GP Management Plans - CVC Program

WHAT IS A GP MANAGEMENT PLAN
Chronic Disease Management Plans or GP Management Plans as they can be known are designed to enable GPs to plan and coordinate the health care of patients with a chronic or terminal disease.  A GP and two other health care providers must be involved in the Team Care Arrangements of a Plan.

WHAT IS A CHRONIC DISEASE
A chronic disease is a condition that is likely to last or has lasted longer than six months.  Some examples of chronic conditions are diabetes, asthma, heart disease, arthritis and palliative care.

WHERE AND HOW DO I MAKE AN APPOINTMENT
GP Management Plan appointments are provided at the Hamilton Medical Group and can be booked through our Front Reception staff.  These plans are conducted by our practice nurses at the Hamilton Medical Group. All patients wishing to take part in the GP Management Plan program will need to be referred by their GP before making an appointment.

 

CVC PROGRAM

This program is an initiative from the Department of Veteran Affairs to improve and better manage the delivery of health care to eligible Gold Card veterans.

The main purpose of the program is to minimise hospital admissions by addressing problems early with a view to keeping veterans in their own home for as long as is practical. It is mainly aimed at veterans with complex care needs involving two or more chronic diseases or conditions and multiple care providers.

There is no obligation on the part of the veteran to participate and they can withdraw from the program at any time.

The program co-ordinator, in our case a Registered Division One Nurse, assesses the veteran and compiles a care plan that is then discussed between the veteran and their doctor (GP). Follow up on a regular basis, according to progressive identified needs of the veteran, occurs by either telephone, clinic visit or home visit and ensures ongoing input of a health care worker that is appropriate to the needs of the veteran at the time. The care co-ordinator will liaise with the veterans GP over the year as appropriate.

The care plan is reviewed yearly or earlier if there is a significant change in the veteran’s health.
This provision of care continues until the veteran either becomes ineligible or decides to withdraw from the program.

At the Hamilton Medical Group, this program is provided by Bev on Thursdays.