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National Home-Based Primary Care Learning Network Application

The National Home-Based Primary Care Learning Network seeks to improve medical practice in the home and expand the evidence base for home-based medical care by fostering communities of best practice engaging in quality improvement and conducting applied research.

Eligibility for participation in the Network requires engagement in ongoing quality improvement, including attendance at monthly workshops, monthly reporting of quality improvement activities, completion of brief surveys, and active involvement in the Learning Network practice community.

Please complete the application below.

Thank you!

Salutation

* must provide value

Mr Mrs Ms Miss Dr

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First Name

* must provide value

Last Name

* must provide value

Role of Applicant in the Practice

* must provide value

Clinician providing patient care (includes MDs, DOs, NPs, PAs, RNs, SW, behavioral health providers, etc)

Administrative Team supporting the administrative activities of the practice (includes practice managers, practice staff members, schedulers, etc)

Clinical Leadership (includes lead clinical provider or decision-maker)

Quality Improvement (includes all practice members participating in quality measurement and improvement activities)

Practice Name

* must provide value

Practice Address
(Include a valid Street, City, State, and Zipcode)

* must provide value

Practice Email (if applicable)

* must provide value

Practice Website (if applicable)

Number of Unique Providers (MD/DO/PA/NP)

* must provide value

Total Provider Full-Time Equivalent (FTE) (MD/DO/DO/NP)
(e.g. a practice with two providers working full-time (100%) and one provider working half-time (50%) = 2.5 FTE)

* must provide value

a. Practice Average Daily Census
(Total number of active patients enrolled in the practice and receive care over the course of a year (not the number of patients you see each day)

* must provide value

b. How are you determining your Average Daily Census?

* must provide value

EMR report

Manual tally

Other

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Please specify other

Name and Email Addresses of Key Practice Leaders who will be responsible for leading the practice in Learning Network activities:

Practice Clinical Leader/Director Name

* must provide value

Practice Administrator

* must provide value

Practice Champion - a provider who will lead other providers in the work will be the practice expert in SimpleQI (our Learning Network QI platform) related to this project

* must provide value

Briefly, describe your practice's previous and current quality improvement activities.

* must provide value

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Home-Based care communities

a. Have you participated in any Home-Centered Care Institute (HCCI) educational activities?

* must provide value

Yes No

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b. Are any members of your practice members of the American Academy of Homecare Medicine?

* must provide value

Yes No

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Do you report any quality measures to payers (commercial or federal?)

* must provide value

Yes No

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If so, which ones?

* must provide value

Briefly describe your practice's motivation for participating in the Learning Network and what you will do to ensure successful participation.

* must provide value

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Please upload the Letter of Support.

Application requires a Letter of Support from Leadership confirming leadership support for practice participation and sharing of quality improvement data. (If part of a Health System, letter from Health System Leadership; if part of a free-standing practice, letter from member of executive leadership team)

If you are ready to submit your application and are waiting for signoff on your letter of support, please feel free to submit your application at this time and then email your Letter of Support to: Naomi Gallopyn - ngallopyn@mgh.harvard.edu

(Applications will only be reviewed if we receive a completed application form which includes a letter of support.)

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