2015 NHPCO Board of Directors Election

Nominee Questionnaire

Nominee name:

Provider member with which the nominee is affiliated:

Relationship to provider member (circle one):EmployeePatient Care Volunteer Owner

Board MemberOther, please describe:

Title:

Educational Background, degrees:

Licensure/Credentials:
(e.g. Nursing Home Administrator)

Part 1 – Expertise/Insights

Your responses will help the Governance Committee prepare for your interview. In addition, if you are placed on the ballot, your responses will be posted on the NHPCO website. For this reason, concise answers are encouraged.

Nominees are strongly encouraged to be succinct.

1. What prompted your interest in serving on the NHPCO Board of Directors?

2. What special expertise would you bring to the board?

3. How can NHPCO meet the needs of a diverse group of hospice and palliative care providers? (i.e. ethnic diversity, rural vs. urban, community based vs. corporate, small vs. large)? What have you done in your own program to serve ethnic diversity in your community?

4. What leadership positions, beyond hospice and palliative care, have you held?

5. What roles do you think hospice and palliative care should play in the health care continuum that it currently does not?

6. What do you think are the most important issues/challenges facing hospice and palliative care in the next five years? What do you see as NHPCO’s role with regard to those issues? How would you, as a board member, help NHPCO fill that role?

7. Describe an innovative or visionary achievement you led that had a broad effect in your community or state.

8. Review the 2015Evaluation ofNominee Characteristics webpage and describe how you would meet the expectations of several topics of your choosing.

Part 2 -- Nominee Characteristics

Individual Characteristics

Answers to these questions will help the Governance Committee identify characteristics needed on the board.

Personal Expertise

Please note any areas of individual expertise or specialty.

(Including but not limited to: advocacy, clinical management, ethics, compliance, dementia caregiving, facility operations, fundraising managed care, palliative care in an ICU, pediatrics, public/media relations, QAPI, and regulatory affairs.)

NHPCO Involvement – (Prior service of at least 2 full terms on any NHPCO Committee)

Describe involvement with NHPCO, such as committee service and conference presentations; please include dates.

State Leadership Experience

Please list the title and dates of state organization leadership roles (state president, state board, or committees)

Hospice and/or Palliative Care Experience Not Listed on Resume

Describe any professional or volunteer experience not listed on your resume/CV that you would like the Governance Committee to consider. Include dates where appropriate

Diversity (response to this question is optional)

NHPCO seeks diversity at the board table. Are you a member of an ethnic or racial group traditionally underserved by hospice and/or palliative care?

Nominee’s Program Characteristics

Program Service Area

Urban Rural Mixed Rural & Urban Service Area
(>75% of service area is urban)(>75% of service area is rural)
For All Nominees:
Specialized Services Your Program Offers
Adult day care
Case management
Complementary therapies
Children’s bereavement program
Community bereavement program
Ethnic diversity program
Facilities (residential or inpatient)
Home care
Information and referral service
PACE
Palliative care consultation service
Pediatric palliative care services
Pre-hospice support
Specialized disease-specific programs, such as dementia or CHF
Transportation
Veterans programs
Other, please describe: / For Palliative Care Director Nominees Only:
Palliative Care Program Type
Hospital/System Based program
______Hospice Palliative Care program
Freestanding Palliative Care program
Nursing Facility, Long-Term Care based
Home Health Agency based program
Government, VA, Tricare program
Other, please describe: