A team-based program providing complex care for veterans

Source: APNA Primary Times Summer 2021 (Volume 21, Issue 2)

The Coordinated Veterans’ Care (CVC) Program, funded by the Department of Veterans’ Affairs (DVA) for eligible veterans, is a team-based program where eligible veterans (participants), their GP and care coordinator (nurse or Aboriginal and/or Torres Strait Islander Primary Health Care Worker) work together as a core Care Team to develop a comprehensive Care Plan and coordinate care. The aim is to meet the holistic health-care needs of the participant and manage their ongoing care.  

The CVC Program is aimed at patients who have complex care needs, and who are at risk of unplanned hospitalisation. The program is available to:  

• Gold Card holders with one or more chronic conditions  
• White Card holders with an accepted mental health condition.  

The program is designed around enabling person-centred care to address the individual needs of each veteran participant. It encourages the proactive engagement of veteran participants in the development, implementation and regular review of their Care Plans. This engagement promotes increased participation and encourages veterans to take a more active role in their health and wellbeing.  

Because each veteran participant’s needs are different, their Care Plan and coordination will be unique to their situation. The CVC Program is about genuine engagement with the participant. Meaningful Care Plans must be developed in collaboration with the participant and other members of their Care Team. The broader Care Team can include other health professionals, depending on the individual participant’s needs.  

A key element of the coordination of care, funded under the CVC Program, is the care coordinator’s role, which involves coordinating and providing ongoing care and support to the participant. The care coordinator’s role is vital to the successful delivery of the CVC Program because of the relationship they build with the patient and the leadership role they take within the Care Team. This ensures that the participant and their needs are at the centre of all CVC Program activities. 

While this involvement will look different for each participant, there are some core activities that will be individualised, and it is important that the care coordinator involves the participant in each activity.  

The CVC care coordinator is responsible for:  

• managing the Care Team’s involvement in the development of the Care Plan  
• monitoring the Care Plan implementation, including engaging with the GP when reviews and renewals are due  
• promoting collaboration and accountability with other health professionals within the Care Team  
• determining an agreed means of communication to suit each Care Team (relating to the Care Plan and outcomes, and for sharing relevant test results and informing the Care Team of incidents, e.g., hospitalisations)  
• maintaining regular contact with the participant.  

The main purpose of the care-planning and coordination activities is to have a proactive approach to improving the management of chronic conditions and the quality of care for the veteran through coordination and planning within a Care Team environment.