DVA's rehabilitation approach

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.

Types of rehabilitation support

There are three types of rehabilitation support that DVA clients can access. These are:

Medical management rehabilitation

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

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

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.

Rehabilitation providers

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:

• achieving as full a physical and psychological recovery as possible;
• improving quality of life through gaining life management skills, a sense of direction for the future and resilience;
• rebuilding social connectedness to family and community;
• finding a new valued role within the community;
• learning to understand and self-manage physical and mental health conditions to the best of the person's ability;
• assisting the person to return to safe and meaningful work at the earliest possible time to minimise further harm to physical and mental health and wellbeing through long term absence from employment; and
• reducing the human and economic cost of disability for ADF members, former members, their families and the broader community.

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:

• care and respect for the client is paramount;
• early intervention processes and practices must operate;
• whole of person rehabilitation needs must be addressed;
• the client, and their significant other, must be actively involved in the development of an appropriate rehabilitation plan/program with realistic goals;
• all key stakeholders must be actively involved in an effectively coordinated plan/program of activities; and
• rehabilitation plans must be focused on whole-of-person goals and outcomes.

The Department will achieve this by:

• adopting the MRCA rehabilitation provisions to drive policy development for all DVA rehabilitation clients;
• using the expertise of the Rehabilitation Advisory Committee as a consultation mechanism with industry to guide our best-practice decision making processes;
• applying nationally consistent standards, practices and principles;
• promoting excellence in service delivery and case co-ordination as the norm;
• adopting the Goal Attainment Scaling method to rehabilitation;
• challenging existing practices and reviewing and revising current approaches and policy;
• adopting a robust structure to measure success for rehabilitation activities;
• developing a supportive work environment which shares knowledge, experiences and expertise;
• promoting the importance of rehabilitation and its outcomes in the lives of DVA clients; and
• acknowledging the role of family, friends and significant others in the client's life in achieving long term positive outcomes in the rehabilitation process.

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.

Rehabilitation Coordinator

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.

Duties relevant to this role

The duties relevant to this role are to:

• ensure early intervention occurs;
• ensure that a client-centric approach to the delivery of rehabilitation and related services occurs;
• establish and maintain contact with the client and other key stakeholders and ensure the client has access to appropriate information and services;
• research and gather information on the client's circumstances;
• to refer the client to approved external rehabilitation providers for assessments and development of a rehabilitation plan;
• to formalise, approve, review and monitor rehabilitation plans and activities (including resource allocation and finances) up to and including plan closure;
• ensure the client is aware of their rights and responsibilities under the relevant Act;
• document activities, decision making processes and maintain appropriate rehabilitation case records;
• ensure the rehabilitation plan, progress report, plan amendment and plan closure report use the Goal Attainment Scaling goal setting and measurement process (please refer to chapter 15 of this Guide [23] for detailed instructions regarding this process);
• ensure goal outcomes are neither too hard nor too easy to ahieve, and that they encompass the whole-of-person approach to rehabilitation;
• ensure progress with the rehabilitation process and momentum is maintained, minimising delays;
• liaise with all key stakeholders and confirm that all activities and steps are implemented according to the recommendations of the treating practitioners or allied health providers;
• ensure that approvals and payments are made in a timely manner so that there are no delays in a person being able to progress with their rehabilitation activities; and
• ensure that key information such as medical reports, rehabilitation assessment reports, occupational therapy and other assessments, specialist medical reviews and other documents that may assist delegates to understand a client's circumstances are saved to the client's TRIM folder.
   

Qualities and skills required

The qualities and skills required are:

• a commitment to early intervention, a whole-of-person approach to rehabilitation and improved levels of functioning of the injured client;
• the ability to engage positively with clients acknowledging their individual circumstances;
• good communication, organisation and liaison skills and ability to initiate activity where required;
• the ability to manage multiple tasks concurrently and maintain focus;
• the capacity to maintain and broaden networks of relevant professional service providers;
• the ability to refer clients to service providers and if necessary seek out additional professional assistance or direction;
• knowledge of the relevant legislations' claims procedures, rehabilitation provisions and administrative requirements;
• an understanding of the DVA Privacy Policy [24] and the Australian Privacy Principles [25]- these principles means that sensitive information (such as medical reports) should only be shared with a third party where explicit client consent has been provided;
• the ability to review rehabilitation plans and activities to ensure accountability, the momentum of activities is maintained and suggest appropriate amendments or actions to secure positive rehabilitation outcomes;
• a commitment to liaising with other stakeholders within DVA including the client's incapacity delegate, liability delegate, case coordinator, the Rehabilitation Appliances Program (RAP) and Veterans' Home Care (VHC) staff to ensure that the client receives client centric and coordinated assistance; and
• an ability to scrutinise client goals before rehabilitation plans are approved, and monitor goals through the rehabilitation process.

Managing relationships with providers and clients

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:

• for an agreed price;
• for a particular client;
• to achieve specific outcomes within an agreed timeframe.

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 service provider's professional code of conduct, and
• be compliant with the APS Code of Conduct. [27]

The APS Code of Conduct

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:

• the need to uphold the APS Values and Code of Conduct;
• the need to achieve the 'contract' outcomes;
• the need to maintain constructive working relationships with the Rehabilitation Service Provider;
• whether the appearance of an actual or potential conflict of interest exists; and
• whether reasonable and effective mitigation arrangements can be put in place that addresses any actual or potential conflicts of interest.

How to manage cases where a potential conflict of interest exists

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:

• acknowledge the interest or relationship with their team leader or manager;
• ensure the situation is fully discussed with management; and
• encourage agreement to be reached to resolve any real or perceived conflict.

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].