

j Only as needed
k
l
m
n

j Other (please specify below)
k
l
m
n

5

6  

14. What types of supervision and organizational support does CTI program staff receive?
(check all that apply)
c Individual clinical supervision
d
e
f
g

c Field work observation/feedback
d
e
f
g

c Team case presentations/feedback
d
e
f
g

c Review/feedback of consumer or client case notes
d
e
f
g

c Resources to support work in the field, e.g., cell phones, etc.
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

 Other 

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84

15. Is there a 'pre­CTI' period during which CTI workers are able to establish relationships
and begin to engage consumers or clients prior to their transition to a new setting in the
community?

j Yes
k
l
m
n
j No
k
l
m
n

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85

16. What is the typical length of time between initial contact and a consumers or clients’
discharge or move to the community (i.e. length of 'pre­CTI' period)?
Other 

j Less than 1 week
k
l
m
n

j 1­2 weeks
k
l
m
n
j 3­4 weeks
k
l
m
n

j More than 1 month
k
l
m
n

j Other (please specify below)
k
l
m
n

5

6  

Yes 

17. How often do CTI workers typically meet with consumers or clients during the ‘pre­CTI
period’?
j Once
k
l
m
n

j 2­3 times
k
l
m
n
j 4 times
k
l
m
n

j Other (please specify below)
k
l
m
n

5

6  

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86

18. Is a CTI Intake Assessment completed?
j No
k
l
m
n

j Yes (please specify when it is completed)
k
l
m
n

5
6  

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87

19. Which of the following are components of the CTI Intake Assessment?
(Check all that apply)
Demographic information

c
d
e
f
g

Psychiatric history 

c
d
e
f
g

(diagnosis, symptoms, 
medications, 
hospitalizations)
Substance use history 

c
d
e
f
g

(diagnosis, symptoms, 
treatment history)
Homelessness/housing 

c
d
e
f
g

history
Reasons for housing 

c
d
e
f
g

loss/risks to housing stability
Financial supports

c
d
e
f
g

Formal & informal supports

c
d
e
f
g

Activities of Daily Living 

c
d
e
f
g

(ADL) skills
Strengths & interests of 

c
d
e
f
g

consumer or client
Other (please specify 

c
d
e
f
g

below)
If 'Other' indicated above, please specify below 

5

6

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88

Other 
20.
Are CTI services delivered in phases?

j No
k
l
m
n

j Yes (please indicate number of phases)
k
l
m
n

5
6  

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89

Yes 

21. How long does each phase of service last?
j 1 to 2 months
k
l
m
n
j 3 months
k
l
m
n

j More than 3 but less than 4 months
k
l
m
n
j More than 4 months
k
l
m
n

j Other (please specify below)
k
l
m
n

5

6  

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90

 Yes 

22. Is a CTI treatment plan completed?
j Yes, at the beginning of CTI services only
k
l
m
n
j Yes, for each phase of service
k
l
m
n
j No
k
l
m
n

j Other (please specify below)
k
l
m
n

5

6  

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91

23. What is the typical timeframe for completion of the treatment plan?
j Within 2 weeks prior to services/phase beginning
k
l
m
n
j Within 2 weeks after services/phase beginning
k
l
m
n
j 3­4 weeks after services/phase beginning
k
l
m
n
j Other (please specify below)
k
l
m
n

5

6  

24. Which of the following focus areas do CTI treatment plans typically address?
(Check all that apply)
Psychiatric treatment & 

c
d
e
f
g

medication management
Money management

c
d
e
f
g

Substance abuse 

c
d
e
f
g

management
Housing crisis management 

c
d
e
f
g

& prevention
Family interventions

c
d
e
f
g

Life skills training

c
d
e
f
g

Other (please specify 

c
d
e
f
g

below)
If 'Other' indicated above, please specify below 

5

6

25. How many of the focus areas indicated in the previous question typically comprise a
CTI treatment plan at any one point in time?
j More than 6
k
l
m
n
j 6
k
l
m
n

j 4­5
k
l
m
n
j 1­3
k
l
m
n

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92

26. Which of the following best describes how treatment plan focus areas are chosen?

c Based on consumer or client’s history or risk of homelessness
d
e
f
g

c Based on goal attainment/new risk areas identified at end of previous phase of CTI service
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

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93

27. How soon after the initial phase of CTI services (months 1­3) begins does contact
between CTI workers and consumers or clients occur using each of the following
methods?
Phone Contact

Home Visits

Setting (e.g., day program)

6

6

Initial Occurrence

Visits to Consumers' Treatment 

6

Other (please specify below) 

5

6

28. How often do CTI workers typically make contact with consumers or clients during the
initial phase (months 1­3) of service?
j Once per month
k
l
m
n

j 2­3 times per month
k
l
m
n
j 4 times per month
k
l
m
n

j Other (please specify below)
k
l
m
n

5
6  

29. How often do CTI workers typically meet with primary mental health and/or substance
use treatment providers during the initial phase (months 1­3) of service?
j Not at all
k
l
m
n

j Once per month
k
l
m
n

j 2­3 times per month
k
l
m
n
j 4 times per month
k
l
m
n

j Other (please specify below)
k
l
m
n

5
6  

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94

30. How often do CTI workers typically meet with housing providers including landlords
during the initial phase (months 1­3) of service?
j Not at all
k
l
m
n

j Once per month
k
l
m
n

j 2­3 times per month
k
l
m
n
j 4 times per month
k
l
m
n

j Other (please specify below)
k
l
m
n

5
6  

31. During the initial phase (months 1­3) of service, do CTI workers hold joint meetings
between:
Consumers or clients and 

Yes

No

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

their community linkages?
Linkages from different 
agencies?

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95

32. Which of the following principles and approaches do CTI staff use in their work with
consumers or clients? (check all that apply)
c Confrontation
d
e
f
g

c Abstinence only
d
e
f
g
c Harm reduction
d
e
f
g

c Stage wise approach (i.e. stages of change)
d
e
f
g

c Office­based assessments
d
e
f
g

c Community­based assessment and skill building
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

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96

33. What is the total length of time consumers or clients typically receive CTI services?
j 3 months
k
l
m
n
j 6 months
k
l
m
n
j 9 months
k
l
m
n

j 12 months
k
l
m
n

j Other (please specify below)
k
l
m
n

5

6  

34. Are consumers or clients ever discharged from CTI services early?
j No
k
l
m
n

j Yes (please give an example of a situation in which early discharge might occur)
k
l
m
n

5

6  

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97

35. Which of the following activities are most likely to occur during the initial phase
(months 1­3) of CTI services?
c CTI worker focuses with consumer or client on work accomplished and long­term goals
d
e
f
g
c CTI worker focuses on assessment and linkage with supports
d
e
f
g

c CTI worker accompanies consumer or client to appointments
d
e
f
g

c CTI worker observes consumer or client trying out skills and adjusts consumer support network
d
e
f
g
c CTI worker encourages consumer or client and caregivers to work out problems on their own
d
e
f
g
c CTI worker substitutes for caregivers when necessary
d
e
f
g

c CTI worker mediates conflicts between consumer or client and caregivers
d
e
f
g

36. Which of the following activities are most likely to occur during the middle phase
(months 4­6) of CTI services?
c CTI worker focuses with consumer or client on work accomplished and long­term goals
d
e
f
g
c CTI worker focuses on assessment and linkage with supports
d
e
f
g

c CTI worker accompanies consumer or client to appointments
d
e
f
g

c CTI worker observes consumer or client trying out skills and adjusts consumer support network
d
e
f
g
c CTI worker encourages consumer or client and caregivers to work out problems on their own
d
e
f
g
c CTI worker substitutes for caregivers when necessary
d
e
f
g

c CTI worker mediates conflicts between consumer or client and caregivers
d
e
f
g

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98

37. Which of the following activities are most likely to occur during the final phase (months
7­9) of CTI services?
c CTI worker focuses with consumer or client on work accomplished and long­term goals
d
e
f
g
c CTI worker focuses on assessment and linkage with supports
d
e
f
g

c CTI worker accompanies consumer or client to appointments
d
e
f
g

c CTI worker observes consumer or client trying out skills and adjusts consumer support network
d
e
f
g
c CTI worker encourages consumer or client and caregivers to work out problems on their own
d
e
f
g
c CTI worker substitutes for caregivers when necessary
d
e
f
g

c CTI worker mediates conflicts between consumer or client and caregivers
d
e
f
g

38. How often do CTI workers typically have contact with consumers or clients during the
final phase (months 7­9) of CTI services?
j Once per month
k
l
m
n

j 2­3 times per month
k
l
m
n
j 4 times per month
k
l
m
n

j Other (please specify below)
k
l
m
n

5
6  

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99

39. Were there any components of the CTI model that were difficult to implement?
j No
k
l
m
n

j Yes (please describe below)
k
l
m
n

5

6  

40. Did your agency make any adjustments or modifications to the CTI model?
j No
k
l
m
n

j Yes (please describe below)
k
l
m
n

5

6  

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100

41. Were any of the following types of evidence­based service interventions fully
imbedded within your implementation of the CTI model?
Yes

No

Motivational Interviewing

j
k
l
m
n

j
k
l
m
n

Cognitive Behavioral 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Peer Support

j
k
l
m
n

j
k
l
m
n

Strengths­Based Case 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Therapy (CBT)
Motivational Enhancement 
Therapy (MET)

Management/Approach
SSI/DI Outreach, Access & 
Recovery (SOAR)
Trauma­Specific 
Intervention (please specify 
below)
Other (please specify 
below)
If 'Trauma­Specific Intervention or 'Other' indicated above, please specify below: 

5

6

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

101

Survey Completed!

Thank you for your time in completing this survey!  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

102

Welcome to the Evaluation of SAMHSA’s Cooperative Agreements to Benefit
Homeless Individuals (CABHI) Program

OMB No. 0930-0339
Expiration Date: 1/31/2017

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 09300339. Public reporting burden for this collection of information is estimated to average 15 minutes per respondent, per
year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, 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 SAMHSA Reports
Clearance Officer, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20857.

Evidence-Based Practice (EBP) Self-Assessment Part 2
Integrated Dual Disorders Treatment (IDDT)

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103

Instructions

You have been asked to complete this part of the survey because your CABHI project is
implementing the Integrated Dual Disorders Treatment (IDDT) model.
This survey seeks additional information to confirm the extent to which this EBP is being
implemented, degree of implementation fidelity, and specific modifications that may have been made
for use by local SAMHSA homeless projects.
Clicking "next" at the bottom of every page moves you to the next set of questions and saves your
answers to that page. Once you have begun the survey, you may go back and modify your
responses at any time. If you are unable to complete the survey, you can return to complete it at a
later date using the same link in the invitation email. The survey will continue where you left off.
Click "next" below to begin taking this survey!

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

104

Grantee Information

1. Please indicate the SAMHSA Homeless project you are
responding for below.
(Select from drop down list)

6

Project:

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105

Respondent Information

2. Please indicate your role(s) in the SAMHSA homeless project? (check all that apply)
c Project Director
d
e
f
g

c Project Manager/Coordinator
d
e
f
g
c Program Manager
d
e
f
g
c Local Evaluator
d
e
f
g

c Mental Health Clinician/Treatment Provider/Supervisor
d
e
f
g

Other Substance Abuse Counselor/Treatment Provider/Supervisor 
c
d
e
f
g

c Integrated Treatment Provider (Mental Health and Substance Abuse)
d
e
f
g
c Trauma Specialist
d
e
f
g
c Case Manager
d
e
f
g

c Benefits Specialist
d
e
f
g

c Peer Specialist/Consumer
d
e
f
g
c Vocation Specialist
d
e
f
g
c Housing Specialist
d
e
f
g

c Education Specialist
d
e
f
g

c Other (please specify below)
d
e
f
g

5
6  

3. What is the name of your agency/organization?
5
6  

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106

4. What is your agency's role(s) in the SAMHSA homeless project? (check all that apply)
c Grantee agency
d
e
f
g

c Administrative/project coordination/oversight
d
e
f
g
c Research/evaluation
d
e
f
g

c Substance abuse treatment provider
d
e
f
g
c Mental health treatment provider
d
e
f
g

c Integrated treatment provider (mental health and substance abuse)
d
e
f
g
c Housing provider
d
e
f
g
c Shelter
d
e
f
g

c Case management provider
d
e
f
g

c Medical care provider (primary or specialized)
d
e
f
g
c Benefits assistance provider
d
e
f
g
c Education provider
d
e
f
g

c Employment or job training provider
d
e
f
g

Other 

c Veterans Administration services provider
d
e
f
g

c Justice/criminal justice provider
d
e
f
g

c Child and family services provider
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

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107

Integrated Dual Disorders Treatment (IDDT) Questions

5. Do staff work with consumers or clients individually or as part of a Multidisciplinary
Team (MDT)?
j Individually
k
l
m
n
j As a MDT
k
l
m
n

j Other (please specify below)
k
l
m
n

5
6  

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108

6. What staff members comprise the MDT? (check all that apply)
c Psychiatrist
d
e
f
g
c Nurse
d
e
f
g

c Case manager
d
e
f
g

c Employment specialist(s)
d
e
f
g

c Integrated treatment specialist
d
e
f
g

c Clinicians (e.g. psychologist, licensed social worker, etc.)
d
e
f
g
c Practitioners of other ancillary rehabilitation services
d
e
f
g
c Other (please specify below)
d
e
f
g

5
6  

7. Are all members of the MDT required to attend treatment team meetings?

j Yes
k
l
m
n
j No
k
l
m
n

j NA
k
l
m
n

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109

8. Does your agency assign Integrated Treatment Specialists to the treatment team or are
consumers or clients referred to Integrated Treatment Specialists (e.g., through a separate
program within the agency)?
j Integrated Treatment Specialists are assigned to the treatment team
k
l
m
n

j Consumers or clients are referred to Integrated Treatment Specialists
k
l
m
n
j No Integrated Treatment Specialists connected with the agency
k
l
m
n

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110

9. How often do Integrated Treatment Specialists attend treatment team meetings?
j Always
k
l
m
n

j Frequently
k
l
m
n

j Sometimes
k
l
m
n
j Rarely
k
l
m
n
j Never
k
l
m
n
j NA
k
l
m
n

10. How involved are Integrated Treatment Specialists in treatment planning with other
members of the treatment team?
j Very involved
k
l
m
n

j Somewhat involved
k
l
m
n
j Not at all involved
k
l
m
n

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111

11. Which of the following philosophies or goals are used by integrated treatment program
staff when treating consumers or clients with co­occurring disorders? (check all that
apply)
c Confrontation
d
e
f
g
c Abstinence
d
e
f
g

c Stages of change
d
e
f
g

c Reduction of use (harm reduction)
d
e
f
g
c Relapse prevention
d
e
f
g

c Other (please specify below)
d
e
f
g

5

6  

12. How often would you say that interventions are consistent with the consumer or
client's stage of treatment (e.g., engagement, persuasion, active treatment, relapse
prevention)?
j 80­100% of the time
k
l
m
n
j 61­79% of the time
k
l
m
n
j 41­60% of the time
k
l
m
n
j 21­40% of the time
k
l
m
n
j 0­20% of the time
k
l
m
n

13. Are integrated treatment program staff offered training on stages of change and the
stages of treatment?

j Yes
k
l
m
n

Other 

j No
k
l
m
n

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112

14. Which of the following services do integrated treatment program consumers or clients
have genuine access to at the agency? (check all that apply)
c Residential Services
d
e
f
g

c Supported Employment (SE)
d
e
f
g
c Family Intervention
d
e
f
g

c Illness Management and Recovery (IMR)
d
e
f
g
c Assertive Community Treatment (ACT)
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

15. Does the integrated treatment program graduate consumers or clients after they have
completed a certain number of sessions or groups?

j Yes
k
l
m
n
j No
k
l
m
n

16. Which of the following happens when a consumer or client's need for services is
reduced?
j They are closed out of services after a defined period of time.
k
l
m
n

j They continue to be served indefinitely and the intensity of services is modified based on individual need.
k
l
m
n

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113

17. How often is it true that consumers or clients are served indefinitely and the intensity of
services is modified based on individual need?
j 80­100% of the time
k
l
m
n
j 61­79% of the time
k
l
m
n
j 41­60% of the time
k
l
m
n
j 21­40% of the time
k
l
m
n

j 20% or less of the time
k
l
m
n
Other 

18. What happens if a consumer or client continually refuses or does not comply with (e.g.,
misses appointments for) integrated treatment program services? (check all that apply)
c They are immediately discharged from the integrated treatment program
d
e
f
g
c Staff initially attempts to engage but may eventually discharge
d
e
f
g

c Staff attempt to engage using assertive outreach techniques as much as possible
d
e
f
g

c Staff consistently use assertive techniques to keep consumers or clients involved in services
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

19. What types of assistance do integrated treatment program staff offer to connect
consumers or clients with as a means of engagement? (check all that apply)
c Housing assistance
d
e
f
g
c Legal aid
d
e
f
g

c Meals or other food resources
d
e
f
g
c Clothing
d
e
f
g

c Medical care
d
e
f
g

c Crisis management
d
e
f
g

c Other (please specify below)
d
e
f
g

5

6  

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114

20. Are integrated treatment program staff offered training in motivational interventions?

j Yes
k
l
m
n
j No
k
l
m
n

21. Which of the following techniques are used by integrated treatment program staff with
consumers or clients? (check all that apply)
c Expressing empathy
d
e
f
g

c Developing discrepancy
d
e
f
g

c Avoiding argumentation
d
e
f
g
c Rolling with resistance
d
e
f
g

c Instilling self­efficacy and hope
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

22. How often do integrated treatment program staff use a motivational approach in their
interactions with consumers or clients?
j 80­100% of the time
k
l
m
n
j 61­79% of the time
k
l
m
n
j 41­60% of the time
k
l
m
n
j 21­40% of the time
k
l
m
n
j 0­20% of the time
k
l
m
n

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115

23. During which phase(s) of treatment are integrated treatment program consumers or
clients offered some form of substance abuse counseling? (check all that apply)
c Engagement: while forming a trusting working alliance/relationship
d
e
f
g

c Persuasion: while helping engaged consumers or clients become motivated to participate in recovery
d
e
f
g

c Active Treatment: while helping motivated consumers or clients acquire skills/supports for managing illness and pursuing goals
d
e
f
g
c Relapse Prevention: while helping consumers or clients in stable remission develop/use strategies to maintain recovery
d
e
f
g

24. Which of the following knowledge/skills are taught to consumers or clients who
receive substance abuse counseling in the integrated treatment program? (check all that
apply)
c How to manage cues to use and consequences of use
d
e
f
g
c Relapse prevention strategies
d
e
f
g

c Drug and alcohol refusal skills
d
e
f
g

Yes 

c Problem­solving skills training to avoid high­risk situations
d
e
f
g

c Coping skills and social skills training to deal with symptoms or negative mood states
d
e
f
g
c Relaxation
d
e
f
g

c Other (please specify below)
d
e
f
g

5

6  

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116

25. Which of the following best describes the types of group treatment offered by the
integrated treatment program?
j No group treatment is offered
k
l
m
n

j Substance use or mental health specific groups are offered only
k
l
m
n

j Groups that address both mental health and substance use are offered
k
l
m
n

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117

26. What proportion of integrated treatment program consumers or clients regularly attend
group treatment focused on both mental health and substance use?
j 65­100%
k
l
m
n
j 50­64%
k
l
m
n
j 35­49%
k
l
m
n
j 20­34%
k
l
m
n

j Less than 20%
k
l
m
n

27. Are family interventions offered to consumers or clients in the integrated treatment
program?

j Yes
k
l
m
n
j No
k
l
m
n

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118

28. Are all consumers or clients asked permission to involve family members or other
supporters in family interventions?

j Yes
k
l
m
n
j No
k
l
m
n

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119

29. What proportion of consumer or clients’ family members or other supporters receive
family interventions for co­occurring disorders?
j 65­100%
k
l
m
n
j 50­64%
k
l
m
n
j 35­49%
k
l
m
n
j 20­34%
k
l
m
n

j Less than 20%
k
l
m
n

30. Does the integrated treatment program ever refer consumers or clients to self­help
groups in the community (e.g., AA, NA, etc)?

j Yes
k
l
m
n
j No
k
l
m
n

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120

31. During which phase(s) of treatment do referrals to self­help groups occur? (check all
that apply)
c Engagement: forming a trusting working alliance/relationship
d
e
f
g

c Persuasion: helping engaged consumers or clients become motivated to participate in recovery
d
e
f
g

c Active Treatment: helping motivated consumers or clients acquire skills/supports for managing illness and pursuing goals
d
e
f
g
c Relapse Prevention: helping consumers or clients in stable remission develop/use strategies to maintain recovery
d
e
f
g

32. How many consumers or clients in the integrated treatment program regularly attend
self­help programs in the community?
j 65­100%
k
l
m
n
j 50­64%
k
l
m
n
j 35­49%
k
l
m
n
j 20­34%
k
l
m
n

j Less than 20%
k
l
m
n

33. Are prescribers (e.g., physicians or nurses) who work with consumers or clients in the
integrated treatment program trained in the evidence­based IDDT model?

j Yes
k
l
m
n
j No
k
l
m
n

34. Are psychotropic medications prescribed to consumers or clients with active
substance use problems?

j Yes
k
l
m
n
j No
k
l
m
n

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121

35. How often is the treatment team in contact with integrated treatment program
consumer or clients’ prescribers?
j Always
k
l
m
n

j Frequently
k
l
m
n

j Sometimes
k
l
m
n
j Rarely
k
l
m
n
j Never
k
l
m
n

36. What types of strategies do prescribers typically use for consumers or clients who do
not take psychiatric medications as prescribed? (check all that apply)
c Encourage consumer or clients’ right to refuse medications
d
e
f
g
c Encourage consumer or clients’ adherence to medications
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

37. Are consumers or clients in the integrated treatment program prescribed medications
that may be addictive?
j Always
k
l
m
n

j Frequently
k
l
m
n

j Sometimes
k
l
m
n
j Rarely
k
l
m
n
j Never
k
l
m
n

38. Are consumers or clients in the integrated treatment program prescribed medications
known to be effective in reducing addictive behavior?
j Always
k
l
m
n

j Frequently
k
l
m
n

j Sometimes
k
l
m
n
j Rarely
k
l
m
n
j Never
k
l
m
n

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122

39. Do integrated treatment program staff offer consumers or clients interventions to
promote health?

j Yes
k
l
m
n
j No
k
l
m
n

40. Which of the following areas are typically addressed with consumers or clients?
(check all that apply)
c Switching to less harmful substances
d
e
f
g
c Finding safe housing
d
e
f
g

c Proper diet and exercise
d
e
f
g
c Safe sex practices
d
e
f
g

c The risk of losing friends and family
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

41. How many integrated treatment program consumers or clients receive interventions to
help them reduce the negative consequences of substance abuse?
j 80­100%
k
l
m
n
j 50­79%
k
l
m
n

j Less than 50%
k
l
m
n

42. Does your integrated treatment program have a protocol to identify consumers or
clients who do not respond to basic treatment?

j Yes
k
l
m
n
j No
k
l
m
n

43. How often are consumers or clients assessed to determine if they are progressing
toward recovery?
j There is no evaluation or assessment process
k
l
m
n
j Annually
k
l
m
n

j At a minimum of every 6 months
k
l
m
n
j At a minimum of every 3 months
k
l
m
n

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

123

44. What percentage of consumers or clients who do not respond to basic treatment are
referred for secondary interventions?
j 80­100%
k
l
m
n
j 61­79%
k
l
m
n
j 41­60%
k
l
m
n
j 21­40%
k
l
m
n

j 20% or less
k
l
m
n

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

124

45. Were any of the following components of the IDDT model difficult to implement?
Yes

No

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Time­unlimited services

j
k
l
m
n

j
k
l
m
n

Outreach strategies used to 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Staff work as a 
multidisciplinary team 
(MDT)
Integrated Treatment 
Specialists work 
collaboratively w/MDT
Services are consistent with 
consumer or clients’ stage 
of treatment
Consumers or clients have 
access to comprehensive 
services

keep consumers or clients 
engaged
Motivational interventions 
used
Substance abuse 
counseling at appropriate 
stage
Group treatment for co­
occurring disorders offered
Family interventions for co­
occurring disorders offered
Alcohol & drug self­help 
groups offered at 
appropriate stage
Pharmacological treatment 
consistent with EBP
Interventions to promote 
health used
Secondary interventions for 
non­responders used
Other (please specify 
below)
If 'Other' indicated above, please specify below 

5

6

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

125

46. Did you make any adjustments or modifications to the IDDT model?
j No
k
l
m
n

j Yes (please describe below)
k
l
m
n

5

6  

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126

47. Were any of the following types of evidence­based service interventions fully
imbedded within your implementation of the IDDT model?
Yes

No

Motivational Interviewing

j
k
l
m
n

j
k
l
m
n

Cognitive Behavioral 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Peer Support

j
k
l
m
n

j
k
l
m
n

Strengths­Based Case 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Therapy (CBT)
Motivational Enhancement 
Therapy (MET)

Management/Approach
SSI/DI Outreach, Access & 
Recovery (SOAR)
Trauma­Specific 
Intervention (please specify 
below)
Other (please specify 
below)
If 'Trauma­Specific' or 'Other' indicated above, please specify below 

5

6

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

127

Survey Completed!

Thank you for your time in completing this survey! 

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

128

Welcome to the Evaluation of SAMHSA’s Cooperative Agreements to Benefit
Homeless Individuals (CABHI) Program

OMB No. 0930-0339
Expiration Date: 1/31/2017

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 09300339. Public reporting burden for this collection of information is estimated to average 15 minutes per respondent, per
year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, 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 SAMHSA Reports
Clearance Officer, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20857.

Evidence-Based Practice (EBP) Self-Assessment Part 2
Illness Management and Recovery (IMR)

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

129

Instructions

You have been asked to complete this part of the survey because your CABHI project is
implementing the Illness Management and Recovery (IMR) model.
This survey seeks additional information to confirm the extent to which this EBP is being
implemented, degree of implementation fidelity, and specific modifications that may have been made
for use by local SAMHSA homeless projects.
Clicking "next" at the bottom of every page moves you to the next set of questions and saves your
answers to that page. Once you have begun the survey, you may go back and modify your
responses at any time. If you are unable to complete the survey, you can return to complete it at a
later date using the same link in the invitation email. The survey will continue where you left off.
Click "next" below to begin taking this survey!

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

130

Grantee Information

1. Please indicate the SAMHSA Homeless project you are
responding for below.
(Select from drop down list)

6

Project:

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

131

Other 

Respondent Information

2. Please indicate your role(s) in the SAMHSA homeless project? (check all that apply)
c Project Director
d
e
f
g

c Project Manager/Coordinator
d
e
f
g
c Program Manager
d
e
f
g
c Local Evaluator
d
e
f
g

c Mental Health Clinician/Treatment Provider/Supervisor
d
e
f
g

c Substance Abuse Counselor/Treatment Provider/Supervisor
d
e
f
g

c Integrated Treatment Provider (Mental Health and Substance Abuse)
d
e
f
g
c Trauma Specialist
d
e
f
g
c Case Manager
d
e
f
g

c Benefits Specialist
d
e
f
g

c Peer Specialist/Consumer
d
e
f
g
c Vocation Specialist
d
e
f
g
c Housing Specialist
d
e
f
g

c Education Specialist
d
e
f
g

c Other (please specify below)
d
e
f
g

5
6  

3. What is the name of your agency/organization?
5
6  

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132

4. What is your agency's role(s) in the SAMHSA homeless project? (check all that apply)
c Grantee agency
d
e
f
g

c Administrative/project coordination/oversight
d
e
f
g
c Research/evaluation
d
e
f
g

c Substance abuse treatment provider
d
e
f
g
c Mental health treatment provider
d
e
f
g

c Integrated treatment provider (mental health and substance abuse)
d
e
f
g
c Housing provider
d
e
f
g
c Shelter
d
e
f
g

c Case management provider
d
e
f
g

c Medical care provider (primary or specialized)
d
e
f
g
c Benefits assistance provider
d
e
f
g
c Education provider
d
e
f
g

c Employment or job training provider
d
e
f
g

c Veterans Administration services provider
d
e
f
g
c Justice/criminal justice provider
d
e
f
g

c Child and family services provider
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

133

Illness Management and Recovery (IMR)

5. Are IMR sessions taught individually, in a group format, or both?
j Individually
k
l
m
n
j In groups
k
l
m
n

j Both individually and in groups
k
l
m
n

6. How many consumers or clients typically participate in an IMR session or group?
j More than 15
k
l
m
n
j 13­15
k
l
m
n
j 11­12
k
l
m
n
j 9­10
k
l
m
n

j 8 or fewer
k
l
m
n

j IMR is only taught individually
k
l
m
n

7. How often are IMR sessions held?
j Weekly
k
l
m
n

j Bi­weekly
k
l
m
n

j Once per month
k
l
m
n

j Other (please specify below)
k
l
m
n

5
6  

8. How often and for what length of time do consumers or clients typically attend IMR
sessions? (Please do not include those who drop out prematurely)
Average total # of months 
attended per consumer or 
client
Average total # of sessions 
attended per consumer or 
client

9. Is there an established curriculum for the IMR sessions?

j Yes
k
l
m
n
j No
k
l
m
n

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134

10.
Yes  Which of the following topics are covered in IMR sessions? (check all that apply)
c Recovery strategies
d
e
f
g

c Practical facts about mental illnesses
d
e
f
g

c Stress­Vulnerability Model and treatment strategies
d
e
f
g
c Building social support
d
e
f
g

c Using medication effectively
d
e
f
g
c Drug and alcohol use
d
e
f
g
c Reducing relapses
d
e
f
g
c Coping with stress
d
e
f
g

c Coping with problems and persistent symptoms
d
e
f
g

c Getting needs met in the mental health system
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

11. Do consumers or clients who participate in IMR receive educational handouts as part
of the program?

j Yes
k
l
m
n
j No
k
l
m
n

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135

12. How often do consumers or clients who participate in IMR receive handouts as part of
the program?
j 90­100% of the time
k
l
m
n
j 70­89% of the time
k
l
m
n
j 40­69% of the time
k
l
m
n
j 20­39% of the time
k
l
m
n

j Less than 20% of the time
k
l
m
n

13. Does the IMR program intentionally involve consumer or clients’ significant others (e.g.
family, friends, other non­paid supports)?

j Yes
k
l
m
n
j No
k
l
m
n

14. If significant others of consumers or clients who participate in IMR are involved, how
are they involved? (check all that apply)
c Significant others are not involved
d
e
f
g

c IMR practitioners have regular contact with significant others
d
e
f
g

c Significant others assist consumers or clients in pursuing IMR goals
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

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15. For what percentage of participating consumers or clients are significant others
involved?
j At least 50%
k
l
m
n
j 30­49%
k
l
m
n

j Less than 30%
k
l
m
n

16. To what extent do consumers or clients who participate in IMR have personally
established goals that are realistic and measurable?
j 90­100% have at least one such goal
k
l
m
n
j 70­89% have at least one such goal
k
l
m
n
j 40­69% have at least one such goal
k
l
m
n

j 20­39% of have at least one such goal
k
l
m
n

j Less than 20% have at least one such goal
k
l
m
n

17. How often is progress toward achieving consumer or client IMR goals reviewed?
j At every session
k
l
m
n

j Some other frequency (e.g. every other session, monthly, etc.)
k
l
m
n
j Infrequently/only as needed
k
l
m
n
j Progress is not reviewed
k
l
m
n

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18. Which of the following strategies are used in IMR sessions? (check all that apply)
c Teaching new information and skills to achieve goals
d
e
f
g

c Encouraging positive perspectives of past experiences
d
e
f
g
c Exploring the pros and cons of change
d
e
f
g

c Instilling hope and belief in self­efficacy
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

19. How often are motivation based strategies used in IMR sessions?
j They are used in at least half (50%) of the sessions
k
l
m
n
j They are used in some sessions (40­49%)
k
l
m
n
j They are used in a few sessions (20­39%)
k
l
m
n

j They are rarely or never used (<20%) in sessions
k
l
m
n

20. Which of the following educational techniques are used in IMR sessions? (check all
that apply)
c Interactive teaching
d
e
f
g

c Checking for understanding
d
e
f
g
c Breaking down information
d
e
f
g
c Reviewing information
d
e
f
g

c Other (please specify below)
d
e
f
g

5

6  

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138

21. How often are educational techniques used in IMR sessions?
j They are used in at least half (50%) of the sessions
k
l
m
n
j They are used in some sessions (40­49%)
k
l
m
n
j They are used in a few sessions (20­39%)
k
l
m
n

j They are rarely or never used (<20%) in sessions
k
l
m
n

22. Which of the following techniques are used in IMR sessions? (check all that apply)
c Reinforcement
d
e
f
g
c Shaping
d
e
f
g

c Modeling
d
e
f
g

c Role playing
d
e
f
g

c Cognitive restructuring
d
e
f
g
c Relaxation training
d
e
f
g

c Other (please specify below)
d
e
f
g

5
6  

23. How often are cognitive­behavioral techniques used in IMR sessions?
j They are used in at least half (50%) of the sessions
k
l
m
n
j They are used in some sessions (40­49%)
k
l
m
n
j They are used in a few sessions (20­39%)
k
l
m
n

j They are rarely or never used (<20%) in sessions
k
l
m
n

24. Are IMR practitioners familiar with the principles of coping skills training?
j No
k
l
m
n

j Some are familiar
k
l
m
n

j The majority are familiar
k
l
m
n

j All practitioners are familiar
k
l
m
n

25. How frequently do IMR practitioners use coping skills principles in their IMR sessions?
j Regularly
k
l
m
n

j Moderately (more than 50% and less than 90% of the time)
k
l
m
n
j Not often (less than 50% of the time)
k
l
m
n
j Never
k
l
m
n

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140

26. Are IMR practitioners familiar with the principles of relapse prevention training?
j No
k
l
m
n

j Some are familiar
k
l
m
n

j The majority are familiar
k
l
m
n

j All practitioners are familiar
k
l
m
n

27. How frequently do IMR practitioners use relapse prevention training in their IMR
sessions?
j Regularly
k
l
m
n

j Moderately (more than 50% and less than 90% of the time)
k
l
m
n
j Not often (less than 50% of the time)
k
l
m
n
j Never
k
l
m
n

28. Are IMR practitioners familiar with the principles of behavioral tailoring for medication
(i.e. skills to assist consumers to avoid missed medications)?
j No
k
l
m
n

j Some are familiar
k
l
m
n

j The majority are familiar
k
l
m
n

j All practitioners are familiar
k
l
m
n

29. How frequently do IMR practitioners use behavioral tailoring for medication techniques
in their IMR sessions?
j Regularly
k
l
m
n

j Moderately (more than 50% and less than 90% of the time)
k
l
m
n
j Not often (less than 50% of the time)
k
l
m
n
j Never
k
l
m
n

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141

30. Were any of the following components of the IMR model difficult to implement?
Yes

No

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

IMR goal setting

j
k
l
m
n

j
k
l
m
n

IMR goal follow­up

j
k
l
m
n

j
k
l
m
n

Motivation­based strategies 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

IMR taught individually or 
in groups of 8 or fewer 
consumers
At least 3 months of weekly 
sessions or equivalent
Comprehensiveness of 
curriculum
Provision of educational 
handouts
Involvement of significant 
others

used
Educational techniques 
used
Cognitive­behavioral 
techniques used
Coping skills training 
provided
Relapse prevention training 
provided
Behavioral tailoring for 
medications used
Other (please specify 
below)
If 'Other' indicated, please specify below 

5

6

31. Did you make any adjustments or modifications to the IMR model?
j No
k
l
m
n

j Yes (please describe below)
k
l
m
n

5

6  

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32. Were any of the following types of evidence­based service interventions fully
imbedded within your implementation of the IMR model?
Yes

No

Motivational Interviewing

j
k
l
m
n

j
k
l
m
n

Cognitive Behavioral 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Peer Support

j
k
l
m
n

j
k
l
m
n

Strengths­Based Case 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Therapy (CBT)
Motivational Enhancement 
Therapy (MET)

Management/Approach
SSI/DI Outreach, Access & 
Recovery (SOAR)
Trauma­Specific 
Intervention (please specify 
below)
Other (please specify 
below)
If 'Trauma­Specific Intervention' or 'Other' indicated above, please specify below: 

5

6

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

143

Survey Completed!

Thank you for your time in completing this survey! 

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

144

Welcome to the Evaluation of SAMHSA’s Cooperative Agreements to Benefit
Homeless Individuals (CABHI) Program

OMB No. 0930-0339
Expiration Date: 1/31/2017

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 09300339. Public reporting burden for this collection of information is estimated to average 15 minutes per respondent, per
year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, 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 SAMHSA Reports
Clearance Officer, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20857.

Evidence-Based Practice (EBP) Self-Assessment Part 2
Supported Employment

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145

Instructions

You have been asked to complete this part of the survey because your CABHI project is
implementing the Supported Employment model.
This survey seeks additional information to confirm the extent to which this EBP is being
implemented, degree of implementation fidelity, and specific modifications that may have been made
for use by local SAMHSA homeless projects.
Clicking "next" at the bottom of every page moves you to the next set of questions and saves your
answers to that page. Once you have begun the survey, you may go back and modify your
responses at any time. If you are unable to complete the survey, you can return to complete it at a
later date using the same link in the invitation email. The survey will continue where you left off.
Click "next" below to begin taking this survey!

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

146

Grantee Information

1. Please indicate the SAMHSA Homeless project you are
responding for below.
(Select from drop down list)

6

Project:

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

147

Respondent Information

2. Please indicate your role(s) in the SAMHSA homeless project? (check all that apply)
c Project Director
d
e
f
g

Other 

c Project Manager/Coordinator
d
e
f
g
c Program Manager
d
e
f
g
c Local Evaluator
d
e
f
g

c Mental Health Clinician/Treatment Provider/Supervisor
d
e
f
g

c Substance Abuse Counselor/Treatment Provider/Supervisor
d
e
f
g

c Integrated Treatment Provider (Mental Health and Substance Abuse)
d
e
f
g
c Trauma Specialist
d
e
f
g
c Case Manager
d
e
f
g

c Benefits Specialist
d
e
f
g

c Peer Specialist/Consumer
d
e
f
g
c Vocation Specialist
d
e
f
g
c Housing Specialist
d
e
f
g

c Education Specialist
d
e
f
g

c Other (please specify below)
d
e
f
g

5
6  

3. What is the name of your agency/organization?
5
6  

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148

4. What is your agency's role(s) in the SAMHSA homeless project? (check all that apply)
c Grantee agency
d
e
f
g

c Administrative/project coordination/oversight
d
e
f
g
c Research/evaluation
d
e
f
g

c Substance abuse treatment provider
d
e
f
g
c Mental health treatment provider
d
e
f
g

c Integrated treatment provider (mental health and substance abuse)
d
e
f
g
c Housing provider
d
e
f
g
c Shelter
d
e
f
g

c Case management provider
d
e
f
g

c Medical care provider (primary or specialized)
d
e
f
g
c Benefits assistance provider
d
e
f
g
c Education provider
d
e
f
g

c Employment or job training provider
d
e
f
g

c Veterans Administration services provider
d
e
f
g
c Justice/criminal justice provider
d
e
f
g

c Child and family services provider
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

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149

Supported Employment Questions

5. What is the average consumer or client caseload size for an employment specialist?
j 81 or more
k
l
m
n
j 61 to 80
k
l
m
n
j 41 to 60
k
l
m
n
j 26 to 40
k
l
m
n

j 25 or fewer
k
l
m
n

6. What services do employment specialists provide? (check all that apply)
c Vocational services
d
e
f
g
c Case management
d
e
f
g

c Individual or group therapy
d
e
f
g

c Staffing for day or residential programming
d
e
f
g
c Other (please specify below) 
d
e
f
g

5

6  

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150

7. How much of the time do employment specialists provide non­vocational services?
j Less than 20%
k
l
m
n
j 20­39%
k
l
m
n
j 40­59%
k
l
m
n
Yes, 
j 60­79%
k
l
m
n

j 80% or more
k
l
m
n

j NA ­ Employment specialists only provide vocational services
k
l
m
n

8. Which of the following most accurately describes the role of employment specialists
(ES) in the program?
j Each ES carries out all phases of vocational service, including engagement, assessment, job development, placement, and coaching, 
k
l
m
n
and follow­along supports. 

j ES provide 2 or more phases of vocational service but not the entire service (e.g. some do engagement and assessment only while others 
k
l
m
n
do job development and placement, etc.) 

j ES specialize in 1 aspect of vocational service
k
l
m
n

j ES maintain caseloads but refer consumers to other programs for vocational service
k
l
m
n

j ES do not carry caseloads and only provide vocational referrals to other vendors or programs
k
l
m
n
j Other (please specify below)
k
l
m
n

5
Yes, 

6  

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151

9. Do employment specialists interact with the treatment team?
j No
k
l
m
n

j Yes, but infrequently
k
l
m
n
j Yes, regularly
k
l
m
n

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152

10. How frequently is contact between employment specialists and the treatment team
made using each of the following methods? Please provide both the number and
frequency of contacts for each method.
Number of Contacts

Frequency of Contacts

Telephone Contact

6

6

Face­to­Face Contact

6

6

Attendance at Treatment 

6

6

Team Meetings

11. Do employment specialists and case managers or case management teams participate
in shared decision making about consumer or client services?
j No
k
l
m
n

j Yes
k
l
m
n

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153

12. Do all employment specialists have the same supervisor?
j No
k
l
m
n

Other   
j Yes
k
l
m
n

13. How frequently do employment specialists receive supervision through the following
methods?
Number of Times Per Month
Individually

6

As a Group

6

Other (please specify) 

5

6

14. Do employment specialists provide services for one another’s consumers or clients?
j No
k
l
m
n

j Yes
k
l
m
n

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154

15. Must consumers or clients meet certain eligibility criteria in order to receive supported
employment services?
j No
k
l
m
n

j Yes
k
l
m
n

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155

16. Which of the following screening criteria are used? (check all that apply)
c Job readiness
d
e
f
g

c Abstinence from substance use
d
e
f
g

c Mild symptoms of mental illness
d
e
f
g

c Minimal intellectual functioning
d
e
f
g
c No history of violent behavior
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

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156

17. Where does the supported employment program accept referrals from? (check all that
apply)
c Case managers
d
e
f
g
c Therapists
d
e
f
g

c Psychiatrists
d
e
f
g

c Family members
d
e
f
g
c Self­referral
d
e
f
g

Yes 

c Other (please specify below)
d
e
f
g

5

6  

18. Vocational assessments that are conducted in the supported employment program are
primarily:
j Office­based assessments done prior to job placement
k
l
m
n

j Pre­vocational assessments conducted at a day program site
k
l
m
n
j Carried out in a sheltered work environment
k
l
m
n

j Based on a series of temporary job experiences
k
l
m
n

j Ongoing assessments that occur in community jobs
k
l
m
n
j Other (please specify below)
k
l
m
n

5

6  

19. Are consumers or clients required to take any steps in the supported employment
program before beginning a job search?
j Yes, some pre­requisites exist (e.g. pre­vocational counseling, participation in an enclave or sheltered work, etc.) before a search for 
k
l
m
n
competitive employment can begin. 

j No, the job search begins as soon as a consumer expresses interest in competitive employment
k
l
m
n

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157

20. How soon after entry into the supported employment program does a consumer or
client typically begin having contact with competitive employers (i.e. start their job
search)?
j Within 1 month
k
l
m
n
j 1­6 months
k
l
m
n
j 6­9 months
k
l
m
n

j 9­12 months
k
l
m
n

j More than 12 months
k
l
m
n

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158

21. How are employer contacts selected? (check all that apply)
c Based on the local job market (i.e. based on which jobs are readily available)
d
e
f
g
c Based on the employment specialist's decisions
d
e
f
g

c Based on the consumer or client's preferences and needs
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

22. How often are employer contacts made based on consumer or client preferences and
needs rather than the job market?
j Most of the time
k
l
m
n

j About 75% of the time
k
l
m
n
j About 50% of the time
k
l
m
n
j About 25% of the time
k
l
m
n
j Never
k
l
m
n

23. Of the types of job options and settings employment specialists offer to consumers or
clients, what percentage are the same/similar (e.g., all janitorial, all in food service
settings)?
j 75­100%
k
l
m
n

j About 75%
k
l
m
n
j About 50%
k
l
m
n
j About 25%
k
l
m
n

j Less than 10%
k
l
m
n

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159

24. How often do employment specialists suggest jobs to consumers or clients that are
temporary, time­limited, or volunteer?
j 75­100% of the time
k
l
m
n

j About 75% of the time
k
l
m
n
j About 50% of the time
k
l
m
n
j About 25% of the time
k
l
m
n

j Employment specialists do not provide options for temporary, time­limited, or volunteer jobs
k
l
m
n

25. How often do employment specialists provide options to consumers or clients for
permanent, competitive jobs?
j 75­100% of the time
k
l
m
n

j About 75% of the time
k
l
m
n
j About 50% of the time
k
l
m
n
j About 25% of the time
k
l
m
n

j Employment specialists do not provide options for permanent, competitive jobs
k
l
m
n

26. When a job has ended, do employment specialists offer to assist consumers or clients
in finding another job?
j Yes Always
k
l
m
n
j Not usually
k
l
m
n

j Depends on the situation
k
l
m
n

If 'Not Usually' or 'Depends' indicated above, please provide an example of why an employment specialist might be less likely to assist a 
consumer or client in finding a new job:  

5

6

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27. How often are employment specialists likely to assist a consumer or client in finding
another job when one has ended?
j About 75% of the time
k
l
m
n
j About 50% of the time
k
l
m
n
j About 25% of the time
k
l
m
n

j Less than 25% of the time
k
l
m
n

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161

28. Are follow­along supports provided to consumers or clients (e.g., job
coaching/counseling, job support groups)?
j No not provided
k
l
m
n

j Provided to less than half
k
l
m
n
j Yes provided to most
k
l
m
n

29. Is there a time limit for providing follow­along supports to consumers or clients?
j Follow­along supports are not provided to consumers or clients
k
l
m
n
j No, there is no time limit
k
l
m
n

j Yes, there is a time limit (please specify time limit)
k
l
m
n

5
6  

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162

30. Are follow along supports provided to employers (e.g., education, guidance)?
j No not provided
k
l
m
n

j Provided to less than half
k
l
m
n
j Yes provided to most
k
l
m
n

31. Is there a time limit for providing follow­along supports to employers?
j Follow­along supports are not provided to employers
k
l
m
n
j No, there is no time limit
k
l
m
n

j Yes, there is a time limit (please specify time limit)
k
l
m
n

5
6  

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163

32. Of the services employment specialists provide, what percentage are provided in the
community (vs. in an office or mental health facility)?
j 70­100%
k
l
m
n
j 60­69%
k
l
m
n
j 40­59%
k
l
m
n
j 11­39%
k
l
m
n
j 0­10%
k
l
m
n

33. Do employment specialists conduct outreach to engage consumers or clients?
c Yes, initially
d
e
f
g

c Yes, if they stop attending vocational services
d
e
f
g
c No
d
e
f
g

If Yes, please specify average number of contacts OR frequency below: 

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164

34. What types of outreach are typically used? (check all that apply)
c Phone calls to the consumer or client
d
e
f
g

c Community visits with consumers or clients
d
e
f
g

c Letters or other written materials sent to the consumer or client’s residence
d
e
f
g

c Phone calls to consumer or clients’ case manager/other care provider (with consent)
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

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165

35. Were any of the following components of the Supported Employment program model
difficult to implement?
Yes

No

Caseload size (1:25)

j
k
l
m
n

j
k
l
m
n

Employment Specialists 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Zero­exclusion criteria

j
k
l
m
n

j
k
l
m
n

Ongoing, work­based 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

(ES) provide only 
vocational services
ES carry out all phases of 
vocational service
Integrating ES with mental 
health treatment team
ES share a supervisor and 
help each other with cases

vocational assessments.
Rapid search for 
competitive jobs
Employer contacts based 
on consumer or client 
preferences/needs vs. job 
market
Provided job options in 
different settings
Providing permanent, 
competitive job options
Helping consumers or 
clients find new jobs
Providing follow­along 
supports
Providing vocational 
services in community 
settings
Providing assertive 
engagement and outreach
Other (please specify 
below)
If 'Other' indicated above, please specify below 

5

6

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36. Did your agency make any adjustments or modifications to the Supported Employment
model?
j No
k
l
m
n

j Yes (please describe below)
k
l
m
n

5

6  

37. Were any of the following types of evidence­based service interventions fully
imbedded within your implementation of the Supported Employment model?
Yes

No

Motivational Interviewing

j
k
l
m
n

j
k
l
m
n

Cognitive Behavioral 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Peer Support

j
k
l
m
n

j
k
l
m
n

Strengths­Based Case 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Therapy (CBT)
Motivational Enhancement 
Therapy (MET)

Management/Approach
SSI/DI Outreach, Access & 
Recovery (SOAR)
Trauma­Specific 
Intervention (please specify 
below)
Other (please specify 
below)
If 'Trauma­Specific Intervention or 'Other' indicated above, please specify below: 

5

6

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Survey Completed!

Thank you for your time in completing this survey!  

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

168

Welcome to the Evaluation of SAMHSA’s Cooperative Agreements to Benefit
Homeless Individuals (CABHI) Program

OMB No. 0930-0339
Expiration Date: 1/31/2017

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 09300339. Public reporting burden for this collection of information is estimated to average 15 minutes per respondent, per
year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, 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 SAMHSA Reports
Clearance Officer, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20857.

Evidence-Based Practice (EBP) Self-Assessment Part 2
SSI/SSDI Outreach, Access, and Recovery (SOAR)

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169

Instructions

You have been asked to complete this part of the survey because your CABHI project is
implementing the Supplemental Security Income (SSI)/Social Security Disability Insurance (SSDI)
Outreach, Access, and Recovery (SOAR) model.
This survey seeks additional information to confirm the extent to which this EBP is being
implemented, degree of implementation fidelity, and specific modifications that may have been made
for use by local SAMHSA homeless projects.
Clicking "next" at the bottom of every page moves you to the next set of questions and saves your
answers to that page. Once you have begun the survey, you may go back and modify your
responses at any time. If you are unable to complete the survey, you can return to complete it at a
later date using the same link in the invitation email. The survey will continue where you left off.
Click "next" below to begin taking this survey!

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170

Grantee Information

1.
Please indicate the SAMHSA Homeless project you are
Other 
responding for below.

(Select from drop down list)

6

Project:

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171

Respondent Information

2. Please indicate your role(s) in the SAMHSA homeless project? (check all that apply)
c Project Director
d
e
f
g

c Project Manager/Coordinator
d
e
f
g
c Program Manager
d
e
f
g
c Local Evaluator
d
e
f
g

c Mental Health Clinician/Treatment Provider/Supervisor
d
e
f
g

c Substance Abuse Counselor/Treatment Provider/Supervisor
d
e
f
g

c Integrated Treatment Provider (Mental Health and Substance Abuse)
d
e
f
g
c Trauma Specialist
d
e
f
g
c Case Manager
d
e
f
g

c Benefits Specialist
d
e
f
g

c Peer Specialist/Consumer
d
e
f
g
c Vocation Specialist
d
e
f
g
c Housing Specialist
d
e
f
g

c Education Specialist
d
e
f
g

c Other (please specify below)
d
e
f
g

5
6  

3. What is the name of your agency/organization?
5
6  

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172

4. What is your agency's role(s) in the SAMHSA homeless project? (check all that apply)
c Grantee agency
d
e
f
g

c Administrative/project coordination/oversight
d
e
f
g
c Research/evaluation
d
e
f
g

c Substance abuse treatment provider
d
e
f
g
c Mental health treatment provider
d
e
f
g

Staff 

c Integrated treatment provider (mental health and substance abuse)
d
e
f
g
c Housing provider
d
e
f
g
c Shelter
d
e
f
g

c Case management provider
d
e
f
g

c Medical care provider (primary or specialized)
d
e
f
g
c Benefits assistance provider
d
e
f
g
c Education provider
d
e
f
g

c Employment or job training provider
d
e
f
g

c Veterans Administration services provider
d
e
f
g
c Justice/criminal justice provider
d
e
f
g

c Child and family services provider
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

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173

SSI/SSDI Outreach, Access & Recovery (SOAR) Questions

5. Of each of the following types of staff, how many are assigned to do SOAR outreach and
Other 

engagement with consumers or clients to assist with SSI/SSDI applications?
Case Managers (specify #)
Outreach Workers (specify #)
Benefits Specialists (specify 
#)
Other (specify #)
Other 
6.
Are staff provided with SOAR training to ensure they have the skills needed to assist

SSI/SSDI applicants?

j Yes
k
l
m
n
j No
k
l
m
n

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174

7. Which of the following is true of the SOAR training staff receives? (check all that apply)
c Training uses or used 'Stepping Stones to Recovery' curriculum
d
e
f
g

Yes 

c Locally­based training is offered on an ongoing­basis
d
e
f
g

c Training includes tips for working with homeless individuals
d
e
f
g
c Other (please specify below)
d
e
f
g

5
6  

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175

Yes 

8. What strategies does staff use to engage SSI/SSDI applicants? (check all that apply)
c Provision of SSI/SSDI­specific information in the course of service delivery
d
e
f
g

c In­reach and outreach in locations where homeless individuals may be located to provide eligibility assistance
d
e
f
g
c Encouraging applicants to sign for case manager to be his/her representative with SSA
d
e
f
g
c Other (please specify below)
d
e
f
g

5

Yes 

6  

9. How often do applicants sign an Appointment of Representative Form (SSA 1696)
designating their case manager/outreach worker/benefits specialist to be his/her
representative with SSA?
j All of the time
k
l
m
n

j Most of the time
k
l
m
n

j Some of the time
k
l
m
n
j Rarely
k
l
m
n
j Never
k
l
m
n

10. Do staff members that assist SSI/SSDI applicants request prior treatment records?

j Yes
k
l
m
n
j No
k
l
m
n

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176

11. Which of the following does staff do in order to help obtain prior treatment records?
(check all that apply)
c Staff work proactively with medical records directors to notify them of SSA information needs
d
e
f
g
c Staff use agency release for each treatment source
d
e
f
g
c Staff use SSA release for each treatment source
d
e
f
g
c Staff offer to copy records
d
e
f
g

c Staff provide cover letter regarding sending information onto SSA
d
e
f
g
c Other (please specify below)
d
e
f
g

5
6  

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177

12. How often does staff write medical summary reports that are co­signed by a treating
physician or psychologist?
j All of the time
k
l
m
n

j Most of the time
k
l
m
n

j Some of the time
k
l
m
n
j Rarely
k
l
m
n
j Never
k
l
m
n

13. How often does staff provide or arrange for medical assessments for SSI/SSDI
applicants, including diagnosis & functioning, with a physician or psychologist?
j All of the time
k
l
m
n

j Most of the time
k
l
m
n

j Some of the time
k
l
m
n
j Rarely
k
l
m
n
j Never
k
l
m
n

14. Do staff members with SOAR expertise review applications for accuracy,
completeness, and clarity prior to submission?

j Yes
k
l
m
n
j No
k
l
m
n

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178

15. Which of the following is true of the SOAR application review process and the staff
who conduct these reviews? (check all that apply)
c A protocol is followed for completing application reviews
d
e
f
g

c Staff reviewing applications received special training regarding review techniques
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

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179

16. Are staff trained on and/or able to submit application information to DDS
electronically?

j Yes
k
l
m
n
j No
k
l
m
n

17. How often does staff electronically submit application information to DDS?
j All of the time
k
l
m
n

j Most of the time
k
l
m
n

j Some of the time
k
l
m
n
j Rarely
k
l
m
n
j Never
k
l
m
n

If not done 'All' or 'Most of the time', please explain: 

5

6

18. Has your agency requested that SSA/DDS do any of the following? Does SSA/DDS do
any of the following? (check all that apply)
Has your agency requested that SSA/DDS?

Does SSA/DDS?

c
d
e
f
g

c
d
e
f
g

Expedite reviews

c
d
e
f
g

c
d
e
f
g

Assign claims 

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

c
d
e
f
g

Flag cases from your 
agency

representatives and/or 
disability examiners who 
specialize in applications 
from homeless people
Communicate directly with 
your agency about 
information needs for 
specific applications
Contact your agency if 
applicant needs a 
consultative exam (CE)

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180

19. How often are consultative exams (CEs) required for SSI/SSDI applicants in your
agency's SOAR program?
j All of the time
k
l
m
n

j Most of the time
k
l
m
n

j Some of the time
k
l
m
n
j Rarely
k
l
m
n
j Never
k
l
m
n

20. Which of the following best describes your agency's approach to CEs for applicants?
(check all that apply)
c Our staff request that applicant's treating physician be the one to conduct the exam
d
e
f
g
c Our staff accompanies applicant or makes sure that applicant gets to exam
d
e
f
g

c We collect all existing medical/functional information relevant to the claim and provide or arrange for needed evaluations prior to 
d
e
f
g
application submission so that CEs are not necessary 

c Other (please specify below)
d
e
f
g

5

6  

21. How often does your agency serve as the representative payee for program clients?
j All of the time
k
l
m
n

j Most of the time
k
l
m
n

j Some of the time
k
l
m
n
j Rarely
k
l
m
n
j Never
k
l
m
n

If not 'All' or 'Most of the time', please explain (e.g., does another agency serve as rep payee or do clients serve as own payee?) 

5

6

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181

22. How often does staff assist consumers or clients receiving SSI/SSDI in accessing and
keeping employment?
j All of the time
k
l
m
n

j Most of the time
k
l
m
n

j Some of the time
k
l
m
n
j Rarely
k
l
m
n
j Never
k
l
m
n

23. Are staff members aware of work incentives under SSI and SSDI?

j Yes
k
l
m
n
j No
k
l
m
n

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182

24. Which of the following is true with regard to how staff learned about and use
information on work incentives?
j Staff learned about and use information on work incentives from the 'Stepping Stones to Recovery' curriculum
k
l
m
n
j Staff learned about and use information on work incentives from another source (please specify below)
k
l
m
n

5

6  

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183

25. Does your homeless project track data related to SOAR application submission and
outcomes?

j Yes
k
l
m
n
j No
k
l
m
n

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184

26. Which of the following SOAR­related data elements are tracked? (check all that apply)
c Date of application submission
d
e
f
g

c Date of initial approval/denial decision
d
e
f
g

c Housing status at time of application (i.e., housed/homeless)
d
e
f
g
c Use of Appointment of Representative form
d
e
f
g
c Other (please specify below)
d
e
f
g

5

6  

27. How is this SOAR­related data tracked?
j HMIS
k
l
m
n

j Other (please specify below)
k
l
m
n

5

6  

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185

28. Were any components of the SOAR model difficult to implement?
j No
k
l
m
n

j Yes (please specify below)
k
l
m
n

5

6  

29. Were any adjustments or modifications made to the SOAR model?
j No
k
l
m
n

j Yes (please specify below)
k
l
m
n

5

6  

30. Does the implementing agency imbed SOAR into another evidence­based service
model (e.g., ACT)?
j No
k
l
m
n

j Yes (please specify below)
k
l
m
n

5

6  

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186

Survey Completed!

Thank you for your time in completing this survey! 

CABHI Evaluation - EBP Self-Assessment Part 1 & 2

187