The recommendations made by the Rehabilitation Provider in the client's Rehabilitation Assessment Report, form the foundation of the Rehabilitation Plan drafted by the provider.
A whole-of-person rehabilitation plan should address all of the client's assessed needs. This means that even if there is evidence that a person has the capacity for employment, and is working towards vocational rehabilitation goals, their rehabilitation plan should also include medical management, or psychosocial activities if this is appropriate for their needs and circumstances.
The plan will provide a structured series of individualised services and activities agreed to by all stakeholders which aim to assist a client to live as full and meaningful life as possible, while facilitating independence and self-management. This may include, if appropriate to the client’s circumstances, financial independence through employment. Such plans may be complex in nature, involving multiple service providers and extend over a reasonable time period. They may also be of short duration if the rehabilitation assessment indicates that the client only requires specific and targeted assistance over a short period to reach their rehabilitation goals.
Vocational, psychosocial and medical management rehabilitation activities may be provided in tandem rather than in sequence to ensure overall progress is maintained and the client remains focused throughout. However, if more appropriate to the client’s circumstances, the plan may include a stepped approach to provide the right support at the right time. For example, medical management and psychosocial rehabilitation may delivered prior to, or concurrently with, re-training, provision of work-related aids and appliances, job search, work placement processes or other similar vocational rehabilitation activities, depending on each client’s individual circumstances and needs.
Whole-of-person rehabilitation plans must:
- be goal and outcome focused;
- clearly demonstrate a focus on the person's whole-of-person needs;
- clearly state the person's rehabilitation goals and proposed services/activities to assist the person to work towards these goals;
- the cost effectiveness of approving and implementing the services/activities;
- clearly outline all case management activities to be undertaken by the rehabilitation provider;
- specify the rehabilitation provider costs and third party costs for all activities;
- include a start date and an end date;
- identify potential barriers to rehabilitation and recovery and include activities to address these;
- be informed by medical evidence as to the appropriateness of proposed rehabilitation activities;
- be realistic and achievable for the client; and
- incorporate Goal Attainment Scaling, consistent with chapter 15 in this library.
Rehabilitation plans should be uploaded electronically by the Rehabilitation Provider to R&C ISH. The Rehabilitation Delegate may need to send the Rehabilitation Provider an email with information about how to upload to R&C ISH and the Transaction Reference Number (TRN) to be used for the individual client.