Hospital Discharge Follow-Up Service RFP Application

A Hospital Discharge Follow Up Service for People with Dementia


Northern Sydney Primary Health Network (PHN) is seeking a suitably qualified provider to pilot a “Hospital Discharge Follow Up Service for People with Dementia”.


Northern Sydney PHN supports a collaborative, patient-centred, whole-system approach to regional health planning. Extensive consultations, undertaken with a range of providers, have resulted in the following desirable outcomes for people with dementia and their carers:

  • Improved consumer experience
  • Improved consumer health outcomes
  • Reduced ED demand and avoidable hospitalisation
  • Improved access to services and supports in the After Hours period (e.g., nights and weekends)

Northern Sydney PHN, Northern Sydney Local Health District (NSLHD), Community Care (Northern Beaches), Primary & Community Care Services, and Alzheimer’s Australia NSW are working in partnership to support local health professionals to guide patients with dementia and their carers with accessing the most appropriate local service to meet their needs.
As part of this work, Northern Sydney PHN undertook a ‘patient journey’ modelling exercise. Some of the themes and issues identified were:

  • An overwhelming number of services to interact with and no clear pathway to navigate the journey
  • Limitations and delays with care transfer communication impacting health outcomes, particularly in the After Hours period
  • Current funding mechanisms for dementia care do not support a proactive management approach
  • No clear ‘case management’ model for dementia patients

To achieve the desirable outcomes, Northern Sydney PHN and partners plan to pilot a hospital discharge follow up service for people with dementia. This project will support people with dementia to be discharged back to their own home as soon as possible following an attendance at ED or an admission to a local hospital.

An important component of the pilot will be to provide post-discharge support for people in the After Hours period. For example, a person discharged from hospital on a Friday afternoon or evening can be supported with transitional arrangements until regular services can provide support during the normal working week.


  • To ensure that all people with dementia or suspected dementia (who fit the criteria) have access to a high quality discharge follow up service
  • To provide a seamless transfer of care from hospital to home
  • To assist people and their carers to access the right service, in the right place, at the right time
  • To develop strong relationships with relevant community health, primary health and tertiary health professionals to facilitate smooth transition of care
  • To facilitate access to services and put into place supports for people in the After Hours period including on weekends when mainstream services are more difficult to establish or access (e.g. emergency access to Meals on Wheels)
  • To reduce re-admission to hospital or deterioration during the After Hours period

Evidence Base

Dementia is a progressive irreversible syndrome of impaired memory, intellectual function, personality and behaviour, causing significant impairment in function.

Types of dementia include:

  • Alzheimer’s Disease
  • Vascular Dementia
  • “Mixed” Dementia (Alzheimer’s Disease and Vascular Dementia)
  • Dementia with Lewy Bodies
  • Frontotemporal Dementia
  • Parkinson’s Disease with Dementia
  • Others – Cruetzfelt Jacob Disease (CJD), Alcohol Related Brain Damage (ARBD)

In Australia, three in ten people over the age of 85 and almost one in ten people over 65 have dementia. In Northern Sydney, there is projected growth of 23% in the population of people aged 75 years and older between 2011 and 2021, indicating a substantial increase in the number of people with dementia in the region over the next 6 years.

In addition, there are approximately 24,700 people in Australia with Younger Onset Dementia (a diagnosis of dementia under the age of 65; including people as young as 30).

On average symptoms of dementia are noticed by families three years before a firm diagnosis is made.

The journeys of many people with dementia and their carers include points of contact with the health system with an absence of helpful advice or information about services, and a series of points of stress, pain or crisis. People with dementia are relatively high users of acute hospitals. In Australia the mean length of stay (LOS) for all hospital separations is 8.6 days, compared with a mean of 19.6 days for any diagnosis of dementia and 30.1 days for separations with a principle diagnosis of dementia (Draper et al, 2011).

In 2010–11, dementia was managed during 444 encounters reported to the BEACH survey. This equates to a rate of 5 encounters for the management of dementia for every 1,000 GP encounters (or 0.5%). Applying this rate to all Medicare-claimed GP consultations in 2010–11 (as sourced from DoHA, 2012) suggests that about 552,000 GP visits during this period involved the management of dementia.

There were 83,226 hospitalisations with dementia recorded as either the principal or an additional diagnosis, accounting for 1 out of every 100 hospitalisations in 2009–10 (1%). Hospitalisations where dementia was the principal diagnosis represented 15% of these.

Women accounted for 57% of hospitalisations with dementia as a principal or additional diagnosis but the age-standardised rates indicate a higher rate of hospitalisations for men (205.3 per 10,000 men aged 60 and over) than women (181.8 per 10,000 women aged 60 and over).

Service Requirements

Northern Sydney PHN is seeking a provider to pilot a ‘Hospital Discharge Follow Up Service for People with Dementia’. The service will support people with dementia and their carers, following an attendance at the Emergency Department or admittance to Hornsby Hospital, Ryde Hospital or the Sydney Adventist Hospital within 24 hours of being discharged. It will also support the prevention of a patient being re-admitted to hospital by ensuring appropriate services are in place.

Northern Sydney PHN is seeking Request for Proposals for the provision of this service, without prescribing a defined operating model for the delivery of the service.

Preliminary criteria for eligibility for this service have been defined through broad consultation as:

  • Person is being discharged after an attendance at the Emergency Department or admission to hospital
  • Person has suspected or diagnosed dementia
  • Person would significantly benefit from post-discharge follow-up within 24 hours at their residence
  • Person would significantly benefit from short term follow-up support, including through supporting access to medication, access to a GP, transportation, nutrition, review of environmental hazards, and identification of additional risks or barriers to implementation of discharge plan
  • Person is not currently enrolled in the Transitional Aged Care Program (TACP/TRANSPAC)

Proposed service models could include elements such as:

  • Liaison with local hospitals to identify an appropriate assessment procedure /protocol for identifying people for the service and implement a referral pathway
  • Follow up with the person and their carer within 24 hours of being discharged from hospital.
  • The areas of support provided to referred persons, including support around accessing medications (knowledge of and access to), referrals (booked and transport arranged) and general well-being. This is to ensure appropriate links to GPs, Specialists, or other services to provide care post discharge.
  • Supporting the development of a plan in consultation with the person and their GP for ongoing needs to appropriate programs and supportive services in the community.
  • Ensuring the person with dementia and their carer are continually informed and consulted throughout the discharge follow up process
  • Providing ongoing monitoring for up to 12 weeks following discharge to ensure all services and care are in place and the person is coping in their home environment
  • Ensure the service is person-centred, with a positive experience for both the person with dementia and their carer.
  • Documenting local needs identified through the delivery of the service.

Proposed Geographic Area

Applicants need to be capable of responding to the needs people with dementia, residing in the areas of Hornsby, Ku-ring-gai, Ryde and Hunters Hill Local Government areas. Services that can offer support and potentially expand across the whole Northern Sydney PHN region would be viewed favourably.

Indicative Funding Envelope and Duration

Funding agreements of up to $150,000 will be offered to preferred applicants for a pilot period of up to 12 months.

Expected Outcomes

Data collection, documentation and tracking are vital to Northern Sydney PHN’s understanding of the success of the service. Program outcomes could include:

  • Improved patient and carer experience as measured against specific patient reported outcome measures (PROMS) and patient reported experiences (PREMS)
  • Contribution to a reduction in hospital re-admissions
  • Better medication compliance of persons with dementia
  • Increased coordination and facilitation of services for persons with dementia
  • Stronger working relationships between community, primary and tertiary care professionals

Proposed Timeline

The proposed procurement activities include a Request for Proposal (RFP) process. Shortlisted RFP respondents will be invited for interviews. The table below outlines the key activities and timelines.

Activity Time/Date
Release of Dementia Discharge Request for Proposal 2 May 2016
Responses to be received via email to tenders@snhn.org.au by 10:00AM on 20 May 2016
Review of Proposals 23-27 May 2016
Interviews with Shortlisted Respondents 30 May – 3 June 2016
Notify successful applicant and inform unsuccessful bidders 6 – 10 June 2016
Contract Negotiation & Execution 6 – 10 June 2016
Commencement of Service 10 June 2016

Evaluation of Request for Proposal

The information that you provide in this Application Form will be used for evaluation purposes therefore it is important that you complete every section accurately. Failure to do so could result in your application not proceeding.

Applicants will be evaluated in five main areas:

Proposed Operating Model

Assessment of the extent to which the proposed operating model demonstrates an understanding of the service requirements. Consideration will be given to Applicants’ demonstration of:

  • Effective patient identification and referral mechanisms, including promotion of the service to key stakeholders
  • Type and range of supports and interventions provided to clients of the service
  • Communication and follow-up strategy with client, carers, and other health providers

Key Objectives

Assessment of the extent to which the provider can demonstrate a link between the proposed operating model and the pilot’s aims and expected outcomes, including any contributions to innovative delivery models. Consideration will be given to the Applicants’ demonstration of:

  • Proposed key objectives of the model and identification of a clear means of meeting these objectives
  • Level of innovation of the service delivery model
  • Proposed outputs (and linked outcomes) through this service, including how these will be captured and measured within the proposed model

Capability to Implement Model

Assessment of the Provider’s experience of undertaking similar work and capability to implement their proposed model, including:

  • Track record of delivery of services with a scope similar to the proposed model within agreed timescales.
  • Experience of similar work to the proposed model.
  • Estimation of the number of patients the service has the capacity to assist.
  • Ability to deliver proposed service model to support patients outside of standard business hours.
  • Skill set and experience of proposed staff delivering model.

Ability to Commence Service

Assessment of the extent to which the proposed model demonstrates:

  • A project planning approach that provides confidence that the work will be completed within the timescales specified.
  • Demonstration of a credible project plan to complete this work in the required timescales.
  • Understanding how to create the environment to enable this initiative to be successful as quickly as possible.

Value for Money

Assessment of the value for money offered by the Provider in undertaking the work specified:

  • Please provide a fixed fee for this work.
  • Any additional benefits offered.

Evaluation Guidelines & Scoring Methodology

After the deadline for the receipt of the RFP Application, a Panel will evaluate the individual responses based on evidence contained within the document. The RFP will anticipate that providers can demonstrate value for money and financial efficiency in delivering the service.

A score for each response will be awarded from the marks available (dependent on the providers’ responses). Marks available will range for 0-3 and weightings for each section are identified as follows:

Section Weighting 0 1 2 3
Criterion 1:

Proposed Operating Model

30% Unable to articulate the requirements and suggested approach. Offers limited understanding of requirements or how they would approach. Offers flexible approach to how they would approach brief, demonstrating understanding of the complexities of brief. Convincing response offering very high level of understanding of brief and approach to piece of work.
Criterion 2:

Key Objectives & Alignment

20% Key objectives do not align with the requirements of the RFP. Objectives and measurement have limited alignment with the requirements. Objectives and measurement align well with the requirements. Objectives and measurement highly aligned with the requirements and the application demonstrates an innovative approach.
Criterion 3:

Capability to Implement Model

20% No skills or past experience in relation to the proposed model, or no response. Skill mix and experience are considered inappropriate to project requirements as currently identified. Skill mix and experience which is considered appropriate to project requirements as known currently. Skill mix and experience is considered highly appropriate and informed to project requirements as known currently.
Criterion 4:

Ability to Commence Service

15% No clear plan to complete the work in the required timescales, or no response. Partially meets requirements to deliver service in required timescales. Demonstrates plan where the service appears to be delivered within appropriate timeframes. Convincing response demonstrating a credible plan to undertake the work in the required timescales.
Criterion 5:

Value for Money

15% Score will be allocated by comparing providers’ proposals.
Total 100%

Additional information

Responses should be contained within the RFP template and should address all of the questions posed within the attached template.

Interviews with shortlisted applicants will be scheduled for the week commencing 30 May 2016.

Please note:

  • Responding to this Request for Proposal does not constitute Northern Sydney PHN’s agreement to a binding contract.
  • Any and all costs for the completion and response to this RFP are borne by the provider and Northern Sydney PHN is not liable for any monies associated therewith.
  • Northern Sydney PHN reserves the right to withdraw this RFP up to the point at which a successful provider is appointed.
  • There may be need to add additional functions to the specification, where this is the case these will be made available to all potential suppliers by 20 May 2016.
  • Copies of the draft funding agreement will be made available to shortlisted applicants.
  • The onus lies with the Applicant to prove that their response was delivered. Late submissions or submissions deemed not to be received will not be given consideration and the supplier may be disqualified.

Contact Details

If you have any questions regarding the RFP, email tenders@snhn.org.au.

Submission Details

Please note that all fields must be completed (including inserting N/A if not relevant to your proposal). All Applications must be submitted in full.

Request for Proposal Application Forms must be submitted by email to tenders@snhn.org.au by 10:00AM on 20 May 2016.

Please contact Northern Sydney PHN via the email address above to seek permission to submit an application via alternative means if required.

    Applicant details

    1.1   Organisation - Provide the following information to identify the legal entity submitting an RFP.

    Are you registered for GST?


    Legal entity type:

    Does your organisation have a website? YesNo

    1.2   Authorised Person Contact Details - Who is the nominated authorised contact person for this application?

    Response to RFP

    All RFP Applications will be assessed against the following criteria. Please do not provide unrequested attachments as Northern Sydney PHN reserves the right to obtain further information and/or explanation from your organisation at any time during the RFP process, if required.

    1.   Criterion 1 – Please describe your proposed operating model for the 'Hospital Discharge Follow Up Service for People with Dementia'. Please include detail around how you would support patient identification, referral, the scope of service delivery, follow-up, and communication with other providers. (maximum 500 words)

    2.   Criterion 2 – Please describe the key objectives of your model. What are the key objectives of your service model and how do these align with the objectives of the pilot? How will these objectives be achieved? How will you measure the key outputs and outcomes? Is this model innovative, and if so, what is innovative about your model? (maximum 500 words)

    3.   Criterion 3 – Please outline your capability and experience in implementing your proposed model. Describe the scope of service that you can provide. Please describe how business can currently, or be expanded to, support patients within 24 hours (including during the After Hours periods such as weekends). Please describe the skill set of the team you are putting forward to deliver the service. Where possible, please include a CV for team members delivering the service. (maximum 400 words)

    4.   Criterion 4 – Please describe your ability to commence service-roll out in June 2016 and expected timelines. Please provide a brief implementation plan. Please detail whether you are able to commence the service in June 2016, and the proposed time it would take from program development to taking actual patient referrals. (maximum 200 words)

    5.   Criterion 5 – Please provide a fixed fee proposal for the delivery of your prosed model. Please indicate time and resources required for the delivery of your model, including a total price. (maximum 200 words)

    Supporting Information

    1.   Referees - Please provide details of two (2) referees who may be contacted to provide confirmation of the claims made in respect of the capacity of the Applicant's organisation to fulfil the nominated services.

    Organisation Name:

    Contact Person:




    Relationship details / Services provided:

    2.   Insurance - Please provide details of insurance policies held as below. Applicants certify that copies of relevant certificates of currency will be provided on request.


    Policy Number:

    Expiry Date:


    Limit: (State whether on a per claim or aggregate basis)

    3.   Subcontracting - Do you plan to subcontract any services?

    Please note: If services are to be subcontracted, prior approval will need to be sought from Northern Sydney PHN on a case by case basis.


    4.   Additional Information - If you wish to provide information about your current activity or business and cannot find an appropriate section in which to enter it you may include it here. For example, you may wish to highlight any relevant local partnerships, relationships or knowledge of the region that would enhance your ability to provide the service. (maximum 500 words)


    This declaration should be signed AFTER completing the Request for Proposal application, it must be signed by a person identified in your organisation's constitution, or holding a position that is identified as being authorised to commit your organisation to the conditions as described in any contract or Funding Agreement with Northern Sydney PHN.

    I acknowledge and certify that:

    • the organisation has read and understood the Request for Proposal;
    • the information in this document is true and correct;
    • none of the organisation’s office bearers, employees or agents have been charged or convicted of committing a criminal offence which will reasonably affect the ability of the organisation to undertake a future service delivery.


    I acknowledge that by lodging this Request for Proposal Application by emailing Northern Sydney PHN I am providing an electronic signature for this Declaration.