The Director of the ADF Rehabilitation Services, Mr Jim Porteous, presented this article at the Defence Health Symposium in Brisbane on 21 October 2006. This article explains the purpose of rehabilitation in the ADF; building a seamless rehabilitation management process; the essence of best practice rehabilitation programs; and the outcomes we expect to achieve.
Purpose
In October 2004, we began redeveloping the ADF’s rehabilitation system to enhance the management of members being rehabilitated, as well as meet the new legislative requirements of the Military Rehabilitation and Compensation Act 2004 (MRCA). A Steering Committee, with representatives from the ADF and the Department of Veterans’ Affairs (DVA), was formed to oversee the redevelopment of the rehabilitation system.
Clinical rehabilitation and a formal return to work (RTW) on restricted duties program have been provided for some time as part of medical treatment through ADF health facilities for illnesses and injury. Specific ADF units provided rehabilitation programs based on unit requirements. The primary drivers of rehabilitation to date have been Army units, due to their inherently higher physical demands and injury rates.
The ADF Rehabilitation Program (ADFRP) is much more than clinical treatment or health care of military personnel. It is an holistic assessment and management system that combines the elements of health care, occupational health and safety, and personnel capability management (Figure 1). Unlike the civilian sector, rehabilitation is provided to our military personnel regardless of whether the injury or illness is work related and compensable.
From a health care perspective, the ADF has a responsibility to provide health care to its members in order to maintain the required level of operational readiness. Rehabilitation focuses on the restoration of physical and mental functioning. It is a key component for facilitating the return of members to a state of readiness (for deployment on a military mission) as soon as is practicable after injury or illness.
The new program has also been developed to ensure the ADF meets its duty of care to members and its responsibilities under the Commonwealth occupational health and safety legislation and the Military Rehabilitation and Compensation Act. As an occupational health and safety initiative, it seeks to reduce the impact of occupational injury, illness and disease, and to minimise the members’ need for compensation.
Most importantly, the new program is workplace or occupational-based as this provides the most realistic environment to assess fitness for work. It focuses on the restoration of productive work functioning. Through rehabilitation more members of the ADF will be employable and deployable, resulting in an increase in military capability. In addition, effective rehabilitation will reduce the number of medical discharges.
We use a case manager to provide continuity of care throughout a member’s rehabilitation through the timely provision of identified services and the coordinated participation of the member, health staff, command elements and rehabilitation decision-makers in the development and delivery of rehabilitation plans.
Through effective rehabilitation the ADF maximizes the personnel dimension of capability with the intent to return an injured or ill member to maximum effectiveness within the ADF environment, or if this is not possible, the civilian environment. The purpose is to maximise the ADF’s ability to fight and win by reducing the impact of occupational injury and illness.
Process overview
The new program involves early identification, treatment and management of injury or illness, through a coordinated response involving all relevant parties. Triggers – Members, health staff and commanders at all levels have a responsibility to ensure that intervention through assessment occurs as soon as practicable after injury or illness. The requirement for a Rehabilitation Assessment is triggered when: • A treating Medical Officer considers it necessary. • A member is to be on sick leave/restricted duties/convalescence > 28 days. • A member requests an assessment. • A member’s Commanding Officer requests an assessment. • A needs assessment by the Military Rehabilitation and Compensation Commission recommends that rehabilitation may be beneficial.
Assessment – Rehabilitation must occur at the earliest possible time in order to optimise the outcomes. Wherever possible, rehabilitation will be workplace-based as this provides the most realistic environment to assess fitness for work.
Rehabilitation Plan – An important element of the Program is an individual’s Rehabilitation Plan. It is aimed at returning injured or ill members to suitable ADF employment, or if appropriate, providing a seamless transition to the civilian environment. All Rehabilitation Plans commence with a thorough assessment of a member’s suitability and capacity to undertake rehabilitation.
Outcome – The three goals of the ADFRP (in priority order) are: Goal 1 – Fit for duty in the pre injury/illness work environment. Goal 2 – Fit for duty in a different position and/or environment. Goal 3 – Transition out of the ADF with the optimal level of function.
Building a seamless rehabilitation process
Rehabilitation is a multi-disciplinary strategy to maximise an individual’s potential for restoration to their pre-injury physical, vocational, social, psychological and educational status (Figure 2). It is much more than clinical management.
Member – When examining the various elements of the ADFRP, we start with the military member as the central element. They have a responsibility to maintain their fitness and ability to deploy on overseas operations, and we want to support, rehabilitate and retain them.
Health Care – Is focused on the achievement of optimal physical and mental recovery.
Compensation and the Transition Management Service (TMS) – Through compensation eligible ADF members may be provided with financial compensation, payment of travel to attend medical appointments, home and car modifications, household services and attendant care at home. In addition, DVA provides transition management services that prepare all members being discharged on medical grounds for civilian life.
Command – The focus of this element is on return to suitable work at the earliest possible time. Service Chiefs are responsible for the prevention and management of work-related injury and illness. Commanders and supervisors are responsible for the health and welfare of members under their command. This includes the provision of a safe workplace and the maintenance of personnel fitness, occupational and military skills, and career management.
Psychosocial – Restoring the individual’s ability to function in the community and their confidence to participate and take control of their rehabilitation.
Case management and coordination – The ADF Rehabilitation Coordinators are responsible for the contracting and coordination of contracted rehabilitation case managers. They support commanders and supervisors in coordinating the rehabilitation of their people, together with Health and Personnel agencies.
Examining the essence of best practice Rehabilitation Programs
One of the many studies that provided the essence of best practice was the 2004 “Workplace-based Return to Work Interventions: A Systematic Review of Quantitative and Qualitative Literature” study by the Canadian Institute for Work and Health. They made a number of recommendations in relation to successful injury management and rehabilitation interventions. These are:
- All workplace-based return to work (RTW) strategies include early contact with the worker by the workplace, a work modification offer, and contact between the workplace and healthcare providers;
- Workplace-based RTW strategies include a strong ergonomic component, as facilitated by ergonomic workplace visits;
- Education for supervisors and managers as part of the interventions;
- Building the confidence in the rehabilitation process and a shared understanding among all parties (injured person, supervisor, physicians and insurance providers), and gaining their commitment;
- Providing adequate and consistent information (including rights and obligations) when communicating with the injured person about return to work;
- Creativity and sensitivity to the needs of all parties be considered an integral part of modified work planning;
- There is careful coordination and consideration of the needs of all parties, and that the feasibility of rehabilitation plans and the ability of the person to successfully negotiate the process is addressed;
- Supervisors are important to the process and are included in RTW planning and offered related training; and
- Rehabilitation and occupational healthcare experts are involved in the process as they are a bridge between the workplace and healthcare providers.
From our experience, these were essential to the development and the successful implementation of our program.
The ADF Rehabilitation Program involves early identification, treatment and management of injury or illness, through a coordinated response involving all relevant parties, in order to reduce the likelihood of an injury or disease becoming a long-term injury or illness. Wherever possible, rehabilitation should be workplace-based as this provides the most realistic environment to assess fitness for work.
An important element of the program is an individual’s Rehabilitation Plan. This is a managed process involving early intervention with appropriate, adequate and timely services based on assessed needs. It is aimed at returning injured or ill members to suitable ADF employment, or if appropriate, providing a transition to the civilian environment.
The principles of the ADFRP are: a. Early intervention to reduce the impact of injury, illness and disease and contribute to enhanced capability. b. Utilisation of evidence based process to establish clear and accurate expectations of the outcome of rehabilitation and reduce psychosocial complications. c. Rehabilitation assessments and plans based on an individual’s needs and the inherent requirements of service. d. Coordinated participation of the member, health staff, command elements and rehabilitation decision-makers in the development and execution of rehabilitation plans. e. Maximising the potential for a positive rehabilitation outcome for the individual, ADF and the community. f. Clear roles and responsibilities reflected in organisational performance agreements combined with accountability as measured against the performance indicators of the Services and Groups.
The principles of the ADF Rehabilitation Program have been developed to suit our Defence Force. And they are based on best practice programs.
Outcomes
We have developed our new program as a strategic initiative that will contribute to the following outcomes: Increased Capability – Increase the ADF’s capability by reducing Workdays Lost Through Injury, as well as support the retention of experience through reduced separations. The aim of the Program is to return all members to duty, either in their pre-injury role or in a new role identified as part of their rehabilitation.
Support Retention – Reduce the number of separations through fewer medical discharges, thereby saving the ADF many millions of dollars a year in separation costs. An Employer of Choice – Support the ADF in meeting its duty of care thereby enhancing its reputation in the community as an employer of choice where ‘people matter’.
Continuity of Care – Dedicated case management for members requiring rehabilitation will coordinate the support of the Chain-of-Command, Health and Personnel services and if required, Department of Veterans’ Affairs. Case management will also provide continuous support for members requiring transition to civilian life.
OHS Strategic Plan – Priority 3 is to “Reduce the impact of occupational injury, illness and disease”.
Early Intervention – Provide rehabilitation programs based on early intervention and focusing on the physical, mental and occupational rehabilitation of members.
Legal Compliance – Support the ADF in meeting its legal obligations under the Defence Act 1903, OH&S Act 1991, the Safety, Rehabilitation and Compensation Act 1988, and the Military Rehabilitation and Compensation Act, 2004.
Author’s affiliation: Australian Defence Force Health Contact author: Director, ADF Rehabilitation Services, ADF Health, Canberra, ACT, Australia 2000 Email: Jim.Porteous@defence.gov.au
