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ECHO Ontario Mental Health at CAMH and U of T: IMPH Application Form

Thank you for your interest in ECHO Ontario Integrated Mental and Physical Health at CAMH. Please fill in the following form to apply.

ECHO Ontario Integrated Mental and Physical Health
(Fridays from 12:00 - 1:15 pm, June 5- August 28, 2020)

Note: This program (formerly known as ECHO Complex Patient Management) is focused on complex conditions (i.e., multi-morbidity with physical and mental health issues) and has been developed with physicians and nurse practitioners in mind. Despite the intended target audience, other health care professionals are welcome to apply.

For more information, as well as a sample curriculum, please see: https://camh.echoontario.ca/programs-cpm/

First Name:

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Last Name:

* must provide value

Email Address:

* must provide value

Phone Number:

* must provide value

Extension (if applicable):

Alternative Phone Number:

Name of Organization (if possible, please avoid acronyms):

* must provide value

Organization Address:

* must provide value

Organization City:

* must provide value

Organization Postal Code:

* must provide value

Which LHIN is your organization a part of?

NOTE: If you are unsure, please input your organization's postal code on this website: http://www.lhins.on.ca/

* must provide value

Central

Central East

Central West

Champlain

Erie St. Clair

Hamilton Niagara Haldimand Brant

Mississauga Halton

North East

North Simcoe Muskoka

North West

South East

South West

Toronto Central

Waterloo Wellington

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What type of setting(s) do you practice in?

* must provide value

Urban

Rural

Both urban and rural

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What is your primary profession? Select which best applies.

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Audiologist

Behaviour Analyst

Case Worker

MD (Family Physician)

MD (Specialist)

Nurse Practitioner

Occupational Therapist

Pharmacist

Physician Assistant

Physiotherapist

Psychologist

Psychotherapist

Registered Nurse

Social Worker

Speech Language Pathologist

Student

Other

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Please specify area of study:

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Please specify:

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Please indicate your primary practice setting:

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Aboriginal Health Access Centre

Academic Hospital

Community Addictions Agency

Community Health Centre

Community Mental Health Agency

Community Mental Health and Addictions Agency

Community Support Services Agency

Family Health Group

Family Health Organization

Family Health Team

Nurse Practitioner-led Clinic

Private Practice / Solo Practitioner

Residency

University/College Health Care Centre

Other

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Please specify:

* must provide value

How many years have you been practicing?

* must provide value

Have you participated in an ECHO program in the past?

* must provide value

Yes

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Which ECHO program(s)?

* must provide value

ECHO Ontario Addiction Medicine and Psychosocial Interventions

ECHO Ontario Adult Intellectual & Developmental Disabilities

ECHO Ontario Complex Patient Management

ECHO Ontario First Nations, Inuit, and Métis Wellness

ECHO Ontario Mental Health

ECHO Ontario Obsessive Compulsive Disorder

ECHO Ontario Psychotherapy (CBT and/or DBT)

ECHO Ontario Psychotherapy: Developmental Trauma and Resilience

ECHO Ontario Trans and Gender Diverse Healthcare

Other

If other, please specify:

* must provide value

Will others from your team participate in this ECHO?

* must provide value

Yes No

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NOTE: Please make sure that any member of your team who will participate completes this application. We require an application from each participant.

How did you hear about ECHO Ontario Programs?

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Communications from professional association (e.g. newsletter, bulletin)

Email from ECHO Ontario Mental Health

Word of mouth (e.g. colleague)

Other

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Please specify which association you belong to:

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Please specify:

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Please note that ECHO sessions are virtual and interactive. It is strongly recommended that you use either a laptop, desktop computer, tablet, or smartphone (with working speakers and microphone) to connect to the weekly sessions, so we are able to interact with you.

It is particularly helpful to see you virtually during ECHO in order to build an effective community of practice. Do you anticipate you will be able to turn your camera on in ECHO sessions?

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Yes No

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If no, please describe rationale:

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Why are you interested in participating in ECHO Ontario Mental Health Programming? (select all that apply)

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To gain and exchange knowledge with an interdisciplinary, specialist team

To connect and network with colleagues

To receive support and recommendations on clients I am supporting

To become more comfortable with supporting complex patients

For Continuing Medical Education (CME) credits

Other

Please specify:

* must provide value

Please note that your participation in this ECHO will include the following:

• Carefully reviewing and signing a Statement of Collaboration agreement (see below);
• Attending a 60-minute online orientation session prior to the first session if you have never participated in one of our ECHO programs;
• Attending at least 60% of the weekly sessions;
• Completing a pre-survey, weekly surveys, and post-survey;
• Delivering a short anonymized case presentation about a client in your practice during a session.

Registration is open on a first come, first serve basis. If the program you are interested in is full you will be placed on a waiting list and contacted when a spot becomes available.

NOTE: Visit our website at https://camh.echoontario.ca/programs-cpm/ for more information about program curriculum.

ECHO Ontario Integrated Mental and Physical Health

Why are you interested in participating in ECHO Ontario Integrated Mental and Physical Health?

* must provide value

Expand

What do you want to learn more about?

* must provide value

Expand

Describe a current or recent case that you have found particularly complex:

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Expand

An important part of the ECHO model is to discuss real, complex patient cases, collectively ask pertinent questions, and develop recommendations for care. All personal information must be de-identified. Prior to the launch of the ECHO cycle we will work with you on an agreed-upon date for presentation, and will help you to prepare and submit this anonymized client case. We hope that you and your client will see this exercise as a helpful opportunity to share and receive feedback from the community of practice. Please confirm the following:

Are you currently working in direct practice with clients?

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Yes

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Do you have a case you would like to discuss during one of the ECHO sessions?

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Yes, I have someone in mind

No, I cannot think of anyone right now, but I will do so prior to ECHO

No, I do not think I can present a case

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If so, please provide a brief rationale:

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Attached below is the ECHO Statement of Collaboration that outlines certain conditions which must be understood and agreed to in order to participate in any of our ECHO programs.

Please review the Statement of Collaboration.

Attachment:ECHO Ontario Mental Health_SoC - 2020 Final.pdf

Carefully review and check to indicate your agreement to the following statements.

I will participate in at least 60% of sessions.

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I agree

I cannot attend 60% of sessions

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Please specify why:

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ECHO case presentations do not create or establish a provider-patient client relationship between any Hub clinician and a patient whose case is presented.

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I agree

I've read the SOC, but have questions. Please contact me. I understand that the ECHO Ontario Mental Health Project team will require my agreement to this item from the SoC prior to my attendance in the session.

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Personal identifying information about patients/clients is not to be shared during ECHO sessions. If this inadvertently occurs, I will follow my own organization's policies and procedures to address the privacy breach.

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I agree

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Recommendations from the Hub do not in any way replace my own diligence and professional expertise with respect to my patients or clients.

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I agree

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The ECHO team records sessions for educational purposes and occasionally takes photos for promotion.

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I agree to this statement, and give ECHO ONMH permission to share photo(s) of me externally in presentations, reports and promotional materials. I understand my name, profession, and/or organization will not be included with the photo.

I agree to this statement, but I do not wish to have my photo shared externally. I understand any image of me will be blurred in photos used in externally facing presentations, reports, and promotional materials.

I've read the SOC, but have questions. Please contact me.

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My participation data will be shared with the Ministry of Health, Ontario Superhub, and ECHO New Mexico as outlined in the Statement of Collaboration.

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I agree

I agree to have my data shared with the Ministry of Health and Ontario Superhub, but want to opt out of sharing with ECHO New Mexico.

I've read the SOC, but have questions. Please contact me.

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I have read and agree to the terms of the Statement of Collaboration with preferences as indicated above.

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I agree

I've read the SoC, but have questions and understand I will be contacted to discuss this prior to being enrolled in the program

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Initial Here

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Add signature

Please provide date:

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D-M-Y

We will set up videoconference orientation sessions prior the start of the programs. Information about case discussion, how to access the session, and the Community of Practice website will be provided during this orientation.

Please select which session you would like to attend.

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I have participated in an ECHO program in the past and already feel oriented!

Thursday, June 4, 2020 at 9:00-10:00AM

I cannot attend the date listed above and I will need to be sent an orientation PDF package.

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This application will be reviewed by our operations team and your participation will be confirmed as soon as possible.

After you have received confirmation of your enrollment in the program we will contact you and provide details about next steps. Applications from rural and underserved areas of the province will be prioritized, given Project ECHO's aim to reduce disparities in access to mental health services.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.