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Medical Aids Subsidy Scheme, Queensland Health

v1.01 04/2020 of 2

MASS Palliative Care Equipment Program - Trial Daily Living and Mobility AidsApplication Information Sheet – please retain for your records

Eligibility – MASS PCEP Mobility and Daily Living Aids

Administrative eligibility for funding assistance through the Medical Aids Subsidy Scheme Palliative Care

Equipment Program (MASS PCEP) is dependent upon the following criteria.

The applicant must:

• Be a permanent Queensland resident with a Queensland delivery address;

• Provide a Medicare Card number for purpose of unique identification;

o Note: in circumstances where an applicant does not have a Medicare Card, please contact MASS

to discuss identification options.

• Have the MASS Palliative Confirmation Form completed by approved persons – please refer to the form

for more information.

Clinical Eligibility – MASS PCEP Mobility and Daily Living Aids

• A life limiting condition with a likely prognosis of 6 months or less diagnosed by a palliative care specialist

or treating specialist/GP with palliative care specialist consultation;

• A Resource Utilisation Group Activities of Daily Living (RUG-ADL) score of 10 or more; AND

• An Australian Karnofsky Performance Scale (AKPS) score of 50 or less / 40 or less for an

electric/adjustable bed or a recliner/riser chair.

• Functional assessment for the applicant completed by the appropriate prescriber for the requested

equipment category.

• Further information on the RUG-ADL and the AKPS:

ahsri.uow.edu.au/content/groups/public/@web/@chsd/@pcoc/documents/doc/uow127752.pdf

How to Apply

Applicants wishing to apply to MASS for Daily Living Aids and/or Mobility Equipment must consult an Occupational Therapist (OT), a Physiotherapist (PT), Rehabilitation Engineer (RE) or a Registered Nurse for rural and remote areas only, in conjunction with an OT or PT. They will provide an assessment of your needs and assist you to choose the most appropriate equipment.

You are required to sign Part A and your prescribing therapist is required to complete and sign Part B.

Alternatively, you can lodge this application electronically through MASS-eApply.

Applicant or Carer Acknowledgement

I confirm that:

1. I have actively participated in the assessment and trial of aid/s and associatedmodifications and accessories

2. the features and options of the aid/s, and any appropriate alternatives have beenfully explained to me by my prescribing health professional

3. the possible cost implications that I may incur as a result of MASS policy or subsidyfunding have been explained to me by my prescribing health professional

4. the aid/s prescribed are suitable for my needs5. I have a safety switch/residual current device installed in my home (only applicable

for MASS subsidy funded mobility and daily living aids that require charging/operation through mains power).

I acknowledge that:

1. MASS PCEP is a trial program and assistance through the MASS PCEP will cease on 30 June 2021

2. MASS PCEP provides subsidy funding assistance, which is not intended to provide for all my needs

3. The equipment remains the property of MASS, unless advised by MASS in writing

4. The equipment must be returned to MASS when I no longer require its use or it is replaced, unless advisedby MASS in writing.

5. Equipment could be allocated from existing MASS stock. MASS may choose to reallocate suitableequipment and not purchase new

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6. MASS takes no responsibility for any injury sustained by me through use of the aid subsidyfunded/allocated by MASS.

I agree to: 1. Inform MASS within 14 days of any change to my residential address or eligibility for MASS PCEP. For

example:

• Relocation to another state;

• Relocation to a residential care facility.

Prescriber Acknowledgement

I confirm that: 1. I have informed the applicant that:

• The MASS PCEP is a trial program which will cease on 30 June 2021.

• Assistance through MASS PCEP is limited to a 6-month loan, an extensionrequest should be submitted if further time is required.

• Completion of the MASS PCEP surveys will assist MASS to provide

reporting and analysis of the trial program progress and outcomes to the

Department of Health as part of the Care in the Right Setting (CaRs)

initiative.

MASS Privacy Statement

YOUR PRIVACY: The Queensland Health, Medical Aids Subsidy Scheme (MASS) collects administrative, demographic and clinical data as part of the MASS application processes, in accordance with the Information Privacy Act 2009 and Hospital and Health Boards Act 2011, in order to assess your eligibility for funding assistance for the supply of aids and equipment. The information will only be accessed by Queensland Health officers. Some of this information may be given to the applicant’s carer or guardian; other government departments who provide associated services; the prescribing health professional for further clinical management purposes; and to those parties (e.g. commercial suppliers, community care and repairers) requiring the information for the purpose of providing aids, equipment and services.

Please send completed applications to the MASS service centre.

Medical Aids Subsidy Scheme PO Box 281, Cannon Hill Qld 4170 Telephone: 07 3136 3524 or 1300 443 570 Fax: 07 3136 3525 Email: [email protected] Website: health.qld.gov.au/mass

mailto:[email protected]

https://www.health.qld.gov.au/mass

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Medical Aids Subsidy Scheme (MASS) Queensland Health

Medical Aids Subsidy Scheme Palliative Care Equipment Program (PCEP) Daily Living and Mobility Aids

(Affix identification label here)

Family name:

Given name(s):

Date of birth: Gender: ☐M ☐F ☐ I

PART A – To be completed by the applicant or carer

Applicant’s Personal Details

1 Name Title Family Name

Given name(s)

Preferred name

2 Date of Birth and Gender ☐ Male ☐ Female

☐ Intersex or Other

3 Permanent Residential Address

Suburb/Town Postcode

4 Delivery Address ☐ Same as residential


5 Postal Address ☐ Same as residential

(for correspondence) ☐ Same as delivery


6 Contact information Telephone

Mobile

Email

7 Medicare Card Number

8 Does the applicant receive other assistance? (e.g. NDIS, NIISQ or other state equivalent, CHSP Services, Palliative Care Services, Transition Care)

☐ No ☐ Yes – Specify type of assistance:

Name

9 Is the applicant currently an in-patient within a hospital or hospice and will not return home? ☐ Yes ☐ No

10 Is the applicant a resident in a Residential Care Facility? ☐ Yes ☐ No

11 Is the applicant a Department of Veterans’ Affairs Gold Card Holder? ☐ Yes ☐ No

If you have answered yes to any of Questions 9 -11 the applicant is not eligible to receive assistance through the MASS PCSP or PSDP.

12 Does the applicant identify with Aboriginal or Torres Strait Islander descent? For applicants of

both Aboriginal and Torres Strait Islander descent, tick both ‘Yes’ boxes.

Aboriginal:

Torres Strait Islander:

☐ Yes ☐ No

☐ Yes ☐ No

13 Country of Birth

☐ Australia ☐ Other

14 Language spoken at home

☐ English ☐ Other

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Family name:

Given name(s):


Carer or Alternative Contact Person – will be contacted for delivery/collection

15 Carer or Alternative Contact Person 1 i Name Title Family Name

Given name(s)

ii Contact Information Telephone

Mobile

Email

iii Relationship to applicant

iv Postal Address ☐ Same as applicant


16 Carer or Alternative Contact Person 2

i Name Title Family Name

Given name(s)

ii Contact Information Telephone

Mobile

Email

iii Relationship to applicant

iv Postal Address ☐ Same as applicant


Applicant or Carer/Guardian Acknowledgement

17 ☐ I agree to accept the conditions stated in the Applicant Information Sheet;

18 ☐ I acknowledge that my information listed in this application is current and correct;

19 ☐ I have been made aware of the following:

☐ The MASS PCEP is a trial program which ceases on 30 June 2021 and MASS may ask me to

complete the participant surveys in order to monitor and review the trial

☐ Equipment provided through the program is on a 6-month loan / rental basis only and MASS must be

contacted to collect the equipment when no longer required.

20 Applicant or Carer/Guardian Signature Signature Print name Date

PART B – To be completed by the prescriber

Palliative Confirmation

1 Resource Utilisation Group, Activities

of Daily Living Score (RUG-ADL)

Score: *must be a score of 10 or more

2 Australian Karnofsky Performance Scale

(AKPS) Score: *must be a score of 50 or less / 40 or

less for a hospital bed

3 Primary Diagnosis

☐ Acquired Brain Injury ☐ Alzheimer’s and Related ☐ Cardiac

☐ Cerebral Palsy ☐ CVA/Stroke ☐ Cystic Fibrosis

☐ Degenerative Neurological Condition ☐ Developmental Delay ☐ Endocrine

☐ Oncology ☐ Spina Bifida ☐ Spinal Injuries

☐ General Medical – Please Specify:

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Family name:

Given name(s):


Equipment Request

4 What are the applicant’s measurements?

☐ Paediatric/Petite ☐ Standard ☐ Bariatric

5 Please complete the relevant equipment request below

Toileting Aid

☐ Bedside Commode Bowl: ☐ Yes ☐ No

Pan with lid: ☐ Yes ☐ No

☐ Over Toilet Frame Splashguard: ☐ Yes ☐ No

☐ Over Toilet Surround Additional Information:

☐ Raised Toilet Seat ☐ 2 inch ☐ 4 inch ☐ 6 inch

☐ Mobile Shower Commode ☐ Attendant Propelled/Transit ☐ Self Propelled

Bowl: ☐ Yes ☐ No


Seat: ☐ Yes ☐ No

Seat Width x Depth:

Additional Information:

☐ Tilt-in-Space Mobile Shower Commode

Bowl: ☐ Yes ☐ No


Seat: ☐ Yes ☐ No

Seat Width x Depth:


☐ Other Similar Purpose Device Specify:

Bathing Aid

☐ Bath Transfer Bench ☐ LHS Handle ☐ RHS Handle

☐ Swivel Bath Seat Additional Information:

☐ Bath Board Additional Information:

☐ Static Shower Chair Additional Information:

☐ Shower Stool Additional Information:

☐ Portable Shower Tray Additional Information:

☐ Other Similar Purpose Device Please Specify:

Height (cm) Weight (kg)

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Family name:

Given name(s):


Equipment Request Continued...

Transfer Aid

☐ Electric Mobile Floor Hoist ☐ Yoke ☐ Pivot


☐ Sling x 1 only ☐ General Purpose

☐ Hygiene

☐ Head Support

☐ Small

☐ Medium

☐ Large

☐ Patient Transfer Platform Additional Information:

☐ Slide Sheet or Wondersheet* *King single with justification only

Slide Sheet: ☐ 1x1m ☐ 2x2m ☐ 2x1m

Wondersheet: ☐ Single ☐ King Single

Please Specify:

☐ Other Similar Purpose Device Please Specify:

Sleep Aid

☐ Electric / Adjustable Bed AKPS Score of 40 or less for a hospital bed

☐ Monkey Bar ☐ IV Pole ☐ Bed Extender


☐ Pressure Redistribution Mattress/Overlay

☐ Foam

☐ Alternating Air Mattress

☐ Alternating Air Overlay

☐ Hybrid

☐ Gel

☐ Sleep Positioning Cushions Please contact MASS on 3136 3524 or [email protected] to discuss sleep positioning cushion requirements.

☐ Bed Backrest ☐ Wedge ☐ Adjustable


☐ Bed Cradle - Adjustable Additional Information:

Note: Separate Bed Rails and Bed Sticks are NOT funded through the MASS PCEP. Bed rails that come standard on an electric/adjustable bed are accepted.

Seating Aid

☐ Electric Recliner Additional Information:

☐ Fall Out / Water Chair Additional Information:

☐ Hilite Chair Additional Information:

☐ Pressure Redistribution Cushion for Seating

☐ Foam ☐ Gel ☐ Air ☐ Hybrid

☐ High Profile ☐ Low Profile

Size:


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Family name:

Given name(s):


Equipment Request

Mobility Aid

☐ Wheeled Walking Aid ☐ Forearm Support ☐ Weight Activated Brakes ☐ Seat

☐ Hopper Frame ☐ Wheels ☐ No Wheels

☐ Manual Wheelchair *Please specify any additionalrequirements e.g. pelvic strap, LHS stump support etc

Seat Width x Depth:


☐ Tilt-in-Space Manual Wheelchair *Or please complete the MASS TISMWC script form if required

Seat Width x Depth:


☐ Power Wheelchair - Basic Please contact MASS on 3136 3524 or [email protected] to discuss Power Wheelchair requirements.

☐ Pressure Redistribution Cushion for Mobility Aid

☐ Foam ☐ Gel ☐ Air ☐ Hybrid

☐ High Profile ☐ Low Profile

Size:

☐ Specialised Stroller - Paediatric *please specify any additionalrequirements e.g. TIS, pelvic strap

Seat Width x Depth:


☐ Portable Ramp/s ☐ 25cm ☐ 50cm OR

☐ Foldable Track Ramps

Note: Crutches, single point sticks and multi-point sticks are NOT funded through MASS PCEP.

Delivery Details

6 Is the applicant an inpatient in a hospital or hospice? ☐ No ☐ Yes – Estimated date of discharge

7 Is there an alternative contact for delivery/collection of equipment and have their details been entered in the Carer/Alternative contact section of Part A? ☐ No ☐ Yes

8 Are there internal/external stairs or tight spaces in the applicant’s place of residence which the supplier/courier will need to be aware of? ☐ No ☐ Yes – this may effect delivery and setup of the item/s.

9 Is the room/area that the equipment will be used in cleared for the supplier/courier to deliver and setup the equipment? ☐ Yes ☐ No – this may need to be completed to facilitate delivery and setup of the item/s.


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Family name:

Given name(s):


Prescriber Details To be completed in full for all applications

1 Full Name

2 Profession

3 Current registration?

☐ Yes ☐ No

4 Organisation name

5 Organisation address


6 Contact Details

Telephone Fax

Mobile

Email

7 Contact Hours

8 Signature and Date

I certify that this information is in accordance with the

MASS PCEP Guidelines and the equipment requested

has been prescribed to suit the applicant’s needs.

Signature Date

9 As the prescriber for Daily Living and/or Mobility

Aids, I acknowledge the following:

☐ I have explained the terms of the MASS PCEP loan /

rental agreement to the applicant and their

family/carer or support person.

☐ I have read and understood the MASS PCEP

Guidelines.

☐ I have attached the signed MASS Palliative

Confirmation form.

Email, Post OR Fax completed forms to a MASS Service Centre

Email: [email protected] Website: health.qld.gov.au/mass

Telephone: 07 3136 3524 or 1300 443 570

Fax: 07 3136 3525

Medical Aids Subsidy Scheme PO Box 281, Cannon Hill 4170


http://www.health.qld.gov.au/mass

Medical Aids Subsidy Scheme, Queensland Health

Palliative Confirmation Form

MASS Palliative Confirmation Form V1.01 04/2020 Page 1 of 1

The Medical Aids Subsidy Scheme (MASS) administers the MASS Palliative Care Equipment Program (PCEP) and the MASS Palliative Syringe Driver Program (PSDP) on behalf of the Department of Health. This program provides Assistive Technology to eligible clients with a palliative condition in their end stage of life.

This form is to confirm that the below named applicant has a palliative condition with a likely prognosis of 6 months or less and therefore meets the clinical eligibility to receive assistance through the program.

Note: A Palliative Care Specialist* MUST confirm the applicant’s likely prognosis of 6 months or less.

*Palliative Care Specialist Definition:

• A Specialist, Doctor, GP or Registrar who is a designated Palliative Care Specialist;

• A Palliative Care Specialist Nurse Practitioner who is part of a Palliative Care Specialist multidisciplinary

team.

This form may be completed by one of the following methods:

1. The applicant’s Palliative Care Specialist completes and signs the form in the first instance;

2. The applicant’s Treating Health Professional completes and signs the form and attaches an email from thePalliative Care Specialist that they have consulted with confirming likely prognosis of 6 months or less.

3. The applicant’s Treating Health Professional completes and signs the form and provides the name and phonenumber of the Palliative Care Specialist that they have consulted with confirming likely prognosis of 6 monthsor less.

In order to access assistance through the MASS PCEP and PSDP, this eligibility requirement must be met.

Applicant’s Details

Name Date of Birth

Address

Suburb/Town Post Code

Email Telephone

Treating Health Professional GP, Registrar, Specialist, Allied Health, Nurse or Palliative Care Specialist

Name Profession

Organisation

Organisation Address

Suburb/Town Post Code

Email Telephone

Signature Date

Initial Assessment

☐ I am the applicant’s Treating Health Professional and have consulted with a Palliative Care Specialist (insert details below), who has confirmed the applicant’s condition has a likely prognosis of 6 months or less.

OR

☐ I am the applicant’s Palliative Care Specialist and confirm that the applicant’s condition has a likely prognosis of 6 months or less.

Consulting Palliative Care Specialist Not required if Palliative Care Specialist has completed the form as the treating health professional. Name Telephone

Organisation

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