15.3.3 Rehabilitation Plan

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 scale, ranging from the most unfavourable outcome through to the most favourable outcome. The middle 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.

Goals vs activities

• Rehabilitation goals are what the client wants to achieve, or the desired outcome that they are working towards.
• 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’.

Completing the rehabilitation plan

When completing the rehabilitation plan, the provider:

1. Enters client’s name and the DVA file number in the footer of the document.
    
2. Completes client details section.
    
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 the specific goals: 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 Delegate is able to determine whether the goals are achievable.
    
4. Define all rehabilitation outcomes. Describe the 'expected outcome' and then describe the remaining rehabilitation outcomes.
    
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 (e.g. 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 (e.g. doing exercise or a social activity).
    
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)
    
7. Indicate importance and challenges in achieving each goal. Mark the appropriate boxes to indicate the level of importance and challenge (a little, moderately or very) the client identifies for each goal.
    
8. Complete agreement section ('Sign-Off and Distribution'). When goals, outcomes and activities have been agreed between the provider and client, the plan is signed by client and provider.
    
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.
    
10. Processing rehabilitation plan documentation
    10.1 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.
    10.2 Once the Rehabilitation Delegate has approved the plan, it can commence.
    10.3 Rehabilitation Delegates are responsible for transposing information from the rehabilitation plan submitted by rehabilitation providers, into R&C ISH. This information includes goals and activities for each goal.

IMPORTANT: The rehabilitation provider must ensure that no treatment costs are included on a 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.

Rehabilitation goals

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.