Application - I Raise the Rates: Promotion of Influenza Immunization through Interprofessional Partnership

ACP’s Center for Quality has received funding from the CDC, GSK and Merck to support our I Raise the Rates initiative. The program aims to increase adult and influenza vaccination coverage among patients with high-risk chronic conditions and racial/ethnic minority adults by using quality improvement (QI) methodology. The 2020-21 flu season is of particular importance as we work to combat the Twindemic of COVID-19 and influenza. Onboarding for this program will begin November 2020. Please complete this application if you are interested in participating. Applicants will be considered on a first come, first served basis.

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* 1. Full Name

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* 2. Credentials

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* 3. Email Address

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* 4. Practice Name

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* 5. Practice Address

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* 6. Number of physicians in your practice

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* 7. Number of non-physician clinical staff in your practice

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* 8. How many clinicians do you anticipate will participate in this program?

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* 9. Please describe your practice type/setting (e.g., academic medical center, residency program, community health center, independent physician association, primary care practice, multi-specialty practice, etc.)

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* 10. Do you have support from your organization’s leadership to participate in ACP’s I Raise the Rates QI program?

Yes

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* 11. Do you have at least one physician and one non-physician team member that can serve as project leads on behalf of your practice for this program?

Yes

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* 12. Do you currently administer flu and other adult vaccines in your practice?

Yes

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* 13. Is your practice located in a rural, urban, or other medically underserved community?

Yes

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* 14. Is your practice able to provide the following data to ACP pre-/post-initiative?

	Yes	No
Immunization rates (de-identified, aggregated at the practice level)	Immunization rates (de-identified, aggregated at the practice level) Yes	Immunization rates (de-identified, aggregated at the practice level) No
Practice assessment survey (completed by one practice lead on behalf of practice)	Practice assessment survey (completed by one practice lead on behalf of practice) Yes	Practice assessment survey (completed by one practice lead on behalf of practice) No
Mini-z survey (completed by each participating clinician)	Mini-z survey (completed by each participating clinician) Yes	Mini-z survey (completed by each participating clinician) No