Commonwealth HACC Program
2013 Commonwealth HACC funding round
APPLICATION FORM
PART THREE: Application for service types not identified as regional priorities
Instructions to complete PART THREE
Completing your application
Before you submit your application, complete the checklist to make sure you have met all the requirements for Part Three of your application.
Please complete forms using Arial 12 point font.
Read the Part Three instructions
Completed Part Three application form on the template provided
Completed the application form in English
Completed a separate Part Three application form for each service type for each region you are applying for
Put your Part Three application form/s with your Part One application form and relevant Part Two application form/s. Do not submit these instructions with your application
What information does Part Three collect?
· Part Three of the application records your claims against the assessment criteria for Commonwealth HACC service types not identified as a priority service type in a region.
· The regional priority service types are at Attachment A of the invitation to apply (ITA).
· General information about the Commonwealth HACC service types is at section 3.2 of the Commonwealth HACC Program Manual.
What if I want to apply for more than one non-priority service type and in more than one region?
· You must complete a separate Part Three application form for each service type that has not been identified as a regional priority and in each region you are applying for funding in.
· The Part Three application form is designed for you to demonstrate the need for the service type in the region you are applying for funding in.
What is the information used for?
· The department will assess Part Three application form against the following criteria:
o Criteria 1 – appropriateness of the proposal to the objectives of service delivery under the Commonwealth HACC program
o Criteria 2 – potential for the proposal to meet the objectives of service delivery under the Commonwealth HACC program
o Criteria 3 – the need for services to be delivered
o Value for money
· More information about these criteria and the assessment approach can be found at section 4.3 and section 5.5 of the Commonwealth HACC Program Guidelines.
What if I need additional funding for set-up costs?
· You can apply for additional funding for set-up costs in the Part Three application form. This includes costs associated with setting up or expanding a service.
· Set-up costs and assets are defined in Attachment C1.1 of the Commonwealth HACC Program Guidelines.
· This funding is only available for the 2013/14 financial year.
· Funding for set-up costs is available for items such as office equipment, recruitment expenses, additional training, promotion costs and leasing of vehicles.
· Funding is not available for capital activities. Capital activities are defined in Attachment D of the Commonwealth HACC Program Guidelines.
How do I complete Part Three?
· You will need to refer to the information in these instructions and the ITA to accurately complete all questions in PartThree.
· You may also need to refer to the Commonwealth HACC Program Guidelines, the Commonwealth HACC Program Manual and the Community Care Common Standards.
Are there word limits for the questions?
· Several questions have a word limit. Only the words contained within the word limit will be assessed.
· More information about word limits can be found in section 3.1.3 of the Commonwealth HACC Program Guidelines.
What if the information in Part Three is not complete?
· The department may determine that an application with incomplete information is non-compliant. Non-compliant applications may not be assessed.
· The handling of non-compliant applications is set out in section 5.4.1 of the Commonwealth HACC Program Guidelines.
Explanation of questions
3A – Service type outputs and funding
· Question 3A contributes to the assessment of value for money. Information about this criterion can be found at page 45 of the Commonwealth HACC Program Guidelines.
Table 3A(i) – Service type outputs and funding
· The table at 3A(i) asks for the total number of outputs and funding per annum that you are seeking.
· The number of outputs should be recorded in the appropriate unit for that service type. For example:
o delivered meals is measured in number of meals
o domestic assistance is measured in number of hours of service
o transport is measured in the number of one way trips.
· Information about the outputs for each service type is at section 3.1 of the Commonwealth HACC Program Manual.
· When calculating the amount of funding sought per annum, you need to consider the total funding required over a full financial year to deliver the number of outputs you have identified in the table 3A(i). This might include funding for:
o workforce associated costs
o running costs for equipment including leasing arrangements
o other administrative costs
· The estimated number of clients is the number of individual clients in one year who would receive the services from the outputs you are seeking funding for.
Table 3A(ii) If you are successful in this funding round, how many weeks after execution of a funding agreement will you be able to commence service delivery?
· This question relates to criterion 2.2 and the assessment of value for money. More information about these criteria can be found at section 4.3 of the Commonwealth HACC Program Guidelines.
· Commencement of delivery is when the first client receives the new services.
· When answering this question you may like to consider the timing to establish:
o administration processes
o service delivery infrastructure
o receipt of referrals
3A(iii) Transport for centre based day care
· ONLY complete this question if you are applying for centre based day care at 3A(i) and transport is part of your service delivery model for centre based day care.
· Transport is a priority service type in every region, therefore if transport is part of your service delivery model for centre based day care you will also need to complete the Part Two application form.
· If your centre based day care service delivery model includes provision of transport to and from the centre, please tick yes and complete Table 3A(iii).
· Question 3A(iii) contributes to the assessment of value for money. More information about this criterion can be found at section 4.3 of the Commonwealth HACC Program Guidelines.
· Table 3A(iii) asks for the total number of trips and funding per annum that you are seeking for the centre based day care service.
· When calculating the funding sought per annum you need to consider the total funding required to deliver the number of outputs you have identified. This might include funding for:
o workforce associated costs
o running costs for equipment including leasing arrangements
o other administrative costs
3B – Geographic coverage
· Question 3B contributes to the assessment of value for money. Information about this criterion can be found at section 4.3 of the Commonwealth HACC Program Guidelines.
· Where your organisation intends to deliver the service to a specific location within a Commonwealth HACC region and not the whole region please indicate in Table 3B(i) the local government area/s that you will be covering and explain why you will be targeting these areas in 3B(ii).
· A table of Local Government Areas by Commonwealth HACC region is available from the department’s website at http://www.health.gov.au/internet/main/publishing.nsf/Content/ageing-rescare-aac-stats-tools.htm
3C – Special needs groups
· Question 2C relates specifically to sub-criterion1.2 and contributes to the assessment of value for money. More information about these criteria can be found at section 4.3 of the Commonwealth HACC Program Guidelines.
· Table 3C seeks information about whether the services will be targeted to a particular Commonwealth HACC special needs group. Special needs groups are described in Appendix B in the ITA.
· You may identify any number of special needs groups. If your application is successful, the information in the table will be reflected in your funding agreement.
· In the right hand column of the table, indicate the percentage of total outputs you are planning to allocate to the special needs group/s you identify.
· The percentages allocated to special needs groups plus the percentage allocated to the general Commonwealth HACC target population should equal 100%.
3D – Need for service type in this region
· Question 3D relates specifically to criterion 3. More information about this criterion can be found at section 4.3 and section 5.5 of the Commonwealth HACC Program Guidelines.
· When answering this question you may like to consider:
o the evidence that there is a need for this service type in the region including the basis of this evidence
o the magnitude of the need
o the impact on clients if the need is not met.
3E – Model of service delivery
· Question 3E relates to the following criteria:
o Criteria 1 – appropriateness of the proposal to the objectives of service delivery under the Commonwealth HACC program
o Criteria 2 – potential for the proposal to meet the objectives of service delivery under the Commonwealth HACC program
o Value for money
· More information about these criteria and the assessment approach can be found at section 4.3 and section 5.5 of the Commonwealth HACC Program Guidelines.
3E(i) Describe how your organisation will deliver the services
· This question relates specifically to sub-criteria 1.1, 1.2, 1.3 and 2.1.
· When answering this question you may like to consider:
o what activities the service will deliver
o how the service will be delivered
o how you will monitor the service.
3E(ii) Describe how the service will meet the needs of clients in the region
· This question relates specifically to sub-criterion 1.1, 1.2, 1.3 and 2.1 and value for money.
· When answering this question you may like to consider:
o how the service delivery model will focus on individual client’s needs including accepting referrals; development of care plans and how the services will be reviewed over time
o where special needs groups have been identified, include how the service delivery model will meet the needs of these groups.
3E(iii) How your organisation will work with the broader community and aged care system in the region?
· This question relates specifically to criterion 2.3.
· When answering this question you may like to consider:
o how your organisation works with other service providers
o how you contribute to the referral pathways in the region, for example, how you receive referrals from and refer clients to other service providers and Medicare Locals.
3F – Set-up costs
· 3F contributes to the assessment of value for money. More information about this criterion can be found at section 4.3 and section 5.5 of the Commonwealth HACC Program Guidelines.
· If you do not require funding for set-up costs, do not complete the table.
· This funding is one off funding and must be spent in the 2013/14 financial year.
· For further information on set-up costs, refer to section 2.3 in the ITA.
· You may add lines to the table if required.
· Please justify each set-up cost listed in 3F(i) in the space at 3F(ii).
· Offers to successful applicants may or may not include funding for any or all of the set-up costs included in the application.
3G – Physical location
· The table at 3F collects details of the physical location from which the majority of services will be delivered within the region. For example your organisation may be delivering services from an outlet or local service office within the region even though the head office for your organisation is in a capital city. Record the outlet or local service office physical address.
· If your organisation delivers services from the head office without having an outlet or service office in the region, record the physical address of the head office.
What do I do with the completed application form Part Three application form?
· Complete the checklist on page 1 of the Part Three instructions.
· Put your completed Part Three application form/s together with your completed Part One and Part Two application form/s (where applicable).
· Only submit the completed Part One application form with the relevant completed Part Two and Part Three forms, according to the instructions at on the front page of the ITA. Do not submit these instructions with your application.
Commonwealth HACC Funding Round – ITA No DoHA/003/1314
Part Three instructions
Page 1
Part Three: application for service types not identified as priorities
Organisation nameCommonwealth HACC SK number (if relevant)
State/Territory
Commonwealth HACC Region
Service type (note this Part Three is for service types not identified as priorities in the region you are applying for funding in)
You must complete a separate Part Three application form for each service type that has not been identified as a priority and for each Commonwealth HACC region that you are applying for.
Failure to complete the correct Part may result in a non-compliant application.
Five priority service types have been identified in each region. These are listed in Appendix A of the ITA. If you wish to apply for a regional priority service type you must complete Part Two application form.
Question 3A – Service type outputs and funding
See ‘Explanation of Questions’ Part Three instructions for important information about completing this question
3A(i) Outputs and funding
Number of outputs of the service type sought per annumFunding sought per annum
(GST exclusive)
Estimated number of clients benefiting from sought outputs per annum
3A(ii) If you are successful in this funding round, how many weeks after execution of funding agreements will you be able to commence service delivery?
Number of weeks3A(iii) Transport for centre based day care
This question is ONLY relevant where you are applying for centre based day care in 3A(i) and transport in 2A(i).