Continuity of nursing for a veteran after a hospital stay

Short answer: refer before discharge so nursing care is in place on day one home. As a treating hospital doctor or discharge planner, you can send a DVA Community Nursing referral directly to Carehaven — we confirm the same business day, check eligibility and arrange an RN assessment, giving your patient a warm handover from ward to home.

Discharging soon? Don't wait until the day of discharge. Send the referral ahead of time — Carehaven confirms receipt the same business day and lines up the RN assessment so there's no gap between hospital and home. Refer a veteran →

Why refer before discharge

The days immediately after a hospital stay are when continuity matters most — wounds need dressing, medication regimens change, and monitoring keeps a recovery on track. Referring before discharge means the receiving provider can prepare, so nursing support is ready when your patient gets home rather than being arranged from scratch afterwards.

Who can refer

Authorised referrers for DVA Community Nursing include GPs, treating hospital doctors, hospital discharge planners and community nurse practitioners. As part of the treating or discharge team, you can initiate the referral directly — DVA generally does not allocate clients, so the referral goes to the provider you nominate.

Typical post-discharge service lines

• Wound care — assessment, dressing and management of surgical and other wounds after discharge.
• Medication support — help with a changed or complex medication regimen following a hospital stay.
• Diabetes care — monitoring and support as the veteran re-establishes routine at home.
• Catheter, continence & stoma care — clinical management and education after a procedure.
• Post-discharge monitoring — nursing review to keep recovery on track and flag concerns early.
• Personal care following clinical assessment — where clinically indicated as part of the plan.

A warm handover, not a cold start

Send the completed DVA referral form (D9389) to Carehaven ahead of the discharge date. We confirm receipt the same business day, check DVA eligibility and service fit, contact the veteran, and arrange an RN home assessment. Care can commence under the DVA standard Schedule of Fees once a valid referral and eligibility check are in place — no separate DVA approval is required to begin — so the transition from ward to home is smooth and your patient is picked up promptly.

Service area: Melbourne's outer north (Donnybrook, Craigieburn, Epping, Whittlesea) through Mitchell and the Macedon Ranges to Greater Bendigo.

Frequently asked

When should I send the referral?

Before discharge wherever possible. Referring ahead lets Carehaven confirm, check eligibility and arrange the RN assessment so care is in place on day one home.

Can a discharge planner refer, or does it have to be the doctor?

Both can. Authorised referrers include treating hospital doctors and hospital discharge planners, as well as GPs and community nurse practitioners.

Does care need separate DVA approval to start?

No. For standard Community Nursing, care can commence once a valid referral and eligibility check are in place.

What if I'm not certain of the veteran's DVA eligibility?

Refer anyway. Confirming eligibility is part of the provider's intake, and Carehaven checks it before care commences.

How fast will Carehaven respond?

We confirm receipt the same business day and move promptly to eligibility check, veteran contact and RN assessment.

Refer before discharge for a warm handover

Same-business-day confirmation. Care in place on day one home.

Refer a veteran →

Or call our intake team on 1300 310 605

What happens after you refer a veteran → Who can refer to DVA Community Nursing? → What DVA Community Nursing can cover at home → Download the one-page referral checklist →

General information for health professionals, not clinical, legal or funding advice. Individual eligibility and funded services are determined by DVA. Sources: DVA Community Nursing provider & referral information (dva.gov.au).