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 condition (set out in 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 Local Medical Officer (LMO) and the LMO’s practice nurse (or a community nurse (via a DVA-contracted community nursing provider) or an aboriginal health worker, if more appropriate).
Essentially the LMO will prepare a comprehensive care plan (GPMP) for the entitled person and the LMO’s practice nurse (or a community nurse or aboriginal health worker) will co-ordinate health care services under the plan. The LMO will provide oversight throughout. In cases where an LMO is unable to obtain the services of a nurse or aboriginal health worker as a care co-ordinator, the LMO 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 LMO 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 LMO 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:
LMO Care Leadership treatment
practice nurse/community nurse/aboriginal health worker/care co-ordination treatment
An ancillary treatment under the program is:
LMO 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 (GPMP) and are in addition to existing treatments available to the entitled person under the Medicare Benefits Schedule and the MRCA Treatment Principles.
The ancillary treatment may be provided by an approved provider of MRCA Home Care services following a request for social support services from a MHC assessment agency. The LMO will have decided the person is socially isolated and that a social support service might prevent the person from being admitted or re-admitted to hospital. The MHC assessment agency will assess the person’s suitability for a social support service.
Note: an identical program for veterans exists under the Treatment Principles made under the Veterans’ Entitlements Act 1986.
6A.2 Treatments under the Coordinated Veterans' Care Program
6A.2.1 LMO Care Leadership treatment/LMO Home Care service (category C) Referral
6A.2.2 An LMO may, under the Coordinated Veterans' Care Program, provide:
(a) LMO Care Leadership treatment; and/or
(b) an LMO Home Care service (category C) Referral;
for an entitled person.
6A.2.3 Practice Nurse Care Co-ordination treatment
6A.2.4 A practice nurse may, under the Coordinated Veterans' Care Program, provide Practice Nurse Care Co-ordination treatment to an entitled person.
6A.2.5 Community Nurse Care Co-ordination treatment
6A.2.6 A DVA-contracted community nursing provider may, under the Coordinated Veterans' Care Program, provide Community Nurse Care Co-ordination treatment to an entitled person.
6A.2.7 Aboriginal Health Worker Care Co-ordination treatment
6A.2.8 An aboriginal health worker may, under the Coordinated Veterans' Care Program, provide Aboriginal Health Worker Care Co-ordination treatment to an entitled person.
6A.3 LMO Approval of Subsequent Period of Care
6A.3.1 Before any subsequent period of care of an entitled person by an LMO commences, being an LMO who is treating the person under the Coordinated Veterans' Care Program (Program), the LMO is to decide if the person’s continued participation in the Program would meet the aims of the Program (i.e. reduce hospitalisation of the person/avoid duplication of services/provide cost-effective treatment).
Note 1: the first period of care by an LMO commences on the date the LMO decides to admit the entitled person to the Program (admission date). Any following period of care by the same LMO is a subsequent period of care. The first period of care by an LMO may also occur where the LMO is a different LMO for the person. Any following period of care by the same LMO is a subsequent period of care.
Note 2: the period of care by an LMO is set out in the Notes for Coordinated Veterans' Care Program Providers and is a period of 3 months.
6A.3.2 For making the decision in 6A.3.1, the LMO is to:
(a) review the entitled person’s file maintained by the LMO and any other information the LMO considers relevant; and
(b) ascertain if the person is eligible for a subsequent period of care by the LMO.
Note: see 6A.6.2
6A.3.3. If the LMO decides the entitled person should continue to participate in the Program, because the person meets the aims of the Program and is eligible for a subsequent period of care by the LMO, the LMO is to:
(a) approve a subsequent period of care by the LMO of the entitled person before the period commences (approval);
(b) make a record of the approval (which may be in electronic form), containing the date of the approval;
(c) store the approval in a readily retrievable form; and
(d) take any necessary steps to facilitate the provision of the subsequent period of care by the LMO to the entitled person.
6A.3.4. Where an LMO approves a subsequent period of care by the LMO for an entitled person, before the expiry of a current period of care by the LMO for the person, the subsequent period of care commences on the day following the day on which the current period of care expired.
6A.3.5. Where an LMO approves a subsequent period of care by the LMO for an entitled person (approval), after the expiry of a current period of care by the LMO for the person, the subsequent period of care commences on the date of the approval.
6A.3.6. If the LMO decides not to approve a subsequent period of care by the LMO of the entitled person, because the person does not meet the aims of the Program or is ineligible for a subsequent period of care by the LMO, the LMO is to:
(a) notify (including by telephone) any DVA-contracted community nursing provider who may have co-ordinated care for the entitled person under the Program immediately before the potential subsequent period of care by the LMO, of the decision;
(b) if the entitled person was receiving a Home Care service (category C) immediately before the potential subsequent period of care by the LMO, notify (including by telephone) the MHC assessment agency for the person, of the decision;
(c) notify the entitled person, in a manner the LMO considers appropriate, of the decision.
6A.4 Commission Financial Responsibility for Treatment under the Coordinated Veterans' Care Program
6A.4.1 The Commission will accept financial responsibility for:
(a) LMO Care Leadership treatment;
(b) Practice Nurse Care Co-ordination treatment;
(c) Community Nurse Care Co-ordination treatment;
(d) Aboriginal Health Worker Care Co-ordination treatment;
provided to an entitled person, during a period of care of the person by the LMO, the practice nurse, the community nurse or the aboriginal health worker, as the case may be, if the treatment is provided:
(a) in accordance with the Principles and the Notes for Coordinated Veterans' Care Program Providers; and
(b) during a period of care provided to the entitled person by the LMO under the Coordinated Veterans' Care Program (Program).
6A.4.2 The financial amounts the Department will pay for:
(a) LMO Care Leadership treatment, Practice Nurse Care Co-ordination treatment and Aboriginal Health Worker Care Co-ordination treatment — are set out in the DVA document entitled: “Department of Veterans’ Affairs Fee Schedules for Medical Services”, in force on the date in Schedule 1;
(b) Community Nurse Care Co-ordination treatment — are set out in the DVA document entitled: “Australian Government Department of Veterans’ Affairs Classification System and Schedule of Item Numbers and Fees — Community Nursing Services”, in force on the date in Schedule 1.
Note: the Department of Human Services will pay fees on behalf of the Department under a Services Agreement.
6A.4.3 Subject to 6A.4.4, the Commission is only to accept financial responsibility for a period of care provided to an entitled person by an LMO, practice nurse, community nurse or aboriginal health worker under the Coordinated Veterans' Care Program (Program) if any previous period of care provided by, respectively, an LMO, practice nurse, community nurse or aboriginal health worker under the Program in respect of the entitled person has expired.
Note: Under the Coordinated Veterans' Care Program a period of care provided by an LMO, practice nurse, community nurse or aboriginal health worker must be in respect of the Coordinated Veterans' Care Program treatment the health care provider may provide under the Program.
6A.4.4 A practice nurse or community nurse (collectively called “nurse 2”) may provide a period of care comprised of, respectively, Practice Nurse Care Co-ordination treatment or Community Nurse Care Co-ordination treatment, to an entitled person under the Program, where a period of care comprised of, respectively, Practice Nurse Care Co-ordination treatment or Community Nurse Care Co-ordination treatment being provided in respect of the entitled person by another practice nurse or community nurse, as the case requires, (collectively called “nurse 1”) under the Program has not expired — if the LMO or DVA-contracted community nursing provider, as the case requires, for nurse 2, has obtained prior approval.
Note 1: Where a period of care provided by nurse 2 and nurse 1 overlaps, and prior approval has been obtained for nurse 2’s period of care, the Commission may accept financial responsibility for the two simultaneous periods of care.
Note 2: “prior approval” is defined in 1.4.1 and 3.2.2 is also relevant. The grant of prior approval is discretionary and for 6A.4.4 will be considered on a case-by-case basis.
6A.4.5 The payment of a fee for Practice Nurse Care Co-ordination treatment and Aboriginal Health Worker Care Co-ordination treatment will be made by the Department to the LMO who employed or engaged the practice nurse or aboriginal health worker, as the case may be, at the time the treatment was provided.
6A.4.6 The payment of a fee for Community Nurse Care Co-ordination treatment provided by a community nurse will be made by the Department to the DVA-contracted community nursing provider who employed or engaged the nurse at the time the treatment was provided.
6A.5 Entitlement to Participation in the Coordinated Veterans' Care Program and to Coordinated Veterans' Care Program Treatment under the program
6A.5.1 Subject to 6A.3 and 6A.6, an entitled person is entitled to participation in the Coordinated Veterans' Care Program (program) and to Coordinated Veterans' Care Program treatment under the program if:
(1) in the opinion of an LMO treating the person:
(a) the entitled person has one or more of the following conditions:
(i) congestive heart failure; or
(ii) coronary artery disease; or
(iii) pneumonia; or
(iv) chronic obstructive pulmonary disease; or
(v) diabetes; or
(vi) some other chronic condition; and
(b) the condition in (1)(a) has resulted in the person being admitted frequently to hospital or could reasonably result in the person being admitted frequently to hospital; and
(c) the entitled person has complex care needs for the condition in (1)(a), being:
(i) one or more of:
(aa) multiple co-morbidities that complicate the treatment regimen for the person;
(bb) the person’s condition is unstable with a high risk of acute exacerbation;
(cc) the condition is contributed to by frailty, age and/or social isolation factors;
(dd) there are limitations in self management and monitoring;
and:
(ii) needs which require a treatment regimen that involves one or more of the following complexities of ongoing care:
(aa) multiple care providers;
(bb) complex medication regimen;
(cc) frequent monitoring and review;
(dd) support with self management and self monitoring.
(2) the person is eligible for treatment under the Act for any injury suffered, or disease contracted, by the person (i.e. person has been granted a Gold Card); and
(3) the person is an Australian resident and living in Australia; and
(4) the person has consented to participation in the program and the admitting LMO has recorded the consent (which may be an electronic record); and
Note: under the Notes for Coordinated Veterans' Care Program Providers the LMO is to store the consent.
(5) the LMO treating the person has prepared, in consultation with the person, a comprehensive care plan (GPMP); and
(6) the LMO admits the person to the program by making a decision to that effect and keeping a record of it.
6A.6 Ineligibility for participation in the Coordinated Veterans' Care Program (program) and for Coordinated Veterans' Care Program Treatment and LMO Home Care service (category C) Referral under the program
6A.6.1 An entitled person is ineligible to be admitted to the Coordinated Veterans' Care Program (Program) by an LMO for the person if any one of the following applies to the person:
(a) the person is receiving residential care; or
Note: receiving residential care (respite) does not disentitle a person to participation in the program.
(b) the person has been diagnosed by a medical practitioner as having a condition that, in the opinion of the LMO, would be likely to be terminal within 12 months after the person is admitted to the program, if the person were to be admitted; or
(c) the person is participating in a health care program provided by the Department of Health and Ageing (Cth) known as:
(i) “Coordinated Care for Patients with Diabetes” (including as a pilot program); or
(ii) “Extended Aged Care at Home program”; or
(iii) “Community Aged Care Program”; or
(iv) “Transition Care”;
or in a program provided by that Department that is essentially the same as one in (i) –(iv) but with a different name.
6A.6.2 An entitled person is not eligible for a subsequent period of care by an LMO under the Program if immediately before the commencement of the potential period of care the matters in (a) or (c) of 6A.6.1 apply to the person.
Note: the period of a period of care by an LMO is set out in the Notes for Coordinated Veterans' Care Program Providers and is a period of 3 months.
6A.7 Date of Admission for Participation in the Coordinated Veterans' Care Program
6A.7.1 Subject to 6A.3 and 6A.6, treatment of an entitled person under the Coordinated Veterans' Care Program (program) commences on the admission day for the person and continues throughout any period of care provided by an LMO to the entitled person under the program.
Note: treatment under the program provided by a practice nurse, community nurse or aboriginal health worker can only occur during a period of care provided by an LMO under the program.
6A.8 LMO Home Care service (category C) Referral
6A.8.1 An LMO treating an entitled person under the Coordinated Veterans' Care Program may decide the person would benefit from a Home Care service (category C) and may refer the person to a MHC assessment agency for an assessment as to the person’s suitability for the service and, depending on the outcome, the agency may allocate responsibility for providing the Home Care service (category C) to an approved provider. The referral is treatment known as: LMO Home Care service (category C) Referral.
Note: for the purposes of 7.3A.1(1)(a)(iii) the referral to a MHC assessment agency is also taken to be a referral to the Commission.
6A.8.2 The LMO may provide an LMO Home Care service (category C) Referral for an entitled person if:
(1) the person is admitted to the Coordinated Veterans' Care Program; and
(2) in the opinion of the LMO:
(a) the person has a limited or inadequate social support network and could reasonably be at risk of hospitalisation for a condition in 6A.5.1(1)(a) because of that social situation; and
(b) the risk of the person being hospitalised for a condition in 6A.5.1(1)(a) may be significantly reduced if the person received a Home Care service (category C).
Note: a referral must comply with the requirements in the definition of Home Care service (category C) Referral.
6A.9 Procedures under the Coordinated Veterans' Care Program.
6A.9.1 An LMO may medically assess an entitled person the LMO is treating to determine if the person would benefit from participation in the Coordinated Veterans' Care Program (program).
6A.9.2 If the LMO decides the entitled person would benefit from participation in the program, and the person is entitled to participate in the program, then the LMO is to inform the entitled person that the person’s participation in the program is conditional upon the person consenting to personal information about the person that is relevant to the person’s treatment under the program being provided to bodies such as:
the Department;
Contractors to the Department who provide services related to the administration of the Program or who would provide a Home Care service (category C) (social support service) to the person;
the Department of Human Services (which pays treatment costs for the Department);
health care providers associated with the person’s treatment under the program.
The LMO is to obtain the person’s consent, if the person is to participate in the program, and record it and store it in a readily retrievable form.
Note: consent may be recorded and stored in electronic form.
6A.9.3 Once an entitled person’s consent is obtained the LMO is to admit the person to the program. This takes the form of the LMO recording in writing (including in electronic form) that the person has been admitted to the program. Participation in the program commences on and from the admission date.
6A.9.4 The LMO is to prepare, in consultation with the person, a comprehensive care plan for the person (GPMP).
6A.9.5 A practice nurse (nurse working for the LMO) or, if appropriate, a community nurse (nurse working for a DVA-contracted community nursing provider) or an aboriginal health worker (working for the LMO) will co-ordinate care services under the GPMP (care co-ordinator). The LMO may need to refer co-ordination of the GPMP to a DVA-contracted community nursing provider if, for example, the LMO does not employ a practice nurse. In some cases the LMO may not be able to secure the services of a care co-ordinator and may need to provide the service themselves but the main role of the LMO is to provide oversight of the care co-ordination under the GPMP.
6A.9.6 Part of the monitoring mechanism for the program involves the LMO assessing the progress an entitled person is making (progress assessment). This is to occur toward the end of a period of care by the LMO and before the LMO provides a further period of care to the person. More details of the procedure is at 6A.3. A progress assessment is not a prerequisite to the commencement of an initial period of care.
6A.9.7 If the LMO decides that the entitled person is socially isolated and that because of that situation the person could be reasonably at risk of being hospitalised for a condition in 6A.5.1(1)(a) and that the risk of hospitalisation may be significantly reduced by the provision of a Home Care service (category C) to the person — then the LMO may refer the person to a MHC assessment agency for an assessment as to the person’s suitability for the service. The referral is called: LMO Home Care service (category C) Referral.
6A.9.8 The MHC assessment agency is to assess a person pursuant to a LMO Home Care service (category C) Referral and is to determine if the person is suitable for a Home Care service (category C), using the standard assessment process that the agency applies to all assessments for services under the MRCA Home Care Program, and is to determine the type, duration and frequency of any Home Care service (category C) to be provided to a person.
6A.9.9 When providing treatment under the Coordinated Veterans' Care Program an LMO, a practice nurse, a DVA-contracted community nursing provider (for a community nurse), and an aboriginal health worker are to comply with the requirements in these Principles and any requirements in the Notes for Coordinated Veterans' Care Program Providers that relate to them.
Part PART 6A - MRCA Treatment Principles - COORDINATED VETERANS' CARE PROGRAM | Zoe