Jan9 - test page

Planetree International’s Fellow in Person-Centered Care (FPCC) is a new professional credential. Becoming a Fellow signals not only your personal conviction that person-centered care is the right thing to do, but also your professional track record of person-centered care in action. The process for becoming a Fellow focuses on expanding your knowledge about person-centered approaches, and then applying that knowledge to improve healthcare.

First Name*

Last Name*

Your name as you would like it to appear on your official Fellow in Person-Centered Care certificate*

First and Last Name, plus credentials

Email*

Job Title/Position*

Organization (If not applicable, enter N/A)*

Site/Department (If not applicable, enter N/A)*

Mailing Address*

Hidden

Country

Country*

Please provide a brief description of why you are pursuing the Fellow in Person-Centered Care Credential. (600 characters or less)*

Permissions*

Planetree is committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, please tick below. You may unsubscribe from these communications at any time. For more information on how to unsubscribe, our privacy practices, and how we are committed to protecting and respecting your privacy, please review our Privacy Policy. Once the Fellows in Person-Centered Care credential is awarded, your name, title, organization and country (as provided in this application) will be published on the Planetree website at https://planetree.org/fellows/fellows-listing/ Please tick the box below to provide your consent to have this information included on the public listing of Planetree Fellows.

Select All
I agree to receive other communications from Planetree.
I agree to allow Planetree to store and process my personal data.
I agree to have my name, title, organization and country published in the Fellows Listing on the Planetree website.

Signature*

By entering my name, I certify all information is true and correct to the best of my knowledge.

Enter Name for Signature*

Date*

Application Fee

The application fee for the Fellow in Person-Centered Care Program is $975 for Planetree members and $1,450 for non-members. There is a discounted rate of $499 for current students and patient/family partners who provide evidence of their current status.

To make arrangements to pay via credit card or to be invoiced, please contact [email protected].

Please note that applications will not be reviewed until payment has been received.

Planetree will not refund the application fee, regardless of the outcome of the application review.

How will you be paying?*

Credit Card (preferred)
Company Check
Pre-paid Fellows Application Fee (as part of enrollment in PCC Professional Certificate Program)
Pre-paid Fellows Application Fee (included in membership)

Planetree Status*

Please check the box that best describes you.

My organization is a Planetree member.
My organization is not a Planetree member.
I am currently a student.
I am currently a patient/family partner.

Evidence of Student or Patient/Family Partner Status

To be eligible for the student and patient/family partner rate, you must provide evidence to validate your status. Students are invited to upload a copy of their current student ID (with the date). Patient/Family Partners can provide evidence in the form of an organizational ID, committee roster with dates or a signed letter validating your role on organizational letterhead.

Max. file size: 128 MB.

Evidence to Earn FPCC Credits

This application prompts you to upload evidence of activities in support of person-centered care that you have participated in over the past 3 years in order to earn credits toward the FPCC credential.

A total of 20 credits is required to earn the FPCC credential.

Applicants must provide evidence of participation in a minimum of one activity within each of the 3 categories: Learning, Doing, Sharing.

All activities presented as evidence must have occurred within 3 years of the date of application.

LEARNING: The following activities focus on continuous learning to inform your professional pursuits and passions related to person-centered care.

Identify at least 1 Learning activity you are seeking FPCC credit for in this application.*

L1. Attended an approved person-centered care, patient experience or culture change conference within the past 3 years. (You are invited to submit up to two conferences for maximum credit.)
L2. Virtually attended a webinar (or stand-alone presentation) on a topic related to person-centered care, patient/resident and family engagement, patient/resident experience, culture change, communication, healthcare consumerism, process improvement (or another related topic) within the past 3 years. (You are invited to submit up to 3 webinars attended for maximum credit.)
L3. Attended a course, workshop, training or continuing education session related to person-centered care, patient/resident and family engagement, patient/resident experience, culture change, communication, healthcare consumerism, process improvement (or another related topic) within the past 3 years. (Note: whereas a webinar for L2 above is a stand-alone presentation that typically lasts 30-90 minutes, a course or training provides more of a deep dive into the subject matter. The content is organized according to an established curriculum or syllabus that includes specific learning objectives. (You are invited to submit up to 3 courses or workshops attended.)
L4. Passed the optional FPCC Competency Exam with a score of 80% or above. (You can access the exam at https://www.surveymonkey.com/r/FPCCexam)

L1 Required Evidence: Evaluation form or certificate of attendance for a person-centered care, patient experience or culture change conference you have attended within the past 3 years (Credit available for up to 2 conferences attended within the past 3 years.)

Credits available: 2 credits per conference (maximum of 4 credits available)

Drop files here or

Max. file size: 128 MB.

L1 Required Evidence, cont'd.: Name and email address of conference contact(s).

Identify a contact person for each conference you are seeking credit for attending.

L2 Required Evidence: Title(s), names of presenter(s) and date(s) of webinar(s) or stand-alone presentation(s) attended within the past 3 years. To earn credit, webinars must be on a topic related to person-centered care, patient/resident and family engagement, patient/resident experience, culture change, communication, healthcare consumerism, process improvement (or another related topic) (You are invited to submit up to 3 webinars for maximum credit.)

Credits available: 1 credit per webinar (maximum of 3 credits available)

Title of Webinar #1

Name of Presenter(s) for Webinar #1

Date of Webinar #1

Name of Hosting Organization or Webinar Series for Webinar #1

Title of Webinar #2

Name of Presenter(s) for Webinar #2

Date of Webinar #2

Name of Hosting Organization or Webinar Series for Webinar #2

Title of Webinar #3

Name of Presenter(s) for Webinar #3

Date of Webinar #3

Name of Hosting Organization or Webinar Series for Webinar #3

L3 Required Evidence: One of the following: Course transcript, copy of syllabus, or certificate of completion for an in-depth course, workshop or training* on a topic related to person-centered care, patient/resident and family engagement, patient/resident experience, culture change, communication, healthcare consumerism, process improvement (or another related topic).

*Note: An educational offering eligible for these credits provides a deep dive into the subject matter. The content is organized according to an established curriculum or syllabus that includes specific learning objectives. (You are invited to submit up to 3 courses or workshops attended.)

Credits available: 2 credits per course (maximum of 6 credits available)

Drop files here or

Max. file size: 128 MB.

L3 Required Evidence, cont'd.: Name and email address of course instructor.

Provide the name and email address for the instructor for each course or workshop you are seeking credit for.

L4 Required Evidence: Score of the FPCC Competency Exam Enter the % score you earned on the FPCC Competency Exam. If you do not know your score, provide the email address you used to log into the exam.

Enter the % score you earned on the FPCC Competency Exam. If you do not know your score, provide the email address you used to log into the exam.

Credits Available: 3 credits

DOING: The following activities focus on practical ways you have applied your knowledge of person-centered care in the field.

Identify at least 1 Doing activity you are seeking FPCC credit for in this application.*

D1. Participated on a site-based (local) person-centered care team, steering committee, work group and/or action team. (You must provide evidence of your presence at 80% of the team's meetings over the course of one year.)
D2. Participated on a patient and family advisory council or a work team that includes patients and family partners as active members. (You must provide evidence of your presence at 80% of the team's meetings over the course of one year.)
D3. Became a trained facilitator of a person-centered care workshop and conducted a minimum of 3 workshops. (Examples include person-centered care retreats, Language of Caring and Expected and Welcome training)
D4. Contributed in a significant way to a person-centered care performance improvement or evaluation project within the past 3 years.
D5. Contributed to a community-based outreach effort to promote patients and families taking an active role in their own health care. (Examples include participation in a health fair, advanced care planning workshop, "mini med school," mobile health screenings, etc.)

D1 Required Evidence: Upload the charter or description of the person-centered care team you participated on.

Credits available: 2 credits

Drop files here or

Max. file size: 128 MB.

D1 Required Evidence cont'd.: How many times did the site-based person-centered care team meet in the one-year period you were an active participant?

D1 Required Evidence, cont'd.: Attendance rosters to demonstrate your participation in at least 80% of the meetings held over the course of one year.

Drop files here or

Max. file size: 128 MB.

D2 Required Evidence: Upload the charter or description of the improvement team you participated on in partnership with patient/resident and family partners.

Credits available: 5 credits

Drop files here or

Max. file size: 128 MB.

D2 Required Evidence, cont'd.: Describe the involvement of patient/resident/family partners on this team.

D2 Required Evidence cont'd.: How many times did this team meet over the one-year period you were an active participant?

D2 Required Evidence, cont'd.: Attendance rosters to demonstrate your participation in at least 80% of the meeting held over the course of one year.

Drop files here or

Max. file size: 128 MB.

D3 Required Evidence: Evidence that you completed a facilitator training that equips you to deliver existing person-centered care workshop content. (Examples include a facilitator certificate or the name and contact information of your trainer)

Credits available: 4 credits

Drop files here or

Max. file size: 128 MB.

D3 Required Evidence, cont'd.: Provide dates of 3 workshops you facilitated within the past 3 years.

D3 Required Evidence, cont'd.: Provide evidence of facilitation of 3 workshops.

(Examples include program evaluation summaries indicating your involvement as facilitator or a training schedule with facilitators identified.)

Drop files here or

Max. file size: 128 MB.

D4 Required Evidence: A completed improvement portfolio worksheet. Access template at: https://docs.google.com/spreadsheets/d/18AuVLPBcwFHQ8WXAOmxhcxU6vd-NF9eTDTVQa_yiGjE/edit?usp=sharing

Credits available: 3 credits

Drop files here or

Max. file size: 128 MB.

D5 Required Evidence: Describe your participation in a community-based outreach event to promote patients/residents and families taking an active role in their healthcare. Be sure to indicate how did the event or program promoted patient and family engagement.

Credits available: 3 credits

D5 Required Evidence, cont'd.: Evidence of participation in the community-based outreach event described above. (Examples of acceptable evidence include promotional materials for the event, photos of participation, screenshots of social media promotion, newsletter articles, etc.)

Drop files here or

Max. file size: 128 MB.

SHARING: The following activities focus on activities that amplify the impact of site-based person-centered care best practices by disseminating them more broadly.

Identify at least 1 Sharing activity you are seeking FPCC credit for in this application.*

S1. Presented a breakout or poster session on topic related to person-centered care at an approved person-centered care or patient experience conference. (You are invited to submit up to two different presentations presented within the past 3 years. Additional credit is awarded for sessions co-presented with a patient/resident/family member.
S2. Published an article on a topic related to person-centered care in a journal, blog, op-ed, letter to the editor, etc. within the past 3 years.
S3. Produced a video about the impact of person-centered care within the past 3 years
S4. Developed and shared an implementation support tool within the past 3 years to support others in person-centered care efforts.
S5. Presented a webinar on a topic related to person-centered care within the past 3 years.
S6. Developed and taught a course or continuing education session related to person-centered care within the past 3 years. (Note: This differs from facilitating a workshop (D3) in that you would have been instrumental in developing the curriculum for this educational opportunity, whereas for D3, you are delivering established content.)
S7. Presented an improvement project an organizational person-centered care fair or educational event within the past 3 years.
S8. Presented on a topic related to person-centered care to the community (for instance at a local library.)

S1 Required Evidence: Title of presentation and name/date/location and hosting organization for up to 2 person-centered care, patient experience or culture change conferences you presented at within the past 3 years.

Credits available: 2 credits per presentation, with an additional 1 credit per presentation possible if co-presented with a patient/resident/family member. Maximum of 6 credits available.

S1 Required Evidence, cont'd.: Were any of the presentation submitted above, co-presented with a patient, resident or family member? If yes, which one and who was your co-presenter?

S1 Required Evidence, cont'd.: Copy of presentation(s).

Please upload PDFs only.

Drop files here or

Accepted file types: pdf, Max. file size: 128 MB.

S1 Required Evidence, cont'd. Copy of program agenda with names of presenters listed.

Drop files here or

Max. file size: 128 MB.

S2 Required Evidence: Copy of article published within the past 3 years with evidence of the author's byline.

Credits available: 3 credits

Drop files here or

Max. file size: 128 MB.

S3 Required Evidence: Provide a link to the video you produced about person-centered care within the past 3 years. (The video can be informative, informational, instructional or a story of impact...or a combination!)

Credits available: 3 credits

S3 Required Evidence, cont'd.: Describe the role you played in developing the video. In other words, how specifically did you contribute to the final product?

S4 Required Evidence: Provide a copy of the person-centered care implementation tool you developed within the past 3 years.

Credits available: 3 credits

Drop files here or

Max. file size: 128 MB.

S4 Required Evidence, cont'd: Do you attest that this tool is an original creation and represents your own work (or the work of a team)?

Yes

S4 Required Evidence, cont'd.: Describe the role you played in developing the implementation tool. In other words, how specifically did you contribute to the final product?

S4 Required Evidence, cont'd.: Provide evidence of how this tool has been used by others to support their person-centered care implementation efforts. (Examples of evidence include screenshot of availability of the tool on an intranet, testimonial of use, etc.)

Drop files here or

Max. file size: 128 MB.

S5 Required Evidence: For a webinar presented on a topic related to person-centered care, patient experience and/or culture change within the past 3 years, indicate: 1.) the name of the session, 2.) the date it was presented and 3.) the hosting organization or education series it was a part of.

Credits available: 2 credits

S5 Required Evidence, cont'd.: Webinar promotional materials (Examples of evidence include email promotion, online events calendar, social media ad, etc.)

Drop files here or

Max. file size: 128 MB.

S5 Required Evidence, cont'd.: Copy of webinar presentation.

Please upload PDFs only.

Drop files here or

Accepted file types: pdf, Max. file size: 128 MB.

S6 Required Evidence: For a course or continuing education session related to person-centered care that you have taught within the past 3 years, submit the course syllabus with evidence of instructor's name. (Alternatively, you may submit evidence of the course description in a course catalog, with evidence of the instructor's name.)

Credits available: 4 credits

Drop files here or

Max. file size: 128 MB.

S7 Required Evidence: A description that covers the organizational person-centered care fair or educational event held within the past 3 years, the improvement project you shared and the format you used to share your project (For instance, a poster, a booth, a panel discussion, etc.)

Credits available: 2 credits

S7 Required Evidence, cont'd.: Evidence of your participation in the program described above. (For instance, photos, a program, flyer, screen shots of social media posts)

Drop files here or

Max. file size: 128 MB.

S8 Required Evidence: A description that includes: 1.) the topic related to person-centered care that you presented in the community; 2.) the format of your presentation (information table, community lecture, etc.) 3.) the date of the event and 4.) the type of community forum (location, meeting, etc.)

Credits available: 2 credits

S8 Required Evidence, cont'd.: Evidence of your participation in the activity described above. (For instance, a flyer, social media post, photos, etc.)

Drop files here or

Max. file size: 128 MB.

Planetree Fellows in Person-Centered Care Application

Application Fee

Evidence to Earn FPCC Credits

LEARNING: The following activities focus on continuous learning to inform your professional pursuits and passions related to person-centered care.

DOING: The following activities focus on practical ways you have applied your knowledge of person-centered care in the field.

SHARING: The following activities focus on activities that amplify the impact of site-based person-centered care best practices by disseminating them more broadly.