Collaborative Improvement and Innovation Network

National Quality Initiative Collaborative Improvement and Innovation Network (NQI CoIIN)

APPLICATION

Please complete the application and return to [email protected] no later than 11:59 PM EDT on Wednesday, July 22, 2014.

Faxed or mailed submissions will not be accepted. The applicant will receive emailed confirmation of SBHA’s receipt of the application.

Notification of acceptance to participate in the NQI CoIIN will be made Wednesday, August 19, 2015 via email to the NQI CoIIN Champion.

Application Section 1: Select a Focus Area

Please indicate your team’s focus area the table below. Refer to the Request for Proposal (RFP) for descriptions of the focus areas.

NQI CoIIN Focus Area ☐ Standardized performance measures ☐ Sustainable business practices

Application Section 2: NQI CoIIN Team Description Section

Please indicate your team’s structure in the table below. Refer to the RFP for examples of three ways to structure your team.

Team Structure ☐ State-led team ☐ County-led team ☐ SBHC sponsor organization-led team

Please indicate team members as applicable. Refer to the RFP for team member descriptions and participation requirements.

1 NQI CoIIN Champion (team lead)

Organization/Department Name:

Address: Type of organization ☐ State government office ☐ School district (check only one): ☐ County government office ☐ Community organization ☐ SBHC sponsoring ☐ Other, please specify: organization NQI CoIIN Champion Title: Name:

NQI CoIIN Champion Phone: Email:

2 Sponsor Organization(s) and SBHC(s) Complete a separate page for each participating sponsoring organization. Use as many pages as necessary to indicate all participating sponsor organizations and participating SBHCs from that sponsor.

SBHC Sponsor Organization

Sponsor Organization Name:

Type of organization ☐ Federally Qualified Health ☐ University medical system (check only one): Center ☐ Local health department ☐ Hospital system ☐ Other, please specify: Sponsor Organization Address:

Contact information for NQI Team member at sponsoring organization

Team member name: Contact Title:

Email: Phone:

Please list the SBHCs that will participate as part of the NQI CoIIN team. Only indicate SBHCs who have committed to participate. Date SBHC Name of EHR (i.e., Opened Participating SBHC Name EPIC, GE Centricity, (MM/YYYY eClinicalWorks, etc.) )

3 4 Application Section 3: NQI CoIIN Focus Area Essay Questions

Please respond to the following three questions. Customize your responses based on your indicated focus area. Word limit: 500 words per response question.

1. What do you see as the top challenges and opportunities to improve school-based health care in your indicated focus area? (performance measure documentation and reporting -OR- sustainable business practices). Refer to page two of the RFP for focus area descriptions.

2. If your SBHC program was selected to participate, what are 2-3 goals you might consider pursuing? Refer to page two of the RFP for focus area descriptions.

3. What strengths will your team members bring to help you achieve the NQI CoIIN focus area goals?

5 Application Section 4: SBHC Basic Data

Complete a separate form for each individual SBHC that would be a member of the NQI CoIIN Team as indicated under Application Section 2: NQI CoIIN Team Description. Please submit data for the 2014-2015 school year or for the most recent school year that data are available.

SBHC Name: Sponsoring Organization: Data from which school year?

Demographic Characteristics/Student Statistics Total # of students enrolled in the school Total # of students enrolled/consented in the SBHC ☐ Students ☐ Family of students users (i.e., siblings, parents, or infants of students) from other ☐ Other people in the community schools Select the ☐ Other, please specify: populations ☐ Out-of- served by school youth the SBHC ☐ Faculty/school personnel Total # of enrolled/consented students enrolled in Medicaid School/Student Population Characteristics Grade levels served by SBHC % American Indian/ Alaska % Filipino: Native: Racial/ethn % Native Hawaiian/ % White: ic Pacific compositio Islander: % n of % Two or Hispanic/Latin more races: student o: % body % Not Black/African reported: American: % Asian: % Other: Total # of students in the school eligible for free or reduced price meals Health Center Operations and Characteristics

6 # of primary care providers1 # of behavioral health providers2 # of days per week the health center offers clinical hours Behavioral/ # of 3 Reproductive Primary Care 4 Oral Vision Other clinical Mental Health Health hours per week by provider type Select Private Public Private Federal Funds State Funds In-kind Other SBHC insurance insurance foundations funding/rev enue ☐ ☐ ☐ ☐ ☐ ☐ ☐ sources Indicate % of total operational expenses covered by each source Visit Data

1 Primary Care Provider: A nurse practitioner, physician’s assistant, or physician.

2 Behavioral Health Provider: Licensed social worker/counselor/therapist, unlicensed social worker/counselor/therapist, psychiatric nurse practitioner, psychiatrist, or psychologist.

3 Primary care clinical hours: Hours per week staff are providing primary care services at the health center or via telehealth technology. Excludes administrative hours.

4 Behavioral health clinical hours: Hours per week staff are providing behavioral health services at the health center or via telehealth technology. Excludes administrative hours.

7 Total # of unduplicate d users during the school year 5 Total # of primary care visits durin g the school year Total # of behavioral health visits during the school year Total # of visits during the school year6 Total # of billable visits during the school year Top 5 Top 5 primary 1. behavioral 1. care 2. health 2. diagnosis 3. diagnosis 3. codes 4. codes 4. (ICD-9 or 5. (ICD-9 or 5. DSM)7 DSM)

5 Definition of an Unduplicated User: An unduplicated user is an individual who has presented themselves to the health center for service with the main medical provider (Nurse Practitioner, Physician Assistant or Physician), or the main mental health provider (minimum Master’s prepared and licensed mental health provider), and for whom a record has been opened. Opening a record includes documenting an assessment, diagnosis and treatment plan. Once per year, the user is counted to generate the number of unduplicated clients utilizing the health center services for that year.

6 Definition of a Visit: A visit is a significant encounter between a health center provider and a user. Each visit should be documented as appropriate to the visit and provider (i.e., medical visits with main medical provider include an assessment, diagnosis and treatment plan documented in the medical record, on encounter form and/or other documentation appropriate to the visit). A user will likely have multiple visits per year.

7 Top primary care and behavioral health diagnoses should be drawn from ICD-9 codes and DSM codes.

8 Application Section 5: Statement of Commitment

(must be completed and signed by the NQI CoIIN Team Champion and all participating sponsoring organizations representatives)

By signing this statement of commitment, I commit to full and active participation should my NQI CoIIN Team be selected to participate in the National Quality Initiative Collaborative Improvement and Innovation Network (NQI CoIIN).

My prospective participation has been approved by my supervisor, and there are no foreseeable barriers to my active engagement in this project. I will make my best effort to participate in all expected project activities and fulfill my NQI CoIIN team responsibilities.

NQI CoIIN Champion Team Member Name

Team Member Signature

NQI CoIIN Team Contact at Sponsoring Organization #1 Team Member Name

NQI CoIIN Team Contact at Sponsoring Organization #2 (if applicable) Team Member Name

NQI CoIIN Team Contact at Sponsoring Organization #3 (if applicable) Team Member Name Team Member Signature

9 Date