Information About the Lead Provider

1. Information about the lead provider
2. Describe your experience in prescribing cardiovascular disease prevention, lifestyle medicine, and chronic condition management to patients.

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1. Are you currently providing hypertension management and referrals to hypertension management programs? If yes, please indicate how long these services have been part of your practice.

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1. Background information about your practice setting
2. Describe the organizational capacity of your practice. Include a brief overview of the size of your practice, the types of providers in your practice, the types of insurance you accept, the services you provide, and the population/communities you serve.

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1. Describe your practice’s patient population:

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1. Are you a WISEWOMAN provider? If yes, please indicate how long you have been a provider of the program’s services.

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1. Describe your practice’s commitment to prevention / lifestyle change.

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1. Institutional Support
2. In addition to the lead provider please provide a list of other staff members who will be involved in the project.Please describe roles and responsibilities they currently have within your organization and the role they will have with this project.

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1. How will they support your demonstration project? Please describe specific roles and responsibilities.

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1. How will your organization support your demonstration project? (Include any current EMR systems and other value-based care practices currently utilized by your organization that will be a part of your project).

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1. Current hypertension management practices implemented by your practice:
2. How does your practicecurrently identify (screen, test) and refer patients with hypertension to evidence-based programs?

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1. What type of hypertension management programs/services does your practice refer your patients to?

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1. Describe how you would use this grant to develop and test innovative models to support the screeningand referral your patients with hypertensionto evidence-based hypertension management programs. Include the following information:
2. The prevalence of hypertension in your patient population.
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3. How will you refer your patients with hypertension to evidence-based programs?
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4. How will you follow up with your patients? How will you periodically check in with your patients and/or the organization that is providing the hypertension management programs?
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1. Workflow
2. How will your proposed screening and referral of your patients with hypertension affect your workflow? Please include any team based care approaches.
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1. Identify ways in which you will manage your workflow.
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1. What tools/materials will you use to test the referral of your patients to an evidence-based hypertension management program?

1. If you proposed using existing materials please provide a copy of the complete set of materials, including online links.
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1. How will these tools/materials help you increase hypertension screeningand referral?
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1. How will you test the effectiveness of the materials/tools that you utilized?
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1. What are your performance measures for the four-month demonstration project? Please be as specific as you can with your measures. Include no more than three performance measures
2. E.g.: I will increase the screeningand referral of my patients with hypertension by 15% during the four-month demonstration period or I will refer 20% of my patients with hypertension to evidence based (community) programs.
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3. Sustainability plan for your demonstration project.
4. How will you continue to screen and refer your patients with hypertension to evidence-based programs after the completion of the 4-month grant period?
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5. How will your practice continue to incorporate and institutionalize the screening and referral processes established by the demonstration project?
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1. Budget:
2. Include a project budget for the amount requested. (Please provide the budget in a separate document.)
3. Include a budget narrative that clearly explains how you will your use the award to achieve the goals and outcomes of the demonstration project.

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1. Timeline: Include a clear and detailed timeline that includes but is not limited to:
2. The start and the end dates for the 4-month demonstration project.
3. When and how often you will communicate with ACPM staff/physician consultants.
4. When you will develop and submit the findings of the project.

QUESTIONS

If you have any questions about this application please email