DVA Gold Card nursing at home

Your dad is coming home from hospital. Or maybe it’s your mum, or your partner. You’re glad. You’re also wondering who will change the dressing, help with the medicines, or check in once everyone has gone home.

If they hold a Department of Veterans’ Affairs (DVA) Gold Card, nursing at home may be covered. DVA calls this Community Nursing. This guide explains how to set it up before discharge day, so you know what to expect.

Can a Gold Card holder get nursing care at home after hospital?

Yes, if there’s an assessed clinical need. DVA’s Community Nursing program pays for nurses to visit a veteran’s home for clinical care and some personal care. That includes wound care, help with medicines, and help with showering or dressing. A Gold Card covers any assessed clinical need. A White Card covers care for conditions DVA has accepted. A written referral is needed first.

You can read DVA’s own overview on its Community Nursing page.

What should you ask before leaving hospital?

Ask the ward team four things before discharge. Will community nursing be needed at home? Has a referral been sent to a nursing provider? If medicines need to be given, is there a signed medication chart? And who should you call if something changes? Write the answers down.

Here’s why each one matters.

• Is community nursing needed? The ward team knows what care your parent needs now. Ask them to say it plainly, for example a wound to dress or medicines to give.
• Has the referral been sent? Nursing can’t start without a written referral. Ask who sent it, and to which provider.
• Is there a signed medication chart? A nurse can only give medicines from a chart signed and dated by the prescriber. If your parent manages their own medicines, a full medicines list helps too.
• Who do you call? Get a name and number for the ward, the provider and the GP. Keep them by the phone.

Your discharge planner may also talk about other programs. For some people, another program may suit the time straight after discharge better. The discharge planner can tell you what’s available.

Who sends the referral for community nursing?

A hospital doctor or the hospital discharge planner can send the referral before your parent leaves. After that, the GP takes over. A GP or a nurse practitioner can also refer. The referral goes straight to the nursing provider. It does not go to DVA, and families can’t send it themselves.

DVA sets out these rules in its Notes for Community Nursing Providers (section 3.2). The referrer can use DVA’s own Community Nursing referral form (D9389) or their own letterhead.

A hospital referral only covers the first stretch after discharge. If your parent needs nursing for longer, their GP sends a new referral. Ask us or your GP if you’re not sure when that is.

If you’re a discharge planner, our referral page lists what to include and how to send it. Or use our DVA community nursing referral checklist. You can also call us to talk it through first.

What happens at the first home visit?

A Registered Nurse comes to your parent’s home to meet them. The nurse asks about their health and what help they’d like. Then the nurse agrees a care plan with your parent and their GP. With your parent’s consent, the nurse also lets the GP know what they found. You’re welcome to be there.

DVA requires this first visit to be a face-to-face assessment by a Registered Nurse, in the client’s home. It’s more than a chat. The nurse may check skin, walking, continence, sleep and eating, depending on what your parent needs.

It’s also a chance for your parent to say how they like things done. What should we call them? Is there a time of day that suits? Who in the family should we talk to? Our service is run by two Registered Nurses, Sujith and Blessy. They have about 25 years of nursing experience each. They assess new clients at home themselves. They’d rather your parent knows who is coming, and why.

Does community nursing cost anything with a Gold Card?

Not if DVA covers the care. Gold Card holders are covered where there’s an assessed clinical need. White Card holders are covered for conditions DVA has accepted. If DVA covers the care, the client pays nothing. We claim from DVA. If any care isn’t covered, we’ll tell you before it starts.

For White Card holders, we check with DVA before care starts. You can see more on our who is covered page.

What doesn’t community nursing cover?

Community nursing covers nursing and some personal care. It doesn’t cover cleaning, shopping, transport, respite or companionship visits. It isn’t Hospital in the Home, and it doesn’t provide care around the clock. For help around the house, call Veterans’ Home Care (VHC) on 1300 550 450.

VHC can also help with low-level personal care when there’s no nursing need. It’s a separate DVA program with its own assessment. Your parent may be able to have both, as long as the services don’t double up. Ask DVA or your GP. Our guide to community nursing or Veterans’ Home Care compares the two. DVA explains VHC on its Veterans’ Home Care page.

You can see the full list of what our nurses do on our services page.

How can you get the home ready for the first visit?

A little preparation makes the first visit easier for everyone. Put the discharge papers, medicines list and medication chart in one place. Have the Gold Card and the GP’s details handy. Clear a path to a chair and the bathroom. Settle any pets in another room.

A few more small things help.

• Keep the hospital paperwork together. A folder on the kitchen table works well. Include any wound or dressing instructions the hospital gave you.
• Bring the medicines out. Put them all in one bag, including any from the chemist or the supermarket. The nurse can then see the whole picture.
• Think about light and space. Good light helps with a dressing or a skin check. A clear table and a firm chair help too.
• Settle the pets. Even a friendly dog can get excited when someone new arrives.
• Tell us about access. Let us know about parking, stairs, a gate code or a side door.
• Write down your questions. It’s easy to forget them on the day. Nothing is too small to ask.

If you can’t be there, that’s fine. Leave your number with your parent. You can also call us afterwards with any questions.

How to arrange nursing care with us

If you’re a family member, ask the discharge planner or ward doctor to send the referral to 3 Star Harmony Solutions. They can use our referral page. If your parent is already home, ask their GP instead.

You’re also welcome to contact us first. We’re happy to explain what to ask for. We’ll tell you whether we can take your parent, and when the first visit will be. If we can’t, we’ll tell you straight away, so the referral can go somewhere else.

We’re a small nursing team based in Lalor, in Melbourne’s north. We’d be glad to hear from you.

This is general information, current at the date shown. It isn’t medical advice. DVA’s rules can change, so please check with DVA or your GP for your own situation. We’re not an emergency service. In an emergency, call 000.