ࡱ> _ 2bjbj 0bb==c| | 888LLL8PL!(!!!12t3<S~U~U~U~U~U~U~$z,~y~8L31@1L3L3y~!!f555L3R!8!S~5L3S~55}q"x!Ў`O3=tL?~|0t<5@xx&8xTL3L35L3L3L3L3L3y~y~5L3L3L3L3L3L3L3L3L3L3L3L3L3L3L3L3|  :  USTF PROJECT CODE:  CALENDAR YEAR OF REPORT REPORTING QUARTER: (CHECK ONE):NAME OF AGENCY: JULY 1 TO SEPTEMBER 301  FORMCHECKBOX NAME OF PROGRAM (Complete a Separate QCMR Form for each PACT Team): OCTOBER 1 TO DECEMBER 312  FORMCHECKBOX PERSON COMPLETING FORM / PHONE #: JANUARY 1 TO MARCH 313  FORMCHECKBOX DATE SUBMITTED:APRIL 1 TO JUNE 304  FORMCHECKBOX CHECK AGENCY REPORTING QUARTER:1  FORMCHECKBOX 2  FORMCHECKBOX 3  FORMCHECKBOX 4  FORMCHECKBOX  CASELOAD 1.  FORMTEXT      2.  FORMTEXT      3.  FORMTEXT      4.  FORMTEXT      5.  FORMTEXT      6.  FORMTEXT      Beginning Caseload (First Day of Qtr.)New Enrollees to Program Element During Qtr.Transfers In to Program Element During Qtr.Transfers From Program Element During Qtr.Terminations From Program Element During Qtr.Ending Caseload (Last Day of Qtr.) Target Caseload (Capacity Caseload):  FORMTEXT       Terminations Related to Functional Improvement:  FORMTEXT       Of the Ending Caseload, how many individuals are: 9A. Medicaid/Familycare enrolled:  FORMTEXT       9B. Non-Medicaid/Familycare enrolled:  FORMTEXT       (Note: The sum of 9A + 9B must equal ending caseload, as indicated in Item 6, (the Ending Caseload on the Last day of the Quarter): FACE-TO-FACE HOURS (UNITS OF SERVICE) Number of Face-to-Face Hours Delivered On-Site :  FORMTEXT       Number of Face-to-Face Hours Delivered Off-Site:  FORMTEXT       Number of Face-to-Face Hours Delivered on Behalf of Consumer:  FORMTEXT       Total Face-to-Face Hours Delivered During the Quarter:  FORMTEXT       (Sum # 10, 11, and 12. This value is auto-calculated). 13A. Of the Total Hours of Service (from item 13), how many were Delivered in the Group Modality:  FORMTEXT       13B. Of the Total Hours of Service (from item 13), how many were Delivered in the Individual Contact Modality:  FORMTEXT       (Note: the sum of 13A + 13B must equal the value in Item 13) CONSUMER OUTCOMES Please report the # of Enrolled Consumers (From the ending caseload) who, were/used: DURING ANY POINT IN THE QUARTERLAST DAY OF THE QUARTER14A. In a psychiatric in-patient unit:  FORMTEXT        FORMTEXT       14B. Incarcerated:  FORMTEXT        FORMTEXT       14C. Homeless:  FORMTEXT        FORMTEXT       14D. Designated Screening Services:  FORMTEXT       NA 14E. In Formal Education Program:  FORMTEXT        FORMTEXT       14F. Other Employment:  FORMTEXT        FORMTEXT       14G. Competitive Employment:  FORMTEXT        FORMTEXT       EMPLOYMENT & EDUCATION MOVEMENT TABLE Record the number of consumers from the ending caseload in the appropriate box. BEGINNING OF QuarterEnd of QuarterNo ActivitySome Activity Other Employment/ Enrolled in Education ProgramCompetitive EmploymentNo ActivitySome ActivityOther Employment/ Enrolled in Education ProgramCompetitive Employment 15A. Number of Consumers (Ending Caseload), who are retired:  FORMTEXT       Note: Total from all sixteen boxes in Item 15, plus number of consumers who are retired (Item 15A) must equal Ending Caseload (Item 6). 15 B. Weighted Team Employment and Education Movement Score:  FORMTEXT       (This value is auto-calculated.) STAFFING Please record staffing information (See instructions below as needed): (Staffing Position)CONTRACTED # of FTEDAYS IN QUARTER POSITION WAS FILLEDPsychiatrist  FORMTEXT        FORMTEXT       Advance Practice Nurse FORMTEXT       FORMTEXT      Clinician FORMTEXT       FORMTEXT      Registered Nurse FORMTEXT       FORMTEXT      Substance Abuse Specialist FORMTEXT       FORMTEXT      Vocational Specialist FORMTEXT       FORMTEXT      Mental Health/Wellness Specialist FORMTEXT       FORMTEXT      Peer Mental Health Specialist FORMTEXT       FORMTEXT      Other (Specify):  FORMTEXT       FORMTEXT       FORMTEXT      Other (Specify):  FORMTEXT       FORMTEXT       FORMTEXT      Other (Specify):  FORMTEXT       FORMTEXT       FORMTEXT      Secretary FORMTEXT       FORMTEXT      TOTAL (Direct Care) [Secretary excl.] FORMTEXT       FORMTEXT       16A. Number of hours per week Psychiatrist provided to the PACT Team per NJAC 10:37J-2.8(d)1:  FORMTEXT       Total Staff Hours (In Transit):  FORMTEXT       DEFINTIONS and INSTRUCTIONS Beginning Caseload (First Day of Qtr.): Refers to the PACT Teams caseload on the first day of the reporting period. 2. New Enrollees to Program Element During Qtr.: Refers to the number of consumers, (exclusive of transfers- in) for whom a case was opened by the PACT Team during the quarter. 3. Transfers In to Program Element During Qtr.: Refers to the number of consumers enrolled by the PACT team during the quarter who were transferred directly from another PACT team. NOTE: Item 2 and Item 3are mutually exclusive. 4. Transfers From Program Element During Quarter: Refers to the number of consumers transferred directly to another PACT Team. 5. Terminations From Program Element During Qtr.: Refers to the number of consumers, (exclusive of transfers-out) for whom a case was closed by the PACT Team during the quarter. NOTE: Item 4 and Item 5 are mutually exclusive. Ending Active Caseload (Last Day of Qtr.): Refers to the PACT Teams caseload on the last day of the reporting period. Target Caseload (Capacity Caseload): Refers to the maximum number of enrollees that a PACT Team can serve at any one time. Information must correspond to the agencys contractual terms, per the Annex A. Terminations Related to Functional Improvement: Refers to terminations in which the consumer has evidenced functional improvement (e.g. no in-patient psychiatric hospital use) over the course of at least two years and has been successfully transferred and linked to a mental health program that is less intensive than PACT. (Partial care/hospitalization programs and intensive supportive housing programs are not considered less intensive than PACT for the purpose of this definition). 9A. Record the number of consumers from the ending caseload who are Medicaid/Familycare enrolled. 9B. Record the number of consumers from the ending caseload who are not Medicaid/Familycare enrolled. Note: The sum of 9A+9B must equal the value of Item 6 (Ending Caseload on the Last Day of the Quarter) Number of Face-to-Face Hours Delivered On-Site: Refers to the cumulative face-to-face contact time (in hours) that all consumers received from PACT staff at the PACT office 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 with consumers: Refers to the cumulative face-to-face contact time (in hours) that all consumers received from PACT staff outside of the PACT team office 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. Number of Face-to-Face Hours Delivered on Behalf of Consumers: Refers to the cumulative face-to-face contact time (in hours) on-site and off-site contact time spent with a person other than the consumer by PACT team staff member(s). Includes family members, significant others, landlords, and other service providers and community entities as long as the activity is directly related to the consumers treatment plan. [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.] Total Face-to-Face Hours Delivered During the Quarter: This field is auto-calculated (Sum of items 10, 11, 12). 13A. Hours (Units) of Service Delivered in Group Modality: Is a subtotal of Total Hours of Service (Units) (Item 13): Refers to the number of hours delivered in the group modality. If one staff member runs a 1 hour group activity, each consumer in the group would be counted as receiving 1 hour of face-to-face contact, up to a limit of six consumers. 13B. Hours (Units) of Service Delivered in Individual Contact Modality: Is a subtotal of Total Hours of Service (Units) (Item 13): Refers to the number of hours delivered in individual contacts. Note: The sum of Item 13A + 13B must equal the value in Item 13. 14A. Psychiatric in-patient unit. Refers to all hospital based psychiatric beds/units that provide 24 hour care and supervision. 14B. Incarcerated. Refers to a municipal, county or state correctional facility. 14C. Homeless. Refers to having no housing. This includes individuals who are temporarily living in a hotel, motel or shelter. 14D. Designated Screening Services refers to State designated Psychiatric Emergency Program that has authority to initiate civil commitment process. Includes mobile services offered by a designated screening program. 14E. Formal Educational Program: Refers to enrollment in any type of school based program such as GED prep, college, trade school, adult education at local high school. 14F. Other employment - Refers to unpaid, transitional, volunteer, Off-The-Books, regular caretaker activity, or any other type of employment other than competitive employment. 14G. Competitive employment: To be considered competitive employment, the job must meet the following criteria: 1) Pays Minimum wage or higher; 2) At least 2 hours per week; 3) Open to all community members (i.e., non-disabled persons are able to apply and get the job, as well). Consumers who work under the table or off the books cannot be included in this count. 14H. 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) gd_$ p1$7$8$H$a$gdu$ p1$7$8$H$a$gdh$ p1$7$8$H$^a$gdu$ & F" p1$7$8$H$a$gdg$ ph^ha$gdEs 4(444444446#7$7%72757Z7a7s7777777:{:|:}:::::::::"<#<$<)<ɽwɽnnbɽhuhA>*䴳5Cu5>*䴳u5Cuu䴳䴳u䴳u6>*䴳u6Cu6Cau5Cau>*䴳au䴳a&)<,<A>C>D>E>z>|>>>>>>>>>>>>>>>>>?ȼvj]QFhYRh_CJaJh_CJOJQJaJh_5CJOJQJaJh"} h_5CJaJhX,hZCJaJhX,hX,CJaJhX,hACJaJh_5CJaJhgCJaJhv(hv(CJaJhv(5CJaJhVhv(5CJaJhuhuCJaJhACJaJhuhACJaJhuhA6CJaJhuhA6>*CJaJ??????!?0?1?2?5?]?r?u?v??????'@(@-@.@/@0@1@2@K@s@u@@@ǿ߳ǨרǨǜ}tk_Skh_h_5CJaJh"} h_5CJaJh_5CJaJhZ5CJaJhX,hX,CJaJhX,hACJaJhh5CJaJhv(hA5CJaJhrh_CJaJhYRh_5CJaJhX,CJaJh_CJaJhV!CJaJhZCJaJhYRh_CJaJh_6CJaJhYRh_6CJaJ ?'@(@@AAEAHAAAA'B(BBBB$ ph1$7$8$H$^ha$gdV!$ ph1$7$8$H$^ha$gdL$ ph1$7$8$H$^ha$gdT_$ p1$7$8$H$a$gdL$ ph1$7$8$H$^ha$gd)  ^gdX,@@@@@@@@@@@@@@AAAAAA!A"ABACADAEAGAHAIAJAļĨĠĘujbWLh"h"CJaJh"hFCJaJhLCJaJhuhACJaJhLhT_CJaJhT_CJaJhWCJaJh)CJaJhCJaJhhCJaJhYRh_5CJaJhX,CJaJh_CJaJhYRh_CJaJhX,6CJaJhV!6CJaJhZ6CJaJhYRh_6CJaJh_6CJaJJAKALAMANAiAkAtAuAAAAAAAAAAAAAAAA&B'B(B)B*B+Bȿul`ThhjS5CJaJhhZ5CJaJhZ5CJaJh"hZCJaJh"h"CJaJhL5CJaJhV!CJaJhvCJaJhLCJaJhx$CJaJhx$hx$CJaJhx$5CJaJhhF5CJaJh0J5CJaJh0J5CJaJh"hI-CJaJh"hFCJaJ+B,B-B.B5B6B8BLBVBBBBBBBBBBBBBBº~peZeOC7hhF5CJaJhvhZ5CJaJh"hf+CJaJh"h"CJaJh"hFCJaJhL5B*CJaJphh6hLCJaJh6hjSCJaJh6h~CJaJhV!CJaJh6hCJaJh6CJaJhA>CJaJhCJaJhh5CJaJhhZ5CJaJh0J5CJaJhZ5CJaJhf+5CJaJBBBC%C/CCCCCCCCCCCCCDDMDNDODPDQDRDTDeDDDDDDDDDDD EEEE~~vj~hhZ>*CJaJhD@hCJaJh"hCJaJhUCCJaJhZCJaJhCJaJhuhF5CJaJh5CJaJh"h"CJaJh"hCJaJhL5CJaJhLCJaJhV!CJaJhCJaJhvCJaJhuhFCJaJ)B&CCC DNDODDEEwEFFGG ^`gdD@h$ p1$7$8$H$a$gdD@h$ p1$7$8$H$^a$gdUC$ ph1$7$8$H$^ha$gdUC$ ph1$7$8$H$^ha$gdL$ ph1$7$8$H$^ha$gdV!EEEEE-E>ETEvEwEcFiFFFFFFF`GaGGGGGG&(6ʶʮvkki]TLhnCJaJhQT5CJaJhQThT_5CJaJUh"hT_CJaJhD@hh2RlCJaJh`?CJaJhD@hCJaJhD@h5CJaJhH/hD@h5CJaJhD@hCJaJhFCJaJhvhF>*CJaJhUCCJaJhuhFCJaJhuhF5CJaJhZ5CJaJh"hCJaJh"h"CJaJ Employment & Education Movement Table: Categorize all consumer in your ending caseload based on the table. Record the number of consumers within the caseload in the box that reflects their movement from the beginning of the quarter to the end of the quarter. The categories to the left (vertical) indicate the consumers vocational/educational status at the beginning of the reporting quarter. The categories found at the top (horizontal) of the table indicate the consumers vocational/educational status at the end of the report quarter. For example, if a consumer began the reporting quarter in the status No Activity (See definition below) and then ended the quarter in the competitive employment status, this consumer would be counted in the number that would be recorded in the upper right hand cell. Thus, If 5 consumers in the caseload moved in this manner (e.g. began the quarter in No Activity and progressed to Competitive Employment), then a 5 would be entered into in the upper right hand cell to reflect these five consumers within the caseload. Note: The sum of the entries into all sixteen boxes in Item 15, plus the value of Item 15 A (retirees) should equal the value found in Item 6 Ending Caseload (Last Day of Qtr.) To reflect the unique characteristics of a particular teams caseload, the matrix below shows how these outcomes (movements) are weighted. (The number entered into each box is multiplied by the weighted box-specific number. The resultant number for all sixteen boxes is then summed. Lastly, the sum is divided by the caseload size.) A team-wide Employment and Education Movement Score then results (found in Item 15B). BEGINNING OF QuarterEnd of QuarterNo ActivitySome Activity Other Employment/ Enrolled in Education ProgramCompetitive EmploymentNo Activity0+1+2+3Some Activity-10+1+2Other Employment/ Enrolled in Education Program-2-10+1Competitive Employment-3-2-10 No Activity: Refers to the number consumers who display no action or behavior of any sort toward education or employment related goals. Some Activity Refers to consumers who have engaged in concrete tasks (e.g. completed an application, developed a resume, went on an interview) related to an education or employment related goals. Other Employment/ Enrolled in Education Program See definitions above Competitive Employment - See definition above Retired A PACT consumer who is at least 60 years old and has no interest in employment or education. 15A. Number of Consumers (Ending Caseload), who are retired: Indicate the number of consumers on your active PACT caseload who are retired/no longer in the work force. 15B. Weighted Team Employment and Education Movement Score: An auto-calculated value based the weighted counts of the values placed in Item 15 (see description of Item 15, above). Staffing Record information per the prompts. Information must correspond to the agencys contractual terms, per the Annex A and Annex B. Staffing positions that are less than 1.0 Full-time equivalent (FTE) should be reflected as a proportion of an FTE e.g. 0.25 FTE, 0.5 FTE, etc. 16A. Number of hours per week Psychiatrist was available (in hours). In accordance with NJAC 10:37J-2.8(d)1 the psychiatrists role is to be reflected as the number of hours per week provided to the PACT team. 17. Total Staff Hours (In Transit) Refers to the total staff time in transportation to and from all consumer related contacts. Does not include time in which a consumer is in the vehicle Periodic audits of information submitted in this report will be conducted by DMHAS. 09-30-2013     Page  PAGE 1 of  NUMPAGES 7 09/30/13 QUARTERLY CONTRACT MONITORING REPORT (QCMR) CONSUMER MOVEMENT REPORT PACT (Revised 09-30-2013) 6efkn $/lv !$&QT]z36<];<>?@¶Т¶袚hT_CJaJh5SCJaJh4rCJaJhWCJaJhWh)>*CJaJhWhQT>*CJaJhWhQT6>*CJaJh)CJaJh"CJaJhnCJaJhfCJaJhUCCJaJhQTCJaJ3Gf %&?@ $$Ifa$gdT_gd$a$gdmO$a$gdn $^a$gdUC$^`a$gdUC $h^ha$gdQT @FJ\t3<=>JYgir7EFHIJKNS˺zrgzhEhV!CJaJhUCCJaJh~CJaJh~CJaJh5SCJaJhUCCJaJhV!CJaJh)CJaJhGSCJaJhQTCJaJhWCJaJhn5CJaJhuh)r5CJaJh)r5CJaJh`?CJaJhmOCJaJh)rCJaJhnCJaJ(STuvw{|()5ngVHVgVhT_CJOJQJ^JaJ hhT_CJOJQJ^JaJ hhT_&hhT_5CJOJQJ\^JaJ&hhT_5CJOJQJ\^JaJhT_CJaJhQThQTCJaJhaCJaJhcFCJaJhp\CJaJh~CJaJhV!CJaJhUCh~6CJaJhUChV!6CJaJhUChV!6CJaJhEhV!CJaJ(uuuu $$Ifa$gdT_ $IfgdT_ukdk=$$Ifl40-(F G0  t<(644 lBa]pytT_()58;0$$$ $$Ifa$gdT_kd!>$$Ifl4r ! -(F G G G G  t2<(644 lBa]p2ytT_5678:;=>@ABPQSTUVXY[\]nڻڳhvCJaJhCJaJhvhACJaJhvhA5CJaJhhT_CJaJhT_CJaJhT_CJOJQJ^JaJ hhT_CJOJQJ^JaJ hhT_hT_CJOJQJ^JaJ hhT_CJOJQJ^JaJ2;>ABPTV=kd ?$$IflXr ! -(G G G G G   t <(644 lBa]p2ytT_ $$Ifa$gdT_VY\]=kd @$$IflXr ! -(G G G G G   t <(644 lBa]p2ytT_ $$Ifa$gdT_=kd A$$Iflr ! -(G G G G G   t <(644 lBa]p2ytT_ $$Ifa$gdT_=88gdkd B$$Iflvr ! -(G G G G G   t <(644 lBa]p2ytT_ $$Ifa$gdT_ GHMN[\]^{DGLUV\]^tw|Ź𱦱~vkvkbY~vkhQT5CJaJhA5CJaJhnhWCJaJh5SCJaJhW5CJaJhQThQT5CJaJhQTCJaJhvh3CJaJh3h3CJaJh3CJaJhAhA5CJaJhv5CJaJhvhACJaJhvhA5CJaJhvhvCJaJhCJaJhvCJaJ HN]^]UVxy ) h^hgd_~ & F# ) gd" ^`gd`?^gd`?h`hgdD@hh^hgdQTgdFh^hgdgdvh^hgdv1TUVW_&)*8d÷}th]U]U]U]U]Uh_~CJaJhuh_~CJaJhuh_~5CJaJhi,5CJaJhD@hh`?CJaJhcFCJaJh`?h`?5CJaJhF'CJaJh`?CJaJhJhD@hCJaJhJhD@h5CJaJhD@h5CJaJhD@hhD@hCJaJhQT5CJaJh4rh4rCJaJh4rhnCJaJhn5CJaJdemnz{ ,DUWX[\}ghjkrtٸ×Îymd[hcF5CJaJh*_5CJaJhFhWD5CJaJh35CJaJhO7yhWD5CJaJh_~5CJaJhuh_~>*CJaJhuh_~5CJaJh"5CJaJh"h"CJaJhuh_~CJaJhT_h_~CJaJh!Lh_~CJaJh!Lh_~5CJaJh_~CJaJh"CJaJ#WXklmnopqrstuvwxyz{|}~ ) gd.\rgdF ^`gd" ) h^hgd_~~gdN$a$gdN ) gd.\rt$ƾ}tlhD@hCJaJhD@h5CJaJhD@h56CJOJQJ hD@hCJhahH5\mHnHu hD@h5\jhfC|5CJU\aJhD@hh0Zjh0ZUh*h"} 5CJaJha5CJaJh"5CJaJh765CJaJh5CJaJh*_5CJaJ($&+,-./12h*h"} 5CJaJhX,h0ZhJhD@h5CJaJhthD@hCJaJhD@hCJaJhaCJaJ-./012 ) gd.\rgdM&$a$gdN} 0&P+p,p-p.p/R4567:pi,/ =! 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