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Guide for General Practice

Front cover of the CVC — Guide for General Practice

The Guide for General Practice has been developed to help with the implementation of the Coordinated Veterans' Program.

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About the CVC Program

The Department of Veterans’ Affairs' (DVA) Coordinated Veterans’ Care (CVC) Program commenced on 1 May 2011.

The CVC Program:

  • uses a proactive approach to improve the management of participants’ chronic diseases and quality of care
  • involves a care team of a general practitioner (GP) plus a nurse coordinator who work with the participant (and their carer if applicable) to manage their ongoing care
  • provides new payments to GPs for initial and ongoing care.

GPs who decide to be involved in the CVC Program are required to:

  • prepare for the program
  • enrol participants in the program
  • provide ongoing care.


The program is aimed at Gold Card holders who are at risk of unplanned hospitalisation. The CVC Program is primarily targeted at patients with one or more specific chronic conditions, i.e. congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease, diabetes or pneumonia.  

GPs can enrol participants in the program if they:

  • pass an eligibility assessment
  • give their informed consent to be involved in the program.

Payments for GPs

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

  • Initial Incentive Payment for enrolling a participant in the program
  • Quarterly Care Payments for ongoing care.
Payments GPs can claim
  Initial Incentive
Payment *
Quarterly Care
Payments *
Total year 1 Total year 2
  $ Item # $ Item #    
GP with practice nurse $430.55 UP01 $449.30 UP03 $2227.75 $1797.60
GP without practice nurse $269.05 UP02 $201.80 UP04 $1076.25 $807.20

*Fees effective: 1 July 2018 


The CVC Program is administered under the Treatment Principles — Coordinated Veterans’ Care Program, the Notes for Providers for the Veterans’ Entitlements Act 1986, and the Military Rehabilitation and Compensation Act 2004.

CVC Program Model of Care

The Model of Care for the CVC Program is based on the core team, which includes the veteran, the veteran’s carer (if applicable), the GP and the nurse coordinator, who is either a practice nurse, Aboriginal health worker or community nurse.

The team uses care planning, coordination and review as the tool to focus on better management and self management of the participant’s health and to incorporate the multidisciplinary team.

CVC Program Model of Care

The sharing of health information is a key feature of the CVC Program. The availability of electronic health records and electronic communication will greatly assist the CVC Program in the sharing of health information amongst all providers of health care for CVC participants.

Regular communication, empowerment and coaching are key to the success of the team.

The care planning cycle is continuous and most participants entering the program will stay on the program.

Benefits for participants

As a result of the program, participants are likely to become:

  • healthier, with less need to be admitted to hospital
  • more educated and empowered to self manage their conditions.

Benefits for health professionals

As a result of the program, health professionals will benefit in numerous ways:

  • GPs receive recognition and compensation, including for non face-to-face time spent in providing comprehensive care to eligible participants
  • help improve the quality of care of participants
  • enhanced opportunity for nurses to work in partnership with the GP
  • efficient alignment of nursing roles with nursing skills
  • receive training and resources for chronic disease management.

Key roles and stagesKey roles and stages

GPs play a lead role and are required to commit sufficient time and resources to the program.

The nurse coordinator (NC) can be one of the following:

  • practice nurse (PN) – this is either a registered nurse or enrolled nurse, and can include a nurse practitioner
  • Aboriginal health worker (AHW)
  • community nurse from a DVA community nursing provider (CN provider).

The GP and nurse coordinator have different roles in the three stages of the CVC Program.

Stage one of the CVC program

Prepare for the CVC Program
Action Role Provide Care
Appoint a NC, ie PN, AHW or CN. GP
Prepare your practice for the CVC Program. GP

Stage two of the CVC program

Enrol participant in the program
Action Role Provide Care
Identify potential participants. DVA/GP
Assess their eligibility for the program. GP
Gain the participant’s informed consent. GP
Conduct a needs assessment. GP/PN
Prepare a Care Plan. GP/PN
Finalise the Care Plan. GP
Consider the need for social assistance. GP

Stage three of the CVC program

Provide ongoing care
Action Role Provide Care
Coordinate treatment services as per the Care Plan. GP/NC
Regularly review, update and renew the Care Plan. GP/NC
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