Please note that the Defence and DVA points of contact noted below are currently under review. Should there be any situations where contact is necessary please refer the matter to the Deputy Commissioner Victoria.

There are two distinct phases of activity regarding serving members who are severely injured, have multiple and complex needs and who may also be classified as 'high profile' cases.

Definitions

A case will be high profile if:

• the member was involved in a major incident involving deaths and/or severe injuries; or
• the case could attract media attention.

A case will be complex if it is likely to require a greater input of resources, both in terms of the number of stakeholders involved and the input required from the ADF Rehabilitation Consultant. A Case Complexity Flags Model is used to assess:

• the nature and severity of the member's clinical conditions, including for example, significant disability, multiple injuries or illnesses (red flags);
• issues identified during the psychosocial assessment including for example, withdrawal from activity of daily living and work, or lack of family or social support (yellow flags);
• perceived features of the work or social environment that may delay recovery or present a barrier to returning to work (blue flags); and
• other objective risk factors relating to financial security, work contact and compensation and include for example, duration of sick/convalescence leave (black flags),

Each coloured flag has an associated rating and the total rating scored is used as an indicator in determining if a case is complex. A rating score of 10 or above may be considered complex, but it is the manner in which the individual manages the problems that identifies complexity, and not necessarily the score.

Phase One

ADF Action

• The ADF Rehabilitation Consultant uses the Case Complexity Flags Model tool during the initial rehabilitation assessment phase. The results of the Case Complexity Flags tool are documented in the Rehabilitation Assessment Report.
• Where a case is identified as complex, the ADF Rehabilitation Consultant will raise the case with ADFRP or Rehabilitation for Reservists Program Regional Rehabilitation Manager.
• Case complexity is reviewed on a three monthly basis as part of the Case Review Report.

ADF - DVA Notification

• The Directorate of Rehabilitation and Compensation (DRC) will inform the Director General Garrison Health Operations (DGGHO) of the case and provide regular progress reports as directed.
• The DGGHO will liaise with the Director General Defence Community Organisation (DGDCO) and the DVA Assistant Secretary, Determination Support and Reviews Branch.
• This is the first formal (high level) communication between the ADF and DVA, which is the trigger point to managing these cases according to the High Profile Case Protocol and the case management framework described in this section of the Guide.

ADF - DVA Communication regarding Rehabilitation and Treatment Needs

• The ADF Rehabilitation Consultant confirms with the DVA National Director, Rehabilitation and Benefits, Determinations Support and Reviews Branch (DS&R), to advise DVA of the status of this 'high profile and or complex case'.
• This is the next level of two-way operational communication required between ADF and DVA.  National Director of Rehabilitation and Benefits will advise the ADFRP or Rehabilitation for Reservists Program Regional Rehabilitation Manager, who in DVA will be assisting in the management and, if required, the transitioning of this case.
• The ADF Rehabilitation Consultant will provide the DVA contact with:
• a report on the current assessed needs of the member, when the member's treating Medical Officer has determined and confirmed that the member is to be released from hospital (military or community);
• details of the member's posting locality;
• what has been recommended by home/ADL assessment;
• what is being provided by other parties; and
• what is being requested of DVA to provide.

Sound communication and regular reporting are essential for the management of these 'high profile / complex cases', especially during the early stages or key stages.  Any change in client's circumstances including for example, discharge from hospital to home, or commencing a Return to Work element of their Rehabilitation Program are of highest priority if the case progresses to the transitioning from the ADF phase.  Refer to Section 4.5 [5] of this chapter for information regarding what assistance DVA can provide to a serving member.

Case conferences are an excellent communication tool and should be conducted wherever appropriate to ensure all key stakeholders are kept informed of the case progress and provide opportunity for stakeholders to contribute to management strategies.

The ADF Rehabilitation Consultant will provide regular progress reports to the Senior Medical Officer/Senior Health Officer.  This is an internal ADF process.

Please note that the Defence and DVA points of contact noted below are currently under review. Should there be any situations where contact is necessary please refer the matter to the Deputy Commissioner Victoria

Phase Two

There are two distinct phases of activity regarding serving members who are severely injured, have multiple and complex needs and who may also be classified as 'high profile' cases. Following are the Phase Two activities.

In situations where the case is to be transitioned across to full and ongoing DVA responsibility, due to actual or pending separation from the ADF, the ADFRP or Rehabilitation for Reservists Program Rehabilitation Consultant and/or the Regional Rehabilitation Manager  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. This information is to be provided through to the member's chain of command until the discharge date.

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 Assistant Secretary DS&R Branch;
• ADFRP or Rehabilitation for Reservist Program Consultant confirms case status with DS&R;
• DS&R advises the client's state specific DVA 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 DVA Initial Liability Delegate (IL) or the Needs Assessment Delegate (NA) identifies 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 National Director Rehabilitation and Benefits will advise the Tasmanian DC directly.

2. Initial Case Conference

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

Key Stakeholders

The key stakeholders are:

• ADFRP or Rehabilitation for Reservists Program Rehabilitation Consultant or Regional Rehabilitation Manager;
• Assistant Director DVA Community Nursing Policy (Clinical);
• 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, e.g. ADFRP or Rehabilitation for Reservist Program Service Providers or Community Nursing Service Providers.

Purpose of the case conference

The 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 DVA Health Card (Gold or White) be expedited;
• current health status, and obtain current health assessments including a full 'whole of person' rehabilitation assessment (including medical, vocational and psychosocial);
• 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;
  (Note: Discussions should include consideration of appointing a service provider who is a member of the national Panel of DVA Contracted Community Nursing Services Providers [7].

• 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 and/or any 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 any significant others involvement

It may be appropriate at the initial stages to include the client, their family and/or any significant others.  However, each case must be considered on its own merit, following consultation with the ADF lead or principal medical practitioner regarding the readiness of the client and family to be able to participate and contribute. It is important to note that consent of the member is required prior to any meeting or communication which includes family members or significant others.

In most cases, this initial case conference will focus on clarifying administrative and process matters rather than care planning. It is important to clarify DVA and ADF responsibilities at this stage as any client involvement prior to this happening could lead to confusion and frustration. 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

The following guidelines should be followed:

• 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 DVA 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 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 Policy (Clinical) to exchange case status information from a rehabilitation and community nursing program standpoint;
• 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 client's 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 Policy (Clinical) 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.

Note: Definitions of specific terms used in this topic are in section 4.6 [8] of this Guide.