Fillable Affinity Group Expression Of Interest Form (Centers for Medicare & Medicaid Services)

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Affinity Group Expression Of Interest Form (Centers for Medicare & Medicaid Services)

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Medicaid Prevention Learning Network
Tobacco Cessation Affinity Group
A. Your Project and Goals
1. The Tobacco Cessation Affinity Group will focus on projects to improve quality and utilization of
medical assistance with tobacco cessation for Medicaid/CHIP enrollees. Has your state previously
undertaken activities in this area, or are you currently engaged in related activities?
No, our state has not yet undertaken work to improve quality and utilization of cessation
services. (
Note: Previous work in this area is not required to participate.)
Yes, our state has previously undertaken work to improve quality and utilization of cessation
services.
If yes, please describe your efforts in this area:
2. Briefly describe the project that will be the focus of your participation in the Tobacco Cessation Affinity
Group. (This could be a quality improvement project, a data linkage effort, or other.)
3. Has your state already started working on this project?
Yes No
If yes, what is the current status of the project?
4. What results does your state hope to achieve by the end of 2015?
5. Is there any specific assistance your state will need, or are there barriers to your success that you
can anticipate? If so, please describe below.
2
B. Your Team
6. Please identify the state Medicaid agency official who will lead your team.
7. Who else will participate on your team? Please specify names and roles (e.g., quality leader, data
manager, health plan representative, external quality review organization representative, health
care provider, consumer/patient representative, other).
C. Medicaid Senior Leadership Expression of Support
8. State teams are expected to have the support of the Medicaid Medical Director or some other senior
leadership in the agency to demonstrate the state’s interest in achieving the project’s goals. Please
indicate below the name of the senior Medicaid official supporting participation.
Senior Medicaid Official supporting participation
Name:
Title
Agency
Send completed Expression of Interest forms or any questions about
participating to Deirdra Stockmann, deirdra.stockmann@cms.hhs.gov
.
Name:
Mailing Address:
Phone:
Title:
City/State/Zip
Email:
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Affinity Group Expression Of Interest Form (Centers for Medicare & Medicaid Services)

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Completed 22 July 2020

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