Form CMS-10640 MAC Participant Form

Participant Form:

The LAN Maternity Multi-Stakeholder Action Collaborative (MAC)
The LAN requests the following information, which will be used to shape the MAC goals, activities and milestones. The LAN
will synthesize the information provided, but will not attribute information to any individual organization.

1. Organizational Details For each representative from your organization that plans to participate in the MAC,
please provide the information below. Please designate at least one person as the MAC Participant Primary
Point of Contact (POC).
Organization Name
City, State
Website Address:
Name
Title
Email
Assistant’s Name
Name
Title
Email
Assistant’s Name

□ MAC POC
Phone
Assistants
Email/Phone

□ MAC POC
Phone
Assistants
Email/Phone

2. Organizational Goals for Participation

Why is your organization committed to participating in the MAC, and what are your top three goals for
participation? Note that the MAC will operate from December 1, 2016 – December 31, 2017.

For questions 3 and 4, please consider reviewing the LAN Maternity Episode Payment
Recommendations, which will provide the context for the LAN’s support.
3. Priority Topics and Associational Outputs/Tools

What are your top 2-3 priority areas on which you want the MAC to focus? In each of these areas, what
concrete deliverables should the MAC collectively develop that would be most useful to your organization
and region?

Participant Form:

The LAN Maternity Multi-Stakeholder Action Collaborative (MAC)
4. Barriers to Success

What do you perceive as your organization’s top 3 barriers – either within your organization, or within your
market – which may arise and could delay progress in implementing maternity care APMs?

5. Your Promising Practices to Share with Other Participants

What are your top 2-3 promising practices related to payment reform (as it relates to delivery system
redesign)?

6. Helpful Tools and Resources

What tools and resources have been most helpful to your organization in its maternity care improvement
efforts? If possible, please provide links related to education, resources, tools, webinars, publications,
surveys, articles, products, or services that your organization used and found helpful.