Care Transitions: Participation Agreement

Health care providers in the Lower Rio Grande Valley cities of Brownsville, Harlingen and Weslaco are invited to participate in this innovative health care improvement project.

Eligible providers should complete each tabbed section of this form. To move to the next tab, click on the red arrow below the form. To return to a previous tab, click on the numbered tabs.

Note: This participation agreement will take about 10 minutes to complete.

Assistance from TMF

If you would like assistance in completing this agreement, please contact Jennifer Markley, project director, at 1-866-439-6863, ext. 663 or CareTransitions@tmf.org.

TMF has received Independent Review Organization accreditation from URAC.

TMF has received Health Utilization Management accreditation from URAC.

1. General * These fields must be completed.
* Provider Name (Doing Business As [DBA]):
Provider Type:	HospitalNursing Home Inpatient RehabHome Health LTACHospice
Corporate Name (if applicable):
* Medicare Provider Number:
* Address Line 1:
Address Line 2:
* City:
* ZIP:

2. Contacts * These fields must be completed.
	Primary Contact (Required)	Secondary Contact (Required)
* First Name:
* Last Name:
Credentials:
* Title:
* Telephone: (xxx-xxx-xxxx)
Fax: (xxx-xxx-xxxx)
E-mail:
Does this contact have Internet access daily?	YESNO	YESNO
Does this contact have access to e-mail daily?	YESNO	YESNO

Each checkbox must be selected to complete enrollment process.
.	Provider agrees to participate with TMF and other community health care providers and stakeholders in the Centers for Medicare and Medicaid (CMS) Care Transitions (CT) Project. CMS may choose to discontinue the project at month 18 if progress is unsatisfactory.
.	Provider understands that the purpose of the CT Project is to work collaboratively in a comprehensive communitywide effort in the Lower Rio Grande Valley to measurably improve the quality of care for Medicare beneficiaries who transition between care settings. The project goal is a minimum reduction of 2 percent in the 30-day hospital readmissions rate by December 2010.
.	Provider will allocate the resources necessary to actively participate, implement interventions and to achieve the goals of the CT Project.
.	Provider will submit to TMF a monthly report that includes current project activities, status of interventions, monthly monitoring data and barriers to success.
.	Provider is willing to test and measure practice innovations, share experiences and openly communicate with TMF and other providers on quality improvement issues.
.	The provider is willing and committed to participate in TMF-sponsored conferences, meetings, teleconferences, webinars and site visits for the purposes of education, shared learning and the spreading of change and practice innovation.
.	Provider agrees to implement a minimum of three evidence-based interventions to reduce avoidable re-hospitalization and to collect and report monitoring data monthly.
.	Provider agrees to participate in a trial implementation of the CARE Tool as an intervention to improve transition communication.
.	Provider agrees to "fast track" their form approval process for timely implementation of interventions.
Disclosure of Provider Participation Provider agrees to grant TMF the ability to publicly identify the provider as a participant in the CT Project for the purpose of promoting participation and promoting the success of the project. AgreeDisagree
Confidentiality Statement Participating providers should clearly indicate which quality improvement activities are related to the CT Project efforts. These activities are part of quality assurance activities, and, as such, are considered protected information and are not subject to disclosure in legal situations or to state surveyors nor do they meet the definition of regulatory requirements. Activities related to compliance with statutory and regulatory requirements are not considered protected information. TMF Health Quality Institute is committed to ensuring the confidentiality of the information shared within the CT Project. Both facilitators and participants are expected to maintain and safeguard the confidentiality of privileged data or information – whether written, photographed or electronically recorded and whether generated or acquired by the team, which can be used to identify an individual patient, practitioner or provider.
.	I have read and understand the Confidentiality Statement as it applies to the Care Transitions Project.

Note: No information is saved until you SUBMIT the agreement.	Continue to Next Tab

3. Provider Commitment to Participate
By selecting each checkbox in the statements below, participants acknowledge they have read and accepted each condition for participation in the Care Transitions Project.

You will receive an e-mail confirming your participation in the project.
* E-mail address to send confirmation to: