CalSIM: Information Gathering Form
Goal: To inform the deliberations of the Cal SIM Accountable Communities for Health Workgroup about the level of interest and activity occurring across California with regard to projects already in existence that may relate to potential Accountable Communities for Health.

Background: California’s proposal to the federal government for a State Innovation Model (SIM) Testing Grant includes support for three pilot Accountable Communities for Health (ACH). An ACH is a multi-institutional collaborative of health care providers and payers, community based organizations, public health, government, and other entities in a given geography that is dedicated to improving the health of the entire community.

1. Your Name:
Your answer
2. Organization:
Your answer
3. Name of project or collaborative:
Your answer
Year the project/collaborative began:
Your answer
4. What is the goal of the project/collaborative and what does it focus on (e.g., does it focus on a particular health issue, such as diabetes)? [Limit 50 words]:
Your answer
5. How does the project/collaborative seek to achieve its goals (e.g., what strategies are used; please highlight any strategies that utilize a combination of clinical and community interventions.) [Limit 150 words]:
Your answer
6. What is the geographic reach of your project/collaborative and how do you define the target population? [Limit 50 words]:
Your answer
7. How is the project/collaborative managed? [Limit 25 words]:
Your answer
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