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Request for Technical Assistance:

We invite you to join the Integrated Care TA program. We are offering several options for participation – to be eligible and evaluated for enrollment, please complete and submit the form below and an HMA team member will be in touch with you soon. Thank you for your interest!

Name*
First Last
Organization*
Department*
Role*
Email*
What term(s) best describes your provider type or organization? (Check all that apply)*
- Health Home provider (My Health GPS and/or My DC Health Home)
- Department of Behavioral Health provider
- Free Standing Mental Health provider
- Long-term Services and Supports provider
- Certified or Waivered Medications for Addiction Treatment (MAT) provider
- Specialty provider
- Federally Qualified Health Center
- Government Agency
- Community-Based Organization
- Other
Other*
How would you like to participate in the ICTA 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 TA 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.

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