EOI Form: My Care Partners program

Organisation legal entity name*

Organisation trading name

(if applicable)

Australian Company Number (ACN)*

Australian Business Number (ABN)*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Primary contact

Primary contact name*

Position*

Phone*

Email*

Secondary contact

Secondary contact name*

Position*

Phone*

Email*

Insurance details

Upload a current Certificate of Currency for each applicable insurance policy:

Medical/Professional Indemnity Insurance (General Practice): minimum $5 million per claim
Public Liability Insurance: minimum $10 million per claim
Professional Indemnity Insurance: minimum $10 million per claim
Workers Compensation Insurance: as required by applicable legislation

Does your practice currently hold the required insurance?*

Yes

No

Insurance commitment*

I do not currently hold the required insurance but agree to obtain it before delivering services if my application is successful.

Medical/Professional Indemnity Insurance (General Practice)

Max. file size: 100 MB.

(Minimum $5 million per claim)

Public Liability Insurance

Max. file size: 100 MB.

(minimum $10 million per claim)

Professional Indemnity Insurance

Max. file size: 100 MB.

(Minimum $10 million per claim)

Workers Compensation Insurance

Max. file size: 100 MB.

(As required by applicable legislation)

Conflict of interest declaration

Do you have a conflict of interest to declare?*

Yes

No

(this refers to any relationship which may affect the decision making for the tender)

Please describe your conflict of interest*

Commissioned Services Agreement (CSA)

Download the Commissioned Services Agreement terms and conditions (PDF)

Agreement with the standard SWSPHN Commissioned Services Agreement (CSA)*

Yes

No

If you answered No above, please cite any departures*

Workforce checklist

My Care Partners relies on a nominated practice team to identify and refer eligible patients. Ongoing referral is required to remain in the program, so your GP workforce’s capacity to engage is relevant here.

Confirm your practice meets the minimum specified personnel requirements:*

At least one GP

At least one Practice Nurse, meeting the minimum hours of 12 hours and 40 minutes per week

At least one Practice Manager/ Administrator

Attach any relevant accreditations (optional)

Max. file size: 100 MB.

Professional References

List 2 professional references for SWSPHN to contact:

Reference one

Name*

Organisation*

Position*

Email*

Phone*

Reference two

Name*

Organisation*

Position*

Email*

Phone*

Application Responses

Strict word limits apply to all responses and will be enforced.

Any content exceeding the stated word limit will not be assessed or considered during the evaluation. Applicants should ensure all relevant information is included, and responses should focus on the central points in the questions as evaluators will only assess content up to the maximum word limit included.

SWSPHN will accept one submission per practice. Applicants will be evaluated and scored against the criteria detailed below.

Criteria Question 1

My Care Partners relies on a nominated practice team to identify and refer eligible patients. Ongoing referral is required to remain in the program, so your GP workforce’s capacity to engage is relevant here.

In addition to your nominated MCP team, how many GPs at your practice are willing to refer and actively engage with patients into My Care Partners? Please provide the number of GPs and FTE of each GP.

Criteria Question 1 (Weighting 30% - Maximum Word Limit 100 words)*

Strict word limits apply to all responses and will be enforced. Any content exceeding the stated word limit will not be assessed or considered during the evaluation.

Criteria Question 2

Your nominated team will be responsible for completing patient activities such as chronic condition management plans and case conferences within set timeframes. We want to understand how the program will stay embedded across your whole practice, not just with the individuals named.

Describe how My Care Partners will be embedded into your practice’s day-to-day workflow, beyond the responsibilities of the nominated MCP team.

Include how you will keep the program visible to all relevant clinical and administrative staff (e.g. team meetings, prompts within clinical software, induction of new staff), and how your practice will sustain this if a nominated team member changes.

Criteria Question 2 (Weighting 25% - Maximum Word Limit 500 words)*

Strict word limits apply to all responses and will be enforced. Any content exceeding the stated word limit will not be assessed or considered during the evaluation.

Criteria Question 3

Participation means regular engagement with the care coordination provider, care planning discussions, clinical huddles and timely follow-up after hospitalisation as well as Community of Practice meetings. We want to understand how your practice will protect time for this.

Describe your practice’s commitment to actively engaging with the program, including how you will set aside protected time for relevant staff to engage with the care coordination provider and SWSPHN.

Applicants should demonstrate genuine commitment to the intent of the program, rather than participation driven primarily by the associated payments.

Criteria Question 3 (Weighting 25% - Maximum Word Limit 500 words)*

Strict word limits apply to all responses and will be enforced. Any content exceeding the stated word limit will not be assessed or considered during the evaluation.

Criteria Question 4

Joining My Care Partners means changes to referral pathways, patient tracking and digital health systems. Tell us how your practice typically manages this kind of change.

Describe your practice’s approach to managing change when implementing new whole-of-practice initiatives, and how this will apply to My Care Partners.

Criteria Question 4 (Weighting 20% - Maximum Word Limit 500 words)*

Strict word limits apply to all responses and will be enforced. Any content exceeding the stated word limit will not be assessed or considered during the evaluation.

Declaration

To be completed by the applicant's authorised representative. Tick each box to confirm your agreement with every statement below.

Application accuracy*

I confirm the contents of this application are, to the best of my knowledge, accurate, complete and do not contain any false, misleading or deceptive misrepresentation, claims or statements.

Other funding*

I declare funding has not been sought or received for this project from any other source.

Evaluation decision*

I understand the evaluation panel’s decision is final, and that no correspondence will be entered into.

Information storage*

I understand and accept information provided in this application may be stored by SWSPHN in various hardcopy and/or electronic formats.

Agreement with SWSPHN*

I understand this application does not create a legal or binding commitment and if successful I will be bound by an agreement with SWSPHN.

Insurance requirements*

I understand I am required to have current and adequate insurances in place, and the premiums are at my own cost.

Reporting requirements*

If this application is successful, I agree to provide reporting requirements in the specified format to SWSPHN on activity levels and outcomes. I am aware components of the reports may be utilised by SWSPHN for auditing or publication purposes.

Recovery of funds*

I understand if the conditions of the funding are not complied with, SWSPHN may seek to recover any funds allocated.

Authorised representative*

I confirm I am an authorised representative of this community/organisation/group.

Name of authorised representative*

Position of authorised representative*

Date*

Primary contact

Secondary contact

Insurance details

Conflict of interest declaration

Commissioned Services Agreement (CSA)

Digital Health Readiness Checklist

Workforce checklist

Professional References

Reference one

Reference two

Application Responses

Criteria Question 1

Criteria Question 2

Criteria Question 3

Criteria Question 4

Declaration