Learning Collaborative Application Form

Applications must be received electronically by Washington Rheumatology Alliance by noon PST on February 24th, 2017. Applications submitted after the deadline will be considered only if space is available. Applicants will be notified in writing of decisions by March 1st, 2017. If you have any questions, contact pm@warheumatology.org.

ORGANIZATION BACKGROUND

Organization Name:

Organization Address:

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Primary Staff Contact Name:

First

Last

Primary Staff Contact Title:

Primary Staff Contact Phone Number:

Area Code

Phone Number

Primary Staff Contact E-Mail Address:

NARRATIVE RESPONSE

Please answer the questions below in three to five sentences:

Provide a brief summary of your organization, including the type of practice, number of rheumatologists on staff, etc.

Describe what your organization hopes to gain from the Learning Collaborative.

Describe what your organization will bring to the Learning Collaborative that will benefit the collaborative and your community.

WRA Membership

As a requirement of participation, all practices must have current WRA members among their practicing rheumatologists.

Name(s) of rheumatologist(s) at your practice that are current WRA member(s):

ORGANIZATION CAPACITY

Technology Assessment. As decision support tools and outcomes measures become increasingly important in chronic disease management, there is a significant need in the care of rheumatoid arthritis patients for accurate, scalable and cost-effective methods of capturing quality population health measures. To better understand where your practice is at in this process, please answer the following questions:

What type of EHR system does your practice currently utilize?

Does your practice utilize any additional population health tools for identifying and tracking gaps or variation in care (i.e. JointMan™)?

Yes

Not yet, but we are currently in the process of implementing one.

On a scale of 1 to 5, how committed is your practice to integrating a population health tool (such as JointMan™) with your EHR system?

If selected as a Learning Collaborative participant provider site, how quickly would your practice be able to consider integration with a population health tool such as JointMan™?

1 month or less

2-3 months

3-6 months

6+ months

ORGANIZATION COMMITMENT

Identify the staff member who will serve as the Implementation Team Leader for your organization. Please note, this person will be the main point of contact for the Learning Collaborative.

Team Leader Contact Name:

First

Last

Team Leader Title:

Team Leader Phone Number:

Area Code

Phone Number

Team Leader E-Mail Address:

Please have your Team Leader and Practice Head verify the statements below. (Note: this may be the same person, depending on your organization’s size and structure):

As the Team Leader, I commit to:
•   Attend all Learning Collaborative meetings and webinars
•   Lead the team in making improvements;
•   Serve as the primary team liaison to the Washington Rheumatology Alliance
•   Coordinate data collection as needed;
•   Submit progress reports in a timely manner;
•   Facilitate the implementation of successful changes throughout the organization; and
•   Provide continuing opportunities to disseminate what has been learned and to continue change processes within the organization.

Team leader agreement:

I agree

As the Practice Head, I unequivocally support and endorse the efforts of my staff in this Learning Collaborative and will provide them with the time (including time needed to attend both mandatory sessions), flexibility, support, and resources to accomplish these goals.

Practice head agreement

I agree

Name of Practice Head:

First

Last

Please verify: