Instructions
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:
- 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 - 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 - 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