CCBHC Community of Practice Year 2 Request for Applications

Introduction and Contact Information

Thank you for your interest in National Council's second year of the CCBHC Community of Practice (CoP)!

The second installment of the CoP provides interested organizations with the option of choosing participation in one of the following tiers:

Base Tier: 4 webinars + in-person meeting in the Fall of 2018. Participation fee: $3,500
Silver Tier: 4 webinars, 1 innovation community + in-person meeting in the Fall of 2018. Participation fee: $5,000
Gold Tier: 4 webinars, 2 innovation communities + in-person meeting in the Fall of 2018. Participation fee: $7,000
Platinum Tier: 4 webinars, 3 innovation communities + in-person meeting in the Fall of 2018. Participation fee: $8,000

For detailed information on each tier, please review the RFA here.

Question Title

* 1. Organizational Profile

Organization Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Phone Number *

Question Title

* 2. Application Primary Contact

First Name

Last Name

Title

Email Address

Phone Number

Question Title

* 3. Please indicate which tier your organization would like to participate in

Base Tier: 4 technical webinars + 1 in-person meeting

Silver Tier: 4 technical webinars + 1 innovation community + 1 in-person meeting

Gold Tier: 4 technical webinars + 2 innovation communities + 1 in-person meeting

Platinum Tier: 4 technical webinars + 3 innovation communities + 1 in-person meeting

Question Title

* 4. Which Innovation Communities are you interested in? (choose up to three based on selected tier)

Transitions of Care

Population Health Management

Value Proposition

Question Title

* 5. Do you already have CCBHC status?

Yes

Question Title

* 6. If your answer to the previous question is no, please explain your organization's interest in the CCBHC model and the TTA offered in this initiative.

Question Title

* 7. Did you already apply or are you planning on applying to SAMHSA's recently announced funding opportunity for CCBHCs?

Yes

Question Title

* 8. What counties is your practice currently serving, including your own? Please list below:

Key Staff Contacts

Certain TTA events are more applicable to CCBHC staff members with specific professional backgrounds. We recommend that each applicant CCBHC designate a key staff person across each of the following domains:

Clinical – Includes licensed clinicians responsible for the clinical services delivered by the CCBHC.
Operational – Leaders who have executive authority over personnel, infrastructure, facilities, compliance, planning and strategy, and board management.
Financial – Leaders who implement financial planning, decision-making, strategy, and monitoring, and cost reporting.
Quality and Data – Staff responsible for tracking, monitoring, analyzing, and reporting on CCBHC quality measures to drive quality improvement and grant compliance.

Please indicate contact information for your key staff. Please note that the staff listed will automatically be enrolled in our CCBHC email distribution list. Please note that the same individual can serve as the point of contact for multiple topic areas.

Question Title

* 9. Clinical Lead (recommended: medical director or an analogous leadership position)

First Name *

Last Name

Title

Email Address *

Phone Number *

Question Title

* 10. Operational Lead (recommended: chief operating officer or an analogous leadership position)

First Name *

Last Name

Title

Email Address *

Phone Number *

Question Title

* 11. Financial Lead (recommended: chief financial officer or an analogous leadership position)

First Name *

Last Name

Title

Email Address *

Phone Number *

Question Title

* 12. Quality and Data Lead (recommended: management staff responsible for tracking, monitoring, analyzing, and reporting on CCBHC quality measures to drive quality improvement and grant compliance)

First Name *

Last Name

Title

Email Address *

Phone Number *

Question Title

* 13. Other Key Staff (e.g., prescribers, clinical supervisors, etc.)

First Name

Last Name

Title

Email Address

Phone Number

Question Title

* 14. Please indicate which of the team members listed above will serve as the the Project Lead. The Project Lead will serve as a key point of contact for CCBHC training and technical assistance considerations. Please note that the Project Lead should be a member of the CCBHC’s executive leadership team.