Cost Questionnaire-Program Administrator

Assisted Outpatient Treatment Evaluation

COST QUESTIONNAIRE

INTRODUCTION

The Assistant Secretary for Planning and Evaluation (ASPE) has contracted with RTI International and its partners—Policy Research Associates (PRA) and Duke University—to conduct a cross-site evaluation of the 2016 Substance Abuse and Mental Health Services Administration grant program, entitled “Assisted Outpatient Treatment Grant Program for Individuals with Serious Mental Illness”. This grant program provides funds for 17 newly implemented assisted outpatient treatment (AOT) programs that are located across the nation.

As part of our evaluation, we are investigating how much it costs to implement an effective AOT program. To achieve this critical aim of our project we are asking AOT program administrators and other program staff to complete this cost questionnaire. Once you have had a chance to review the questionnaire items, and fill in answers to as many items as possible, we will review your responses and schedule a short meeting to discuss your responses and any items that are particularly difficult to answer.

We ask for detailed information regarding program expenses incurred during the most recently completed fiscal year (as defined by your organization). Most of the information we ask for should be included in expense reports. If the information is not available in an expense report, please provide your best estimate. Because budgets do not always coincide with actual resource use, please use expense reports rather than budgets to obtain the information requested in this questionnaire.

Your participation is completely voluntary. Although RTI and its partners are funded by ASPE, we are not part of that federal agency (or any other federal agency). We are independent contractors who are tasked with evaluating the AOT program. We greatly value any information you provide us about the cost of implementing and maintaining your AOT program. No identifying information (name, title, organization’s name) will appear in any report or publication unless we specifically ask for, and receive, your approval.

Please contact Will Parish with any questions or if you need assistance in providing this information. He can be reached by phone at 919.316.3989, or by email at wparish@rti.org.

SECTION A. PRELIMINARY INFORMATION

1. Please provide the date when this questionnaire was completed:

Month		Day		Year

2. Please indicate the fiscal year for which the financial information provided in this module correspond:

	to
(Month/Year)		(Month/Year)

SECTION B. AOT TRAINING

3. As part of implementing the AOT program, did your staff receive any training?

___	Yes
___	No  Go to Question 4

1. How many persons have been trained?

Total number of trained persons?

2. Please describe who provided funding for these trainings? If you self-funded, please indicate accordingly.

3. Approximately how much did you spend on trainings?

Total cost of trainings?

$

4. Have you experienced any staff turnover since the beginning of this project?

___	Yes
___	No  Go to Question 5

1. To what extent has staff turnover impacted your AOT program?

A very little impact
A little impact
Neither a little nor a big impact
A big impact
A very big impact

2. Did you provide any additional training to address staff turnover?

___	Yes
___	No  Go to Question 5

1. Does the expense included in Question 3.c include spending for these additional trainings?

___	Yes  Go to Question 5
___	No

2. How much did these additional trainings cost?

Total cost of additional trainings?

$

IMPORTANT: For the remainder of the questionnaire, please answer all questions as they pertain to the AOT program for the fiscal year identified in Question 2 (henceforth referred to as “the fiscal year”). Please reference expense reports, rather than budgets, in answering all remaining questions. For some questions, we ask that you prorate your expenses to reflect expenses that were made on behalf of your AOT program. While you may not track your expenses in this way, we ask that you provide your best guess as to what percentage of your organization’s activities are associated with your AOT program and use this information to prorate expenses accordingly.

SECTION C. CONSUMER INFORMATION

In the table below, please provide information about the number of persons who were enrolled in your AOT program during the most recent fiscal year and the average AOT order length. Note that the “Total number of AOT orders” refers to the number of new AOT orders that occurred during the most recent fiscal year plus any AOT orders that occurred prior to the most recent fiscal year and which are still active orders.

5. For the fiscal year, what was the:

Total number of AOT orders?
Total number of new AOT orders?
Average AOT order length (in weeks)?

SECTION D. AOT PROGRAM PERSONNEL EXPENSES

6. For all staff in your organization who are involved with your AOT program, please use the table below to record the job title/position, whether they were newly hired for the AOT program, an approximation of their time that is devoted to your AOT program as a percent of full-time hours (e.g., 40 working hours per week), and their annual salary. Please include fringe benefits and payroll taxes in the annual salary.

		Job title or position		New hire?		% of full time devoted to your AOT program		×		Annual salary	=		Adjusted annual salary
Example:		Counselor		Yes		50	%		$	50,000		$	25,000
a.							%		$			$
b.							%		$			$
c.							%		$			$
d.							%		$			$
e.							%		$			$
f.							%		$			$
g.							%		$			$
h.							%		$			$
i.							%		$			$
k.							%		$			$
l.							%		$			$
m.							%		$			$

7. For the fiscal year, list all consultants or contracted personnel that provided services for your AOT program, an approximation of their time that is devoted to your AOT program as a percent of full-time hours (e.g., 40 working hours per week), an estimated annual salary.

Helpful Hint: Do not include any contracts that you have with an external agency or organization to provide services, such as housekeeping services. This information will be reported in Question 9.

FOR EXAMPLE

Suppose you have a contract with a registered nurse (RN), and you pay $25,000 per year for this RN to come in two days a week (or approximately 16 hours a week) to deliver basic medical treatments for your clients. However, on average this RN is only providing services to AOT program enrollees for about 25% of this time. The first line of the table below shows how you would record this information.

		Personnel type		% of full time devoted to your AOT program		×		Annual expense	=		Adjusted annual expense
Example:		Registered nurse		25	%		$	25,000		$	6,250
a.					%		$			$
b.					%		$			$
c.					%		$			$
d.					%		$			$
e.					%		$			$
f.					%		$			$

8. For the fiscal year, list all volunteer workers involved with your AOT program, an approximation of their time that is devoted to your AOT program as a percent of full-time hours (e.g., 40 working hours per week), and an estimated hourly compensation rate if you had to pay for their services.

FOR EXAMPLE

Suppose you have a person who volunteers 20 hours per week as a guardian ad litem, and they spend half their time working with clients in your AOT program. If you had to hire a staff person to fulfill their tasks, you might have to pay an annual salary of $20,000. The first line of this table shows you how you would record this information.

		Personnel type		% of full time devoted to your AOT program		×		Estimated annual salary	=		Adjusted annual salary
Example:		Guardian ad litem		50	%		$	20,000		$	10,000
a.					%		$			$
b.					%		$			$
c.					%		$			$
d.					%		$			$
e.					%		$			$
f.					%		$			$

SECTION E. NONLABOR AOT PROGRAM EXPENSES

9. For the fiscal year, please use the table below to record all nonlabor AOT program expenses incurred on the behalf of your AOT program. For some nonlabor expenses you will need to estimate an adjusted annual expense to account for instances where resources are shared across your AOT program and other activities in which your organization is engaged. For example, unless you only use your building space for your AOT program, your rent payments should be prorated based on the amount of time you use your building space to fulfill AOT program objectives.

		Expense type			Adjusted annual expense
a.		Building and facility expenses (e.g., rent)		$
b.		Contracted Services (e.g., maintenance, housekeeping, etc.)		$
c.		Medication-related expenses		$
d.		Supplies and minor equipment (e.g., office supplies, computers)		$
e.		Miscellaneous items (e.g., utilities, garbage, insurance, etc.)		$
f.		Overhead/administrative charges		$
g.		Other, please specify in the space below		$

10. Do you receive any nonlabor resources in-kind or free of charge? For example, donated supplies or equipment, or building space that is fully paid off. If yes, please describe what resources you receive in-kind or free of charge.

SECTION F. TOTAL LABOR AND NONLABOR AOT PROGRAM EXPENSES

11. Please use the table below to calculate the total AOT program expenses (labor and nonlabor). If you did not report a value for any of the previous questions referenced below, please leave the amount blank. For the paid employee and consultant or contract personnel expenses, report the figure in the “Adjusted annual salary” or “Adjusted annual expense” columns, respectively.

Item		Reported in question number…		Amount
Paid employee expenses		6.a	$
		6.b	$
		6.c	$
		6.d	$
		6.e	$
		6.f	$
		6.g	$
		6.h	$
		6.i	$
		6.k	$
		6.l	$
		6.m	$
Consultant or contract personnel expenses		7.a	$
		7.b	$
		7.c	$
		7.d	$
		7.e	$
		7.f	$
Nonlabor expenses		9.a	$
		9.b	$
		9.c	$
		9.d	$
		9.e	$
		9.f	$
		9.g	$
Total:			$

Thank you for completing this cost questionnaire!

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-NEW. The time required to complete this information collection is estimated to average 1.25 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:  U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer