PFAC Application Advisory Form

PFAC Application Advisory Form
Background  

Connie is an independent, not-for-profit, and neutral organization authorized by state statute (CGS 17b-59d and 17b-59g) to develop and operate a statewide health information exchange (HIE) in Connecticut. An HIE is a safe, confidential way of sharing health information electronically among doctors’ offices, hospitals, labs, radiology centers, and other health care organizations. This timely sharing of information allows health care providers and organizations to provide safer, more efficient, patient-centered care. All health care providers licensed in the state with an electronic health record are required to contribute to Connie. This allows the patient’s care team — and others as approved by the patient — to access patient records across health care settings.   

Connie recognizes that meaningful patient and family engagement is essential to delivering quality health care, and this extends to how organizations securely exchange information to inform a patient’s care team. Connie’s Patient and Family Advisory Committee (PFAC) demonstrates this commitment to patients and families — and facilitates ongoing conversation and learning. The PFAC works collaboratively with Connie leadership to ensure that the patient and family perspective is integrated into all aspects of the HIE. 
Vision Statement

The PFAC envisions a Connecticut health care system where interoperability and data sharing empower patients and families to make informed health decisions and equip health care providers with the records they need to provide the best care possible.
The PFAC has two primary goals:  

1. To serve as a forum for patients and families to share their diverse perspectives and feedback about how to ensure Connie effectively empowers patients through access to their health data 
2. To increase understanding, among Connecticut communities, of the role of health data exchange in improving care coordination, care delivery, and ultimately patient health outcomes 

PFAC members must be committed to: 
- Connie’s mission and the concept of health information sharing to improve health care quality, safety, and value  
- Be willing to share their perspectives and think beyond their own experiences 
- Act in “good faith” to maintain the privacy of information and perspectives shared within the committee 
- Consistently attend and actively participate in meetings — in person or virtually 
Connie will strive to select individuals who represent a balance of the following factors: 
- Historically marginalized or underserved in health care (e.g., people of color, people with disabilities, people who identify as LGBTQ+)
- Understanding of the health care system 
- Health care utilization and types of practices or systems for seeking care 
- Health-related needs, diseases, and types of conditions 
- Health insurance status 
- Caregiving experience  
- Expertise in patient outreach and education 
- Level of understanding of health information technology 
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age

15-1718-2425-3435-4445-6465 or over
Gender

WomanManTransgenderNon-binary/non-conformingPrefer not to respond
Phone Number
Please enter a valid phone number.
Email
example@example.com
Primary Language Spoken
Race/Ethnicity
Type of insurance you have had experience with (select all that apply):

UninsuredUnder insuredPrivate insurance (either through work or paid directly)MedicaidMedicare
Types of health care providers you have had experience with (select all that apply):

Providers in private practiceSpecialistsEmergency Room Providers (ER or ED)Providers within a large health system (e.g. Yale New Haven Healthcare or Hartford Healthcare)Federally qualified health center or free clinic providersBehavioral Health Providers (including mental health and/or substance abuse disorder treatment)Providers at an Urgent CareI don't visit the doctorOther (describe):
Please describe any health-related needs and/or disabilities you have experience with, either directly or through providing care to another person.
Did you personally experience these health issues, or provided care to another person with the issues described above? (select all that apply)

These were my health issuesI provided care to someone else
Please describe your relationship to the person you took care of (e.g. your child, parent, neighbor, client)
How comfortable are you with technology? (select the answer that best describes your comfort level and experience)

Experienced with technology, use a variety of cloud-based systems and health care applications regularlySomewhat experienced, have used apps like MyChart or Apple HealthLimited experience, but feel somewhat comfortable with technologyI don’t use technology to navigate healthcare
Why:

I am intimidated by technologyI don’t trust technology to keep my information secureOther
Please describe why you are interested in participating in Connie’s Patient and Family Advisory Committee.
Is there anything else you would like to add?
Should be Empty: