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zdMp8YsKVJNZX9Z6HGjGe6qL2aAYbnpBNwXDtrrLSDTsiRTM2ykpy8bGa6KPpLw7ImRpgm3nEzcwfeJupKuvzYwUFZqRRkxfgXFaFXrzzXzLxAyv92ueBfSu8T3u

MACS for MOMs ECHO Registration Form

Maryland Addiction Consultation Service

MACS is a grant-funded program sponsored by the Maryland Department of Health. Therefore, the names of participating prescribers as well as information collected by MACS may be shared with state officials as requested. Project ECHO® collects participation data for each teleECHO™ programs. This data allows Project ECHO to measure, analyze, and report on the movement’s reach. It is used in reports, on maps and visualizations, for research, for communications and surveys, for data quality assurance activities, and for decision-making related to new initiatives.

Please complete the survey below.

Thank you!

Sign-Up Date

* must provide value

M-D-Y

Provider First Name

* must provide value

Provider Last Name

* must provide value

Provider Type

* must provide value

Please specify:

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Primary Practice Name (if applicable):
("Missing" if field left blank or "N/A" if not applicable)

* must provide value

Phone Number

* must provide value

Would you like to receive text messages from MACS at this phone number?

Yes

reset

Alternative Phone Number (if applicable)

Provider Email

* must provide value

Do you work in a maternal health or addiction treatment setting? Or do you consistently work with pregnant/postpartum patients?

Yes

reset

If no, are you joining with your care team? (i.e. are you joining with a physician, NP, PA, or midwife from your practice?)

Yes

reset

Thank you for your interest in this ECHO! A program coordinator will be reaching out to you to discuss MACS ECHO offerings as this ECHO series is currently reserved for practices working with pregnant/postpartum patients. If you have any questions, please call 1-855-337-MACS (6227), email MACS@SOM.umaryland.edu or visit www.marylandmacs.org
Thank you!

Fax Number

Gender

Please self-describe:

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Do you consider yourself Hispanic or Latino?

What do you consider to be your racial identity? (Select all that apply)

Alaska Native American

American Indian

Asian

Black or African American

Native Hawaiian/Pacific Islander

White

Prefer to self-describe

Missing

Please self-describe:

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Primary Practice Address: Street Name

* must provide value

Primary Practice Address: City

* must provide value

Primary Practice Address: State

Primary Practice Address: Zip Code

Primary Practice Address: [County]

Please specify if "Other":

Type of Practice

Solo or Private Practice

Academic Medical Center

Federally Qualified Health Center (FQHC)

Addiction Treatment Program

Public Health Department

Community Mental Health Center

Other

Pain managment

Missing/No Response Given

Please specify if "Other":

Provider Type of Specialty

Family Medicine

Internal Medicine

Addiction Medicine

Emergency Medicine

Psychiatry

Pediatrics

Obstetrics/Gynecology

Maternal Health

Other

Pain medicine

Missing/No Response Given

Please specify if "Other":

Years in Practice

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Do you have your buprenorphine waiver?

* must provide value

If yes, how many patients are you waivered to see?

30 patients

100 patients

275 patients

Other

Missing/No Response Given

Please specify if "Other":

If yes, how many patients are you currently seeing?

Are you accepting new patients?

Yes

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Have you ever had formal addiction training in addition to your buprenorphine waiver training?

Yes

Missing/No Response Given

reset

Please specify if "yes":

Information about Project ECHO:

Project ECHO is owned by the Regents of the University of New Mexico (UNM), the rights to which have been assigned or licensed to the University of New Mexico Health Sciences Center (UNMHSC). Project ECHO communities track their growth and activities within the iECHO database.

This is a non-contractual agreement outlining the roles and responsibilities between the MACS TeleECHO Clinic and any learning partner participating in our TeleECHO Clinic.

As part of this agreement, MACS will:
Provide best practice tools and tele-mentoring through case-based learning TeleECHO Clinic sessions.

Each 60-minute MACS TeleECHO Clinic will include the following:
-A brief lecture
-Case presentation
-Q & A
-Patient recommendations

As a learning partner, I agree to:

- Complete the pre and post-assessments
- Participate in each of 60-minute MACS TeleECHO Clinic case-based learning sessions, using a virtual meeting platform
- Submit de-identified case(s) and present them to the group during TeleECHO clinics

I understand that:

- Project ECHO case consultations do not create or otherwise establish a provider-patient relationship between any ECHO clinician and any patient whose case is being presented in a TeleECHO clinic session.
- While the case consultations and TeleECHO clinic sessions may offer recommendations regarding effective evaluation, care, and treatment options, these represent recommendations only.
- The patient's treating provider retains sole responsibility for selecting and implementing the plan for evaluation, care, and treatment of the patient.

Please enter your initials indicating that you have read and agree to the terms of the MACS TeleECHO Clinic as described above:

* must provide value

When will you present a case for a teleECHO clinic?
Tuesdays 8am-9am:
September 13
October 11
November 8
December 13
January 10
February 14

Knowledge about initiating MOUDs

* must provide value

Knowledge about prescribing MOUDs for patients already on MOUDs who transfer from another prescriber

* must provide value

Developing practice protocols and workflows

* must provide value

Resources for toxicology screenings

* must provide value

Knowledge about prescribing for patients with dual diagnoses (any combination of medical, mental health, and SUD diagnoses)

Assessing risk for diversion and overdose

Knowledge related to consent and information sharing associated with MOUDs

* must provide value

Lack of case management support in the primary care or OB/GYN setting for people with SUDs

* must provide value

Access to addiction treatment providers and programs for pregnant patients

Managing patients' expectations

Please briefly describe any other major challenges:

Screening pregnant patients for SUDs

* must provide value

Administering behavioral health screenings for SUDs to pregnant patients

* must provide value

Requesting a patient to complete a toxicology screen and discussing results with the patient

* must provide value

Conducting brief interventions with pregnant patients who use opioids or other substances

* must provide value

Prescribing MOUDs for pregnant patients

* must provide value

Screening postpartum patients for SUDs

* must provide value

Providing information on Neonatal Abstinence Syndrome/Neonatal Opioid Withdrawal Syndrome

Prescribing MOUDs for nonpregnant patients

Discussing state reporting laws with patients

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