13.C4 Goals in practice: Rehabilitation Plans B

Introduction

This section includes:
  • The Rehabilitation Plan Template
  • Template instructions
  • Two examples
  • Prompt questions and times for completing the template.
When you have reviewed the template and examples you may find it useful to rate your current practice.

 

How do you rate your current practice?
Questions and answers here

To what extent DOES your service's

Rehabilitation Plans include goals, steps and action plans

    

Rehabilitation Plans include achievement ratings for goals, steps and action plans .

    

Rehabilitation Plans include a section on progress 

    

Rehabilitation plans include client generated goals

    

Rehabilitation plans are part of a goal setting and review process

    

GOALS in Rehabilitation Plans use SMART goals characteristics

    

STEPS in Rehabilitation Plans use SMART goals characteristics

    


 

Print your responses for your records

What needs to happen in your service to improve practice?

Template instructions

The following template has been used to provide an example of how to record a client’s rehabilitation plan. 


When reading the templates, please note:

  • each client goal is numbered e.g. Client Goal 1
  • each step corresponding to a particular client goal is numbered in relation to that goal e.g. 1a), 1b)
  • each action plan corresponding  to a particular step is numbered in relation to the step e.g. 1a), 1b).
On subsequent TABS two sample plans using the template have been provided.  The first includes a progress report on a previous plan. The second presents the next stage of rehabilitation. 
  • The First Example documents the client’s goal and his progress over the plan period towards the achievement of his goal, each of the steps and whether each element of the action plan was completed.  Note in Step 1a), even though Jack has only partially achieved his home exercise program, he has still been able to achieve his step of safely ascending and descending a flight of 16 stairs independently.  In contrast to this, even though Jack has achieved all of the elements of his action plan 1c), he has only partially achieved step 1c) - performing all aspects of his personal hygiene independently.  This discrepancy between the two indicates that something unaccounted for has prevented him achieving the step.  Discussion with Jack revealed that his mother has been helping him shower at home; he is also fearful of falling in the shower.  New steps and action plans were written to accommodate those issues that were identified since the previous plan.
  • The Second example documents the follow-on plan, which lists subsequent steps and the action plans to achieve them. 

 

Template

DATE of PLAN:

Plan No:  

Plan Period:

CLIENT GOAL:  1

Achievement

Ideally, it is a client generated goal but may be client focused. 
This should ideally be a participation-level goal, or at least an activity level goal. 
In some situations an impairment level goal may be appropriate, particularly early after injury or for very low functioning clients when it is unrealistic for participation or activity-level goals to be set.  However, very broad participation goals may also be appropriate e.g. remain living in community, return to live at home. 
The SMARTAAR Goal Worksheet can be used to ensure the goal is a high quality client-centred participation goal.

To what degree has the client achieved their goal?

CLIENT STEP 1a)

Achievement

     CLIENT STEP 1b)

Achievement

      CLIENT STEP 1c)

   Achievement

This is generally a list of CLIENT-FOCUSED activities or impairment-level goals but can also be client generated.

If an impairment-level goal is the actual goal, this section may have very little or no information.

 

To what degree has the client achieved this Step?

This is generally a list of CLIENT-FOCUSED activities or impairment-level goals but can also be client generated.

If an impairment-level goal is the actual goal, this section may have very little or no information.

 

To what degree has the client achieved this Step?

This is generally a list of CLIENT-FOCUSED activities or impairment-level goals but can also be client generated.

If an impairment-level goal is the actual goal, this section may have very little or no information.

 

ACTION PLAN 1a) Achievement

ACTION PLAN 1b)

Achievement

ACTION PLAN 1c)

Achievement

What intervention is required?

Who from?

How frequently?

This includes any action that the client and/or their significant others need to take.

 

To what degree has the client achieved each element of the Action Plan?

What intervention is required?

Who from?

How frequently?

This includes any action that the client and/or their significant others need to take.

 

To what degree has the client achieved each element of the Action Plan?

What intervention is required?

Who from?

How frequently?

This includes any action that the client and/or their significant others need to take.

 

PROGRESS
This section should comment on both the progress towards the goal and on the steps.  Issues affecting progress including potential barriers should be described.  It should also include details of any parts of the action plan that have not been fully implemented, the effectiveness of services already provided and describe the rationale when new / additional services are requested.

 

 


 

 

 

 

 Example 1

DATE of PLAN:  30/6/12          

Plan No:  1

Plan Period: 30/6/2012 - 31/9/2012

CLIENT GOAL: 1

Achievement

Jack will be ready to return to living independently in his own home by September 2012

2

   CLIENT STEP 1a)

Achievement

CLIENT STEP 1b)

Achievement

CLIENT STEP 1c)

Achievement

Jack will be able to safely ascend and descend a flight of 16 stairs independently by 31/9/12

 

3

Jack will be able to independently perform the weekly shop using online ordering of home-delivery

 

3

Jack will be able to perform all aspects of his personal hygiene independently

 

2

ACTION PLAN 1a)

Achievement

ACTION PLAN 1b)

Achievement

ACTION PLAN 1c)

Achievement

Weekly physiotherapy for weeks 1-6 to address deficits in balance and mobility - includes the prescription of a home-based exercise program

 

3

Weekly occupational therapy to improve memory and planning skills/ strategies

 

 

3

Weekly physiotherapy for weeks 1-6 weeks, to address balance issues that are currently impacting on ability to safely negotiate Jack’s home bathroom

 

3

Fortnightly physiotherapy for weeks 7-12 weeks to address deficits in balance and mobility - includes the prescription of a home-based exercise program

 

3  

Fortnightly speech therapy to improve computer literacy

 

3

Fortnightly physiotherapy for weeks 6-12 weeks to address balance issues

 

3

Performance of home exercise program 4 days/week

 

2

 

 

Installation of a grab rail within the shower recess in both his mother’s home and his home

 

3

 

 

 

 

Purchase of a shower chair

3

PROGRESS   Jack has achieved the steps regarding negotiation of stairs and performance of online grocery shopping but not the step of independent showering. Jack has diligently attended all of therapy sessions and completed his home exercise program. His balance has improved to a level to enable him to safely shower independently and this has been confirmed by occupational therapy shower assessment. Unfortunately, this ability has not transferred to the home setting. Jack remains fearful of falling, despite having demonstrated the ability to shower safely without assistance. His mother continues to provide assistance in the shower.

 

In the example above, the client’s progress towards their primary goal (living
independently) remains the same, but the steps and action plan (and time frame) for
achieving this have changed. The change indicates different steps were needed to
address Jack’s lack of progress in the initial plan.

As impairment can often affect multiple aspects of functioning, it is common for the
same strategies to be part of action plan to address more than one step, and possibly
more than one goal. Therefore, some strategies in the action plan will be repeated
throughout the rehabilitation plan. This emphasises the importance of those
interventions to all involved.

 

Example 2

DATE of PLAN:  31/9/12      

Plan No:  2

Plan Period: 1/10/12 – 31/12/12

CLIENT GOAL: 1

Achievement

Jack will be ready to return to living independently in his own home by January 2013.

 

    CLIENT STEP 1a)

Achievement

CLIENT STEP 1b)

Achievement

CLIENT STEP 1c)

Achievement

Jack’s mother will only provide assistance to Jack that has been assessed as necessary by the OT

 

Jack will feel confident to practice independent showering at home

 

Jack will maintain the ability to ascend and descend a flight of 16 stairs

 

ACTION PLAN 1a)

Achievement

ACTION PLAN 1b)

Achievement

ACTION PLAN 1c)

Achievement

Jack’s mother will receive further education weekly from the OT regarding level of assistance for weeks 1-3

 

Fortnightly psychology sessions to help overcome the fear of falling.

 

Jack will perform a home-based exercise program 4 times per week as prescribed by the physiotherapist.

 

Jack’s mother will receive further education weekly from the OT regarding level of assistance at week 7   

 

Practice of independent showering with standby assistance from the occupational therapist to reinforce ability

 

Monthly review with the physiotherapy to monitor performance

 

Jack’s mother will receive counselling weekly for weeks 1-4 from the social worker to assist her to understand the need to let Jack practice his independent living skills

 

 

 

 

 

PROGRESS

 

 

Tips: Plan Prompt questions and considerations

Client Goal

  1. Is the goal SMART, client centred and useful for rehabilitation? Does it clearly describe how the client will benefit from recommended action plan? If you are unsure, use the SMARTAAR Goal Worksheet to revise goal statement.
  2. Does the goal appear to reflect client identified priorities?
  3. Is there information regarding level of client engagement? Client generated or client focused goal?
  4. How realistic is the goal given your knowledge of the nature and impact of the client’s injuries and their progress to date?

Client Steps

  1. Is the step (a goal statement) SMART, client centred and useful for rehabilitation? Does it clearly describe how the client will benefit from recommended action plan? If you are unsure, use the SMARTAAR Goal Worksheet to revise goal statement in relevant step.
  2. Does the step appear to reflect client identified priorities / needs? Steps may often be client focused rather than client generated – has the level of client engagement been reported?
  3. How realistic is the step given your knowledge of the nature and impact of the client’s injuries and their progress to date?
  4. Consider, if the client can perform all the steps, will they successfully achieve their goal? Are there additional steps needed? Ensure all steps contribute to achievement of this goal (and each goal they are described for).
  5. Do steps describe what the client will be able to do as a consequence of the action plan? If no, should it be an action?
  6. If too many steps are needed per goal, does the goal need to be broken into more than one goal?

Action Plan

  1. Are ALL recommended actions you think are necessary for the client to achieve their steps and goal included? This includes services for which funding is requested and other actions which don’t need separate funding e.g. referrals, request for GP to consider allied health plan for mother’s counselling, ADHC funded services, client and family actions including home programs. Ensure actions are related to each step. Are all necessary? Do others need to be added?
  2. Are level of services requested and level of steps and goal well matched? Consider appropriateness of service (cost, clinical consensus, evidence base), appropriateness of provider (relevance, availability), expected degree of benefit to client. Have alternatives been considered but discounted -explain?
  3. If the actions are extensive (high level type and amount of services), should the step be broken down into more than one step?
  4. Are the actions consistent with available evidence, clinical practice and guidelines?
  5. Is there information the client has agreed to / collaborated in developing the action plan?
  6. If too many actions are needed per step, does the step need to be broken into more than one step?

Rehab Plan as a whole

  1. Does overall plan tell a cohesive story about how recommended actions will address clinical needs and support client to achieve steps and goals?
  2. Is the level of client engagement in the report described? If goal and step are client focused and different from client generated priorities, e.g. because client lacks insight and goal is not realistic in given time frame, is this recorded in the report (somewhere?)
  3. When funding for services is requested, is there information that describes how this is related to the nature and impact of their injuries? When requested services are for other people e.g. family, describe how the client will benefit from these services and why this is an injury related request for the client. When assessing funding requested services is it clear how the client will benefit? Do the requested services meet scheme specific funding criteria?
  4. Is the type and intensity of services requested in line with:
    o the desired level of change in the client in the specified time frame as described in steps and goals?
    o criteria for funding as relevant?
  5. Does the plan describe client’s progress with actions, steps and goals to date, including issues affecting progress and how these will be addressed? Does the plan describe reasons for variations in projected action plan and impact on client progress towards steps & goals?
  6. Consider whether number of goals and steps in whole plan reflects realistic rehabilitation plan for specified period.