MND Victoria Logodonatenow

Twitter pageFacebook pageInstagram

Inpatient 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 Inpatient Palliative Care Top Up Funding available for people diagnosed with MND and who are clients of your service.

The electronic application form on the MND Victoria website is to be used to apply for the Inpatient Palliative Care Top Up Funding available for people diagnosed with MND and who are clients of your service.

Eligibility criteria

  • The patient for whom funding is sought must have a diagnosis of Motor Neurone Disease
  • The patient for whom funding is sought must have been admitted to the health service with a care type of 8 (Palliative Care) or Z51.5 (Palliative Care).
  • There are four patient scenarios that will be eligible for top up funding, each with specific eligibility criteria
  • High needs on admission (maximum of $4,000)
      • ALSFRS-R less than or equal to 15
      • Application for $1000 eligible on day 1
      • Application for additional $3000 eligible on day 19
    • Bulbar MND (maximum of $4,000)
      • ALSFRS-R score on items 1, 2, 3, 5 less than or equal to 4
      • No PEG in situ
      • Application for $1,000 eligible on day 1
      • Application for additional $3,000 eligible on day 19
    • High cognitive and behavioural management issues (maximum of $4,000)
      • Cambridge Behavioural Inventory Revised positive in 6 categories (6 categories scoring 3 or 4 in the assessment)
      • ALSFRS–R score on items 1, 2, 3, 5 less than or equal to 8
      • No PEG in situ
      • Application for $1,000 eligible on day 1
      • Application for additional $3,000 eligible on day 19.
  • The designated inpatient palliative care service requesting funding must include the care plan outlining the extended services that the patient will receive.
  • The executive officer or their nominee of the health service signs the application to confirm that if the application for top up funding is not successful, the length of stay and access to any appropriate treatment or services will not be altered.
  • The health service has not previously received funding for this patient in their current admission.
  • There is funding still available within the capped budget for the program.

The Form

The form has a series of fixed spaces and check boxes to include information. Spaces will expand when you enter information in the free text sections. Click on check boxes

Requesting Staff Member

Name – two fields for First and Last Names

Email – email address of requesting staff member

Date of Application – DD/MM/YYYY

Client Information

Name – two fields for First and Last Names

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

Patient UR Number – enter client identification number from patient record

Diagnosed MND – select Yes or No

Admission Start Date - use the standard layout DD/MM/YYYY

Admission Care Type 8 – select Yes or No

Z51.5 Palliative Care – select Yes or No

Eligibility Type

There are three types of eligibility:

      1. High Needs on Admission – check box
        ALSFRS-R equal to or less than 15 – check box
        Application for initial payment (day 2) – check box
        Additional Payment (day 19) – check box
        Day 19+ - check box
      2. Bulbar MND – check box
        ALSFRS-R on items 1,2,3 and 5 equal or less than 4 – check box
        No PEG in situ – check box
        Initial Payment – check box
        Additional Payment – check box
        Day 19+ - check box
      3. High Cognitive and Behavioural Issues
        Cambridge Behavioural Inventory Revised positive in 6 categories – check box
        ALSFRS-R on items 1,2,3 and 5 equal or less than 8 – check box
        No PEG in situ – check box
        Initial Payment – check box
        Additional Payment – check box
        Day 19+ - check box

Summary of Patient’s care plan – this is a free text box and provides 600 characters of space to summarise the care plan requiring additional services

Supporting documents - attachments

Patient’s care plan – patient’s care plan outlining the extended services that the patient will receive. ALSFRS-R – click on the link to complete

Cambridge Behavioural Inventory Revised - click on link to complete

Total Budget

High needs on admission $1000– check box

Day 19+ $3000- check box

High needs on admission and day 19+ $4000- check box

Health Service Details

Health Service – Name of the Health Service

Providing Campus – use if there are multiple sites in the service

Authorised person - the person who can sign on behalf of the palliative care service – check boxes for consent, access and evaluation as required for eligibility – click to insert an ‘X’ to signify agreement

Banking Details – to facilitate fund transfer

Best Contact – select eMail or Phone

Save application for your records

All documents regarding the Palliative Care In-Patient Top Up funding initiative can be found at http://mnd.asn.au/health-professionals.html 

MND Victoria
Back to Top