Good assessments will inform the development of a plan of care. The plan of care will include the provision of interventions for rehabilitation, on occasion this plan of care may only be to refer to other services. Assessment B occurs within the Care Module and following this the planning of care commences.

The following steps guide the planning of care:

a.         Set a rehabilitation goal

b.         Select the right intervention and its dosage

c.         Support where needed with an assistive product and referral to additional services

a.         Set a rehabilitation goal

The first step in developing a rehabilitation plan is to set a goal (s). This informs the selection of appropriate interventions for rehabilitation that best meet the person’s needs. This supports person-centered care and results in greater client motivation and satisfaction. The person and or caregivers are involved in this step.

Examples of questions to ask when you want to set a rehabilitation goal include:

- What can’t you do since your injury that you want to get back to?

- What are you finding more difficult since your injury that you’d like to be easier?

- How will you know when you’re ready to stop coming to see me?

Persons who require rehabilitation usually have big goals.

First of all, guide the person to break down the goal into smaller goals such as learning how to use a wheelchair and practicing muscle strengthening exercises, standing, taking a few seps with a walking frame, walking with a stick and finally walking without a stick.

Each of the goals that is set with the person should:

• Be functional and specific.
• Be short-term and time-bound
• Be achievable
• Relate to everyday activities

b.  Select the right intervention and its dosage

The next step after setting a rehabilitation goal is to select the appropriate intervention for the person. The type of intervention selected should correspond to the results of the assessment. Each rehabilitation pathway has assessments linked to specific interventions. Rehabilitation interventions selected may include all or some of the following:

• provision of preventive, promotive, restorative and compensatory
• provision of pharmacological agents
• provision of assistive products

Some rehabilitation interventions include exercises. It is important during the planning process to determine the exercise prescription (dosage, sets, repetitions and rest periods). The following are definitions of the common terms used during an exercise prescription:

• Exercise dosage - the amount of exercise performed in total.
• Repetitions – the number of times you repeat an exercise eg. 12 knee extensions
• Set – A group of repetitions performed without rest eg. 3 sets of 10 knee extensions
• Rest – The time in between each set of repetitions eg. 3 sets of 10 knee extensions with 45 seconds rest in between
• Frequency – The number of sessions and time in between sessions eg. twice per day
• Duration – the amount of time the total exercise programme lasts for each time eg. 30-40 mins   

An important factor when prescribing exercise is to provide rest periods in between sets of exercise. This is because tiredness may result in non-adherence to the prescription and an increase in injury incidence.

It is important that you feel confident the person is performing the exercises with the correct technique before encouraging them or their caregivers to perform the exercises at home or in between visits.

Once you are happy that the person understands the exercises and is performing them correctly, you should encourage them to perform them in between sessions, with a caregiver if appropriate.

Remember the following points when teaching the person and their caregiver how to do exercises at home:

Remind them that the same principles apply when exercising at home, they should; be aware of exertion, fatigue and pain levels during exercises, and need to perform the exercises in an appropriate and safe position and take a rest between exercises and sets

Tell the person to stop exercises immediately if they experience any sudden pain, severe shortness of breath, dizziness or light-headedness

NOTE: It is important to record or write the exercise plan for the person especially for those with limitations in cognition.

c.         Support where needed with an assistive product and referral to additional services

All the rehabilitation pathways have links to assistive technology. Refer to the assistive products module for indications and how to select, fit and use these assistive products.

During the assessment, if there is any contraindication or any need that requires a referral to another medical specialist or social services, facilitate this.