VHC Guidelines - Assessment Agency - CVC Social Assistance

The Coordinated Veterans' Care (CVC) program aims to better manage and coordinate primary and community care for Gold Card holders who are most at risk of being admitted and readmitted to hospital.

Download the PDF version of VHC Guidelines - Assessment Agency

Social Isolation

Engagement with others is an important part of keeping healthy and happy. There are life events that can make socialising challenging at times.Unfortunately, these life events are more common for older and frailer people e.g. death of partner and/or friend, family moving away, loss of driving license, loss of physical health and/or depression. There are generally a wide range of community activities and opportunities for socialising but it can be hard for some people to find out about them and take the first step in becoming involved. The social assistance activities available under the CVC program aim to help people navigate these community arrangements in their location so they can pursue interests or make new friends.

In addition to simply participating in activities it is important that the veteran or war widow/widower feels that they are contributing, that they belong and that they do not feel like a burden. This will ensure that the veteran or war widow/widower has a more positive experience and outcome.

Overview

The CVC program encourages Local Medical Officers (LMOs) or General Practitioners (GPs) to work as part of a team to provide comprehensive coordinated care for veteran or war widow/widower Gold Card holders who are most at risk of hospitalisation due to their chronic conditions and complex care needs.

The LMO/GP will assess whether a Gold Card holder meets the eligibility criteria for the program and, if they consent and are eligible, enrol them in the program. A General Practitioner Management Plan (GPMP) is prepared and the LMO/GP’s practice nurse or community nurse will work with the CVC participant to implement and coordinate the plan.

It is recognised that some people have poorer health and higher hospitalisation which may be exacerbated by social isolation. An important component of the CVC program is therefore to introduce social assistance through the VHC program for the program participants identified as being socially isolated.

The LMO/GP will also decide whether the participant may benefit from, and therefore should be assessed for, social assistance provided through the VHC program. Only a small subgroup of CVC program participants are expected to be referred for social assistance. A referral from a LMO/GP for a social assistance assessment does not guarantee that the CVC participant will be assessed by the VHC assessment agency as requiring these services, or that appropriate social assistance is available.

CVC social assistance delivered through the VHC program is primarily the provision of short term services to encourage longer term socialisation outcomes.

Services will be short term (up to 12 weeks) intensive services focussed on building the confidence of participants to promote ownership and motivation for their ongoing social health, with a view to establishing and maintaining long term benefits. These benefits include re-entry into community life, expanding the type and frequency of social contact and encouraging the veteran or war widow/widower to proactively engage with communities of interest.

Importantly, the focus on short term intervention rather than ongoing services also aims to promote social health and independence rather than dependency.

For CVC social assistance to be successful it is important for veterans or war widow/widowers to understand the intent of social assistance and, in particular, the short term nature of services. To facilitate this, the VHC assessment agency should forward the DVA Factsheet – CVC Social Assistance in addition to the VHC care plan to relevant veterans or war widow/widowers upon completion of an approval for CVC social assistance.

Eligibility & Access

To be eligible to be assessed for CVC social assistance provided through the VHC program, a person must:

• have a DVA Gold card;
• have chronic disease(s) and complex care needs such that they are at risk of being admitted or readmitted to hospital (as determined by the LMO/GP);
• be living in the community;
• be admitted as a participant of the CVC program by the LMO/GP; and
• be referred by their LMO/GP to the VHC assessment agency for an assessment of social assistance needs.

Veterans or war widow/widowers are not eligible for social assistance provided through the VHC program if they:

• are not a participant in the CVC program; and
• do not have a referral for assessment from their LMO/GP.

LMO/GPs are the initial entry point to the CVC program and, as such, are required to identify participants who may benefit from CVC social assistance and refer them to the VHC assessment agency. On receipt of the referral from the LMO/GP, the VHC assessment agency will conduct an assessment using the online validated VHC assessment instrument to determine what services, if any, the veteran or war widow/widower will receive.

All veterans and war widow/widowers not in the CVC program but assessed for other VHC services and who may also require social assistance should continue to be referred to the Home and Community Care (HACC) program or other community based services for social support services.

If a VHC assessment agency feels that a veteran or war widow/widower who is not currently participating in the CVC program would benefit from doing so, and meets the general eligibility criteria listed above, they should encourage the veteran or war widow/widower to discuss this option with their LMO/GP.

There are no restrictions on the use of other DVA services in conjunction with the CVC programs social assistance provided through the VHC program.

The CVC program is a program designed for Gold Card holders who are living in the community and NOT in residential aged care facilities or receiving:

• Coordinated care for Patients with Diabetes (including any pilot programs) (CCPD);
• Extended Aged Care at Home (EACH);
• Community Aged Care Package (CACP);
• Transition Care; or
• other similar programs.

Referral

The referral from an LMO/GP should be made to the VHC assessment agency listed in the VHC Guidelines - Assessment Agency and should include, at a minimum, the veteran or war widow/widower’s name and contact details together with the LMO/GP’s contact details.

Some veterans and war widow/widowers who may be eligible to participate in the CVC program may already be receiving VHC services. However, for CVC social assistance services (delivered through the VHC program), a referral from the LMO/GP will still be required for all veterans and war widow/widowers, regardless of what other services they are currently receiving.

Referrals from LMO/GPs will be valid for a 6 month period in case there is a delay in commencing services or until approved social assistance services have ceased, whichever is the later.

Assessment

VHC assessment agencies will be required to perform an appropriate assessment using the online validated VHC assessment instrument to:

• determine the type (i.e. community or home based socialisation) of service to be provided;
• frequency of service;
• duration of social assistance that the veteran or war widow/widower will receive (approvals should only be up to 12 weeks except in special circumstances); and
• allocate services to a contracted VHC service provider.

The VHC assessment agency will allocate a block of time (as an upper limit) to allow flexibility for the VHC service provider to claim for payment for the amount of service they actually delivered (up to the amount prescribed). See section - Social Assistance Activities below.

The VHC assessment agency should complete:

• a full VHC assessment where there has not been a VHC assessment undertaken or the last VHC assessment or review was completed more than three months previously; or
• a shortened CVC social assistance assessment, if completed within three months of a VHC assessment or review having taken place.

This allows assessors to recognise and effectively capture the needs of those veterans and war widow/widowers who have had regular VHC assessments in the past and are already receiving VHC services and those seeking services for the first time.

At the completion of an assessment and where services have been approved the VHC assessment agency should, at a minimum:

• send the VHC service provider the VHC service plan;
• send the veteran or war widow/widower a VHC care plan;
• send the veteran or war widow/widower the DVA Fact sheet – Social Assistance and DVA Fact sheet – Rights and Responsibilities (where veteran or war widow/widower is new to the VHC program); and
• advise the LMO/GP of the assessment outcome; an LMO Feedback Form is available to assist VHC assessment agencies if needed.

It is important to note that the CVC social assistance component of the CVC program is aimed at providing short term support to enable veterans and war widow/widowers to engage in social activities on a regular and ongoing basis in the longer term. Therefore, if during the assessment, it is the VHC assessor’s judgement that the veteran or war widow/widower requires more longer term social assistance they should be referred to HACC or other community based social support services. Assessors should provide an explanation in the appropriate comments field within the VHC assessment instrument regarding why long-term social support is needed.

Short term CVC social assistance and activities should be targeted, tailored and staged to meet individual client needs and should focus on attempting to address the underlying causes of social isolation as well as the cultural and environmental factors of the isolation (e.g. lack of personal or community transport - focus on how CVC participant can be put in touch with local community transport to facilitate participation in activity, as well as supporting the actual participation). Recommendations should be kept in-line with the overarching goals of a short term intervention designed to result in long term outcomes. Note: Help text in the Assessment Instrument will give VHC assessment agencies some direction.

When considering the CVC program’s overarching goal of short term intervention for long term benefit, multiple requests for CVC social assistance should be reviewed closely before services are approved.Services will be short term, up to 12 weeks, and can only be extended once for another 12 weeks if this will maximise the benefits of the service to the veteran or war widow/widower.

Note that the type of social assistance actually approved will be dependent upon existing community networks, capacity and/or availability of a VHC-contracted service provider in the veteran or war widow/widower’s region and the VHC program budget allocation for this service type.

The comments field in the VHC assessment instrument will allow VHC assessment agencies the opportunity to add comments about specific activities that may be recommended as a result of undergoing the assessment.           

Travel

The hourly fee paid to VHC service providers already includes a component for travel costs, therefore additional travel costs are not claimable.However, travel time is included in the block hours allocated by the VHC assessment agency to allow for travel from the veteran or war widow/widower’s home to the community based activities and return.

If travel time required is greater than ½ hour each way please note that this would be considered a barrier to the activity and should be addressed by the VHC service provider in conjunction with the CVC participant. In addition, the time spent on travel should ideally be less than the time spent on undertaking the actual activities.

Where travel is undertaken, appropriate insurance, registration and license requirements should be adhered to by the VHC service provider.

Communication Flow

The CVC program is a model of care based on the LMO/GP taking responsibility for overall coordination of care.Good communication with other key players is important for this to be effective.

The LMO/GP will refer the veteran or war widow/widower for social assistance.The referral should, at a minimum, include:

• contacts details of veteran or war widow/widower;
• contact details of the LMO/GP; and
• any other relevant information.

Under the CVC program the LMO/GP is working as part of a team to deliver more coordinated primary and community care.Where the LMO/GP considers that social isolation could be a contributing factor to hospitalisation then the VHC assessment agency becomes a part of the CVC program team.

Therefore, the details of the outcome of the assessment, including service end date, should be communicated back to the veteran or war widow/widower’s LMO/GP after the assessment has been completed.The feedback should be provided and include, as a minimum:

• the veteran or war widow/widower’s full name and contact details;
• assessment outcomes;
• any service approval details i.e. activity details, start and end date.

In addition, if there has been a change of circumstance for the veteran or war widow/widower since the referral was made, including:

• end date extended due to hospital stay;
• services are extended beyond the original 12 week period;
• unavailability of VHC service provider for provision of CVC social assistance; or
• anything else discovered during the assessment that may be of value to the LMO/GP in providing coordinated primary and community care for the veteran or war widow/widower.

This information must be provided by the VHC assessment agency to the participant’s LMO/GP and an LMO Feedback Form will be available to assist VHC assessment agencies in sharing this information.

LMO/GPs will monitor the progress of CVC social assistance via contact with the veteran or war widow/widower and through feedback received from the VHC assessment agency.

Social Assistance Activities

A number of types of short term social assistance can be provided under the CVC program.CVC Social assistance can be provided to an individual through structured activities on a one-on-one basis either on accompanied outings in limited circumstances, in the home or through community based activities.These services will be aimed at providing short term support (over a maximum 12 weeks period) to encourage veterans and war widow/widowers to engage in social activities on a regular and ongoing basis in the longer term.

The following paragraphs describe examples of social assistance that may be offered however, the type of social assistance actually approved will be dependent upon existing community networks, capacity and/or availability of a VHC-contracted service provider in the veteran or war widow/widower’s region and the VHC program budget allocation for this service type.

CVC social assistance activities, if provided or facilitated by a care worker, may include (but not be limited to):

Community based socialisation:

1. Assisting to identify interests/activities they might like to do.
   Peer support is primarily directed towards meeting the veteran or war widow/widower’s need for social contact and/or accompaniment to participate in community life. 
    
2. Identify what is available in the community. 
   Existing group/s that are of interest e.g. a Men’s Shed type group, DVA Day Club or Ex-Service Organisation (ESO) with regular activities.Once the group activity has been agreed to, the support would continue for up to 12 weeks.    
    
3. Supporting and encouraging involvement.
   This could involve assisting the veteran or war widow/widower to engage in the group activity by attending the activity with them, talking with the organisers ahead of time to ensure a good ‘fit’ and perhaps follow-up.
    
   Where possible, the VHC assessment agency and/or VHC service provider may provide information on the means of transport available to allow the veteran or war widow/widower to continue to participate in activities after CVC social assistance has concluded.

Once the veteran or war widow/widower has received the short term support, responsibility for attending the activity would fall back to the veteran or war widow/widower and VHC social assistance would cease.

Home based socialisation:

• involves visiting the veteran or war widow/widower in their home and providing companionship and social assistance.This could involve:
• supporting and encouraging the veteran or war widow/widower to start to engage in a community activity
• communication, including using social media and letter writing to support/assist veterans or war widow/widowers to keep in touch with family and friends e.g. Skype and or using email*.

*Where the veteran or war widow/widower does not have access to this type of technology, other forms of communication, should be considered e.g. telephone and/or letter writing.

Accompanied outings (limited circumstances)

The use of accompanied outings as a valid CVC social assistance activity should be used in very limited circumstances, for example, where the veteran or war widow/widower has difficulties which prevent other more focussed social support from working.When warranted, accompanied outing may include:

• accompanying the veteran or war widow/widower to an appointment, such as a hair appointment.This may include transportation, where the major need is to have someone with them, rather than getting from one place to another.
• supporting/assisting to keep up with essential activities outside the home but within the community such as bill-paying, banking or shopping, with the veteran or war widow/widower and care worker performing the activities together.
• excursions and day trips may be offered to some veterans or war widow/widowers.These activities should be aimed at visits to places of interest that promote social interaction and community inclusion.

Other

• assisting with the preparation of meals e.g. taking the veteran or war widow/widower shopping to buy ingredients and help them prepare a meal;
• may include practical assistance with the task of eating in limited circumstances; or
• a combination of home and community based socialisation.

The veteran or war widow/widower is responsible for the costs associated with participation in socialisation activities.Where there are costs involved i.e. day club fees, arrangements between the VHC service provider and veteran or war widow/widower must be agreed upon before the service is undertaken.

Where a veteran or war widow/widower’s opportunity to participate in social assistance activities is impacted by a lack of existing community networks, capacity and/or availability of a VHC-contracted service provider they may be referred to HACC.

Hours Approved

As the VHC assessment agency will be determining the type of service, and the individual tasks under these services types will be confirmed by the VHC service provider on a case by case basis, the approval by VHC assessment agencies will be based on the limits outlined below.

The approved hours would be considered the upper limit and would include travel from the CVC participant’s home to and from the community based activity, if required.The block of time will allow flexibility for a VHC service provider to claim for payment for the amount of service they actually deliver (up to the amount prescribed).

Social assistance approval options:

• Home based socialisation - 2 hours per week for 12 weeks.
• Community based socialisation - 4 hours per week for 12 weeks.
• Accompanied outings - 4 hours per week for 12 weeks.
• Other (combination of two of the above) – 6-8 hours per week for 12 weeks.

These service levels approved will be upper amounts only, and will allow flexibility for VHC service providers to claim for payment for the amount of service they actually deliver (up to the upper amount prescribed by the VHC assessment agency).

On receiving the service plan from the VHC assessment agency, VHC service providers will determine the actual details of the service with the CVC participant, deliver the service and claim online for the actual hours of service provided within the prescribed block of time allocated by the VHC assessment agency.

VHC service providers will need to demonstrate through appropriate documentation (e.g. time sheets) that they have actually delivered the services they have claimed for.

Conclusion of services

If additional CVC social assistance services are requested by the veteran or war widow/widower, the VHC assessment agency may review the veteran or war widow/widower and, if appropriate, consider whether to extend services for a short period of time (up to an additional 12 weeks) to maximise the outcomes of the CVC social assistance.However, given the CVC program goal of short term support for longer term outcomes, extension of CVC social assistance delivered through the VHC program should not generally be considered.As outlined above, in the rare cases where services are extended beyond the original 12 week period the veteran or war widow/widowers LMO/GP should be advised.

If longer term social assistance is required, it is more appropriate that the veteran or war widow/widower be referred to HACC or other community based social support services.

Linkages with HACC services

A CVC participant can receive CVC social assistance through the VHC program and social support through the HACC program concurrently as long as tasks undertaken by each program are different.In situations where a VHC assessment agency becomes aware of a veteran or war widow/widower receiving social assistance/support through both the HACC and CVC program, they should liaise closely with the HACC provider to ensure that services are reasonable and well coordinated (for example, so that not all of the social assistance/support activities are delivered on a Monday).

If veterans or war widow/widowers are already receiving social support services from HACC, they should be encouraged to remain with HACC as these social support services, unlike the social assistance activities available through the VHC program, are available as long term services.

Personnel

The qualifications and experience required of VHC assessment agency staff assessing and approving CVC social assistance is the same as that required for the VHC program.These requirements are outlined in the VHC Guidelines.

For additional information on training, OH&S and insurance issues please refer to the VHC Guidelines.

Copayment Arrangements

While veterans and war widow/widowers are expected to pay a small copayment for services they receive through the VHC program (with the exception of respite services), the number of hours of service for which a veteran or war widow/widower may be asked to pay a copayment is capped.CVC social assistance activities are subject to the following copayments and caps:

Copayments are not related to a veteran or war widow/widower’s income or assets.

The veteran or war widow/widower is responsible for the costs associated with participation in socialisation activities.Where there are costs involved i.e. day club fees, arrangements between the VHC service provider and veteran or war widow/widower must be agreed upon before the service is undertaken.

For additional information on copayments including collection, waivers etc please refer to the VHC Guidelines.

Payment Arrangements

As with other VHC services, payments to VHC assessment agencies for the provision of assessment and coordination services are automatically generated when an assessment approval is completed.

The annual fee paid covers the assessment and coordination function for all VHC services, including CVC social assistance services, for each veteran and war widow/widower.

Anniversary payments made to VHC assessment agencies in the years subsequent to the year of initial assessment will be activated by an assessment for CVC social assistance when the online validated VHC assessment instrument is used.

For additional information on payment arrangements and anniversary payments please refer to the VHC Guidelines.

Managing the Budget

Unlike the budget for VHC services which is managed by VHC assessment agency at a regional level, the budget for CVC social assistance will be managed as one central budget within the VHC system.

VHC assessment agencies will be regularly updated on the budget capacity for this service, as well as having the capability to check the budget, and will be advised when all funds have been allocated for each financial year. However, VHC assessment agencies will not be expected to manage the budget.

Waiting lists

The CVC program has a fixed budget for the provision of CVC social assistance.It is not expected that this budget will be exceeded if only a minority of CVC program participants are referred and most of these receive short term focussed CVC social assistance services.However, should either of these not occur, at some point during a financial year the need for CVC social assistance may be greater than the amount of money left in the budget for these services.If this situation occurs, the VHC assessment agency should consider the following options:

• refer the eligible veteran or war widow/widower to HACC for the provision of social support services; or
• if waitlists for this service are implemented by DVA, place the eligible veteran or war widow/widower on a waitlist for the provision of CVC social assistance.

If DVA determines that waitlists for CVC social assistance are required, these waitlists would be managed by DVA.