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15.3.3 Rehabilitation Plan

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Last amended 
31 May 2017

A rehabilitation plan is developed by the provider in conjunction with the client as a result of the rehabilitation assessment. It may include medical management, psychosocial and/or return to work activities. The plan provides a structured series of individualised activities and goals.

The provider and client determine the rehabilitation goals (up to four) and set outcomes. Each goal has described five possible outcomes rated on a 5-point scale, ranging from -2 (representing the most unfavourable outcome) through to +2 (representing the most favourable outcome). The zero (0) point is identified as the “expected outcome”. The client and provider believe the client should be able to achieve at least the “expected outcome” by the end of the rehabilitation plan.

An image showing the range of Goal Attainment Scaling outcomes

 

Goals vs Activities

Goals are what the client wants to achieve, or the desired outcome that they are working towards.

The rehabilitation activities are the things that the client will do to reach that outcome.

Goals should be specific, and as a general rule, multiple activities will be included to help the person to reach their goal. For example, the goal of ‘improvement to physical functioning’ could have the activities of ‘attend physiotherapy appointment 1 time per week and complete all exercises recommended by the therapist’, ‘walk around the block 4 times per week’ and ‘support from XX (eg. family member) to assist with developing a weekly routine’.

Completing the Rehabilitation Plan

When completing the DVA Form D1347 Rehabilitation Plan, the provider:

Step 1. Enters client’s name and the DVA file number (not the Defcare Case ID) in the footer of the document

Step 2. Completes client details section

Step 3. Defines rehabilitation goals, timeframes and categories

  • 3.1 Provider and client to set relevant goals (up to four)* and timeframes
  • 3.2 Notate the most applicable category for these specific goals: either medical management, vocational or psychosocial

Note: Providers should avoid setting goals and outcomes that could be too easily met or too difficult to achieve. Goals and expected outcomes should be described in such a way that the Coordinator is  able to determine whether the goals are achievable.

Step 4. Define all rehabilitation outcomes

  • 4.1 Describe the “expected outcome” (0) and then describe the remaining rehabilitation outcomes (-2, -1, +1 and +2).

Step 5. Define activities to achieve rehabilitation goal(s)

  • 5.1 Discuss with the client, the activities to be undertaken to achieve the goal(s)
  • 5.2 Record the general services that are required to achieve the goal (eg. relevant appointments, case management etc) and those that are more focused on what the client aims to do in order to achieve the specific outcomes (eg. doing exercise or a social activity)

Step 6. Specify parties involved for the activities and dates associated with each activity

  • 6.1 Specify the parties involved e.g. the client, provider, employer, medical professional, etc
  • 6.2 Specify the start and end dates for the activities (do not have to reflect the same start or end dates as the overarching Plan but must not go outside the start and end dates of the Plan)

Step 7. Indicate importance and challenges in achieving each goal

  • 7.1 Mark the appropriate boxes to indicate the level of importance and challenge (a little, moderately or very) the client identifies for each goal

Step 8. Complete agreement section ('Sign-Off and Distribution')

  • 8.1 When goals, outcomes and activities have been agreed between the provider and client, the Plan is signed by client and provider

Step 9. Indicate costs involved with activities outlined in the Plan

  • 9.1 Identify all relevant goals for each activity
  • 9.2 Indicate the costs involved in terms of provider costs, third party costs and the total costs for each activity identified in the Plan

Step 10. Processing Rehabilitation plan documentation

  • 10.1 For all new rehabilitation referrals from 29 May 2017, upload the rehabilitation plan together with the assessment report and any relevant documentation to R&C ISH using the client's unique Transaction Reference Number. All rehabilitation cases that commenced prior to 29 May 2017 will require you to follow the process of emailing rehabilitation related documentation to the client's DVA Rehabilitation Coordinator.
  • 10.2 Once the Rehabilitation Coordinator has approved the plan, it can commence.
  • 10.3 Rehabilitation Coordinators are responsible for transposing information from the rehabilitation plan submitted by rehabilitation providers, into R&C ISH. This information includes goals, activities for each goal and LSI scores.

IMPORTANT: The rehabilitation provider must ensure that no treatment costs are included on a medical management Rehabilitation Plan. Treatment costs are covered by the normal medical payment arrangements, usually through the DVA Health Card system.

* Note: It is considered, as a general rule, that too many goals may have a negative impact on the client as they may be trying to achieve too much in a short space of time. However, setting more than four goals might be appropriate, in some circumstances, if the provider and client consider it could be beneficial for the client and they are highly motivated. It is important that the provider and client are both confident that the client could be realistically expected to achieve more than four goals, before these are included on the rehabilitation plan.