Strengthening Primary and Community Care for Australia's Veterans Most at Risk

The Coordinated Veterans’ Care (CVC) Program

Strengthening Primary and Community Care for Australia’s Veterans Most at Risk

The CVC Program is a planned and coordinated health care model for eligible Gold Card holders with one or more chronic conditions, complex care needs and who are at risk of unplanned hospitalisation. In particular it is targeted at veterans with one or more of the following conditions:

  • congestive heart failure
  • coronary artery disease
  • pneumonia
  • chronic obstructive pulmonary disease
  • diabetes.

The model of health care within the CVC Program involves an ongoing partnership between a core team and is based around the development of a personalised comprehensive Care Plan. The core team consists of the veteran, the veteran’s carer (if applicable), the General Practitioner (GP) and a nurse coordinator, who is a practice nurse (PN), Aboriginal health worker (AHW) or community nurse (CN).
The team uses care planning, coordination and review to focus on planned and coordinated management and self-management support of the veteran’s health to incorporate the multidisciplinary team in primary and community care. Regular communication, empowerment and coaching are the keys to the success of the team.

Benefits for participants

As a result of the program, participants will:

  • improve their quality of life with less need to be admitted to hospital
  • supported, educated and empowered to self-manage their conditions

Benefits for health professionals

  • GPs receive recognition and financial compensation, including for non-face-to-face time spent in providing comprehensive care to eligible participants
  • Helps to improve the quality and coordination of care for participants
  • Provides enhanced opportunity for nurses to work in partnership with the GP
  • Efficient alignment of nurse coordinator role with nursing skills
  • Training and resources for chronic disease management are provided for all health professionals