Please complete the agreement below. Please contact Nadine Grosso at ngrosso@mehca.org with any questions.

*1.Yes! My facility would like to engage in this voluntary opportunity to reduce the off label use of anti-psychotic medications utilizing the Maine Dementia Care Partnership Toolkit, Is it for me or you? Dementia Care Change Package.(Required.)

Agree

*2.As a participant, I agree to the expectations outlined below and will begin the process on May 1, 2022 and complete the work by October 31, 2022.

• Identify residents who may benefit from A/P reduction
• Establish a facility-specific A/P reduction percentage goal over a 6-month period
• Provide staff education using the toolkit resources
• Implement one toolkit item/strategy
• Embrace a person-centered approach to this work
• Conduct pre- and post-analysis of outcomes specific to your journey

(Required.)

Agree

*3.Contact Information for Authorized Representative(Required.)

Name

Company

Title

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

*4.Each participating home must select two project coordinators (Can be Administrator, DON, or any department leader of your choosing.)

Please provide first project coordinator's contact information below.(Required.)

Name

Job Title

Email Address

Phone Number

*5.Please provide second project coordinator's contact information below.(Required.)

Name

Job Title

Email Address

Phone Number