Application Package (A) - BC Centre for Palliative Care A - 2016...Brochure created # Volunteers respite servicestrained % # Brochures distributed # Respite visits made # Families

Version Date: August 2016

Seed Grant Program

Application Package (A)

For

Cycle 2: September, 2016 Competition

Convening, Collaborating, Catalyzing to Create Capacity

Version Date: August 2016 Page 2 of 12

Seed Grant Program

Cycle 2: September, 2016 Competition

The BC Centre for Palliative Care in partnership with the BC Hospice Palliative Care Association invite all Hospice Societies through British Columbia to apply to the Seed Grant Program. The Seed Grant Program provides funding, guidance and support resources for novel, scalable projects that help promote any of the following strategic priorities for palliative and end of life care in BC:

1. Advance Care Planning: Promote and facilitate public and private conversations about Advance Care Planning;

2. Palliative Care Education: Raise awareness of and provide education to the public, formal care providers, and informal caregivers about the palliative approach to care;

3. Compassionate Communities: Engage and empower local communities to look after terminally ill

patients, providing palliative care closer to home and improving the end of life experiences in the community

Complete applications must be received by email to: [email protected] no later than September 26th, 2016. All applicants will be notified of the results by email by October 21th, 2016.

For more information about Cycle 2, please see the Seed Grant Guidelines and informational presentation at http://www.bc-cpc.ca/cpc/seed-grants/

mailto:[email protected]

http://www.bc-cpc.ca/cpc/seed-grants/



Seed Grant Application (A)

Project Overview

Title of Project:

Project lifetime:_________ (12 months maximum)

Budget Requested: $ _______________ ($5000 maximum):

Applicant Information:

Name of Hospice Society:

Address:

Contact Person Name:

Title:

Email: Phone: Fax:

Identify ONE (1) Person who will be responsible for leading the project.

Project Lead Name:

Title:

Email:

Phone: Fax:



Project Information:

Funding Priorities – Check ONE funding priority that this project most closely aligns with

☐ Advance Care Planning

☐ Palliative Care Education

☐ Compassionate Communities

The project will be take place in the:

☐Interior Health Region

☐Northern Health Region

☐Fraser Health Region

☐Vancouver Island Health Region

☐Vancouver Coastal/Providence Health Region

The community in which the project will take place is:

☐A community in an urban or suburban area

☐A community in a rural area (>10,000 and <40,000 residents

☐A First Nation community

☐A community in other remote area (<10,000 residents)

Highlight the primary focus of impact for your project

☐The general public

☐Patients with serious illness

☐Frail seniors

☐Young adults with life limiting illness

☐Families and informal caregivers of patients with serious illness

(you can check more than one category):

☐Minority ethnic population

☐Health care professionals and formal caregivers (paid)

☐Individuals with mental illness

☐Homeless people

☐Other group,________________________(specify)

Brief Description of the Project (no more than 300 words):



Signature:

Name of the Organization that will receive and administer the fund: _________________________________________________________________________________ Name of Authorized Person: ___________________________________________ Authoritative Signature: ________________________________________________



Project Details

The Problem

Provide a clear understanding of the problem and identify the population group(s) who are affected by this problem

(Not More than 200 words)

The Opportunity

Provide a clear understanding of the opportunity at hand (include, where relevant, if this project could be scalable

across multiple settings, age groups, cultural backgrounds, etc) (Not More than 200 words)



Project Goal and Objectives– describe what the project will try to achieve

Partners

List of Partners who expressed interest or expected to work with and participate in the project’s activities

Partner’s Name Expected Role in Project

Team Members

List of team members who will be involved in the project

Name Area of Expertise Role in the Project Email address



Activities and Timeline List the activities that will be undertaken to achieve the project objectives. Highlight the month during which an activity will take place (see sample below).

Key Activities Examples

Months 1 2 3 4 5 6 7 8 9 10 11 12

1 Develop education materials Develop post-session evaluation questionnaire

for participants

2 Recruit educator Prepare interim progress report for funder 3 Arrange the logistics of the education session

(venue, printing, facilitator,..)

3 Advertise for the education session 4 Deliver session 1 Collect completed evaluation questionnaire from

participants after session 1

Prepare interim progress report for funder

Analyze evaluation data

Prepare final report for funder



Evaluation

Please list the evaluation measures that you will use to evaluate the project and the sources of data required to report on these measures. We encourage applicants to develop a LOGIC MODEL for their proposed projects using the template provided in Appendix B (Optional). A LOGIC MODEL may assist the applicants to identify the important components of their project: the resources required to develop the project, the activities (what will be done), the participation (who will be reached), and the outcomes (the changes that the activities will result in). More importantly, A LOGIC MODEL can assist the applicants to easily define evaluation measures for their projects through which they can demonstrate the outcomes achieved by the projects and how they were achieved. Please refer to Appendix A which illustrates an example of a LOGIC MODEL and how it is being used in evaluation.

Please list the evaluation measures and how you are going to collect data to report on these measures.

Measure Data source/collection method Examples: Number of workshops conducted Project document

Number of participants who attended the workshops Project document

% of participants who reported after the workshop better understanding of the topic discussed

Post-workshop questionnaire



Budget Important Notes:

The total amount requested from the BC CPC, not including any cost sharing, MUST not exceed $5,000. Funds must only be used for the approved project. Grant funds MUST be used within one year of their start dates. Any unused funds will be recoverable by the BC CPC.

Please refer to Pages 8 of the Seed Grant Guidelines for use of the Award Money If the total direct costs exceed the amount requested, identify sources of co-funding and you may attach letters of commitment if available.

Anticipated Expenditures for the Project

ITEM Estimated Cost Funding Source

TOTAL ESTIMATED COSTS $

TOTAL COST by SOURCE OF FUNDING REQUEST TO BC CPC $

Other funding sources (please specify below)

$

$

$

TOTAL $



Appendix A: A LOGIC MODEL Example

INPUTS OUTPUTS

OUTCOMES

ACTIVITIES (WHAT WE PLAN

TO DO)

DEVELOP

TRAINING

MANUAL

DEVELOP

INFORMATION

PACKAGES

TRAIN

VOLUNTEERS

MARKETING

CONDUCT

WORKSHOPS

PARTICIPATION (WHO WE WILL

REACH)

PERSONS WITH

SERIOUS ILLNESS

FRAIL SENIORS

HOME HEALTH

CARE PROVIDERS

RESIDENTIAL

CARE PROVIDERS

FAMILY

CAREGIVERS

WHAT THE RESULTS ARE (In terms of

LEARNING/ACTION/CONDITION)

CHANGE IN:

LEARNING

AWARENESS

KNOWLEDGE

ATTITUDES

SKILLS

ASPIRATIONS

MOTIVATIONS

PERSON/FAMILY SATISFACTION

CONFIDENCE LEVELS

CHANGE IN:

END OF LIFE EXPERIENCE FOR

FAMILIES

QUALITY OF LIFE FOR PATIENTS

WHAT WE INVEST (REQUIRED RESOURCES)

INFORMATION/DATA

STAFF

VOLUNTEEERS

MONEY

PARTNERS

EXPERTS

EQUIPMENT

The Problem:

Family caregivers of

patients with terminal

illness often feel

physically exhausted

and emotionally

fatigued but they are

reluctant to leave the

bedside of their loved

ones because they do

not

want them to be

lone.

A Training manual developed

Brochure created

# Volunteers trained

# Brochures distributed

# Respite visits made

# Families who received respite services (by

type of service)

Families:

% Families who are aware of the availability

of respite services

% Families who feel comfortable to use

respite services

% Families who are satisfied with the service

received

Trained volunteers

Increase in level of knowledge about respite

care

Increase in confidence level to provide respite

care

# Families affected by the

problem

# Partners recruited

Partners ‘contribution

(cash and in-kind)

# (and profile) of experts

recruited

# of volunteers recruited

Suggested

Evaluation

Measures

Project Goal To provide respite for

family caregivers whose

loved ones are in their

final days of life

Objectives

Train volunteers to

offer vigil services;

Offer emotional support

by phone



Appendix B: LOGIC MODEL Template

INPUTS OUTPUTS

OUTCOMES

ACTIVITIES (WHAT WE PLAN

TO DO)

PARTICIPATION (WHO WE WILL

REACH)

WHAT THE RESULTS ARE (In terms of LEARNING/ACTION/CONDITION)

WHAT WE INVEST (REQUIRED

RESOURCES)

The Problem:

Evaluation

Measures

Project Goal

Objectives

Documents

Application Package (A) - BC Centre for Palliative Care A - 2016...Brochure created # Volunteers respite servicestrained % # Brochures distributed # Respite visits made # Families