Maryland Community Integrated Medical Home -- Stakeholder Application

Maryland State Innovation Models (SIM): Application for Stakeholder Engagement Process
Name*
Degree(s)
E-mail Address*
Phone Number*
Organization*
Title*
Organization Location*
HospitalPrimary care practiceSpecialty medical practiceLong-term careSafety net providerLocal health departmentPharmacyBehavioral healthDentistryCommunity health organizationNon-profit organizationPatient/consumerResearch/academicHealth plan/insurance carrierEmployer group/businessOther (specify below)
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Payer/ProviderLocal Health Improvement Coalition
Note: You MUST be able to attend the following meetings of the stakeholder group for which you are applying, as well as the all stakeholder summit:

Payer/Provider Group:

May 9, 12:30 - 5pm

June 5, 12:30 - 5pm

July 9, 12:30 - 5pm

Local Health Improvement Coalition (LHIC) Group:

May 17, 8:30am - 1pm

June 18, 12:30 to 5pm

July 16, 12:30 to 5pm

Stakeholder Summit

July 31, 8:30am - 5pm
Please upload your resume:*

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If you selected the Payer/Provider Group---Please rate your experience/knowledge in the following areas:

Experience working with payers and providers and general ability to represent a broad swath of payers or providers

	1	2	3	4	5

1 is None, 5 is Very Significant

Describe

Knowledge of and experience working with innovative payment and delivery models, such as the patient-centered medical home (PCMH), accountable care organizations (ACOs), global budgets, and bundled payment

	1	2	3	4	5

1 is None, 5 is Very Significant

Describe

Familiarity and experience with health data and performance measurement, both claims-based and clinical quality metrics

	1	2	3	4	5

1 is None, 5 is Very Significant

Describe
YesNo
Describe
Letter of endorsement from association, trade group, parent company, or related entity:

Upload a File

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Additional letter of endorsement from association, trade group, parent company, or related entity:

Upload a File

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If you selected the Local Health Improvement Coalition Group---Please rate your experience/knowledge in the following areas:

Experience in working with population health data in a variety of formats (for example, tables, diagrams, and “hot spotting” maps) for planning local action to address health improvement goals

	1	2	3	4	5

1 is None, 5 is Very Significant

Describe

Experience with the integration of public health and community-based resources with the health care delivery system

	1	2	3	4	5

1 is None, 5 is Very Significant

Describe

Experience in health care workforce planning and development, including education and training, to meet population health needs

	1	2	3	4	5

1 is None, 5 is Very Significant

Describe
Letter of Endorsement from Local Health Improvement Coalition in your area.

Upload a File

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Comments/Notes
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Maryland State Innovation Models (SIM): Application for Stakeholder Engagement Process

If you selected the Payer/Provider Group---Please rate your experience/knowledge in the following areas:

If you selected the Local Health Improvement Coalition Group---Please rate your experience/knowledge in the following areas: