The Coordinated Veterans’ Care (CVC) Program: What It Is and Who Qualifies

What CVC actually is

Not a payment, and not a service you book. CVC is a structured, planned-care arrangement run through your GP practice, aimed at veterans with chronic conditions who are at risk of ending up in hospital. It is administered under the Treatment Principles for both the VEA and the MRCA, and the detail sits in DVA’s Notes for Coordinated Veterans’ Care Program Providers.

The point of it is coordination. A veteran with five chronic conditions, four providers and a complicated medication list does not usually fail for lack of treatment — they fail in the gaps between providers. CVC funds someone to own those gaps.

The six eligibility criteria — all must apply

Clause 28 of the Notes. Every one of these must be satisfied before enrolment:

1. You hold a current Gold Card (Veteran Card – All Conditions), or a White Card (Veteran Card – Specific Conditions) with an accepted mental health condition.
2. You are living in the community — not in residential aged care.
3. You are diagnosed with one or more chronic conditions.
4. You are at risk of unplanned hospitalisation.
5. You have complex care needs.
6. You have given informed consent to participate.

“Complex care needs” means one or more of

• Multiple comorbidities that complicate treatment
• An unstable condition with high risk of acute exacerbation
• A condition contributed to by frailty, age and/or social isolation
• Limitations in self-management and monitoring

A complex treatment regimen means one or more of

• Multiple care providers
• A complex medication regime
• Frequent monitoring and review
• Support needed with self-management and monitoring

That third bullet under complex care needs — frailty, age or social isolation — is worth noticing. Social isolation is a recognised complicating factor, not a soft extra. A great many veterans meet it.

Who is ineligible

• Currently residing in a residential aged care facility
• A participant in the Department of Health Transition Care Program
• Diagnosed with a condition the GP considers likely to be terminal within 12 months — and note this exclusion applies only to initial enrolment. If a terminal diagnosis occurs after enrolment, it does not end participation.

Gold versus White Card — a detail that matters

A Gold Card holder is entitled to DVA-funded treatment for all conditions, service-related or not, so CVC coordinates everything.

A White Card holder with an accepted mental health condition is entitled to funded treatment for accepted conditions, and may also access Non-Liability Health Care or PAMT for others. The care plan must still cover all conditions — with the funding source identified for each. That distinction is where White Card CVC plans typically go wrong.

The care team

Core team: the GP (clinical oversight, 90-day reviews, claiming); the Coordinator — a practice nurse, an RN or EN employed by a DVA-contracted community nursing provider, or an Aboriginal and Torres Strait Islander Primary Health Worker; the veteran, as an active partner; and a carer where relevant. Where no suitable coordinator is available, the GP may act as coordinator.

Broader team: specialists, pharmacists, allied health, the contracted community nursing provider, hospital discharge planners.

The Coordinator is the day-to-day point of contact and must make contact at least monthly — health coaching, checking adherence, catching emerging problems early. A practice nurse coordinator must also do at least one home visit per year.

What the care plan has to contain

Clause 46 sets the minimum. A compliant plan includes:

• A description of all chronic and other health conditions
• For each condition: current care guide, targets, red flags, background, current management and most recent results
• A medication list with dose, frequency and known adherence
• Allergies and adverse reactions
• Self-management goals and strategies
• Family and carer contact details
• Other treatment providers and their contacts
• Referrals
• Devices in use

It must be developed collaboratively with the veteran, tailored to them, and treated as a live document. A signed copy must be given to the veteran and to each member of the care team. It does not get submitted to DVA — but it must be stored on the patient file.

In practice the plans that work add a symptom action plan in traffic-light form: green means carry on, amber means take these steps, red means this is an emergency — with a clear escalation path from self-management to coordinator to GP to emergency department. Clause 46 does not require it. Veterans use it more than any other page.

The 90-day cycle and the item numbers

A period of care is 90 days. Claims go through Medicare, and all CVC items must be bulk-billed — no gap to the veteran.

• UP01 — initial assessment and enrolment, GP with a practice nurse
• UP02 — initial assessment and enrolment, GP without a practice nurse
• UP03 — completion of a 90-day period of care, review with practice nurse
• UP04 — completion of a 90-day period, review without practice nurse
• UP05 / UP06 — initial and subsequent care coordination, claimed by a DVA-contracted community nursing provider acting as coordinator

Two rules that catch practices out: UP01 and UP02 can only be claimed once in the life of a patient — across all GPs and any re-enrolment. And UP03/UP04 are claimed every 90 days retrospectively. CVC items can be claimed in addition to other MBS and DVA fee schedule items.

Before that first claim — the checklist

All of this must be complete before UP01/UP02 can be claimed and the first period of care begins:

1. Every clause 28 criterion met
2. Informed consent obtained and recorded on the patient record
3. A comprehensive assessment undertaken
4. A care plan developed collaboratively with the veteran
5. A signed copy given to the veteran
6. A signed copy given to each care team member
7. Enrolment recorded in the patient file

You stay enrolled for as long as you remain eligible and are benefiting. The plan is reviewed in person with the GP at the end of each 90-day period.

What CVC is not

It is a treatment and coordination program, not a compensation one. It pays nobody anything and rates no impairment. It does not need an accepted service-related condition — a Gold Card holder qualifies on the card alone, regardless of what caused the chronic disease.

It is also not household services, not Veterans’ Home Care, and not community nursing — though a CVC plan should reference all of them where they apply. And it sits entirely apart from the claims side of DVA: if you have conditions that have never been claimed, that is a separate job, and the place to start is having the record read properly with a chart review.

How to get onto it

Ask your GP. Veterans can also self-nominate — you do not have to wait to be identified. If your GP has not run CVC before, the eligibility toolbox and the provider Notes are on the DVA website, and the practice does not submit an enrolment form to DVA at all; it simply claims UP01 or UP02 once the seven steps above are done.

If your GP is not interested, that is a reason to find a GP who understands veterans’ health. Which is, more or less, what we do.

Talk to us

Call 0429 146 039 or email reception@vhc.org.au — Veterans Health Centre, Ipswich, Queensland.

Related reading

DVA healthcare at VHC · Veteran Card eligibility · Non-liability health care · Household services · The Veterans’ Health Check

General information for Australian veterans, current as at 12 September 2026; not medical advice. Based on DVA’s Notes for Coordinated Veterans’ Care Program Providers (effective 1 July 2021) and the Treatment Principles under the VEA and MRCA. Where the Notes and the Treatment Principles conflict, the Treatment Principles prevail. Clause numbers and item numbers change — confirm current arrangements with DVA on 1800 VETERAN (1800 838 372).