Instructions: Module 2B - TheMeasurementGroup.com

SPNS COOPERATIVE AGREEMENT EVALUATION

MODULE 2B: INTERVENTION SERVICES FORM

Citation: Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1997). Module 2B: Intervention-Services Form. Available: www.TheMeasurementGroup.com. Culver City, California: The Measurement Group.

Answer questions by either filling in a circle, or writing a number or letter in a square box. If the answer goes in a square box, you must use a CAPITAL LETTER or number that does not touch the side of the box. Print only one letter or number in each box. If the letters or numbers that you print touch the sides of the boxes, or if you do not clearly print the information, the computer will "kick out" the form and we will need to return it to you to be completed correctly. If the question asks the answer to be filled in a circle, make sure that the circle is completely darkened. Only darken one circle for each question unless the instructions specifically tell you to darken as many as apply for that question.

Specific Parts of the Module 2B: INTERVENTION SERVICES FORM

Visit/Daily Summary. Darken the circle next to "Visit" if you are using this form to record a client’s visit. Darken the circle next to "Daily Summary" if you are using this form to record a summary of daily activities.

ID Letters/ID Numbers. These boxes are provided for entering the unique identifier your site is using to track client information. The four boxes on the left are to be used for letters, while the ten boxes on the right are reserved for numbers. You may use letters, numbers, or a combination of letters and numbers, for identification purposes. If you use a combination of letters and numbers, however, please use the letters first in your alphanumeric sequence (for example, if your unique identifier is MD-1479, the letters "M" and "D" would be entered in the first two of the four boxes reserved for letters and the numbers "1", "4", "7", and "9" would be entered into the first four of the ten boxes reserved for numbers). If you are unsure about a client’s unique identifier, check with your project director.

Site. This is a code to identify your project in the cross-cutting evaluation. It should be pre-printed on the form. Site codes are 3 letters.

Sub-Provider. This field may be used to designate specific sites or providers within your project. If appropriate, enter the code for the service provider agency doing the activity. Provider codes can be up to 3 letters.

Intake/Service Date. Enter the numbers representing today's date (the date of the activity) in these boxes. Enter the month as a number from 01 to 12 for January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the current year (for example, "95" for 1995). Make sure that if a month or day is less than 10, you place a "0" before the number.

Staff Code. Each staff member should be assigned a unique number code (up to 3 digits). Make sure than each new staff member has a unique code. Do not reassign any staff codes that have been previously assigned. Enter the 3-digit code for the person who provided the services. If the staff code is less than 3 digits, place "0"s before the number. For example, 3 is "003."

Part A: SERVICES (all that apply)

Instructions for Part A sections 1 through 6 are given below. Definitions are provided for the various services listed following the instructions below.

HIV Prevention/Intervention. Darken the circle next to the kind(s) of HIV Prevention/Intervention services received by the client. Write in the number of minutes spent today in providing this service(s) in the boxes next to "Minutes Today." If the number of minutes is less than 3 digits, place "0"s before the number. For example, 30 minutes is "030." HIV prevention/intervention services may include HIV risk assessment, HIV pre-test counseling, HIV testing, HIV post-test counseling, HIV prevention, and other HIV-related services as defined below.

Mental Health Services. Darken the circle next to the kind(s) of Mental Health services received by the client. Write in the number of minutes spent today in providing this service(s) in the boxes next to "Minutes Today." If the number of minutes is less than 3 digits, place "0"s before the number. For example, 30 minutes is "030." Mental health services may include individual therapy/counseling, psychiatric evaluation, psychosocial assessment, individual crisis intervention, and other mental health services as defined below.

Group Counseling. Darken the circle next to the kind(s) of Group Counseling services received by the client. Write in the number of minutes spent today in providing this service(s) in the boxes next to "Minutes Today." If the number of minutes is less than 3 digits, place "0"s before the number. For example, 30 minutes is "030." Group counseling may include crisis intervention, family/couple counseling, group counseling, peer support group, and other group counseling as defined below.

Substance Abuse Services. Darken the circle next to the kind(s) of Substance Abuse services received by the client. Write in the number of minutes spent today in providing this service(s) in the boxes next to "Minutes Today." If the number of minutes is less than 3 digits, place "0"s before the number. For example, 30 minutes is "030." Substance abuse services may include 12 step groups, relapse prevention, substance abuse treatment/counseling, and other substance abuse services as defined below.

Case Management/Advocacy. Darken the circle next to the kind(s) of Client Management/Advocacy services received by the client. Write in the number of minutes spent today in providing this service(s) in the boxes next to "Minutes Today." If the number of minutes is less than 3 digits, place "0"s before the number. For example, 30 minutes is "030." Case management/advocacy may include advocacy services, clinical assessment, educational services, financial services, housing, legal services, medical, vocational services, and other case management as defined below.

Other Services. Darken the circle next to the kind(s) of other services received by the client. Write in the number of minutes spent today in providing this service(s) in the boxes next to "Minutes Today." If the number of minutes is less than 3 digits, place "0"s before the number. For example, 30 minutes is "030." Other services may include activities, accompaniment, family planning, information and referral, recreation, and transportation as defined below.

Other Services #1. If the services you provided are not listed, write a brief description of the service provided in the boxes where indicated.

Other Services #2. If the services you provided are not listed, write a brief description of the service provided in the boxes where indicated.

The following are definitions for the services listed in Part A.

Section 1 HIV Prevention/Intervention
HIV Risk Assessment	The systematic determination of the level, extent, and behaviors of risk for HIV infection, re-infection, or transmission.
HIV Pre-test Counseling	Counseling related to addressing the client’s concerns and questions before being tested for HIV.
HIV Testing	The provision of the test to detect the presence of HIV.
HIV Post-test Counseling	Counseling related to addressing the client’s concerns and reactions after being tested for HIV.
HIV Prevention	Counseling, therapy, education, or other activities that focus on the prevention of HIV infection, including topics such as sexual activity, injection drug use, and pediatric risk issues.
Other HIV-related services	For example, a group that provides support for issues specifically related to HIV.

Section 2 Mental Health Services
Individual Therapy/Counseling	Counseling or therapy for a problem or issue in which a client participates alone with the counselor.
Psychiatric Evaluation	Evaluation conducted by a mental health clinician that assesses the client’s mental status, the presence of psychiatric disorders, and psychological functioning as related to psychiatric disorders, such as anxiety, depression, and thought confusion. Usually conducted by a psychiatrist, psychiatric social worker, or psychiatric assistant.
Psychosocial Assessment	Assessment of the client’s psychological functioning as related to his/her social well-being, such as interpersonal skills, social activities, social reinforcement, social support, and coping skills.
Crisis Intervention (individual)	Clinical/therapeutic response to a crisis experienced by the client, such as suicide intervention. If marked here, this would indicate an individual crisis intervention.
Other Mental Health	Mental health services not coded elsewhere.

Section 3 Group Counseling
Crisis Intervention (group)	Clinical/therapeutic response to a crisis experienced by the client, such as suicide intervention. If marked here, this would indicate a group crisis intervention.
Family/couple counseling	Counseling or therapy in which the client participates along with family members or partner.
Group counseling	Counseling or therapy for a problem or issue in which a client participates along with other clients.
Peer support group	Support discussion activity involving peers for any topic or issue, including HIV.
Other group	Other group counseling activity not coded elsewhere.

Section 4 Substance Abuse Services
12 Step Group	A group that provides support using the 12-step model to address substance abuse and other problems/issues, such as AA, CA, NA. Note that HIV support groups are coded separately in "Other HIV-Related Services."
Relapse prevention	Counseling, therapy, education, or other activities related to the prevention of substance abuse relapse.
Substance abuse treatment/counseling	The provision of services related to substance abuse, such as outpatient substance abuse counseling, residential treatment for substance abuse, and substance detoxification.
Other substance abuse services	Other substance abuse services not coded elsewhere.

Section 5 Case Management/Advocacy
Advocacy services	Advocacy on behalf of the client or assistance to the client to gain medical or social services, benefits, entitlements, etc. Advocacy does not include coordination and follow-up on medical treatment.
Clinical Assessment	The assessment of evaluation of client’s clinical needs, such as mental health needs, psychiatric evaluations, etc.
Educational services	1) Provision of information including information dissemination/outreach about medical and psychosocial support services and counseling, or 2) preparation/distribution of materials in the context of medical and psycho/support services to educate clients about HIV/AIDS.
Financial services	Provision of financial services, including assistance with payments to agencies directly or indirectly via vouchers, assistance with insurance matters, and assistance with personal finances such as budgeting or balancing a checkbook.
Housing	Assistance in locating and obtaining suitable, on-going, or transitional shelter. Includes costs associated with finding a residence and/or subsidized rent.
Legal services	Assistance provided to clients with respect to wills, discrimination, and matters related to the protection of civil rights and other legal needs of clients related to their HIV status.
Medical	The management or coordination of obtaining medical services.
Vocational services	Assistance to the client for obtaining employment or training to obtain employment.
Other case management	Other case management services not coded elsewhere

Section 6 Other Services
Activities	Low-intensity activity generally of a social nature, such as arts and crafts and other hobbies.
Accompaniment	Accompanying client or patient to obtain services or to other service-related activity
Family planning	Services related to contraception/birth control and other family planning issues
Information & referral	Sessions in which only information about and/or referrals to other agencies or services is provided.
Recreation	A physical recreational activity that takes place outside the service milieu, such as games, sports, movies, and outings.
Transportation	The provision of transportation or vouchers for transportation.
Other Services	Other services not coded elsewhere. Code up to 2 additional services.

Part B: TOPICS DISCUSSED (all that apply; optional)

The following are definitions for the topics discussed listed in Part B. Darken the circles next to all the topics that apply. Use the boxes next to the "Other topic" boxes to write in topics not listed.

Services-Related
Alternative therapy	Therapy modalities that are considered non-traditional, such as new age therapies, acupuncture, folk healing, herbal therapies.
Basic needs/advocacy	The level and scope of need of the client for advocacy or assistance to gain medical or social services, benefits, entitlements, etc. Does not include litigation, which should be coded under legal services.
Discharge planning	A range of topics discussed at discharge relating to bolstering the client’s functioning and life without the program. May include preparation for job or job training, referrals to social and medical services.
Education	Topics related to obtaining general education or education in specific areas. Note that education about HIV should be coded under "HIV-Specific" topics.
Medical services/needs	Topics related to obtaining medical services or treatment or to medical needs of clients.
Medication	Topics related to medication, such as type, dosage, change, and effects of medication.
Nutrition/diet	Topics related to eating, nourishment, diet, foods, etc.
Relocation	Topics related to moving from one dwelling to another, either temporarily or permanently.
Service linkages	Topics related to the coordination of services and linking clients to the appropriate range of services.
Sexually Transmitted Diseases	Topics related to sexually transmitted diseases, such as syphilis, herpes, gonorrhea. Note that HIV is coded separately under "HIV Specific" topics.
Substance Abuse	Topics related to substance abuse, including issues about treatment, recovery, and relapse.

Psychosocial Issues
Child Care/parenting	Topics relating to strategies, problems, or solutions for obtaining child care or discussing issues such as parenting skills, etc.
Death and dying	Topics related to death and dying.
Emotional problems	Issues related to psychological problems or mental health concerns, such as depression, anxiety, confusion, and loneliness and alienation.
Financial problems	Topics related to any financial problems that the client may be experiencing.
Gender	Topics related to gender, such as women’s issues.
Grief and loss	Topics related to feelings and thoughts about dying or being affected by others’ illness or death.
Interpersonal issues	Topics related to relationships with others, getting along with others, interpersonal communication, etc.
Legal problems	Topics related to legal problems, such as job or housing discrimination, child custody, incarceration.
Life Skills	Topics related to the practical skills of daily living, such as balancing a checkbook and time management.
Self Identity/Sexuality	Topics related to identity, sexual orientation, and sexuality.
Spirituality	Topics related to religion and spirituality.
Violence/victimization	Topics related to violence at home or in the community.
HIV-Specific
HIV risk reduction	Topics related to risk factors for HIV infection and re-transmission, such as unprotected sexual behavior and injected drug use.
Living with HIV	Topics related to the experience of living with HIV.
Other
Pregnancy planning	Topics related to planning or terminating a pregnancy.
Contraception	Topics related to preventing pregnancy or birth control.

Part C: SERVICE LOCATION (all that apply)

The following are definitions for the service locations listed in Part C. Darken the circles next to all the service locations that apply. Use the boxes next to Other to write in service locations not listed.

Service Location
Assisted Living Facility	A living arrangement in which clients are assisted in daily living tasks; includes nursing homes.
Case Management Office	The office of service providers who provide a range of client-centered services that links clients and other family members with health care, psychosocial and other services to ensure timely, coordinated access to appropriate services.
CBO	Community-based organization; includes non-hospital-based AIDS services and volunteer organizations, private non-profit social service and mental health organizations, hospice programs, home health care agencies, rehabilitation programs, substance abuse treatment programs, case management agencies, mental health care providers.
Court	A place of adjudication where legal decisions are rendered.
Drop-In Center	An informal setting providing support in which clients can have informal social contact.
Home	The place of permanent dwelling of the client.
Home Hospice	A hospice program providing nursing care, counseling, physician services, and palliative therapeutics during the terminal stages of the client’s illness rendered in the client’s home.
Hospital (Inpatient)	Care in a hospital in which the patient stays overnight.
Hospital Clinic (HIV)	Care in a unit of a hospital specializing in HIV.
Hospital Clinic (Primary Care)	Care in a unit of a hospital that provides services focusing on the prevention of illness and the ongoing management of chronic conditions and acute health problems.
Jail	Place of incarceration after committing or possibly committing a crime or infraction.
Job	Place of employment.
Medical Office	Non-hospital based locale that provides medical services.
Outpatient Clinic (HIV)	An outpatient clinic specializing in HIV care or services.
Outpatient Clinic (Primary Care)	An outpatient unit of a hospital that provides services focusing on the prevention of illness and the ongoing management of chronic conditions and acute health problems.
Restaurant	A public locale serving food.
Shelter	A place providing extremely short-term, transitional housing.
Skilled Nursing Facility	A living arrangement in which clients are assisted in daily living tasks by professional allied health providers.
Street	Outside of any dwelling or buildings, social service agencies, hospitals, or other housed services.
Telephone	Services provided via the telephone.
Van	A mobile facility that provides services.
Other	Other service locations not coded elsewhere

Part D: SERVICES PROVIDED BY (all that apply)

The following are definitions for the service providers listed in Part D. Darken the circles next to all the service providers that apply. Use the boxes next to "Other" to write in service providers not listed on the form.

Services Provided By:
Attorney	A professional trained in the practice of law.
Case Manager	Provides a range of client-centered services that link clients and other family members with health care, psychosocial and other services to ensure timely, coordinated access to appropriate services. Includes on-going assessment of the needs of clients and family members.
Child Care Worker	A provider of child care services.
Counselor	A provider of counseling services. Note that psychologist and psychiatrist are coded elsewhere.
Dietitian	Provides nutritional and dietary counseling.
Health Educator	Provides education and training on health issues.
Midwife	A professional, usually licensed, who assists women in giving birth at home or in the hospital.
Nurse/Nurse Practitioner	A professional, usually licensed, to practice nursing.
Outreach Worker	Seeks out persons in the community in need of services; provides information and referrals.
Pharmacist	A professional trained to dispense medications.
Physician	A professional licensed to practice medicine.
Physician Assistant	A professional trained to provide basic medical services, usually under the supervision of a physician.
Psychiatrist	A licensed physician with specialized training in the discipline of psychiatry.
Psychologist	A professional licensed to practice psychology.
Social Worker	A professional, usually licensed, to practice social work.
Student (Medical/Healthcare)	A student training to be a physician or to be another type of health care provider.
Student (Other)	A student training in a field other than medicine or health care.
Treatment Advocate	Provides advocacy or assistance to client to ensure the access to appropriate health care.
Other Treatment Provider	A treatment provider not coded elsewhere.

If you are using the short version of this form (the one that is letter-sized and does not include the staff code boxes at the bottom of the page), stop here. If you are using the long version (legal-sized and includes the staff code boxes), please continue. You may use either version of the form.

For each of the following service categories, enter the 3-digit staff code (s) of the person (s) providing the service (s). Note that for each service category you may enter the codes for up to four persons. Remember that each staff member should be assigned a unique number code (up to 3 digits). Make sure than each new staff member has a unique code. Do not reassign any staff codes that have been previously assigned. If the staff code is less than 3 digits, place "0"s before the number. For example, 3 is "003."

For HIV Prevention/Intervention services provide the staff codes for up to four persons who provided HIV prevention/intervention services.

For Mental Health Services provide the staff codes for up to four persons who provided mental health services.

For Group Counseling services provide the staff codes for up to four persons who provided group counseling services.

For Substance Abuse Services provide the staff codes for up to four persons who provided substance abuse services.

For Case Management/Advocacy services provide the staff codes for up to four persons who provided case management/advocacy services.

For Other Services provide the staff codes for up to four persons who provided services not listed in the staff boxes above.

Module 2

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