2021 Regional complex care convening application
Host organization information:
Name of host organization
*
Primary sector of organization
*
Behavioral Health
Consumer Engagement
Criminal Justice
Education
Employment
Environmentalism
Faith/Religious
Government
Hospital/Healthcare
Insurance/Payer
Policy/Advocacy
Social Services
Other
State
*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Region of focus
*
e.g. city, county, multi-state region
Description of your organization (100 word max)
*
0/100
Brief summary of the complex care barrier. Past topics are listed on our website: nationalcomplex.care/regional-convenings (100 word max)
*
0/100
Description of complex care barrier, including: How the barrier is multi-sector in natureHow it affects people with complex health and social needsHow addressing the barrier would contribute to the development of a complex care ecosystem in your community (500 word max)
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0/500
Describe how the National Center can help your community address the issue described above (300 word max)
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E.g. subject matter expertise, stakeholder convening, access to national networks
0/300
Preliminary convening agenda & description (500 word max)
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0/500
Diversity of experiences and identities is necessary for a strong field of complex care, so priority will be given to proposals that represent this value in the diversity of the project team and convening attendees. Please describe how your convening will include participants with diverse identities and backgrounds (ethnicity & race, gender & gender identity, geography, lived experience, type of professional experience, and type of organization). (200 word max)
0/200
Inherent to the practice of complex care is acknowledging and addressing the systematic differences in the health status and available health resources for different population groups. Describe how your project will improve health equity in your community. (200 word max)
0/200
As a host organization, I guarantee that my organization will:
*
Provide resources to support the planning of an event, including the ability to secure the appropriate venue (if needed) and facilitate on-the-ground logistics;
Seek advising from consumers and/or social sector organizations on the development of the convening;
Participate in at least one planning call per month with the National Center;
Develop one public-facing product about the project.
Optional: Letter of support from a partner organization describing previous cross-sector collaboration
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Point of contact information:
First name
*
Last name
*
Title
*
Organization
*
Email
*
example@example.com
Phone number
*
-
Area code
Phone number
Twitter handle of organization (if available)
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