Residency Learning Collaborative Application

Residency Learning Collaborative Application

Residency Learning Collaborative Application

Implementing Postgraduate Residency Training Programs for Family or Psychiatric Mental Health Nurse Practitioners

Application to participate in an intensive learning collaborative designed to take your practice from planning to implementation.

Post-Graduate Residency Learning Collaborative

Timeline and Overview:

•Applications are open from September 1st - October 13th

•Applicants must be available for an interview the week of October 16th-20th

•Final Decisions: October 23rd

•First LC Session: November 8th

Expectations:

-Each Health Center will identify a team and a “leader” or “coach”

-Team Leader/Coach and team members will meet weekly

-Team Leader/Coach will meet bi-weekly with CHC “Mentor”

-Team members will join each learning session (9 sessions total)

-Team members will utilize the online learning community regularly- sharing best practices, lessons learned, and tools/resources (teams will post something on the site at least once/week)

-Health center will implement a residency program within 2 years of LC participation

Completing the application

Please complete the application below and return to . If you have any questions or need clarification, please don’t hesitate to contact us!

INFORMATION ABOUT YOUR ORGANIZATION/PRACTICE

  1. Contact information

Provide the following information about your health center organization (i.e., grantee organization, parent organization for multi‐site health centers)

  1. FQHC Name:

Administrative Office Address (number/street/zip):

Health Center UDS #:

Total number of service site locations:

  1. Name of person completing application:

Name (first and last):

Title:

Email:

Phone:

  1. Primary contact for this application (if different than above)

Name (first and last):

Title:

Email:

Phone:

  1. Health Center Organization Leadership Team

Provide the following information about leadership staff at your health center

organization (i.e., grantee organization, parent organization for multi‐site health centers).

  1. Chief Executive Officer

Name (first and last):

Email:

  1. Chief Financial Officer

Name (first and last):

Email:

  1. Chief Medical Officer/Medical Director

Name (first and last):

Email:

  1. Demographics
  1. It is helpful for NCA to understand more about your FQHC. Please provide the information below.
  1. Number of Medical Providers:____Physicians____ Nurse Practitioners____Physician Assistants
  1. Number of Mental Health Providers:____ Physicians____ Nurse Practitioners____Clinical Psychologists____Licensed Clinical Social Workers____Others
  1. Number of Staff:____ Registered Nurses____Licensed Practical Nurses____Medical Assistants____Office staff (receptionists, etc.)
  1. Infrastructure
  1. Does your FQHC currently host any type of postgraduate residency or fellowship programs, for example, for family practice physician residents?

☐Yes

☐No

If Yes, what types of residency or fellowship programs do you host?

  1. Does your FQHC currently host pre-licensure health professions students, for example, medical, dental, social work or nursing (either RN or NP) students?

☐Yes

☐No

INFORMATION ABOUT YOUR EXPERIENCE WITH PRACTICE IMPROVEMENT

  1. Improvement work
  1. Describe your organization’s Quality Improvement (QI) infrastructure? What QI practices do you currently use?
  1. Provide an example of work you have done to change/improve your practice, regardless of its success. How did it go? What did you learn?

INFORMATION ABOUT YOUR MOTIVATION AND EXPECTATIONS FOR JOINING

THE LEARNING COLLOBORATIVE

  1. Which postgraduate residency program is your health center planning on starting?

☐Postgraduate Family Nurse Practitioner Residency or Fellowship Program

☐Postgraduate Psychiatric Mental Health Nurse Practitioner Residency or Fellowship Program

Please tell us why your team wants to participate in this Learning Collaborative and what you expect to accomplish during your participation. (250-300 words)Please type your response below:

ADDITIONAL QUESTIONS

  1. Is your organization able to dedicate one staff person to lead this project for up to 4 hours per week?

☐Yes

☐No

  1. Does your organization have access to a video-conferencing system?

☐Yes

☐No

  1. Have you received support from your senior leadership team (listed in Question 2) to move forward with this program?

☐Yes

☐No

  1. Does your organization plan to launch a residency program by September 2018?

☐Yes

☐No

☐No, but we will launch in 2019

CEO/President Name: ______

CEO/President Signature: ______

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