GOLD COAST PRIMARY HEALTH NETWORK PARTNERS IN RECOVERY COMPLEX NEEDS ASSESSMENT PANEL (Adults) - COMMUNITY LEAD AGENCY APPLICATION FORM DEADLINE FOR APPLICATIONS 5.00 PM FRIDAY 2 ND OCTOBER 2015 1 P a g e
COMPLEX NEEDS ASSESSMENT PANEL COMMUNITY LEAD AGENCY APPLICATION FORM 2015 Gold Coast Complex Needs Assessment Panels The Gold Coast Complex Needs Assessment Panels bring together key decision makers in government and non-government organisations to provide a coordinated approach when assessing and planning the service and support requirements of people with complex needs. Complex Needs Assessment Panels aim to improve and integrate service delivery to achieve positive outcomes in overall quality of life and health. This is achieved by addressing issues and barriers the person is facing through a flexible approach to case planning and the implementation of ongoing holistic interventions. The panels' function also involves advocating within members organisations, networks and sectors to ensure the effectiveness of collaborative partnerships. Members of the panel are required to have decision making ability within their respective organisations, enabling a more effective and clearer pathway for recommendations made through the panel process. On the Gold Coast four panels operate: Complex Needs Assessment Panel for Young People (10 to 17 years) Complex Needs Assessment Panel for Adults up to 64 years (CNAPA) (for individuals who are Hospital and Health Service case managed) Complex Needs Assessment Panel for Integrated Support (CNAPIS) Complex Needs Assessment Panel 65+ year old (CNAP65+) The need for a CNAP Community Panel Partners in Recovery Gold Coast has identified that service delivery gaps exist for individuals who require needs assessment and case management services, and are not currently receiving case management by Gold Coast Hospital and Health Service (GCHHS). Individuals who are GCHHS case managed are currently referred to the CNAPA panel. Consultation with current CNAP Panel leaders determined the most effective way to reduce this gap and meet the needs of adults with complex mental health disorders in the region is to expand the current CNAPA panel. The establishment of a new panel, Complex Needs Assessment Panel Community (CNAP Community), aims to facilitate greater care for people with a mental illness by improving service access, planning and coordination, and is intended to promote a continuum of care for adults. Referrals to the CNAP Community panel would be for individuals who are not GCHHS case managed. 2 P a g e
Your Invitation to Apply Partners in Recovery invites applications from the community services sector to become the Lead Agency for CNAP Community. Seed funding will be provided through Partners in Recovery Gold Coast to the successful applicant who will then be required to undertake planning and implementation of this new panel. Conditions of Funding 1. Available Funding and project delivery time frame Available funding Available funding for this initiative is $20,000 excluding GST. Project delivery timeframe Funding is available from the execution date of the Service Agreement. 2. Eligibility requirements and funding exclusions Eligibility Criteria Applications will not be considered eligible for assessment unless all of the following eligibility criteria are met. Applicants must be a viable legal entity as defined by ATO: A not-for-profit incorporated association or company A government agency or statutory body A company or partnership A not-for-profit organisation with other legal status A community group in an auspice arrangement with one of the above, or Sole Traders ie general practitioners, allied health professional, nurses etc. And meet the following requirements: An ABN or provide evidence they have applied for one, or be auspiced by an organisation that does have an ABN. Deliver all funded activities in the Gold Coast Primary Health Network geographical region (Appendix B). Ensure that the declaration at the end of the application is made by the CEO or equivalent. This person must have ultimate financial and management responsibility for the organisation applying for funding. Current Public Liability insurance policy with a minimum of $10 million in cover and $5 million Professional Indemnity per event. 3 P a g e
3. What are the responsibilities of the Successful Applicant? The successful applicant must agree to: Enter into a Service Agreement. Applicants can review the Service Agreement upon request. Must be able to commence the first panel in December 2015. Receive half of the funding with the remainder of the funding withheld until a review is undertaken on the success of the CNAP Community Panel five months after its commencement. Ensure the sustainability of the CNAP Community Panel after PIR funding has ended by providing the chair and secretariat to the monthly panel process. Report progress twice during the terms of agreement to the GCPHN using the standard template. Present the outcomes of the project as part of the final reporting requirement to share learnings. Be responsible for the reporting and financial acquittal of the grant within the timeframe specified in the Service Agreement Appropriately acknowledge Partners in Recovery for the assistance provided for the project. 4. Project information Information regarding the funding available: The current CNAPA panel meets monthly at Ashmore Community Mental Health. The CNAP Community panel will meet for one hour at the end of the current CNAPA panel meeting. The successful applicant will provide the chair and secretariat to the CNAP Community panel meeting. The successful applicant will provide administration support during the month (between panel meetings) in receipting panel referrals, rostering individuals regular review by the panel, and undertaking any other administrative or panel tasks during the month. 5. Important information about the application process Applications for this funding opportunity should be submitted by 5pm on Friday 2 nd October 2015. Given the tight timeframe for organisations to submit applications for this funding, Partners in Recovery can provide assistance to organisations in relation to their application. This assistance does not include writing any content for the application. The Selection Panel The assessment panel will comprise of representatives from Gold Coast Primary Health Network, Partners in Recovery, Gold Coast Hospital and Health Service and a CNAP panel member organisation. We expect that funding decisions would be notified within three weeks of closing. 4 P a g e
Key dates This funding opportunity closes 5pm Friday 2 nd October 2015 Decision advised First payment First panel meeting Within three weeks of close date On signing of the Service Agreement First Monday in December Contact Information To ensure a fair and transparent process for all applicants we ask that all questions and queries be sent via email to pirfunding@gcphn.com.au so that the response can be made available on the Partners in Recovery website www.pirgoldcoast.com.au to all potential applicants. 6. Accessibility If you have difficulty reading a standard printed document and would like to receive this publication in an alternative format such as large print or braille please email pirfunding@gcphn.com.au If English is not your first language and you require a translating and interpreting service please email pirfunding@gcphn.com.au Instructions to Applicants Before you begin, please read the Lead Agency Application Form (this document) paying particular attention to the eligibility criteria and funding recipient s responsibilities. Applicants must complete all relevant sections of the application form, including the checklist and declaration. Applications must be received by 5.00pm, Friday 2 nd October 2015. Applications must be typed and submitted electronically via email. To ensure a fair and transparent process for all applicants we ask that all questions and queries need to be sent via email so that the responses can be made available on the Partners in Recovery website to all potential applicants. E-mail: Web: pirfunding@gcphn.com.au www.pirgoldcoast.com.au Application requirements A complete application form Letters of support (if applicable) Evidence of legal entity status (eg. Certificate of Incorporation) Evidence of current Public Liability and Professional Indemnity Insurance (eg. Certificate of Currency) 5 P a g e
1. ABOUT YOUR ORGANISATION 1.1 DETAILS OF LEGAL ENTITY In this section you are required to provide information about your organisation/business or if you are submitting this application under the auspices of an organisation you are asked to supply the information on the organisation auspicing you here. Registered business name Street address Trading name of Legal Entity (if different from above) Postal address (if different from above) Telephone Email Website (if applicable) 6 P a g e
Incorporation Status of Applicant Organisation or Auspice Organisation where appropriate Is the organisation registered for GST? (place a cross in the answer) Yes No Is the organisation GST exempt? (place a cross in the answer) Yes No If Yes; please provide evidence of this with you applications Is the applicant organisation incorporated? (place a cross in the answer) Yes No Type of legal entity Please indicate legal entity type (and attach copy of current certificate) Australian Business Number 1.2 CONTACT DETAILS In this section you are required to provide contact details of your authorising officer and key project contact person. 1.2 (a) Principal Contact Person The principal contact person is the person who is legally authorised to enter into Service Agreements on behalf of your Legal Entity or the auspicing organisation. The principal contact must complete the declaration at the end of this application and will be required to sign a Gold Coast Primary Health Network Service Agreement for the Provision of Funding if your application is successful. Note: For incorporated organisations this is generally an office bearer of the management committee eg. Chairperson, President, Secretary or CEO. Authorised contact name 7 P a g e
Position title Email Landline Telephone Mobile 1.3 INSURANCE Does the applicant organisation hold a minimum $10 million Public Liability and $5 million Professional Indemnity insurance? No Yes You are ineligible for funding Please provide Certificates of Currency as evidence Expiry Date of Insurance Policies 1.4 ORGANISATION / BUSINESS INFORMATION Provide a brief summary of the kind of work the applicant organisation usually performs (maximum 200 words) 8 P a g e
2. APPLICATION DETAILS In this section, you are required to provide specific details on the proposed project, including what your project aims to achieve and timeframe. 2.1 Capacity Statement Include a statement of your suitability, experience and availability to undertake the role as CNAP Community Panel Lead Agency (maximum 200 words) 3. PROJECT MANAGEMENT 3.1 Who is involved in implementing the project and what are their key roles and responsibilities in the delivery of the project? Insert additional lines as required. Name Role and responsibilities 3.2 Implementation Plan Include a detailed plan outlining the proposed approach for the work required and timelines for implementation (maximum two A4 pages) 3.3 Evidence of Planned Approach Using the table provided, list the activities/milestones that will be undertaken to complete the project and when they will be completed. Activity/milestones eg. Hold information session Expected date of achievement eg. September 2015 9 P a g e
4. EVALUATION How do you plan to collect information and analyse information to evaluate and report the gains, outcomes and learnings of the project? (maximum 150 words) 5. SUSTAINABILITY Describe the sustainability of the CNAP Community Panel after PIR funding has ended, as this is a condition of funding. (maximum 200 words) 6. RISK MANAGEMENT Partners in Recovery recognises that risks arise in all projects. In assessing your application we consider how well you recognise risks and how you plan to manage them. In this section provide specific details about potential project risks you have identified and what actions you will undertake to manage and mitigate these risks. Risk Actions to mitigate risk 7. PROJECT BUDGET Please provide a Project Budget which lists income and expenditure directly related to the project. Provide a detailed breakdown and description of all project expenses. 10 P a g e
8. SERVICE AGREEMENT Successful applicants will be notified by email. We would appreciate it if you could review the draft Service Agreement and note below any clause or condition your organisation would wish to discuss prior to receiving the Service Agreement. Clause Comment 11. DECLARATION Please read and sign the following declaration: I have read and accept the General Conditions outlined in the Partners in Recovery Lead Agency Application Form. I declare that the organisation is financially viable and able to manage the project within the timeframe and within budget. I declare that all information provided in this application is true and correct. I understand that this application does not create a legal or binding commitment, arrangement or understanding between Gold Coast Primary Health Network and the applicant organisation. Any such commitment, arrangement or understanding will be the subject of further negotiation and documentation, including a Service Agreement. Additional specific conditions may be included in the Agreement. I understand and accept that information provided in this application will be stored by Gold Coast Primary Health Network in various formats including hard copy and/or electronic storage. I have supplied all the following application requirements and supporting documentation: A complete application form Letters of support (if applicable) Evidence of legal entity status (eg. Certificate of Incorporation) Evidence of current Public Liability and Professional Indemnity Insurance (eg. Certificate of Currency) 11 P a g e
Signed by authorised organisation representative Signature Name Position Date Thank you for taking the time to complete this application. 12 P a g e