Clinic Application for the Cardiovascular Prevention Enhancement Program
Please enter your responses in red after each > symbol.
Please be brief in your responses, but feel free to add lines or pages as necessary.
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Clinic name:
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Contact person’s name:
Email address:
Direct phone number:
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Clinic street address:
Clinic city/town, state and zip:
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County where clinic is located:
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Is your clinic part of a larger healthcare organization?
If yes, what organization?
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Number of full-time equivalent providers:
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Number of visits per year:
Number of unduplicated patients served in the past year, ages 18 and up:
Number of such patients, ages 18 and up, diagnosed with hypertension:
Number of such patients, ages 18 and up, diagnosed with type 2 diabetes:
Number of such patients, ages 18 and up, diagnosed with a lipid disorder:
Total number of such patients, ages 18 and up, with any of the three above
disorders or any combination of them
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For questions 8 through 10, if precise data are not readily available, please provide estimates.
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Patient population race
% African-American/Black:
% Asian:
% Hawaiian/Pacific Islander:
% Native American/Alaskan:
% White
% Multiple or other races
Total (should be 100%)
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Patient population ethnicity – % Hispanic/Latino/Latina: >
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10. Primary payer mix
Commercial
Medicare
Medicaid
Military
Self pay
Other
Total (should be 100%)
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Are your responses to questions 8 through 10 based on data or estimates? >
11. Does your clinic use an electronic medical record?
If so, what system?
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12. What significant changes are planned at your clinic regarding EMRs in the next year, if any?
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13. Is your clinic recognized as a patient-centered medical home? >
If yes: What organizations recognizes your clinic as a patient-centered medical home, and when
was that recognition attained?
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If no: Are you planning to seek PCMH recognition, and if so, by when?
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14. Is your clinic part of an accountable care organization (ACO)? >
If not: Is your clinic considering become part of an ACO, and if so, by when?
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15. WIPHL will need to conduct a phone interview of your proposed Prevention Specialist (PS) to
ensure his or her compatibility with this project.
Do you plan to hire a new staff person or assign a current staff person as PS?
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Do you know who you might wish to assign to serve as your PS? >
If so:
Name:
Degrees and certifications, if any
Position and current responsibilities:
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Why do you believe this individual would be a good fit for the PS position?
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How many hours per week can you commit your PS to this role?
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What other non-PS responsibilities will your PS have, if any?
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16. Prevention Specialist training intensity and format will depend on the preferences and constraints
of the clinics that are selected to participate. Training will take place in Madison.
Would your PS be able to participate in:
3 days of initial training, then 2 days of follow-up training the next month?
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5 days of initial training in one week, then 3 days of follow-up training the next month? >
5 days of initial training in one week, then 5 days of follow-up training the next month? >
17. Will you be able to provide your PS with …
- Dedicated space to meet privately with patients
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- A dedicated phone to conduct follow-up with patients
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- Laptop computer with Access 2010 software for running the CPEP registry program >
18. Please list the quality improvement projects you’ve engaged in during the last five years.
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19. Please describe your biggest quality improvement success in the past five years.
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20. What projects or significant changes will your clinic be involved in during spring and summer of
2014?
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21. Will you intend to submit fee-for-service claims for the BSI services your Prevention Specialists?
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22. A goal of CPEP is that participating clinics will sustain expanded BSI delivery for patients with
cardiac risk factors after participating in this grant-sponsored project.
What is already in place in your clinic or its environment to help attain sustainability?
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What else would need to happen to attain sustainability in your clinic or its environment?
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23. Project Team – We and others have found that projects involving new clinical service delivery in
busy, complex healthcare settings succeed best when a quality improvement team oversees a formal
yet fairly simple quality improvement process.
One important role on the quality improvement team is Champion. A Champion is typically a formal
or informal authority figure – usually an administrator, clinician, nurse or manager – who may or
may not be involved with day-to-day project management but is visibly committed to the project’s
success. He or she would frequently speak forcefully in favor of the project, and would be willing to
help sway individuals who might pose barriers to success.
Who would serve as your CPEP Champion?
Name
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Position
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Number of years at the clinic
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Another important role is Manager. A Manager typically leads Project Team meetings, oversees
implementation of plan-do-study-act (PDSA) cycles, and takes responsibility for day-to-day project
implementation.
Who would serve as your CPEP Manager?
Name
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Position
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Number of years at the clinic
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In clinics, QI Teams work best when there is representation from each key segment of clinic staff,
including, of course, your Prevention Specialist. The team designs initial workflow modifications,
tracks quality metrics, and optimizes workflow to maximize performance on metrics. Who would
represent various staff segments on your QI Team?
Administration
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Manager
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Provider
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Nurse
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Medical Assistant
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Receptionist
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Billing
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Lab
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Others, if any
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24. A key aim of CPEP is to have your Prevention Specialist meet at least once a year with as many
patients as possible who have hypertension, type 2 diabetes, or a lipid disorder to conduct
screening, assessment, and intervention, and to offer ongoing support for behavior change.
What barriers do you foresee to implementing a new workflow toward this end, and how do you
envision working through those barriers?
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25. Please attach letters from key clinic administrators, managers, providers or others demonstrating
your clinic’s commitment to the project.
Thank you very much for completing this application.
Please email any questions and submit the application to Dr. Rich Brown at: [email protected]
Applications must be received by Friday, February 28 at 5:00 pm central time.
In fairness to other applicants, applications received after the deadline will not be considered.