Stage one: Detailed Goal-Setting Assessment
Our initial assessment involves standard measures, and is followed by working with client and their family to set goals.
Stage two: Design and delivery of a tailored rehabilitation and or support package
Packages are coordinated and led by the case manager. Packages are designed to target the individual needs of the client and their family. If applicable we have a wide range of programmes and materials available. These include: memory retraining, anger management, problem solving/executive skills, managing behaviour/emotions, anxiety management. The case manager may recommend recruitment of a rehabilitation assistant or support worker to work with the client and their family to practice exercises, skills, and strategies.
Step 3: Monitoring progress
Progress is reviewed on an ongoing basis by the case manager and team. A monthly report is provided identifying progress towards goals, and setting further goals as appropriate. Specific outcomes are targeted and measures specified to assess rehabilitation effectiveness.
Step 4: Discharge planning / final discharge
This is a key consideration from the early stages of the rehabilitation process. Goals should be tailored to enable a smooth transition either to independent living or to any local support networks which may be needed after rehabilitation. It is an integral part of the process to liaise with local services, and arrange further activities, placements, supports, and overall structure. All of this happens during rehabilitation, rather than as an end-stage. At the end of the process, there is a discharge pack for the client, their family and others involved, specifying what is needed to maintain or advance progress.