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 VHC assessment agency (an agency under the Veterans’ 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 Treatment Principles.
The ancillary treatment may be provided by an approved provider of Veterans’ Home Care services following a request for social support services from a VHC assessment agency. The general practitioner 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 VHC assessment agency will assess the person’s suitability for a social support service.
6A.1A In this Part:
accepted mental health condition means that the entitled person has a mental health condition for which the person is entitled to be provided with treatment under Part V of the Act on the basis that the condition is due to a war‑caused injury or war‑caused disease.
Note: The paragraph 1.4.1 definition of “war‑caused” includes a person with a DRCA disability.
Note 2: A veteran or eligible ADF member who receives treatment for a mental health condition as a member of a class of persons specified in Part 2 of the Veterans’ Entitlements (Expanded Access to Non‑Liability Health Care for Mental Health Treatment) Determination 2017 (Instrument 2017 No. R24), as in force from time to time; will not be eligible for the Coordinated Veterans’ Care Program.
6A.2 Treatments under the Coordinated Veterans' Care Program
6A.2.1 GP Care Leadership treatment/GP Home Care service (category C) Referral
6A.2.2 A general practitioner may, under the Coordinated Veterans' Care Program, provide:
(a) GP Care Leadership treatment; or
(b) a GP Home Care service (category C) Referral; or
(c) both (a) and (b);
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 and/or Torres Strait Islander Health Worker Care Co‑ordination treatment
6A.2.8 An Aboriginal and/or Torres Strait Islander health worker may, under the Coordinated Veterans' Care Program, provide Aboriginal and/or Torres Strait Islander Health Worker Care Co‑ordination treatment to an entitled person.
6A.3 GP Approval of Subsequent Period of Care
6A.3.1 Before any subsequent period of care of an entitled person by a general practitioner commences, being a general practitioner who is treating the person under the Coordinated Veterans' Care Program (Program), the general practitioner 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 a general practitioner commences on the date the general practitioner decides to admit the entitled person to the Program (admission date). Any following period of care by the same general practitioner is a subsequent period of care. The first period of care by a general practitioner may also occur where the general practitioner is a different general practitioner for the person. Any following period of care by the same general practitioner is a subsequent period of care.
Note 2: the period of care by a general practitioner 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 general practitioner is to:
(a) review the entitled person’s file maintained by the general practitioner and any other information the general practitioner considers relevant; and
(b) ascertain if the person is eligible for a subsequent period of care by the general practitioner.
Note: see 6A.6.2
6A.3.3. If the general practitioner 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 general practitioner, the general practitioner is to:
(a) approve a subsequent period of care by the general practitioner 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 general practitioner to the entitled person.
6A.3.4. Where a general practitioner approves a subsequent period of care by the general practitioner for an entitled person, before the expiry of a current period of care by the general practitioner 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 a general practitioner approves a subsequent period of care by the general practitioner for an entitled person (approval), after the expiry of a current period of care by the general practitioner for the person, the subsequent period of care commences on the date of the approval.
6A.3.6. If the general practitioner decides not to approve a subsequent period of care by the general practitioner 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 general practitioner, the general practitioner 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 general practitioner, 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 general practitioner, notify (including by telephone) the VHC assessment agency for the person, of the decision;
(c) notify the entitled person, in a manner the general practitioner 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) GP Care Leadership treatment;
(b) Practice Nurse Care Co‑ordination treatment;
(c) Community Nurse Care Co‑ordination treatment;
(d) Aboriginal and/or Torres Strait Islander Health Worker Care Co‑ordination treatment;
provided to an entitled person, during a period of care of the person by the general practitioner, the practice nurse, the community nurse or the , Aboriginal and/or Torres Strait Islander Health Worker Care Co‑ordination treatment 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 general practitioner under the Coordinated Veterans' Care Program (Program).
6A.4.2 The financial amounts the Department will pay for:
(a) GP Care Leadership treatment, Practice Nurse Care Co‑ordination treatment and Aboriginal and/or Torres Strait Islander Health Worker Care Co‑ordination treatment — are set out in the DVA document entitled: “Department of Veterans’ Affairs Fee Schedules for Medical Services”, referred to in Schedule 1;
(b) Community Nurse Care Co‑ordination treatment — are set out in the DVA document entitled: “DVA Community Nursing Schedule of Fees”, referred to 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 a general practitioner, practice nurse, community nurse or Aboriginal and/or Torres Strait Islander Primary Health Care worker under the Coordinated Veterans' Care Program (Program) if any previous period of care provided by, respectively, a general practitioner, practice nurse, community nurse or Aboriginal and/or Torres Strait Islander Primary Health Care 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 a general practitioner, practice nurse, community nurse or Aboriginal and/or Torres Strait Islander Primary Health Care 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 general practitioner 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 and/or Torres Strait Islander Health Worker Care Co‑ordination treatment will be made by the Department to the general practitioner who employed or engaged the practice nurse or Aboriginal and/or Torres Strait Islander Primary Health Care 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.4A Arrangements with Service Providers
6A.4A.1 For the purpose of facilitating the provision of Coordinated Veterans' Care Program treatment to entitled persons, the Commission or the Department may enter into an arrangement with a person to:
(a) assist in identification of possible participants in the Coordinated Veterans' Care Program and provide general support to the Commission or Department in respect of the program including:
(i) data analysis to identify and notify potential participants and their usual general practitioner or medical practitioner;
(ii) undertaking ongoing analysis and reporting to support program evaluation and monitoring;
(iii) promoting the program and providing supplementary support materials for general practitioners and participants in the Program; or
(b) deliver training modules and resources in Chronic Disease Management to general practitioners, medical practitioners, Practice Nurses and Community Nurses; or
(c) undertake ongoing and independent monitoring and evaluation of the Coordinated Veterans' Care Program .
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 a general practitioner treating the person:
(a) in the opinion of a general practitioner treating the person the entitled person has a chronic health condition (including an accepted mental health 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 entitled person is eligible for treatment under the Act:
(a) as a Gold Card holder; or
(b) as a White Card holder with an accepted mental health condition; 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 general practitioner has recorded the consent (which may be an electronic record); and
Note: under the Notes for Coordinated Veterans' Care Program Providers the general practitioner is to store the consent.
(5) the general practitioner treating the person has prepared, in consultation with the person, a Comprehensive Care Plan; and
(6) the general practitioner 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 GP 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 a general practitioner 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 general practitioner, 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 Department of Health Transition Care Program.
6A.6.2 An entitled person is not eligible for a subsequent period of care by a general practitioner 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 a general practitioner 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 a general practitioner to the entitled person under the program.
Note: treatment under the program provided by a practice nurse, community nurse or Aboriginal and/or Torres Strait Islander Primary Health Care worker can only occur during a period of care provided by a general practitioner under the program.
6A.8 GP Home Care service (category C) Referral
6A.8.1 A general practitioner 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 VHC 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: GP Home Care service (category C) Referral.
Note: for the purposes of 7.3A.1(1)(a)(iii) the referral to a VHC assessment agency is also taken to be a referral to the Commission.
6A.8.2 The general practitioner may provide a GP 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 general practitioner:
(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 A general practitioner may medically assess an entitled person the general practitioner is treating to determine if the person would benefit from participation in the Coordinated Veterans' Care Program (Program).
6A.9.2 If the general practitioner decides the entitled person would benefit from participation in the program, and the person is entitled to participate in the program, then the general practitioner 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 general practitioner is to obtain the person’s consent, if the person is to participate in the program, 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 general practitioner is to admit the person to the program. This takes the form of the general practitioner 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 general practitioner is to prepare, in consultation with the person, a Comprehensive Care Plan for the person.
6A.9.5 A practice nurse (nurse working for the general practitioner) or, if appropriate, a community nurse (nurse working for a DVA‑contracted community nursing provider) or an Aboriginal and/or Torres Strait Islander Primary Health Care worker (working for the general practitioner) will co‑ordinate care services under the Comprehensive Care Plan (care co‑ordinator). The general practitioner may need to refer co‑ordination of the Comprehensive Care Plan to a DVA‑contracted community nursing provider if, for example, the general practitioner does not employ a practice nurse. In some cases the general practitioner 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 general practitioner is to provide oversight of the care co‑ordination under the Comprehensive Care Plan.
6A.9.6 Part of the monitoring mechanism for the program involves the general practitioner assessing the progress an entitled person is making (progress assessment). This is to occur toward the end of a period of care by the general practitioner and before the general practitioner 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 general practitioner 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 general practitioner may refer the person to a VHC assessment agency for an assessment as to the person’s suitability for the service. The referral is called: GP Home Care service (category C) Referral
6A.9.8 The VHC assessment agency is to assess a person pursuant to a GP 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 Veterans’ 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 a general practitioner, a practice nurse, a DVA‑contracted community nursing provider (for a community nurse), and an Aboriginal and/or Torres Strait Islander Primary Health Care 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.