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Community Palliative Care Top Up Funding Application Instructions

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.

Eligibility criteria

  • 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 community palliative care service requesting funding must include a plan and timetable of anticipated activities (including objective measurement) and services that the client will receive, and budgeted costs of the activity. The budget may consist of a quote, for example phased payments, or be costed against a single item.
  • 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 signs to confirm 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

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 – two fields for First and Last names
Email – email address of requesting staff member

Client details

Name – two fields for Surname and First Name
Address – single field, use the format {number} {street} {suburb} {postcode)
Gender – enter M or F
Date of Birth – 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
Member of MND Victoria – select Yes or No
Current ESAS – extract from Client Record and insert

Summary of Client Needs

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
Supporting Document – attach documents such as quote, ESAS etc. if applicants deems as necessary to support the application
Other Document – as above


Authorised person - the person who can sign on behalf of the palliative care service – select Yes or No for consent, access, evaluation and alternative funding sought and not available
Program Access – select Yes or No
Evaluation – select Yes or No

Agency Details

Palliative Care Agency Name – Name of Health Service
Name of Authorised Person – Name of Person
Funding Required – the amount of funding requested to address needs – must match total budget excluding GST.
Banking Details – to facilitate fund transfer

Completion of Form

Best Contact – select eMail or Phone

Save application for your records, complete CAPTCHA test and submit form.

All documents regarding the Palliative Care Community Top Up funding initiative can be found at

MND Victoria
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