The recommendations made by the Rehabilitation Provider in the client's Rehabilitation Assessment Report, form the foundation of the Rehabilitation Plan (the plan) drafted by the provider.
Two types of plans can be drafted around the assessment report recommendations:
- Whole-of-person rehabilitation plans; or
- Specific service(s) plans which are appropriate when the client only has short term needs for services such as household or attendant care services, aids and appliances or assistance with modifications to motor vehicles.
Rehabilitation plans should be uploaded electronically by the Rehabilitation Provider to R&C ISH. The DVA Rehabilitation Delegate will 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.
Whole-of-person rehabilitation plans
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 of this Guide.
Specific service plans
Specific service plans are “in house” plans that are managed by the DVA Rehabilitation Delegate, and not by a rehabilitation provider. “In house” plans are distinct from whole-of-person rehabilitation plans and are generally only created where a client requires targeted assistance and the Rehabilitation Coordinator is satisfied that the client has no other rehabilitation needs.
“In house” specific service plans can be created to assist the client's:
- independence and functioning in the home, community or workplace through the provision of aids, appliances or alterations that cannot be provided through the Rehabilitation Appliances Program; and/or
- provision of household services and/or attendant care services; and/or
- mobility and independence by the provision of modifications to, or purchase of, a motor vehicle through the Motor Vehicle Compensation Scheme or section 39 of the DRCA.
For example, an “in house” specific service plan will be required to provide aids, appliances or alterations through section 56 of the MRCA, if the Rehabilitation Delegate is satisfied that the client does not require any other rehabilitation assistance. This plan is used as an administrative mechanism only, to enable funding to be released. Please refer to section 10.3.4 of this Guide for further information about information about determinations for specific service plans that have been opened to enable provision of aids and appliances.
Issues that are not identified or addressed at the first available opportunity have the potential to return in the long-term as far more costly and complex barriers to successful rehabilitation. It is therefore recommended that a general principle, whole-of-person rehabilitation plans are utilised rather than specific service plans, unless there is clear evidence that the client has no other rehabilitation needs or barriers to rehabilitation for which they require support.
Goal Attainment Scaling does not apply to specific service plans.