House Call Advisory Network Application - Home Centered Care Institute

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Section 1: Personal Information

Full Name(Required)

First Last

Your Email Address(Required)

Enter Email Confirm Email

Credentials(Required)

Phone Number(Required)

Professional Title

Organization/Employer

Location(Required)

City State

Preferred Method of Contact(Required)

Section 2: Professional Background

Education and Training(Required)

(Include degrees, certifications, and relevant training)

Degree

(Required)

Institution

Certifications and Relevant Training

Years of Experience in Home-Based Care(Required)

In which of the following types of home-based care do you have experience and expertise?(Required)

(Check all that apply)

Home-Based Primary Care

Home-Based Palliative Care

Home-Based Urgent Care

Hospice

Hospital at Home

Other (Specify):

Experience and Expertise More Info

Current Scope of Work(Required)

(Briefly describe your current role, responsibilities, and the populations you serve.)

Section 3: Subject Matter Expertise

Areas of Expertise(Required)

(Check all that apply.)

Geriatric Syndromes

Mental Health

Wound Care

In-Home Procedures

Palliative Care

Hospice

Credentialing

Chronic Care Management

Transitional Care Management

Advanced Primary Care Management

Advance Care Planning

Hospital at Home

Telehealth / Remote Patient Monitoring

Care Coordination

Patient, Caregiver, and Family Engagement

Value-Based Care Models

ACOs

Healthcare Policy/Advocacy

Health IT and Electronic Health Records

Billing and Coding

Practice Operations (e.g., geographic scheduling, inventory management, policies/procedures, transportation)

Provider Safety

Technology Integration for HBPC

Human Resources Recruiting/Retention

Human Resources Team Building

Human Resources Workforce Development

Human Resources DEI

Healthcare Law/Legal Compliance

Marketing and Practice Growth

Rural Medicine

Community Health Specialist/Community Health Service Provider

Other Clinical Care (specify):

Specialty Care (specify):

Other (please specify):

Specialty Care More Info

Other Clinical Care More Info

Other Area of Expertise

Experience with Specific Patient Populations

(E.g., geriatric, palliative, high-risk, underserved communities, rural medicine)

Key Achievements in Home-Based Care

(E.g., implemented a new model of care, improved patient outcomes, led a research project)

Section 4: Engagement Opportunities

Areas of Interest(Required)

(Check all that apply)

Select All

Speaking engagements (e.g., webinars, conferences)

Peer mentorship

1-on-1 Consultation on area(s) of subject matter expertise

Writing thought leadership articles/blogs

Media interviews

Content Development/Resource Development (Educational Products)

Availability(Required)

(Approximate hours per month you can dedicate to the HCCI House Call Advisor Network)

1-5 Hours/Month

5-10 Hours/Month

10+ Hours/Month

Section 5: Additional Information

Why are you interested in joining the HCCI House Call Advisor Network?(Required)

(Required)

I confirm that I have no financial, professional, or personal interests that could be perceived as a conflict of interest as a member of the HCCI House Call Advisor Network. If any potential conflicts arise, I will disclose them promptly.

Upload Resume/CV(Required)

Drop files here or

Accepted file types: pdf, doc, png, jpg, jpeg, docx, xls, xlsx, ppt, pptx, Max. file size: 50 MB, Max. files: 1.

Attach Supporting Documents (Optional)

Publications or presentations related to home-based primary care, and Professional Recommendations