IPF Champion Confirmation and Agreement

Transcription

1 IPF Champion Confirmation and Agreement To: XXXXX From: Jeanelle M. Spencer, PhD Date: <<insert date>> Thank you for accepting the invitation to participate as the IPF Champion for the upcoming CME activity, EARLY DIAGNOSIS AND INDIVIDUALIZED MANAGEMENT OF IPF: Strategies for Shared Decision-making to Improve Outcomes **THIS COMMUNICATION CONTAINS ESSENTIAL INFORMATION REGARDING YOUR PARTICIPATION, HONORARIUM, AND DISCLOSURE INFORMATION. PLEASE REVIEW CAREFULLY, COMPLETE THE INFORMATION ON THE LAST PAGE, SIGN AND RETURN NO LATER THAN XX-XX-2016, TO CONFIRM YOUR PARTICIPATION IN THIS PROGRAM. This Activity is jointly provided by Potomac Center for Medical Education (PCME, Accredited Provider) and Rockpointe Corporation (Joint Provider); and supported by educational grant from Boehringer Ingelheim Pharmaceuticals, Inc.. This letter is to serve as an Agreement between NAME OF CHAMPION (IPF Champion) and PCME. Information about this Activity and details of the IPF Champion s commitment are listed below. TARGET AUDIENCE AND EDUCATIONAL OBJECTIVES The target audience for this Activity will be pulmonologists, allergists, immunologists, hospitalists, respiratory therapists, rheumatologists, internists, radiologists, pathologists, NPs, Pas, Nurses, and other health care professionals who are part of the multidisciplinary care team for aptients with IPF. Below are the draft educational objectives for the Activity that will need to be discussed and agreed upon during the planning of the Activity and addressed (as applicable) within the scope of CME Grand Rounds Meetings (15 meetings), and the enduring Archive on mycme. At the conclusion of this Activity, participants should be able to demonstrate the ability to: Identify patients presenting with signs and risk factors of IPF and refer for HRCT to confirm diagnosis earlier in disease progression Incorporate the most recent guidelines to develop an individualized management plan for each IPF patient, considering comorbidities, preferences, needs, and resources Internal Project Code 1914 Page 1

2 Describe strategies to facilitate a multidisciplinary care team approach, including shared decision-making through provider-patient communication on symptom control, sideeffect management and therapy adherence DISCLOSURE It is noted that the IPF Champion previously submitted, and PCME reviewed, disclosure information and came to resolution (if necessary). Failure to disclose and/or failure to respond in a timely manner will result in disqualification from participation in this CME/CE activity. In accordance with the ACCME s Policy on Content Validation and PCME s standards for quality, an IPF Champion s activity in the educational activity must be free of commercial bias, and any information regarding commercial products/services is to be based on scientific methods generally accepted by the medical community. When discussing therapeutic options, an IPF Champion may only use generic names. If it is necessary to use a trade name, then those of several companies must be used. ROLES AND RESPONSIBILITIES IPF Champion Member s role will include: Participate in an initial planning call with the Rockpointe Science Specialist, Jeanlle Spencer, PhD followed by a 2nd introduction call with the speaking faculty Assist in the collaboration between PCME and your institution s CME/CE department for the scheduling of this CME/CE activity Completion of a baseline survey regarding the hospital s current practice in IPF screening and management Attend the live presentation and introduce yourself as the IPF Champion o Assist faculty with the engagement of attendees o Gather and provide feedback on your institution s barriers to care and identify possible solutions o Track Q&A Work in collaboration with the Rockpointe Science Specialist and the educational steering committee, on the development of processes to improve the screening and management of IPF, specific to your hospital setting and staff availability Collaborate with internal hospital teams to develop and emplace an institutional action plan to resolve identified barriers o o Act as point of contact between hospital staff and the steering committee, relaying questions refarding care of a patient or specific process to the steering committee and brining gnasers to staff for implementation Ongoing training of colleagues on the following: Screening strategies and confirmation of IPF Consideration of comorbidities and risks for side effects If the patient is a candidate for treatment, practical strategies for initiation and maintenance of IPF therapy Anticipation and management of side-effects, and management of patient expectations (patient education) Patient referral and utilization of resources for patient support Completion of a 30-day post-activity survey on the progress and ongoing barriers Completion of a subsequent post-activity survey ( days) on progress and ongoing barriers Participation in a post-activity outcomes-oriented phone interview Internal Project Code 1914 Page 2

3 Assist in the review of the publication/poster on the analysis of compiled data from all 15 participating sites Please initial here to indicate you have read, understand, and agree to the policy as listed in the Travel and Reimbursement section. Failure to provide the requested expense report within 30 days after the ToV (or event) occurs will result in withholding reimbursement of your expenses. PROGRAM EVALUATION PCME will develop the baseline survey, 30-day post-activity survey and the subsequest post-activity survey for this Activity. It will include an assessment of the activity and the instution s incorporation of new IPF patient screening strategies and IPF therapy management practices. Results will be provided to the IPF Champion once the summarization is complete. PHYSICIAN PAYMENT SUNSHINE ACT ( OPEN PAYMENTS ) RELATED TO CME GRANTS The ruling set forth by Centers for Medicare and Medicaid Services (CMS) in 2014 states payments or other transfers of value, including payments made to physician covered recipients for purposes of attending or speaking at continuing education events, which do not meet the definition of an indirect payment as defined at are not reportable. That said, funders have interpreted this ruling in different ways, and some funders do require special reporting when it comes to physician payments. As such, we are requiring the following information: Compensation of Covered Recipients serving as the IPF Champion at a program (including CME) includes honoraria. PLEASE PRINT CLEARLY Physician First Name Textual first name, as listed in the National Plan & Provider Enumeration System (NPPES) Middle Name (optional) Textual middle initial or middle name, as listed in the National Plan & Provider Enumeration System (NPPES) Physician Last Name Textual last name, as listed in the National Plan & Provider Enumeration System (NPPES) Recipient Primary Business Street Address Line 1 The first line of the primary practice/business street address Recipient Primary Business Street Address Line 2 The second line of the primary practice/business street address Recipient City The primary practice/business city Recipient State The primary practice/business state Recipient Zip Code The 9 digit zip code for the primary practice/business location Physician Primary Type Medical Doctor (MD); Doctor of Osteopathy (DO); Doctor of Dentistry (DDS); Doctor of Podiatric Medicine (DPM); Doctor of Optometry (OD); Chiropractor (DCP) Internal Project Code 1914 Page 3

4 Physician NPI Individual NPI for Physician (not NPI of any group physician belonging to) Physician License State and State License Number Paired state and official state license number; the pairing includes the 2 letter state abbreviation, followed by a hyphen, followed by the state license number and may include up to 5 "Physician License State and License Number" pairs, if a physician is licensed in multiple states. Maximum of 5 comma separated pairs of the state and license number; AA-XXXXXXXXXXXXXXXXX FEE FOR SERVICE To compensate the IPF Champion for his/her involvement in Activity, payment will be made in the amount of: $250 for participation as the IPF Champion by providing collected data from participants over ~ 4 months IPF Champion should complete and return the attached W9 form to assist with expediting payment. Please initial here to indicate you have read, understand, and agree to the policy as listed in the Travel and Reimbursement section. Failure to provide the requested expense report within 30 days after the ToV (or event) occurs will result in withholding reimbursement of your expenses. CONTACT INFORMATION The IPF Champion must provide the information below. This information will NOT be released outside of PCME, and will be used only to contact the IPF Champion for issues relating to the Activity outlined in this Agreement: PLEASE PRINT CLEARLY Address (where you can receive overnight packages/fedex): This is the address that will be used to send your honorarium Office Phone Number: Mobile Number (to be used only on day of scheduled activity): Preferred address: Administrative Assistant s (AA) Name: AA Telephone and If the IPF Champion is unable to fulfill the obligations of this Agreement, he/she must notify PCME no later than 30 days prior to the scheduled Activity. Faculty Presenter By: PCME By: Jeanelle Spencer, PhD, Science Specialist Internal Project Code 1914 Page 4

5 Once again, thank you for accepting the invitation to participate in this upcoming activity. The PCME staff looks forward to working with you. Should you have any questions, please contact our offices at Please return this signed document within one week of receipt to: Potomac Center for Medical Education FAX: or MAIL: 8335 Guilford Road, Suite A, Columbia, MD Enclosures: Resources: W-9 Form Please access for policy documents related to the planning and development of a CME activity such as the Standards for Commercial Support, as well as, and for important training on certified education. cc: Jeanelle Spencer, Tom Sullivan, CEO Internal Project Code 1914 Page 5