ED Buprenorphine Implementation Support for the Carolinas

Application Deadline: November 29, 2023 at 5:00pm ET

Applicant Information

Name of person completing this form (first, last)

Credentials

Job title

Phone

Site Information

Hospital name

Emergency Department address (street, city, zip code, state)

Counties your Emergency Department serves

Is your hospital rural?

Is your hospital a Critical Access Hospital?

Champion

Please indicate who will be the champion for this program at your facility.

Is the site champion the person completing this form?

Additional Participants

You may also list other key participants from your facility (optional).

Name (first, last)

General Information

Is buprenorphine being actively administered or prescribed in your ED?

Please briefly describe why your site is interested in participating in this opportunity and what you hope your site can learn or accomplish. (Up to 200 words.)

Please briefly describe the need for this service in your emergency department and community. Include any relevant data on overdose emergency department utilization. (Up to 200 words.)

List any active or potential referral partners that patients can be connected to for ongoing MOUD treatment after ED initiation. If none, please briefly describe any plans to identify referral partners. (Up to 200 words.)

Please briefly describe how you plan to sustain the program after this project period ends. (Up to 200 words.)

Readiness

Which of the following best describe your hospital's readiness to begin treating patients experiencing opioid use disorder? (Select all that apply.)

We have a champion who's started leading the advancement of on-site MOUD access

We have the support of our administrative team for on-site MOUD

Buprenorphine is on formulary

Buprenorphine being actively administered or prescribed in our ED

Options for patient referral to ongoing treatment are known by clinical and support staff

None of the above

Other (please describe)

Attestation

Please check the box to attest that leadership at your site is willing to sign a Participation Agreement to commit to the program requirements described in the Activities section of the Request for Applications, if your site is selected to participate.

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