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.
may be wheelchair dependant as a result of a spinal cord injury or brain injury.
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.
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.
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.
(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.
formulate agreed management pathways (medical, nursing, psychosocial and when or if appropriate vocational).
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.
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.
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.
participate in case conferences when convened by DVA Community Nursing Program.
participate in case conferences when convened by DVA.
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 of this Guide.