1. Practice Name:
* must provide value
2. Type of Practice:
* must provide value
Primary Care Urgent Care Neurology Neurosurgery Occupational Medicine Orthopedics Physical Medicine and Rehabilitation Pain Medicine/Pain Management Physical Therapy Occupational Therapy Behavioral Health Substance Use Disorder Chiropractic Lifestyle Medicine or Integrative Medicine Vocational Rehabilitation or Training Other
Please describe other type of practice
First name of the RETAIN contact person for the practice:
* must provide value
Last name of the RETAIN contact person for the practice:
* must provide value
Phone number of the RETAIN contact person for the practice:
* must provide value
Fax number for RETAIN communication with the practice:
Email address for RETAIN communication with the practice:
* must provide value
Title or position of RETAIN contact person for the practice:
Preferred method for RETAIN to contact the practice:
Telephone
Email
Fax
Other
If other, please describe:
Preferred time(s) for RETAIN to contact the practice:
Practice Street Address:
* must provide value
Practice City/Town:
* must provide value
State
* must provide value
AK AL AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code:
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Practice Mailing Address (if different from street address):
4. About how many patients does the practice serve?
* must provide value
< 2,000
2,000 - 2,999
3,000 - 3,999
4,000 - 4,999
5,000 - 6,999
7,000 - 8,999
>9,000
5. Screening Method
Tablet
Link and QR code for use with patient's mobile phone
Paper form
Prefer to discuss with VT RETAIN before selecting
Other
How many tablets will you need?
Fax paper screening forms back to VT RETAIN (secure fax #:603-676-4209)
Have them picked up by the VT RETAIN team
Approximately how many patients will you see per day?
6. Other than English, what are the most common languages spoken by patients in your clinic?
Spanish
Chinese
French
Vietnamese
German
Nepali
Swahili
Arabic
Somali
Other (Specify)
7. How would you prefer to receive your free provider Category 1 provider CME (1.0)?
In person
Live video
Link to pre-recorded video
Prefer to discuss with VT RETAIN before selecting
Please indicate preferred date and time (if known):
Now M-D-Y H:M
Please note preferred date and time:
Now M-D-Y H:M
8. VT RETAIN offers free Work-Health Coach training to care managers in enrolled primary care offices. This is not a requirement to participate in VT RETAIN , rather it is an option for practices interested in developing this expertise within their own clinic. Training involves didactic sessions, weekly case reviews, self-directed learning, and mentoring from a VT RETAIN Work-Health Coach and can be tailored to meet the needs of the participating clinic. The goal is to develop skills to prevent work disability early in the patient’s injury or illness process. VT RETAIN can provide up to 0.20 FTE to support embedded care managers in this role depending on their preferred level of involvement.
Would you like VT RETAIN to train your embedded care manager(s) to serve as a Work-Health Coach?
Yes
No
Prefer to discuss with VT RETAIN before selecting
Name of care managers who want SAW/RTW training (if known):
Contact info of care managers who want SAW/RTW training (if known):
Indirect cost rate (if any):
9. How do your providers want to receive information from our Work-Health Coaches (check all that apply)?
Patient return-to-work plan and discharge summary
Monthly updates from the Work-Health Coach working with your patients
Each provider will make their own personalized plan with their Work-Health Coach
Coach-access to our Electronic Medical Record (EMR) for staff messaging and chart review
Other
Prefer to discuss with VT RETAIN before selecting
For coach-access to our Electronic Medical Records (EMR), we prefer to use:
Own EMR agreement
The VT RETAIN EMR agreement
Prefer to discuss with VT RETAIN before selecting
10. The VT RETAIN study is open to patient enrollment. We would like to have all practices enrolled by June, 2022. What is the earliest date that your practice can start screening patients? (Exact start date depends on multiple factors and may vary.)
January 5, 2022
After January 5,2022
Prefer to discuss with VT RETAIN before selecting
10a. The VT RETAIN study is open to patient enrollment. We would like to have all practices enrolled by June, 2022. What is the earliest date that your practice can start screening patients? (Exact start date depends on multiple factors and may vary)
Preferred start date (if known):
Prefer to discuss with VT RETAIN before selecting
Preferred start date (if known):
Today M-D-Y
11. RTW services provided by the practice (check all that apply):
* must provide value
Vocational counseling
Vocational rehabilitation
Vocational retraining
Physical functional capacity evaluations
Cognitive functional capacity evaluations
Job simulation
Embedded rehabilitation (e.g. physical therapy, occupational therapy)
Embedded behavioral health services
Medication assistance for substance use disorders
Embedded care management
Same day or urgent care appointments
Telemedicine/telehealth visits
None
Other
If other please describe:
12. Please check all that apply to your practice:
We are a Federally Qualified Health Center
We accept workers' compensation insurance
We accept Medicare/Medicaid
Other
If other please describe:
Please provide the name and contact information for the financial contact in your practice (if different from the RETAIN contact)Name:
Contact information of the financial contact in your practice.
13. Any other information or comments you would like to provide (optional):
Date of entry:
* must provide value
Today M-D-Y
Thank you for enrolling. We look forward to working with you! - The VT RETAIN Team
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