Together 2 Goal Innovator Track: CVD Cohort

Together 2 Goal® Innovator Track: CVD Cohort

Application Cover Sheet

Organization Name

Project Title

Primary contact information (name, title, e-mail, phone, address)

Sponsor CONTACT INFORMATION (CEO, medical director, department head)

SPONSOR’S SIGNATURE

Together 2 Goal® Innovator Track: CVD Cohort

Application

Instructions

• Please remove all patient, provider, and organization identifiers.
• Please note the word count limits for each question.
• Applications are due by close of business (5:30p.m. PT) onFebruary 28th, 2018.Submit one electronic copy of the application .
• Selected participants will be notified via email on March 15th, 2018.

Evaluation Criteria

The AMGA Foundation CVD Advisory Committee will review each application and use the following criteria for acceptance into the CVD Cohort of the Together 2Goal® Innovator Track.

1. Committed Resources

• Ability to dedicate staffing and resources to CVD Cohort
• Ability and commitment to development of framework and measures
• IT plan and the ability to identify targeted populations, track data, and meet reporting requirements

1. Potential impact

• Number of patients impacted
• Opennes to innovation and quality improvement
• Feasibility and scalability
• Willingness to change organizational structure and processes

1. Sustainability

• Funds/resources/staff available to implement and sustain CVD risk management program beyond completion of the CVD Cohort
• Ability to monitor program to ensure ongoing effectiveness

Organizational Profile:Include an organizational profile that gives the reader an understanding of the size and scope of your organization without revealing your organization.(250 words or less)

1. Do you presently have capabilities in place for identifying patients with diabetes that are at high CVD risk? If so, please describe the process.(300 word limit)
2. Indicate commitment that dedicated IT resources will be available.
3. Include information about EHR, registries, and other data strategies.
4. Attach relevant outcomes in the appendices.

1. Briefly describe your current CVD management programs (e.g.lifestyle modification, pharmacotherapy, smoking cessation counseling), if any.(300 word limit)

1. Describe your team’s willingness to develop the sustainability structures and processes to ensure what you develop will be integrated into your organization for the long term?(200 word limit)

1. Will your proposed program be a pilot at 1-2 sites or organization-wide? How many patients will be impacted?

(200 word limit)

1. Describe the challenges and barriers you expect to encounter and how you plan to address them. (300 word limit)

1. Describe the leadership commitment and resources (people and financial) that will be committed to the project and how you intend to sustain the program once participation in this Cohort has ended. (300 word limit)
2. Include project and implementation team members and advisory committee member
3. Include additional financial resources
4. Funds, staff, and resources available to continue the program

1. Is your organization currently tracking or reporting on any CVD measures for patients with diabetes? If so, what are those measures?(300 word limit)

1. Does your organization currently have a method for capturing patient feedback or input in program effectiveness or experiences?(300 word limit)

For further information or questions, contact .

Page 1