Universal EOI
Expression of Interest (EOI) for Participation
The Center for Medicaid and CHIP Services (CMCS) Quality Improvement (QI) program provides state Medicaid and CHIP agencies and their QI partners with the information and expert support to improve care and health outcomes.
CMCS-sponsored affinity groups allow state Medicaid and CHIP agencies and their partners to work and learn alongside other state teams. QI advisors, subject matter experts, and state team peers provide guidance and support through group workshops and one-on-one meetings, including QI tools to identify, implement, and test data-driven interventions to achieve improvement.
Please use this form to indicate your interest in the affinity group. This form should be filled out by the project lead or project manager and completed by [date].
Project Lead Name*
[First Name]
[Last Name]
Email*
[Free text]
State*
[Drop down menu of 50 states, DC, territories]
Position in your organization*
Affiliation*
[Drop down menu of State Medicaid or CHIP Agency, State Medicaid or CHIP Managed Care Plan, Other State Agency, Other]
Which Affinity Group would you like to participate in?
[Free text]
Have you decided on a specific quality improvement project? *
[Drop down menu of Yes, No]
If yes, briefly describe your proposed intervention(s).
[Free text, character limit of 250 words]
If yes, has your proposed intervention(s) worked in some other context, for example in another Medicaid or CHIP program, or another state?
[Drop down menu Yes, No, Unknown]
What quality measure(s) will you use to track your improvement? *
[Free text]
What is your baseline performance for this quality measure(s)? *
[Free text]
Please list any state team members and/or QI partners you have identified so far.
[Free text]
Who in your organization’s executive leadership supports this improvement project? *
[Free text Name and title of sponsor]
Please share any other information relevant to your Expression of Interest in this Affinity Group
[Free text]
PRA Disclosure Statement The purpose of this PRA package is to collect information that is voluntarily submitted by state Medicaid and CHIP agencies regarding participation in a CMCS Quality Improvement Affinity Group. Under the Privacy Act of 1974, any personally identifying information obtained will be kept private to the extent of the law.
Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 #82). The time required to complete this information collection is estimated to average three hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
*Required answers
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Expression of Interest (EOI) for Participation |
| Author | Doris Lotz |
| File Modified | 0000-00-00 |
| File Created | 2024-10-08 |