LTC Year of Care Funding Model
Application to be an Early Implementer Site 
To be submitted by Friday 25th May 2012

Completed application forms should be submitted to Jacquie White – jacquie.white@bradford.nhs.uk

Please read the document “QIPP Long Term Conditions Year of Care Funding Model – Early Implementers: Supporting Notes for Applications”, which details the application criteria before completing this form.
Name of Project Lead		
Organisation		
Department		
Position		
Telephone and email contacts		
Please ensure the Project Lead or a representative is available in the week commencing 28th May 2012 to discuss the application if necessary.
Organisational commitment : Please provide the name of the CEO who will sponsor the project / application and to ask them to briefly state their support and why they are interested in participating as an early implementer site	
Sponsor (name / position)	
	
Sponsor’s contact details	
	
Sponsor’s statement of commitment	

Partner Organisations commitment: The application should come jointly from the CCG(s) and Social Care Commissioners and from providers of primary care, community services, acute care, and social care (including third and independent providers as appropriate).  Please provide the name of the Clinical Chair/Lead & CEO from each of the partner organisations and ask them to briefly state their support and why they are interested in participating as an Early Implementer site	
Partner (name / position/organisation)	
	
Partner contact details	
	
Partner statement of commitment	

Briefly describe the provision of integrated LTC care in your area including how the population is served by each participating service and with reference to the three key drivers in the QIPP LTC workstream (risk profiling, integrated neighbourhood care teams, systematised self-care). Please also indicate how you intend to ensure you are compliant with the Public Sector Equality Duty in delivering services	

(please do not exceed 1 page A4)	
Briefly describe how you will meet the requirements we are looking for and which will support your application – local relationships; local commitment & capacity; engagement with the national approach:	

(please do not exceed 2 page A4)	
Briefly describe how you will meet the data requirements of an early implementer site including the level of costing data for LTC that is currently available and plans for development/improvement	

(please do not exceed 1 page A4)	
	
What other local/national projects are you involved in that link to/support this work?	

(please do not exceed ½  page A4)	
Briefly describe how you would propose to take forward this project locally including project management, governance, use of national and local resources, risks and timescales	

(please do not exceed 1 page A4)	

Thank you for your interest, successful applicants will be notified by Friday 1st June 2012
If you are unsuccessful are you interested in being a “fast follower” site: Yes/No