ࡱ> q` .bjbjqPqP ::#J<````III8LIhJ}(L&NQNQNQNQR*UV{{{{{{{$~h|\RR\\|``NQNQ4|```\d`NQNQ{`\{``j[p|\ sNQL pa$@I\dr2u|0}Ir\]bd ssrWVX`YZrWrWrW||_^rWrWrW}\\\\6pGpG`````` QUARTERLY CONTRACT MONITORING REPORT (QCMR) CLIENT MOVEMENT REPORT PARTIAL CARE SERVICES USTF PROJECT CODE:  FORMTEXT      REPORTING QUARTER: (CHECK ONE):NAME OF AGENCY:  FORMTEXT       JULY 1 TO SEPTEMBER 301  FORMTEXT      NAME OF PROGRAM:  FORMTEXT       OCTOBER 1 TO DECEMBER 312  FORMTEXT      PERSON COMPLETING FORM/PHONE #:  FORMTEXT      JANUARY 1 TO MARCH 313  FORMTEXT       DATE SUBMITTED:  FORMTEXT       APRIL 1 TO JUNE 304  FORMTEXT       CHECK AGENCY REPORTING QUARTER:1  FORMTEXT      2  FORMTEXT       3  FORMTEXT       4  FORMTEXT       1.  FORMTEXT       2.  FORMTEXT       3.  FORMTEXT       4.  FORMTEXT       5.  FORMTEXT       6.  FORMTEXT       Beginning Active Caseload (First Day of Qtr.)New Enrollees to Program Element During Qtr.Transfers to Program Element During QtrTransfers From Program Element During QtrTerminations From Program Element During Qtr.Ending Active Caseload (Last Day of Qtr.) TARGET GROUPS7. Number of Target Group Members:NEW ENROLLEESTRANSFERS7A.Clients who were Discharged from State Hospitals and Enrolled in this Program Within 30 Days of Discharge. FORMTEXT       FORMTEXT      7B.Clients who were Discharged from County Hospitals and Enrolled in this Program Within 30 Days of Discharge. FORMTEXT       FORMTEXT      7C.Clients who were Discharged from a Short-Term Care Facility/Involuntary Psychiatric Unit and Enrolled in this Program within 30 Days of Discharge.  FORMTEXT       FORMTEXT      7D.Clients who were Discharged from another Hospital and Enrolled in this Program Within 30 Days of Discharge. FORMTEXT       FORMTEXT       CLIENT MOVEMENT REPORT BEGINNING ACTIVE CASELOAD: Consist of clients who have had at least one face-to-face contact with your agency in the last 90 days and were active on the last of the previous quarter. The Beginning Caseload is equal to the Ending Caseload of the previous reporting quarter. NEW ENROLLEES: Clients who were newly enrolled in your agency during the reporting quarter and were enrolled in this program element prior to enrollment in any other program element within your agency. TRANSFERS TO: Refers to clients who are already registered within your agency in another program element, and are being transferred to this program element service. TRANSFERS FROM: Refers to clients who are registered within your agency in this program element, but for whom this program has ceased to provide services on an ongoing basis and for whom another program element of your agency is going to provide services on an ongoing basis. TERMINATIONS: Clients who are no longer receiving services at your agency. ENDING ACTIVE CASELOAD: Is the active caseload on the last day of the reporting quarter. It is calculated in the following manner: Add #1 (Beginning Active Caseload) + #2 (New Enrollees) + #3 (Transfers To). Subtract #4 (Transfers From) and #5 (Terminations) = Ending Caseload #6. DUPLICATED COUNT OF TARGET GROUP MEMBERS AMONG NEW ENROLLEES AND TRANSFERS TO: Refers to the count of clients who entered this program element within 30 days of their discharge from the hospital. The definitions of New Enrollees and Transfers To are the same as stated above. Therefore, the number of New Enrollees or Transfers To indicated in categories 7A, 7B, 7C, and 7D, should be the same or less than the number indicated in items #2 and #3 of this form. 7A. STATE HOSPITAL: Refers to the states five psychiatric hospitals located in New Jersey only: Greystone Park, Trenton, Ancora, Hagedorn, and Ann Klein. 7B. COUNTY HOSPITALS: Refers to the six county hospitals located in New Jersey only: Essex, Burlington, Camden, Hudson, Bergen, and Union. 7C. SHORT-TERM CARE FACILITIES: Refers to inpatient, community-base mental health treatment facilities that provide acute care and assessment services to the mentally ill. The Commissioner, Department of Human Services must designate the facility. 7D. OTHER HOSPITAL: Refers to any psychiatric hospital or psychiatric unit within a hospital that is not a State, County or STCF Hospital in New Jersey; include as Other any Facility located outside of New Jersey. QUARTERLY CONTRACT MONITORING REPORT (QCMR) LEVEL OF SERVICE REPORT PARTIAL CARE SERVICES USTF PROJECT CODE:  REF Text1   REPORTING QUARTER: (CHECK ONE)NAME OF AGENCY:  REF Text2   JULY 1 TO SEPTEMBER 30 1  REF Text6   NAME OF PROGRAM:  REF Text3   OCTOBER 1 TO DECEMBER 312  REF Text7   PERSON COMPLETING FORM/PHONE #:  REF Text4  JANUARY 1 TO MARCH 313  REF Text8  DATE SUBMITTED:  REF Text5  APRIL 1 TO JUNE 304  REF Text9   CHECK AGENCY REPORTING QUARTER: 1  REF Text10  2 REF Text11   3  REF Text12   4  REF Text13    INFORMATION RELATED TO ENROLLED CLIENTS 1. Of the Ending Caseload for Regular PC/PH, how many clients are: A. Medicaid/Familycare Enrolled  FORMTEXT       B. Medicaid/Familycare Non-Enrolled  FORMTEXT       (1A. + 1B. must equal Total Regular PC/PH ending caseload) 2. Of the Ending Caseload for Acute PH, how many clients are: A. Medicaid/Familycare Enrolled  FORMTEXT       B. Medicaid/Familycare Non-Enrolled  FORMTEXT       (2A. + 2B. must equal Total Acute PH ending caseload) Regular PC/PH Acute PH3. Average Daily Attendance  FORMTEXT       FORMTEXT       4. Physical Client Capacity  FORMTEXT        FORMTEXT       5. Total Units of Service  FORMTEXT        FORMTEXT       6. Of the Total Regular PC/PH Units of Service Provided how many were provided to individuals who were: A. Medicaid/Familycare Enrolled  FORMTEXT       B. Medicaid/Familycare Non-Enrolled  FORMTEXT       (6A. + 6B. must equal Total Regular PC/PH Units of Service) 7. Of the Total Acute/PH Units of Service Provided how many were provided to individuals who were: A. Medicaid/Familycare Enrolled  FORMTEXT       B. 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Services may include counseling, psychoeducation, medication monitoring and other psychiatric care, prevocational training, direct skills teaching, and recreation and social events, available on a half-day or full-day basis for no fewer than five days per week.  UNITS OF SERVICE: Refers to the total count of units of service provided to all partial care clients. The definition of a unit of service is 1 hour = 1 unit; e.g. client attends for 2 hours of partial care services = 2 units of service. PHYSICAL CLIENT CAPACITY: Refers to the space in which the PC/PH is located as limited by legal constraints such as fire codes, as well as what capacity the provider would feel comfortable serving, were resources made available to fund this capacity. QUARTERLY CONTRACT MONITORING REPORT (QCMR) LEVEL OF SERVICE REPORT PARTIAL CARE SERVICES USTF PROJECT CODE:  REF Text1   REPORTING QUARTER: (CHECK ONE)NAME OF AGENCY:  REF Text2   JULY 1 TO SEPTEMBER 30 1  REF Text6   NAME OF PROGRAM:  REF Text3   OCTOBER 1 TO DECEMBER 312  REF Text7  PERSON COMPLETING FORM/PHONE #:  REF Text4  JANUARY 1 TO MARCH 313  REF Text8   DATE SUBMITTED:  REF Text5   APRIL 1 TO JUNE 304  REF Text9   CHECK AGENCY REPORTING QUARTER: 1  REF Text10   2  REF Text11   3  REF Text12   4  REF Text13    SERVICES RELATED TO ENROLLED CLIENTS OR UNENROLLED INDIVIDUALS 8. Number of Staff Face-to-Face Outreach Contacts Provided with Individuals Residing in: A. Independent Living Arrangements  FORMTEXT       C. Nursing Homes  FORMTEXT       B. Boarding Homes  FORMTEXT       SERVICES RELATED TO UNENROLLED INDIVIDUALS 9. Number of Residents of State or County Psychiatric Hospitals that: A. Participated on-site in the program to prepare for discharge.  FORMTEXT       B. Were served by your staff at the hospital to prepare for discharge.  FORMTEXT       10. Number of Socialization/Recreation Group Sessions for Former or Inactive Partial Care Clients  FORMTEXT           7/07 Submit Forms 30 days after the close of a Quarter to the QCMR Coordinator at the following address: Division of Mental Health Services, PO Box 727, Trenton, NJ. 08625-0727 7/07 Submit Forms 30 days after the close of a Quarter to the QCMR Coordinator at the following address: Division of Mental Health Services, PO Box 727, Trenton, NJ. 08625-0727 7/07 Submit Forms 30 days after the close of a Quarter to the QCMR Coordinator at the following address: Page 1 of 2 Division of Mental Health Services, PO Box 727, Trenton, NJ. 08625-0727 rtvxz|~tt$ !$Ifa$gdU $IfgdQ_ !gkd81$$Ifl&) t0644 la rtvƬȬʬJķziVLC;+heBh;5CJOJQJaJhOJQJh5OJQJh%L@OJQJ$h5CJOJQJaJmHnHu!hCJOJQJaJmHnHuhyOJQJmHnHuhOJQJmHnHu*h62OJQJfHmHnHq uh62OJQJmHnHuhu OJQJmHnHuhm5OJQJmHnHuhn5OJQJmHnHuh%5OJQJmHnHuhU5OJQJmHnHuƬȬʬJƭvvff$$If]a$gdeB$]a$gd%L !  !r@@@fkd1$$IflFhb t6    44 la ƭ:0 vjjj $]a$gd;ikd72$$IfTl t0644 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