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This chapter provides an introduction to the DVA's whole of person approach to rehabilitation.
Details about rehabilitation aims, rehabilitation framework, rehabilitation principles and protocols, the role of the rehabilitation coordinator and rehabilitation policy development can also be found in specific sections of this chapter.
DVA's approach to rehabilitation is much broader than just treatment to promote physical recovery from an injury or illness related to service in the Australian Defence Force (ADF).
DVA uses a whole of person approach to rehabilitation which can be best explained by the following definition of rehabilitation used by the Australian Faculty of Rehabilitation Medicine:
"The combined and coordinated use of medical, psychological, social, educational and vocational measures to restore function or achieve the highest possible level of function of persons physically, psychologically, socially and economically; to maximise quality of life and to minimise the person's long term health care needs and community support needs."
As a member of the Heads of Workers' Compensation Authorities Australia and New Zealand (HWCA), DVA embraces the rehabilitation philosophies outlined in the HWCA Biopsychosocial Injury Management Package [3], which is also available from the Rehabilitation service providers [4] page on DVA's website.
There are three types of rehabilitation support that DVA clients can access. These are:
Medical management rehabilitation is provided as an adjunct to treatment. It helps to restore or maximise a person's physical and psychological function by helping them to manage their treatment or health needs. This may involve helping the person to coordinate their medical treatment appointments or surgical interventions, to help them to understand medical information, to manage their self care needs and to look at their need for aids and appliances, particularly after surgery. Medical management rehabilitation is usually provided where a person is having difficulties managing their treatment or has high support needs.
Further information about medical management rehabilitation can be found in Chapter 5 [5] of this Library.
Psychosocial rehabilitation interventions aim to change perceptions of injury, pain, the future, loss and life changes as a result of injury or illness. They aim to help alleviate anxiety associated with accepting that an injury has occurred, enhance the recovery process and assist in maintaining or improving a client's wellbeing. Psychosocial interventions help address barriers to the person reaching their rehabilitation goals.
A client's rehabilitation program may focus solely on a package of psychosocial interventions. However, it is more likely that psychosocial activities will be offered in conjunction with medical and/or vocational rehabilitation services.
Further information about psychosocial rehabilitation can be found in Chapter 6 [6] of this Library.
Vocational rehabilitation is a managed process that provides an appropriate level of assistance, based on assessed needs, necessary to achieve a meaningful and sustainable employment outcome. Vocational rehabilitation can assist a person to remain in their current employment, or to find alternative employment if that is not possible.
Services may include vocational assessment, guidance or counselling, functional capacity assessments, work experience, vocational training and job seeking assistance.
Vocational rehabilitation incorporates the concept of suitable employment. Suitable employment means that a person's skills, training and experience, together with their medical situation, are assessed. The focus is what the person can do rather than what they cannot do.
There is a growing body of evidence internationally about the health benefits of safe and meaningful work and the importance of employment in helping a person get their life back on track after a work related injury or illness.
Further information about vocational rehabilitation can be found in Chapter 9 [7] of this Library.
DVA utilises Comcare approved or Military Rehabilitation and Compensation Commission (MRCC) endorsed rehabilitation providers to work with individual clients to develop whole-of-person rehabilitation plans tailored to their unique needs and circumstances.
Further information about rehabilitation providers can be found in Chapter 11 [8] of this Library.
The aim of rehabilitation is to help a person adapt to, and wherever possible, recover from an injury or illness that is related to their Australian Defence Force (ADF) service.
This is explained in the Military Rehabilitation and Compensation Act 2004 (MRCA [10]) as:
"The aim of rehabilitation is to maximise the potential to restore a person who has an impairment, or an incapacity for service or work, as a result of a service injury or disease to at least the same physical and psychological state, and at least the same social, vocational and educational status, as he or she had before the injury or disease."
The main focus of rehabilitation is on:
Goal Attainment Scaling is central to achieving the aims of a DVA rehabilitation program. This is because the Goal Attainment Scaling process provides an opportunity for veterans to reflect on their life satisfaction and identify goals and objectives to help them start to make life changes, or set a new direction, after a service injury or disease. The support of a rehabiiltation provider in helping the veteran to set, work towards and achieve rehabilitation goals helps to build confidence and a sense of hope for the future.
DVA's whole-of-person rehabilitation focus is underpinned by research into the health benefits of good work. More information about the health benefits of good work can be found in section 9.1 of this library. [11]
DVA is committed to providing rehabilitation services based on best practice principles.
These principles are:
The Department will achieve this by:
In 2004, the MRCA Ex-Service Organisations (ESO) Working Group, in conjunction with the Military Rehabilitation and Compensation Commission (MRCC), developed a set of Principles and Protocols to guide the delivery of rehabilitation under the Military Rehabilitation and Compensation Act 2004 (MRCA [10]).
At that time, the Principles and Protocols were seen as a way of clearly setting down some expectations about how the rehabilitation provisions of the MRCA should operate in practice.
(Italics are quotes from the Act)
1. "The aim of rehabilitation is to maximise the potential to restore a person who has an impairment, or an incapacity for service or work, as a result of a service injury or disease to at least the same physical and psychological state, and at least the same social, vocational and educational status, as he or she had before the injury or disease." source: section 38 of MRCA [10].
2. A person can be considered for rehabilitation where the Military Rehabilitation and Compensation Commission (the Commission) has accepted liability for an injury or disease, which causes incapacity for work, or caused impairment that requires medical or social rehabilitation.
3. If the Commission has accepted liability for a person's injury or disease that person can request an assessment for suitability to undertake rehabilitation and that request must be complied with.
4. The Commission can determine that a person undertakes a rehabilitation program having regard to the following:
5. Any reference to written reports or relevant material in the Act, may include reports provided from the person's principal treating practitioner and any other report provided by the claimant in respect of both assessments of the person's capacity for rehabilitation and the development of the rehabilitation program.
6. The rehabilitation program can include vocational and social rehabilitation.
7. Persons with suitable qualifications or expertise in rehabilitation will assess a person's capacity for rehabilitation and where applicable provide guidance on the type of program the person should undertake.
8. If a person fails to undertake a rehabilitation assessment or program without reasonable excuse the Commission may suspend the person's right to compensation (but not treatment).
9. Rehabilitation will be coordinated, integrated and adequately resourced to achieve effective outcomes.
10. Relevant incapacity payments (income replacement) are payable whilst a person is undertaking a rehabilitation program and they are unfit for work.
11. All determinations relating to rehabilitation, with the exception of a determination relating to the suspension of compensation for refusing or failing to undergo a rehabilitation examination, or refusing or failing to undertake a rehabilitation program, are original decisions and subject to review and appeal.
1. Where a person seeks a payment for impairment or incapacity for work a delegate will consider whether that person should undertake an assessment of capacity to undertake rehabilitation.
2. Where it is considered that such an assessment should be undertaken, a written determination must be made.
3. A person may request an assessment of their capacity for rehabilitation at any time.
4. Persons who have requested an assessment, or where it has been determined that such an assessment is required, will be referred to a rehabilitation provider for a professional and comprehensive assessment.
5. The rehabilitation assessment is a comprehensive investigation undertaken by a suitably qualified or experienced professional in the field of medical management, psychological and vocational rehabilitation to measure the capacity and needs of the person.
6. The suitably qualified or experienced professional who will perform the rehabilitation assessment is determined by the rehabilitation authority from a list of approved providers.
7. In the event that a dispute arises between a person and the approved provider performing the rehabilitation assessment, the Department will endeavour to resolve the issues. If the issues cannot be resolved, the Department undertakes to use its best endeavours to assign another approved provider to conduct the rehabilitation assessment.
8. Subsection 41(1) of the MRCA [10] defines that: "vocational assessment and rehabilitation consists of or includes any one or more of the following:
A vocational assessment will also include an assessment of employability taking into account age, capability, tertiary and other qualifications, and labour market conditions.
9. Vocational training and education is generally provided to return a person to the workforce to at least the level of the person's former employment. If, in order to regain employment, the rehabilitation assessment determines that education or training to a higher level, including tertiary studies, is required to achieve reasonable likelihood of a return to the workforce, and such assistance is considered to be appropriate and cost effective, training or education to that level will be considered.
10. Matters that must be considered when determining the cost effectiveness of further education include:
Further education will only be supported when the client is undertaking a vocational rehabilitation plan and working towards a return to work goal.
Further information about retraining and further education can be found in section 9.7 [16] of this Guide.
11. It is important, as part of a whole-of-person approach to rehabilitation, that psychosocial rehabilitation is always considered. The aim of psychosocial rehabilitation is to assist a person to maximise their functioning in the community, manage their life circumstances as effectively as possible, and to work towards a fulfilling an meaningful future by providing appropriate behavioural and basic training skills for living and participating in a community setting.
12. A rehabilitation program will only be developed if the person has undergone an assessment of their capacity for rehabilitation by a suitably qualified provider.
13. The rehabilitation program will be described by a rehabilitation plan. It will list the goals that both the client and the provider believe to be achievable, as well as provide an indication of how difficult the client perceives these goals will be to achieve. It will list the services that will be provided, the time period covered under the plan and the expected outcome at the completion of the plan.
14. All parties to the plan, which includes, at a minimum, the person's rehabilitation coordinator (delegate), an approved rehabilitation provider and the person will be consulted during the preparation of the plan. This will enable each party to commit to the plan and goals within the plan. The consultation will include providing the person with information and options to allow them to make informed decisions. Please refer to Goal Attainment Scaling in Chapter 15 of this Guide [17] for detailed instructions on how to develop a plan.
15. DVA's whole of person approach to rehabilitation means that support and services can have a primary focus on:
Rehabilitation support is tailored to each client's individual circumstances. It is likely that a rehabilitation plan may include activities across each of these three areas.
16. The plan will include an outline for the coordination arrangements for each of the rehabilitation services.
17. Rehailitation plans are subject to review, as requested, to ensure they remain relevant to the person's current needs.
18. Any major changes to a rehabilitation plan, including closure of the plan, must be based on discussions between the client, their treatment doctor (if appropriate) and the rehabilitation provider, and be agreed by the rehabilitation coordinator.
19. Rehabilitation services, including assessment, are to be provided by approved rehabilitation providers only.
Approved rehabilitation providers are:
20. The delivery of the services will be coordinated to ensure they are delivered in an efficient and and timely manner and are appropriate to the client's current needs and circumstances.
21. The Commonwealth will meet the cost of all rehabilitation activities approved by a rehabilitation coordinator (delegate). This includes examinations, assessments, aids, appliances (where they can not be provided through the Rehabilitation Appliances Program) and other activities included in a plan. Treatment costs, including nursing care costs, cannot be met through a rehabilitation plan.
22. Where a person is incapacitated for work due to a combination of compensable and non-compensable conditions, or being medically discharged due to a non-compensable condition, the Commission will consider paying for rehabilitation costs of the non-compensable injuries if it has the potential to be cost effective in facilitating a return to improved functioning and a return to work outcome.
23. If there is a requirement to travel to undertake a rehabilitation examination, then the Commonwealth will pay compensation for any costs reasonably incurred in that journey. If the person is also required to stay in accommodation in the area as a result of the journey then compensation for all reasonable costs will be paid.
24. Section 48 of the MRCA [10] describes that when: "determining the amount payable, the rehabilitation authority must have regard to:
Further information about travel to undertake a rehabilitation assessment can be found in section 9.1 of the MRCA policy manual [18] and chapter 90 of the SRCA general handbook. [19]
25. Where a person fails to accept an offer of suitable employment, or fails to begin or continue such employment, without reasonable excuse, the person can be deemed to be earning the amount that they would have received if they had been in this employment.
26. If a person fails to seek suitable work as part of an agreed vocational rehabilitation plan, they can also be deemed to be earning an amount that they could reasonably be expected to earn, having regard to the labour market. If the person can show genuine yet unsuccessful attempts to obtain employment, they will not be “deemed” when suitable employment is not possible.
Section 5 of the MRCA [10] defines: "suitable work for a person means work for which the person is suited having regard to the following:
27. Discussions must always occur between the person's rehabilitation coordinator, and their incapacity delegate, before a deeming decision is made.
28. Where a person's injury or disease results in an incapacity for work, the rehabilitation authority, through the rehabilitation provider and the rehabilitation coordinator, must take all reasonable steps to assist the person to find suitable work in the civilian workforce.
29. If liability for the injury or disease ceases, the requirement to provide assistance in finding suitable work also ceases.
30. A person's capacity for rehabilitation may vary from time to time depending on their medical status. This may mean that a person not previously able to undertake rehabilitation due to medical factors may subsequently be able to do so. Alternatively, a person in a rehabilitation program may no longer be able to continue that program due to medical factors.
It is important that the person's rehabilitation provider is proactive in informing the rehabilitation coordinator of any changes to the client's circumstances that are creating barriers to them participating in their rehabilitation program. The rehabilitation coordinator must liaise with the client's incapacity delegate to ensure that the client is able to access their correct entitlements if they are not able to participate in employment or rehabilitation for a period of time.
31. The provision and review of treatment and rehabilitation will continue to be relevant in post working age years. A person may at any time request that the Commission undertake a review to ensure that they are receiving the most appropriate level of rehabilitative services. The review must consider whether appropriate levels of household services, attendant care services, assistance with motor vehicle modifications, medical management, psychosocial and vocational rehabilitation programs and services are being provided.
32. The frequency of reviews will be determined taking account of advice from treating physicians and specialists, and as specified in a rehabilitation plan. Up to the age at which incapacity payments would normally cease, the Commission will at a minimum, undertake a review at least every 5 years, including consideration of whether appropriate treatment and services are being provided. A more regular review cycle is highly recommended. Where a principal treating practitioner states that a review must be undertaken with particular care, the rehabilitation coordinator or the incapacity delegate must first contact the treating practitioner. In this case, a file review may be more appropriate. It is vital that the incapacity delegate and the rehabilitation coordinator communicate regularly to better manage activities that are being undertaken regarding the client.
33. The Commission or a person can at any time seek a review of services being provided.
34. Where a person's capacity for work changes following a medical review, a reassessment of their rehabilitation capacity should also be undertaken. This would involve the person undergoing an assessment for rehabilitation. The incapacity delegate and the rehabilitation coordinator must work together in a coordinated way in this circumstance, and ensure that each is aware of activities being undertaken regarding the client.
35. All aspects of a rehabilitation plan, including the selection of provider are subject to review.
36. Further information about a person's appeal rights can be found in section 13.4 [20] of this Library.
37. A person has the right to be accompanied by a person of their choice, including a family member, an ex-service organisation or ADF service representative, or a legal representative to interviews and in phone conversations relating to any aspect of their claim including at reconsideration and appeal. The only exceptions are VRB proceedings, which are non-adversarial and legal representation is not permitted.
38. Legal Aid may be available in respect of AAT matters, subject to relevant Legal Aid guidelines and priorities, including merit and/or means testing for eligibility.
39. Determinations relating to the suspension of compensation for refusing or failing to undergo a rehabilitation examination, or refusing or failing to undertake a rehabilitation program are not “original determinations” and are not subject to either reconsideration or review by the Veterans' Review Board or the Administrative Appeals Tribunal. These decisions can only be appealed on a matter of law to the Federal Court. All other determinations concerning rehabilitation are “original determinations” and are subject to merit review.
40. While an ADF member is still serving, the Chief of the Defence Force is their rehabilitation authority. For members of the Permanent Forces and Reservists on continuous full time service (CFTS), rehabilitation support is provided through the ADF Rehabilitation Program (ADFRP). For all other Reservists, rehabilitation support is provided through the Rehabilitation for Reservists Program (R4R). Interaction between the ADFRP/R4R and DVA is necessary to ensure ADF members are aware of and able to utilise all services and support available to them from DVA. This includes compensation, household services, attendant care services, rehabilitation aids and appliances and DVA's motor vehicle assistance schemes.
Permanent force members and Reservists on CFTS also have access to a variety of entitlements through the ADF's Career Transition Assistance Scheme (CTAS), including training, resume preparation, job seeking and on-the-job training.
41. It is important that timely support is provided to members who are in the process of separating from the ADF to ensure that there is a smooth transition of rehabilitation authority from the Chief of the Defence Force to the MRCC. Interaction between the member's ADFRP Rehabilitation Consultant/R4R Case Manager and the DVA location who will be managing their ongoing rehabilitation is vital. Wherever possible, DVA is required to continue rehabilitation activities that have been approved by the ADFRP/R4R, and to continue to have the person's plan managed by the same rehabilitation provider.
Further information about the ADF rehabilitation programs can be found in Chapter 4.1 of this library [21].
Coordination and liaison are critical elements of any rehabilitation program. All parties involved in the recovery of an individual need to be aware of the activities and plans for the client's improved functioning, their safe and sustainable return to work or social engagement ultimately leading towards an improved quality of life.
The Rehabilitation Coordinator is a link between the client, treating medical practitioners, allied health workers, rehabilitation service providers, the client's employer, training organisations and the Department.
The role of the Rehabilitation Coordinator is to ensure that we provide our rehabilitation clients with a program of activities tailored to the person's individual needs and goals aimed at returning the person to a meaningful level of functioning. The program of activities must be consistent with medical advice, the relevant legislation and Departmental policies that apply to the client.
The Rehabilitation Coordinator is to ensure clients achieve their agreed outcomes by liaising with providers, evaluating and scrutinising goals and Goal Attainment Scaling scores and by monitoring client progress. Rehabilitation Coordinators are responsible for authorising the approval of a plan, once they are satisfied that the goals are achievable and will assist the client to achieve the specified outcomes.
The duties relevant to this role are to:
The qualities and skills required are:
The Rehabilitation Coordinator has responsibility for the decision of who will provide what services.
When choosing a particular Rehabilitation Service Provider, the Rehabilitation Coordinator is entering into a professional business arrangement to contract on the Department's behalf for approved services:
The Rehabilitation Coordinator needs to be confident that the working relationship between a client and the Rehabilitation Service Provider will lead to positive rehabilitation gains. Therefore, any actual or potential conflict of interest must be disclosed by the parties concerned and the Rehabilitation Coordinator needs to take steps to avoid the conflict of interest. See also section 13.2.7 [26] in this Library.
As soon as possible after becoming aware of the relevant facts regarding possible conflict of interest (financial or of another nature), the Rehabilitation Coordinator should consult with their Manager and notify the Rehabilitation Service Provider and the client of any necessary changes to the service arrangements. This is to avoid any suggestion of influence on the outcome by the provider's (or client's) proximity to the Rehabilitation Coordinator as the decision-maker.
All dealings with selected Rehabilitation Service Providers must also meet:
The APS Code of Conduct [27]requires all APS officers to 'behave honestly and with integrity in the course of their APS employment'. In contract management, this is reinforced by the fact that the Australian Government is a model contractor. Therefore, Rehabilitation Coordinators must deal with all Rehabilitation Service Providers and clients they work with, fairly, honestly, with courtesy and respect, without harassment or bias.
In any dealings with Rehabilitation Service Providers and clients, DVA staff should not act in any way that calls into question standards of ethical behaviour.
Judgement on conflict of interest and other ethical issues (such as offers of gifts etc) will often involve a number of potentially competing considerations including:
A person may have an interest (pecuniary or otherwise) that could conflict with the proper performance of their function as the Rehabilitation Coordinator, or Service Provider. 'Interests' may include financial interests such as shareholdings or directorships of companies; or relationships such as family, personal relationships, or connections surrounding sporting, social or cultural activities.
Clients being managed by the staff member or using the services of a rehabilitation service provider where a potential conflict of interest exists, may be reluctant to disclose information fully and frankly, because of privacy and or perceived bias, which could place all parties in challenging and difficult circumstances and impact adversely on the progress of the rehabilitation process.
Where there is a known interest or relationship between a DVA staff member, a rehabilitation service provider or a client, the DVA staff member has the responsibility to:
It is preferable that service arrangements are at 'arms-length'. Where it would be in the best interests of a client to have that particular rehabilitation service provider, a different team member, possibly the office manager should manage the referral process. Sometimes, it may involve the client's case being managed from another DVA office.
By following the above practice, such relationships will be transparent and be seen to be managed appropriately by other rehabilitation service providers, staff members and clients. This will remove any notion of a conflict of interest, perceived or otherwise and relationships with all stakeholders will remain robust and transparent and be based on a professional and ethical footing.
Overall policy development for rehabilitation activities covered under Safety, Rehabilitation and Compensation Act 1988 (SRCA [29]), Military Rehabilitation and Compensation Act 2004 (MRCA [10]) and the Veterans' Vocational Rehabilitation Scheme (VVRS [30]) rests with the Rehabilitation Policy Section of the Rehabilitation, Case Escalation and MRCA Review Branch.
The Rehabilitation Policy Section guides and co-ordinates the development of rehabilitation policies and service delivery models across DVA, to improve the coordination and integration of existing services. The specific rehabilitation policy function was formalised prior to the introduction of the MRCA and charged with coordinating the 'whole of person' approach to rehabilitation adopted by DVA.
More information about DVA's rehabilitation approach can be found on the DVA website's Rehabilitation page [31] and also on the Rehabilitation Service Providers page [4].
Links
[1] https://clik.dva.gov.au/user/login?destination=comment/reply/21084%23comment-form
[2] https://clik.dva.gov.au/user/login?destination=comment/reply/21087%23comment-form
[3] http://www.dva.gov.au/sites/default/files/files/providers/rehabilitation/Biopsychosocial.pdf
[4] http://www.dva.gov.au/health-and-wellbeing/rehabilitation/rehabilitation-service-providers
[5] https://clik.dva.gov.au/rehabilitation-policy-library/5-medical-management-rehabilitation
[6] https://clik.dva.gov.au/rehabilitation-policy-library/6-psychosocial-rehabilitation
[7] https://clik.dva.gov.au/rehabilitation-policy-library/9-vocational-rehabilitation
[8] https://clik.dva.gov.au/rehabilitation-policy-library/11-rehabilitation-service-providers
[9] https://clik.dva.gov.au/user/login?destination=comment/reply/21086%23comment-form
[10] http://www.comlaw.gov.au/Series/C2004A01285
[11] https://clik.dva.gov.au/rehabilitation-policy-library/9-vocational-rehabilitation/91-what-vocational-rehabilitation
[12] https://clik.dva.gov.au/user/login?destination=comment/reply/21090%23comment-form
[13] https://clik.dva.gov.au/user/login?destination=comment/reply/21089%23comment-form
[14] https://clik.dva.gov.au/user/login?destination=comment/reply/21083%23comment-form
[15] https://clik.dva.gov.au/user/login?destination=comment/reply/21091%23comment-form
[16] https://clik.dva.gov.au/rehabilitation-library/9-vocational-rehabilitation/97-retraining-and-further-education
[17] https://clik.dva.gov.au/rehabilitation-library/15-goal-attainment-scaling
[18] https://clik.dva.gov.au/military-compensation-mrca-manuals-and-resources-library/policy-manual/ch-9-other-benefits-under-military-rehabilitation-and-compensation-act-2004/91-compensation-travel-and-accommodation-costs-reasonably-required-or-incurred-under-military-rehabilitation
[19] https://clik.dva.gov.au/military-compensation-srca-manuals-and-resources-library/general-handbook/ch-90-compensation-travel-and-accommodation-costs-under-safety-rehabilitation-and-compensation-act-1988-srca
[20] https://clik.dva.gov.au/rehabilitation-policy-library/13-rights-and-obligations/134-reconsideration-and-review-mechanisms-rehabilitation
[21] https://clik.dva.gov.au/rehabilitation-policy-library/4-adf-rehabilitation-programs/41-overview-adf-rehabilitation-programs
[22] https://clik.dva.gov.au/user/login?destination=comment/reply/21092%23comment-form
[23] https://clik.dva.gov.au/rehabilitation-policy-library/15-goal-attainment-scaling
[24] http://www.dva.gov.au/site-information/privacy
[25] https://www.oaic.gov.au/individuals/privacy-fact-sheets/general/privacy-fact-sheet-17-australian-privacy-principles
[26] https://clik.dva.gov.au/rehabilitation-library/13-rights-and-obligations/132-claimant-and-delegate-responsibilities-and-conflict-interest/1327-conflict-interest-issues-rehabilitation-service-providers
[27] http://www.apsc.gov.au/publications-and-media/current-publications/aps-values-and-code-of-conduct-in-practice
[28] https://clik.dva.gov.au/user/login?destination=comment/reply/21085%23comment-form
[29] http://www.comlaw.gov.au/Series/C2004A03668
[30] http://www.comlaw.gov.au/Series/F2005B01424
[31] http://www.dva.gov.au/health-and-wellbeing/rehabilitation