Development Scheme (MPDS)

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Māori Provider
Development
Scheme (MPDS)

2013/16

A
pplication form


Citation:
Ministry of Health. 2013.
Māori Provider Development Scheme (MPDS)
2013/16:
A
pplication form.

Wellington: Ministry of Health.

Published in
June 2013

by the

Ministry of Health

PO Box 5013, Wellington

6145
, New Zealand


HP

5671

This document is available
at w
ww.h
ealth
.govt.nz




Māori Provider Development Scheme (MPDS) 2013/16: Application form

iii

Instructions

Please:



read the accompanying
Māori Provider Development Scheme (MPDS) 2013/16: Guidelines
for completing the application form

(the
Guidelines
)

before filling out this form



provide all information requested

within the application form and outlined in the
Guidelines in order for your application to be considered



submit
one (1) electronic copy as a
Microsoft WORD

document only
.

Please ensure
the file size does not exceed 2

MB, and that any

quotes fo
r items/act
ivities over $5,000 and
other images are attached in a separate PDF file



email your electronic copy to:
MPDSadministrator@moh.govt.nz


Electronic applications are available on the Ministry
’s

website,
www.health.govt.nz


The decision of the Ministry of Health is final.

No further correspondence will be entered into.


Closing date and time for submitting applications

is
12.00 pm, Friday 26

July 2013







Māori Provider Development Scheme (MPDS) 2013/16: Application form

v

Contents

Instructions

iii

Section 1: Provider details

1

1

Contact details

1

2

Eligibility

1

3

Governance and service delivery

2

4

Quality

2

5

Workforce

3

6

Information technology

3

7

National health providers and national disability providers

4

8

Māori Provider Capacity Assessment Tool

4

9

Organisation development plan

4

Section 2: Funding categories

5

Provider Assistance: Infrastructure Support

5

Provider Assistance: Information Technology

6

Workforce Development

6

Service Integration

7

Quality

7

Best Practice

8

Section 3: Budget

9

Section 4: Other

10

Risk
management

10

Additional information

10

Checklist

10

Provider endorsement

11





Māori Provider Development Scheme (MPDS) 2013/16: Application form

1

Section 1
:

Provider details

ALL PARTS
OF THIS SECTION ARE
COMPULSORY

TO COMPLETE
.


1

Contact
d
etails

Name of applicant/organisation







Legal entity status







Charities Commission
r
egistration
n
umber







Trading as

(if different from above)







Provider number







Provider type

(p
lease tick one)

National


Regional


National
d
isabilit
y


DHB
r
egions you provide services within








CEO contact details

Key MPDS contact person

Name







Name







Position

CEO/Kaiwhakahaere

Position







DDI







Organisation phone







Fax







Fax







Mobile







Mobile







Email







Email







Postal address
(including post code)







Postal address

(including post code)







Physical address







Physical address








2

Eligibility

Please tick one.

An
existing

Māori health provider or a Māori organisation with a relevant Ministry of Health
and/or DHB and/or PHO contract?


Part of a
joint venture

with a Māori health provider?


In the process of
developing

a contract with the support of the DHB, PHO and/or the Ministry
of Health?



Health funding details

Complete all sections.

Contract
n
umber

Type of
s
ervice

Contract
v
alue

(per annum GST excl
usive
)

Funder

(DHB/
Ministry
/

PHO)











































































2

Māori Provider Development Scheme (MPDS) 2013/16: Application form

Do you receive development funding from any other central government agencies (eg,
Te Puni
Kōkiri
,
Ministry of Social Development
, Ministry of Education)?

Yes


No



If so, please complete the following section.

Contract
number

Type of service

Contract value

(per annum GST exclusive)

Funder










































































3

Governance

and service delivery

Refer to the MPDS Guidelines
‘E
ligibility
for MPDS funding’
section before completing this
question.

If sufficient information is not provided to meet the eligibility requirements,
your
application will not be considered.


D
escribe
who

you deliver services to
,

including
% of Mā
ori people using
your
services
.







D
escribe your
governance

arrangements,
including
:



% of M
ā
ori in governance roles



confirmation that the beneficiaries/members
who appoint the governance are majority
M
ā
ori



e
vidence that high levels of M
ā
ori
representation
are
maintained
.







I
n the event of closure or wind
-
up,
will
assets
be

disbursed to a Māori community or an
organisation with the same or similar service
?

If no, please provide further details
.








4

Quality

Is your organisation accredited or certified?







Please describe the

q
uality systems

within
your organisation.

I
nclude details of
your
accreditation
, and/or

certification if applicable,
current status, year attained
.










Māori Provider Development Scheme (MPDS) 2013/16: Application form

3

5

Workforce

Note: Only include staff members who are directly involved in health service provision
.


Area

Total number
of staff

Māori

Non
-
Māori

Full
-
time

Part
-
time

Full
-
time

Part
-
time

1

Me
dical
p
ractitioners































2

Nursing































3

Midwifery































4

Dental































5

Dieticians































6

Pharmacy































7

Physiotherapy































8

Psychologists































9

Other
clinical


p
lease

specify











































10

Community
h
ealth
w
orkers































11

Kuia/kaum
ā
tua/kai
ā
whina/ng
ā

manaaki































12

Health
m
anagement
and

a
dministration































13

Other
n
on
-
clinical


p
lease specify












































Total
































6

Information
t
echnology

Systems/
a
pplications/
s
oftware

Example

Ap
plication n
ame

N
umber
of

u
sers

Office
a
utomation
s
ystems

Microsoft
Office
,
Microsoft Outlook
,
Visio













Accounting
and

p
ayroll
a
pplications

MYOB, Cashbook
,
Moneyworks,
Q
uicken
,
Quickbooks, Xero













Practice/
c
lient
m
anagement
s
ystems

MedTech, CMS Profile, Penelope
,
Whanau Tahi, Concerto, Predict
,
Sintra, Excess
,
Life Data













Performance
m
onitoring

Microsoft Access
,
Microsoft Excel













Online
a
pplications

Dropbox, BackPack
,
Box













Social
m
edia

Facebook, Twitter













Other

Survey Monkey















4

Māori Provider Development Scheme (MPDS) 2013/16: Application form

7

National

health

providers and national
disability providers

The Ministry will review the

n
ational Māori health providers


and

n
ational disability providers


funding streams in 2013, and
consider
options for improvements for 2014/15

onwards
.


In the meantime,
n
ational

health

p
roviders
and

n
ational
d
isability
p
roviders

are
not required

to complete the MPCAT, nor will they be supported to develop an organisation development
plan in 2013/14.

These providers will remain on a one
-
year MPDS contract for 2013/14.


8

M
ā
ori
P
rovider
C
apacity
A
ssessment
T
ool

A
ll

regional Māori health and disability
providers who did not complete a self
-
assessment in
2012/13
are required

to complete an MPCAT
self
-
assessment.


To access MPCA
T
,
email
all enquiries directly to:

Barry Gribben

CBG Research Ltd

Barry.gribben@cbg.co.nz


In the space below, please

summarise

your MPCAT results and current state of your
org
anisation. Please keep the description to no more than 300 words.

You do not need to attach
the results to this application.









9

Organisation
d
evelopment
p
lan

In 2012/13 the Ministry of Health supported
r
egional M
ā
ori
h
ealth
and

d
isability
p
roviders who
were not a part of Wh
ā
nau Ora
c
ollectives or Better
,

Sooner
,

More Convenient

primary health

initiatives

to compile a
three
-
y
ear
o
rganisation
d
evelopment
p
lan. Th
e Ministry will continue to
support
r
egional M
ā
ori
h
ealth
and

d
isability
p
roviders who are not a part of Wh
ā
nau Ora
c
ollectives or Better
,

Sooner
,

More Convenient
initiatives
to compile these plans in 2013

2016.


To be considered for
three
-
y
ear

MPDS funding,
r
egional

ori
h
ealth
and

d
isability
p
roviders
are
required

to submit a
three
-
ye
ar
o
rganisation
d
evelopment
p
lan that has been informed by
the results of the M
ā
ori
p
rovider
c
apacity
a
ssessment.
Please attach

this plan

if
y
ou have not
already

submitted

it

to the Ministry of Health.


In the space below, please
summarise

your organisational development plan and what your
priority areas for development

are
. Please keep the description to no more than 300 words.











Māori Provider Development Scheme (MPDS) 2013/16: Application form

5

S
ection
2:

F
unding categories

NOTE FOR ALL CATEGORIES

Using your MPCAT results and organisational development plan (if applicable)
,

please describe
the items/activities required by your organisation within ea
ch funding category to
achieve your
development goals.


Refer to the MPDS Guidelines for further information about each category.
Please keep the
informa
tion to no more than 300 words and ensure that all items/activities are clearly detailed
by category an
d
the y
ear (1

3)

in which

you are applying.


Note:

If you are applying for a part
-
time or full
-
time staff resource within any of the categories
below
, please ensure you
attach

a draft
j
ob description for the proposed position. Requests for
staff positions will only be considered for
three
-
y
ear contracts and must be related to the
funding categories and considered essential to achieving the
three
-
y
ear development goals.
MPDS does not fund

staff positions for service delivery.


Provider
A
ssistance:
I
nfrastructure
S
upport








Item/activity for which requested funding will be
used

Amount requested from
Ministry

(GST
exclusive)

10%

provider
contribution

(GST
exclusive)

Total


(GST
exclusive
)


Year 1

Year 2

Year 3









$






$






$






$






$













$






$






$






$






$












$






$






$






$






$












$






$






$






$






$






Total

$






$






$






$






$








6

Māori Provider Development Scheme (MPDS) 2013/16: Application form

Provider
A
ssistance:
I
nformation
T
echnology








Item/activity for which requested funding will be
used

Amount requested from
Ministry

(GST exclusive)

10%

provider
contribution

(GST
exclusive)

Total


(GST
exclusive
)


Year 1

Year 2

Year 3









$






$






$






$






$













$






$






$






$






$












$






$






$






$






$












$






$






$






$






$






Total

$






$






$






$






$







Workforce
D
evelopment








Item/activity for which requested funding will be
used

Amount requested from
Ministry

(GST exclusive)

10%

provider
contribution

(GST
exclusive)

Total


(GST
exclusive
)


Year 1

Year 2

Year 3









$






$






$






$






$













$






$






$






$






$












$






$






$






$






$












$






$






$






$






$






Total

$






$






$






$






$









Māori Provider Development Scheme (MPDS) 2013/16: Application form

7

Service
I
ntegration








Item/activity for which requested funding will be
used

Amount requested from
Ministry

(GST exclusive)

10%

provider
contribution

(GST
exclusive)

Total


(GST
exclusive
)


Year 1

Year 2

Year 3









$






$






$






$






$













$






$






$






$






$












$






$






$






$






$












$






$






$






$






$






Total

$






$






$






$






$







Quality








Item/activity for which requested funding will be
used

Amount requested from
Ministry

(GST exclusive)

10%

provider
contribution

(GST
exclusive)

Total


(GST
exclusive
)


Year 1

Year 2

Year 3









$






$






$






$






$













$






$






$






$






$












$






$






$






$






$












$






$






$






$






$






Total

$






$






$






$






$








8

Māori Provider Development Scheme (MPDS) 2013/16: Application form

Best
P
ractice








Item/activity for which requested funding will be
used

Amount requested from
Ministry

(GST exclusive)

10%

provider
contribution

(GST
exclusive)

Total


(GST
exclusive
)


Year 1

Year 2

Year 3









$






$






$






$






$













$






$






$






$






$












$






$






$






$






$












$






$






$






$






$






Total

$






$






$






$






$









Māori Provider Development Scheme (MPDS) 2013/16: Application form

9

S
ection

3:

B
udget

Category total

Amount requested from
Ministry

(GST exclusive)

10% provider
contribution

(GST
exclusive)

Total


(GST
exclusive)


Year 1

Year 2

Year 3



Infrastructure

$






$






$






$






$






Information Technology

$






$






$






$






$






Workforce Development

$






$






$






$






$






Service Integration

$






$






$






$






$






Best Practice

$






$






$






$






$






Quality

$






$






$






$






$






T
otal

$

$

$

$

$



10

Māori Provider Development Scheme (MPDS) 2013/16: Application form

S
ection

4:

O
ther

Risk
m
anagement

What risks have been ident
ified in the purchase and completion of the

items/
activities

you have
requested
, and how will they be mitigated?


Risk

Likelihood

Consequences

Risk
l
evel

Mitigation
s
trategy






















































































































































































Additional information

You are required to
include

a copy of the most recent audited
financial

statements or
accounts reviewed by a
c
hartered
a
ccount
ant

if the total amount you are applying for is more
than $50,000.00.

I
f

your organisation was established in the last 12

months
,

please include a
copy of your organisation

s interim financial statements and copies of recent bank statements.


Please add any further information regarding your organisation

that

may be of relevance to this
application. (Please attach additional pages i
f required.)


Checklist


Have you read the
MPDS 2013/16
:

Guidelines

for completing the application form
?


Are all sections relevant to your application completed?


Are all parts

of

Section 1
:

Provider
d
etails


within the application form completed?


Have you attached

evidence of legal status and constitution?


Have you attached

the organisational development plan
, if
it was
not previously supplied to the Ministry (if
applicable)
?


If you have applied for an FTE resource within any of the funding categories, have you attached a draft
j
ob
description?


Have you attached

additional information to support
your application?


Have you attached

a copy of your most recent audited financial statements or accounts reviewed by a
c
hartered
a
ccount
ant
,

if the total amount you are applying f
or is more than $50,000.00
?


Is the provider endorsement signed (refer overleaf)?




Māori Provider Development Scheme (MPDS) 2013/16: Application form

11

Provider endorsement

Funding conditions

I certify that the application is true and correct and
that no conflict of interest exists at the
time of this application being submitted.

In signing this form, the applicant declares that
:



no other funding is received for the proj
ect outlined in the application



m
y organisation is not under investigation by a
ny statutory body (
Accident
Compensation Corporation
, NZ Police, Audit NZ, Health and Disability Commissioner,
or Ministry of Health)
.

The applicant acknowledges and understands the following
.

(i)

The Ministry may release summary information about the succ
essful applicant(s).

(ii)

If the application is successful, the Ministry may share the information in your
contract, including contract details and the contract value
,

within the Ministry of
Health and with other relevant government bodies.

(iii)

Informati
on held by the Ministry is subject to request(s) under the Official
Information Act 1982. The Ministry also has other obligations in relation to
information, such as reporting to Parliament and a duty to consult other interested
parties at any time during
the process.

(iv)

The Ministry retains the right to publish, promote and make publicly available
information about funded initiatives.

(v)

Successful applicants must agree to participate in any evaluation of
MPDS

that the
Ministry or its agents may wish to

undertake.

In addition, the applicant acknowledges and understands that funding under the Ministry
of Health

s Māori Provider Development Scheme is contingent on the completion of
reporting for the previous year

s contract.

The Ministry of Health reserves

the discretionary right to:

(i)

withhold any contract payment, if reporting requirements are not met

(ii)

decline new funding applications from providers who have outstanding reporting
requirements.


Important

By typing your name here you are

electronica
lly signing


this form.


Signature







Designation







Date