Palliative Care Provider Membership - Alabama Hospice and Palliative Care Organization

Comments

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Corporate Office Information

Company Name(Required)

Company Address(Required)

City / State / ZIP(Required)

Palliative Care Service

Palliative Care Service Name(Required)

Palliative Care Service Address(Required)

Palliative City / State / ZIP(Required)

Primary Contact

Individual who will receive all Provider information from AHPCO, listed as primary contact on the AHPCO Website and Membership Directory and serving as Voting Delegate.

Primary Contact — First Name(Required)

Primary Contact — Last Name(Required)

Primary Contact Title(Required)

Primary Contact Phone(Required)

Primary Contact Email(Required)

Secondary Contact

Secondary Contact — First Name

Secondary Contact — Last Name

Secondary Contact Title

Secondary Contact Phone

Secondary Contact Email

Section Two — Dues

Membership dues for the Palliative Care Provider Membership are $250.00.

Palliative Care Provider Membership Dues

Price:

Total

Section Three — Palliative Care Program Overview

AHPCO advocates for palliative care in Alabama in conjunction with The Alliance for Care at Home. Please answer the following to help these efforts.

What type(s) of communities does your palliative care program serve?(Required)

Urban

Rural

Mixed

Palliative Care Model (select all that apply)(Required)

Hospital

Inpatient Unit

Clinic

In Home

Is your palliative care program affiliated with a hospice?(Required)

Yes

Age Group Served(Required)

Pediatric

Adult

Both

Average Daily Census

Please enter a number greater than or equal to 0.

Number of patients served in the last 12 months

Please enter a number greater than or equal to 0.

Is your palliative line of business profitable?

Yes

Dominant Ownership Status

Corporation

Individual

Joint Venture

Non-Profit Organization

Healthcare Authority

Government

Partnership

LLC

Other

If 'Other', please specify ownership

Funding Sources (approximate percentage from each, totaling 100%)

Financial support from hospital / other org (incl. salary stipends, excl. philanthropy) (%)

Please enter a number greater than or equal to 0.

Fee for Service clinician billing (incl. Medicare Part B) (%)

Please enter a number greater than or equal to 0.

Bonus payments for quality measures (%)

Please enter a number greater than or equal to 0.

Subsidy from partner organizations (%)

Please enter a number greater than or equal to 0.

Financial contracts / service agreements with other providers or vendors (where you do not bill the payer directly, including value-based purchasing agreements) (%)

Please enter a number greater than or equal to 0.

Philanthropic and foundation support (%)

Please enter a number greater than or equal to 0.

Not funded (%)

Please enter a number greater than or equal to 0.

Other funding source — please specify

Other funding source (%)

Please enter a number greater than or equal to 0.

Does your palliative care program provide services remotely?(Required)

Yes

If Yes, what percentage of your patients use telehealth?

Please enter a number greater than or equal to 0.

Telehealth modalities used (select all that apply)

Telehealth (Audio & Video) — clinician ↔ patient

Telehealth (Audio & Video) — non-clinician ↔ patient

Section Four — In-Home Palliative Care

Counties Served (In-Home Palliative Care)

Autauga

Baldwin

Barbour

Bibb

Blount

Bullock

Butler

Calhoun

Chambers

Cherokee

Chilton

Choctaw

Clarke

Clay

Cleburne

Coffee

Colbert

Conecuh

Coosa

Covington

Crenshaw

Cullman

Dale

Dallas

DeKalb

Elmore

Escambia

Etowah

Fayette

Franklin

Geneva

Greene

Hale

Henry

Houston

Jackson

Jefferson

Lamar

Lauderdale

Lawrence

Lee

Limestone

Lowndes

Macon

Madison

Marengo

Marion

Marshall

Mobile

Monroe

Montgomery

Morgan

Perry

Pickens

Pike

Randolph

Russell

Shelby

St. Clair

Sumter

Talladega

Tallapoosa

Tuscaloosa

Walker

Washington

Winston

Wilcox

Year palliative care program was established

Please enter a number greater than or equal to 0.

Year in-home palliative care program was established (if different)

Please enter a number greater than or equal to 0.

Total in-home visits last year

Please enter a number greater than or equal to 0.

Total telehealth visits last year (in-home)

Please enter a number greater than or equal to 0.

Do you cap the number of patients in your in-home program?

Yes

If Yes, what is the cap?

Please enter a number greater than or equal to 0.

Disciplinary makeup (select all that apply)

Physician

CRNP

LPN

Social Worker

Aide

Chaplain

Other

If 'Other', specify discipline

Average Visit Frequency by Discipline

LPN — average visit frequency

RN — average visit frequency

Nurse Practitioner — average visit frequency

Social Worker — average visit frequency

Aide — average visit frequency

Chaplain — average visit frequency

Do you provide on-call services?

Yes

On-call discipline (select all that apply)

LPN

Palliative care staffing

Full time

Contracted

Shared with Another Line of Business

If shared, please describe

Do you provide DME and medications? If so, does the program provide regardless of pay source, or only through the patient's healthcare insurance?

Tracking — select all that apply

Emergency Department Visits

Hospital Admissions

Non-Hospital Deaths

Referrals to Hospice

Visits per Patient

Office Practice Length of Service

Length of Service

Advance Care Planning

Cost of Care

Savings Cost of Care

Other

If 'Other' tracking, describe

Agreement

I have read and agree to AHPCO's Ethics, Antitrust Compliance, and Collection of Information Statements.(Required)

I have read and agree

Communication Preferences

I prefer NOT to receive occasional AHPCO communications

Do NOT include my contact information in vendor lists

Credit Card

Become a Palliative Care Provider Member

Corporate Office Information

Palliative Care Service

Primary Contact

Secondary Contact

Section Two — Dues

Section Three — Palliative Care Program Overview

Funding Sources (approximate percentage from each, totaling 100%)

Section Four — In-Home Palliative Care

Average Visit Frequency by Discipline

Agreement