TFK Early Childhood Mental Health Services

Service Delivery Report

Code Book

TFK Early Childhood Mental Health Services

Service Delivery Report

Code Book

Revised February 26, 2009

Table of Contents

Page Number

Documentation Instructions...... 3

Definitions...... 3

Report Sections...... 3

Section A: Monthly Child Specific Information and Services...... 4

Section B: Aggregate Child Specific Information and Services...... 7

Section C: Monthly General Classroom/FCC Home Services...... 8

Section D: Aggregate General Classroom/FCC Home Services...... 8

Section E: Monthly Baseline Information...... 9

Section F: Monthly Aggregate Data Summary...... 10

Section G: Biannual Summary Data...... 10

Section H: Additional Service Activity Log Codes...... 11

Double Checking Your Work...... 11
Documentation Instructions

  • Please complete all information. Please do not leave any columns blank.If the number is zero, enter“0”. If the question does not apply, enter “NA”.If the question does apply and you do not have the information, enter “U” (Unknown). If you need computer assistance, please speak with Beth Ciavattone.
  • If you work in more than one of the programs listed on the first page, please complete a separate report for each program.
  • Please note that the formulas have been entered to calculate totals. Please do not enter anything in the total lines highlighted in gray.
  • Please return the completed forms via email to Beth Ciavattone() by the 15th of each month (5:00 p.m.). If the 15th falls on a weekend, completed forms are due the next work day. Please retain back-up copies for your personal file.

Definitions

Please use the following definitions of terms for the purpose of this report:

  • Age Categories:*Infantages birth-15 months of age

*Toddlerages 15 to 33 months of age

*Preschoolages 2.9 years to 5 years old

*School Ageages 5 to 12 years of age

  • Case management means creating linkages to other available and appropriate community resources, social services, mental health agencies, public schoolspecial education, and early intervention in order to promote the coordination andcontinuation of services for children and families.

Report Sections

  1. Monthly Child Specific Information and Services
  2. Aggregate Child Specific Information and Services
  3. Monthly General Classroom/FCC Home Services
  4. Aggregate General Classroom/FCC Home Services
  5. Monthly Summary Data: Baseline Information
  6. Monthly Summary Data: Aggregate Data Summary
  7. Biannual Summary Data (July-December, 2008; January-June, 2009)

Emotional/Behavioral Issues (Primary Issue/Unduplicated Child Count)

Strategies/Interventions Benefitting the Child

Program Outcomes

  1. Additional Service Delivery Codes

A. Monthly Child SpecificInformation and Services (Observation/Consultation/Therapy)

This section is to record only the clients referred and served during the month reported.

  1. Name of Referred Child (names of all referred children; with and without consent)
  2. Date of Referral
  3. Parental Consent: Y N
  4. Waiting for Services: Y N
  5. Referred to Other Agency: Y N
  6. Receiving Services: Y N (by type)
  7. Month/Year Child Specific Services Began (billable and non-billable)
  8. Client Case Number (actual #, Pending:P, Not Applicable:NA)
  9. Birthdate
  10. Gender
  11. Age Category (infant, toddler, preschool, school age)
  12. Insurance (Type; Billable:B or Un-billable: U)

MBHP

  1. MBHP

MCO’s

  1. Neighborhood Health Plan Beacon
  2. Neighborhood Health Plan
  3. BMC Healthnet
  4. Network Health
  5. Beacon Fallon-Medicaid

Medicaid

  1. Paramax

Other

  1. Blue Cross
  2. HMO Blue
  3. Beacon Fallon Commercial
  4. Harvard Pilgrim
  5. Tufts
  6. Tricare
  7. Fallon
  8. Other Insurance: List type

Not Billed To Insurance

  1. Self pay (full or sliding fee)
  2. No insurance/Free
  3. Unknown
  1. TFK Information Sheet: Y N NA
  2. Ethnic/Racial background
  3. Income level
  4. Subsidized Care
  5. Child Care Agency Name
  6. Site Specific Name/FCC Home (or NA)
  7. Program Street Address
  8. City/Town
  9. Program Type (center-based, family child care, public school)
  10. Name of Classroom
  11. Capacity Census of Classroom/FCC Home (ask site)
  12. Names of Educators who received consultation services
  1. Emotional/Behavioral Issues (Biannual Summary)

Emotional/Behavioral Issues (Primary Issue Only/Unduplicated Child Count: 1 per child)

  1. Aggression (biting, hitting, etc – peers and adults)
  2. Oppositional (defiant, disobedient)
  3. Over-activity/Impulsivity (restless, uncontrolled)
  4. Attention (inability to focus, follow directions)
  5. Anxiety (nervous, fearful, extreme shyness)
  6. Attachment (separation distress, neediness)
  7. Depression (withdrawal, sadness)
  8. Post Trauma (history of trauma, loss)
  9. Peer relations/social skills (difficulty taking turns, sharing, negotiating, social bullying)
  10. Other: Please list
  1. Strategies/Interventions (Biannual Summary/code list)

Strategies/Interventions Benefitting the Child (Can be more than 1 per child)

  1. Consultation to Staff
  2. Modeling of Behavior Management Strategies for Staff
  3. Staff Group Training
  4. Individual Behavior Plan
  5. Consultation to Parent/Guardian
  6. Case Management (see definition)
  7. Programmatic Modification (i.e. schedule)
  8. Physical Facility Modification
  9. Additional Staffing Support (i.e. paraprofessionals)
  10. Referral to Therapy
  11. Currently receiving therapy on-site/at consultants clinic
  12. Currently on a waiting list for therapy
  13. Referral to outside clinic for therapy
  14. Referral to Special Education Services/Supports
  15. Medication
  16. Other: Please explain
  1. Formal Plan (IFSP, IEP, Referral in process:P, or NA)
  1. # hrs working 1:1 with child (clinical case record open)

Assessment102/9102Open clinical case record with client ID

Play therapy106/9106Open clinical case record with client ID

Crisis intervention101/9101Open clinical case record with client ID

  1. # hrs of group therapy(clinical case record open)

3 or more children109/9109Open clinical case record with client ID

  1. # hrs spent with family(case record opened or un-opened)

Family therapy107/9107Open clinical case record with client ID

Family consultation110/9110 Open clinical case record with client ID

Scheduled face-to-face or telephone

No open clinical case record

Scheduled face-to-face or telephone

  1. # hours observing the child (case record open or un-opened)

433No open clinical case record

?If open clinical case record, this activitycould occur within a billable consultationhour and thus be captured within theconsultation category

  1. # hrs of child specific consultation with staff

Case consultation108/9108Open clinical case record with client ID

Scheduled face-to-face or telephone

No open clinical case record

Scheduled face-to-face or telephone

  1. # hrs of case management

225Direct face-to-face or telephone collateralcontacts to access/coordinate services

10Indirect collateral

  1. # hrs of clinical prep63Prep of consultation/training material

64Prep of formal cons report (followed by ID)

  1. Developmental Profile: Y/N/NA
  2. TOPS Pre: Y/N/NA
  3. TOPS Post: Y/N/NA
  1. BASC: Parent (P)/Teacher (T)/Both(B)
  • Intake
  • 4th Session or 60 Days
  • Post
  1. CANS: Y/N/NA
  • Intake
  • Reviews
  1. Eyberg Scores (Eyberg Score or NA if one has not been administered)
  2. Child Program Outcomes (Biannual Summary)

Child Program Outcomes (Unduplicated child count: I per child)

  1. Retained successfully in the program
  2. Transitioned from current program to a new program that could better address child’s needs
  3. Suspended temporarily from the program due to behavioral issues
  4. Expelled from the program (due to behavioral issues)
  5. Aged-out of the program
  6. None of the above
  1. Month/Year Child Specific Services Ended (billable and non-billable):
  2. Date of Child Care Program Discharge (non-behavioral issues):
  3. Reason for Child Care Program Discharge (non-behavioral): (Aged Out:1; Other:2)
  4. Psychotherapy Continuing: Y N

Please remember: If you make any changes to the child specific information on the Monthly Tab, that those changes are reflected in the Aggregate Tab.

B. Aggregate Child Specific Information and Services (Observation/Consultation/Therapy)

This section is to record the aggregate data for each child referred and served. This is a running list to which you add new clients referred and served and update the number of hours of service for those clients served every month. For example if you spent 4 hours observing the child in January and 4 hours observing the child in February, when you submit your February report you would indicate 4 hours on the Monthly Child Specific and 8 hours on the Aggregate Child Specific (4 hrs for Jan + 4 hours for Feb = 8 hrs total).

Those columns where the data is totaled are indicated below:

28. Total# hrs working 1:1 with child (clinical case record open)

29. Total# hrs of group therapy (clinical case record open)

30. Total# hrs spent with family (case record opened or un-opened)

31. Total# hours observing the child (case record open or un-opened)

32. Total# hrs of child specific consultation with staff

33. Total# hrs of case management

34. Total# hrs of clinical prep

C. Monthly General Classroom/FCC Home Services (Observation/Consultation/Training)

1. Child Care Agency Name

2. Site Specific Name/FCC Home

3. Program Street Address

4. City/Town

5. Program Type (center-based, family child care, public school)

6. Targeted Age Category (infant, toddler, preschool, school age)

7. Name of Classroom

8. Capacity Census of Classroom/FCC Home

9. Names of Educators who received consultation services

10. Collaborative Classroom Assessment: Y N

11. # hrs of observation provided432

12. # hrs of consultation provided437

13. # hrs of clinical prep63

14. # hrs of staff training provided21

15. Staff training topics (list each topic)

D. Aggregate General Classroom/FCC Home Services (Observation/Consultation/Training)

This section is to record the aggregate data for each classroom/FCC home referred and served. This is a running list to which you add classroom/FCC home referred and served and update the number of hours of service for that classroom/FCC home served every month. For example if you spent 4 hours observing a classroom in January and 4 hours observing the same classroom in February, when you submit your February report you would indicate 4 hours on the Monthly General Classroom/FCC Home Services and 8 hours on the Aggregate General Classroom/FCC Home Services (4 hrs for Jan + 4 hours for Feb = 8 hrs total).

Those columns where the data is totaled are indicated below:

11. Total # hrs of observation provided432

12. Total # hrs of consultation provided437

13. Total # hrs of clinical prep 63

14. Total # hrs of staff training provided 21

E. Monthly Baseline Information

** Please do not type in areas highlighted in gray – they are self-calculating **

Question / Where to Find the Data
Enter the number of new children added to the Monthly Child Specific Services tab (Section A)
1 a-d. / Enter the number of children who were referred but not served and indicate in appropriate questions. Please enter “0” for these questions if all children who were referred received services
This row automatically totals everything from Question 1a-d.
Out of the number of children reported in Question 1, enter the number of children who have received services.
3a / Enter the number of new families receiving services based on the number of new children reported on the Monthly Child Specific Services tab (Section A)
Enter the number of children whose parents refused services in an earlier month indicated on the Monthly Child Specific Services tab (Section A)
Enter the number children whose were wait-listed in an earlier month indicated on the Monthly Child Specific Services tab (Section A)
Enter of the number of children on the Monthly Child Specific Services tab (Section A) who are continuing from the previous month.
This row automatically totals everything in Questions 3, 4, 5, and 6.
Enter the number of new classrooms indicated on the Monthly General Classroom/FCC Home Services Tab (Section C).
Enter the number of classrooms indicated on the Monthly General Classroom/FCC Home Services tab (Section C) who are continuing from the previous month.
This row automatically totals the number of classrooms that were provided services for the month. The number should equal the total number of center-based classrooms indicated on the Monthly General Classroom/FCC Home Services Tab.
Enter the number of new FCCs indicated on the Monthly General Classroom/FCC Home Services Tab (Section C).
Enter the number of FCCs indicated on the Monthly General Classroom/FCC Home Services tab (Section C) who are continuing from the previous month.
This row automatically totals the number of FCCs that were provided services for the month.
Information found in Column 43 in Section A.
Information found in Column 41 in Section A.
Information found in Column 41 in Section A.

F. Monthly Aggregate Data Summary

Column / Report Section where report information can be found
1 / A17,18,20,21 C1,2,4,5
2 / A28
3 / A29
4 / A30
5 / A31
6 / C11
7 / Baseline Info E3
8 / Baseline Info E1b
9 / C14
10 / A32
11 / C12
12 / A33
13 / A34 + C13
14 / H2 (See Page 11)

G. Biannual Summary Data

Emotional/Behavioral Issues (Primary issue only /one code per child)

e.g., 30 children received services between July 1 – Dec 31; 30 primaryissues documented on form.

Strategies/Interventions Benefitting the Child(can be more than 1 code perchild)

e.g., 30 children received services between July 1 – Dec 31; for eachchild, count all that was beneficial under his/her “primary issue”;since children may benefit from more than one strategy/intervention,they can be counted in more than one strategy.

Program Outcomes(one code per child)

e.g., 30 children received services between July 1 – Dec 31; 30 outcomecodes documented on form.

H. Additional Service Activity Log Codes (this data that may be used for other reports)

1. Client specific paperwork 11 (followed by client ID)

2. Travel28

3. Supervision Received24

4. Supervision Provided23

5. Training Provided21

6. Training Received22

7. Sick29

8. Vacation30

9. Holiday31

10. Leave of Absence32

11. Personal Time33

12. Jury Duty/Bereavement39

13. Clinical Team Meetings44

14. Other10

Double Checking Your Work

The last tab in the workbook, entitled Program Totals (pink tab), is an accumulation of all the hours indicated in Monthly Aggregate Data Summary (Section F). The data on the tab is all self-calculating, therefore, the data should not be corrected by changing the numbers on this tab.

Each month, the data from the Totals row on the Monthly Aggregate data Summary (Section F), transfers the data to the Program Totals tab. Since the Monthly Aggregate data Summary is a reflection of the hours of services provided during that month, the Totals row on the Program Totals tab is a reflection of the hours of service provided to date. Therefore, that Totals row should match the hours indicated in the Aggregate Child Specific Information and Services (Section B) and Aggregate General Classroom/FCC Home Service (Section D).

If the numbers in the Totals row do not match the Aggregate tabs (Sections B and D), then there are two possible areas of error:

  1. The data reported in the Monthly Aggregate Data Summary (Section F) is incorrect. To correct this data, go back to the Monthly Child Specific Information and Services (Section A) and Monthly General Classroom/FCC Home Services (Section C) for each month and double check that you reported the correct hours for each category.
  1. If the error is not resolved then there was a mistake in adding the hours of service to the aggregate each month. To correct this error, go back a re-add each month’s hours to the aggregate.

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Revised 2/26/09

EEC MH Grant Report Categories 2-26-09.doc