Quarterly Report Form

DBHDID FY 2018 Project Report Form FORM 172

PROGRAM: DID BH SA

CENTER NAME & NUMBER

DIVERTS

PROJECT TITLE REPORTING PERIOD: 1st (July-Sep.)

Assertive Community Treatment 2nd (Oct.-Dec.)

SERVICE 3rd (Jan-Mar)

4th (Apr-Jun)

E-MAIL ADDRESS OF SUBMITTER

AREA CODE PHONE NUMBER

REPORT SUBMITTED BY:

SIGNATURE TITLE DATE

of 3 DBHDID FY 2018 Project Report Form FORM 172 Objective Statement 1:

Staffing: The ACT team must have a minimum staff of 4.0 FTE NOT including the prescriber, office manager, or in-reach specialist. (1.0 FTE Team Leader/Therapist; 1.0 FTE Case Manager; .50 FTE Nurse; .50 FTE Peer Specialist and 1.0 FTE other, at a minimum)

Measurement Methods:

Submission of ACT team member names, team role, FTE status, and work location.

Submission of who is providing psychiatric prescriber coverage for the team and a description of how the ACT team will be able to access prescriber services to meet consumer needs.

A. B. C. D.

Projected for Period Actual This Period Annual Projection Actual YTD

Narrative A:

Narrative B: In box B above, please indicate the number of FTE included on the ACT team during this period.

Please list name, team member role, and amount of FTE for each ACT team member, including the prescribers working with the ACT team. (Please indicate whether prescribers are contract employees or agency staff) Describe how the team will have priority access to prescribers, for persons served by the team.

Narrative C: Provide the number of FTEs and team member roles anticipated to be included on ACT team for year.

Narrative D: Provide a YTD summary including any deficiencies in staffing that occurred during the year.

of 3 DBHDID FY 2018 Project Report Form FORM 172

Objective Statement # 2:

List number of individuals served by ACT during the period.

ASA consumers = persons with SMI transitioning from personal care homes or at risk of being readmitted to a personal care home

DIVERTS consumers = persons with SMI transitioning from hospitals/other institutions not PCHs or at risk of being readmitted to a hospital/other institution not PCHs or persons at risk of first admission to PCH/hospital/other institution

Measurement Methods:

1. Total number of persons served by ACT during the period.

2. Total number of ASA consumers served by ACT during the period.

3. Total number of DIVERTS consumers served by ACT during the period.

A. B. C. D.

Projected During Actual This Period Annual Projection Actual YTD Period

Narrative A: Total number of persons projected to be served by ACT for the period.

Narrative B: In box B above, please report the total number served for # 1, #2 and #3. Narrative B: Please report the following: #1:Total number of persons served by ACT during the period; #2: Total number of ASA consumers served by ACT during the period; #3: Total number of DIVERTS consumers served by ACT during the period;

Narrative C: Total number projected to be served by ACT for the year. Narrative D: Actual YTD number served by ACT for the year.

DBHDID Review:

Name Title Date