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3.8.3 Development of the Rehabilitation Plan
Developing a rehabilitation plan
A client will be motivated to participate in a rehabilitation plan when they have been actively engaged in planning rehabilitation activities that will enable them to reach their rehabilitation goals. Therefore, the development of a plan and the goals within it must be a collaborative process involving the client and the rehabilitation service provider. It is important that clients are never asked to sign blank rehabilitation plans. DVA delegates may refer to Chapter 3 of the Rehabilitation Procedures Guide for further information about signing rehabilitation plans.
Where appropriate, the client's treating medical practitioner, allied health professionals, the client's family and employers/work colleagues should also be involved. The Rehabilitation Coordinator’s role is to consider and approve the agreed rehabilitation plan if they are satisfied that the agreed rehabilitation activities are likely to lead to a positive outcome for the client.
Good communication is a key to managing expectations and ensuring a mutual understanding of what an individual client's plan may include and the role and responsibilities of the client in meeting their rehabilitation goals. It is essential that the client has made a significant contribution to developing the activities and goals of their rehabilitation plan, to ensure that the client is engaged with their rehabilitation program, motivated to achieve their identified goals, and comfortable when signing their rehabilitation plan.
DVA’s whole-of-person approach to rehabilitation must always be used to guide decision making, and ensure that a client’s rehabilitation plan is always tailored to their current needs and circumstances. This approach reinforces that vocational rehabilitation must not be the only, or the first priority, in assisting a person to build a new life for themselves after a service related injury.
It is important that the information available to the provider as part of the referral for a rehabilitation assessment provides flexibility for a range the issues to be discussed during the rehabilitation assessment process, and for a comprehensive assessment of the person’s whole-of-person needs to occur. Rehabilitation Coordinators must be aware that information in the rehabilitation referral must be released to the client if they request it.
It may be beneficial to hold a case conference prior to the rehabilitation plan being signed, so that all parties are aware of the proposed activities and rehabilitation goals and are ‘on the same page’.
When developing a rehabilitation plan, it is important that the roles and responsibilities of the rehabilitation provider and Rehabilitation Coordinator are clearly defined and maintained during the rehabilitation process. This helps to ensure that the integrity of the relationship between the client and provider is maintained. Please refer to section 13.1 of this Guide for further information about the roles and responsibilities of those involved in the rehabilitation process.
Approving a whole-of-person rehabilitation plan
Before approving the services and activities in the plan the Rehabilitation Coordinator is to consider any the following points that are relevant to the client’s circumstances:
- any written report as a result of any examinations conducted to ascertain the person’s capacity for rehabilitation, the kinds of rehabilitation from which the person would benefit, and any other information relating to the provision of a rehabilitation program for the person;
- the overall goals of the plan (i.e. are they likely to lead to durable and sustainable changes in the person’s life );
- whether the activities in the plan are Specific, Measurable, Achievable, Realistic within a given Timeframe (SMART);
- the time involved;
- the cost effectiveness of approving and implementing the services/activities;
- the short-term and long-term benefits to the client;
- the potential to improve the client's wellbeing, independence, functioning and opportunity to be engaged in work after completing the rehabilitation program;
- the client’s attitude to the program;
- the relative merits of any alternative and appropriate rehabilitation program; and
- any other matter the rehabilitation authority considers relevant.
Note: See Goal Attainment Scaling in chapter 15 of this Guide for "how to" steps on goal setting and navigating the rehabilitation plan form.
When considering cost effectiveness and whether the financial outlay for certain services and supports will result in the client achieving their rehabilitation goals, it is important to note that low upfront costs for short-term gains don't necessarily equate to desired long term, durable and sustainable quality outcomes for either the client or the Department.
The program of activities recommended is to have clearly defined goals with expected short-term and longer-term objectives to be achieved within clearly defined timeframes.
The plan must have a start date and an anticipated end date.
The rehabilitation service provider must itemise all costs for the recommended services and activities listed on the plan.
The Rehabilitation Coordinator must approve rehabilitation activities in a timely fashion to prevent delays and ensure that rehabilitation activities can commence as soon as possible. This helps to maintain momentum and facilitate positive outcomes for clients.
Communicating with clients about their proposed rehabilitation plan
It is expected that the Rehabilitation Coordinator will be proactive in appropriately managing and communicating with clients about any issues that may arise during the rehabilitation process.
Rehabilitation providers must not be asked to inform the client of any concerns the Rehabilitation Coordinator may have about the client’s attitude, proposed rehabilitation plan, or the client’s willingness or commitment to participate in their rehabilitation activities. Rehabilitation providers must not be asked to communicate any decisions that the Rehabilitation Coordinator has made, or any other delegate decisions to the client. This is particularly relevant to deeming decisions.
Recording rehabilitation plans
From 28 May 2017 DVA Rehabilitation Co-ordinators are required to record rehabilitation goals, activities, dates for activities and LSI and GAS scores in R&C ISH for all new cases. For information about how to do this, please refer to Chapter 3 of the Rehabilitation Procedures Guide.
Signing rehabilitation plans
DVA delegates are asked to refer to Chapter 3 of the Rehabilitation Procedures Guide. for information about signing rehabilitation plans.
Determination of a rehabilitation plan
DVA Rehabilitation Coordinators must issue a determination whenever a decision is made that a client is to undertake a rehabilitation program. It is mandatory that R&C ISH standard letters are used when communicating with clients about the approval of their rehabilitation plan. Letters generated from R&C ISH will automatically attach to the client’s UIN folder in TRIM.
The determination letter together with the the appropriate rights and obligations document (return to work, or non-return to work) and the signed rehabilitation plan constitute a formal determination that a person is undertake a rehabilitation plan under section 37 of SRCA, section 51 of MRCA or section 13.2 of the VVRS Instrument. This formal determination is a reviewable decision.
The points relevant to the client’s circumstances, must be noted in the determination letter. For example, if a client is to undertake a non-return to work rehabilitation program that encompasses medical management and psychosocial support, there will be no requirement to state in the determination that the person’s ability to engage in employment after completion of their plan has been considered.
For further information about what needs to be provided to the client as part of making a determination that they are to undertake a rehabilitation plan, DVA delegates are asked to please refer to Chapter 3 of the Rehabilitation Procedures Guide.