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1.5 The role of the Rehabilitation Coordinator

Last amended 
4 April 2023

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 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 and the Australian Privacy Principles - 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 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

The APS Code of Conduct 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.