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4Ms of Age- and Dementia-Friendly Care ECHO Series Registration

Thank you for your interest in the 4Ms of Age- and Dementia-Friendly Care ECHO series.

Please complete the information below to register for this series. For questions related to prior knowledge or current practice, please complete as applicable to your situation.

M-D-Y H:M

I heard about Project ECHO from

If other, please describe

Preferred salutation

* must provide value

Dr.

Miss

Mrs.

Ms.

Mr.

Rev.

Other

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If other, please indicate your preferred salutation.

* must provide value

First name

* must provide value

Last name

* must provide value

E-mail

* must provide value

Phone number

* must provide value

Phone extension

Cell phone number

Behavioral Health

Medicine

Nursing

Physician Assistant

Public Health

Other area

If you selected "Job Not Listed", Please describe your job type.

What is your highest level of education?

* must provide value

Less than high school

High school or equivalent

Vocational or technical school

Associate degree

Bachelor's degree

Master's degree

Practice doctorate degree

Research doctorate degree (e.g., PhD)

Other doctorate degree (e.g., EdD)

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Credentials

* must provide value

ATC

BSN

BSW

CGC

CHES

CMA

CNA

CNE

CNNP

CNS

CRC

CRNP

DDS

DMD

DNP

DPT

FNP

LCGC

LCSW

LPN

LSW

MBA

MEd

MOT

MPH

MSN

MSOT

MSW

NCC

NREMT

PA-C

PhD

Other

Not applicable

If other, please list your credentials

* must provide value

Are you a student, resident, or fellow?

* must provide value

Student

Resident

Fellow

Not applicable

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What is your gender?

Female

Male

Not reported

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Please select your academic year

* must provide value

First Year

Second Year

Third Year

Fourth Year

Fifth Year or More

N/A

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After graduating, I intend to become employed or pursue further training in a:

* must provide value

Medically underserved community

Rural setting

Primary care setting

None of the above

Choose not to report

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Can we contact you in the future with short follow-up questions about your career track? If yes, please provide a personal email address

* must provide value

What year were you born?

Ethnicity

Race

Rural Residential Background Status
(Rural - a geographical area located in a non-metropolitan county, or an area located in a metropolitan county designated by the Federal Office of Rural Health Policy as being considered rural)

Select Disadvantaged Background
Disadvantaged Background - refers to a citizen, national, or a lawful permanent resident of the United States, the Commonwealths of Puerto Rico or the Marianas Islands, the U.S. Virgin Islands, Guam, American Samoa, the Trust Territory of the Pacific Islands, the Republic of Palau, the Republic of the Marshall Islands, or the Federated State of Micronesia who is:

Environmentally Disadvantaged - an individual's environment inhibited him/her from obtaining the knowledge, skills, and abilities required to enroll in and graduate from a health professions school.

Economically Disadvantaged - an individual from a family with an annual income below a level based on low-income thresholds, according to family size established by the U.S. Census Bureau, adjusted annually for changes in the Consumer Price Index, and adjusted by the Secretary of the U.S. Department of Health and Human Services, for use in all health professions programs. A family is a group of two or more individuals.

Educationally Disadvantaged - an individual who comes from a social, cultural, or educational environment that has demonstrably and directly inhibited the individual from obtaining the knowledge, skills, and abilities necessary to develop and participate in a health professions education or training program.

Not reported

Current Military Status

Active Duty Military (A person who serves in one of the seven uniformed services of the United States.)

Reservist

Not applicable

Not reportable

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Veteran Status
(A veteran is any person who has served in one of the seven uniformed services of the United States.)

Veteran - Retired

Veteran - Prior Service

Individual is not a Veteran

Not Reported

Not Applicable

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In which setting do you work?

* must provide value

Private Practice

Academic Medical Center

Hospital

Health Center

Primary Care Provider

Other

Not applicable

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If other, please describe your work setting

Do you work in a medically underserved community?

* must provide value

Yes

Not applicable

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Is your clinic a Federally Qualified Health Center (FQHC)?

* must provide value

Yes

Not applicable

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Do you practice in a rural health clinic?

* must provide value

Yes

Not applicable

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Specialty or area of practice

If other, please include your specialty

Facility, clinic, medical center, or organization name

* must provide value

Address 1

* must provide value

Address 2

City

* must provide value

State/Terrority

* must provide value

County

* must provide value

Country

* must provide value

If other, what country?

* must provide value

Zip code

* must provide value

Are you a Primary Health Network employee?

* must provide value

Yes

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Are you a Penn State Health or Penn State College of Medicine employee?

* must provide value

Yes

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What department?

* must provide value

What is your Penn State mailcode?

* must provide value

Have you participated in Project ECHO before?

Yes

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Did you participate in a past 4Ms ECHO?

Yes

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Are you interested in presenting a patient case?

Yes

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Have you received training on the 4Ms in the past?

Yes

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I am a provider who sees patients.

Yes

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Approximately how many patients are under your care?

Approximately how many patients over 65 are under your care?

I can detect cognitive impairment.

Yes

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I can plan appropriate referral/follow-up for someone with cognitive impairment.

Yes

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I am confident in my ability to manage care of those living with dementia.

Yes

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I understand the link between oral health and overall health.

Yes

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I am confident in my ability to promote oral health to my patients.

Yes

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I feel confident performing oral health evaluations with older adults.

Yes

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I can exchange meaningful information about my patient's health, including oral concerns, with other health care professionals.

Yes

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Please select the most significant barriers you experience when delivering care to older adults.

Lack of time to assess patients

Lack of time to counsel patients and their families

Insurance/reimbursement issues

Lack of consensus on professional guidelines

Lack of knowledge to do so

Difficulty in addressing cognition with patients

Provider burnout

Lack of clinic support

I am able to provide age friendly care to all of my older patients

Other

If other, please describe.

If you could make one change to help facilitate your ability to provide care for older adults, what would it be?

I am participating in this ECHO series

To increase my competency in care of older adults

To access expert knowledge

To gain continuing education credits

To meet management requirement

Other

If other, please describe.

Strongly Disagree

Disagree

Neither Agree nor Disagree

Agree

Strongly Agree

Access to specialist expertise and consultation is an important area of need.

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Access to specialist expertise and health professionals from other specialties is a benefit to my clinical practice.

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Access to expertise in pharmacology is a benefit to my clinical practice.

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Learning about complex chronic disease topics though participation in Project ECHO, is an effective way to enhance clinical knowledge and expertise.

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Case-based learning as the focus for discussion is an impactful way of learning.

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Didactic (lecture) sessions are an effective way to develop clinical knowledge and skills.

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