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OUD ECHO Survey A: Fellowship Application

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This program is designed to train Illinois primary care providers (physicians, nurse practitioners, and physician assistants) in the assessment and treatment of opioid use disorders in their clinical settings. The training will provide not only clinical guidance but also provide technical support around the clinical workflows, policies, and protocols to ensure compliance with clinical standards and evidence-based practice. Each participant will receive a certificate, approximately 40 hours of continuing education credits, and up to $2000 in training reimbursement* upon full completion.

Fellowship Components Include:

1. Online Weekend Immersion Course (Sat: 8:00-5:00, Sun: 8:45 - 3:30)

Cohort 9: June 24-25, 2023

Cohort 10: April 13-14, 2024

2. Weekly ECHO didactic/case webinars on Tuesdays, 12pm - 1pm

Cohort 9: 7/25/23-3/5/24 (see schedule here)

Cohort 10: 5/21/24-11/12/24

Please fill out the application completely.

Cohort 9 Application Deadline: 5/31/23

Cohort 10 Application Deadline: 4/5/24

*Reimbursement paid in four installments: $500 for completion of the training weekend, $500 for attending at least twenty webinars, $500 for presenting a case of a patient for whom the fellow prescribed buprenorphine, and $500 for expanding practice to include at least five patients with OUD.

Last Name

* must provide value

First Name

* must provide value

Credentials

* must provide value

MD/DO (Physicians)

DNP/ANP/FNP (Nurse Practitioners/APRNs)

PA (Physician Assistant)

Other

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Other

Email Address

* must provide value

Phone Number

* must provide value

Discipline or Specialty (Select your primary field)

* must provide value

Primary Care Provider (Internal Medicine, Family Medicine, General Practice)

Psychiatry or Mental Health Provider

Addiction or Substance Use Treatment Provider

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Name of your PRIMARY practice location

* must provide value

Five-digit zip code of your PRIMARY practice location

* must provide value

Do you treat patients who live in Illinois at your primary practice location?

* must provide value

Yes

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This program is funded with money from the state of Illinois. Thus, participants must treat patients who are living in Illinois. You are thus not eligible to apply.

Which of the following practice settings best describes the PRIMARY setting where you are currently prescribing buprenorphine or planning to prescribe buprenorphine?

* must provide value

Community Health Center/FQHC/Rural Health Center

Emergency Department

Hospitalist/Inpatient Consult Team

Licensed Addiction Treatment Facility (licensed outpatient, residential, opioid treatment program)

Private Practice

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