Please allow 5-10 minutes to complete this form in one sitting.
WHO SHOULD COMPLETE
I ndividuals who are interested in participating in the USA CON SOUTH SANES ECHO® should complete the pre-registration survey form below. Gathering this data helps our team learn information about you and your organization. The pre-registration survey asks for demographical data, as well as information related to integrated healthcare. Once your pre-registration survey information is received, you will receive a separate email to register for the USA CON SOUTH SANES ECHO® sessions.
QUESTIONS?If you have any questions, please email us at rthomas@southalabama.edu.
Name: Credentials: Title: Email:
Last name
* must provide value
First name
* must provide value
Email:
* must provide value
Q1.1 Organization Information
Name: Address: City: County: State: Zipcode: Phone Number:
Q1.4
Q1.5
Q1.6
Q1.2 What best describes your organization? (Select all that apply)
Q1.3 Please describe the population served by your organization. (Select all that apply)
What is your organization's caseload? What is the percent adult? Adult 65 years and older
Adult 45 to 64 years
Adult 25 to 44 years
Adult 18 to 24 years
What is the percent adolescent? Adolescent 12-17 years old What is the percentage child? Child 6-11 years old
Child 0-5 years old
Do provider relationships go beyond increasing successful referrals with an intent to achieve shared patient care at your organization?
EXAMPLES can include: coordinated service planning, shared training, team meetings, use of shared patient registries to monitor treatment progress.
* must provide value
Yes No
Do you have SANEs, behavioral health, and medical providers physically or virtually located at your organization?"Virtual" refers to the provision of telehealth services, and the "virtual" provider must provide direct care services to the patient, not just a consult, meaning that the provider visually sees the patient via televideo and vice versa.
* must provide value
Yes No
Do providers personally communicate on a regular basis to address specific patient treatment issues at your organization?
EXAMPLE: Some form of ongoing communication via weekly/monthly calls or conferences to review treatment issues regarding shared patients, such as a SART (sexual assault response team).
* must provide value
Yes No
Read the following groupings of clinical delivery characteristics and select the column number that best describes your organization.
Column 1 Column 2 Column 3 Column 4 Column 5 Column 6
1 2 3 4 5 6 ·Screening and assessment done according to separate practice models
·Separate treatment plans
·Evidence-based practices (EBP) implemented separately
·Screening based on separate practices; information may be shared through formal requests or Health Information Exchanges
·Separate treatment plans shared based on established relationships between specific providers
·Separate responsibility for care/EBPs
·May agree on a specific screening or other criteria for more effective in-house referral
·Separate service plans with some shared information that informs them
·Some shared knowledge of each other's EBPs, especially for high utilizers
·Agree on specific screening, based on ability to respond to results
·Collaborative treatment planning for specific patients
·Some EBPs and some training shared, focused on interest or specific population needs
·Consistent set of agreed-upon screenings across disciplines, which guide treatment interventions
·Collaborative treatment planning for all shared patients
·EBPs shared across system with some joint monitoring of health conditions for some patients
·Population-based medical and behavioral health screening is standard practice with results available to all and response protocols in place
·One treatment plan for all patients
·EBPs are team selected, trained and implemented across disciplines as standard practice
Indicate which clinical delivery characteristics apply to your organization. Select all that apply.
* must provide value
Indicate which clinical delivery characteristics apply to your organization. Select all that apply.
* must provide value
Indicate which clinical delivery characteristics apply to your organization. Select all that apply.
* must provide value
Indicate which clinical delivery characteristics apply to your organization. Select all that apply.
* must provide value
Indicate which clinical delivery characteristics apply to your organization. Select all that apply.
* must provide value
Indicate which clinical delivery characteristics apply to your organization. Select all that apply.
* must provide value
Read the following groupings of characteristics and select the column number that best describes your practice/organization.
Column 1 Column 2 Column 3 Column 4 Column 5 Column 6
1 2 3 4 5 6 ·No coordination or management of collaborative efforts
·Little provider buy-in to integration or even collaboration, up to individual providers to initiate as time and practice limits allow
·Some practice leadership in more systematic information sharing
·Some provider buy-in to collaboration and value placed on having needed information
·Organization leaders supportive but often co-location is viewed as a project or program
·Provider buy-in to making referrals work and appreciation of onsite availability
·Organization leaders support integration through mutual problem-solving of some system barriers
·More buy-in to concept of integration but not consistent across providers, not all providers using opportunities for integration or components
·Organization leaders support integration, if funding allows and efforts placed in solving as many system issues as possible, without changing fundamentally how disciplines are practiced
·Nearly all providers engaged in integrated model. Buy-in may not include change in practice strategy for individual providers
·Organization leaders strongly support integration as practice model with expected change in service delivery, and resources provided for development
·Integrated care and all components embraced by all providers and active involvement in practice change
Indicate the practice/organization characteristics that correspond to your organization. Select all that apply.
Indicate the practice/organization characteristics that correspond to your organization. Select all that apply.
Indicate the practice/organization characteristics that correspond to your organization. Select all that apply.
Indicate the practice/organization characteristics that correspond to your organization. Select all that apply.
Indicate the practice/organization characteristics that correspond to your organization. Select all that apply.
Indicate the practice/organization characteristics that correspond to your organization. Select all that apply.
It is strongly recommended that all participants attend every ECHO® session, as this will make learning much more meaningful and will ensure each participant gets the most out of this opportunity.
Please indicate if you are committed to attending and participating in all of the ECHO® sessions.
* must provide value
I agree. I am committed to attending and participating in all of the ECHO® sessions.
I do not agree.
Submit
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