Clinical Advisory Panel Shared Savings Request Form

WHC Clinical Advisory Panel
Shared Savings Request Form

Welcome! This form is here to help organizations in Marion and Polk counties request funding for healthcare quality improvement activities. We're excited to support local initiatives and projects that (A) enhance health quality, (B) track progress towards better health outcomes, AND (C) are based on solid clinical or community health evidence and best practices. Our focus is on benefiting PacificSource Marion-Polk CCO members and the wider Marion-Polk community without adding additional costs to members. To be considered, please fill out this form completely. While we can't guarantee funding for all requests, we promise to consider each one thoughtfully. The WHC Clinical Advisory Committee will review submissions and provide an initial response within 45 days. Don't hesitate to reach out to Jamal Furqan at jfurqan@willamettehealthcouncil.org for any questions. Let's work together to make a positive impact on healthcare quality in our community!
Name and Organization

First and Last Name of RequesterOrganization Name
Contact Information

Email AddressPhone Number
Title of Request / Project
Duration of the Project

Start Date - the start date should reflect when the initiative is available to the population being served.End Date - the end date should reflect the final date the project will be sustained given the amount of funding requested.
Description of the Project
Describe the healthcare quality improvement activity, including who will participate, what each party will do with the funds, why they will be doing these activities, when they will begin, where activities will take place, and how activities will be conducted.
Focus Population (e.g., children 0-5, SMI/SPMI, IDD, etc.)
List the population(s) these quality improvement activities are prioritized for or focused on.
Funding Amount Requested
Input the total dollar amount requested for this project.
What types of activities will funds be used for? (select all that apply)

Other
Other Funding Sources and Amounts Utilized
Input the name of any other organization(s) funding this project. Include how much is being received from the source(s).
Will this initiative reduce health disparities in any of the following areas? (select all that apply)

Other
Describe how this initiative is intended to reduce health disparities.
Beneficiary Organizations
List the name of each organization that may receive funds directly from the Willamette Health Council as a result of this request, and the amount for each organization. If beneficiary organizations are not yet known, indicate "TBD" and the type of organization that may access the targeted funding (e.g., TBD - Health Promotion Trainer - $5000).
Expected Health Outcomes:
Describe the project's goal or expectations for improving health outcomes over the next 12 months and 24 months.
Describe in detail how this project will measure progress toward desired health outcomes and/or quality improvements.
Research, evidence, or accreditation basis:
Describe how this project is grounded in evidence-based care, widely accepted best clinical or community practice, or criteria issued by recognized professional health associations, accreditation bodies, government agencies or other nationally recognized health and social care organizations. Include a citation or link to the evidence/best practice.
Will this project impact any of the following CCO Quality Incentive Measure categories? (select all that apply)

Other
Should be Empty:

WHC Clinical Advisory Panel

Shared Savings Request Form