Coordinated Veterans’ Care: A collaborative approach to managing chronic conditions

Ms Carolyn Campbell1, Ms Anna Polson1

1Department Of Veterans’ Affairs


The Department of Veterans’ Affairs Coordinated Veterans’ Care (CVC) Program is a team-based program encouraging partnership and collaboration between the participant, GP, nurse coordinator and a wide range of health professionals and community supports. CVC involves a proactive approach to improve the management of participants’ chronic conditions and quality of care for eligible Gold Card holders at risk of unplanned hospitalisation.

CVC Care Teams use a person centred approach to care planning, coordination and review, as the model to support better outcomes and self-management of the veterans’ health. The program emphasises a coordinated approach, partnering and utilising a multidisciplinary team to provide tailored and flexible support based on an individual’s goals.

The coordination of care for those living with chronic conditions is pivotal in the empowerment of participants by promoting self-management, providing education and linking participants with other health providers for a holistic approach.

Through the CVC Program and the coordination of the care plan, participants can access a wide range of health services to assist in the management of their chronic conditions. The sharing of health information amongst all partnering health care providers enables better health outcomes for participants. Regular communication, empowerment and coaching are key to the success of the team.

The CVC Program has proven to be effective in reducing hospitalisations and is considered to be a leading practice approach to the coordination of health care services facilitating and promoting partnerships to support health outcome. Amid the changing landscape of health care and the emergence of different chronic conditions, the CVC Program will continue to lead the way in delivering high quality coordinated care to the veteran population.


Carolyn Campbell and Anna Polson are in the Nursing Programs and Operations section at the Department of Veterans’ Affairs and oversee the Coordinated Veterans’ Care (CVC) Program.