2018 Innovation Community Application: Implementing Pain Management Guidelines in Integrated Care Settings

Implementing Pain Management Guidelines and Supports in Health Center Settings

2018 Learning Community Application
CIHS' Pain Management Project Extension for Community Health Outcomes (ECHO) Initiative Learning Community will support health centers integrating behavioral health services in understanding the policies and best practices for chronic pain management.

Please continue below if you are interested in applying for this opportunity.
Organization Name:*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Contact Person Name - This is the person responsible for correspondence regarding this application and the person who will be contacted regarding acceptance or nonacceptance into the Learning Community.*

First NameLast Name
Contact Person Title*
Contact Person Email*
Phone Number*

Area CodePhone Number
Core Implementation Team Information
Each organization is required to identify an Innovation Community Core Implementation Team (CIT). The CIT will support the lead prescriber in implementing policy, planning, and workflow changes related to the stated learning community aims and goals. The CIT members are expected to engage in collective problem solving and to learn from the experience of other learning community member organizations.
CIT Lead Prescriber:*

NameEmail
Behavioral Health Clinician:*

NameEmail
Primary Care Clinician:*

NameEmail
Administrative Lead:*

NameEmail
Additional CIT Member (Optional):

Name/EmailRole
Additional CIT Member (Optional):

Name/EmailRole
Signed by CEO/Executive Director: *
By signing this application I confirm that I have allotted the necessary time for my team to attend 2 coaching calls, bi-monthly learning sessions, internal implementation meetings as needed and a final report and evaluation, as well as, other activities as needed to successfully participate in this Learning Community.
Date*

MonthDayYear

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American Indian or Alaska Native
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Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
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Implementing Pain Management Guidelines and Supports in Health Center Settings

Core Implementation Team Information

Organizational Summary

Organizational Self-Assessment