Victorian Telehealth Specialist Clinic Funding 2017
Expression of Interest – Application Form (Attachment 1)
Due Friday 18 July 2016, 2:00pm

This template is for Victorian funded public health services wishing to submit an expression of interest to apply for 12 months’ project funding for the 2017 Victorian Telehealth Specialist Clinic Project Funding.

The purpose of the project funding is to support Victorian health services to establish, increase and embed telehealth services in specialist clinics to improve access for patientsto specialist services.

What’s in scope?

Key focus areas for the 2017 Victorian Telehealth Specialist Clinic project funding are:

  • Specialist clinic reviewappointments and preadmission clinics that can be appropriately provided via telehealth
  • Regional patients or patients who have difficulty travelling due to limited mobility
  • Reduction in waiting lists for specific disciplines for example; Chronic disease, Oncology, Obstetrics, Endocrinology, Nephrology, Pain Management, Orthopaedics, Rheumatology, Cardiology, Genetics etc.
  • Public health services who deliver outreach clinics
  • Patients requiring transfers between hospitals for specialist appointments

What’s not in scope?

  • Projects where purchase of IT or equipment is the main component of the project
  • Projects that are currently funded through other targeted initiatives/grants
  • Ongoing operational costs
  • Projects where the primary intent is research
  • Recurrent positions or non-sustainable initiatives.
  • Payment for clinical staff costs

Please note that the Telehealth unit reserves the right to negotiate project key deliverables and budget allocation before confirming final project funding.

Completing the Template

  • You should carefully read the EOI funding application guidelines and the department publication Critical Success Factors: how to establish a successful telehealth serviceprior to completing this template. EOIs will be assessed against these Critical Success Factors.
  • The EOI funding guidelines and Critical Success Factors: how to establish a successful telehealth serviceare downloadable from:

How to Submit

Applications must be submitted as a word attachment online via the 2017 Victorian Telehealth Specialist Clinic Project Online form. Any supporting evidence andletters of support will also be required to be attached as one PDF.

The link to the online submission form is available at

Level of Funding and Duration

Funding Period / Funding Level
12 months / $200,000 (excluding GST)

Submission Timetable

Please note late applications will not be accepted
Expressions of interest open / 18/09/17
Closing date for expression of interest / 13/10/17 5:00pm
EOIs evaluation by Evaluation Panel / 18/10/17 – 10/11/17
Advice to applicants / 27/11/17

Questions?

Please contact Penelope Watson, Telehealth Manager

Email: Phone: 03 9096 1405

1.Victorian Telehealth Specialist Clinic 2017 InitiativeProposed Project Name:

2.Contact Details

2.1.Primary Contact for this Expression of Interest

Name of lead organisation
Key contact
Position title
Telephone number
Email address

3.Project Information

3.1.Project Overview

a)Is this project a new innovation or scaling a proven project?

New Innovation

Proven ProjectProven Project Name:

b)Have you submitted any other telehealth project grant requests elsewhere? If so, please list them.

3.2.Project Purpose, Scope and Planning

Critical Success Factor 1: A clear purpose has been established

a)What is the problem that needs to be solved using telehealth? (include supporting evidence i.e. identified patient cohort numbers, distance, catchment area).

b)What are you proposing to do to address the problem? Describe the proposed project including what’s in scope and what’s out of scope.

c)List the target specialist clinics for this project.

d)What will be the key outcomes of this project? Please list at a minimum 3 and a maximum of 5 expected outcomes. Examples can include but not limited to patient experience, cost effectiveness, staff productivity and training, health outcomes, improved access.

Expected outcome
(i.e. telehealth offered to rural patients, clinics enabled for telehealth) / Description of how you plan to achieve the outcome / Expected KPIs (can be revised when submitting project plan)
(i.e. no of clinics)
1.
2.
3.
4.
5.
Critical Success Factor 4: Project planning and a readiness assessment informs implementation

e)How will you determine the readiness of the health service, from an organisational, clinician and consumer perspective to implement your telehealth proposal?

f)Provide a 12 month project timeline or Gantt chart which includes key project deliverables/milestones. The minimum milestones are listed, please insert additional milestones as required. The project timeline should allow for:

  • a minimum of 3 months preparation for recruitment, engagement of key stakeholders and establishment of local governance groups, collection of baseline data, setting up local guidelines and resources, feedback forms, commencement of mapping of patient flows.
  • at a minimum 6 months to implement the telehealth model
  • 2 months for evaluation and implementation of a sustainability plan

Milestones / Date
Project Steering Committee formed
Project Officer appointed
Project Plan completed
Project Plan provided to DHHS
Project implementation commences
Mid way project milestones achieved – specify deliverables
Six month progress report provided to DHHS
Evaluation completed
Final project report submitted to DHHS

3.3.Project team capacity, capability and governance

Critical Success Factor 2:There is strong leadership and dedicated coordination

a)Has the project gained support from senior leadership: please provide details of the executive/senior sponsors, clinical leads and project team lead?

Name / Position / Organisation
Project Lead
Head of Unit/s
Executive sponsor

b)Provide a summary of the project governance structure (a diagram is acceptable).

c)Provide a summary of existing project management expertise which will lead the project to drive the sustainable implementation, integration and organisation change? If there is no existing project management/clinical redesign expertise how do you plan to address this?

Critical Success Factor 8:Clinical responsibility and governance protocols have been clearly articulated

d)How will clinical protocols be developed to integrate telehealth in to business as usual?

Critical Success Factor 7:Change management is a focus

e)What change management strategies will be used to implement telehealth into specialist clinics? (i.e. mapping of workflows to integrate telehealth, training and education of clinicians, administration staff and patients).

3.4.Technology

Critical Success Factor 5: Technology and clinical service needs are well matched

a)List the video conferencing technologiesthat your organisationhas.

b)Are any of the above suitable to support specialists clinics consultations with patients?

YesNoDon’t Know

If Yes please list the one that will be used:

c)Will you be using Healthdirect Video Call for your project?YesNo
If yes, do you have support from your ICT team to allow downloading Google Chrome, opening ports etc. to enable Video Call? Yes No

d)Has a needs/readiness assessment been completed of the existing ICT infrastructure to support the project, including a mitigation strategy for supporting video consultations in a thin client environment?

YesNo

e)Please provide a letter of support for the project proposal from your CIO and Regional Health Alliance (if applicable).

Letter provided YesNo

3.5.Scalability and Sustainability

Critical Success Factor 6: A sustainable workforce model underpins the service

a)Describe how sustainability will be built into the project and post project – i.e. the workforce required to support the project such as administrators, clinicians, IT.

Critical Success Factor 9: A sustainable funding model is in place

b)This funding for this project is non recurrent; how will the telehealth program attract a sustainable revenue base after project completion and what strategies will be employed to ensure it receives ongoing support from the executive?

3.6.Engagement and Partnerships

Critical Success Factor 3: Key stakeholders and consumers recognise the benefits and are engaged

a)How will you consult and engage stakeholders, including administration staff, clinicians and consumers in the planning and implementation of your project? Provide a brief communications plan and engagement strategy.

Critical Success Factor 10: Services are consumerfocused and consumers are supported in adopting telehealth

b)How will you assess consumer (patients, clinicians, administrators)technical needs and provide support to assist them in using the telehealth service?

Critical Success Factor 12: Involvement and collaboration across the sector

c)Do you have partners involved in the project?Yes No

d)How will the partners be involved in the project? A genuine need for the partnership must be identified with your partner organisation/s; this must be clearly linked to3.2 Project Purpose, Scope and Planning.

e)List the partners involved in the project (a letter of support must be provided for each partner). (Insert additional rows as required)

Partner Organisation
Letter of Support Provided
Key contact Name
Position Title
Partner Organisation
Letter of Support Provided
Key contact Name
Position Title

3.7.Evaluation

Critical Success Factor 11: There is ongoing review and audit and evaluation.

a)How do you plan on evaluating the project implementation and outcomes?(Is there an evaluation process in place, what data will be captured and what baseline measures will be used? How will the patient, clinician and staff experience be evaluated?)

Please note all project related telehealth activity data must be reported as per the data collection requirements set by the departmentwhich includes the VINAH data elements. This will be provided with project report templates.

4.ProjectBudget

Complete the following budget in each line item, excluding GST for each line item. Please provide sufficient detail to clearly justify the inclusion of all items. Boxes can be expanded as required to provide more detailed information.

Item / Cost excluding GST
Staffing costs including on-costs, proposed EFT, staff classification
Equipment
Operational costsi.e. staff training, resource development, web page, evaluation support, travel etc. (please itemise).
Administrative costs i.e. office/computer access, phone calls, stationery, printing, etc. (please itemise)
Other costs
Total funding request
Other funding sources / Cost excluding GST
In kind support from participating organisations
Other funding sources if applicable
Total

5.Any other supporting information?

Victorian Telehealth Specialist Clinic Funding 2017 Application Form1