Kindred Gentiva Hospice Foundation

2016 Fellowship Grant

Application Form

Complete this form only after you have read the Application Instructions.

ALL boxes must be completed and all information must be typed.

The AAHPM Fellowship Grant Advisory Group will consider only complete applications that are received

by 4:00 pm ET Thursday, July 28, 2016

CONTACT INFORMATION

1.  Institution Name:

2.  Program Director:

(include first, middle initial and last name)

E-mail:

Telephone Number(s): Daytime

3.  Program Coordinator or Primary Contact to be copied on correspondence:

(include first, middle initial and last name)

E-mail:

Telephone Number(s): Daytime

4.  Sponsoring Institutional Department:

5.  Mailing Address (Please fill in the address where you want to receive ALL materials)

PROGRAM DEMOGRAPHICS AND PERFORMANCE

6.  List ACGME or AOA program number:

List year initial accreditation received:

Current accreditation cycle length:

Total number of approved positions for 2017:

Date of most recent or scheduled site visit:

7.  Year of first graduated fellow:

8.  List all participating training sites/institutions in which trainees rotate and the percentage of time spent at each.

Training Sites / Institutions / Percentage of Time in Weeks
(total should equal 52 weeks including vacation allowed)
1. / weeks
2. / weeks
3. / weeks
4. / weeks
5. / weeks
6. / weeks
7. / weeks
8. / weeks

9.  Describe the patient population seen in your training program including an estimate of amount of time devoted to each population. (Limit responses to 200 words or less)

10.  List all current fellows and how they are funded.

Fellows Name / How the Fellow is Funded / Multiple Year
Commitment by Funder
1. / Select OneGME FundedOther Insitutional Funding (Hospice, VA, etc)PhilanthropySingle Year Grant / Select OneYesNo
2. / Select OneGME FundedOther Insitutionally Funded (Hospice, VA, etc)PhilanthropySingle Year Grant / Select OneYesNo
3. / Select OneGME FundedOther Insitutionally Funded (Hospice, VA, etc)PhilanthropySingle Year Grant / Select OneYesNo
4. / Select OneGME FundedOther Insitutionally Funded (Hospice, VA, etc)PhilanthropySingle Year Grant / Select OneYesNo
5. / Select OneGME FundedOther Insitutionally Funded (Hospice, VA, etc)PhilanthropySingle Year Grant / Select OneYesNo
6. / Select OneGME FundedOther Insitutionally Funded (Hospice, VA, etc)PhilanthropySingle Year Grant / Select OneYesNo
7. / Select OneGME FundedOther Insitutionally Funded (Hospice, VA, etc)PhilanthropySingle Year Grant / Select OneYesNo
8. / Select OneGME FundedOther Insitutionally Funded (Hospice, VA, etc)PhilanthropySingle Year Grant / Select OneYesNo
9. / Select OneGME FundedOther Insitutionally Funded (Hospice, VA, etc)PhilanthropySingle Year Grant / Select OneYesNo
10. / Select OneGME FundedOther Insitutionally Funded (Hospice, VA, etc)PhilanthropySingle Year Grant / Select OneYesNo

11.  Briefly describe your program’s current selection process for fellows or ideal candidate for your program. (Limit responses to 300 words or less)

12.  List all past HPM subspecialist fellows from the previous 5 years indicating the year they completed fellowship and their current institutional/organizational affiliations and current job titles.

Past Fellow’s Name and Year Completed Fellowship
Example: Jane Smith (2009) / Past Fellow’s Current Institution/Organization / Past Fellow’s Current Job Title
1.
2.
3.
4.
5.
6.
7.
8.

FACULTY

13.  List all physician faculty followed by non-physician team members that will be directly involved with fellowship training for the current (or future in known) academic year.

Physician Faculty Name & Credentials
Example: John Smith, MD FACP / Percentage Dedicated Time in HPM
(percent FTE) / Estimate of Direct Fellow Contact Time (in weeks) / Current HPM Certification
(select most recent certification) / Additional Certifications Held & Expiration Date
1. / Select OneABMSAOAABHPMHMDCB
2. / Select OneABMSAOAABHPM
3. / Select OneABMSAOAABHPM
4. / Select OneABMSAOAABHPM
5. / Select OneABMSAOAABHPM
6. / Select OneABMSAOAABHPM
7. / Select OneABMSAOAABHPM
8. / Select OneABMSAOAABHPM
9. / Select OneABMSAOAABHPM
10. / Select OneABMSAOAABHPM
Non-Physician Team Members Involved in Instruction
(Name / Credentials)
(e.g., social worker, APN) / Percentage Dedicated Time
in HPM
(percent FTE) / Estimate of Direct Fellow Contact Time (in weeks) / Role in Program / HPM Certification and Expiration Date
(Example: CHPN)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

14.  List all teaching staff who teach primarily in the hospice, nursing home, and/or long-term care setting (may also be listed above).

Name / Credentials / Role in Hospice, LTC, and/or Nursing Home Program / Current Certifications (select most recent certification) / Length of time serving in role
(list in months & years) / Estimate of Direct Fellow Contact Time
(in weeks)
1. / Select OneABHPMABMSACHPNAOACHPNCHPLNCHPNACHPCAHMDCBN/A
2. / Select OneABHPMABMSACHPNAOACHPNCHPLNCHPNACHPCAHMDCBN/A
3. / Select OneABHPMABMSACHPNAOACHPNCHPLNCHPNACHPCAHMDCBN/A
4. / Select OneABHPMABMSACHPNAOACHPNCHPLNCHPNACHPCAHMDCBN/A
5. / Select OneABHPMABMSACHPNAOACHPNCHPLNCHPNACHPCAHMDCBN/A
6. / Select OneABHPMABMSACHPNAOACHPNCHPLNCHPNACHPCAHMDCBN/A
7. / Select OneABHPMABMSACHPNAOACHPNCHPLNCHPNACHPCAHMDCBN/A
8. / Select OneABHPMABMSACHPNAOACHPNCHPLNCHPNACHPCAHMDCBN/A
9. / Select OneABHPMABMSACHPNAOACHPNCHPLNCHPNACHPCAHMDCBN/A
10. / Select OneABHPMABMSACHPNAOACHPNCHPLNCHPNACHPCAHMDCBN/A

15.  Briefly describe how the above teaching staff are evaluated by trainees with particular emphasis on teaching skills. (Limit response to 300 words or less)

16.  Describe three (3) strengths of your total teaching staff composition. (Limit responses to 300 words or less)

CURRICULUM AND EVALUATION
Limit responses to 300 words or less per question.

17.  Describe three (3) strongest/innovative aspects of your curriculum in regards to hospice training.

18.  Describe how your program assesses the competencies in hospice medicine of your fellows.

19.  What will grant funds enable your program to do in 2017-2018 that it would otherwise be unable to do without grant funding?

Note: If awarded you must agree (by way of attestation below) you will share any resources your program is able to develop with the extra funding provided by this grant. This allows other training programs to also benefit from the Kindred Gentiva Foundation grant and thereby demonstrate a much larger impact from the funding.

20.  Describe how your program demonstrates a commitment to and interest in caring for the hospice and home health population within your curriculum.

21.  Describe collaboration with other community institutions (e.g., hospices, home health agencies, long term care facilities, nursing homes) and their role in the training of fellows.

22.  Describe your institution’s support of training fellows in hospice and palliative care.

23.  Describe the evaluation process for the overall fellowship program and individual fellow performance within hospice and home setting (samples will be required as part of your application).

In addition to the completed application form, the following are required:

·  Biosketch, not to exceed 4 pages each, for your fellowship program director and 4-5 primary teaching team members of any discipline. Use the NIH Biographical Sketch samplewhen preparing biosketches

·  A letter of support from the Sponsoring Department Chair or institutional equivalent including the institutions commitment to provide the remaining funds for the salary and benefits and plans for program sustainability

·  A letter of support from the senior administrator (i.e., CEO, COO, Executive Director, etc.) of the hospice in which the fellows rotate including the organization’s commitment to training HPM fellows in the future

·  A concise, 3 pages, maximum, description of the fellowship curriculum including required rotations and didactics and evaluation system for fellows which includes sample block schedule

·  Institutional PGY salary and benefits schedule

·  Up to three (3) sample evaluation tools for fellows

All application materials should be emailed as word or pdf documents

by 4:00 pm ET Thursday, July 28, 2016 to .

PROGRAM DIRECTORS ATTESTATION

By entering your name in the bracketed field below, you as Program Director represent that the information provided in this application is accurate and complete. You also understand that if awarded, the funding of $43,500 must be applied to the salary and benefits of one fellow; the award will not cover indirect costs.

In addition, you also understand that if awarded, you will share any resources your program is able to develop with the extra funding provided by this grant. This allows other training programs to also benefit from the Kindred Gentiva Hospice Foundation grant and thereby demonstrate a much larger impact from the funding.


[] (Program Director must enter his/her name)

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