To complete this application, respondents should first refer to:

VNPP Round 4.9 NP models in chronic disease management & aged care Guidelines, and

Nurse Practitioner Candidate Support Packages Funding Guidelines 1 for the details of the policy and funding framework, eligibility, selection criteria for funding of services and funding deliverables and conditions.
Name of Service Provider
Key Contact for submission - Name
Position/Title
Telephone Number E-mail Address
APPLICATION FOR TARGETED AREA:
Complete separate application for each targeted area .
 Chronic Disease Management
 Aged care
N UMBER OF NPC SUPPORT PACKAGES YOU ARE
SEEKING
___ Chronic Disease Management NPCs
___ Aged care NPCs
OVER VIEW OF PROPOSED MODEL
Briefly describe the proposed model of care that a NP role will support (max 500 words)
Include elements such as which part of the care continuum is the model servicing, what are the service parameters including hours of operation, site/settings, client groups or exclusions, referral pathways etc. What specific service gaps does the proposed model and specific NP role anticipate it address? How does this align with relevant key strategy/policy directions?
SPECIFIC DHS SELECTION CRITERIA (max. 3 A4 pages)
KSC 1: Provide brief information about your organisational commitment to develop and expand NP services (to date and current) including appointment of NP candidate in targeted area within designated period.
KSC 3: Provide summary informa tion that demonstrates your organisation’s capacity to successfully manage workforce initiatives of this size/type or previous experience in service development initiatives.
KSC 4: Describe the level of support at both executive level and the specific clinical sponsors (who are considered clinical leaders in area) and their roles within the organisation for this initiative.
1 http://www.health.vic.gov.au/nursing/furthering/practitioner/np-candidates
Department of Health

KSC 5: Describe to what extent your organisation is committed to collaborating with other health services including participating in a DHS NP collaborative/Community of Practice in the course of developing the NP model.
KSC 6: Briefly describe the processes that will be used (existing or new) to engage stakeholders, consumers and community in model development.
KSC 7: Describe how you will recruit/appoint/deploy appropriate project support such as, project coordinator, to enable the work to commence within the required period.
KSC 8: Describe the proposed governance arrangements including project management roles and governance structures
(including roles and responsibilities for all sites if collaborative model).
KSC 8 (Continued): If a collaborative model, the details of all collaborating sites and evidence of the agreement for all sites must be provided.
ANY OTHER INFORMATION IN SUPPORT OF THIS APPLICATION.
Declaration by CEO
In submitting this application, the signatory to the application confirms they have read the VNPP Round 4.9 NP models in chronic disease management & aged care Guidelines and declares that the information contained in the application, including all attachments, is to the best of their knowledge true accurate and complete in all material particulars.
CEO Name
Signature
Date ……./…..../…....
NOTE:
If a collaborative model, a letter of agreement/support is required from CEO’s of all services involved.
If you are unable to insert an authorised electronic CEO signature, a hard copy is required by DHS to be delivered within two weeks of the closing date.
Submitting your Application
Applications (using the VNPP Round 4.9 Application template) should be sent electronically to:
Dan.Schiftan@health.vic.gov.au no later than 28 September 2011 .
Page 2 Department of Health