Coleman Fellows Palliative Medicine Training Program: Phase II

Interdisciplinary Training for Clinicians

FELLOW’SAPPLICATION

Please complete and return by November 1, 2014 to:

Aliza Baron, M.A., Project Coordinator

Name:______

Phone:Please provide at least two means for reaching you.

Home______

Work ______

Cell ______

Email:Primary______

Secondary______

Employment: Full-time

Part-time

Practice Type: Private Practice

Academic Medicine

Private Practice with faculty appointment

Military

Other: Please describe ______

Current Job Title: ______

Current Employer: ______

Specialty:Primary______

Secondary______

Tertiary______

Current Board Certifications/Advanced Degrees: ______

______

Please describe additional faculty development or professional training you have had.

______

______

Please describe other special skill sets (e.g. proficiency with statistical software).

______

______

How did you hear about this program?

Professional organization: ______

Nominated by Coleman Palliative Medicine Fellow: ______

Hospital leadership or supervisor: ______

Graduate or Professional Program: ______

Other: ______

Did your institution participate in Project PREP (Preventing Readmissions through Effective Partnerships)?

Yes Participant(s) name(s): ______

No

NARRATIVE

In order to better understand your experience and interest in palliative care and the institution’s vision and current state, please provide us with the following information. Please limit to 2 pgs., not including CV.

  • A description of your current or planned activities in palliative medicine, including:
  • your role as an educator, administrator and/or clinical leader
  • your ability to implement a new program
  • A description of a practice improvement projectaddressing a palliative care need at your institution
  • A description of the current state of palliative care at the health care system where you are employed
  • If your health care system has an active clinical program, please include:
  • the average number of initial and follow-up inpatient consults per month
  • average numbers of outpatients (ambulatory clinic, home-based) per month
  • # FTE devoted to the service (i.e. physicians, mid-level providers, social work, chaplaincy support)
  • rudimentary data on consult reason and patient diagnoses
  • If your health care system does not have an active clinical program, please provide plans and a timeline for its establishment.
  • Curriculum Vitae

LEADERSHIP ENGAGEMENT

The Coleman Palliative Medicine Training Program aims to build a strong partnership between participating health care organizations and the Program. Please provide the name(s) and contact information for hospital leader(s) who would participate in the Program and are submitting a letter of support.

Name: ______

Position: ______

Email and phone: ______

Name: ______

Position: ______

Email and phone: ______

LETTER OF SUPPORT

Please include a letter of commitment written and signed by an institutional or administrative leader(e.g., Department Chair, Nurse Administrator, Hospital or Hospice CEO). The letter should:

  1. Outline the health care system’s plans to increase access to palliative care
  2. Pledgeto:
  3. Support your involvement by protecting a portion of your time
  4. Attend an annual leadership summit
  5. Meet bi-annually with the institution’s team of Coleman Palliative Medicine Fellow(s) and Jr. Mentor(s) (as applicable)
  6. Participate in a reverse site visit with a program mentor
  7. Share data on health care expenditures

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