Until there's a cure ... there's care

 

** Please be advised that, due to a much greater than expected number of funded applications, the MND Victoria Inpatient Palliative Care Top Up Funding has been expended for the current financial year.  Therefore no further applications for funding will be accepted until 1 July 2018.  Thank you for your understanding.**

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 identify key aspects of the care plan, outlining the extended services that the patient will receive.
  • The executive officer or their nominee of the health service completes the declaration 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 – one field for First and Last Names

Email – email address of requesting staff member

Date of Application – DD/MM/YYYY

Client Information

Name – one fields for First and Last Names

Address – individual fields for street, suburb/town, state, and postcode

Gender – select Male, Female or Other – Not Stated

Date of Birth – select or use the standard layout DD/MM/YYYY

Patient UR Number – enter client identification number from patient record

MND Vic Member – select Yes or No

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

Admission Care Type 8 – select Yes or No

Supporting Documentation Completed

These documents do not need to be attached to the application but the Health Service may be required to submit them at the request of MND Victoria.

ALSFRS-R – select yes or no

Cambridge Behavioural Inventory Revised - select yes or no

Patient’s care plan – select yes or no

Eligibility Type

There are three types of eligibility:

  1. High Needs on Admission
    High Needs on Admission – select Yes or No
    5 Palliative Care – select Yes or No
    ALSFRS-R equal to or less than 15 – select Yes or No
    Initial payment $1000 (day 2) – select Yes or No
    Additional Payment (day 19) – select Yes or No
    Day 19+ $3000 select Yes or No

  2. Bulbar MND
    Bulbar MND – select Yes or No
    PEG in situ – select Yes or No
    Initial Payment – select Yes or No
    Additional Payment – select Yes or No
    Day 19+ - select Yes or No
  1. High Cognitive and Behavioural Issues
    High Cognitive and Behavioural Issues – select Yes or No
    Cambridge Behavioural Inventory Revised positive in 6 categories – select Yes or No
    ALSFRS-R on items 1,2,3 and 5 equal or less than 8 – select Yes or No
    PEG in situ – select Yes or No

Care Plan Details

This is a free text box to summarise the care plan requiring additional services

Total Budget

Only one item from the following should be selected Yes

High needs on admission $1000 – select Yes or No

Day 19+ $3000 - select Yes or No

High needs on admission and day 19+ $4000 - select Yes or No

Health Service Information

Health Service – Name of Health Service

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

Banking Details – to facilitate fund transfer

 

Consent

Authorised person - the person who can sign on behalf of the palliative care service – select Yes or No for client consent and confirmation of programme access.

Palliative Care Agency Contact Details – Insert email and phone number

Palliative Care ABN – Enter Agency ABN number

Palliative Care Agency Address – Enter address

Payment Details

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

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 In-Patient Top Up funding initiative can be found at Top Up Funding