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15.3.4 Rehabilitation Plan Amendment
A Rehabilitation Plan Amendment is completed:
- *when any changes to goals and/or the short or long term activities are required;
- if the timeframes to complete activities of the plan need to be adjusted (this includes an extension to the Plan itself);
- *if additional rehabilitation activities need to be included; or
- where the approved funding for the plan activities requires a minor amendment.
NOTE: A Rehabilitation Plan Amendment is not used when the overall focus of the client's rehabilitation program changes, for example, where a client moves from a non-return to work program to a return to work program, or vice versa. Where this occurs, the original program should be varied by the creation of a new Plan. DVA Rehabilitation Coordinators must issue a determination letter whenever a rehabilitation program is varied. More information about this can be found in section 3.8.4 of this Guide.
* It is not necessary to make an amendment to a Plan if the client is unable to undertake all planned future activities related to an existing goal in the current Plan. In such cases, before the Plan is discussed with the client, it should be considered whether the client’s primary care provider (GP, specialist) should be engaged to help the client to manage any particular health issue which may be preventing the client from currently undertaking that activity or achieving their rehabilitation goal.
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 (e.g. family member) to assist with developing a weekly routine’.
New or Amended Goal
When completing the DVA Form D1336 Rehabilitation Plan Amendment, 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 Amendment is signed by client and provider
Step 9. Indicate costs involved with activities outlined in the Plan Amendment
- 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 amendment documentation
- 10.1 For all new rehabilitation referrals from 29 May 2017, upload the rehabilitation plan amendment and any other relevant documentation to R&C ISH using the client's unique Transaction Reference Number (TRN). 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 Coordinator has approved the Plan Amendment, it can commence.
- 10.3 Rehabilitation Coordinators are responsible for transposing information from the rehabilitation plan amendment submitted by rehabilitation providers, into R&C ISH. This information includes goals, activities for each goal and LSI scores.
IMPORTANT: The 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.
# It is considered that, as a general rule, 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.
Change of Outcome(s)
If a change to any outcome is required, an amendment may be undertaken. This may occur if there are exceptional and unanticipated circumstances that have arisen since plan development. This ensures all clients attain their expected outcomes.
Change of Activities or Timeframes Where Goals Have Not Changed
If a change of timeframes is required, but the goal(s) remains the same, the activities associated with the goal may be revised, or new activities added for that goal. When amending or adding new activities, the provider must indicate the parties involved, dates for each new activity, and any costs associated with the activities .
If the only change is to extend the time of the plan, to enable extra time for rehabilitation activities to be completed, the GAS information is not required as it is already included in the Rehabilitation Plan. Information should be provided in the amendment about why the extra time is required.
Rehabilitation Goals are what the client wants to achieve through their rehabilitation plan. They will have a vocational, medical management or psychosocial focus. An example for each is provided below.
- Vocational goal – return to sustainable part-time work.
- Medical Management goal – identify appropriate medical professionals in my local area and start accessing treatment regularly.
- Psychosocial goal – to increase level of social activity and community participation.
A client may be working towards a mix of vocational, medical management and/or psychosocial goals concurrently, or may initially focus on achieving specific types of goals (e.g. medical management goals) before moving on to others. This will be determined by what is most appropriate for each client given their individual circumstances and needs.