ࡱ> OQN7 bjbj(( 4NJdJd3338kD3%33333"0 <$$$$$$$$I')z%DDD%33-%6DF33$D$&3=gp$c%<%,y*y*&&y*#(DDDDDDD%%DDD%DDDDy*DDDDDDDDD : ANNEX A PROGRAM COMMITMENTS EARLY INTERVENTION AND SUPPORT SERVICES (EISS) PROGRAM DESCIPTION: Provide rapid access to short term, recovery-oriented, crisis intervention services. Serves persons who are 18 years of age or older, who are experiencing exacerbated symptoms of a mental illness. Services include assessment, psychiatric evaluation, pharmacologic interventions, short-term counseling and psychotherapy, psycho-education, time-limited case management, referral and linkage. NAME OF AGENCY: CONTRACT NUMBER: BUDGET MATRIX CODE: BUDGET MODIFICATION NO: (0 = Original) ___ Target Enrollment (e.g. Caseload) _______ Total Admissions _______ Total Episodes of Care _______ Face-to-Face Contact Hours On-site _______ Face-to-Face Contact Hours Off-site _______ Total Face-to-Face Contact Hours _______ Access: 100% of consumers will be offered a face to face contact with a mental health professional within 24 hours of referral. YES NO 90% of consumers, who request or need access to a psychiatric prescriber, will be offered a face to face appointment with a prescriber within 24 hours of enrollment. YES NO Evaluation: Agency will complete annual program evaluation, inclusive of pre-post BASIS-24 results. YES NO Agency will submit program data to DMHAS upon request. YES NO STAFFING: (Please specify the amount of EISS staff time for each type of staff. For Staff that work in more than one agency program, reflect only the portion of the staff persons time that is allocated to the EISS program. Staff Total # of FTEs Director _______ Psychiatrist _______ Advanced Practice Nurse _______ Registered Nurse _______ Masters Level Clinicians _______ Bachelor Level Staff _______ Other Direct Care: Specify _______ _______ Other Direct Care: Specify _______ _______ TOTAL DIRCET CARE _______ Clerical Support _______ Security _______ TOTAL ALL EISS Staff _______ HOURS OF OPERATION: (Please specify hours:) SUNDAY _______ TO _______ MONDAY _______ TO _______ TUESDAY _______ TO _______ WEDNESDAY _______ TO _______ THURSDAY _______ TO _______ FRIDAY _______ TO _______ SATURDAY _______ TO _______ EISS WILL PROVIDE 24/7 ON-CALL STAFF AVAILABILITY (TO PROCESS REFERRALS AND TO RESPOND TO ENROLLED EISS CONSUMER CALLS): YES NO EISS Annex A Definitions. Target Enrollment refers to the number of consumers that the EISS program can serve at a point in time, when at full capacity. Admissions (New Enrollees) - refers to the number of consumers admitted to EISS during the year. Total Episodes of Care refers to the number of episodes in which EISS staff provide, at a minimum, a face-to-face assessment of the consumers mental health needs. Includes both consumers who are admitted to EISS, as well as consumers who are immediately referred at assessment and are not enrolled in EISS. Face-to-face on-site contact hours - refers to cumulative face-to-face contact time consumers or members of a consumers' family/support system receive from EISS staff at the EISS location. [Does not include telephone contact time; 60 minutes of face-to-face service provided to one 1 consumer = 1 hour of face-to-face service, irrespective of how many staff are present: (e.g. One staff provides a one hour group session to four consumers = 4 Hours of Face-to-Face Service; Two staff provides a one hour group session to four consumers = 4 Hours of Face-to-Face Service). No rounding (e.g. from 50 minutes to 1 hour) is permitted. 45 minutes of face-to-face service provided to one 1 consumer = .75 hour of face-to-face service.] Record and sum actual duration of each face-to-face contact to produce cumulative total face-to-face hours. Face-to-face off-site contact hours - refers to cumulative face-to-face contact time consumers or members of a consumers' family/support system receive from EISS staff, outside of the EISS location. Travel time to and from contact is excluded. [Does not include telephone contact time; 60 minutes of face-to-face service provided to one 1 consumer = 1 hour of face-to-face service, irrespective of how many staff are present: (e.g. One staff provides a one hour group session to four consumers = 4 Hours of Face-to-Face Service; Two staff provides a one hour group session to four consumers = 4 Hours of Face-to-Face Service). No rounding (e.g. from 50 minutes to 1 hour) is permitted. 45 minutes of face-to-face service provided to one 1 consumer = .75 hour of face-to-face service.] Record and sum actual duration of each face-to-face contact to produce cumulative total face-to-face hours.     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