SCHCHA 2023 H.O.M.E Award Nomination Form

SCHCHA H.O.M.E. Awards Nomination

Please fill out this form to nominate for an award.
THANK YOU for nominating a HERO from your agency! SCHCHA's Annual HOME Awards Ceremony is a special event and nominating someone for these awards is an opportunity to celebrate all the great things they do each and every day. GUIDELINES: - Be sure to fully answer each question (answers are part of the scoring criteria). - Do not use the name of the nominee or any identifying information (such as agency name) on your narrative or in your answers. - The only place the nominee's name and agency should appear is in the nominee first/last name fields at the top of this form. - The Association's PR Committee will receive the narrative portion of the nominations only so that the awards selection process will remain anonymous. - Simply choose the nomination category you are submitting from the drop down menu below and complete the section. - You may submit more than one entry. Contact sue@ahhcnc.org with any questions.
Select an award category for your nominee below, then click next until you find the appropriate application for that category. Please fill out the application in its entirety. The categories this year are: Professional of the Year, In-Home Aide of the Year, Physician of the Year, Family Caregiver of the Year, and NEW - SCHCHA Hospice Veteran Partnership Leadership Award. Be sure to fill out your contact information on the last page and then hit submit.

Make sure you are completing the appropriate form for your selected category. Click next to advance to each nomination form. You can complete more than one nomination category in your submission.
Professional of the Year

The nominee may be, but is not limited to: a registered nurse, licensed practical nurse, therapist, therapy assistant, nutritionist, pharmacist, clergy/chaplain, or social worker who has worked in home care and/or hospice for a minimum of three years. This award is intended to recognize a clinical professional in a direct care or mid-level management role.
- Nominee's Name
  
  First NameLast Name
- Nominee's Title and Credentials
- Nominee's Agency Name
- Nominee's Agency Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Number of Years Worked in Home Care and/or Hospice
- To submit a nomination form on an eligible individual, address the following items below and check off each scored item as complete. Forms not fully completed with all scoring criteria will be disqualified from nomination. Do not use the name of the nominee or any identifying information (such as agency name) in your answers. Please describe your nominee by responding individually to the following items:
- Describe the clinical care provided by this individual and/or how he/she serves as an advocate for patients. (25 pts.)
- Example
- Describe how this individual supports an interdisciplinary team approach. (25 pts.)
- Example
- Describe how this individual works to enhance the care that the agency as a whole provides. Provide examples of innovation, professional skills, and/or leadership qualities demonstrated by the nominee. (20 pts.)
- Example
- Describe efforts undertaken by this individual to enhance their professional growth, as well as the agency's growth. Include formal education, as well as workshops and other continuing education. (15 pts.)
- Example
- This individual deserves this distinguished award over all other nominees because...Use 100 words or less. (15 pts.)
- Example

Make sure you are completing the appropriate form for your selected category. Click next to advance to each nomination form. You can complete more than one nomination category in your submission.
In-Home Aide of the Year

This award is designed to recognize in-home aides in the home health and hospice industry. The nominee must have a minimum of one year experience working in home health and/or hospice.
- Nominee's Name
  
  First NameLast Name
- Nominee's Title and Credentials
- Nominee's Agency Name
- Nominee's Agency Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Number of Years Worked in Home Care and/or Hospice
- To submit a nomination form on an eligible individual, address the following items below and check off each scored item as complete. Forms not fully completed with all scoring criteria will be disqualified from nomination. Do not use the name of the nominee or any identifying information (such as agency name) in your answers. Please describe your nominee by responding individually to the following items:
- Describe the care provided by this individual and how he/she serves as an advocate for patients. (30 pts.)
- Example
- Describe how this individual supports other members of the interdisciplinary team. (25 pts.)
- Example
- Describe this individual's work habit and how he/she demonstrates excellence. (15 pts.)
- Example
- Describe efforts undertaken by this individual to enhance their professional growth. (10 pts.)
- Example
- This individual deserves this distinguished award over all other nominees because...Use 100 words or less. (15 pts.)
- Example

Make sure you are completing the appropriate form for your selected category. Click next to advance to each nomination form. You can complete more than one nomination category in your submission.
Physician of the Year

This award is presented annually to a physician who has demonstrated a philosophical commitment to assisting home health and/or hospice patients who wish to remain at home.
- Nominee's Name
  
  First NameLast Name
- Nominee's Title and Credentials
- Nominee's Agency Name
- Nominee's Agency Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Number of Years Worked in Home Care and/or Hospice
- To submit a nomination form on an eligible individual, address the following items below and check off each scored item as complete. Forms not fully completed with all scoring criteria will be disqualified from nomination. Do not use the name of the nominee or any identifying information (such as agency name) in your answers. Please describe your nominee by responding individually to the following items:
- Care-planning Process – actively participates in the care planning process, Understands Medicare/Medicaid coverage guidelines; timely paperwork completion/signature in accordance with regulatory requirements; Communicates problems with the plan of care instead of deleting care on orders (30 pts.)
- Example
- Care management and collaborative team approach – demonstrates excellence in care management to enhance patient care and quality of life. Courteous, respectful, listens and is available to staff during and after hours regarding patient care. (30 pts.)
- Example
- Outstanding consultative services – available for in-services, willing to share knowledge, discuss information on disease management, protocols, equipment, etc. Available to review policies, procedures on a consultative basis. (20 pts.)
- Example
- Other attributes – serves above and beyond the call of duty, patient advocate, makes home visits, participates in case conference (20 pts.)
- Example

Make sure you are completing the appropriate form for your selected category. Click next to advance to each nomination form. You can complete more than one nomination category in your submission.
Family Caregiver of the Year

This award is presented to a non-paid family caregiver who goes above and beyond the call of duty to promote patient/client well-being and enhanced quality of life including but not limited to factors such as comfort, safety and independence.
- Nominee's Name
  
  First NameLast Name
- Nominee's Title and Credentials
- Nominee's Agency Name
- Nominee's Agency Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Number of Years Caregiving in Home Care and/or Hospice
- To submit a nomination form on an eligible individual, address the following items below and check off each scored item as complete. Forms not fully completed with all scoring criteria will be disqualified from nomination. Do not use the name of the nominee or any identifying information (such as agency name) in your answers. Please describe your nominee by responding individually to the following items:
- Describe how the caregiver promotes the patient/client’s well-being, quality of life, and maximum independence. (30 pts.)
- Example
- Describe the caregiver’s ability to learn care instructions and to intervene appropriately. (20 pts.)
- Example
- Describe the adjustments made in caregiver’s personal life to provide care. (20 pts.)
- Example
- Other attributes (attitude, flexibility, dependability, willing to advocate) (20 pts.)
- Example
- This caregiver deserves this distinguished award over all other nominees because . . . Use 100 words or less. (10 pts.)
- Example

Make sure you are completing the appropriate form for your selected category. Click next to advance to each nomination form. You can complete more than one nomination category in your submission.
SCHCHA Hospice-Veteran Partnership Leadership Award

This award is designed to recognize a hospice employee who is a leader within their organization and their communities in efforts to better serve Veterans and their families. The nominee must have a minimum of one (1) year experience in a hospice setting. The nominating organization must be a member of SCHCHA and must be a participating organization in the NHPCO We Honor Veterans program.
- Nominee's Name
  
  First NameLast Name
- Nominee's Title and Credentials
- Nominee's Agency Name
- Nominee's Agency Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Number of Years Caregiving in Home Care and/or Hospice
- To submit a nomination form on an eligible individual, address the following items below and check off each scored item as complete. Forms not fully completed with all scoring criteria will be disqualified from nomination. Do not use the name of the nominee or any identifying information (such as agency name) in your answers. Please describe your nominee by responding individually to the following items:
- Recount examples of this individual’s actions that demonstrate their commitment to Veterans and their care. (350 words or less). (40 pts.)
- Example
- When others comment on this individual and their impact on Veterans, what are the most common descriptors used? (20 pts.)
- Example
- What do Veteran patients/clients, their families, and the hospice staff most value about this individual’s contributions to your agency (100 words or less) (20 pts.)
- Example
- Describe the value of this individual’s contributions and impact to your organization’s ability to provide care to Veterans and their families but also their impact in acknowledging and showing appreciation to Veterans. (100 words or less). (20 pts.)
- Example

- Your Name*
  
  First NameLast Name
- Your E-mail Address*
- Your Phone Number*
  
  Area CodePhone Number
- Your Agency Name*
- Your Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Should be Empty:

SCHCHA H.O.M.E. Awards Nomination

Professional of the Year

In-Home Aide of the Year

Physician of the Year

Family Caregiver of the Year

SCHCHA Hospice-Veteran Partnership Leadership Award