2 Behavioral Health

0915-XXXX XX/XX/20XX

Federal Office of Rural Health Policy (FORHP)

Office for the Advancement of Telehealth (OAT)

Telehealth Network Grant Program (TNGP)

BEHAVIORAL HEALTH MODULE

This module will be used if the SB-TNGP offers behavioral health services.

The information in this section is collected for each student receiving behavioral health services via telehealth during the measurement period.

Data Element Dictionary

The data element dictionary documents definitions, allowable values, sources for information, and instructions for abstraction.

The data elements are designed to provide the necessary data to calculate the measures. A data collection tool will be used for data entry.

Throughout this document there are references to “the measurement period.” There will be two measurement periods, each six months in duration. These will be January 1 – June 30 and July 1 – December 31.

Public Burden Statement:  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is 0915-XXXX.  Public reporting burden for this collection of information is estimated to average XX hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857

Data element number:	Behavioral Health - 1
Variable name:	Referral source
Variable definition:	Indicates the referral source for this student receiving telehealth behavioral health services as part of the SB-TNGP
Data collection level:	Student
Criteria:	Students who received telehealth behavioral health services through the SB-TNGP during the measurement period
Valid (allowable) values:	Check only one of the following. Options for response are: □ Student self-referred □ Student was referred by their parent/guardian □ Student was referred by a teacher at the school □ Student was referred by a guidance counselor at the school □ Student was referred by an administrator at the school □ Student was referred by SBHC staff or the school nurse □ Student was part of a registry indicating services were needed □ Other – please specify:__________________________________________ □ Unknown: Unable to determine from telehealth log or student visit record
Note for abstractions:	If student had multiple encounters or multiple referral sources, indicate the first referral source for this student for telehealth behavioral health services.
Source for definitions:	Rural Telehealth Research Center

Data element number:	Behavioral Health - 2
Variable name:	Primary behavioral health diagnosis
Variable definition:	Primary behavioral health diagnosis category for this student
Data collection level:	Student
Criteria:	Students who received telehealth behavioral health services through the SB-TNGP during the measurement period
Valid (allowable) values:	Check up to 3 boxes that represent the disorders being treated or addressed in services with this student through the SB-TNGP during the measurement period: □ Intellectual Disability, Communication, and Autism Spectrum Disorders □ Attention-Deficit/Hyperactivity Disorder and Learning Disorders □ Bipolar or Depressive Mood Disorders □ Anxiety or Obsessive-Compulsive Disorders □ Trauma- and Stressor-Related Disorders □ Feeding & Eating, Elimination, or Sleep-Wake Disorders □ Disruptive, Impulse-Control, and Conduct Disorders □ Substance-Related and Addictive Disorders □ Adjustment Disorders and Family/Systems problems □ Disorder Type not listed □ Other – please specify _______________________________________________ □ ICD-10 code(s) can be entered instead of check box ________________________
Note for abstractions:
Source for definitions:	Rural Telehealth Research Center

Data element number:	Behavioral Health - 3
Variable name:	Screening for clinical depression using an age-appropriate standardized tool and follow-up plan if positive screen
Variable definition:	Indicates whether or not the student was screened with an age-appropriate risk assessment that includes a depression screening or a standardized depression screen, and follow-up plan is established if necessary
Data collection level:	Student
Criteria:	Students who received telehealth behavioral health services through the SB-TNGP during the measurement period
Valid (allowable) values:	Check only one of the following. Options for response are: □ Yes to Both Screening and Follow-up: The student completed a risk assessment that included a depression screening and follow-up plan is set if necessary □ Yes to Screening and No Follow-up Needed: The student completed a risk assessment that included a depression screening and follow-up plan is not necessary □ Yes to Screening but No Follow-up Plan Set: The student completed a risk assessment that included a depression screening and follow-up plan was necessary BUT was NOT set □ No: The student did NOT complete a risk assessment
Note for abstractions:	An age-appropriate risk assessment that includes a depression screening would be the PHQ-2 (and, if positive, then PHQ-9). Similar tools are acceptable.
Source for definitions:	SBHA http://www.sbh4all.org/resources/quality-counts/five-performance-measures/ NQF endorsed; CMS measure American Psychological Association http://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/patient-health.aspx https://www.prohealthmd.com/zebrowski/sites/prohealthmd.com.zebrowski/files/documents/PHQ2-9.pdf

Data element number:	Behavioral Health - 4
Variable name:	Student was assessed for suicide risk
Variable definition:	Indicates whether or not the student receiving behavioral health services had suicide risk assessed during the measurement period
Data collection level:	Student
Criteria:	Students who received telehealth behavioral health services through the SB-TNGP during the measurement period
Valid (allowable) values:	Check only one of the following. Options for response are: □ Yes with tool: Indicates the student had suicide risk assessed using a validated tool □ Yes by interview: Indicates the student had suicide risk assessed by interview and not by a validated tool □ No: Indicates the student did NOT have suicide risk assessed
Note for abstractions:	Examples of a validated risk assessment tool are: GAPS: https://www.ncbi.nlm.nih.gov/books/NBK232700/; Columbia Suicide Severity Rating Scale; ASQ (Ask Suicide-Screening Questions Toolkit); and the PHQ-9
Source for definitions:	Physician Consortium for Performance Improvement. NQF Endorsed. AHRQ National Quality Measures Clearinghousehttps://www.qualitymeasures.ahrq.gov/summaries/summary/49975

Data element number:	Behavioral Health - 5
Variable name:	Student completed a comprehensive risk assessment and then provider discussed common health risk behaviors
Variable definition:	Indicates whether or not the student completed a comprehensive risk assessment DURING THE PAST 12 MONTHS and then the provider discussed common health risk behaviors
Data collection level:	Student
Criteria:	Students who received telehealth behavioral health services as part of the SB-TNGP during this measurement period
Valid (allowable) values:	Check only one of the following. Options for response are: □ Yes to Both Assessment and Discussion: During the past 12 months the student completed a comprehensive risk assessment AND the provider discussed common health risk behaviors □ Yes to Assessment Only: During the past 12 months the student completed a comprehensive risk assessment BUT the provider did not discuss common health risk behaviors □ Yes to Discussion Only: During the past 12 months that the student did NOT complete a comprehensive risk assessment, BUT the provider did discuss common risk behaviors   □ No: During the past 12 months the student did NOT complete a comprehensive risk assessment and the provider did NOT discuss common risk behaviors
Note for abstractions:	The risk assessment should be administered annually; the date of the completion must be within the last 12 months.
Guidelines for abstraction:	A validated risk assessment should be used. Examples include the Youth Risk Behavior Surveillance System (YRBSS) https://www.cdc.gov/healthyyouth/data/yrbs/index.htm; Bright futures tool: https://brightfutures.aap.org/Bright%20Futures%20Documents/CoreTools15-17YearVisit.pdf; RAAPS: http://www.possibilitiesforchange.com/raaps/; Child and Youth Mental Health Assessment (ChYMH); Achenbach Child Behavior Checklist (CBCL); Strengths and Difficulties Questionnaire
Source for definitions:	CDC. https://www.cdc.gov/healthyyouth/data/yrbs/index.htm; SBHA http://www.sbh4all.org/resources/quality-counts/five-performance-measures/

Data element number:	Behavioral Health - 6
Variable name:	Perceived impact from services
Variable definition:	Indicates whether or not the student or caregiver in case of young student reported mental health improved
Data collection level:	Student
Criteria:	Students who received telehealth behavioral health services through the SB-TNGP during the measurement period
Valid (allowable) values:	Check only one of the following. Options for response are: □ The student (or caregiver) reported mental health improvement □ The student (or caregiver) reported NO mental health improvement □ The student (or caregiver) was unsure or did NOT REPORT about mental health improvement □ Unknown or no documentation during this time
Note for abstractions:	Response should be based on the latest client report before the end of the measurement period.
Source for definitions:	Maine School Based Health Alliance

Data element number:	Behavioral Health - 7
Variable name:	Number of telehealth encounters that the student received for behavioral health
Variable definition:	Indicates how many encounters for behavioral health services that the student received that involved telehealth
Data collection level:	Student
Criteria:	Students who received telehealth behavioral health services as part of the SB-TNGP during this measurement period
Skip logic:	NOTE that the response to this question will be used to determine the extent of ENCOUNTER level data collection. In particular, a high number of behavioral health visits will trigger instructions to only complete ENCOUNTER level data collection for the first visit each month.
Valid (allowable) values:	Any numeric character
Note for abstractions:	An encounter can be of any duration, and it can be scheduled or impromptu.
Source for definitions:	SB TNGP Funding Opportunity Announcement (FOA)

Data element number:	Behavioral Health - 8
Variable name:	Number of non-telehealth encounters that the student received for behavioral health in the school setting
Variable definition:	Indicates how many encounters for behavioral health services that the student received in the school setting that did not involve telehealth
Data collection level:	Student
Criteria:	Students who received telehealth behavioral health services as part of the SB-TNGP during this measurement period
Valid (allowable) values:	Any numeric character or NA indicating that the data are “Not Available”
Note for abstractions:	We understand that this information will not be available in many schools, in which case enter NA. An encounter can be of any duration, and it can be scheduled or impromptu. Complete only for students who had telehealth behavioral health services. The school setting means the setting where the SB-TNGP operates.
Source for definitions:	Rural Telehealth Research Center

Data elements that are collected at the ENCOUNTER level

The information in this section will be collected for SB-TNGP telehealth behavioral health encounters.

Instructions

NOTE the following questions are to be answered for each telehealth behavioral health ENCOUNTER if the number of telehealth behavioral health encounters for the student during the measurement period is less than 6. If the number of telehealth behavioral health encounters during the measurement period is more than 6, then answer the following questions for each ENCOUNTER that was the first encounter of the month.

Data element number:	Behavioral Health - 9
Variable name:	Type of behavioral health provider seen via telehealth
Variable definition:	Indicates the type of licensed provider the student saw for telehealth behavioral health services during this encounter
Data collection level:	Encounter
Criteria:	Students who received behavioral health services via telehealth as part of the SB-TNGP during this measurement period
Valid (allowable) values:	Check ALL that apply. Options for response are: □ Psychiatrist □ Psychiatric or Mental Health Nurse Practitioner □ Clinical Psychologist □ School Psychologist □ Nurse Psychotherapist □ Clinical Social Worker □ Professional Counselor □ Mental Health Counselor □ Marriage and Family Therapist □ Other – please specify:__________________________________________ □ Unknown: Unable to determine from telehealth log or student visit record
Note for abstractions:
Source for definitions:	Rural Telehealth Research Center

Data element number:	Behavioral Health - 10
Variable name:	Type of behavioral health service provided via telehealth
Variable definition:	Indicates the type of telehealth behavioral health services the student received during this encounter
Data collection level:	Encounter
Criteria:	Students who received behavioral health services via telehealth as part of the SB-TNGP during this measurement period
Valid (allowable) values:	Check ALL that apply. Options for response are: □ Assessment □ Individual counseling □ Group counseling □ Family counseling □ Medication management □ Service or assessment for crisis or emergent behavioral health need □ Other – please specify:__________________________________________ □ Unknown: Unable to determine from telehealth log or student visit record
Note for abstractions:
Source for definitions:	Rural Telehealth Research Center

Data element number:	Behavioral Health - 11
Variable name:	Telehealth technical success
Variable definition:	Indicates whether or not telehealth technology was administered successfully
Data collection level:	Encounter
Criteria:	Students who received behavioral health services via telehealth as part of the SB-TNGP during this measurement period
Valid (allowable) values:	Check only one of the following. Options for response are: □ Successful: The telehealth encounter was technologically successful □ Unsuccessful: The telehealth encounter was technologically NOT successful □ NA: Not Applicable □ Unknown: Unable to determine from telehealth log or student visit record
Note for abstractions:	Successful administration means that voice and video quality were sufficient to complete the consultation. Technical drop-outs of the telemedicine system did not occur. Unsuccessful administration means that the voice and/or video quality were not of sufficient quality to complete the consultation (e.g. unreachable network, poor image quality, poor audio signal quality). If unable to determine whether the telehealth consultation was technically successful, select ‘Unknown.’
Source for definitions:	Modified PIMS; Rural Telehealth Research Center

Data element number:	Behavioral Health - 12
Variable name:	Immediate disposition
Variable definition:	Indicates the student’s immediate disposition at the conclusion of this encounter
Data collection level:	Encounter
Criteria:	Students who received behavioral health services as part of the SB-TNGP during this measurement period
Valid (allowable) values:	Check only one of the following. Options for response are: □ Student was released to resume regular school schedule □ Student was released from school to parent/guardian’s care □ Student was transferred to other health care □ Other – please specify: _____________________________________ □ Unknown: Unable to determine from telehealth log or student visit record
Note for abstractions:
Source for definitions:	Rural Telehealth Research Center

Data element number:	Behavioral Health - 13
Variable name:	Follow-up referral
Variable definition:	Indicates whether or not the student was referred for follow-up care at the end of the encounter
Data collection level:	Encounter
Criteria:	Students who received behavioral health services as part of the SB-TNGP during this measurement period
Valid (allowable) values:	Check only one of the following. Options for response are: □ Student was determined to NOT need referral for follow-up care □ Student was referred for follow-up return visit to SB-TNGP WITH telehealth □ Student was referred for follow-up return visit to SB-TNGP WITHOUT telehealth □ Student was referred to primary care provider outside of school □ Student was referred to specialty care outside of school □ Student was referred for other care outside of school □ Other – please specify: _____________________________________ □ Unknown: Unable to determine from telehealth log or student visit record
Note for abstractions:
Source for definitions:	Rural Telehealth Research Center

Data element number:	Behavioral Health - 14
Variable name:	Avoided travel
Variable definition:	Indicates whether or not the student avoided travel for care because of this encounter
Data collection level:	Encounter
Criteria:	Students who received behavioral health services as part of the SB-TNGP during this measurement period
Skip logic:	NOTE the response to this question will be used for skip logic for the next two questions.
Valid (allowable) values:	Check only one of the following. Options for response are: □ Avoided travel for this encounter: The student received services through the SB-TNGP and if they had not received those services during this visit then the student would have had to see a provider elsewhere □ Did not avoid travel for this encounter: The student received services through the SB-TNGP but if they had not received those services during this visit then the student would NOT have had to see and travel to a provider elsewhere □ NA: Not Applicable □ Unknown: Unable to determine from telehealth log or student visit record
Note for abstractions:
Source for definitions:	Rural Telehealth Research Center

Data element number:	Behavioral Health - 15
Variable name:	Provider if travel was avoided
Variable definition:	Indicates the type of provider the student would have seen if travel was avoided because of this encounter
Data collection level:	Encounter
Criteria:	All students who received any behavioral health service as part of the SB-TNGP during this measurement period where travel was avoided
Skip logic:	NOTE that if the response to the previous question indicates that travel was avoided then this question will follow.
Valid (allowable) values:	Check only one of the following. Options for response are: □ Psychiatrist □ Psychologist □ Licensed Clinical Social Worker □ Counselor □ Emergency Department or Urgent Care □ Other – please specify:__________________________________________ □ Unknown: Unable to determine from telehealth log or student visit record □ NA: Not Applicable
Note for abstractions:
Source for definitions:	Rural Telehealth Research Center

Data element number:	Behavioral Health - 16
Variable name:	Patient travel miles to likely source of care
Variable definition:	Indicates the number of miles from the school to the type of provider the student would have likely seen if travel was avoided because of this encounter
Data collection level:	Encounter
Criteria:	All students who received any behavioral health service as part of the SB-TNGP during this measurement period
Skip logic:	NOTE that if the response to the previous question indicates that travel was avoided then this question will follow.
Valid (allowable) values:	Any numeric character
Note for abstractions:	Enter miles from the School to student’s likely provider as specified in the previous question. Use Google maps or similar program to determine travel miles by car one way.
Source for definitions:	Modified PIMS

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