Virginia Opioid Addiction ECHO: De- Identified Case Study Submission

Thank you for submitting a case study!

Some benefits to submitting and presenting are...

-You will recieve valuable feedback regarding your case from our participating experts during the ECHO clinic

-A list of suggestions provided during the ECHO clinic will be sent to you as a reference after the clinic

-Your organization will be able to utilize suggestions and improve patient care!

DO NOT provide any patient specific information nor include any Protected Health Information.

Questions? contact projectecho@vcuhealth.org

Date:

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M-D-Y

Presenter name:

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Presenter Email:

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Presenter Phone Number

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ECHO ID: ______
NOTE: The ECHO ID will be auto-generated and will be emailed to the above address upon submission.

Have you presented at a TeleECHO clinic before?

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Yes No

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Are you following up on a previous patient?

Yes No

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Please state your main question(s) or what feedback/suggestions you would like from the group today?

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Demographic Information (e.g. age, sex, race, education level, employment, living situation, social support, etc.)

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Physical, Behavioral, and Mental health background information (e.g. medical diagnosis, reason for receiving opioids, lab results, current medications, current or past counseling or therapy treatment, barriers to patient care, etc.)

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What interventions have you tried up to this point ?
Additional case history (e.g. treatments, medications, referrals, etc.)

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What is your plan for future treatment? What are the patient's goals for treatment?

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Other relevant information

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By signing below, you have acknowledged that Project ECHO case consultations DO NOT create or otherwise establish a provider-patient relationship between any ECHO clinician and any patient whose case is being presented in a teleECHO clinic.

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