This is the enrollment form for both ISP and FAST.
Innovation Support Project (ISP)
Support for primary care practices that serve Medicaid patients to improve the quality of care while enhancing the opportunity to succeed in new payment models, including Medicaid's Alternative Payment Model (APM) for Primary Care.
Facilitating Alcohol Screening and Treatment (FAST)
Join us for a six-month facilitated quality improvement program to address unhealthy alcohol use. The Agency for Healthcare Research and Quality (AHRQ) has funded efforts across the United States to help primary care practices increase efforts to address patients' unhealthy alcohol use.
In which project(s) does your practice wish to enroll? (You may enroll in both)
Which of these approximate timing options would work best for your practice:
Start with ISP (FEB-JUNE 2020), then begin FAST (July 2021)
Start with FAST (MAY 2020), then begin ISP (October 2021)
Either option would work for my practice
Note: exact start date will depend on several factors. FAST is about 9 month program, and ISP is a min of 12 Months.
Please indicate your preference. Please note, all practice support will begin as virtual until further notice due to COVID-19 precautions.
Monthly, in - person visits by a trained practice facilitator
Monthly virtual "visits" with a trained practice facilitator, with one visit per calendar quarter in-person
Either option would work for my practice
Note: exact start date will depend on several factors. FAST is about 9 month program, and ISP is a min of 12 Months.
Are you interested in potentially participating in IT-MATTTRS Team Training to support patients with opioid Use Disorder by offering Medication Assisted Treatment?
Yes
No
A member of the Practice Innovation Program at CU will contact you to discuss the MAT Team training program. Please enter the official practice name:
* must provide value
If your practice has a different, preferred practice name, please enter it here:
Practice Group National Provider Identifier (NPI):
* must provide value
Is your practice part of a larger organization (such as a hospital system, independent practice association, FQHC network, etc.)?
Yes
No
Please Type in the name of the Organization:
Primary Contact Person - First Name:
* must provide value
Primary Contact Person - Last Name:
* must provide value
Primary Contact Person - Role:
* must provide value
Primary Contact Person - Phone Number:
* must provide value
Primary Contact Person - Email Address:
* must provide value
Clinician Champion: This is a clinician in your practice who will be a lead person for this project.
Clinician Champion - First Name:
Clinician Champion - Last Name:
Clinician Champion - Email Address:
* must provide value
Staff Champion: This is the person who will be a staff lead and the primary point of contact for the practice facilitator.
Staff Champion - First Name:
Staff Champion - Last Name:
Staff Champion - Email Address:
Practice address (street address):
AR CO IA KS NE NV NM OK UT WY AZ
Practice county:
* must provide value
Adams Alamosa Arapahoe Archuleta Baca Bent Boulder Broomfield Chaffee Cheyenne Clear Creek Conejos Costilla Crowley Custer Delta Denver Dolores Douglas Eagle Elbert El Paso Fremont Garfield Gilpin Grand Gunnison Hinsdale Huerfano Jackson Jefferson Kiowa Kit Carson Lake La Plata Larimer Las Animas Lincoln Logan Mesa Mineral Moffat Montezuma Montrose Morgan Otero Ouray Park Phillips Pitkin Prowers Pueblo Rio Blanco Rio Grande Routt Saguache San Juan San Miguel Sedgwick Summit Teller Washington Weld Yuma Unknown
Person whom we should contact regarding health information technology (HIT) or electronic health records (EHR) issues.
Lead HIT/EHR Contact - First Name:
Lead HIT/EHR Contact - Last Name:
Lead HIT/EHR Contact - Email Address:
Total number of primary care clinicians at this practice site, including all MD's, DO's, PA's, NP's (by person count, e.g. 8 providers):
Did your practice participate in any of the following projects?(check all that are applicable)
Is your practice recognized or accredited by a national organization as a patient-centered medical home (PCMH)?
Yes
No
By which of the following national accrediting bodies (check all that apply):
Please specify the 'Other' accrediting body:
Practice specialty:(check all that apply)
Please specify the 'Other' specialty type:
****NEW Practice specialty:****** (check all that apply)
This will serve as a holding variable for the new SPECIALTY category for practices. New levels will be added as this category is revamped for future projects
Does your practice provide comprehensive primary care services?
Yes
No
Which of the following best describes the practice's ownership? (Check all that apply)
****NEW Which of the following best describes the practice's ownership?****** (Check all that apply)
This will serve as a holding variable for the new OWNERSHIP TYPE category for practices. New levels will be added as this category is revamped for future projects
Specify the 'Other' type of practice:
Please give the approximate percentage of your patients in the following payer categories: (should add up to 100%)
Dual Medicare and Medicaid:
Commercial or Private Insurance:
View equation Which electronic health record (EHR) system does the practice use?
Not Listed Allscripts AdvancedMD Amazing Charts Athenahealth Care360 Cerner eClinicalWorks e-MDs EPIC GE/Centricity Greenway Medical McKesson/Practice Partner NextGen Practice Fusion Sage/Vitera SOAPware Aprima Optum Caretracker CureMD Health Fusion/Meditouch MicroMD (Henry Schein) Kareo LSS/Meditech Medworxs Office Ally Open EMR Practice Studio Praxis Smart Cloud CPSI (Evident)
Please specify the 'Other' type of EHR the practice uses:
* must provide value
What version of your EHR are you using?
Is your practice currently working with HDCO (Health Data Colorado) to report eCQMs?
Yes
No
Not sure
Which of the following do you report Clinical Quality Measures from?
Which registry do you use?
Prime
Azara
Other (Specify)
Please specify the 'Other" registry:
For the ISP project you will select one measure set to report over the course of the project. These measures are aligned with the Medicaid APM program.
Adult Measures Pediatric Measures Despression Screening: NQF 0418 Depression Screening: NQF 0418 BMI (Adult): NQF 0421 Maternal Depression Screening: Quality ID 372 Alcohol and other drug screening: NQF 0004 Weight Assessment: NQF 0024 Hemoglobin A1c: NQF 0059 Childhood Immunizations: NQF 0038
Which measure set do you plan on reporting for the length of this project?
Adult Measure Set
Pediatric Measure Set
Can you report each measure below out of your EHR?
Please indicate which of the below practice transformation organizations that you would like to provide practice facilitation support for ISP:
* must provide value
I don't know, and would like help deciding Centura Physician Group Colorado Access Colorado Children's Health Access Program (CCHAP) Colorado Community Health Network (CCHN) Colorado Health Neighborhoods Colorado Regional Health Information Organization (CORHIO) Colorado Rural Health Center Community Care Alliance Denver Health HealthTeamWorks (HTW) High Plains Research Network John Snow, Inc. (JSI) Michigan Medical Advantage Pediatric Care Network (PCN) PHP /CCHA (Physician Health Partners / Colorado Community Health Alliance) Rocky Mountain Health Plans (RMHP) Telligen Texas Medical Foundation (TMF) UC Health Department of Family Medicine
Does your practice have an integrated behavioral health professional available?
Yes, full-time onsite
Yes, part-time onsite
Yes, available virutally
No
SBIRT Implementation Initial Assessment: Please respond to your practice's CURRENT use of alcohol and treatment guidelines. Please note if you do all of these all of the time, your practice is both unusual and unlikely to benefit from the support in this project!
Does the practice have the ability to report the following information from your EHR or other source?
Please indicate which one of these practice transformation organizations you would most like to provide practice facilitation for the Facilitating Alcohol Screening and Treatment project:Note that because of funding issues, the choices for PTO are limited for this project.
Contexture (formerly CORHIO)
HealthTeamWorks (HTW)
High Plains Research Network
Rocky Mountain Health Plans (RMHP)
Colorado Community Health Network (CCHN)
Thank you for your interest in our projects. You will be contacted within a few days regarding your application. If you have any questions regarding the study or application process please contact Allyson Gottsman at allyson.gottsman@cuanschutz.edu or practiceinnovation@ucdenver.edu
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