6A.1Outline

6A.1 Outline

The “Coordinated Veterans' Care Program” (program) is an initiative that aims to improve the health of a class of entitled persons so they have fewer hospital admissions.

The entitled persons are:

 Gold Card holders with complex care needs due to diagnosis of a particular chronic health condition (set out in Principle 6A.5); and

 White Card holders with an accepted mental health condition with complex care needs due to the diagnosis of that mental health condition as a chronic health condition (set out in Principle 6A.5).

The element of the program intended to reduce hospital admissions is external oversight of a person’s health regimen for a period of care of 3 months (carried over to consecutive periods of 3 months if the treatment is proving positive).

The oversight will be performed by a general practitioner and the general practitioner’s practice nurse (or a community nurse (via a DVA‑contracted community nursing provider) or an Aboriginal and/or Torres Strait Islander Primary Health Care worker, if more appropriate).

Essentially the general practitioner will prepare a comprehensive care plan for the entitled person and the general practitioner’s practice nurse (or a community nurse or Aboriginal and/or Torres Strait Islander Primary Health Care worker) will co‑ordinate health care services under the plan. The general practitioner will provide oversight throughout. In cases where a general practitioner is unable to obtain the services of a nurse or Aboriginal and/or Torres Strait Islander Primary Health Care worker as a care co‑ordinator, the general practitioner may provide that care co‑ordination.

In addition to having their health care services overseen and co‑ordinated, some entitled persons in the program who the general practitioner considers are socially isolated and would benefit from a service under a particular community care program aimed at providing the person with more social contact, may be referred by the general practitioner to a MHC assessment agency (an agency under the MRCA Home Care Program) for an assessment as to the suitability of the person for a social support service under that Program.

Accordingly, two main treatments are provided under the program:

 GP Care Leadership treatment

 practice nurse/community nurse/ Aboriginal and/or Torres Strait Islander Primary Health Care worker/care co‑ordination treatment

An ancillary treatment under the program is:

 GP referral for social support service assessment

The main treatments relate to the oversight and co‑ordination of health care services under the entitled person’s comprehensive care plan and are in addition to existing treatments available to the entitled person under the Medicare Benefits Schedule and the MRCA Treatment Principles.