Participant Agreement for Nursing Home Collaborative

______(name of facility) is agreeing to participate in the Primaris Nursing Home Quality Collaborative. Primaris will be coaching you through the process and offer the following services:

 Educational sessions on topics critical to you.  Best practices and evidence-based strategies.  Peer networking and sharing via collaborative sessions and webinars.  Face-to-face best practice sharing sessions twice annually in Kansas City, St. Louis, Columbia and Springfield.  Tools and resources for topics such as QAPI, INTERACT II, antipsychotic use and others important to you.

As a participant, my home will develop strategies for overall quality within my organization, by working to:

 Utilize a data-driven and proactive approach to quality improvement.  Identify opportunities for improvement.  Address gaps in systems through planned interventions in order to improve the overall quality of care.  Form an interdisciplinary team to improve systems of care in areas identified for improvement.  Participate in collaborative session and webinars.  Share best practices and lessons learned.

As Missouri’s Medicare Quality Improvement Organization, Primaris provides clinical improvement resources, expertise, and real-time tailored assistance geared toward your nursing home’s needs reinforcing your already existing efforts. Participating nursing homes aren’t charged for program materials, consultations or coaching.

Signed agreement form must be received by January 15, 2013 and can be faxed, mailed or emailed to: ------ATTN: Tanya Fisher MAIL: Primaris, 200 N. Keene Street, Suite 101, Columbia, MO 65201 EMAIL: [email protected] FAX: 573-777-9051 ------

______Administrator Signature Date

______Director of Nursing Signature Date

Topics of interest include:

MO-12-56-NH GEN October 2012 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Quality Assurance Process Improvement Falls (QAPI) Urinary Tract Infections INTERACT II Staff retention Pressure ulcer Consistent assignment Antipsychotic use Other: ______

For email returns only: By checking this box, I signify that the above typed signature serves as my official signature.

200 N. Keene Street Suite 101 Columbia, MO 65201 www.primaris.org

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