Integrated Care Innovation Fund 2016-2017
Application form

Title

Insert the title of your proposed project

Organisation and partners

Lead HHS:
HHS CE signature:
Partnering PHN:
PHN CEO signature:
Other Partner(s):

Principal project lead

Title:
Name:
Position:
Organisation:
Department / Unit:
Address:
Phone:
Email:

Prompts have been included initalics in the application template to assist you in developing your

proposal. Applicants are not expected to address all of the prompts. Prompts should be used as a

guide only. Please add any information which may assist the Selection Committee to rate your proposal.

Title

Insert the title of your proposed project

Description of the initiative

  • This section should be no more than 400 words.
  • Rationale: Briefly describe how you know there is a problem, your proposed intervention and how you will know there has been an improvement.
  • Scope of the project and patient cohort.
  • Identify project milestones and key dates to be applied for tracking project implementation.
  • How will the project deliver better integration of care?Briefly outline the role of the HHS and the role of the PHN and the roles of any other partners?
  • A one-page Program Logic Model must be completed ( see template )

Assessment criteria 1 - Innovation

  • Clear description of the innovation in lay terms.
  • Why would this change be considered innovation ?
  • What is the condition the innovation will be used to treat/diagnose/manage? Please provide details on indications, contraindications, inclusion criteria and exclusion criteria as relevant.
  • What is the population need? Please provide details on burden of disease, prevalence and incidence.
  • What is current practice? What is the gap in current practice? Does the innovation replace or adjunct to current practice?
  • What other interventions are appropriate comparators to the innovation, even if they are not currently in use in Queensland?
  • Where else has the innovation been implemented in Australia and the rest of the world? What have the experiences been in these locations?
  • What clinical guidelines influence the management of these patients?

Assessment criteria 2 – Strategic alignment

Describe how the proposed innovation helps Queensland Health achieve the following strategic and access improvement objectives (where relevant). Please indicate how the achievements can be measured:

  • Strategic Objective 2.3 – Support HHSs in maximising patient safety outcomes and patient experience.
  • Strategic Objective 2.4 – Ensure investment strategies are aligned to patient outcomes
  • Strategic Objective 2.5 – Continuously improve clinical governance systems and regulatory frameworks to ensure accountable, safe, high-quality health services—leading to increased performance and public confidence in the health sector.
  • Strategic Objectives 3.3 – Commission services that deliver healthcare to maximise clinical and cost effectiveness to meet the needs of the community.
  • Strategic Objective 5.2 - Develop strategic partnerships with providers to deliver health priorities.
  • Strategic Objective 5.3 – Utilise robust, culturally-appropriate and ethical processes to engage with all partners.
  • faster turn-around times for ambulances at public hospitals,
  • shorter stays in emergency departments,
  • timely access to specialist outpatient services, and
  • improved access to surgical services;

Assessment criteria 3 - Benefits

How will the proposal deliver better integration of care and address fragmentation in services, so that patients can move easily between services?

What are the benefits to patients, for example?

  • quality of life
  • mortality
  • effectiveness of diagnosis or treatment
  • patient experience
  • care provided closer to home
  • increased care options and patient choice
  • delivery of efficient care (no or shorter waiting periods)

What are the benefits for HHS, for example?

  • cost savings
  • reduction in hospitalisation
  • reduction in waiting lists
  • reduced avoidable hospitalisations
  • partnership building with PHN
  • partnership building with other partners/stakeholders

What are the benefits for PHNs, for example:

  • Up-skilling or professional development for general practitioners e.g. participation in a beacon practice model
  • On-call specialist support
  • Faster turn-around times for referrals or discharge summaries
  • Cost savings
  • Partnership building with HHS
  • Partnership building with other partners/stakeholders

What are the benefits to any other partners, for example:

  • Sustainability of service delivery
  • Promotion of services provided
  • Expansion of services provided
  • Increased access to information regarding diagnoses, assessment and treatment

Anticipated outcomes should be specific, measurable, attainable and time-framed.

Assessment criteria 4 – Partnership and governance

What is the governance structure, accountabilities, and who makes decisions?

  • What resources (financial, human) will the HHS, PHN and other partners/stakeholders provide, across the life of the project?
  • What are the key responsibilities of the HHS, PHN and other partners/stakeholders?
  • Have there been successful collaborations between the HHS, PHNand other partners/stakeholders in the past?
  • Clearly identify the project clinical lead and project manager.
  • Describe how you will monitor, measure and report on the achievement of outcomes? This includes the setting of performance indicators which are defined, measurable and achievable.
  • Is the data required to measure and assess performance indicators available in existing information systems?
  • How will the data needed to assess outcomes or performance indicators be collected or extracted?
  • Timeframes, key dates and milestones. Please include all components of the project here such as staff recruitment, procurement and IT system implementation.
  • Consider what your communication and change management plan will look like.
  • What are the risks and potential barriers to the implementation of your innovation as proposed? What mitigation strategies can be put in place?

Assessment criteria 5 – Organisational capability

  • What are the skills and experience of the project team members, hospital, HHS, PHN and collaborating partners to implement the innovation and deliver on proposed outcomes? Have you implemented similar programs in the past?
  • Is there an Information Technology component associated with the technology? Is this software or hardware? Please provide a description along with discussions you’ve had with your local IT team and Health Services Information Agency. How will it integrate with current systems? What testing is required? Who will support it? Have you investigated the Government Information Technology Conditions (GITC) framework? What are the timeframes for each stage of IT implementation?
  • Are there any regulatory or national accreditation standards applicable to the innovation? For example, national standards, registration with the Therapeutic Goods Administration, State Laws, Local Council Regulations. Provide Australian Register of Therapeutic Goods numbers and specific names of standards and regulations as relevant.
  • How will the innovation impact on other services? What support will be required from other departments or other parts of the healthcare system?
  • What training is required?
  • If your innovation requires the provision of equipment, devices, Information Technology or other services from a third party local or international manufacturer, distributer or service provider, please comment on the company’s/companies’ experience delivering products and services related to the clinical field of your innovation and ability to deliver the outcomes you have proposed.
  • Is the project already at a stage of development where funding from industry or venture capital could reasonably be secured in a public private partnership?

Assessment Criteria 6 – Sustainability

  • How will systemic changes be embedded into ongoing practice and existing recurrent funding envelope?
  • How will the project become self-sustaining?
  • Will the project result in an increase in own source revenue?
  • What are the key success factors for this project?

Assessment Criteria 7 - Scalability

  • If successful, how could your innovation be expanded throughout Queensland?

Pre-submission checklist

This checklist is intended to assist applicants to ensure their application is complete prior to submission.

  • Signed by HHS CE
  • Signed by PHN CEO
  • Budget template attached
  • Additional supporting documents (where relevant), e.g. return on investment, letters of support, reference list attached
  • Conflict of interest forms attached where necessary
  • Application form no longer than 10 pages (Ariel font, size 10)
  • A one page Program Logic Model.

The application form, budget template and any supporting documentation should be submitted to by 5pm on Friday, 1 April 2016.

Sign-off by Principal Applicant
Name and title / Signature
Organisation / Date / /
Sign-off by HHS Chief Executive
Name and title / Signature
Organisation / Date / /
Sign-off by Primary Healthcare Network Chief Executive Officer
Name and title / Signature
Organisation / Date / /

Conflict of Interest Declaration

I, ,

confirm the following conflicts of interest of myself and my immediate family in relation to my role as a member of theIntegrated Care Innovation Fund (insert name of your project) project presently and in the last two years, and consent to Queensland Health collecting and using this information on a confidential basis as described in this form.

Private Interests

  1. Other significant sources of income

Please provide details of income from other than your main source of employment relating to contracts, office held in return for payment or other reward, or a trade, vocation or profession engaged in by you.

  1. Office holder

Please provide the name of any company, trustee company or incorporated associations or other entity in which you hold office, whether it is a public or private body, and the name of the office held by you.

  1. Shareholdings and other business interests

Please provide details of any shareholdings, investments or other business interests you or your immediate family may have. Please provide details of all such holdings of which you are aware, which could reasonably raise an actual, potential or perceived conflict of interests, or an interference with your public duties.

Professional interests include any companies or other organisations involved in the development, manufacture or marketing and distribution of health technologies in which you or your immediate family have or have had a professional involvement, including but not limited to making a public statement about that company or a product of that company.

Please provide the name and nature of operations of the company, partnership, association or other entity, and the nature of the interest.

  1. Trusts

Please provide the name and nature of the operations of any trust of which you are aware, which could reasonably raise an actual, potential or perceived conflict of interests, or an interference with your public duties, such as:

  • Any trust of which you are a beneficiary;
  • The name of the trustee or any trust of which you are a trustee; or
  • Any trustee company of which you are a director and in which a member of your immediate family is a beneficiary.
  1. Real Estate

Please provide details of the location and purpose of any real estate owned by you, including your residence or member of your immediate family’s residence, which could reasonably raise an actual, potential or perceived conflict of interests, or an interference with your public duties.

  1. Agreements

Please provide details of any contracts, agreements or understandings entered into by you or an immediate family member, of which you are aware, that gives rise to an obligation or an expectation of reward. Only provide information which could reasonably raise an actual, potential or perceived conflict of interests or an interference with your public duties.

  1. Health Conditions

Please provide details of any health conditions you or your immediate family may have, of which you are aware, which could reasonably raise an actual, potential or perceived conflict of interest or an interference with your public duties.

  1. Future Interests

Please provide details of any future interests you or your immediate family may have, of which you are aware of at the present time, which could reasonably raise an actual, potential or perceived conflict of interest or an interference with your public duties

  1. Other Interests

Please provide details of any other significant financial or other interests held or accruing to you or a member of your immediate family, of which you are aware, which could reasonably raise an actual, potential or perceived conflict of interest or an interference with your public duties.

Examples of substantial financial or other interests:

  • Being a principal or key employee of a material professional advisor supplying services; and
  • Interests in contracts, trusts or other business arrangements not already covered.

Name:

Signature:

Date:

Expiry:______

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