Rehabilitation planning

Rehabilitation planning is needed in any complex case, where complexity is demonstrated by the involvement of more than one or two people or (not and) by the need for a prolonged period of active intervention. Ideally it should occur when any person is first seen within a rehabilitation context, because it forces a consideration of long-term goals. Even if the patient is only seeing one professional perhaps six times over a couple of months, it is likely that discussing a plan with the patient and formally documenting it would improve efficiency and effectiveness and it might avoid missing important actions.

Planning usually requires the meeting, at the same time and, in normal circumstances, in the same place, of as many of the people or teams involved with the patient as possible. Notwithstanding the advice earlier that formulation should occur as part of the first stage, in reality it will inevitably and quite appropriately, also occur as part of any planning meeting.

Planning meetings are needed, because in any complex case many people will be involved, usually including people from other services and organisation, and always including family or friends. Actions will be needed from many people, and often actions are interdependent even if they do not have to be undertake simultaneously. Without a planning meeting, it is likely that actions will be overlooked or not identified, or forgotten.

The graphic shows, first, why meetings are needed. it then goes through the five stages detailed below. It ends by showing the outputs, the potential goals of the meeting. The specific purpose of any one meeting will determine its precise content and goals.

Stage one – share information

Often a rehabilitation planning meeting will be the first time that the many different people involved have met together. It is vital to take the opportunity to share information (at first), because often people who see the person in other settings or who have known the person for a long time will see quite different behaviours. This is not any attempt to deceive or mislead. It is normal for some activities to be undertaken better or worse in different contexts.

It is also an opportunity to review any earlier formulation, modifying it if appropriate. Then the formulation should be shared. Often other people will not ever have had an explanation of what they observe, and it can increase their ability to help.

Stage two – prognosis and treatment

The discussion about the formulation will lead naturally on to the future, and discussion of what interventions might be able to help. Again the opportunity to get information from other people knowing the person in a different context will help to check on, and develop ideas about what the person might want. People may well give the goals they expect the rehabilitation team to want them to say. The discussion should improve the concordance between the goals that the treating team consider possible and the patient’s own goals.

Stage three – set long- and medium-term goals

Goal setting will be covered in more detail elsewhere on the site. At present, suffice it to say that setting goals with or for the person is likely to increase their engagement with the rehabilitation process, provided the patient agrees both that they are desirable and that they are achievable. They are more effective if they are challenging, and not too easily achieved. Further information on goal setting in rehabilitation is in this book.

Stage four – agree short-term goals

This stage is both the easiest and the hardest. It is easiest because most people attending will come with ideas about what they can or could do. But the risk is that, unless the earlier stages have been completed, there is no coherent plan and some of the actions will be contrary to what the patient wants.

Therefore it is also the hardest, because often someone may be asked not to undertake an action they believe will help, or maybe asked to undertake something that they had not thought of.

Another important part of this stage is to set a review date by which most of the short-term actions should have been undertaken. It ensures action will actually happen.

Stage five – documentation

This part is often overlooked, which risks seriously undermining the work put in. A full analysis and plan is often a valuable guide for a year or longer, needing only minor changes as time passes. It is vital to record fully all parts: the formulation and prognosis; the long-term and medium-term goals (which will only change slowly); the immediate s short-term actions; and the review date and what measures of change will be used.

In addition to their professional knowledge and skills, and the information they bring, people attending the meeting need two other skills. The first, vital but only needed by one person, is to be able to chair or lead a meeting. Being a good chair of a (rehabilitation) planning meeting requires a host of skills:

  • able to keep in mind the whole situation;
    • using the biopsychosocial model framework as an aide memoire helps;
  • avoiding the meeting becoming focused on minor issues;
  • being able to keep everyone focused, stopping people who are repeating information or deviating from the topic;
  • ensuring everyone present contributes and understands;
  • not allowing professional jargon to be used;
  • summarising; questioning; and
  • ending the meeting with a clear action plan.

The other skill, needed by everyone involved in rehabilitation, is to be able to participate in planning meetings productively, giving information and opinions simply, clearly, and politely when needed but not repeating material already covered or talking about inessential matters.


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