Grant Application FormSevere Behaviour Response Teams

This grant activity will support the establishment of a mobile workforce of clinical experts who will provide timely and expert advice to residential aged care providers that request assistance with addressing the needs of people with very severe and extreme Behavioural and Psychological Symptoms of Dementia (BPSD).

The SBRTs will be a nationally consistent operation, although applications for individual state or territory SBRTs will be considered. Applications from either single service providers or consortiums of providers will also be considered.

SBRTs will focus solely on aged care residents posing a significant risk to either themselves or others.

Information for applicants

Closing Date Applications must be submitted by 2:00 pm (AEST) Wednesday, 15 July 2015.

Application Pack Read all information in the Application Pack before completing this Application Form. The Application Pack is available on the Department of Social Services (D S S ) website. Applications will be assessed using the process outlined in the Programme Guidelines Overview.

Application Help Information about the application process is available on the DSS website. Follow the links on this website if you have a question about the application process. Please allow five working days for a response. Answers to questions will also be available on the DSS website. Questions lodged after Wednesday, 8 July 2015 will not be answered.

If you require assistance or support in using and/or submitting this Application Form, please email grants@dss.gov.au.

How to Lodge Application forms must be completed and submitted via e-mail to selections@dss.gov.au and must be lodged by the closing date and please quote SBRT2015-15 on all documents. Applications must not be submitted after this time.

DSS will acknowledge receipt of your application by email. Please email grants@dss.gov.au if you have not received acknowledgement within 48 hours of submitting your application.

National Relay Service (NRS)

DSS uses the NRS to ensure our contact numbers are accessible to people who are deaf or hard of hearing or have a speech impairment. For further details on accessing the NRS, please visit the DSS website.

Use of InformationDSS may use the information, other than personal information, provided in this Application Form to assist DSS to:

(a) comply with the Australian Government requirement to publish the names of all grant recipients on the DSS website,

(b) inform staff negotiating and establishing Grant Agreements of risks and issues which need to be addressed in the Grant Agreement for that programme, and/or

(c) inform future assessments for applications.

You can only apply if you agree to DSS using the information (not personal information) you provide in this form for the purposes listed at (a), (b) and (c) above.

I agree

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Part 1: Eligibility1. Organisation type and financial status

Is your organisation or lead agency non-government?

Non-government

State/Territory, Local government

Is your organisation or lead agency not for profit?

Not for profit

For profit

Is your organisation a registered charity?

Yes1

No

2. Organisation entity type2

Please check all applicable boxes.

Incorporated association incorporated under Australian State/Territory legislation

Incorporated cooperative incorporated under Australian State/Territory legislation

Aboriginal corporation incorporated under the Corporations (Aboriginal and Torres Strait Islander Act 2006)

Organisation established through specific Commonwealth or State/Territory legislation

Company incorporated under Corporations Act 2001 (Commonwealth of Australia)

Partnership

Trustee on behalf of a trust

Individual

An Australian Local government body

An Australian State/Territory government

If you have not ticked any box from the list above, your organisation is not able to apply for funding. You should refer to the Programme Guidelines for further information.

1 In future not-for-profit charities that are registered with Australian Charities and Not-for-profits Commission (ACNC) will not need to complete some sections of this application form. DSS is working with ACNC and Office of the Registrar of Indigenous Corporations (ORIC) to reduce the number of times the same information is provided to the Australian Government.2 Only Australian legal entities are eligible to receive funding for the provision of services in Australia.

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Part 2: Applicant details3. What is the legal name of your organisation?

This is the name that appears on all official documents and legal papers. It may be different to your trading name.

     

DSS enters into a Grant Agreement with this legal entity only.

All further responses within this Application Form must relate to this entity

4. What is the trading name (business name) of your organisation?This is the name your organisation trades or provides services under.

     

5. What is the business address and main contact details of the applicant? (physical address not PO Box)

Enter the contact person’s address if your organisation does not have its own registered address etc.

Building/floor      

Street no. and name      

Suburb/town      

State      

Postcode      

Telephone      

Fax      

Email address      

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6. What is the postal address of your organisation?

Same as above

Postal Address

Building/floor      

Street no. and name or PO Box      

Suburb/town      

State      

Postcode      

7. What is the outlet name, where the service will be delivered? (If different to Q3 or Q4.)

     

8. What is the outlet’s physical address?

Building/floor      

Street no. and name      

Suburb/town      

State      

Postcode      

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9. If more than one outlet is going to be used to deliver the service please list

Enter the contact person’s address if your organisation does not have its own registered address

(physical address not PO Box)

Building/floor      

Street no. and name      

Suburb/town      

State      

Postcode      

(physical address not PO Box)

Building/floor      

Street no. and name      

Suburb/town      

State      

Postcode      

10. Who are the authorised contact persons for this application?

Preferred contact Alternative contact

Title            

First name            

Surname            

Position in organisation            

Telephone number            

Mobile number            

Fax number            

Business email address            

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Part 2a: Consortium detailsConsortium Definitions Lead agency – This is the legal entity, specified in Part 2, which if successful will be offered a

Grant Agreement by DSS.

Consortium – This is the combined group of entities that is applying for funding through this application form. DSS will only contract with individual providers. Applicants may determine that efficient or effective service delivery is best achieved through the use of a network of providers through a sub-contracting arrangement. This can be recorded in responses to the selection criteria. A successful grant recipient who utilises an authorised sub-contracting arrangement will be held liable for all obligations contained in the terms and conditions of the Grant Agreement. This includes monitoring, management, financial performance, service outcomes, and specifically insurance coverage. Note that the consortium does not sign any Grant Agreement with the Department.

Consortium member eligibility – Place any entity restrictions here e.g. local government (note lead agency eligibility is covered in Part 1).

11. Consortium details (Lead agency details must be completed in Part 2.)

Please list the legal names of all members of the consortium and provide a brief description of each member’s role in the delivery of the services.

Organisation legal name

ABN Role in consortium

1.                   (eg. Lead agency and contract signatory)

2.                  

3.                 

4.                 

5.                 

The Department will not accept changes to consortium arrangements that, in the opinion of the Department, represent a material change to an application.

Further evidence of the consortium arrangements may be sought from successful applicants prior to the signing of the Grant Agreement.

12. Does your organisation plan to sub-contract any or all of the service provision, if this application is successful?

Yes

No

If yes, successful applicants may be asked to provide details of those sub-contracting arrangements and the organisations involved.

Note: If you are submitting a joint application, letters of support from the consortium members must be attached to this applciation.

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Part 3: Financial details13. Does your organisation have an Australian Business Number (ABN)?

Yes

No

If yes, what is the ABN of your organisation?

     

If your organisation has an ABN branch number, please provide it here.

     

14. Is your organisation registered for GST?(Questions on GST requirements should be addressed to the Australian Taxation Office.)

Yes

No

15. If you would like recipient created tax invoices (RCTI/s) to be sent to an alternative email address to that of the preferred contact listed in Q10, please provide the new email address here.

     

If this is left blank RCTI/s will be sent to the preferred contact email address at Q10.

16. Please provide details of your organisation’s bank account for payment should your application be successful.

Record the account details of the organisation listed at Q3 only. DSS will not make cheque payments or payments to a third party.

DSS is unable to fund your organisation if you do not provide bank account details.

BSB number      

Account number      

Account name      

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Part 4: Financial viability and governanceApplicants who are currently funded by DSS do not need to complete Questions 17, 18 and 19.

17. Please attach the following information: Your organisation’s most recent audited financial statements (with previous year for

comparison)

Are these statements fully compliant with Australian accounting standards?

Yes

No

If no, what is your rationale for preparation of financial statements which are not fully compliant with Australian accounting standards?

     

A current financial statement (income and expenditure, balance sheet, and statement of equity - this statement does not need to be audited).

An income and expense budget, for the financial year for which funding is sought. (Excluding the funding being applied for in this application).

18. Please indicate if your organisation has the following:Please check where applicable

An organisation chart

Duty statements for all positions

Financial policy and procedures (systems manual)

Delegations (authorised financial delegates or decision makers)

Business plan

Risk management plan

Minutes of board meetings

As a part of our financial viability verification process you may be asked to provide copies of these documents.

Can you provide copies of these documents within 7 days of a request by us?

Yes

No

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19. Please check if any of the following apply to your organisation.

Any form of litigation or enquiry during the past three years, current or pending.

NOTE: If you have settled a claim on confidential terms, please indicate this in your response.

Any significant financial matter which may impact on the organisation e.g. insolvency or voluntary administration.

Future commitments or contingent liabilities that might materially affect the organisation.

If you have checked any of the above (Q19) please provide a short explanation here (further information may be requested).

     

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Part 5: Activity Details

20. Will the applicant employ staff under the Social, Community, Home Care and Disability Services Industry Award 2010 to deliver this Activity?

Specifically under one the following schedules:

a) Schedule B - Classification Definitions - Social and Community Services Employees; and

b) Schedule C- Classification Definitions- Crisis Accommodation Employees.

Yes

No

21. Will the applicant employ staff to deliver this Activity under either of these awards?a) Social and Community Services (Western Australia) Interim Award 2011; orb) Crisis Assistance and Supported Housing Industry – WA Interim Award 2010.

Note: Applicants may be eligible to receive Australian Government SACS Supplementation if delivering an in scope programme and they employ SACS workers to deliver the programme.

Further information on SACS is available on the DSS website.

Yes

No

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Part 6: Responses to selection criteriaYou must limit your responses to 3000 words per criteria.The Selection Criteria is weighted in the following way.

Criterion 1 – 25%

Criterion 2 – 25%

Criterion 3 – 20%

Criterion 4 – 20%

Criterion 5 – 10%

PLEASE NOTE: Criteria 1 and 2 will be assessed first. Each Criterion attribute will be scored on a rating scale of one to five, with a minimum score of three required for each attribute. Applications that do not achieve a score of 15 or above for Criterion 1 (5 attributes) and 21 or above for Criterion 2 (7 attributes) will not be assessed further.

1. Provide a detailed description of the proposed service delivery model your organisation plans to implement that includes but is not limited to:

a. the structure of a multidisciplinary and interdisciplinary model (including nursing, medical and allied health input), with access to specialist psycho geriatric staff with skills in behavioural management;

b. details of specified personnel and mechanisms for sourcing specialist sub-contractors (if required), detailing relevant attributes commensurate with providing a high level of clinical and psychosocial support;

c. a risk based, referral mechanism for DBMAS to SBRT to enable nationally consistent referrals, and which takes into account both client characteristics and risk factor factors. Upon agreement of this referral mechanism with the Department, the successful SBRT will need to work with DBMAS to ensure this referral mechanism is clearly documented and implemented to ensure only appropriate cases are referred to the SBRT;

d. clear clinical governance arrangements regarding personal, medical and specialist care needs of clients;

e. a clinical and bio psychosocial3 care pathway for the service episode that includes actions, interventions and assessment activities.

Limit 3000 words

2. Provide a detailed description of how your organisation will deliver the following Core Service Elements:

a. delivery of a nationally consistent operation covering all Commonwealth residential aged care homes and flexible funded services;

b. undertaking short term case management including assessments to ascertain causes of the behaviours, facilitating appropriate diagnostic interventions and assisting care staff in resolving the immediate crisis;

c. undertaking longer term case management including assisting care staff to develop long term care plans;

3 A biopsychosocial model is the interaction between one's genetic makeup (biology), mental health and personality (psychology), and sociocultural environment (social) that contribute to health or illness. Source: Boundless. “The Biopsychosocial Model.” Boundless, 03 Jul. 2014.

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d. devising transition strategies between acute and residential care, that support the transition process without managing the logistics; and

e. provision of information, hands on education, training and follow up assistance as needed; f. building and sustaining relationships with other relevant Commonwealth Programme

providers such as DBMAS and DTSC; andg. building and sustaining relationships with other relevant state and territory government

psychogeriatric units, Primary Health Networks and other health organisations as required.

Limit 3000 words

3. Provide evidence of your organisation’s demonstrated skills and experience in a similar service delivery model which must include:a. achieving improved client outcomes;b. providing service delivery to special needs groups, including CALD, LGBTI and Indigenous

Australians, as noted under section 2.4 of the Ageing and Service Improvement Programme Guidelines, May 2015;

c. supporting existing provider and health systems, including transition processes; andd. maintaining linkages across the different disciplines and sectors for continuity and co-

ordination of care.

Limit 3000 words

4. Provide an overview of current and proposed infrastructure within your organisation that will enable the achievement of the desired outcomes of the project which must include:a. facilitating initial responses to referrals within 24-48 hours either by face to face or video

conference contact, including for rural and remote clients; andb. strategies for ensuring access to remote and rural providers, accounting for the differences

in capacity, access to technology and distance from services that may exist.

Limit 3000 words

5. Provide a response to the Department’s aforementioned benchmarking requirement which addresses the following components:a. the Applicant’s proposed handling of the benchmarking data requirements;b. the Applicant’s proposed approach to collection and analysis of the data;c. the Applicant’s proposed Key Performance Indicators (KPI) to allow measurement of the

above requirements; andd. the Applicant’s proposed target measures of these KPI’s.

Limit 3000 words

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Part 7: DeclarationPlease read and complete the following declaration.

I declare that:

The information, including financial information, contained in this form is true and accurate.

I have read, understood and agree to abide by the Programme Guidelines Overview.

I have read, understood and accept the terms and conditions of funding and my organisation will be able to fully comply with those conditions;

I understand that incomplete applications may not be considered;

I have read, understood and agree to the Grant Agreement, should this application be successful.

I agree to receiving a Recipient Created Tax Invoice (RCTI/s) for this funding if this application is successful. If and where any personal details of a third party are included, the third party has been made aware of, and

given their permission for, those details to appear in this application.

I am not aware of any perceived or actual conflict of interest that will arise by submitting this application. (For more information please see the Programme Guidelines Overview). Describe below any conflicts of interest that have been identified.

I give consent to the Department of Social Services to make public the details of the applicant and the funding received, should this application be successful.

Describe any conflicts of interest that may occur from submitting this application.

     

If any financial information requested at Q17 has not been submitted please list any missing documents here.

     

I understand and agree to the declaration above

I acknowledge that giving false or misleading information to DSS is a serious offence under Section 137.1 of the Criminal Code Act 1995 (Cth).

Signature      

Date      

Name (please PRINT)      

Position in organisation      

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22. Please provide an estimate of the time taken to complete this Application Form, including:

actual time spent reading the guidelines, instructions and questions,

time spent by all employees in collecting and providing the information, and

time spent completing all questions in the Application Form.

Hours       Minutes      

Grant Agreement

Successful applicants must agree to sign a Grant Agreement with the Australian Government Department of Social Services (DSS).

The General Grant Terms and Conditions are included in the application pack.

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Part 8: Application checklistTo ensure that your application is complete, use the following checklist.

Part 1 Eligibility: Have you responded to all relevant areas?

Part 2 Applicant details: Have all details been completed?

Part 2a Consortium details: Have you listed all consortium members and completed the table at Q11. Have you provided all supporting documentation?

Part 3 Financial Details: Have all questions been completed?

Part 4 Financial Viability and Governance: Have you provided the documents requested at question 17, and completed all questions?

Short explanation to question 19 has been attached if required

Part 5 Activity Details: Have all questions been answered?

Part 6 Responses to selection criteria: Have you addressed selection criteria 1 to 5, in this application, in line with the Programme Guidelines Overview?

Part 7 Declaration: Have you read and completed the declaration carefully?

Part 8 Application checklist (this part): Have you completed the application checklist?

Note: applications that are incomplete may not be considered.

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