ࡱ>  bjbjUU 4??F J J 8l/s????6td<v.x.x.x.x.x.x./13Fx.66x.??A/&&&4??v.&v.&&V+@n,?MD"4+ b.W/0/+x4&4n,n,l4,&x.x.&/4J  e:  QUARTERLY CONTRACT MONITORING REPORT (QCMR) DESIGNATED SCREENING SERVICES USTF PROJECT CODE:  FORMTEXT      REPORTING QUARTER: (CHECK ONE) JULY 1 TO SEPTEMBER 30  FORMTEXT       NAME OF AGENCY:  FORMTEXT      OCTOBER 1 TO DECEMBER 31  FORMTEXT       NAME OF PROGRAM:  FORMTEXT      JANUARY 1 TO MARCH 31  FORMTEXT       PERSON COMPLETING FORM/PHONE #  FORMTEXT       APRIL 1 TO JUNE 30  FORMTEXT       DATE SUBMITTED:  FORMTEXT      YEAR:  FORMTEXT       CHECK AGENCY REPORTING QUARTER: 1.  FORMTEXT       2.  FORMTEXT       3.  FORMTEXT       4.  FORMTEXT        1. Total Duplicated Episodes of Care (Admissions to DSS) Provided by the Designated Screening Service:  FORMTEXT       A. # Adults (age 18 and above):  FORMTEXT       B. # Youth (thru age 17):  FORMTEXT       2. Total Duplicated Episodes of Care (Admissions to DSS) with Disposition to discharge to the community:  FORMTEXT       A. # Adults (age 18 and above):  FORMTEXT       B. # Youth (thru age 17):  FORMTEXT       3. Total Duplicated Episodes of Care (Admissions to DSS) with Disposition to voluntary inpatient psychiatric bed:  FORMTEXT       A. # Adults (age 18 and above):  FORMTEXT       B. # Youth (thru age 17):  FORMTEXT       4. Total Duplicated Episodes of Care (Admissions to DSS) with Disposition to involuntary inpatient psychiatric bed:  FORMTEXT       A. # Adults (age 18 and above):  FORMTEXT       B. # Youth (thru age 17):  FORMTEXT       5. Total Duplicated Episodes of Care (Admissions to DSS) with Disposition to inpatient setting:  FORMTEXT       Adults (to State psychiatric hospitals):  FORMTEXT       Adults (to County psychiatric hospitals):  FORMTEXT       Adults (Short Term Care Facilities):  FORMTEXT       Adults (Short Term Care Facilities  Consensual Admission):  FORMTEXT       Adults (Private Psychiatric Facility/Unit):  FORMTEXT       Adults (Medical)  FORMTEXT       Youth (Private Psychiatric Facility/Unit):  FORMTEXT       Youth (Children s Crisis Intervention Service units (CCISs):  FORMTEXT       Youth (Other):  FORMTEXT       6. Total Episodes of Care (Admissions to DSS) On-Site:  FORMTEXT       A. # Adults (age 18 and above):  FORMTEXT       B. # Youth (thru age 17):  FORMTEXT       7. Total Episodes of Care (Admissions to DSS) Off-Site:  FORMTEXT       A. # Adults (age 18 and above):  FORMTEXT       B. # Youth (thru age 17):  FORMTEXT       8. Total number of staff face-to-face follow-up contacts delivered.  FORMTEXT       A. # Adults (age 18 and above):  FORMTEXT       B. # Youth (thru age 17):  FORMTEXT       9. Total number medication follow-up contacts delivered.  FORMTEXT       A. # Adults (age 18 and above):  FORMTEXT       B. # Youth (thru age 17):  FORMTEXT       10. Total number of crisis telephone contacts delivered:  FORMTEXT       11. Recidivism (# of Episodes of Care Involving Repeat Service Users):  FORMTEXT       12. Total Units (Hours) of Services Delivered:  FORMTEXT       Total Units (Hours) of Services Delivered By Episode of Care Disposition Type: A. Episodes Ending with Discharge To Community:  FORMTEXT       B. Episodes Ending with in-patient transfer:  FORMTEXT       13. Total Units (Hours) of Services Adults/Youth: Hospital/Inpatient Unit:  FORMTEXT       Emergency Room:  FORMTEXT       Community:  FORMTEXT       Jail:  FORMTEXT       Nursing Home:  FORMTEXT       Other:  FORMTEXT       Total Units of Service Provided to Adults:  FORMTEXT       Hospital/Inpatient Unit:  FORMTEXT       Emergency Room:  FORMTEXT       Community:  FORMTEXT      ZʼpV:) hhCJOJPJQJaJ7j *hhCJOJPJQJUaJmHnHu2j *hh{^CJOJPJQJUaJ# *hhCJOJPJQJaJ,j *hh{^CJOJPJQJUaJ#hh5CJOJPJQJaJ hhy CJOJPJQJaJhCJOJPJQJaJ&hh56CJOJPJQJaJ hD56CJOJPJQJaJ hf&956CJOJPJQJaJ\. d$1$7$8$Ifgdd1$7$8$gd$d1$7$8$a$gd$d1$7$8$a$gdf&9 Z ^ ` t v x    . 0 2 < ų}vų\}ųB}2j *hh{^CJOJPJQJUaJ2j *hh{^CJOJPJQJUaJ hT@h7j *hhCJOJPJQJUaJmHnHu2jt *hh{^CJOJPJQJUaJ# *hhCJOJPJQJaJ,j *hh{^CJOJPJQJUaJ hhCJOJPJQJaJ#hh5CJOJPJQJaJ F xeeed$1$7$8$Ifgdkd$$Ifl0|) t0644 lapyt< > F H j l > @ T V X 龤ww]C2j *hh{^CJOJPJQJUaJ2j *hh{^CJOJPJQJUaJ hhCJOJPJQJaJ7j *hhCJOJPJQJUaJmHnHu2j* *hh{^CJOJPJQJUaJ# *hhCJOJPJQJaJ hT@h#hh5CJOJPJQJaJ,j *hh{^CJOJPJQJUaJF H j xeeed$1$7$8$Ifgdkdz$$Ifl0|) t0644 lapyt > H xeeed$1$7$8$Ifgdkd$$Ifl0|) t0644 lapytX b d    H J j l ̻̗}̩v̗\̻̗B2j *hh{^CJOJPJQJUaJ2jZ *hh{^CJOJPJQJUaJ hT@h2j6 *hh{^CJOJPJQJUaJ# *hhCJOJPJQJaJ#hh5CJOJPJQJaJ hhCJOJPJQJaJ,j *hh{^CJOJPJQJUaJ7j *hhCJOJPJQJUaJmHnHuH J j xeeed$1$7$8$Ifgdkd$$Ifl0|) t0644 lapyt    ( * , 6 8 : @ B D X Z \ f h j p r t 黴w飻]飻2jT *hh{^CJOJPJQJUaJ2j *hh{^CJOJPJQJUaJ# *hhCJOJPJQJaJ hhCJOJPJQJaJ hT@h#hh5CJOJPJQJaJ7j *hhCJOJPJQJUaJmHnHu,j *hh{^CJOJPJQJUaJ : < j l xeeOeOeOe$d$1$7$8$Ifa$gdd$1$7$8$IfgdkdB$$Ifl0|) t0644 lapyt DϳϢ~dϳϐ]YUQMQMQ~heh@z|~ϳϯϙϳϯ{wϙ]ϳϯYUYUYhehf2j  *hh{^CJOJPJQJUaJhh2j  *hh{^CJOJPJQJUaJ# *hhCJOJPJQJaJhf&9hϳϯϲϳϣρ<2j *hh{^CJOJPJQJUaJ# *hhCJOJPJQJaJhhheh hRTV`bfhϳϯύsϳϫkύQϳϣ2j *hh{^CJOJPJQJUaJh<OJQJ2j  *hh{^CJOJPJQJUaJ# *hhCJOJPJQJaJhBhhh<h"@""v#$$$$T%%%&b&&''x''tPtttFu^gdn & Fgd `gdegdegdD|$~$$$$$$$$$$$&%(%,%.%B%ϳϢ~sh`XF# *hh)CJOJPJQJaJh)PJ^Jh PJ^Jh h PJ^Jh hePJ^Jh CJOJPJQJaJhDh heCJOJPJQJaJ h(jheCJOJPJQJaJ7j *hheCJOJPJQJUaJmHnHu,j *hh{^CJOJPJQJUaJ2j *hh{^CJOJPJQJUaJB%D%F%P%R%r%v%x%%%%%%%%%%%%%%%%%& & &ϳϫϑwϳϫϑ]ϳϫϑC2j *hh{^CJOJPJQJUaJ2j| *hh{^CJOJPJQJUaJ2j *hh{^CJOJPJQJUaJ# *hh)CJOJPJQJaJh)PJ^Jh PJ^J7j *hh)CJOJPJQJUaJmHnHu,j *hh{^CJOJPJQJUaJ2j *hh{^CJOJPJQJUaJ &&&4&:&<&P&R&T&^&`&n&v&x&&&&&&&&&&&ļ̪ļ̪vkckL,j *hnh{^CJOJPJQJUaJhnPJ^JhnhnPJ^J2j *hh{^CJOJPJQJUaJ2jh *hh{^CJOJPJQJUaJ# *hh)CJOJPJQJaJh)PJ^Jh PJ^J,j *hh{^CJOJPJQJUaJ7j *hh)CJOJPJQJUaJmHnHu& ' ''''''L'N'P'R'f'h'j'Ӽ~v_M3_2j *hh{^CJOJPJQJUaJ# *hh)CJOJPJQJaJ,j *hh{^CJOJPJQJUaJh)PJ^Jh PJ^Jh h PJ^JhnhnPJ^JhnCJOJPJQJaJ#j *hhnUmHnHu,j *hnh{^CJOJPJQJUaJ2jT *hnh{^CJOJPJQJUaJ# *hnhnCJOJPJQJaJj't'v''''''''''''''''(t t"t$t(t*t>t@tBtLtNtPt\t^tļ̪ļ̪vtlļ̪Rl2j,! *hh{^CJOJPJQJUaJh1]PJ^JU2j  *hh{^CJOJPJQJUaJ2j@  *hh{^CJOJPJQJUaJ# *hh)CJOJPJQJaJh)PJ^Jh PJ^J,j *hh{^CJOJPJQJUaJ7j *hh)CJOJPJQJUaJmHnHu Jail/Juvenile DC:  FORMTEXT       School:  FORMTEXT       Other:  FORMTEXT       Total Units of Service Provided to Youth:  FORMTEXT       Submit to: HYPERLINK "mailto:dmhs.qcmr@dhs.state.nj.us"dmhs.qcmr@dhs.state.nj.us Revised 04-26-2013 QUARTERLY CONTRACT MONITORING REPORT (QCMR) DESIGNATED SCREENING SERVICES DEFINITIONS: Episodes of Care: Refers to the provision of mental health services by designated screening service program staff to a consumer that includes, at a minimum, a comprehensive face-to-face assessment of the consumer s mental health needs and a disposition that includes a transfer (to an in-patient unit) or a discharge plan to the community with aftercare recommendations. (A person who is discharged to the community and is seen face-to-face by designated screening staff for several follow-up contacts counts as one episode of care.) Note:  Duplicated counts acknowledge that multiple episodes of care may be provided to the same consumer in a reporting period. Units (Hours) of Services: Is the aggregate duration in hours of all of the episodes of care that were delivered during the reporting period. One unit is equal to one hour of episode duration, irrespective of staffing matters. Record actual time; Do not round time. Note: An episode of care commences at the time in which face-to-face interaction between designated screening service staff and a consumer/family/ collateral informant is initiated and concludes when the face-to-face interaction between designated screening service staff and a consumer/family/ collateral informant ends. (Face-to-face follow up contact time subsequent to the provision of a discharge plan is NOT included in the episode duration calculation, as this output is collected elsewhere). Illustration: Face-to-face contact with Bill and screening staff is initiated at 9:00 AM. Bill is provided with his aftercare plan at 11:30 AM and Face-to-face contact with screening staff terminates. This episode of care has a duration of 2.5 hours and the Screening program would accrue 2.5 Units of Service. On-Site: Refers to services delivered in the building/campus/hospital that houses the designated screening program. Off-Site: Refers to services delivered outside the building/campus/hospital that houses the designated screening program. NOTE: For the purpose of fields 6 and 7 above, the episode of care should be classified based on where the initial face-to-face contact occurred. A mobile outreach that results in transport of the consumer back to the emergency department should be classified as an off-site episode of care. Staff Face-to-Face Follow-up Contacts: Refers to an in-person contact, irrespective of length, between designated screening staff and a consumer subsequent to the provision of a discharge plan. Medication Follow-Up Contacts Delivered: Refers to an in-person contact, irrespective of length, between designated screening staff and a consumer subsequent to the provision of a discharge plan, for the specific purpose of meeting the person s medication related needs. Crisis Telephone Contacts: Refers to the aggregate number of telephone contacts between designated screening program staff and a consumer/family/collateral informant. Recidivism (# of Episodes of Care Involving Repeat Service Users): Refers to the number of episodes of care during the reporting period, in which a consumer presents to the designated screening service (the same designated screening service) within 30 days of the conclusion of a previous episode of care. 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