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8.6.2 Transitioning clients from ADF to DVA

Phase Two

In situations where the case is to be transitioned across to full and ongoing DVA responsibility, due to separation from the ADF, the ADFRP Rehabilitation Coordinator and or the PCM will maintain regular contact with the designated DVA staff.  This is to ensure all required medical, allied health, rehabilitation, other services and supports are in place ready for the member at their post separation location, and this information is to be provided through to the chain of command until the member's discharge date.

Note: The titles of the preceding ADF personnel may change.  This document will be amended when confirmation has been received from Defence as to final titles.

For those ADF clients who have sustained severe and catastrophic injury and have been clinically assessed as requiring high level care and multiple service provision the following provides a guide to managing the client's transition from ADF service provision to DVA service provision.

Injury or Case Type

Typically clients categorised as requiring high level care:

  • are individuals whose injury or condition has resulted in serious, long term or permanent disability;
  • require up to 24 hour / seven days per week care and assistance including nursing and personal care; and/or
  • may be wheelchair dependant as a result of a spinal cord injury or brain injury.
Management Pathway

1.Identification and Notification

  • primary communication pathway entry point:
  • ADF through the DGGHO informs DVA National Manager RC&SS Group
  • ADFRP Coordinator confirms case status with DVA National Director Rehabilitation and Benefits who;

advises

  • the client's state specific Deputy Commissioner (DC), the DC's Director or Assistant Director responsible for Rehabilitation and Compensation claims and the Assistant Director DVA Community Nursing Policy (Clinical)*;

or

  • by the usual claims processes where the Initial Liability Delegate (IL) or the Needs Assessment Delegate(NA) indentifies a high care needs case:
  • the Delegate notifies their location Director or where applicable their Assistant Director who is to inform the National Director Rehabilitation and Benefits.

* Tasmanian cases are to follow the Melbourne location management pathway, however where the case is or will be located in Tasmania the DVA National Director Rehabilitation and Benefits will advise Tasmanian DC directly.

2. Initial Case Conference

It will be the DVA location Director or Assistant Director responsible for Rehabilitation and Compensation claims responsibility to liaise with the Assistant Director DVA Community Nursing Policy, Clinical, and to convene an initial case conference - to include the ADF and DVA stakeholders identified below to clarify responsibilities and processes.

  • Key Stakeholders:
  • ADFRP Case Manager;
  • Assistant Director DVA Community Nursing, Clinical, Policy;
  • DVA location Director or Assistant Director responsible for Rehabilitation and Compensation claims;
  • DVA location Community Nursing Contract Manager;
  • DVA location Rehabilitation Coordinator; and
  • If appropriate, or if already in place, current service providers, eg:
  • ADFRP Service Providers or Community Nursing Service Providers.
  • Purpose of the case conference is to clarify:
  • ADF separation status and dates;
  • current treatment pathway.  If the client is at the pre-separation stage, can the provision of a Repatriation Health Card (Gold or White) be expedited;
  • current health status, and obtain current health assessments including a full 'whole of person' rehabilitation assessment (medical and allied health);
  • current treatment regimes and location, eg hospital, rehabilitation centre or home;
  • how long this arrangement is expected to continue;
  • who is or who will be providing primary (medical, psychological, allied health and nursing) care.  Discussions should include consideration of appointing a service provider who is a member of the national panel of DVA Contracted Community Nursing Services Providers. The following internet link directs you to the list of DVA Contracted Community Nursing Services Providers -

http://authoring-internet/service_providers/community_nursing/contracted_providers/Pages/index.aspx

  • timing for new assessment/s for transfer of care from ADF providers to DVA providers, including, medical, nursing and rehabilitation; and
  • timing for involvement of client and family or significant others to:
  • build positive working relationships;
  • manage stakeholder expectations; and
  • formulate agreed management pathways (medical, nursing, psychosocial and when or if appropriate vocational).

Client, Client's Family and or Significant others Involvement

It may be appropriate at the initial stages to include the client, their family and or significant others.  However, each case must be considered on its own merit, following consultation with the ADF lead or principle medical practitioner regarding the readiness of the client and family to be able to participate and contribute.

In most cases, this initial case conference will focus on clarifying administrative and process matters rather than care planning.  Any client involvement prior to clarification of ADF and DVA responsibilities could be counter productive.  This will allow for the carefully timed inclusion of the client and introduction to their case management staff who have a clear understanding of their respective roles and responsibilities.

3. Guidelines for treatment and care provision arrangements:

  • ADF to provide medical treatment as required whilst client is a serving member and request support from DVA for those services they are unable to provide (once liability has been determined);
  • DVA location to issue Repatriation Health Card (Gold or White Card) as soon as possible to minimise delays when transitioning client into the community and to DVA responsibility;
  • while the client remains a serving member, where possible, the choice of any service provider should be a service provider from a panel of DVA contracted service providers or DVA preferred service providers to ensure the transfer to DVA service provision is as seamless and efficient as possible;
  • following the provision of a Gold or White Card and the client's transition to DVA responsibility, the appointed DVA Contracted Community Nursing Service Provider must arrange to undertake a new and comprehensive assessment of the client's needs in accordance with the DVA Guidelines for the Provision of Community Nursing Services;
  • based on the outcomes of that assessment the DVA contracted Community Nursing Service Provider will need to submit an Exceptional Case Unit (ECU) application, as the care needs for this client group will fall beyond the routine DVA Community Nursing Program Schedule of Fees; and
  • clear communication pathways between Rehabilitation and Compensation staff and DVA's Community Nursing Program are to be established and maintained, to ensure continuity of care and access to entitlements.

4. Post Transition monitoring and management

Regular case conferencing and monitoring is to occur to ensure any changes in the client's condition are reassessed and treatment and care adjusted accordingly as soon as practicable.

  • The DVA location Rehabilitation Coordinator will:
  • confirm during the development of the client's rehabilitation program, timelines for reporting, ie weekly or even daily if the case requires, for the first three months, from the rehab service provider;
  • closely monitor these progress reports;
  • be responsive to sudden onset / or acute changes in client needs;
  • communicate with the DVA location community nursing contract manager and Assistant Director DVA Community Nursing, Clinical, Policy to exchange case status information from a rehabilitation and community nursing program standpoint; and
  • convene case conferences when and where appropriate; and
  • participate in case conferences when convened by DVA Community Nursing Program.
  • The Rehabilitation Service Provider will:
  • in consultation with stakeholders develop a client centric rehabilitation plan around the needs as identified following the transition to DVA responsibility;
  • provide progress reports as agreed;
  • be responsive to sudden onset / or acute changes in client needs and report such changes promptly to DVA Rehabilitation Coordinator; and
  • participate in case conferences when convened by DVA.
  • The DVA location community nursing contract manager and Assistant Director DVA Community Nursing, Clinical, Policy in consultation with the ECU will:
  • closely monitor DVA contracted community nursing service providers reports and reassessments and care; and
  • convene case conference when and where appropriate; or
  • participate in case conferences when convened by the DVA Rehabilitation Coordinator.