Signup Form | Integrated Care DC

Name*

First Last

Organization*

Department*

Role*

Email*

What term(s) best describes your provider type or organization? (Check all that apply)*

Other*

How would you like to participate in the Integrated Care DC Program? (Check all that apply)*

Join the listserv to receive emails with program-wide announcements and updates on resource and tool development.
Engage in virtual learning sessions and webinars to learn and share best practices with other providers and partners to be convened at least once per month.
Enroll in individual practice coaching. Participating provider teams will receive individualized support from an HMA coach and will be expected to participate in all group learning sessions over a minimum one-year period to work toward practice transformation goals.

NOTE: Enrollment for Phase 1 of the individual coaching sessions has ended. If you request individual practice coaching, you will be included on the list for evaluation for Phase 2, with more information coming in late summer 2021.

In order to drive practice transformation, multi-level representation and engagement are vital. What team members would be engaged in regular coaching sessions and technical assistance activities?*

Practice transformation manager lead
Clinical champion lead
Executive/leadership sponsor
IT or HIE lead

Practice Transformation Manager Name*

Practice Transformation Manager Title*

Clinical Champion Lead Name*

Clinical Champion Lead Title*

Executive/Leadership Sponsor Name*

Executive/Leadership Sponsor Title*

IT or HIE Lead Name*

IT or HIE Lead Title*

Is your team committed to participating in at least 12 months of technical assistance?*

Yes
No

What are your main goals for practice transformation to integrate physical and behavioral health care?*

Are you participating in any other technical assistance programs with DHCF such as HIE Connectivity?*

Yes
No

Which ones?*

Please include additional information and questions here.

Request for Technical Assistance:

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