Table 3.

Template elements

Item	Description
Mission	Includes specific services that the agency engages in to address the mission
Organizational structure	How is the organization organized internally (e.g., hub and spoke model)? Nonprofit, for profit, government agency? Number and locations of regional centers
Patients/populations served	Indicate population the center is attempting to reach (e.g., all individuals with Down Syndrome in a state) and the actual number served (within the context of a time frame)
Services provided	Direct care, enabling, infrastructure building, population-based, etc.
Funding	What is the source of funding and the amount of funding over a specified period of time? Include mechanism for how funds are distributed (e.g., accreditation, reimbursement, satellite offices) and percentage from all funding sources; if there is a central coordinating body, how is it funded? (excluding physician fees unless the central coordinating body is the recipient or payer of such fees); include budget when available (if not available, include % of budget used for services being described)
How do they reach underserved populations (if they do)?
Cross-state line challenges (licensure, etc.)
Impact	How do you measure the impact and/or success of your services? Please share any data you have on impact or outcomes
Mental health services provided
Resources	Is there a set of resources that the central coordinating body makes available to satellite centers? If so, what are these resources?
How does an entity (clinic, provider, etc) become a part of the system?	Application, evaluation process, etc.
Staffing	Are there staffing issues, who is a part of the team?
Telephone consultation	Telemedicine technology (current or planned usage)
Please list any gaps/barriers that you (as the reviewer) have identified through the review process