Pharmacist Chronic Disease Management Pilot
Application form

Pharmacist Chronic Disease Management Pilot – Expression of Interest1

Submission due date:10March 2017, 5pm

Submission to:Workforce Innovation and Reform
Email:
Phone: 9096 7154

Pharmacy

Pharmacy name / Click here to enter text.
Pharmacy address / Click here to enter text.
Proprietor’s name / Click here to enter text.
Main contact name / Click here to enter text.
Main contact title / Click here to enter text.
Main contact number / Click here to enter text.
Main contact email / Click here to enter text.
Is the proposed pharmacy a registered pharmacy premises under the Pharmacy Regulation Act 2010, and meets minimum standards in accordance with the Pharmacy Regulation Act 2010 and the Victorian Pharmacy Authority guidelines?
(Please provide proof of registration of premises) / Yes ☐ / No ☐
Does the owner of the pharmacy hold a current licence under the Pharmacy Regulation Act 2010?
(Please provide proof of licence to carry on a pharmacy business) / Yes ☐ / No ☐
Does the pharmacy have professional indemnity insurance?
(Please provide proof of insurance) / Yes ☐ / No ☐
Hours and days of operation / Click here to enter text.
Average number of scripts per day / Click here to enter text. /
Dispensing system used / Click here to enter text. /
Please explain the current pharmacy staffing model (i.e. how many full time, part time and casual pharmacists and what hours are they rostered) / Click here to enter text. /
Number and description of other staff working at pharmacy / Click here to enter text. /
Names of pharmacists participating in pilot / Click here to enter text.
Please provide AHPRA-issued registration numbers of each participating pharmacist / Click here to enter text.
Name of professional indemnity insurance for each pharmacist and level of coverage.
Please note you will be required to confirm and provide evidence of insurance. Information will be provided to assist you. / Click here to enter text. /
Please answer the following questions in relation to the pharmacy
Does the pharmacy currently run any professional clinical services? If so, please list the professional services provided and provide a brief explanation of how the service is run. / Yes ☐ / No ☐
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Does the pharmacy have a private counsellingroom? Please explain the area and provide a photograph with the application. / Yes ☐ / No ☐
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Does the pharmacy have a suitable cohort of patients with chronic diseases that are being considered for inclusion in the pilot that attend the nominated general practice?
(Please indicate the approximate number of patients for each chronic condition and/or therapy) / Yes ☐ / No ☐
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Is the pharmacy and the pharmacist(s) willing to comply with the communication protocol proposed in the pilotincluding the possible use of an IT or Cloud-based system as determined by the department? / Yes ☐ / No ☐
Is the pharmacy and the pharmacist(s) willing to help facilitate in the evaluation of the pilot and collect, store and provide de-identified qualitative and quantitative data? / Yes ☐ / No ☐
Is the pharmacy and the pharmacist(s) willing to maintain strict patient confidentiality and patient records in accordance to the Health Records Act 2001? / Yes ☐ / No ☐
Is the pharmacy and the pharmacist(s) willing to utilise an interpreter service if required? / Yes ☐ / No ☐
Does the pharmacy currently have any point of care devices or has access to any? If so, please list the brand name and model of the device(s). / Yes ☐ / No ☐
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Does the pharmacy have the capacity to be able to provide a clinical professional service uninterrupted for up to 30 minutes at a time? / Yes ☐ / No ☐
Training for pilot site pharmacists is a mandatory requirement for participation in the pilot. Are the applying pharmacists willing to undergo the necessary training? / Yes ☐ / No ☐
Do the applying pharmacists have any recent training in chronic disease management? If so, please list and provide a brief description of training. / Yes ☐ / No ☐
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Is the pharmacy participating in any other trials or pilots? If so, please list which ones. / Yes ☐ / No ☐
Click here to enter text. /

General practice

Name of general practice / Click here to enter text.
General practice address / Click here to enter text.
General practice contact number / Click here to enter text. /
General practice email / Click here to enter text. /
Hours and days of operation / Click here to enter text. /
Name of practice manager (if applicable) / Click here to enter text.
Does the practice have a practice nurse(s)? / Yes ☐ / No ☐
Name of main contact person:
Name of medical practice software that is currently used? / Click here to enter text. /
Number of general practitioners participating in the pilot / Click here to enter text. /
Names of general practitioner(s) participating in pilot / Click here to enter text.
Please provide AHPRA registration numbers of each participating general practitioners / Click here to enter text. /
Please answer the following questions in relation to the nominated general practice:
Does the general practice have a suitable cohort of patients with chronic diseases that are being considered for inclusion in the pilot?
(Please indicate the approximate number of patients for each chronic condition and/or therapy) / Yes ☐ / No ☐
Click here to enter text. /
Does the general practice have a current wait list for new patients? / Yes ☐ / No ☐
What is the average wait time for booking of non-emergency appointments? / Click here to enter text. /
Is the general practice and general practitioner(s) willing to comply with the communication protocol proposed in the pilot including the possible use of an IT or Cloud-based system as determined by the department? / Yes ☐ / No ☐
Is the general practice and general practitioner(s) willing to comply with the model of care proposed in the pilot? / Yes ☐ / No ☐
Is the general practice and general practitioner(s) currently utilising My Health Record? / Yes ☐ / No ☐
Are any patients being managed under a General Practitioner Management Plan (MBS item 721)? / Yes ☐ / No ☐
If so, how many patients? / Click here to enter text. /
Are any patients being managed under a Team Care Arrangement (MBS item 723)? / Yes ☐ / No ☐
If so, how many patients and what other health professionals are involved? / Click here to enter text. /
What is the general practice’s experience with digital health and health technology? (i.e. Does the general practice participate in any eHealth incentives) / Yes ☐ / No ☐
Any comment:
Click here to enter text.
Is the general practice and general practitioner(s) willing to help facilitate in the evaluation of the pilot and collect, store and provide de-identified qualitative and quantitative data? / Yes ☐ / No ☐
Is the general practice and general practitioner(s) willing to maintain strict patient confidentiality and patient records in accordance to the Health Records Act 2001? / Yes ☐ / No ☐
Is the general practice and general practitioner(s) willing to utilise an interpreter service if required? / Yes ☐ / No ☐
Is the general practice participating in any other trials or pilots (i.e. Australian Primary Care Collaboratives Program? If so, please list which ones. / Yes ☐ / No ☐
Click here to enter text.
Does the general practice utilise a recall reminder system? / Yes ☐ / No ☐

Please answer the following questions:

Please provide a brief explanation of why you are interested in applying for this pilot and what value can you bring to the pilot?
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Please explain the staffing model that the pharmacy would use to enable this pilot. (In the descriptionplease include information regarding how the pharmacy will be staffed to provide patients uninterrupted access to the pilot site pharmacistsand how the pilot will be implemented, managed and monitored).
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Please describe how the pharmacy will ensure access for pilot site patients, including hours the service will be available to pilot patients and how visits to the pharmacy when the pilot site pharmacists are not available will be managedas well as how pilot site pharmacist(s) and general practitioner(s) will be informed.
Click here to enter text.
Please explain how thepharmacyprovides patient centred, coordinated care and a commitment to multi-disciplinary care.
(Your answer may consist of a description of services the pharmacy offers to patients, collaboration with other health care professionals and/or how the pharmacy increases access to care for patients).
Click here to enter text.
Please explain how thegeneral practiceprovides patient centred, coordinated care and commitment to multi-disciplinary care.
(Your answer may consist of a description of services the general practice offers to patients, collaboration with other health care professionals and/or how the general practice increases access to care for patients).
Click here to enter text.
Please describe how the general practice will ensure access for pilot site patients, including hours the service will be available to pilot patients and how visits to the general practice when the pilot site general practitioners are not available will be managed as well as how pilot site pharmacist(s) and general practitioner(s) will be informed.
Click here to enter text.
Please explain the relationship that the pharmacy has with the nominated general practice and general practitioner(s).
(i.e. Does the pharmacy have a memorandum of understanding with the general practice and/or does the pharmacy undertake any shared clinical services with the general practice and/or explain how the collaborate/communicate with the general practice and general practitioners):
Click here to enter text.

Signatures are required from the pharmacy owner, participating pharmacists, general practice manager and participating general practitioners.

By signing the expression of interest you agree to comply with all legal requirements, guidelines and processes determined by the Department of Health and Human Services.

Pharmacy:

Name of pharmacy proprietor:
Click here to enter text. / Signature of pharmacy proprietor:

Name of participating pharmacist:
Click here to enter text. / Signature of participating pharmacist:

Name of participating pharmacist:
Click here to enter text. / Signature of participating pharmacist:

Name of participating pharmacist:
Click here to enter text. / Signature of participating pharmacist:

General practice:

Name of practice manager:
Click here to enter text. / Signature of practice manager:

Name of participating general practitioner:
Click here to enter text. / Signature of participating general practitioner:

Name of participating general practitioner:
Click here to enter text. / Signature of participating general practitioner:

Name of participating general practitioner:
Click here to enter text. / Signature of participating general practitioner:

Pharmacist Chronic Disease Management Pilot – Expression of Interest1