State Innovation Model (SIM) Practice Application
By completing the application below you are demonstrating your practice's interest in participating in SIM. Please note that all completed applications will be reviewed by an expert panel that will provide recommendations to the SIM Office who will make the final selection of practices offered the opportunity to participate in the first SIM cohort beginning in February 2016. Thank you for your interest in participating in SIM.
Saving Work & Continuing Later:
If you want to stop and return to the application later, simply scroll to the bottom of the page, and click on "Save & Return Later". The system will provide you a "Return Code" that you need to write down and save, as you will be required to enter the "Return Code" in order return to the appropriate application. After you are given the "Return Code" you will be asked to input an e-mail address to which a link will be sent in order to return to your application.
Return codes can also be sent to other members of the practice if necessary by contacting: SIMPracticeInfo@ucdenver.edu or calling the program managers at 303-724-8968.
Questions:
If you have questions, please click to consult the full "Practice Request for Application" document or attend one of the three webinars. Information is posted on the University of Colorado's Practice Transformation website located at http://www.ucdenver.edu/practicetransformation.
You may also send questions to SIMPracticeInfo@ucdenver.edu or call 303-724-8968. All questions that are asked will be included with responses in written form in the Frequently Asked Questions (FAQs), which will be updated at least weekly. (Link to the September version is available below)
1. Please enter your full practice name:
* must provide value
2. What is your organization's name (if appropriate)?
3. Practice's address (Street address)
5. Is the practice located in Colorado?
Yes
No
6. In which state is your practice (if not CO)?
8. Please list your practice's website, if applicable
9. Lead medical provider's full name and credentials
10. Lead medical provider's email address
11. Person whom we should contact regarding health information technology (HIT) or electronic health records (EHR)
12. Lead HIT/EHR contact's email address
13. Contact person (Please enter their full name) for communication regarding the SIM Program
* must provide value
SIM program contact's email address
* must provide value
14. Which of the following describes your practice type? (Check all that apply):
15. Please describe how your practice meets the Institute of Medicine definition of primary care?
"Primary care" is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. An applicant primary care practice must be capable of providing a majority of their patients' comprehensive primary, preventive, chronic, and urgent care.
16. How would you describe your community?
Urban
Suburban
Rural
17. In which region is your practice located?
Nurse Practitioners/Advanced Practice Nurses
Licensed Clinical Social Workers
Other Behavioral Clinicians
19. Please provide the total number of other practice staff members (front and back office, any not accounted for above) in your practice.
20. Which of the following describes your practice's ownership?
21. Please estimate the total number of patient visits per year at this practice.
22. Which of these age groups make up a meaningful (by your definition) percentage of your patient population? Check all that apply:
Approximate % of Medicare
Approximate % of Medicaid
Approximate % of Employer, self-insured or commercial
Approximate % with no insurance
Approximate % of other payer category
Total percentage of payer categories=
View equation
24. Please specify what other payer category you have in your practice
25. Do you serve medically underserved populations or people in need? If so, in what setting?
26. Does your practice have internet access?
Yes
No
27. Does your practice use an electronic health record (EHR) system or electronic medical record (EMR) system? Do not include billing record systems.
Yes, all electronic
Yes, part paper and part electronic
No
28. What is the name of your current EHR/EMR system? (choose one)
All Scripts
advancedMD
Amazing charts
Athenahealth
Care360
Cerner
eClinicalWorks
e-MDs
EPIC
GE/Centricity
Greenway Medical
McKesson/Practice Partner
NextGen
Practice Fusion
Sage/Vitera
SOAPware
Other
Please specify other EHR/EMR system.
29. Is your current system certified to meet Meaningful Use as defined by Health and Human Services / ONC?
Yes
No
Don't know
30. Have your providers participated in Meaningful Use?
Yes
No
Don't know
MU Stage 1
MU Stage 2
32. Are you able to perform the following functions? Does your EHR have any of the following capabilities? Choose all that apply
33. Is your practice connected to an HIE?
Yes
No
CORHIO
QHN
Other
Please specify other HIE.
35. Do you report quality measures to any groups outside your practices (such as value based modifier program, PQRS, meaningful use, or local QI projects quality measure reporting).
Yes
No
36. Do you share any patient health information (e.g., lab results, imaging reports, problem lists, medication lists) electronically (not fax) with any other providers, including hospitals, ambulatory providers, or labs?
Yes
No
37. Please indicate if your practice has generated any of the following clinical quality measures (from your EHR dashboard, custom EHR reports, stand-alone registry, or other reporting tools) in the last 6 months: (Select all that apply)
38. At your practice are there plans for installing a new EHR/EMR system within the next 18 months?
Yes
No
Maybe
Unknown
39. Does your practice use a registry (either included in or separate from your EHR) to track patients with specific conditions?
Yes
No
Unknown
40. Select the conditions for which your practice uses a registry. (Check all that apply)
41. Please specify other conditions.
42. During meetings in your practice, how often (if ever) are registry data or clinical quality measures discussed?
Never
Infrequently
Often
43. Please specify how frequently and in what venue (provider meetings, partner meetings, staff meetings, QI team meetings).
44. At present or within the past 24 months, has your practice participated in any Quality Improvement programs with practice facilitation?
Yes
No
45. Please briefly describe the program or programs and name of the organization(s) that has provided practice facilitation. In your description, please describe the areas you worked on.
46. Is your practice recognized as a PCMH?
Yes
No
47. Through which organization?: select all that apply
48. What level (if appropriate)?
50. When did your practice receive PCMH Recognition? (If exact month, day, and year is unknown please estimate to the best of your knowledge.)
Today D-M-Y
a. The concepts of the medical home are understood and actively supported by practice leaders
(0) Not at all
(1)
(2)
(3)
(4) Completely
b. A culture of shared leadership has been created, with everyone sharing responsibility for change and improvement in the practice
(0) Not at all
(1)
(2)
(3)
(4) Completely
a. Our practice has an effective quality improvement team that is scheduled to meet regularly
(0) Not at all
(1)
(2)
(3)
(4) Completely
b. Staff members are actively and regularly involved in QI team meetings
(0) Not at all
(1)
(2)
(3)
(4) Completely
c. The QI team has a sustainable, reflective QI process that deals effectively with challenges and conflict
(0) Not at all
(1)
(2)
(3)
(4) Completely
a. We are able to extract data from our medical record systems for registries (lists of patients with particular conditions and with key information about those patients)
(0) Not at all
(1)
(2)
(3)
(4) Completely
b. Workflows for maintaining accurate registry data have been reliably implemented
(0) Not at all
(1)
(2)
(3)
(4) Completely
c. Quality measures and other data are used as a central area of focus for the practice’s improvement activities
(0) Not at all
(1)
(2)
(3)
(4) Completely
a. Our practice has an ongoing, reliable system for empanelment and panel management within our data systems and practice processes
(0) Not at all
(1)
(2)
(3)
(4) Completely
b. Each patient is assigned a personal clinician, with a team to serve as back-up when the personal clinician is unavailable
(0) Not at all
(1)
(2)
(3)
(4) Completely
a. Standardized protocols and standing orders have been created to maximize the efficiency of the practice workflow
(0) Not at all
(1)
(2)
(3)
(4) Completely
b. Team members have defined roles that makes optimal use of their training and skill sets
(0) Not at all
(1)
(2)
(3)
(4) Completely
c. Team huddles are used to discuss patient load for the day and to plan for patient visits
(0) Not at all
(1)
(2)
(3)
(4) Completely
a. Patients and families are actively linked with community resources to assist with their self-management goals
(0) Not at all
(1)
(2)
(3)
(4) Completely
b. Patients and families are provided with tools and resources to help them engage in the management of their health between office visits
(0) Not at all
(1)
(2)
(3)
(4) Completely
c. Personalized shared care plans are developed collaboratively with patients and families
(0) Not at all
(1)
(2)
(3)
(4) Completely
a. Our practice uses a standardized method or algorithm for identifying its high risk patients
(0) Not at all
(1)
(2)
(3)
(4) Completely
b. Our practice has a patient recall system to identify and bring in patients for needed care
(0) Not at all
(1)
(2)
(3)
(4) Completely
c. Our practice provides care management services for patients and families identified as being high risk or needing additional assistance and/or contact between visits
(0) Not at all
(1)
(2)
(3)
(4) Completely
a. Our practice has a system to insure that patients are able to see their own clinician as often as possible
(0) Not at all
(1)
(2)
(3)
(4) Completely
a. Patients and families can reliably and quickly access their personal clinician or a care team member to answer questions or deal with problems
(0) Not at all
(1)
(2)
(3)
(4) Completely
b. Patients can reliably make an appointment with their personal clinician or a care team member within defined and acceptable time periods
(0) Not at all
(1)
(2)
(3)
(4) Completely
a. A structured system is in place for assuring appropriate follow-up and care planning for patients undergoing transitions of care (such as discharge from hospital, ER visit, etc.)
(0) Not at all
(1)
(2)
(3)
(4) Completely
b. Our practice communicates actively with specialists and community resources to coordinate care based on the patient's personalized care plan
(0) Not at all
(1)
(2)
(3)
(4) Completely
a. Our practice is actively working to improve our care of behavioral health conditions
(0) Not at all
(1)
(2)
(3)
(4) Completely
b. A system has been implemented to screen or otherwise identify patients with behavioral health conditions, concerns, or contributing factors
(0) Not at all
(1)
(2)
(3)
(4) Completely
c. Protocols and work flows have been implemented for collaboration between primary care and behavioral health providers, such as effective handoffs, communication, and standardized follow up
(0) Not at all
(1)
(2)
(3)
(4) Completely
51. How does your practice currently address the behavioral health needs of your patients?
52. Has your practice employed a behavioral health professional?
Yes, currently
Yes, in the past, but not currently
No
53. Please describe the role of the Behavioral Health Professional in your practice and how they function at your clinic.
54. Please describe the role and functions of the behavioral health professional and why they are no longer there.
55. For your co-located, contracted or employed behavioral health professionals in your clinic, please describe how behavioral health professionals and physical health providers communicate and document the care each provides. Are there mechanisms in place to collaborate on care?
56. Does your practice prepare an annual budget?
Yes
No
57. Has your practice participated in non-fee-for-service payments from a Payer in the last 24 months (i.e. shared savings, PMPM, global payments?
Yes
No
58. Does your practice have existing payments or mechanisms for supporting behavioral health integration?
Yes
No
59. Please tell us why you wish to participate in SIM Practice Transformation Activities
60. Practice attests to having the ability and interest in participating in alternative payment models such as per member per month (PMPM), bundled payments, global payments, shared savings
* must provide value
Agree
Disagree
61. Practice attests to the ability and willingness to account for funding from SIM such as the Practice Transformation Fund.
* must provide value
Agree
Disagree
62. Practice attests that both practice leadership and system leadership, if applicable, support the intention to move toward increasing integrated primary care and behavioral health.
* must provide value
Agree
Disagree
63. By signing this application to be considered for participation in SIM, we commit to two years of practice transformation, attend learning sessions, submit quality measures, meet milestones, participate in a learning community for practices and participate in on-going evaluation.
* must provide value
Agree
Disagree
64. By signing this application, we affirm that the application was completed by the staff and/or providers at practice site with approval of the organization, if a part of an organization.
* must provide value
Agree
Disagree
Please enter your full name and credentials. This will be considered an electronic signature, attesting that all information you provided in this document is true, and you agree to the statements listed above.
* must provide value
Who completed this application? Please give the name(s) and role(s) in the practice.
* must provide value
Submit
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