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M1/2011 Determinations/Health as made
This Determination introduces a new service for certain clients of the Department of Veterans' Affairs (DVA). The service is Coordinated Veterans' Care and its aim is to better coordinate treatment services for certain clients with certain chronic conditions so that their hospital admissions may be reduced.
Administered by: Veterans' Affairs
Registered 30 Mar 2011
Tabling HistoryDate
Tabled HR10-May-2011
Tabled Senate10-May-2011
Date of repeal 19 Mar 2014
Repealed by Veterans' Affairs (Spent and Redundant Instruments) Repeal Regulation 2014
EXPLANATORY STATEMENT

 

MRCA Treatment Principles (Coordinated Veterans' Care Program) Determination 2011

 

EMPOWERING PROVISION

 

Subsection 286(3) of the Military Rehabilitation and Compensation Act 2004 (the Act).

 

PURPOSE

 

The attached determination (M1/2011) amends the MRCA Treatment Principles.  The MRCA Treatment Principles is a legislative instrument made under subsection 286(3) of the Act and sets out the circumstances in which the Military Rehabilitation and Compensation Commission (Commission) may accept financial liability for treatment provided to entitled persons (members of the Defence Force (including former members) or their dependants).

 

The purpose of the attached determination is to provide a new treatment to certain clients of the Department of Veterans’ Affairs (DVA).  The treatment is Coordinated Veterans’ Care and is provided under the Coordinated Veterans’ Care Program.

 

The clients eligible for the treatment are members, former members, or their dependants, who are eligible for treatment under the Act for all conditions (called Gold Card holders) and who have a chronic condition that either causes them to be hospitalised or is likely to cause them to be hospitalised (entitled persons).

 

The aim of the treatment is to better manage and coordinate these entitled persons’ care in the home and community so that they are healthier and have less need for admission to hospital.

 

The concept of the treatment is that if the health care of a person with a chronic condition is co-ordinated by health care practitioners there is a reasonable likelihood that the health of the person can be maintained to a degree such that they will not need to be hospitalised for their condition or hospitalised as regularly as they may otherwise have been had the treatment not been available.

 

Under the Program a medical practitioner will oversee the co-ordination of the entitled person’s health care.  The actual co-ordination of the health care may be undertaken by a practice nurse employed by the medical practitioner, a community nurse or an aboriginal health worker.

 

If a medical practitioner considers an entitled person is socially isolated and that this could be having an impact on the person’s condition and resulting in hospital admissions the medical practitioner may refer the person to an agency operating under the MRCA Home Care Program (a care program under the Act) for an assessment for a social support service under the Program and, if the person is assessed as suitable, the provision of a social support service.

 

RETROSPECTIVE

 

No. 

 

CONSULTATION

 

Yes – A Clinical Reference Group comprising clinicians from the medical community and ex service organisations has met and consultation taken place on the Discussion Paper for the exercise .

The Discussion Paper was made available on DVA’s Web Site.

 

DOCUMENTS INCORPORATED-BY-REFERENCE

 

Yes.

 

The following non-legislative documents in force on 1 May 2011 are, on commencement of the attached instrument, incorporated into the MRCA Treatment Principles:

 

1.       Notes for Local Medical Officers (paragraph 1.4.1);

2.       Department of Veterans’ Affairs Fee Schedules for Medical Services (paragraph 3.5.1);

3.       Notes for Providers of Optometric Services/Dispensers of Optical Appliances (paragraphs 1.4.1 and 7.1A.1);

4.       Optometrist Fees for Consultation (paragraph 3.5.1);

5.       DVA Schedule of Fees Orthoptists (paragraph 3.5.1);

6.       Pricing Schedule for visual aids (paragraph 3.5.1);

          7.       Notes for Local Dental Officers (paragraphs 1.4.1 and 5.1.1);

8.       Fee Schedule of Dental Services for Dentists and Dental Specialists (paragraph 3.5.1);

9.       Fee Schedule of Dental Services for Dental Prosthetists (paragraph 3.5.1);

10.     Notes for Chiropractors (paragraphs 1.4.1 and 7.1A.1);

          11.     Chiropractors Schedule of Fees (paragraph 3.5.1);

12.     Notes for Diabetes Educators (paragraphs 1.4.1 and 7.1A.1);

13.     Diabetes Educators Schedule of Fees (paragraph 3.5.1);

14.     Notes for Dietitians (paragraphs 1.4.1 and 7.1A.1);

15.     Dietitians Schedule of Fees (paragraph 3.5.1);

16.     Notes for Exercise Physiologists (paragraphs 1.4.1 and 7.1A.1);

17.     Exercise Physiologists Schedule of Fees (paragraph 3.5.1);

18.     Notes for Occupational Therapists (paragraphs 1.4.1 and 7.1A.1);

19.     Occupational Therapists Schedule of Fees (paragraph 3.5.1);

20.     Notes for Osteopaths (paragraphs 1.4.1 and 7.1A.1);

21.     Osteopaths Schedule of Fees (paragraph 3.5.1);

22.     Notes for Physiotherapists (paragraphs 1.4.1 and 7.1A.1);

23.     Physiotherapists Schedule of Fees (paragraph 3.5.1);

24.     Notes for Psychologists (paragraphs 1.4.1 and 7.1A.1);

25.     Psychologists Schedule of Fees (paragraph 3.5.1);

26.     Notes for Podiatrists (paragraphs 1.4.1 and 7.1A.1);

27.     Podiatrists Schedule of Fees (paragraph 3.5.1);

28.     Social Workers Schedule of Fees (paragraph 3.5.1);

29.     Clinical Counsellors Schedule of Fees (paragraph 3.5.1);

30.     Notes for Speech Pathologists (paragraphs 1.4.1 and 7.1A.1);

31.     Speech Pathologists Schedule of Fees (paragraph 3.5.1).

32.     Australian Government Department of Veterans’ Affairs      Classification System and Schedule of Item Numbers and Fees — Community Nursing Services;

33.     RAP National Schedule of Equipment (paragraph 11.2A.1);

34.     Rehabilitation Appliances Program (RAP) National Guidelines (paragraph 11.2A.1).

35.     Notes for Coordinated Veterans' Care Program.

 

At the time the attached instrument was made, all the documents were available on the Internet (Department of Veterans’ Affairs web page – under Health – Doctors/Health Care Professionals):

 

http://www.dva.gov.au/

 

and at the time the attached instrument was made all the documents were available, or could be made available, at:

 

Department of Veterans’ Affairs (ACT Office), Lovett Tower, 13 Keltie St, Woden ACT 2606 / GPO Box 9998 Woden ACT 2606. 

Tel.no:(02) 6289 6243.

 

Any State or Territory Office of the Department of Veterans’ Affairs:

Tel.no: 133 254.

 

 

FURTHER EXPLANATION

 

Attachment A.

 


Attachment A

 

Items                              Explanation

 

[1]     sets out the name of the instrument.

 

[2]     provides that the instrument commences on 1 May 2011.

 

[3]     ensures that providers previously referred to as “community nursing providers” under the MRCA Treatment Principles before the MRCA Treatment Principles were amended by the attached instrument and who entered into arrangements with the Repatriation Commission or Commission to provide community nursing services are recognised on and after the commencement of the attached instrument as “DVA-contracted community nursing providers”.  There has simply been a name-change and a more accurate name adopted.

 

Schedule

 

1.-1A.         are definitions sections.

 

1B.    includes a co-payment from the recipient of a Home Care service (category C)(social support service), who is an exempt entitled person, as an exempt amount, meaning that the amount is not payable by the person as a co-payment for the service.

 

1C.    includes the recipient of a Home Care service (category C)(social support service) as an exempt entitled person meaning that the person is not to be charged a co-payment for the service.

 

2.      substitutes a more accurate name (DVA-contracted community nursing provider) for a community nursing provider under the Treatment Principles.

 

3.      inserts a new part in the MRCA Treatment Principles – Part 6A (Coordinated Veterans’ Care Program).

 

6A.1
 
is an outline of the Coordinated Veterans’ Care Program.

 

6A.2 – 6A.2.2

 

set out the treatments that an LMO (Local Medical Officer) may provide to an entitled person under the Coordinated Veterans’ Care Program, being:

 

·        LMO Care Leadership treatment (oversight of care coordination)

·        LMO Home Care service (category C) Referral (referral of socially isolated person for social support service)

 

6A.2.3

 

sets out the treatment that a practice nurse may provide to an entitled person under the Coordinated Veterans’ Care Program, being:

                                                                       

·        Practice Nurse Care Co-ordination treatment (co-ordination of health care services for the entitled person)

 

6A.2.5

 

sets out the treatment that a DVA-contracted community nursing provider may provide to an entitled person under the Coordinated Veterans’ Care Program, being:

                                                                       

·        Community Nurse Care Co-ordination treatment (co-ordination of health care services for the entitled person)

 

6A.2.7

 

sets out the treatment that an aboriginal health worker may provide to an entitled person under the Coordinated Veterans’ Care Program, being:

                                                                       

·        Aboriginal Health Worker Care Co-ordination treatment (co-ordination of health care services for the entitled person)

 

6A.3 – 6A.3.6

 

specify the conditions for the renewal of a period of care by an LMO.

 

6A.3.1

 

requires an LMO to decide, before providing a subsequent period of care (3 months) to an entitled person in the Coordinated Veterans’ Care Program, whether the person’s participation in the Program meets the aims of the Program.

 

6A.3.2

 

states that for the purposes of making a decision about whether an entitled person should continue in the Program for a further period of care the LMO is to review the person’s medical file and any other relevant information and ensure the person remains eligible for the program e.g. person is not in residential care.

 

6A.3.3

 

sets out the action an LMO is to take if the LMO decides an entitled person should continue in the Program for a further period of care, namely:

 

·        approve a further period of care of the person by the LMO.

·        record the approval and its date.

·        store the approval.

·        take any steps necessary for the further period of care to be provided.

 

6A.3.4

 

specifies the time when a subsequent period of care by an LMO commences where the care is approved before the expiry of a current period of care provided by the LMO.  The time is the day following the day the current period of care by an LMO expires.

 

6A.3.5

 

specifies the time when a subsequent period of care by an LMO commences where the care is approved after the expiry of a current period of care provided by the LMO.  The time is the date of the approval.

 

6A.3.6

 

sets out the action an LMO is to take if the LMO decides an entitled person in the Program should not continue in the Program because the person does not meet the aims of the Program or is no longer eligible for the Program.  In these circumstances the LMO is to:

 

·        notify any DVA-contracted community nursing provider who may have co-ordinated care for the entitled person in the period before the possible new period of care.

·        notify any relevant agency that arranged for a social support service to be provided to the entitled person in the period before the possible new period of care.

·        notify the entitled person in a manner the LMO considers appropriate.

 

6A.4 – 6A.4.6

 

state the conditions on which the Commission will accept financial responsibility for treatments under the Coordinated Veterans' Care Program (Program).

 

6A.4.1

 

provides that the Commission will accept financial responsibility for the various treatments under the Program but only if any requirements in respect of the treatments in the Treatment Principles, or the document incorporated into the Treatment Principles called the Notes for Coordinated Veterans' Care Program Providers, are satisfied and the treatments are provided during a period of overarching treatment by an LMO.

 

6A.4.2

 

specifies that the financial amounts DVA will pay for treatments under the Program other than Community Nurse Care Co-ordination treatment, are set out in the Repatriation Medical Fee Schedule in the DVA document entitled: “Department of Veterans’ Affairs Fee Schedules for Medical Services”.

 

For Community Nurse Care Co-ordination treatment under the Program, the financial amounts DVA will pay for this treatment is

set out in the DVA document entitled: “Australian Government Department of Veterans’ Affairs Classification System and Schedule of Item Numbers and Fees — Community Nursing Services”.

 

6A.4.3

 

makes it a condition of the Commission accepting financial responsibility for a period of care under the Program in respect of an entitled person that there is no other period of care being provided in respect of the person under the Program.

 

Even if an entitled person has changed a health care provider under the Program and is no longer physically being cared for by the former health care provider, nevertheless until the period of care the former health care provider was prepared to provide to the person has expired, a new one under the Program cannot commence and the Commission cannot accept financial responsibility for it.

 

6A.4.4

 

provides that the exception to 6A.4.3 is where the care is Practice Nurse Care Co-ordination treatment or Community Nurse Care Co-ordination treatment (nurse coordination treatment). 

 

If periods of care for these treatments overlap and the LMO or DVA-contracted community nursing provider, as relevant, obtains the Commission’s prior approval, then concurrent periods of care of nurse co-ordination treatment may be provided to an entitled person under the Program and the Commission can accept financial responsibility for that treatment.

 

6A.4.5

 

states that the payment of a fee for Practice Nurse Care Co-ordination treatment and Aboriginal Health Worker Care Co-ordination treatment will be made by DVA to the LMO who employed the practice nurse or aboriginal health worker at the time they provided this treatment under the Program.

 

6A.4.6

 

states that the payment of a fee for Community Nurse Care Co-ordination treatment will be made by DVA to the DVA-contracted community nursing provider who employed or engaged the community nurse at the time the treatment was provided.

 

6A.5 – 6A.5(6)

 

set out the criteria an entitled person needs to satisfy in order to participate in the Coordinated Veterans’ Care Program (Program) and receive treatment under it.

 

6A.5.1(1)

 

provides that an entitled person is entitled to participate in the Program if in the opinion of an LMO treating the person the person:

 

·        has one or more of the conditions in 6A.5.1(1)(a).

·        the condition has resulted in the person being frequently  hospitalised or could reasonably result in the person being frequently hospitalised.

·        has complex care needs.

·        the needs require treatment that involves one or more complexities of ongoing care.

 

6A.5.1(2)

 

states that an entitled person must have been granted a Gold Card (A DVA identification card that signifies the holder is eligible for treatment of any injury or disease under the Act) if the person is to participate in the Program.

 

6A.5.1(3)

 

states that an entitled person must be an Australian resident and living in Australia if the person is to participate in the Program.

 

6A.5.5(4)

 

requires an entitled person to consent to participating in the Program and requires the LMO who admits the person to the Program to record the consent.

 

6A.5.5(5)

 

requires an LMO for an entitled person to prepare, in consultation with the person, a comprehensive care plan for the person, if the person is to participate in the Program.

 

6A.5.5(6)

 

states that an LMO must admit an entitled person to the Program by making a decision to that effect and recording it, if the person is to participate in the Program.

 

6A.6 – 6A.6.2

 

set out the grounds that will make an entitled person ineligible for participation in the Coordinated Veterans’ Care Program (Program).

 

6A.6.1(a)

 

provides that if an entitled person is receiving residential care the person is ineligible for participation in the Program.

 

6A.6.1(b)

 

provides that if an entitled person has been medically diagnosed as having an illness likely to be terminal within 12 months after being admitted to the Program then the person is ineligible for participation in the Program.

 

6A.6.1(c)

 

provides that if an entitled person is participating in certain Commonwealth funded health care programs, then the person is ineligible for participation in the Program.

 

6A.6.2

 

provides that an entitled person is ineligible for a subsequent period of care under the Coordinated Veterans’ Care Program

if immediately before the potential period of care the person is receiving residential care or is participating in a program in 6A.6.1(c).

 

6A.7

 

specifies that subject to the approval of a subsequent period of care by an LMO (6A.3) and to the person not being ineligible for treatment under the Coordinated Veterans’ Care Program (6A.6) (Program), treatment commences for an entitled person under the Program on the day the person is admitted to the Program by the person’s LMO and continues throughout a period of care provided by an LMO to the person under the Program.

 

6A.8 – 6A.8.2

 

introduces the treatment of LMO Home Care service (category C) Referral, which is the process whereby an LMO may refer an entitled person in the Coordinated Veterans’ Care Program (Program), who is socially isolated, to an agency that will assess the person’s suitability for a social support service and, if appropriate, allocate responsibility for providing the service to a provider under the Program.

 

6A.8.2

 

enables an LMO to provide a LMO Home Care service (category C) Referral to an entitled person in the Program if, in the opinion of the LMO:

 

·        the person is socially isolated and could reasonably be at risk of hospitalisation for a condition in 6A.5.1(1)(a) because of that social isolation; and

·        the risk of the person being hospitalised could be significantly reduced if the person received a Home Care service (category C).

 

6A.9-6A.9.9

 

set out the procedures relating to the admission of an entitled person to the Coordinated Veterans’ Home Care Program (Program).

 

6A.9.1

 

provides that a LMO treating an entitled person may medically assess the person for participation in the Program.

 

6A.9.2

 

deals with the issue of consent in relation to participation in the Program and, in particular, makes it a condition of a person’s participation in the Program that the person consents to relevant personal information being provided to parties connected to the Program.

 

6A.9.3

 

provides that admission to the Program can only occur after an entitled person’s consent to information-disclosure has been obtained and that the person is admitted to the Program when a record is made of the fact.  Participation in the Program (treatment) commences from the admission date.

 

6A.9.4

 

requires the LMO to prepare a comprehensive care plan for the entitled person and for the LMO to consult the entitled person in the course of preparing the plan.

 

6A.9.5

 

describes the care-coordination for an entitled person that is to occur under the Program.  The coordination will be governed by the comprehensive care plan for the person.

 

6A.9.6

 

refers to the need for an LMO to assess the progress of an entitled person in the Program.  The assessment is to occur before a further period of care can be provided by an LMO to an entitled person in the Program.  The issue is dealt with more specifically in 6A.3 of the attached instrument.

 

6A.9.7

 

describes the process whereby the LMO may refer an entitled person in the Program who the LMO considers to be socially isolated to an agency (called a MHC assessment agency under the MRCA Treatment Principles) for assessing the person’s suitability for a social support service and, if appropriate, allocate responsibility for providing the service to a provider under the Program.

 

6A.9.8

 

requires a VHC assessment agency to which an entitled person has been referred, to determine to determine if the person is suitable for a social support service under the Veterans’ Home Care Program, and the type, duration and frequency of any such service.

 

6A.9.9

 

makes it clear that an LMO, a practice nurse, a DVA-contracted community nursing provider (for a community nurse), and an aboriginal health worker are to comply with the Treatment Principles and with any relevant conditions in the Notes for Coordinated Veterans' Care Program Providers when providing treatment under the Program.

 

                   4. Part 7.3A MRCA Home Care Program

 

5.      substitutes 7.3A.1(1).  The new provision provides that for the purposes of the MRCA Home Care Program (MHC) the Commission may:

 

·        assess an entitled person’s suitability for one of the services offered under MHC.  A “category A service” is a personal care service (e.g. domestic assistance, home and garden maintenance), a category B service is also a personal care service but one, while funded by DVA, is arranged by the Department of Health and Ageing and the States and Territories (known as HACC) and a “category C service” is a social support service.

 

6.                substitutes 7.3A.4.  The new provision states:

 

·        the Commission (in practice the Commission’s delegate – a MHC assessment agency) is to inform a person who is unsuitable for a MHC service of its decision and is to give reasons.

·        where a person is suitable for a MHC service, the Commission is to determine the type, duration and frequency of the service.

·        Commission is to allocate responsibility for providing a “category A service” or a “category C service” to a MHC provider.

·        Commission is to provide a “category B service” (in practice this is delegated to a contractor).

 

6A.    inserts a new 7.3A.4A which provides express authority for a MHC provider to provide a service under the MHC.

 

6B.    modifies 7.3A.5(ii) to take into account the changed terminology in 7.3A.1(1) (“need” replaced with “suitability”).

 

7.      inserts a new 7.3A.6B which provides that the Commission may accept financial responsibility for a category C service (social support service) provided to an entitled person under the MHC if:

 

·        the provider of the service has an arrangement with the Commission or the Department to provide services under the MHC.

·        the service was requested by a MHC assessment agency pursuant to an assessment by the agency and a referral from an LMO under the Coordinated Veterans’ Home Care Program.

·        the service accords with the request from the MHC assessment agency.

·        the service satisfies any requirements in the DVA document “Notes for Coordinated Veterans’ Home Care Providers” that relate to providers of category C services under the MHC.

·        the entitled person is not prevented from receiving the service under the MRCA Treatment Principles e.g. receiving residential care.

·        the service is not essentially the same as a category A or category B service the person is receiving under MHC (double dipping).

 

8.       is a drafting amendment.

 

9.       applies the current limits on charges for category A services also to category C services (social support services).  This means that an entitled person cannot be charged a co-payment that exceeds $5 per hour and cannot be charged a proscribed amount.

 

10.     applies the Note to 7.3A.10 to entitled persons who receive a category C service.  The Note now makes it clear that if an entitled person is an exempt entitled person then the person is not required to pay the co-payment for a category A or category C service the person would otherwise be required to pay.

 

11.     requires the Commission to pay the co-payment (exempt amount) that an entitled person would otherwise pay for a category A or category C service had the person not been exempted from paying the co-payment.

 

12.     states the position regarding prior approval under the MHC.  A “prior approval” requirement means the approval of the Commission must be obtained before a payment for a service under the MHC may be claimed.  Paragraph 7.3A.13 is in the same form it was in before the attached instrument except that it includes a category C service.

 

Generally, prior approval is not required for the provision of a service under the MHC except that if emergency short term home relief (ESTHR) is required within 24 hours after a previous service of ESTHR then the Commission’s prior approval is required.

 

13.     incorporates documents into the MRCA Treatment Principles in the state they were in on 1 May 2011.

 

A new document in the schedule is the Notes for Coordinated Veterans’ Home Care Providers.