Application Form - ECHO Ontario Wound and Skin

Background Information

*UPDATE December 2020*

Project ECHO Ontario Skin and Wound Care is in its final cohort of its current funding commitment. Interested organizations should apply, and if funding is renewed, will be conducted if further cohorts go ahead. Visit https://wound.echoontario.ca/ for the latest updates

*END UPDATE*

This is the application form for Project ECHO Ontario Skin and Wound.

Project ECHO (Extensions for Community Health Outcomes) Ontario Skin and Wound offers evidence-based mentorship and case-based learning on skin and wound care at no cost to Ontario health care providers. Project ECHO is based on a Hub and Spoke model. A resource team (Hub) comprising of physicians, nurses and allied health providers provide community partners (Spokes), with guidance on patients with complex skin and wound care needs. Spokes are comprised of health care professionals from across the province interested in expanding their knowledge in wound care. Continuing Medical Education (CME) credits will be rewarded to physicians.

A Spoke can be one or more health providers gathered at:

- A Family Health Team
- An Aboriginal Health Centre or a Community Health Centre
- A Long-Term Care Home
- A Hospital

- A Nursing Clinic

Each session is broadcast online via Zoom technology. To participate in Project ECHO Ontario Skin and Wound sessions, you will need an Internet enabled device capable of video conferencing such as any computer, laptop, tablet or mobile phone. Sessions will be held weekly on Wednesday afternoons, 2 pm to 4 pm.

Please note priority for acceptance into Project ECHO Ontario Skin and Wound will be given to health care providers in rural/remote/Northern communities, groups working towards forming an interprofessional team, and providers caring for Indigenous peoples and under-serviced populations.

The partners facilitating the Project ECHO Ontario Skin and Wound:

· WoundPedia
· Registered Nurses Association of Ontario
· Queen's University

Please note to participate in Project ECHO Ontario Skin and Wound your team must sign a Statement of Collaboration outlining roles and responsibilities related to this Project. Also note; the information gathered will be used to follow up with your team with regard to application.

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* 1. As a community partner (Spoke), would you like to participate in Project ECHO Ontario Skin and Wound?

Yes - Proceed

I would like more information

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* 2. The ECHO sessions will be delivered in 2 cycles, each cycle comprising of 8 weekly sessions. Select the cycle (s) you are interested in (multiple can be selected)

Cycle 1: Lower leg and foot ulcers, including diabetic foot ulcers and venous leg ulcers

Cycle 2: Chronic wounds, including pressure injuries, malignancies, inflammatory ulcers and post-surgical wounds

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* 3. What is your first name and last name?

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* 4. What is your email address?

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* 5. What is your telephone number?

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* 6. What is the name of your Clinic/Organization?

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* 7. What City/Town/Village is your Clinic/Organization based in?

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* 8. What is the Postal Code of your Clinic/Organization? Skip if unknown

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* 9. Which LHIN/Region(s) do you perform skin and wound care in?

Central

Central West

Mississauga Halton

North West

North East

Champlain

Waterloo Wellington

Toronto Central

Erie St. Clair

Hamilton Niagara Haldimand Brant

South West

South East

Not Sure

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* 10. What is your profession?

Other (please specify)

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* 11. What is your area of practice specialty or expertise e.g. pediatrics, complex care, geriatrics?

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* 12. What is your primary practice setting?

Family Health Team

Community Health Centre

Aboriginal Health Access Centre

Nurse Practitioner Led Clinic

Primary Care Solo Practice

Home Care Provider

Home Care Clinic

Nursing Station

Community Hospital

Academic Hospital

Long Term Care

Other (please specify)

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* 13. Including yourself, how many team members would be joining you on these ECHO sessions?

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* 14. Are you interested in attending Boot Camps for additional hands-on training and in-person skills development? Note Boot Camps are optional and will be offered twice a year

Yes, I am interested in learning more about Boot Camps

No, I am not interested at this time

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* 15. Is your organization a Registered Nurses Association of Ontario’s Best Practice Spotlight Organization?

Yes, my organization is already a Best Practice Spotlight Organization

No, my organization is not a Best Practice Spotlight Organization

I'm uncertain whether or not my organization is a Best Practice Spotlight Organization

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* 16. Are you interested in learning more about the Registered Nurses Association of Ontario’s Best Practice Spotlight Organization?

My organization is already a Best Practice Spotlight Organization

My organization wishes to become a Best Practice Spotlight Organization

I would like to learn more about the Best Practice Spotlight Organization

We are not interested in the Best Practice Spotlight Organization program at this time.

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* 17. Select All of the Following Priority Areas that Apply to Your Organization

Rural... communities in Ontario are those with a population of less than 30,000 that are greater than 30 minutes away in travel time from a community with a population of more than 30,000

Remote... without year-round road access, or which rely on a third party (e.g. train, airplane, ferry) for transportation to a larger centre.

Northern

Working Towards Forming an Inter-professional Team or Already Within an Inter-Professional Team

Caring for Indigenous People

Caring for other Vulnerable Populations e.g. housing insecure

Application Form - ECHO Ontario Wound and Skin

Background Information

Question Title

* 1. As a community partner (Spoke), would you like to participate in Project ECHO Ontario Skin and Wound?

Question Title

* 2. The ECHO sessions will be delivered in 2 cycles, each cycle comprising of 8 weekly sessions. Select the cycle (s) you are interested in (multiple can be selected)﻿

Question Title

* 3. What is your first name and last name?

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* 4. What is your email address?

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* 5. What is your telephone number?

Question Title

* 6. What is the name of your Clinic/Organization?

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* 7. What City/Town/Village is your Clinic/Organization based in?

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* 8. What is the Postal Code of your Clinic/Organization? Skip if unknown

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* 9. Which LHIN/Region(s) do you perform skin and wound care in?

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* 10. What is your profession?

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* 11. What is your area of practice specialty or expertise e.g. pediatrics, complex care, geriatrics?

Question Title

* 12. What is your primary practice setting?

Question Title

* 13. Including yourself, how many team members would be joining you on these ECHO sessions?

Question Title

* 14. Are you interested in attending Boot Camps for additional hands-on training and in-person skills development? Note Boot Camps are optional and will be offered twice a year

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* 15. Is your organization a Registered Nurses Association of Ontario’s Best Practice Spotlight Organization?

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* 16. Are you interested in learning more about the Registered Nurses Association of Ontario’s Best Practice Spotlight Organization?

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* 17. Select All of the Following Priority Areas that Apply to Your Organization

* 2. The ECHO sessions will be delivered in 2 cycles, each cycle comprising of 8 weekly sessions. Select the cycle (s) you are interested in (multiple can be selected)