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Innovation Award

Become a Pioneer by Diversifying Home-Based Care to Drive Revenue

The HCCI & Elea Institute Innovation Award program aims to help Illinois-based palliative care organizations implement Chronic Care Management (CCM) services to expand and diversify services to assist with driving revenue.

"*" indicates required fields

Practice Information

Legal/Registered Name of Practice*

Doing Business As (DBA) Practice Name (if different from above)

Practice Address*

Street Address Address Line 2 City State ZIP Code

Practice Type*

Hospice and Palliative Care

Palliative Care

Other (please specify)

If you selected "Other," please specify your Practice Type*

Primary Contact Information

Full Name*

First Name Last Name

Credentials*

Type "N/A" if you have no credentials to enter.

Job Title*

Your Email Address*

Enter Email Confirm Email

Direct Phone*

Job Role*

Chief Medical Officer/Medical Director

Chief Clinical Officer/Clinical Director

Nursing Executive/Director/Manager

Clinical Staff - Physician

Clinical Staff - Physician Assistant

Clinical Staff - Nurse Practitioner

Medical Assistant/ Nursing Assistant

Social Worker

Psychologist

Pharmacist

CEO/ President/ Executive Director

CFO

Other Executive Administrator (non-clinical)

Practice Manager/ Operations

Resident/ Fellow

Student/ Trainee

Professor/ Assistant or Associate Professor

Program Officer/ Director/ Manager

Other (please specify)

If you selected "Other," please specify additional Job Role(s)*

Are you authorized to sign agreements on behalf of your practice?*

Yes

No

Authorized Signer Information

If you are not authorized to make commitments or sign agreements on behalf of your organization, please provide the contact information of your organization's authorized signer. If you have not done so already, we highly encourage you to discuss and align with the authorized representative regarding your organization's implementation of Chronic Care Management and the HCCI & Elea Institute Innovation Award initiative.

Authorized Signer Name*

Authorized Signer First Name Authorized Signer Last Name

Authorized Signer Credentials*

Type "N/A" if you have no credentials to enter.

Authorized Signer Job Title*

Authorized Signer Email Address*

Enter Email Confirm Email

Authorized Signer Direct Phone*

In what year was your practice established?*

Please select the counties your practice serves from the following list.*

Boone

Cook

DeKalb

DuPage

Kane

Kendall

Lake

LeSalle

Lee

McHenry

Ogle

Will

Winnebago

Other (please specify)

If you selected "Other," please specify additional County or Counties*

What is your current active palliative patient census?*

What is the current active patient census for other programs (e.g., hospice or home health)?

Does your practice have a Certified Electronic Health Record (EHR) system currently in place?*

To read more about Certified Electronic Health Record (EHR) systems click here.

Yes

No

Will your practice have a Certified Electronic Health Record (EHR) system within 30 days of acceptance to the Innovation Award program?*

Yes

No

Does your practice provide 24/7 patient access to care, defined as offering on-call services including after-hours coverage, so the patient has access to clinical advice and guidance?*

Yes

No

How would you describe the Payer Mix at your practice? (select all that apply)*

Medicare Fee-for-Service (FFS)

ACO-Affiliated Practice

Medicaid

Value-Based Contracts (e.g., Alternative Payment Model Participation, PMPM Contracts)

Self-Pay, including concierge and private pay

Other (please specify)

If you selected "Other," please specify*

What is the total full-time equivalent (FTE) for each type of professional currently employed by your practice?

Enter up to two decimals, e.g., “1.25” and enter 0 if N/A.

Physician(s)

Please enter a number greater than or equal to 0.

Nurse Practitioner(s)

Please enter a number greater than or equal to 0.

Physician Assistant(s)

Please enter a number greater than or equal to 0.

RN(s)

Please enter a number greater than or equal to 0.

LPN(s)

Please enter a number greater than or equal to 0.

Medical Assistant(s): office-based only

Please enter a number greater than or equal to 0.

Medical Assistant(s): travel with provider

Please enter a number greater than or equal to 0.

Social Worker(s)

Please enter a number greater than or equal to 0.

Psychologist(s)

Please enter a number greater than or equal to 0.

Pharmacist(s)

Please enter a number greater than or equal to 0.

Non-clinical Front Office Staff (e.g., Receptionist)

Please enter a number greater than or equal to 0.

Practice Manager(s)

Please enter a number greater than or equal to 0.

Coder(s)/Biller(s)

Please enter a number greater than or equal to 0.

Other, Please Specify:

Please list the type of professional followed by the FTE. Enter up to two decimals, e.g., “1.25” and 0 if N/A. Click the plus sign to add additional Types of Professionals currently employed by your practice.

Type of Professional

FTE (Enter up to two decimals, e.g., “1.25” and 0 if N/A))

By submitting this application, I acknowledge and understand the Centers for Medicare & Medicaid Services (CMS) requirements for offering Chronic Care Management (CCM) services. I recognize that participation in the Innovation Award: Become a Pioneer by Diversifying Home-Based Care to Drive Revenue program will require my practice to adhere to these standards. If accepted into the program, I confirm that our practice will be prepared to implement and sustain CCM services in compliance with CMS guidelines to ensure the highest quality of care for our patients.*

I acknowledge

Electronic Signature*

Date*

MM slash DD slash YYYY

Comments

This field is for validation purposes and should be left unchanged.

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