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Is participation mandatory?
DVA is encouraging all CN Providers to participate in the Program.
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Does the client still require a Registered Nurse (RN) visit at their home each month for a valid claim?
Yes. The aim of the Program is to provide enhanced coordinated care for veterans and war widows/ers with chronic complex conditions. It is expected that the level of care coordination will reflect the complex needs of the individual.
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What is the difference between the CVC and the DVA Community Nursing Programs?
The CVC Program has specific eligibility criteria and is a targeted program aimed at veteran, war-widow/widower and dependant Gold Card holders with chronic diseases and complex care needs who are at an increased risk of hospitalisation. The CVC Program is an enhanced community care initiative in which the LMO/GP will provide ongoing coordinated care services and additional support through a Practice Nurse in the LMO/GPs practice or a Community Nurse through a DVA-contracted community nursing provider.
DVA’s Community Nursing Program provides community nursing services to meet an entitled person’s assessed clinical and/or personal care needs and is available to both Gold and White Card holders.
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Are White Card holders eligible for the CVC Program?
No, white card holders are not eligible for the CVC Program.
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How will an LMO/GP know if an entitled person is participating in any of the following programs:
- Extended Aged Care at Home Packages;
- Community Aged Care Packages;
- Transition Care (see next question)*; or
- a similar program with a different name.
As part of the eligibility assessment, LMOs/GPs will ask a potential participant/or carer whether they are in any of those programs. The LMO/GP is not expected to make any further enquiries.
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What rules apply to Transition Care?
A Gold Card holder receiving Transition Care cannot be admitted to the CVC Program or the Community Nursing Program until the period of Transition Care has expired. Refer to Attachment E of the Guidelines for the provision of community nursing services – effective 1 March 2010, section 4.2.6.5 Transition Care Program for further information on transition care.
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What does the CVC Program mean to me as a community nurse?
The Model of Care for the CVC Program is based on the core team, which includes the participant, the participant’s carer (if applicable), the LMO/GP and the nurse coordinator, who is either a practice nurse, Aboriginal health worker or, if the LMO/GP does not have access to a practice nurse, a community nurse. The LMO/GP determines whether the nurse coordinator role will be performed by a Practice Nurse, or Aboriginal Health Worker, or a Community Nurse. Where none of these are available or suitable, the LMO may perform the coordination role.
As a nurse coordinator, community nurses will be working closely with the LMO/GP, the participant and any carer to coordinate care for the participant using the GP Care Plan prepared by the LMO/GP and sent with the referral for CVC care coordination. From the GP Care Plan, community nurses will develop a Community Nursing Management Plan (CNMP), which will detail the Community Nursing (CN) care coordination activity that will take place.
CN care coordination activity could include:
- coaching and assisting the participant with their self management goals;
- assisting with self monitoring and recording of vital signs;
- education on emergency warning signs;
- assistance with making appointments with other health professionals;
- providing appointment reminders, including what to take (e.g. x-rays) or requirements/restrictions (e.g. fasting on day of appointment etc);
- sending the GP Care Plan to other health professionals as agreed with the LMO/GP;
- support for carers;
- monitoring the participant’s condition e.g vital signs;
- post appointment follow up with other health care professionals and the participant;
- providing regular feedback to the LMO/GP.
The CNMP will include:
- detailed information about the participant’s medical history;
- goals and strategies for self management;
- a list of medications, dose and frequency;
- appointments for specialists and other health professionals, medication reviews etc; and
- symptoms the participant should watch out for and report on.
The LMO/GP will regularly review the GP Care Plan to monitor progress, make any necessary changes, and ensure care is ongoing and planned.
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What happens if the LMO/GP does not supply a copy of the GP Care Plan when a participant is referred to a DVA-contracted community nursing provider?
The DVA-contracted community nursing provider should contact the LMO/GP to obtain a copy of the GP Care Plan.
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Is there a mandatory format for the Community Nursing Management Plan (CNMP)?
There is no mandatory format. DVA-contracted community nursing providers should use the format that provides the required information to undertake CN care coordination services that best suits the needs of the participant and their organisation.
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What information do community nurses need to supply to other health professionals?
DVA-contracted community nursing providers should supply information they feel is clinically appropriate and necessary to support/improve the CVC Program participant’s care regime. If agreed with the LMO/GP, the community nurse should liaise with and provide a copy of the GP Care Plan, to other health professionals involved in the care of the participant.
One of the purposes of providing care coordination services is to improve the communication and information flow between the whole team undertaking care of the CVC Program participant. Providing up-to-date relevant information to all the health professionals involved in the participant’s care is one of the ways to improve outcomes for the participant and the team.
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Do services have to be provided in the client's home?
There is a minimum requirement of one (1) face-to-face visit by a registered nurse per 28-day claim period. However, not all services will have to be provided in home, for example some services such as arranging health care appointments may be able to be arranged by phone.
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Can responsibilities of care coordination such as providing and coordinating appointment reminders and feedback with other health professionals, be handled by office coordinators?
The responsibility of care coordination lays with the assigned Community Nurse and the role of liaising with other health professionals is vitally important to the extended care coordination role. The Guidelines have been updated to reflect the roles and responsibilities for care coordination activities.
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Are the “Initial Care Coordination” and the ongoing “Subsequent Care Coordination” payments regarded as additional components to other base item numbers?
Yes.
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Why is clinical monitoring excluded from the items that can be claimed with CVC Program item numbers under the Classification System and Schedule of Item Numbers and Fees – Community Nursing Services?
The CVC Program provides care coordination services, the same services are provided in the Clinical Monitoring client type – claiming both would be considered a duplication of services and payments.
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What will happen if a LMO/GP refers a participant to a different DVA-contracted community nursing provider?
The Guidelines for the provision of community nursing services – effective from 1 May 2010 (Guidelines) prohibits two providers from claiming for the same entitled person under the DVA Community Nursing Program. If duplication of referrals occur the existing DVA-contracted community nursing provider should contact the LMO/GP to discuss referral of the CVC Program services to the existing provider. The second DVA-contracted community nursing provider should contact DVA to discuss payment via the prior approval process, if CVC Program services have been provided.
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What will happen if a LMO/GP uses a practice nurse and there is already a DVA-contracted community nursing provider providing DVA Community Nursing Program services to the CVC participant?
If the practice nurse is aware of the community nursing services, the practice nurse will contact the DVA-contracted community nursing provider to advise that the person is now a CVC participant and to coordinate services so they are not duplicated.
Once a person has been enrolled on the CVC Program, the LMO/GP will start receiving monthly patient reports listing recent DVA paid services (including community nursing) provided to the participant.
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What referral date should be used by a DVA-contracted community nursing provider when a CVC participant re-enters the DVA Community Nursing Program for assessed clinical and/or personal care services after a period of absence?
If this occurs DVA-contracted community nursing providers should contact the Community Nursing section on 1300 550 466 or VHC&CNSDOPS@dva.gov.au. Refer to the Guidelines section Guidelines for the provision of community nursing services – effective 1 March 2010, section 1.5 Contacting DVA.
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Will I receive any training?
Yes. Training and resources in Chronic Disease management will be available free of charge for general practitioners, practice nurses and community nurses through the Australian General Practice Network assisted by Flinders University, Baker IDI Heart and Diabetes Institute and the Australian Practice Nurses Association. Training will be a mix of on-line and face to face workshops supported by CD/DVD where access is a problem. The training modules will be progressively rolled out from September 2011. The dedicated website for the training and resources is www.cvcprogram.net.au.
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Will completion of the training contribute to my continuing professional development points?
Yes. Modules will have appropriate accreditations/certifications.
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Is the training being offered through the CVC Program mandatory?
Whilst all community nurses providing CN care coordination under the program are encouraged to complete the CVC Program training modules, only Module One is mandatory and it is only mandatory for enrolled nurses providing care coordination under the program. Module One should be completed by enrolled nurses within a reasonable time of the module becoming available. At this stage it is expected that Module One will be available on-line in September 2011. The training available through the CVC Program will be accredited and will attract CPD hours.
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Will CN Providers need to re-tender?
Re-tendering is not required. New item numbers have been added to the Classification System and Schedule of Item Numbers and Fees (Schedule of Fees). These new item numbers can be claimed in addition to the current Classifications after 1 May 2011.