This chapter provides guidance on how the DVA Rehabilitation Forms are completed using Goal Attainment Scaling.
Step 1. Enter client's name and DVA file number (not Defcare case ID) in the footer of the DVA Form D1334 Rehabilitation Assessment Report [3].
Step 2. Complete client details sections.
Step 3. Complete remainder of the Report.
Step 4. For all new rehabilitation referrals from 29 May 2017, upload the assessment report together with the rehabilitation plan and other relevant documentation to R&C ISH using the client's unique Transaction Reference Number. All existing rehabilitation cases that commenced prior to 29 May 2017 will require you to follow the current process of emailing rehabilitation related documentation to the client's Rehabilitation Coordinator.
A rehabilitation plan is developed by the provider in conjunction with the client as a result of the rehabilitation assessment [4]. It may include medical management, psychosocial and/or return to work activities. The plan provides a structured series of individualised activities and goals.
The provider and client determine the rehabilitation goals (up to four) and set outcomes. Each goal has described five possible outcomes rated on a scale, ranging from the most unfavourable outcome through to the most favourable outcome. The middle point is identified as the “expected outcome”. The client and provider believe the client should be able to achieve at least the “expected outcome” by the end of the rehabilitation plan.
Goals vs Activities
Goals are what the client wants to achieve, or the desired outcome that they are working towards.
The rehabilitation activities are the things that the client will do to reach that outcome.
Goals should be specific, and as a general rule, multiple activities will be included to help the person to reach their goal. For example, the goal of ‘improvement to physical functioning’ could have the activities of ‘attend physiotherapy appointment 1 time per week and complete all exercises recommended by the therapist’, ‘walk around the block 4 times per week’ and ‘support from XX (eg. family member) to assist with developing a weekly routine’.
Completing the Rehabilitation Plan
When completing the DVA Form D1347 Rehabilitation Plan [5], the provider:
Step 1. Enters client’s name and the DVA file number (not the Defcare Case ID) in the footer of the document
Step 2. Completes client details section
Step 3. Defines rehabilitation goals, timeframes and categories
Note: Providers should avoid setting goals and outcomes that could be too easily met or too difficult to achieve. Goals and expected outcomes should be described in such a way that the Coordinator is able to determine whether the goals are achievable.
Step 4. Define all rehabilitation outcomes
Step 5. Define activities to achieve rehabilitation goal(s)
Step 6. Specify parties involved for the activities and dates associated with each activity
Step 7. Indicate importance and challenges in achieving each goal
Step 8. Complete agreement section ('Sign-Off and Distribution')
Step 9. Indicate costs involved with activities outlined in the Plan
Step 10. Processing Rehabilitation plan documentation
IMPORTANT: The rehabilitation provider must ensure that no treatment costs are included on a medical management Rehabilitation Plan. Treatment costs are covered by the normal medical payment arrangements, usually through the DVA Health Card system.
* Note: It is considered, as a general rule, that too many goals may have a negative impact on the client as they may be trying to achieve too much in a short space of time. However, setting more than four goals might be appropriate, in some circumstances, if the provider and client consider it could be beneficial for the client and they are highly motivated. It is important that the provider and client are both confident that the client could be realistically expected to achieve more than four goals, before these are included on the rehabilitation plan.
A Rehabilitation Plan Amendment is completed:
NOTE: A Rehabilitation Plan Amendment is not used when the overall focus of the client's rehabilitation program changes, for example, where a client moves from a non-return to work program to a return to work program, or vice versa. Where this occurs, the original program should be varied by the creation of a new Plan. DVA Rehabilitation Coordinators must issue a determination letter whenever a rehabilitation program is varied. More information about this can be found in section 3.8.4 of this Guide [7].
* It is not necessary to make an amendment to a Plan if the client is unable to undertake all planned future activities related to an existing goal in the current Plan. In such cases, before the Plan is discussed with the client, it should be considered whether the client’s primary care provider (GP, specialist) should be engaged to help the client to manage any particular health issue which may be preventing the client from currently undertaking that activity or achieving their rehabilitation goal.
Goals vs Activities
Goals are what the client wants to achieve, or the desired outcome that they are working towards.
The rehabilitation activities are the things that the client will do to reach that outcome.
Goals should be specific, and as a general rule, multiple activities will be included to help the person to reach their goal. For example, the goal of ‘improvement to physical functioning’ could have the activities of ‘attend physiotherapy appointment 1 time per week and complete all exercises recommended by the therapist’, ‘walk around the block 4 times per week’ and ‘support from XX (e.g. family member) to assist with developing a weekly routine’.
New or Amended Goal
When completing the DVA Form D1336 Rehabilitation Plan Amendment [5], the provider:
Step 1. Enters client’s name and the DVA file number (not the Defcare Case ID) in the footer of the document
Step 2. Completes client details section
Step 3. Defines rehabilitation goals, timeframes and categories
Note: Providers should avoid setting goals and outcomes that could be too easily met or too difficult to achieve. Goals and expected outcomes should be described in such a way that the Coordinator is able to determine whether the goals are achievable.
Step 4. Define all rehabilitation outcomes
Step 5. Define activities to achieve rehabilitation goal(s)
Step 6. Specify parties involved for the activities and dates associated with each activity
Step 7. Indicate importance and challenges in achieving each goal
Step 8. Complete agreement section ('Sign-Off and Distribution')
Step 9. Indicate costs involved with activities outlined in the Plan Amendment
Step 10: Processing rehabilitation plan amendment documentation
IMPORTANT: The provider must ensure that no treatment costs are included on a medical management Rehabilitation Plan. Treatment costs are covered by the normal medical payment arrangements, usually through the DVA Health Card system.
# It is considered that, as a general rule, too many goals may have a negative impact on the client as they may be trying to achieve too much in a short space of time. However, setting more than four goals might be appropriate in some circumstances if the provider and client consider it could be beneficial for the client and they are highly motivated. It is important that the provider and client are both confident that the client could be realistically expected to achieve more than four goals, before these are included on the Rehabilitation Plan.
Change of Outcome(s)
If a change to any outcome is required, an amendment may be undertaken. This may occur if there are exceptional and unanticipated circumstances that have arisen since plan development. This ensures all clients attain their expected outcomes.
Change of Activities or Timeframes Where Goals Have Not Changed
If a change of timeframes is required, but the goal(s) remains the same, the activities associated with the goal may be revised, or new activities added for that goal. When amending or adding new activities, the provider must indicate the parties involved, dates for each new activity, and any costs associated with the activities .
If the only change is to extend the time of the plan, to enable extra time for rehabilitation activities to be completed, the GAS information is not required as it is already included in the Rehabilitation Plan. Information should be provided in the amendment about why the extra time is required.
Rehabilitation Goals are what the client wants to achieve through their rehabilitation plan. They will have a vocational, medical management or psychosocial focus. An example for each is provided below.
A client may be working towards a mix of vocational, medical management and/or psychosocial goals concurrently, or may initially focus on achieving specific types of goals (e.g. medical management goals) before moving on to others. This will be determined by what is most appropriate for each client given their individual circumstances and needs.
Goals vs Activities
Goals are what the client wants to achieve, or the desired outcome that they are working towards.
The rehabilitation activities are the things that the client will do to reach that outcome.
Goals should be specific, and as a general rule, multiple activities will be included to help the person to reach their goal. For example, the goal of ‘improvement to physical functioning’ could have the activities of ‘attend physiotherapy appointment 1 time per week and complete all exercises recommended by the therapist’, ‘walk around the block 4 times per week’ and ‘support from XX (eg. family member) to assist with developing a weekly routine’.
Progress Report
For the DVA Form D1330 Rehabilitation Progress Report [5], the provider will:
Step 1. Enter the client’s name and DVA file number (not Defcare Case ID) in the footer of the document.
Step 2. Complete the client details section
Step 3. Document the identified activities for each goal.
Step 4. Provide a summary of the Progress Report.
Step 5. Sign the Progress Report. Upload the Progress Report and any other relevant documentation to R&C ISH using the client's unique Transaction Reference Number (TRN). Rehabilitation Coordinators are not required to sign the Progress Report.
Step 6. Rehabilitation Coordinators are responsible for transposing information from the documentation submitted by the rehabilitation providers, into R&C ISH. This information includes goals and activities for each goal.
For the DVA Form D1335 Rehabilitation Closure Report [5], the provider will:
Step 1. Complete client’s name and DVA File Number (not Defcare Case ID) in the footer of the document.
Step 2. Complete client and plan details sections.
Step 3. Determine Goal Attainment Scaling outcomes and activities
Step 4. Complete agreement section (Sign-Off and Distribution of Closure Report)
Step 5. Indicate costs incurred with activities outlined in the final Rehabilitation Plan
Step 6. Upload the closure report and any other relevant documentation into R&C ISH using the client's unique Transaction Reference Number (TRN).
Step 7. Rehabilitation Coordinators are responsible for transposing information from the documentation submitted by rehabilitation providers, into R&C ISH. This information includes goals and activities for each goal.
Rehabilitation Goals are what the client wants to achieve through their rehabilitation plan. They will have a vocational, medical management or psychosocial focus. An example for each is provided below.
A client may be working towards a mix of vocational, medical management and/or psychosocial goals concurrently, or may initially focus on achieving specific types of goals (e.g. medical management goals) before moving on to others. This will be determined by what is most appropriate for each client given their individual circumstances and needs.
Links
[1] https://clik.dva.gov.au/user/login?destination=comment/reply/79525%23comment-form
[2] https://clik.dva.gov.au/user/login?destination=comment/reply/79527%23comment-form
[3] https://www.dva.gov.au/about-us/dva-forms/rehabilitation-assessment-report
[4] https://clik.dva.gov.au/rehabilitation-policy-library/15-goal-attainment-scaling/153-dvas-rehabilitation-process-goal-attainment-scaling/1532-rehabilitation-assessment-report
[5] https://www.dva.gov.au/get-support/find-forms
[6] https://clik.dva.gov.au/rehabilitation-policy-library/15-goal-attainment-scaling/153-dvas-rehabilitation-process-goal-attainment-scaling/1533-rehabilitation-plan
[7] https://clik.dva.gov.au/rehabilitation-policy-library/3-rehabilitation-process/38-dva-rehabilitation-reporting-documents/384-changes-rehabilitation-plan