APPLICATION FOR BROKERAGE Part 1

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ALFRED HEALTH CARER SERVICES provides a range of services to support carers living in the southern metropolitan region. Carer Services has a limited amount of brokerage funding to assist with once-off or short term needs to maintain the caring relationship.

ELIGIBILITY[1]

The carer lives in the southern metropolitan region of Melbourne.

The carer is a family member, friend or neighbour, who provides regular and sustained care and assistance to a dependent family member/friend without payment for their caring role (not including pension or benefit). The assistance has to be ongoing, or is likely to be ongoing, for at least six months (except for palliative care) and be provided for everyday types of activities (for example: self-care, mobility, and communication). There is no citizenship, residency or visa requirement.

The person receiving care does not live in permanent residential care and requires ongoing personal, domestic, social or emotional assistance as a result of frailty, dementia, mental illness, disability or terminal illness.

Brokerage may be approved for:

  • In home support via personal care worker to provide in home respite, meals or cleaning
  • Overnight stays in a facility (community respite house, rehabilitation centre, hospice, aged care home or a supported residential service, or other accommodation for carer)
  • Support for person requiring care to participate in a community based program/facility including social and recreational activities
  • Education and counselling to assist with carer role

ASSESSMENT OF APPLICATION

To help us process this application as quickly as possible, please ensure you provide all information and supporting documentation.

Complete the following forms:

This Application for Brokerage

Minimum Data Set (Part 2)

Brokerage requests will be considered with regards to funding availability, equity of access and priority of need. Requests will be assessed on the basis of:

  • Whether the service or activity is primarily intended to provide respite and/or protect the carer’s health and wellbeing
  • Whether there will be a significant benefit to the carer
  • The carer’s / care recipient’s capacity to meet the cost of the service or activity (supporting information required)
  • Whether alternative funding sources have been exhausted.

APPROVAL OF APPLICATION

If approved, you will be required to book and coordinate the service or activity.

For in home respite

Complete a ‘Safety Assessment Prior to Home Visit’ form with carer prior to booking respite

PLEASE NOTE

  • You must obtain our approval for any changes to the booking.
  • Notify us if any incidents or issues occur during service delivery. For example: personal carer late or not turning up, complaints, potential harm or risk of harm which occurred for staff or clients.
  • Payment is only made for costs approved prior to the service or activity.

Please complete the form below and return with all supporting documentationto:

Fax: 9076 6139 Email:

Spell Check Document <- Double Click “Spell Check Document”

APPLICANT CONTACT DETAILS
Your Name: Organisation:
Position: Date of application:
Telephone: Fax: / Email:
CARER AND CARE RECIPIENT INFORMATION
Please fill in the Minimum Data Set (Part 2)
Carer name: / Carer Suburb:
Details of existing formal & informal supports, and why unable to meet this need:
DETAILS OF BROKERAGE REQUEST
Request is for: Respite Activity Other service
Is the need for this service or activity: Once-Off Ongoing – describe plan to meet ongoing need:
Intended benefit for the carer:
Alternative care to undertake a tasks usually performed by the carer
Will directly protect the carers’ health / wellbeing
Details:
DETAILS OF SERVICE REQUESTED:
PCA requirements (skills & experience):
Tasks to be undertaken during respite:
Details of any specific client response strategies (attach any relevant care or treatment plans)
Shift details (Dates & times): Preferred supplier if known
Funding request
Total cost: $(as per Invoice) / Carer / care recipient contribution: $
Other sources of funding obtained:$
Please attach supporting documentation, or evidence of sources explored / exhausted. / Request for Alfred Health Carer Services contribution: $
Payment method: Direct payment Carer Reimbursement
OUTCOME OF REQUEST
Approved Not approved: Reason for not approved / notes:
Date: / Name: / Position:
Signed:
Confidential / Last Updated 10/10/2016
H:\Service Data\Equipment

[1]Commonwealth Respite and Carelink Centre Program Manual 6th edition July 2012, Department of Health and Ageing, pages 46-48