Practice Engagement (Peer-to-Peer Learning) Project

Thank you for your interest in the ACEs Aware project in Orange County. Please complete this Enrollment Survey after you have read and understood the project Letter of Invitation in its entirety.
 
Note: Each individual physician who would like to claim MOC Part 4 Credit must complete the Enrollment Survey for themselves. Providers who do not want to claim MOC credit can also enroll! The final deadline to enroll is November 11, 2020.
 
Questions or comments? Contact the project manager, Bianca Tomuta at bianca@aap-oc.org
 
Contact Information

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* 1. Participating Physician Contact Information

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* 2. Please provide the following information for the practice you are primarily associated with.

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* 3. Your American Board of Pediatrics (ABP) ID number will be needed to provide you Maintenance of Certification (MOC) credit once you have met the participation criteria. Please provide your ABP ID number:

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* 4. Are you seeking ABP MOC Part 2 credit for your participation in this project?

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* 5. Are you seeking American Board of Pediatrics (ABP) Maintenance of Certification (MOC) Part 4 credit for your participation in this project?

ACEs Training

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* 6. Have you completed the 2-hour ACEs Aware online training? (training.acesaware.org)

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* 7. Have you self-attested to completing the ACEs Aware training? (www.acesaware.org/screen/provider-training)

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* 8. Have all your practice staff received training on Adverse Childhood Experiences (ACEs)?

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* 9. What type of ACEs training has your staff received?

ACEs Screening

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* 10. Are you a Medi-cal provider?

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* 11. Are you currently screening your patients for ACEs using the Pediatric ACEs and Related Life-events Screener (PEARLS)?

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* 12. What percentage, if any, of your patient population is being screened using the PEARLS Screening?

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* 13. Does your practice have a follow-up plan for patients who screen positive for ACEs (defined as 4 or more positive replies on the PEARLS screener)?

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* 14. Please share any Orange County resources that are great for ACEs/Mental Health referrals.

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* 15. Please select all that apply regarding you and the OC Children's Screening Registry.

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* 16. What Electronic Medical/Health Records System is your practice utilizing?

Quality Improvement (QI)

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* 17. How familiar are YOU with quality improvement work using the Model for Improvement or the Plan-Do-Study-Act (PDSA) cycles?

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* 18. How familiar is your PRACTICE (office staff and colleagues) with quality improvement work using the Model for Improvement or the Plan-Do-Study-Act (PDSA) cycles?

Participation and Consent
My participation in this project is completely voluntary. I may refuse to participate or may stop participating at any time and for any reason without penalty. If I withdraw before meeting the requirements established for me to be eligible for ABP MOC Part 4 credit, I understand that I no longer qualify for that credit.

If I have any questions about my rights as a research subject or the protection of human subjects, I may contact Jamie McDonald, MPH, at the American Academy of Pediatrics-Orange County Chapter at (949) 752-2787, ext. 101 or at jamie@aap-oc.org.
I agree to participate in this ACEs Aware Practice Engagement (Peer-to-Peer Learning) Project under the conditions outlined in the Letter of Invitation. By providing an electric signature, I also agree not to share practice performance data, other than my own, outside of the ACEs Aware. 

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* 19. Do you consent to participate in the ACEs Aware Practice Engagement (Peer-to-Peer Learning) Project with the AAP-OC Chapter?

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* 20. Please select which day of the week is best for a monthly practice webinar to take place for 1 hour during lunch.

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* 21. Are you available to attend a 2-hour Kick-off Virtual Meeting on Wednesday, October 21, 2020 from 6:00-8:00PM? If so, you can register to attend here. (Registration will open in new window/tab)

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