Jenny's case study
Jenny is recovering from orthopaedic injuries as well as a brain injury, acquired when she fell down a cliff while walking along a track near the sea. Following the accident, Jenny suffers from:
- cognitive fatigue
- poor emotional regulation
- reduced organisational abilities.
She was in her final year of school at the time of her injury but was a reluctant student. Jenny doesn’t want to go back to school. Her peers have almost completed their exams and Jenny wants to be able to celebrate the end of school with them on a three-day trip to Melbourne. Jenny’s friends are trying to be supportive, but struggle with her over-reactions at times.
When discussing the potential barriers to Jenny going on the trip, Jenny admitted that she struggles to be able to stand or walk for more than five minutes due to pain in her leg. She also agreed that she is sometimes slow to get organised in the mornings but thought that would be all right once she got home.
She was not able to identify that her friends were struggling to be with her for long periods of time.
The following plan for this goal was devised with Jenny and her therapy team.
Plan #3
Date of plan: 15 May
Plan period: 1 September to 15 December
Client goal: Jenny wants to fly to Melbourne with her friends for three days in December.
| Client step | Action plan | |
|---|---|---|
Client step A: Walking Be able to walk to the shops and back (1km each way) within an hour when her friends visit her. |
| |
Client step B: Time management Be ready for therapy sessions as noted on her timetable (showered and dressed) by 8:30am. |
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Client step C: Self-awareness Jenny will be able to recognise signals from her parents and friends (Katie and Mel) when she is talking over people, missing other’s body language, or saying things that make others uncomfortable. |
| |
Progress: 2nd October
Jenny’s walking is progressing well. She is keeping up the pace with her friends. Although she still has some pain, she thinks it is diminishing.
She needs to be reminded to use her smart phone for all alarms. She thinks she can remember changes to her daily schedule without it but fails to update the alarms as needed.
Her friends are reporting that at first Jenny was shocked and resistant to their feedback, but as she spends more time with them, they think she’s more responsive to the script. More training sessions for them have been scheduled.
The goal is still for her to travel to Melbourne, but her mother is talking about going too and staying nearby.
Jenny’s rehabilitation plan is reviewed using the plan evaluation questions.
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Question | Y/N | Evidence |
|---|---|---|
1. Is the plan person-centred? | Y | The goal is clearly an aspiration expressed by Jenny. She has told the team that she wants to go to Melbourne with her friends. She has been included in identifying some strategies to achieve the steps, such as walking with her friends to the shops. |
2. Are the goals meaningful to the person – even if assigned goals are used? | Y | The goal is directly related to an activity Jenny would have participated in had she not had her injury. Some of the steps and activities have been directed by the clinicians, but are clearly related to helping Jenny achieve her goal. |
3. Does the plan appropriately include body function, activity and/or participation level goals? | Y | This is a participation level goal. Some of the steps and actions include activity and body function sub-goals to help Jenny work towards her more aspirational, participation goal. |
4. Is the described desired outcome specific? | Y | Both the goal and the steps include specific activities and specific desired, observable behaviours. |
5. Is the goal measurable? | Y | Whether she goes to Melbourne or not with her friends is measurable. |
6. Is the goal and/or the steps achievable? | Y | It is unknown at the time of setting the goal if it is achievable, but there are achievable steps included in the plan. Progress will determine if the goal needs to be modified by Jenny, with guidance from her family and rehab team. |
7. Are the actions and strategies relevant and related to the goals and aspirations? | Y | The plan links clinical interventions to Jenny’s goal which helps her see the relevance of what she is doing in therapy. |
8. Does the plan include a reasonable time frame for assessing the outcomes? | Y | The three month timeframe is related to when the planned trip is going to occur, and is defined in the plan. It is an ambitious timeframe but motivating for Jenny. |
9. Is there evidence of effective teamwork and engagement of the person’s significant others? | Y | Ward staff, occupational therapist, physio and psychologist, as well as family and friends are involved with, and committed to, Jenny’s plan. Where more than one discipline is involved in achievement of a goal, roles are described and collaboration across the team is implied. |
10. Has the plan adequately considered personal and environmental factors? | Y | Jenny has a pre-injury reluctance regarding school, the plan focusses on an activity she does want to engage in. Jenny has friends who are willing to assist in the rehab process, even though they find some of Jenny’s behaviours challenging. Jenny’s parents are supportive. |
Auditing rehabilitation plans pre- and post-training
Auditing rehabilitation plans provides the opportunity to evaluate compliance with the principles of person-centred rehabilitation planning at both an individual and a service level.
- Audit template - individual (DOC 59.0 KB)
You can use this template with plans written before and after completion of this toolkit to assess the impact the training has had on your rehabilitation plans. - Audit template - aggregated (DOC 59.9 KB)
Teams and service managers can complete this template to identify where the team is doing well and where improvement in person-centred rehabilitation planning is required.
The templates can be modified to include other aspects of qualitative planning that the team wishes to assess and measure.