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* 1. Please provide your contact information below

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* 2. What is your current professional role? Please select all that apply.

Each ECHO session consists of 4 key content areas:
1. Didactic presentation
2. Presentation Q&A
3. Case presentation
4. Participant discussion

Case presentations take about 5-7 minutes and do not involve personal health information. The key elements of a case presentation are:

Problem to be solved (i.e., chief complain or current barrier)
Contextual details (e.g., patient information, social determinants, community design)
The ask (e.g., What do you need from the think tank? What questions can we answer?)

After filling out this case presentation form, we’ll develop slides with a brief summary of information to facilitate the conversation during the session. You’ll get the benefit of the expert think tank to help you with problem-solving in your rural environment- and we’ll provide a written report of the recommendations.

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* 3. Part one: Tell us a bit about the problem you need help solving. This could be a clinical case, program development case, outreach effort, or something related to a social determinant of health.

{examples}

A rural oral health patient is experiencing uncontrolled diabetes that is exacerbating their oral health. 

We need to design a communications campaign to support water fluoridation in a rural community.

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* 4. Part two: Tell us some of the context around this problem. What are the contributing factors? What are the barriers? What are the opportunities? 

Additional context may include:
-Patient demographic information
-Patient medical/dental history
-Patient or program strengths
-Patient or program barriers
-Patient or program priorities
-Stakeholders involved (e.g. organizations, clinical team, community members, etc.)


{examples}

My patient has diabetes and struggles with substance abuse. They are in a low-income area and do not have health insurance. 

This rural community is fearful of additives in their water and thinks fluoride is poisonous. Several parents are concerned for their children if their water were fluoridated.

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* 5. Part three: What is your clear ask of the group? What questions do you need answered?

{examples}

What types of resources are available to my patient? How could I provide culturally responsive clinical care? 

What types of messaging techniques would be helpful for this rural community? What communities have used successful messaging models in this topic area?

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* 6. Part four: What is your current proposed plan of action? If clinical, do you need a clarifying diagnosis?

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* 7. Upload any additional relevant materials that might be helpful to support your case presentation (e.g. radiographs, clinical notes, programmatic forms, documentation, etc.)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 8. Please let us know if you have a particular preference to present your case alongside a certain topic or month. Note: case presentations do not have to relate to didactic presentations.
  • Risk-stratified care (March)
  • Teleprevention and teledentistry (April)
  • Minimally invasive care (May)
  • Integrated care (June)
  • Personalized and predictive care (July)
  • Veteran oral health (August)
  • LGBTQIA+ rural oral health (September)
  • Value-based care (October)
  • Interoperability (November)
  • Caring for special-needs populations (December)

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