Center Director First Name
* must provide value
Center Director Last Name
* must provide value
* must provide value
Center Director Phone Number
* must provide value
Is the person filling out this application the Center Director?* must provide value
Yes
No
Application Contact First Name
Application Contact Last Name
Application Contact Email
Application Contact Phone
Name of Center* must provide value
Center Address* must provide value
Center Address Line 2
Center City* must provide value
Center State* must provide value
Center Zip Code* must provide value
Center Main Email Address* must provide value
Center Website* must provide value
Regarding the Center Director, please check all applicable descriptors:* must provide value
Is Board certified in Pulmonary Medicine
Has at least three (3) years' post-pulmonary fellowship clinical experience in the care of patients living with PF
Is responsible for providing the operational oversight of the Center including all patient and affiliate programs
Coordinates the efforts of the institution and core care team to provide care, teaching, and research at the Center
Coordinates the provision of education to the institution and/or affiliated schools regarding recent advances in PF research and clinical care
Coordinates the research responsibilities of the Center. This should include establishing ongoing collaborations with other investigators within the institution, seeking out local and/or national funding for research by the core center staff, and providing access for research fellows, residents, medical students, and allied health professionals to become involved in PF-related research areas
Please upload the Center Director's CV or NIH Biosketch:* must provide value
Associate Center Director First Name* must provide value
Associate Center Director Last Name* must provide value
Regarding the Associate Center Director, please check all applicable descriptors:* must provide value
Is Board certified in Pulmonary Medicine
Has at least three (3) years' post-pulmonary fellowship clinical experience in the care of patients living with PF
Is responsible for providing the operational oversight of the Center including all patient and affiliate programs
Coordinates the efforts of the institution and core care team to provide care, teaching, and research at the Center
Coordinates the provision of education to the institution and/or affiliated schools regarding recent advances in PF research and clinical care
Coordinates the research responsibilities of the Center. This should include establishing ongoing collaborations with other investigators within the institution, seeking out local and/or national funding for research by the core center staff, and providing access for research fellows, residents, medical students, and allied health professionals to become involved in PF-related research areas
Please upload the Associate Center Director's CV or NIH Biosketch:* must provide value
Please provide the full name(s) and email(s) of nurse(s) or allied health professional(s), or equivalent clinical staff, dedicated toward working with patients to aid in obtaining medications, durable medical equipment (DME), including oxygen, prior authorizations, etc., to improve patient care:* must provide value
Please provide the full name and email of the Lead Site Coordinator. This role should be filled by a Nurse or Allied Health Professional with ILD experience in the outpatient and inpatient delivery of care or research with patients living with ILD.* must provide value
Please provide the full name and email of the Research Coordinator:* must provide value
Please provide the full name(s) and email(s) of the radiologist(s) with expertise in thoracic imaging:* must provide value
Please provide the full name(s) and email(s) of the pathologist(s) with expertise in pulmonary pathology:* must provide value
What is the average wait time for a new, non-urgent appointment? Please select the answer that best applies:
* must provide value
Four (4) weeks or less
More than four (4) weeks but less than eight (8) weeks
More than eight (8) weeks but less than twelve (12) weeks
Greater than twelve (12) weeks
What is the average wait time for a new, urgent consult? Please select the answer that best applies:
* must provide value
Two (2) weeks or less
More than two (2) weeks but less than four (4) weeks
More than four (4) weeks but less than eight (8) weeks
Greater than eight (8) weeks
Is there a direct line or electronic option for patients to reach the ILD program? * must provide value
Yes
No
How often does your Center hold multidisciplinary diagnosis meetings, regardless of patient volume? Please select the answer that best applies:* must provide value
Once a week
Once every two (2) weeks
Once a month
Other
Please explain your answer to the above:
Can patients connect to local ILD support groups through your Center?* must provide value
Yes
No
Name and Location of Support Group:
Frequency of Meetings (i.e. monthly, quarterly, other):
Is your Center able, as feasible, to incorporate use of the published PFF High-Resolution Computerized Tomography (HRCT) protocol?* must provide value
Yes
No
Does your Center participate in clinical research, with an emphasis on clinical trials?* must provide value
Yes
No
Please list current ILD research studies that your Center is conducting; include clinical trials, translational, and basic studies. You may include NCT or short titles. (You may choose to skip this field and proceed to the next, where you are asked to upload this list as a file, but you MUST respond to one of these fields based on your preferred format):
Please upload a list of current ILD research studies that your Center is conducting IF you chose to skip the previous field; include clinical trials, translational, and basic studies. You may include NCT or short titles:
Please upload a list of your Center's publications over the past three years; please limit to 10 publications:* must provide value
Does your Center have an established telemedicine infrastructure to increase access of care to patients lacking proper transportation and/or patients who live beyond a reasonable distance of the Center?* must provide value
Yes
No
Please explain your response to the above:
Does your Center have a pulmonary hypertension specialist on site or is your Center able to refer patients through an established connection and referral process, demonstrating that a network of care is available?
* must provide value
Yes
No
Please explain your response to the above:
Does your Center have a lung transplant specialist on site or is your Center able to refer patients through an established connection and referral process, demonstrating that a network of care is available?
* must provide value
Yes
No
Please explain your response to the above:
Does your Center have a rheumatologist on site or is your Center able to refer patients through an established connection and referral process, demonstrating that a network of care is available?
* must provide value
Yes
No
Please explain your response to the above:
Please select all additional personnel affiliated with your Center. Please note that these team members must be available for consultation/coordination of care.* must provide value
Other pulmonologists, nurses, and allied health professionals (involved in the care of ILD)
Cardiologist
Gastroenterologist
Genetics/Genetic Counselor
Infectious Disease Specialist
Social Worker
Thoracic Surgeon
If your patients require any consultations in any of the above areas not checked, how does your Center handle these needs? Please enter "N/A" if all answers were checked. * must provide value
Does your Center have accreditation by an entity that is approved by CMS?
* must provide value
Yes
No
Please select all outpatient and inpatient facilities and services to which your Center provides access:* must provide value
Intensive Care Unit
Respiratory Care
Outpatient Clinic
Clinical Research Program
Pulmonary Function Diagnostic Service
Pulmonary Rehabilitation Program
Palliative Care Program
Access to Specialty Pharmacy
Does your Center have a referral plan for procedures or services not found at your site?
* must provide value
Yes
No
Does your Center have a mechanism to deliver outpatient clinic reports and discharge summaries to referring physicians?
* must provide value
Yes
No
What is the number of unique ILD patients at your Center in a year? Please select the range that best applies:* must provide value
150 or fewer
151 -250
251-500
501-750
751-1,000
Greater than 1,000
The CCN provides multiple opportunities to collaborate with the PFF and the CCN (see the diagram on the last page of the CCN criteria for more details). Please submit a 500 word narrative of how your center will actively engage with the Network:
* must provide value
Please write 3-5 sentences explaining your interest in joining the Care Center Network:* must provide value
Please include any information here to clarify your answers to the above questions or that would be pertinent to consideration of your application:
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