Rehabilitation journey
Your rehabilitation journey has four phases: Referral and Intake, Assessment and Planning, Intervention, File Closure.
Your VAC Case Manager, RSS and RSPs will support you during each phase to achieve the best possible outcome. Here’s what to expect at each phase:
1. Referral and intake
Your rehabilitation journey begins when your VAC Case Manager determines you are eligible for the Rehabilitation Program. They will explain the Rehabilitation Program to you and refer you to PCVRS.
Once PCVRS receives your referral you will be contacted to schedule your intake interview. They will explain how to access and use the PCVRS Participant Portal.
At the intake interview, you will meet with your RSS. You are welcome to include a support person in this step of the rehabilitation journey should you decide to. The purpose of the intake interview is to:
- Discuss barriers caused by your health problems that are impacting your roles at home, at work, and in the community.
- Assess rehabilitation potential and readiness to improve your health functioning and employability.
- Identify rehabilitation assessments required to determine your medical, psychosocial and vocational rehabilitation needs.
- Obtain consent to gather information. For example, your RSS may ask for your consent to get information from your healthcare professionals.
- Outcome Measure – – Your RSS will ask you to complete questionnaires which we refer to as outcome measures. These help us understand, your current state to best inform your rehabilitation plan.
After the intake interview, your RSS will provide your VAC Case Manager with a progress update recommending next steps and assessments.
2. Assessment and Planning
Your RSS will recommend that you attend rehabilitation assessments based on your eligible health problems.
These assessments help to:
- understand your medical, psycho-social and vocational rehabilitation needs
- identify goals and objectives for your Rehabilitation Plan
- suggest ways to address barriers caused by your eligible health problems
here may be multiple assessments required to understand your rehabilitation needs. These assessments are rehabilitation focused and are done by Rehabilitation Service Professionals (RSPs) — trained health professionals who understand Veterans’ unique needs.
The results of your rehabilitation focused assessments will help determine if you need a Rehabilitation Plan and what it should look like. If appropriate, it will be developed with you, your VAC Case Manager, and your RSS.
3. Intervention
Your RSS will arrange rehabilitation services to meet your rehabilitation needs. These services will be specific to the rehabilitation goals that have been created with you. They may include services for your mental health, physical health or help with employment.
- During this phase, your RSS will meet with you to review your progress and communicate with you and your RSPs.
- To meet your rehabilitation needs, you will participate in specialized appointments with our Rehabilitation Service Professionals (RSP’s). These appointments are designed to provide consistent support, and their frequency, such as multiple times per week or month, will align with your rehabilitation plan.
- Your RSS will provide regular progress updates to your VAC Case Manager.
- Communication is the key to success. You, your RSS and your VAC Case Manager work together throughout your rehabilitation journey and can make any necessary revisions.
- Outcome Measures will also occur at this stage, to provide us with an update on your progression.
4. File closure
Your RSS will recommend completion or closure of the Rehabilitation Program when:
- You achieve or mostly achieve your rehabilitation goals
- No further rehabilitation needs are identified
- Further rehabilitation intervention will not be effective for your eligible health problems
- Participation in your Rehabilitation Plan is not occurring
- Outcome Measures will also occur at this stage, to provide PCVRS
You will have a chance to discuss this with your RSS and VAC Case Manager before your plan is closed.
Depending on your circumstances, you may continue case management services with your VAC Case Manager.
5. VAC Programs and Services
A VAC Case Manager or Veteran Service Agent (VSA) may continue to support you with your ongoing needs after your Rehabilitation Plan is closed. Please speak to your VAC Case Manager to discuss additional services and benefits offered through VAC.
