Provide Ongoing Care

The Model of Care for the CVC Program is based on the team, which includes the veteran, the Gold Card holder’s carer (if applicable), the GP and the nurse coordinator, who is a PN, CN or AHW. The CVC model encourages a proactive approach by the care team. Utilising tools such as the Flinders Program™ to assess self-management capacity and support results in collaborative problem definition, enables targeted goal setting that leads to a personalised Care Plan. Self-management support is provided by the care team:

  • through information so that the veteran better understands what will improve their condition and what will make their condition worse
  • using motivational and behaviour change counselling and support addressing the physical and emotional demands of chronic conditions to empower the veteran to follow their self-management goals, e.g. lose weight or do more exercise
  • through active and sustained follow-up (reliable follow-up leads to better outcomes) with regular communication with the team reviewing, updating and renewing the Care Plan.

Care planning, coordination and review within the multidisciplinary team through the sharing of health information is a key feature of the CVC Program. The availability of electronic health records (PCEHR) will assist in the sharing of health information amongst all providers of health care for CVC participants.

Ongoing care provided under the CVC Program is not a replacement of the continued interaction between the GP and the patient with regular consultations and medical management still needed.

Coordinate treatment services as per the Care Plan

The nurse coordinator is responsible for coordinating treatment services for each Gold Card holder based on their Care Plan with the GP providing regular advice and guidance to the coordinator. As the nurse coordinator can be a PN, CN or AHW duties will vary slightly. For specific details please refer to pages 23 and 24 of the DVA Brochure –  CVC Program – A Guide for General Practice

Coordinating treatment services for the participant involves the following:

  • monitor progress according to the Care Plan
  • monitor physical and mental condition
  • maintain regular contact – at least monthly
  • provide advice, e.g. medication, health coaching, motivational counselling
  • liaise with the carer and keep them informed of progress and changes to the Care Plan
  • make appointments with other care providers if necessary, and provide a copy of the Care Plan to all specialists, allied health practitioners and other care providers (as appropriate and agreed with the GP)
  • monitor the actions of all care providers (e.g. prescriptions, tests, referrals and recommendations) through feedback from the veteran, carer, consultation reports and calls to other care providers
  • liaise with emergency and / or hospital discharge departments
  • consider and address ongoing social isolation issues
  • provide regular feedback about the participant’s condition to the GP, including advice on their need for social assistance services and alerts where changes occur in their condition
  • provide feedback to the GP – at least monthly
  • maintain up-to-date records of all monitored actions and coordination activity.

Contact with the participant may be by telephone, in rooms or through home visits. Home visits are not mandatory but highly recommended for PNs and AHWs.


Regularly review, update and renew the Care Plan

The care team is expected to review treatment services for the participant on a regular basis with the Care Plan being reviewed / updated at least every six months and renewed at least every 12 months.

DVA produces a quarterly Patient Treatment Report (PTR) from its payment data for each CVC participant. The report includes health services received, medication history and clinical pathways. The first PTR for a participant is sent to the GP in a hard copy format and subsequent PTRs are available online via Health Professional Online Services (HPOS). The PTR is intended to be used as a support tool to assist in identifying potential gaps in patient care.

 Summary of responsibilities


Summary of responsibilities

Care Plan templates and tools

Instructions for importing Sample Care Plan templates and the Flinders Program™ tools into current versions of Medical Director, Best Practice and Zedmed medical software are available with templates provided for the following documents:

  • CVC comprehensive Care Plan
  • CVC patient friendly Care Plan
  • Care Plan self-management page
  • Partners in Health Scale
  • Cue and Response interview
  • Problem and Goals Assessment.

Accredited training

Online training and resources are provided for GPs, PNs, nurse coordinators, CNs, AHWs and Allied Health Professionals. The accredited training will further develop your understanding of self-management, care planning and the benefits and processes of multi-disciplinary care in a primary care environment. Details of the online training can be found here.

Resources (delivering the CVC Program)

For eligible serving or ex-serving Defence personnel, or their families who are concerned about their mental health visit or call the Veterans and Veterans’ Families Counselling Service (VVCS) on 1800 011 046 for free, confidential counselling and support 24 hours a day.

At Ease also has clinical resources and factsheets for health professionals who may be treating members of the veteran and defence community.

vetAWARE is available for all health professionals as well as for representatives of ex-service organisations who want to learn more about the common mental health challenges faced by veterans and what help is available. To access the vetAWARE online training program, visit DVA’s Learning Management System, DVAtrain.



Information for Practice Managers

The CVC Program requires ‘buy in’ across the whole practice, and excellent teamwork is required to implement high standard coordinated care for the participant in an efficient and effective way. Administrative support for clinical activities, scheduling of participant contact and claiming activities contributes to the success of a ‘whole of practice’ approach to implementation of the CVC Program Model of Care.

How to claim

The CVC Program provides payments for ongoing team-based, quarterly periods of care to complement the existing fee-for-service arrangements, noting that the CVC MBS items are in addition to all existing MBS Schedule items.

By participating in the CVC Program, GPs can claim the following payments through existing payment arrangements with Medicare:

  • Initial Incentive Payment for enrolling a participant in the program. This is a one-off payment made to the GP for enrolling a person in the program and completing all enrolment activities.
  • Quarterly Care Payments for ongoing care.Paid quarterly as part of ongoing clinical care leadership of a participant in the CVC Program. A claim is submitted upon completion of each quarter (the previous quarter must have expired before claiming) and the new quarter commences.

A GP who uses a PN or AHW as the care coordinator is paid at the higher rate shown in the table below. A GP who uses a CN or does the coordination themselves is paid the lesser amount (where a CN is used, the DVA contracted nursing provider is paid for the nurse coordination activity). In claiming any item, a GP is confirming that all steps necessary for the enrolment of a Gold Card holder or for the ongoing coordination of care have been done. DVA may conduct post payment audits to ensure compliance.

Payments GPs can claim – fees effective 1 July 2014









                                                        Claiming date ready reckoners

These reckoners will assist in calculating the date of service and the claiming date for each CVC enrolled patient with further information to be found in the How to Claim section on the DVA website.

The full fee schedule for CVC Program items is on the CVC Program Fees section on the DVA website. Payments are in addition to all existing LMO Fee Schedule items for consultations and chronic disease management items.