2017 Dental Medical Integration for Diabetes Pilot Evaluation

Final Evaluation of the Dental Medical Integration for Diabetes Pilot

Please complete the following pilot evaluation. Results will be tabulated and converted to a heat map grid that will be used to:
• Reflect results of individual pilots
• Affirm agreement around key findings
• Document findings in a succinct and shareable way.

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* 1. (Required) Contact Info

Name *

Organization

Email Address

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* 2. (Required) Using a scale from 0 to 10, where 0 is complete disagreement (or not present) and 10 is the strongest agreement, what number would you use to rate this expansion proposal?

	0 Disagree	1	2	3	4	5 Agree	6	7	8	9	10 Strongly Agree
Outcome Achievement: Pilot was successful in delivering planned activities	Outcome Achievement: Pilot was successful in delivering planned activities 0 Disagree	Outcome Achievement: Pilot was successful in delivering planned activities 1	Outcome Achievement: Pilot was successful in delivering planned activities 2	Outcome Achievement: Pilot was successful in delivering planned activities 3	Outcome Achievement: Pilot was successful in delivering planned activities 4	Outcome Achievement: Pilot was successful in delivering planned activities 5 Agree	Outcome Achievement: Pilot was successful in delivering planned activities 6	Outcome Achievement: Pilot was successful in delivering planned activities 7	Outcome Achievement: Pilot was successful in delivering planned activities 8	Outcome Achievement: Pilot was successful in delivering planned activities 9	Outcome Achievement: Pilot was successful in delivering planned activities 10 Strongly Agree
Measurement Sufficiency: Outcome measures are sufficient indicators of pilot achievement and success.	Measurement Sufficiency: Outcome measures are sufficient indicators of pilot achievement and success. 0 Disagree	Measurement Sufficiency: Outcome measures are sufficient indicators of pilot achievement and success. 1	Measurement Sufficiency: Outcome measures are sufficient indicators of pilot achievement and success. 2	Measurement Sufficiency: Outcome measures are sufficient indicators of pilot achievement and success. 3	Measurement Sufficiency: Outcome measures are sufficient indicators of pilot achievement and success. 4	Measurement Sufficiency: Outcome measures are sufficient indicators of pilot achievement and success. 5 Agree	Measurement Sufficiency: Outcome measures are sufficient indicators of pilot achievement and success. 6	Measurement Sufficiency: Outcome measures are sufficient indicators of pilot achievement and success. 7	Measurement Sufficiency: Outcome measures are sufficient indicators of pilot achievement and success. 8	Measurement Sufficiency: Outcome measures are sufficient indicators of pilot achievement and success. 9	Measurement Sufficiency: Outcome measures are sufficient indicators of pilot achievement and success. 10 Strongly Agree
Improved Health Outcomes: The Pilot activities resulted in improvements in healthcare including the perception of healthcare.	Improved Health Outcomes: The Pilot activities resulted in improvements in healthcare including the perception of healthcare. 0 Disagree	Improved Health Outcomes: The Pilot activities resulted in improvements in healthcare including the perception of healthcare. 1	Improved Health Outcomes: The Pilot activities resulted in improvements in healthcare including the perception of healthcare. 2	Improved Health Outcomes: The Pilot activities resulted in improvements in healthcare including the perception of healthcare. 3	Improved Health Outcomes: The Pilot activities resulted in improvements in healthcare including the perception of healthcare. 4	Improved Health Outcomes: The Pilot activities resulted in improvements in healthcare including the perception of healthcare. 5 Agree	Improved Health Outcomes: The Pilot activities resulted in improvements in healthcare including the perception of healthcare. 6	Improved Health Outcomes: The Pilot activities resulted in improvements in healthcare including the perception of healthcare. 7	Improved Health Outcomes: The Pilot activities resulted in improvements in healthcare including the perception of healthcare. 8	Improved Health Outcomes: The Pilot activities resulted in improvements in healthcare including the perception of healthcare. 9	Improved Health Outcomes: The Pilot activities resulted in improvements in healthcare including the perception of healthcare. 10 Strongly Agree
Reduced Costs: The Pilot activities reduced healthcare costs.	Reduced Costs: The Pilot activities reduced healthcare costs. 0 Disagree	Reduced Costs: The Pilot activities reduced healthcare costs. 1	Reduced Costs: The Pilot activities reduced healthcare costs. 2	Reduced Costs: The Pilot activities reduced healthcare costs. 3	Reduced Costs: The Pilot activities reduced healthcare costs. 4	Reduced Costs: The Pilot activities reduced healthcare costs. 5 Agree	Reduced Costs: The Pilot activities reduced healthcare costs. 6	Reduced Costs: The Pilot activities reduced healthcare costs. 7	Reduced Costs: The Pilot activities reduced healthcare costs. 8	Reduced Costs: The Pilot activities reduced healthcare costs. 9	Reduced Costs: The Pilot activities reduced healthcare costs. 10 Strongly Agree
Improved Access: Pilot activities resulted in improved access to health care.	Improved Access: Pilot activities resulted in improved access to health care. 0 Disagree	Improved Access: Pilot activities resulted in improved access to health care. 1	Improved Access: Pilot activities resulted in improved access to health care. 2	Improved Access: Pilot activities resulted in improved access to health care. 3	Improved Access: Pilot activities resulted in improved access to health care. 4	Improved Access: Pilot activities resulted in improved access to health care. 5 Agree	Improved Access: Pilot activities resulted in improved access to health care. 6	Improved Access: Pilot activities resulted in improved access to health care. 7	Improved Access: Pilot activities resulted in improved access to health care. 8	Improved Access: Pilot activities resulted in improved access to health care. 9	Improved Access: Pilot activities resulted in improved access to health care. 10 Strongly Agree
State Metrics: The Pilot activities resulted in or will result in improved IHN-CCO metrics.	State Metrics: The Pilot activities resulted in or will result in improved IHN-CCO metrics. 0 Disagree	State Metrics: The Pilot activities resulted in or will result in improved IHN-CCO metrics. 1	State Metrics: The Pilot activities resulted in or will result in improved IHN-CCO metrics. 2	State Metrics: The Pilot activities resulted in or will result in improved IHN-CCO metrics. 3	State Metrics: The Pilot activities resulted in or will result in improved IHN-CCO metrics. 4	State Metrics: The Pilot activities resulted in or will result in improved IHN-CCO metrics. 5 Agree	State Metrics: The Pilot activities resulted in or will result in improved IHN-CCO metrics. 6	State Metrics: The Pilot activities resulted in or will result in improved IHN-CCO metrics. 7	State Metrics: The Pilot activities resulted in or will result in improved IHN-CCO metrics. 8	State Metrics: The Pilot activities resulted in or will result in improved IHN-CCO metrics. 9	State Metrics: The Pilot activities resulted in or will result in improved IHN-CCO metrics. 10 Strongly Agree
Transformational: The Pilot activities created a newly imagined form, function, or structure of health care delivery that contribute to a sustainable, healthy community.	Transformational: The Pilot activities created a newly imagined form, function, or structure of health care delivery that contribute to a sustainable, healthy community. 0 Disagree	Transformational: The Pilot activities created a newly imagined form, function, or structure of health care delivery that contribute to a sustainable, healthy community. 1	Transformational: The Pilot activities created a newly imagined form, function, or structure of health care delivery that contribute to a sustainable, healthy community. 2	Transformational: The Pilot activities created a newly imagined form, function, or structure of health care delivery that contribute to a sustainable, healthy community. 3	Transformational: The Pilot activities created a newly imagined form, function, or structure of health care delivery that contribute to a sustainable, healthy community. 4	Transformational: The Pilot activities created a newly imagined form, function, or structure of health care delivery that contribute to a sustainable, healthy community. 5 Agree	Transformational: The Pilot activities created a newly imagined form, function, or structure of health care delivery that contribute to a sustainable, healthy community. 6	Transformational: The Pilot activities created a newly imagined form, function, or structure of health care delivery that contribute to a sustainable, healthy community. 7	Transformational: The Pilot activities created a newly imagined form, function, or structure of health care delivery that contribute to a sustainable, healthy community. 8	Transformational: The Pilot activities created a newly imagined form, function, or structure of health care delivery that contribute to a sustainable, healthy community. 9	Transformational: The Pilot activities created a newly imagined form, function, or structure of health care delivery that contribute to a sustainable, healthy community. 10 Strongly Agree
Barriers: Barriers were identified and sufficiently explained.	Barriers: Barriers were identified and sufficiently explained. 0 Disagree	Barriers: Barriers were identified and sufficiently explained. 1	Barriers: Barriers were identified and sufficiently explained. 2	Barriers: Barriers were identified and sufficiently explained. 3	Barriers: Barriers were identified and sufficiently explained. 4	Barriers: Barriers were identified and sufficiently explained. 5 Agree	Barriers: Barriers were identified and sufficiently explained. 6	Barriers: Barriers were identified and sufficiently explained. 7	Barriers: Barriers were identified and sufficiently explained. 8	Barriers: Barriers were identified and sufficiently explained. 9	Barriers: Barriers were identified and sufficiently explained. 10 Strongly Agree
Scalable: The Pilot is scalable.	Scalable: The Pilot is scalable. 0 Disagree	Scalable: The Pilot is scalable. 1	Scalable: The Pilot is scalable. 2	Scalable: The Pilot is scalable. 3	Scalable: The Pilot is scalable. 4	Scalable: The Pilot is scalable. 5 Agree	Scalable: The Pilot is scalable. 6	Scalable: The Pilot is scalable. 7	Scalable: The Pilot is scalable. 8	Scalable: The Pilot is scalable. 9	Scalable: The Pilot is scalable. 10 Strongly Agree
Replicable: The Pilot is replicable.	Replicable: The Pilot is replicable. 0 Disagree	Replicable: The Pilot is replicable. 1	Replicable: The Pilot is replicable. 2	Replicable: The Pilot is replicable. 3	Replicable: The Pilot is replicable. 4	Replicable: The Pilot is replicable. 5 Agree	Replicable: The Pilot is replicable. 6	Replicable: The Pilot is replicable. 7	Replicable: The Pilot is replicable. 8	Replicable: The Pilot is replicable. 9	Replicable: The Pilot is replicable. 10 Strongly Agree
Self-sustaining: The activities/impacts are self-sustaining.	Self-sustaining: The activities/impacts are self-sustaining. 0 Disagree	Self-sustaining: The activities/impacts are self-sustaining. 1	Self-sustaining: The activities/impacts are self-sustaining. 2	Self-sustaining: The activities/impacts are self-sustaining. 3	Self-sustaining: The activities/impacts are self-sustaining. 4	Self-sustaining: The activities/impacts are self-sustaining. 5 Agree	Self-sustaining: The activities/impacts are self-sustaining. 6	Self-sustaining: The activities/impacts are self-sustaining. 7	Self-sustaining: The activities/impacts are self-sustaining. 8	Self-sustaining: The activities/impacts are self-sustaining. 9	Self-sustaining: The activities/impacts are self-sustaining. 10 Strongly Agree

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* 3. Recommendations:

Close-out

Refine and Re-propose

Expand/Replicate

Other (please specify)

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* 1. (Required) Contact Info

Question Title

* 2. (Required) Using a scale from 0 to 10, where 0 is complete disagreement (or not present) and 10 is the strongest agreement, what number would you use to rate this expansion proposal?

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* 3. Recommendations:

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* 4. Comments: