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

Prepare Your Practice

The Coordinated Veterans’ Care (CVC) Program provides eligible Gold Card holders with a practice team based model of coordinated health and community care. CVC health care is based around a personalised comprehensive Care Plan developed in collaboration with the CVC participant to educate and empower themselves in improved self-management of their chronic condition/s. Care is an ongoing partnership between the CVC participant, their General Practitioner (GP) and a nurse coordinator.

It is a targeted program for Gold Card holders with one or more chronic conditions, complex care needs and at risk of unplanned hospitalisation. The targeted conditions include:

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

Care is GP led, with a nurse coordinator working with the CVC participant (and carer if applicable). Implementing the CVC Program involves the following:

  • The practice team is aware of and ready to implement the program
  • Eligible Gold Card holders are identified
  • GP assessment of the Gold Card holder’s eligibility to participate
  • GP explains the Program to the Gold Card holder and obtains informed consent
  • A comprehensive assessment is done by the GP or nurse coordinator
  • A care plan is prepared by the care team with the Gold Card holder
  • A patient friendly version of the Care Plan is given to the Gold Card holder
  • GP may assess a Gold Card holder for social assistance and if appropriate refer them to a Veterans’ Home Care (VHC) assessment agency
  • Nurse coordinator coordinates all aspects of Gold Card holder’s health care using the Care Plan
  • Nurse coordinator provides regular feedback to the GP
  • Care Plan is reviewed regularly and updated.

More detailed information about what is required for the CVC Program and instructions on each stage – Preparing your practice, Enrolling participants and Delivering ongoing care can be found from the links below or from the downloadable PDFs:

Click on the stages below for more information

Prepare - Stage 1 Rounded-glossy-black-icon-arrow Enrol - Stage 2 Rounded-glossy-black-icon-arrow Provide Care- Stage 3


Accredited training incorporating the latest clinical evidence for self-management care planning in multi-disciplinary care in a primary care environment has been developed for GPs, Primary Care Nurses (PN), Aboriginal Health Workers (AHW) and Community Nurses (CN). Health professionals are encouraged to undertake the four online modules for more in-depth information with Enrolled Nurses (EN) and Aboriginal Health Workers required to complete at least Module One of the online training.

  • Module 1:    Is your service ready?
  • Module 2:    Care Planning and Coordination with the CVC Program
  • Module 3:    Managing Care Plans with disease-specific elements
  • Module 4:    Veterans’ social isolation, mental health and wellbeing.

The training can be accessed from from the training page or from