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

Care Planning

The CVC Program involves an ongoing partnership between the core team and is based on a personalised comprehensive Care Plan. The Care Plan actively involves the veteran in goal-setting, identifying interventions and other self-management aspects including processes for monitoring, reviewing and evaluating the plan.
Whilst there is no mandated care plan template for the CVC Program, the checklist of the minimum requirements for a Care Plan includes the following points and requires that a patient friendly version of a Care Plan to be provided to the veteran. Minimum requirements include a description of all chronic and other health conditions with:

  • 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

A comprehensive needs assessment of the veteran underpins the development of the comprehensive Care Plan and includes a review of the veteran’s current self-management of their health, lifestyle and mental health by the GP or nurse coordinator. The CVC Program toolkit includes questionnaires for use in conducting a comprehensive needs assessment.

Care Plan templates have been developed, including versions of the tools, in a number of practice software compatible formats. Currently developed versions are available in ZedMed, Best Practice and Medical Director. Rich text format (rft) templates are also available for import into practice software, see Tools and Templates  for further details and instructions.

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