application form draft v5pme - oregon...application materials should include your resume or a brief...
TRANSCRIPT
Interest Form Workgroup Recruitment
SocialDeterminantsofHealthMeasurementWorkgroup:Screeningforsocialneeds
Oregon Health Authority
The purpose of this form is to assist the Oregon Health Authority (OHA) in evaluating the qualifications of applicants for the new Social Determinants of Health (SDOH) Measurement Workgroup: Screening for social needs. The SDOH Measurement Workgroup will make recommendations to the Coordinated Care Organization (CCO) Metrics and Scoring Committee regarding the development of an incentive measure for potential inclusion in the CCO Quality Incentive Program. The tentative dates of the first two meetings are April 1, 2020 from 9:30am‐12:30pm and May 6 from 9:30am‐12:30pm.
□ Applications must be submitted no later than 5pm on 31 January 2020.
□ Send this interest form and supplemental materials to:
□ Application materials should include your resume or a brief biographical sketch, and
this completed form.
You can get this document in another language, large print, braille or a format you prefer. Contact Sara Kleinschmit 971.304.9229, or 7‐1‐1. Or, email [email protected] for alternate format requests or call 7‐1‐1.
Overview
As part of the agreement with the Centers for Medicare & Medicaid Services (CMS) as required by the Special Terms and Conditions of Oregon’s Section 1115 demonstration, the Oregon Health Authority has established a Quality Incentive Program to provide financial incentives to reward CCO performance on a set of access, quality and outcome metrics (“incentive metrics”) selected annually by the Metrics & Scoring Committee. Through this program, CCOs achieve financial rewards if they meet specific performance benchmarks or improvement targets.
Given direction from Governor Brown and the Oregon Health Policy Board, as well as in the 1115 demonstration agreement with CMS, the CCO contracts beginning in 2020 include a focus on addressing the social determinants of health and health equity. Given its history of innovative measurement and this renewed focus, the Metrics & Scoring Committee has asked the Oregon Health Authority to work to create a measure related to the social determinants of health – specifically, to incentivize screening for individual health‐related social needs. The Committee could then choose to include this measure in the Quality Incentive Program. To this
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end, the Oregon Health Authority is establishing a public workgroup to develop this measure concept and make recommendations to the Metrics & Scoring Committee.
Commitment
The Oregon Health Authority is committed to ensuring that a diverse group of individuals are welcomed to the table, and that workgroup recommendations are truly representative of the populations served by the Oregon Health Plan. Individuals from all areas of the State are encouraged to apply (direct travel expenses are reimbursable). The workgroup seeks members who can:
Regularly attend monthly workgroup meetings from April – October 2020 (generally, the1st Wednesday of the month from 9:30am – 12:30pm at 421 SW Oak Street in Portland.Any exceptions to this meeting time for the months of June through October will beprovided upon appointment or sooner as available). Members are able to join remotelyon occasion via conference line and webinar if needed, though in‐person attendance ishighly encouraged.
Contribute policy, technical, and/or experiential expertise related to addressing thesocial determinants of health, particularly in relation to individual health‐related socialneeds. Of particular importance will be translating this experience into a meaningfulmetric for Oregon CCOs.
Spend approximately one additional hour each month to prep prior to the meetings(i.e., review of meeting materials).
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PERSONAL DATA
Preferred Title (e.g., Mr, Mrs, Ms, Dr, etc.)
First Name: Last Name:
Mailing Address:
City: State: Zip:
Organization:
Occupation or Job Title:
Home Phone: Business Phone:
E‐mail:
OHA wants to ensure that the SDOH Measurement Workgroup includes representation from a diverse group of areas, potentially including those below. Please indicate the subject areas in which you are currently working and/or could provide expertise and experience (select all that apply):
□ Provider (please indicate type)o Primary careo Behavioral healtho Oral healtho Traditional health workero Other (______________)
□ Health system organization (please provide detail)o Urban CCOo Rural CCOo Local public health authorityo FQHC staff/admino Private clinic staff/admino Tribal health clinico Behavioral health (not limited to providers)o Oral health (not limited to providers)
□ Social Determinants of Health and Equity organization (please provide detail)o Social serviceso Community‐based organizationo Housingo Other (_________________)
□ Children’s health care□ Oregon Health Plan consumer/consumer advocate (e.g., CCO Community Advisory
Council [CAC] member)□ General public (please provide detail): _______________________
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InterestinappointmentPleaselimityourresponsestoonepage.
Enteryourresponsesbeloworonaseparatesheet.
(1) Please describe why you are interested in serving on the workgroup, and the perspective and experience (lived and/or professional) you would bring. In particular, please note experience and/or understanding related to the impact of social needs and social determinants of health (e.g., housing, food insecurity) on health and health equity, and the roles the health care system can play in addressing individual social needs.
(2) Please describe any experience you may have with health care quality measure development.
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By submitting this form, I agree to participate in all meetings unless extenuating circumstances would preclude participation.
Signature Date
OHA is committed to ensuring diverse representation on all boards and committees. To help achieve this goal, we would appreciate you providing the following information. These questions are optional and your answers are confidential. Under state and federal law, this information may not be used to discriminate against you.
Gender Identity: � Decline to answer
� LGBTQ (check if applicable) � Decline to answer
Please see the next page regarding race/ethnicity demographic information.
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Race, Ethnicity, Language, and Disability (REALD)
These questions are optional and your answers are confidential. We would like you to tell us your race, ethnicity, language and disability background so that we can find and address health and service differences.
� Yes � No � Don't know/Unknown � Don't want to answer/Decline
If yes, which format?
1. Do you need written materials in an alternate format (Braille, large print, audio recordings, etc.)?
2. How do you identify your race, ethnicity, tribal affiliation, country of origin, or ancestry?
American Indian or Alaska Native
� American Indian � Alaska Native � Canadian Inuit, Metis,
or First Nation � Indigenous Mexican,
Central American, or South American
Hispanic or Latino/a � Hispanic or Latino/a
Central American � Hispanic or Latino/a
Mexican � Hispanic or Latino/a
South American � Other Hispanic
or Latino/a
Asian � Asian Indian � Chinese � Filipino/a � Hmong � Japanese � Korean � Laotian � South Asian � Vietnamese � Other Asian
Native Hawaiian or Pacific Islander
� Guamanian or Chamorro � Micronesian* � Native Hawaiian � Samoan � Tongan* � Other Pacific Islander
Black or African American � African American � African (Black) � Caribbean (Black) � Other Black
Middle Eastern/Northern African � Northern African � Middle Eastern
White � Eastern European � Slavic � Western European � Other White
Other Categories � Other (please list)
_______________ � Don't know/Unknown � Don't want to answer/Decline
4. If you selected more than one racial or ethnic identity above, please CHOOSE the ONE that best
Race and Ethnicity
3. Which of the following describes your racial or ethnic identity? Please check ALL that apply.
represents your racial or ethnic identity:If you have more than one primary racial or ethnic identity please check here:
You can get this document in other languages, large print, braille, or a format you prefer. We accept all relay calls or you can dial 711. Contact Sara Kleinschmit:Phone: 971-304-9229Email: [email protected]
OHA 0074 (9/18)Continued on next page 6 of 7
Language5. In what language do you want us to:
Speak with youWrite to you
7. Do you need an interpreter for us tocommunicate with you?
� Yes � No
6. Do you need a sign language interpreter forus to communicate with you?
� Yes � No
If yes, which type do you need us to communicate with you? (ASL, PSE, tactile interpreting, etc.)
8. How well do you speak English?
� Very Well � Well � Not Well
� Not at all � Don't know/Unknown � Don't want to answer/Decline
� Don't know/Unknown � Don't want to answer/Decline
Disability
9. Are you deaf or do you have seriousdifficulty hearing?
� Yes � No
If yes, at what age did this condition begin? ____
10. Are you blind or do you have seriousdifficulty seeing, even when wearing glasses?
� Yes � No
If yes, at what age did this condition begin? ____
11. Does a physical, mental, or emotionalcondition limit your activities in any way?
� Yes � No
If yes, at what age did this condition begin? ____
12. What is your age today? __________
13. Do you have serious difficulty walking orclimbing stairs?
� Yes � No
If yes, at what age did this condition begin? ____
� Don't know/Unknown � Don't want to answer/Decline
14. Do you have difficulty dressing or bathing? � Yes � No
If yes, at what age did this condition begin? ____
15. Because of a physical, mental, or emotionalcondition, do you have serious difficulty:
a. Concentrating, remembering ormaking decisions? � Yes � No
If yes, at what age did this condition begin? ____
b. Doing errands alone such as visiting adoctor's office or shopping?
� Yes � No
If yes, at what age did this condition begin? ____
� Don't know/Unknown � Don't want to answer/Decline
� Don't know/Unknown � Don't want to answer/Decline
� Don't know/Unknown � Don't want to answer/Decline
Your answers will help us find health and service differences among people with and without functional difficulties. Your answers are confidential.
Please stop now if the person is under age 5
Please stop now if you/the person is under age 15
� Don't know/Unknown � Don't want to answer/Decline
� Don't know/Unknown � Don't want to answer/Decline
� Don't know/Unknown � Don't want to answer/Decline
� Don't know/Unknown � Don't want to answer/Decline
OHA 0074 (9/18)
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