FCAAP PCMH Transformation Project

Intake Assessment

Thank you for your interest in the PCMH project sponsored by FCAAP and Sunshine Health. Please complete this assessment to help us learn about your practice. This assessment is not a guaranteed spot into the PCMH project.
Name*

First NameLast Name
Title [e.g., Dr, ARNP, PA-C, RN, Administrator]*
Practice Name*
Date Opened*
Number of sites*
Estimated number of staff members*
Estimated number of providers*
Email*
example@example.com
Best Contact Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What EMR do you have?*
What EMR challenges do you have?*
Do you have any of the following software products?*

CHADISPhreesiaTelehealth platformPatient portalPatient recallers/reminders
Percentage of Medicaid/ managed Medicaid patients:*
Are you currently receiving MPIP incentives with Florida Managed Medicaid Plans? If so, please list the plans giving incentives. *
This project is co- sponsored by Sunshine Health. Do you accept Sunshine Health?*

YesNo
Largest commercial payer:*
This project is co-sponsored by FCAAP. Are you a current Florida Chapter of the American Academy of Pediatrics member [FCAAP] ?*

YesNo
If you are not a member of FCAAP, would you be willing to become a member. The cost is $200 a year.*

YesNo
Are you currently certified as a Patient-Centered Medical Home with any of the following organizations?*

NCQAAAAHCTJCURACNone
What are your office hours? *
Do you have evening or weekend hours?*
If you do not have extended hours, would you be willing to extend at least one hour a week outside of regular business hours?*

YesNo
Are you a "NO PAPER" office?*

YesNo
Are you a "hybrid" type of office. Some of your work is within the EMR and some is on paper charts, spreadsheets, or sticky notes?*

YesNo
How is your billing handled?*

In-houseExternal billing companyPartnered with EMR/ Practice Management System
What types of chronic conditions do you see in your patient population?*

AsthmaObesityPremature InfantsADHDDepression/AnxietySocial/mood disordersDiabetesDevelopmental DelaysAutismCerebral Palsy
What services do you offer in-house?*

Behavioral health managementFluoride varnish applicationCOVID testingCOVID vaccineAsthma care [breathing treatments, spirometry, medication management]Hearing/Vision assessments
Do you employ/co-locate with any of the following?*

NutrtionistLactation SpecialistLCSW/CounselorPsychiatryNone
Do you agree to fully participate in the PCMH program? Implementing any necessary workflows.*

YesNo
Should be Empty:

Intake Assessment