Caring for our veterans and war widows

A program launched last week will bring a positive step forward in the wellbeing and quality of care of chronically ill veterans and war widows.

Launched by the Department of Veterans Affairs, the Coordinated Veterans’ Care (CVC) Program will pay general practitioners and nursing providers to coordinate care for veterans and war widows who are at risk of hospitalisation.

With the aim to improve the health of participants through improved community based care, the program provides ongoing planned and coordinated care from GPs and nurses. It will also educate and empower participants to self-manage their conditions, while encouraging the most socially isolated to participate in community activities.

Australian Medical Association president, Dr Steve Hambleton, tells DPS eNews the program is “proactive and interactive” in chronic disease management.

“With this approach, the doctor or nurse can keep in touch with veterans by carrying out a health care plan.”

Dr Hamblton says the nation-wide program looks at a person’s health care records and results, and proactively contacts a person to see if they are complying with the care plan designed for them.

“It’s a new style of health care and will be reviewed in the first three years to see if it has helped to cut costs and the number of hospitalisations,” Dr Hambleton says.

The Department of Veterans Affairs hopes to recruit about 17,000 veterans and about 27,000 GPs will be involved in the program.

“It will be a great program because it will build relationships between nurses and doctors and it is very good because there is no extra red tape – for instance, no formal registration is required,” Dr Hambleton says.

As part of the program:

• The GP ensures any changes to the practice are carried out before enrolling a participant in the program.
• A comprehensive assessment of the person is carried out by the practice nurse or the GP if no practice nurse is available.
• A personalised Care Plan for the individual is prepared and agreed on by the patient, carer or family member.
• The general practice nurse, a community nurse or the GP coordinates treatment services set out in the Care Plan.
• The nurse coordinator provides regular feedback to the GP who is responsible for the overall provision of care to a person under the program.
• There are various criteria which must be met in order to be eligible to participate in the program. This may include:
• The person has, or could result, in frequent hospitalisation.
• The person must not be living in a residential aged care facility that provides nursing or personal care.
• The person should not be diagnosed with a condition that, in the opinion of the GP, would be likely to be terminal within 12 months (this applies only for initial admission and not when diagnosis occurs after admission to the program).
• Must not be participating in any of the following Commonwealth Department of Health and Ageing programs, such as Extended Aged Care at Home, Community Aged Care Package or Transition Care.

Principal Medical Adviser to the Department of Veteran Affairs and Repatriation Commission, Graeme Killer, tells DPS eNews the program is “getting on the front foot and dealing with veterans and war widows who have chronic medical conditions resulting in them going in and out of  hospital”.

Mr Killer says chronic conditions associated with growing older, such as coronary artery disease and diabetes are illnesses many veterans have.

“These conditions have not been adequately and properly managed. Veterans often end up in hospital and are then discharged. Then because the conditions become very complex, they are often forced to return to hospital,” Mr Killer says.

“What the Coordinated Veterans Care Program will do is provide financial resources for GPs to spend more time working on a care plan…as we live longer, and may develop chronic conditions, we need some sort of health care strategy,” he says.

Describing it as a win-win situation for all, Mr Killer says the Coordinated Veterans Care Program will be beneficial to the entire Australian health care system.

“Veterans and war widows will be winners to better health care, GPs will be winners to providing more resources in primary care and Australia will be a winner for reducing the need for older Australians to go into hospitals,” Mr Killer says.

“This is an important program, not just for veterans in Australia, but it is a health resource, pioneering better management plans for all of Australia,” he adds.