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Expression of Interest Form

An Opportunity to Improve the Quality of Children’s Health Care through Customized Technical Assistance

Please complete and send forms to CHIPRADemoEval@ahrq.hhs.gov no later than February 25, 2016. States will be notified of the decision by March 31, 2016. The selection team may call the principal contact to clarify aspects of this application before making a selection.

Name of principal contact:
Title: Agency:
Address:
Direct phone: Email:
  1. The knowledge transfer program will support projects designed to improve the quality of children’s health care. Please summarize your proposed project here, including its relevance to at least one of the five CHIPRA Quality Demonstration Grant Program categories shown in the Table, Potential Topic Areas for Knowledge Transfer. If the project spans multiple categories, please provide a strong rationale. You may propose a topic not listed as long as you clearly describe how the topic relates to an activity conducted within the Demonstration. Also, please describe your interest in learning more about the work being done by one or more CHIPRA Demonstration State; make sure to include the name the State and the aspect of their project that you are interested in. (Limit: 2 pages)
 
  1. The knowledge transfer program will support projects designed to improve the quality of children’s health care. Please summarize your proposed project here, including its relevance to at least one of the five CHIPRA Quality Demonstration Grant Program categories shown in the Table, Potential Topic Areas for Knowledge Transfer. If the project spans multiple categories, please provide a strong rationale. You may propose a topic not listed as long as you clearly describe how the topic relates to an activity conducted within the Demonstration. Also, please describe your interest in learning more about the work being done by one or more CHIPRA Demonstration State; make sure to include the name the State and the aspect of their project that you are interested in. (Limit: 2 pages)

 

 

  1. Please list the key individuals who are or will be involved in your project, including their titles and roles in the project. Please indicate which individuals you expect to directly participate in this knowledge transfer effort. Please note: project teams will participate in 1-hour conference calls at least every other month with a knowledge transfer team starting in the first month of the program. The knowledge transfer team will also arrange for at least two conference calls and attempt to arrange an in-person meeting with staff from Demonstration State projects over the course of the project.
 
  1. Please describe any other resources available for the project, including other staff or financial support.
 
  1. What goals or milestones do you hope to reach by the end of program (March 2017)? Please include any potential metrics you envision using that can help you assess whether you’ve attained your goals. (Limit: 1/2 page)
 
  1. Describe any barriers to success that you have experienced in prior work related to your proposed project so we can understand how to best target potential resources (Limit: 1 page).
 
  1. What kinds of technical assistance would be most helpful to your State’s child health care quality improvement efforts (e.g., enhancing use of data and data analytics, hiring and effectively using practice facilitators, using electronic health records to generate quality measures)?
 
  1. Please describe the partners (for example, medical practices, clinics, health plan representative, external quality review organization representative, consumer/patient representative, other) you have engaged in your quality improvement project and indicate their role in the project and  their level of engagement.
 
  1. Participants are expected to have the support of the State Medicaid director or CHIP director. Please provide the name and contact information for the senior State official supporting this application and attach a letter of support.
 
Title:
Address:
Direct phone:
Page last reviewed January 2016
Page originally created January 2016

 

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