Application Survey for the Improving Continuity of Care

Assessment of a Training Program to Improve Continuity of Care for Children and Families Affected by Fetal Alcohol Spectrum Disorders

Improving Continuity of Care for Children and Families Affected by Prenatal Alcohol Exposure

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Form Approved

OMB No. xxxx-xxxx

Exp. Date: xx/xx/xxxx

The public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to - CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (xxxx-xxxx)

Thank you for your interest in, and accessing the application survey for, the project, Improving Continuity of Care for Children and Families Affected by Prenatal Alcohol Exposure (PAE). The following application may be completed by your clinic’s Lead Preceptor or other designated representative. The survey will take you approximately ten minutes to complete. Please use the survey's "previous" and "next" arrow buttons to navigate within the survey. If you are unable to finish the survey in one sitting, you may return to the survey later. However, to retrieve your previous responses, you must use the same computer. (Assuming that your computer will accept cookies, the program will save the pages that you have previously completed until you finish the survey or the survey closes.)

The deadline for submitting applications is XXXX. However, we strongly encourage you to complete your application as early as possible. Completed applications will be accepted on a first-come, first-served basis. The project is scheduled to run from October 2021 through January 2022.

**NOTE: To complete the survey, you’ll need to have certain information handy. Specifically, you will need to provide:

• Contact information for your continuity clinic (address, phone, etc.), the resident program director, and lead precepting attending physician (Name, email address, and telephone number).

• The number (or approximate number) of pediatric precepting attending physicians in your practice.

• The number (or anticipated number) of first year pediatric residents (interns) in your practice during the project timeline, October 2021-January 2022.

If you have questions about eligibility, please contact Josh Benke at 630/626-6081 or [email protected], or Rachel Daskalov at 630/626-6063 or [email protected]. Thank you!

Name of person completing this application and practice role:

________________________________________________________________

Primary contact regarding this application and practice role:

________________________________________________________________

Primary contact's email address:

________________________________________________________________

Practice Name:

________________________________________________________________

Practice Address:

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Main Phone:

________________________________________________________________

Fax:

________________________________________________________________

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Does the practice have more than one location?

• Yes (1)

• No (2)

Is the primary/main practice location: [check one]

• Urban (inner city) (1)

• Urban (non-inner city) (2)

• Suburban (3)

• Rural (4)

Continuity clinic size (by number of pediatricians): [check one]

• Small (1-3 pediatricians) (1)

• Medium (4-6 pediatricians) (2)

• Large (≥7 pediatricians) (3)

Practice type: [check one]

• Independent practice (1)

• Hospital affiliated practice (2)

• Affiliated with a university or medical school (3)

• County public health department/clinic (4)

• Federally Qualified Health Center (FQHC) or Community Health Center (5)

• Other (please specify) (6) ________________________________________________

Does the practice accept new patients?

• Yes (1)

• No (2)

Does the practice have any plans to stop accepting new patients in the next 8 months (through January 2021)?

• Yes (1)

• No (2)

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How many precepting attending physicians participate in your continuity clinic program?

• 1-3 (1)

• 4-6 (2)

• ≥7 (3)

How many first-year residents (interns) do you anticipate will participate in your continuity clinic program during the project period (October 2020-January 2021)?

• 1-3 (1)

• 4-6 (2)

• ≥7 (3)

How many residents has the lead precepting attending physician precepted over the course of their career?

________________________________________________________________

In your continuity clinic, will the lead precepting attending physician instruct or observe the same pool of interns on a regular basis for the duration of the proposed project timeline (October 2020-January 2021)?

• Yes (1)

• No (2)

In general, does the continuity clinic currently screen for prenatal alcohol exposure (PAE)?

• Yes (1)

• No (2)

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Each participating continuity clinic project practice must identify a team consisting of:

A Resident Program Director who will serve as project champion.


A lead precepting attending physician who will attend the training-of-trainers in October 2020 (date TBD) at the AAP offices in Itasca, IL and be responsible for implementing the resident training curriculum in the continuity clinic setting.
 

Team Member 1 (Resident Program Director)

• Name: (1) ________________________________________________

• Credentials: (2) ________________________________________________

• Practice Role: (3) ________________________________________________

• Preferred Email: (4) ________________________________________________

• Phone: (5) ________________________________________________

Team Member 2 (lead precepting attending physician)

• Name: (1) ________________________________________________

• Credentials: (2) ________________________________________________

• Practice Role: (3) ________________________________________________

• Preferred Email: (4) ________________________________________________

• Phone: (5) ________________________________________________

Is the lead precepting attending physician from your continuity clinic available to attend the in-person training-of-trainers meeting in October 2020 (date TBD) at the AAP offices in Itasca, IL?

• Yes (1)

• No (2)

Do you anticipate that your practice will require local IRB approval to participate?

• Yes (1)

• No (2)

• Unsure (3)

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Please briefly describe the attributes or strengths that your continuity clinic would bring to Improving Continuity of Care for Children and Families Affected by Prenatal Alcohol Exposure.

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Does the practice/continuity clinic anticipate any major changes over the next 8 months, such as new leadership, a change in practice management structure, or a new EHR system?

• Yes (1)

• No (2)

Display This Question:

If Does the practice/continuity clinic anticipate any major changes over the next 6 months, such as... = Yes

If yes, please describe.

________________________________________________________________

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Thank you for your interest in the Improving Continuity of Care for Children and Families Affected by Prenatal Alcohol Exposure project. If you have questions about participation criteria (see below) or need additional information before completing your application, please contact Josh Benke at 630/626-6081 or [email protected], or Rachel Daskalov at 630/626-6063 or [email protected]. Thank you!


Participation Criteria:

• Represent a pediatric continuity clinic in the continental United States

• Have identified two team members for your practice: a lead precepting attending physician and a resident program director

• Commit to the Lead Precepting Attending Physician attending an in-person training-of-trainers meeting at the AAP offices in Itasca, IL in October 2020 (date TBD).

• Commit to implementing a resident training curriculum during the program timeline (November 1 – January 31, 2021).

• Participate in a brief call to verify eligibility (if requested).