Care coordination for veterans with chronic conditions

DVA’s Coordinated Veterans’ Care (CVC) Program uses a proactive approach to improve the health, wellbeing and quality of life of participating veterans. It also aims to reduce the risk of unplanned hospitalisations.

Taking part in the program helps veterans to be actively involved in managing their chronic conditions by working closely with their GP and care coordinator (typically a practice nurse).

Once enrolled in the program, the participant will work with their GP and care coordinator as a core care team to develop a comprehensive care plan, tailored to the participant’s individual needs.

The care plan includes an individualised assessment of the medical conditions, health care needs and actions to manage and improve health outcomes. The care team will then deliver services outlined in the care plan, and the care coordinator will ensure regular contact, coordination of treatment with the wider care team, and provide support and education to actively manage the participant’s health.

Participants may have a larger care team to support their unique goals, which can include other health professionals such as pharmacists, physiotherapists and mental health specialists, as well as ex-service organisations (ESOs), family and carers.


Veterans may be eligible for the program if they have:
• a Veteran Gold Card and one or more chronic conditions, or
• a Veteran White Card with a DVA-accepted mental health condition, and are at risk of unplanned hospitalisation. Veterans interested in the program should talk to their GP about whether it could be of benefit to them. Veterans or GPs who have questions about whether they are eligible for CVC are encouraged to contact DVA.

Social Assistance

CVC participants may be able to access up to 12 weeks of Social Assistance through the Veterans’ Home Care (VHC) Program. Social Assistance is a service designed to help reconnect socially isolated CVC participants with community life. This can be done through regular visits, activities or courses, assistance in making social contacts, or connecting the participant with a community group or ESO. To access Social Assistance, participants will need a referral from their GP, and should call a VHC Assessment Agency on 1300 550 450.

More information

Speak to your GP or visit the CVC Program – Information for veterans and the CVC Social Assistance pages on the DVA website.

Information for GPs is available on the CVC Program pages and the CVC Toolbox of the DVA website.