Form 1 Evidence Based Telehealth Network Program (EB-TNP) Outco

Public Burden Statement: The purpose of this collection is to collect performance and clinical measures for the Behavioral Health Integration (BHI) Evidence Based Telehealth Network Program (EB-TNP). 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 information collection is 0906-XXXX and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit (42 U.S.C. 254c-14). Data will remain private to the extent allowed by the law. Public reporting burden for this collection of information is estimated to average 5 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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 14NWH04, Rockville, Maryland, 20857 or paperwork@hrsa.gov.  Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement. 

Behavioral Health Integration (BHI)

Evidence Based Telehealth Network Program (EB-TNP)

Outcome Measurement Report

Form 1: Priorities

Only include services provided at sites that are supported with BHI EB TNP funding in the table below.

Did you provide services to patients in any of the following categories because of any BHI EB TNP funding during this reporting period?
	Yes	No
Behavioral Health
Substance Use Disorder (SUD)
Sub-SUD: Opioid Use Disorder

Grantee Comments:

Form 2: Originating and Distant Sites

Complete Form 1. Priorities before inputting data in this form. Only sites that are supported with BHI EB TNP funding should be included.

List of Selected Sites (Modify the List of Sites if Needed) and Settings (Modify the List of Settings if Needed)

Site Name	Street Address	City/Town	County	State	Zip Code	Originating or Distant Site (O/D)	Originating Site: Is this site a Patient’s home residence? (Y/N)	Distant Site: Is this site a Provider’s home residence? (Y/N)	Rural site?	Setting

Number of Each Type of Site in this Reporting Period
Originating Sites1
Distant Sites2

Form 3: Specialties and Services, by Site

Complete Form 2. Originating and Distant Sites before inputting data in this form.

Only include current active sites and specialties that are supported with BHI EB TNP funding during this reporting period. Data populated in ‘Total Sites with New Access to Services’ is the total number of ‘No’ responses for the selected specialty in the ‘Was the specialty available in your community prior to this BHI EB TNP funding?’ category.

List of Sites (Modify the List of Sites if Needed)/ List of Specialties (Modify the List of Specialties if Needed)

Originating Site	Patient’s Home Residence? (Y/N)	Specialty(s) actively available at this site through telehealth	Was specialty available in your community prior to this BHI EB TNP funding? (Y/N)

Total Sites with New Access to Behavioral Health Service(s)	Number
Number of sites that have access to [specialty from configure report] services where access did not exist in your community prior to this BHI EB TNP funding

Form 4: Volume of Services, by Site and Specialty

Complete Form 3. Specialties and Services, by Site before inputting data in this form.

Only include unique patients seen and encounters occurring as the result of BHI EB TNP funding. Real-Time Encounters are encounters that are live, two-way interactions between a person and a provider using audiovisual telecommunications technology. Store-and-Forward Encounters, also called asynchronous, are the transmission of health information through digital images or pre-recorded videos through electronic communication to a practitioner who uses the information to make an evaluation.

Enter 0 if there is no data to report.

Site Name	Originating or Distant Site (O/D)	Setting	Specialty	Is the Specialty a Primary Care service, Behavioral Health service, or both?	Provider Type for this Specialty? (e.g. Primary Care, Psychiatrist, Psychologist, LCSW, etc.)	Does the Provider Type have the flexibility to deliver telehealth service(s) from their own home? (Y/N)	Unique Patients	Number of Real-Time Encounters	Number of Store-and- Forward Encounters	Provider to Provider Encounters	Total Encounters

Total Number of Unique Patients served at the Originating Site because of BHI EB TNP funding
Total Number of Encounters at the Originating Site because of BHI EB TNP funding
Total Number of Unique Patients served at the Distant Site because of BHI EB TNP funding
Total Number of Encounters at the Distant Site because of BHI EB TNP funding
Total Number of Unique Patients served because of BHI EB TNP funding
Total Number of Encounters because of BHI EB TNP funding

Form 5: Patient Travel Miles Saved

Complete Form 4: Volume of Services, by Site and Specialty before inputting data in this form.

Only sites and specialties that are supported with BHI EB TNP funding should be included.

Miles from the patient’s location to where the patient could receive health services in the absence of telehealth.

Use a web mapping platform or similar program to determine the shortest travel miles by car one way. (If multiple routes are possible, choose shortest travel miles. Round trip will be assumed to be twice one way travel.)

For group sessions/clinics, each patient should be counted separately, as each would have had to travel for these sessions.

Originating Site

Specialty

Name of location where patient would have been referred in absence of telehealth

Miles from Originating (patient) site to location where patient would have been referred in the absence of telehealth

Total Encounters

Miles Saved (Miles X Encounters X 2)

Specialty	Total Miles Saved	Total Encounters

Form 6: Other Uses of the Telehealth Network

Complete Form 5. Patient Travel Miles and Time Saved before inputting data in this form.

Only include sessions that are supported with BHI EB TNP funding. Enter 0 if there is no data to report. If information in ‘Formal and Informal Education’ is unknown, enter ‘UNK’. Distance learning is the education, of a provider or other person, through electronic communication such as video conferencing.

Categories	Number of Sessions
Administrative Meetings
Distance Learning
Other

Formal and Informal Education	Total Number of Sessions	Total Number of People
Formal Education (sessions are used to fulfill formal education, licensure or certification requirements)
Informal Education (sessions used to meet regulatory practice requirements, as well as supervision/advice requested by remote practitioners)

Grantee may specify types of training (i.e., grand rounds, virtual nurse training, etc.):

Form 7: Mental/Behavioral Health

Complete Form 6: Other Uses of the Telehealth Network before inputting data in this form.

Only include sites that are eligible for and receive BHI funding. Enter 0 if there is no data to report.

Mental/Behavioral Health	Number
Total number of adults who received Mental/Behavioral Health services where access did not exist prior to the BHI grant
Total number of pediatric and adolescent patients who received Mental/Behavioral Health services where access did not exist prior to the BHI grant
Mental/Behavioral Health Form Comments
Is Mental/Behavioral Health Form Complete?

Mental/Behavioral Health Form File Attachment
File Name	File Type	File Size	Upload Date

1 Originating site is the location where a patient gets physician or practitioner medical services through telehealth. Per the HRSA Behavioral Health Integration (BHI) Evidence Based Telehealth Network Program (EB-TNP) Fiscal Year 2024 Notice of Funding Opportunity (HRSA-24-010), BHI EB-TNP funds can only be used for originating sites located in rural areas that also are Medically Underserved Areas, have Medically Underserved Populations, or are frontier communities.

2 A distant site is the location where a physician or practitioner provides medical services through telehealth.

HRSA-24-010

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