Central West LHIN

Section 1a - Pre-Proposal Name & Organization

Organization and Contact Information:

Organization Name:

Contact Name:

Contact email address:

Facility Key or Program Number:

IFIS Recipient Number:

Mailing Address:

Street

City

Postal code

Has the CEO of your organization approved the submission of this pre-proposal?

Section 1b - Proposed Improvement Summary

Provide a brief description of the capital project, along with the date of submission of the capital request and the name of the MoHLTC consultant assigned to this capital request.

This pre-proposal is being submitted to the following other LHINs:

Alignment with LHIN Integrated Health Service Plan (IHSP)

Please identify which of the LHIN IHSP priorities relate to this proposed improvement and explain how they are connected maximum 150 words

Pre-proposals that do not align with a LHIN IHSP or MoHLTC priorities

Please identify why this proposed improvement should be a priority for the local health of the community maximum 150 words

Section 1c - Define the Project

Overview: Identify the LHIN population (health service consumers) that would benefit from the proposed service improvement, and the service or quality gap that exists now.

Benefit to the Community: 

Describe how this proposal will improve the health care system and/or health status of the community (e.g. health outcomes, access to health services, quality of care, coordination of services, patient’s choice, uptake of best practice).  

Collaboration:

Describe your partnerships and how the collaborating HSPs will work together, (in general terms) to implement the proposal.

Health System Sustainability: 

Identify how this proposal will result in efficiencies to the health care system and/or your organization, (e.g. reduced duplication of services, new model of care, reduce length of stay, reduce readmissions, demonstrated cost benefit, collaborative budgeting, reinvestment of existing resources).

Section 2 - Health Service Provider Partners

Identify HSPs that you collaborated with in developing this pre-proposal and the nature of that collaboration.

Section 3 - Service Details and Financial Impact

Proposed Service Change

Provide Details i.e. additional number of visits, services provided or residents (clients) served, etc.

Funding Requirements 

check appropriate boxes and insert $ amounts   

Amount $ of Savings: 

Source of Savings:

Amount $ of One-Time Project Funding needed :  

Amount $ of Capital Funding required: 

One-Time Start Up Funding is required:

insert $ amounts in appropriate boxes

Start-up Funding Required:

Consultation/training     $ 

Staffing         & #160;               $ 

Other           0;               $ 

Ongoing (Base) Operating (out -year) funding is required:

insert $ amounts in appropriate boxes

Ongoing (Base) Operating Funding Required: 

Staffing: $  

Supplies: $ 

Other: 

Specify type of operating funding required:

Specify $ amount of operating funding required:

Other Funding Sources 

insert funding source and $ amount

Specify other funding source(s) and $ amount(s)

Project Timeline:

Please provide estimated timelines for project development and implementation:

Reminder: You may wish to print a copy of your submission for your records now.