A critical step in the case management for a client participating in a rehabilitation program is regular and timely reviewing and monitoring. Regular progress reporting by the rehabilitation service provider for all VVRS, MRCA and DRCA clients is mandated.
The key tool for progress reporting is the Rehabilitation Progress Report which is DVA form D1330 and can be accessed through the DVA forms portal (this form applies for VVRS, MRCA and DRCA clients).
Rehabilitation Coordinators may agree on a reporting period that is most appropriate to the client's circumstances. The maximum reporting period must not be more than every 6 months. It is essential that if significant issues arise, such as deterioration in a client's symptoms or conditions, or life changes that will impact on a client's rehabilitation progress, that rehabilitation providers are pro-active in contacting the client's Rehabilitation Coordinator and informing them. The agreed reporting period must be recorded in the client's R&C ISH case.
Rehabilitation service providers are required to provide the Rehabilitation Coordinator with Rehabilitation progress reports that.
- re-state the goals and objectives identified in the client's rehabilitation plan or amendment;
- document plan objectives and interventions in the plan details table provided, so that they progressively accumulate over time - this allows the reader to easily identify outcomes and status of interventions in chronological order;
- document developments or activities undertaken during a set period of the rehabilitation plan;
- are succinct but provide necessary detail (WITH NO SURPRISES);
- are not the Rehabilitation Coordinator's sole source of information - major or significant developments are to be communicated to the Rehabilitation Coordinator by the rehabilitation service provider at the time of the incident or event;
- are provided at a time period agreed following negotiations between the rehabilitation service provider and the Rehabilitation Coordinator (the agreed period should be noted in the client's ISH claim by the Rehabilitation Coordinator);
- are consecutively numbered;
- are distributed by the rehabilitation service provider to all stakeholders, as identified by the Rehabilitation Coordinator; and
- where appropriate, accompany the rehabilitation service provider's monthly invoice.
Note: See Goal Attainment Scaling in chapter 15 of this Guide for "how to steps" on completing a rehabilitation progress report.
Progress reports should be uploaded by the Rehabilitation Provider electronically to R&C ISH. Documents uploaded to R&C ISH will be saved in the client’s TRIM file and flagged as new info in R&C ISH.
To upload to R&C ISH, the DVA Rehabilitation Coordinator 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. Any follow-up items or recommendations from the progress report need to be recorded and actioned in R&C ISH.
The Rehabilitation Provider is required to sign the progress report to authenticate the information provided in it. There is no requirement for the Rehabilitation Coordinator to sign the progress report.
Monitoring the reporting process
All parties involved in implementing any aspect of a client’s rehabilitation, including pre and post plan activities, have a responsibility to monitor those activities, provide feedback and ensure the activities are progressing. This team input helps to provide the best possible opportunity for the client to reach their rehabilitation goals.
The Rehabilitation Coordinator
The Rehabilitation Coordinator has overarching responsibility for the progress and the direction a rehabilitation case takes. Input is sourced from all parties including client interviews, client files and reports, assessment reports, medical and allied health reports, case correspondence, rehabilitation progress reports, phone calls or conversations.
Effective monitoring by the Rehabilitation Coordinator involves:
- on-going communication with all stakeholders;
- continuous reviews of strategies with stakeholders, in particular the client, rehabilitation service providers, treating doctors /specialists, allied health providers, employers, co-workers and significant others from the client’s support network;
- communication with other business areas of the department, to ensure that client is able to access services (for example, treatment or nursing care) to meet their needs;
- timely approval of, and payment for, activities being undertaken through the rehabilitation plan; and
- the maintenance of client data and sound recording of information relating to the case management of the client.
The Client
The client is the key player in the process of reporting and providing feedback on whether the approved rehabilitation activities are helping them to progress towards their rehabilitation goals. They are also an important feedback source on the accuracy of events occurring and reported on by other stakeholders. Ongoing contact with the client by the Rehabilitation Coordinator is vital to make certain that changes in the client circumstances are acknowledged and where necessary are addressed by appropriate interventions as quickly as possible.
Rehabilitation Service Providers
Rehabilitation service providers play the critical role of case manager in the rehabilitation process, providing ongoing and proactive support to the client, management and implementation of recommended and approved rehabilitation interventions, and the close monitoring of the client’s responses and progress. They are expected to regularly document and report progress to the Rehabilitation Coordinator (with timing as agreed to following negotiations with the Rehabilitation Coordinator). Providers are expected to maintain regular contact with the client, the Rehabilitation Coordinator and key service providers. The intensity of this contact will be determined by the complexity of the case or as discussed and agreed with the Rehabilitation Coordinator.
Specialists, Treating Practitioners and Allied Health Providers
Specialist, treating practitioners and allied health providers contribute to the rehabilitation of the client by providing crucial information such as a diagnosis or prognosis regarding the client’s medical condition(s). Their reporting guides the client through the recovery process, with recommended treatment pathways, clarifying functional restrictions and limitations and suggesting appropriate aids, appliances or modifications which can help maximise potential functioning. They are significant contributors to the process providing regular medical reviews and reports. They also provide important input on a client’s psychosocial circumstances.
Other contracted service providers
Other contracted service providers who are delivering services for the client can provide reports on progress or on the results relating to specific services being provided such as progress with training courses or work preparation activities.
Monitoring the referral to assessment
In order to ensure timely progress of a referral through to the completion of a rehabilitation assessment or an assessment for a specific rehabilitation service, it is essential that the Rehabilitation Coordinator maintains close monitoring of the service providers’ actions through ISH and those of the client. All parties will need to be adequately prepared to begin the process and be informed of prescribed deadlines and input required.
Monitoring from the assessment recommendation stage through to plan, plan amendment, services approval and implementation stage
This is the most involved phase in the rehabilitation process. Unless the process moves without delay, immediate and urgent needs can not be addressed nor can early interventions be implemented. Close monitoring ensures providers meet prescribed deadlines and clients are aware of what is expected of them.