Enrol participants in the program

The CVC Program targets veterans, war widows, war widowers and dependents who are Gold Card holders with one or more chronic condition, complex care needs and at risk of unplanned hospitalisation. The program is primarily focused on Gold Card holders with the following conditions:

  • congestive heart failure (CHF)
  • coronary artery disease (CAD)
  • chronic obstructive pulmonary disease (COPD)
  • diabetes
  • pneumonia.

Enrolling a potential participant in the program involves:

  • a GP assessment of the Gold Card holder’s eligibility to participate
  • explaining the program to the Gold Card holder and obtaining informed consent
  • conducting a needs assessment by the GP and/or nurse coordinator
  • preparing a Care Plan with the Gold Card holder
  • giving a patient friendly version of the Care Plan to the Gold Card holder
  • a GP assessment of the need for social assistance and, if appropriate, referral to a VHC assessment agency.

Identifying potential CVC participants

Individuals may be identified as potential participants for the program in the following ways:

  • DVA may identify potential participants using predictive modelling to analyse the health care data of Gold Card holders
  • A Gold Card holder may ask to participate
  • A care provider – carer, specialist, allied health worker etc, hospital discharge planner or community nurse may recommend a Gold Card holder be assessed by their GP to participate
  • GP may identify one of their Gold Card holders as suitable.

Initial screening: When identifying a veteran as a possible participant, or a request for an assessment appointment is received, either the GP or PN needs to check the patient’s medical record to ensure there are no obvious disqualifying factors (i.e. terminal condition or living in a residential aged care facility: see Eligibility Checklist). The Gold Card holder can be contacted and the CVC Program explained to them. An assessment appointment can then be made if the patient is interested in the program.

Assessing eligibility for the program

During the assessment appointment the GP assesses the potential participant using the Eligibility checklist criteria below.

Eligibility Checklist

Eligibility checklist

 

* Note regarding the Department of Social Services Home Care Packages Program: A Home Care Package is a coordinated package of services tailored to meet specific care needs. A Home Care Package provides services that can help a person to stay at home and give choice and flexibility in the way that care and support is provided to the client. Home care providers receive funding from the Australian Government to provide these services across four levels of Home Care Packages.

  • Level 1 supports people with basic care needs
  • Level 2 supports people with low-level care needs (equivalent to the former Community Aged Care Packages)
  • Level 3 supports people with intermediate care needs
  • Level 4 supports people with high care needs (equivalent to the former Extended Aged Care at Home and Extended Aged Care at Home Dementia packages).

Gold Card holders on Levels 3 or 4 Home Care Packages would be ineligible for the CVC Program as they are already receiving high level coordinated health care.

Consent

When seeking informed consent the GP explains to the Gold Card holder:

  • what it means to be on the program
  • that their health information will be shared with other health professionals involved in their care
  • that a nurse will coordinate their health care
  • a Care Plan will be developed by the GP, the nurse coordinator and the Gold Card holder working together
  • they will receive a patient friendly version of the Care Plan
  • that details of health services used by them through DVA will be made available to their GP
  • their privacy will be protected under the relevant legislation

A suggested script for obtaining informed consent can be found on page 32 in the DVA Brochure  CVC Program – A Guide for General Practice

Needs assessment

A comprehensive needs assessment of the participant is undertaken to assess their current self-management of their health, lifestyle and mental health by either the GP or nurse coordinator. The CVC Program toolkit includes questionnaires for use in conducting a comprehensive needs assessment – The CVC Program Toolkit – needs assessment

Preparing and finalising a Care Plan

To allow flexibility for GPs, there is no mandated Care Plan template for the CVC Program. There is however, a checklist of the minimum requirements for a Care Plan for a CVC participant which should include:

  • a description of all chronic and other health conditions, including:
    • current care guide
    • targets
    • red flags
    • background information
    • current management
    • most recent results
  • medications list including dose, frequency and known adherence
  • allergies and adverse reactions
  • self-management goals and strategies
  • any family and / or carer contact details
  • significant medical events and results
  • other treatment providers and their contact details
  • referrals planned and reasons for referral
  • devices being used.

The Care Plan is a comprehensive version of a General Practitioner Management Plan (GPMP), which is an existing LMO Fee Schedule item and is billed as a separate service to the CVC items. The GP or nurse coordinator discusses the Care Plan with the participant to ensure that the veteran understands the goals of the Care Plan, the interventions and self-management aspects, the methods of monitoring and evaluating the plan, and the need for regular monitoring and review.

It may take several sessions to obtain the information you require for the Care Plan and also prepare the patient friendly version in consultation with the participant. When this is complete, the participant is asked to consent to the Care Plan and is provided with a patient friendly version of the Care Plan.

Consider the need for social assistance

The GP and /or nurse coordinator should also consider whether the participant could benefit from CVC Social Assistance which provides a short-term service to CVC enrolled patients to enable (re)engagement in community based activities.This requires a GP referral to VHC assessment agency (VHCAA). For information on the nearest VHC assessment agency, phone 1300 550 450 and for further information on Social Assistance refer to the CVC section of the social assistance page on the DVA website.

Enrolment summary

  • identify potential participants
  • assess eligibility for the program
  • gain informed consent
  • conduct a needs assessment
  • prepare a Care Plan with the participant (this may be prepared over a period of time)
  • finalise the Care Plan, including a patient friendly version, with the participant
  • consider the need for social assistance.

There is no enrolment form to complete and return to DVA. When all steps are completed, the GP records the enrolment and consent on the patient’s record. By enrolling a Gold Card holder in the CVC Program, a GP is accepting the clinical leadership and oversight role for the participant.

Submitting the Initial Incentive Payment claim

The Initial Incentive Payment can now be claimed; the first quarter of care commences but cannot be claimed until the 90 day quarter is complete. Claiming the Initial Incentive Payment will automatically inform DVA that the Gold Card holder is now a participant in the CVC Program. The Initial Incentive Payment is a one-off payment paid only once per Gold Card holder, made to the GP for undertaking steps to meet enrolment requirements. If the nurse coordinator is a CN, it is very important that the GP submits their first claim promptly, as a claim by the CN will be rejected if the GP’s Initial Incentive Payment has not yet been made.

Quarterly Care Payments are claimed on a 90 day basis for a period of ongoing clinical care. The Date of Service for each quarterly period is the first day of the quarterly period and the claim for payment is made after the last day of the quarterly period (more information about CVC billing is included in the delivering care section).