Instructions to complete the electronic application form
The electronic application form on the MND Victoria website is to be used to apply for the Community Palliative Care Top Up Funding available for people diagnosed with MND and who are clients of your service.
- The client for whom funding is sought must have a diagnosis of motor neurone disease
- The episode length of stay for the client must be 90 days or longer before an application can be made, however, the 90 days do not need to be consecutive. Clients can be admitted to the service and discharged more than once as long as their overall stay is 90 days prior to the application being made.
- Activity must be designed to respond to identified needs of the client and address quality of life and well being.
- The service must declare that it has sought alternative sources of funding for the activities and that no funding is available within the time frame required. Alternative sources of funding or service may include Commonwealth Carer Respite funding, Statewide Aids and Equipment Program etc.
- The service undertakes to collect and report the outcomes of the Edmonton Symptom Assessment Scale (ESAS) measure on clients before and after the activity as outlined in the plan of activities. The ESAS item of specific interest is “Wellbeing”. Where the activity is a service delivered over a longer period (a course of intervention) ESAS should be collected during the intervention as well.
- The service undertakes to report the outcomes of the activity, and the expenditure against budget
- The executive officer or their nominee of the community palliative care service confirms that if the application for top up funding is not successful, access to the usual programs of the service will not be prevented.
- The community palliative care service has not previously received funding for this client in the previous 12 months.
- There is funding still available within the capped budget for the program.
The form has a series of fixed spaces to include information. It will expand to fill the page when you enter information in the free text sections.
Requesting Staff Member
Name – a single fields for First and Last names
Email – email address of requesting staff member
Date – DD/MM/YYYY
Name – a single fields for Surname and First Name
Address – individual fields for street, suburb (city), state, and postcode
Sex – select Male, Female or Other – Not Stated
Date of Birth – select or use the standard layout DD/MM/YYYY
VINAH Number – enter identifying number from patient record
LOS 90 days+ - select Yes or No
Aged Care Facility Resident – select Yes or No
MND Victoria Member – select Yes or No
Current ESAS – extract from Client Record and insert
Summary of QoL needs – this is a free text box and provides space to identify QoL needs
Plan of Anticipated Activities - this is a free text box and provides space for the plan to meet needs. Include a timetable of delivery, objective measurement, services and budget
Total Budget – identify amount being requested
Alternative Funding Sought:
Commonwealth Respite, Statewide Equipment Aids or Other Funding: select yes or no to indicate whether funding has already been sought from these programmes. If selecting yes for Other, please indentify the funding source in the associated field.
Palliative Care Agency Name – Name of Health Service
Funding Requested – the amount of funding requested to address needs – must match total budget excluding GST.
Banking Details – to facilitate fund transfer
Authorised person - the person who can sign on behalf of the palliative care service – select Yes or No for client consent, programme access, evaluation.
Name of Authorised Person – two fields for the name of the person authorised to submit application on behalf of the agency.
Funding Required - to facilitate fund transfer into which the funds should be paid upon approval of the application.
Email and Phone – of authorised person
Banking Details – to facilitate fund transfer
Best Contact – select eMail or Phone
Supporting Documentation (if applicable)
Other Document/s – as above
Submitting the Form:
After completing the form, click Save Complete at the bottom of the page. If the form has been successfully submitted, a green message will appear at the top of the screen and you will receive an automated email acknowledging receipt to the email address that you provided. A copy of the submitted form will be attached to the email. This may take up to 20 mins to arrive.
All documents regarding the Palliative Care Community Top Up funding initiative can be found at Top Up Funding