Fillable Physiotherapy: Treatment Management Plan (Services Australia)

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Physiotherapy: Treatment Management Plan (Services Australia)

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Physiotherapy: Treatment Management Plan
1
Health care providers should deliver services according to the principles outlined in the Clinical
Framework for the Delivery of Health Services. The TMP is an important communication tool
that requires Physiotherapists to demonstrate they are adopting the principles of the
Framework in the treatment of the worker’s injuries.
Contact details
Worker’s name
Date of birth
Claim No.
Occupation
Employer
Referring medical practitioner
Insurer
Workplace rehabilitation provider (if applicable)
Clinical assessment
Date of injury
Number of consults to date
Number of consults since last surgery (if applicable)
Physiotherapists’ diagnosis
Area/s treated
Screening tools/questionnaires
(e.g Orebro – DD/MM/YYYY; Initial score – 76; High risk of long term disability and failed return to work)
Tool
Date
administered
Initial
score
Interpretation of
results
Date re-
administered
Subsequent
score
Outcome
Functional measures (select relevant activities)
(e.g. lifting - 10kg floor to waist, 15 repetitions; walking – 5km, moderate intensity, limited due to pain)
Functional activity
Initial/as last
reported
Current
Expected/goal
(within denoted
timefr
ame)
lifting – floor to waist
lifting – waist to shoulder height
working above shoulder height
sitting
standing
walking
pushing/pulling
bending/twisting/squatting
driving
other (specify)
Briefly comment on the workers adherence to treatment
Biopsychosocial factors
Have you identified, or are you aware of, any factors that may impact the workers return to
work?
Biological factors
Yes No
Psychosocial factors
Yes No
Other
Yes No
If you have identified any factors that may impact the workers return to work, do you have
any recommendations for addressing them?
(e.g. diagnostic imaging, specialist referral, reassurance, education regarding injury and treatment expectations,
work site assessment, etc.)
2
Current work status
Hours
Current duties
Pre-injury hours at work
per week
Pre-injury duties
Current hours at work
per week
Alternative/modified duties
Not working
I would like more information about the duties and the associated physical demands
of the workers pre-injury occupation/available duties
Return to work progression
Has the worker’s hours and/or duties progressed in the last six weeks? Yes No
Provide details
Is the worker likely to return to the functional capacity required to perform their pre-injury
duties?
Yes
Anticipated timeframe
No
Comment:
Unsure
Comment:
Do you have any comments to assist the medical practitioner certify capacity for the worker?
(e.g. consider current functional measures, modifications to the workplace)
Proposed management plan
Physiotherapy consultations
Number of treatment sessions proposed
to be conducted over
weeks
Utilising service codes PB001, PC001 or PG001, as per the WorkCover WA rates, fees & payments for physiotherapy
Treatment proposed
Exercise based program
Supervised exercise programs require a cost proposal for prior approval by the insurer. Refer to the WorkCover WA
rates, fees & payments for exercise-based programs
Have self-management strategies been implemented? Yes No
Physiotherapist’s details
Name
Telephone
Practice
Email address
Signature
Date:
A copy of this form has been sent to (please tick):
Insurer/Self-insurer
Medical Practitioner
Other (Specify)
Insurer approval
Note to insurer: It is expected that a response be provided to the physiotherapist within three
to five business days of receipt of this TMP.
Approved
Not Approved
Further information required (specify)
Insurer contact name
Telephone
Signature
Date
click to sign
signature
click to edit
3
Useful resources for physiotherapists
Links to screening tools
• Orebro (Long-Form, Short-Form)
• STarT Back
• Outcome Measure Compendium
Resources available at the WorkCover WA website
• Clinical Framework for the Delivery of Health Services
• Using the Flags Model: A practical guide for GPs
• Your role in supporting injured workers – a snapshot of the clinical framework
Explanatory notes – completing the TMP
The TMP is intended to provide greater clarity about future treatment options for workers who
are likely to require more than ten physiotherapy consultations. It will also provide approved
insurers and self-insurers with a mechanism to determine whether the treatment and costs are
reasonable under the workers’ compensation legislation.
The following notes may assist physiotherapists and insurers:
Notes for physiotherapists
• A TMP may be requested or required when the physiotherapist is of the view that treatment
will be required beyond ten consultations.
• The TMP may be initiated by a physiotherapist or requested by an approved insurer or self-
insurer (note - there is a maximum combined total of three reports permitted without prior
approval from insurer or self- insurer).
• A copy of the TMP should be provided to the worker, treating medical practitioner and
insurer/self-insurer.
• All sections of the TMP should to be completed.
• Completion of the TMP is a billable item – refer to item PR003 of the
WorkCover WA rates,
fees & payments for physiotherapy.
• “Physiotherapist’s diagnosis” may differ from the medical practitioner’s injury description
on a certificate of capacity. This information will assist the claims management process by
highlighting the need to obtain clarity around the diagnosis.
• You are not required to elaborate on the self-management strategies you have
implemented. It is expected you empower the worker to manage their injury, through
education, setting expectations, developing self-management strategies and promoting
independence from treatment.
Notes for insurers and self-insurers
• Insurers and self-insurers have a responsibility to determine whether treatment for workers
is “reasonable” (pursuant to Clause 17 – Payment of medical and other expenses of
Schedule 1 to the Workers’ Compensation and Injury Management Act 1981
).
• The TMP may be used as a mechanism to assist in determining whether any treatment
proposed by a physiotherapist is a “reasonable” expense.
• It is desirable that insurers and self-insurers respond to physiotherapists in a timely manner.
To avoid potential delays in physiotherapy treatment, the benchmark for responding to
physiotherapists is within three to five business days from receipt of the TMP.
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Physiotherapy: Treatment Management Plan (Services Australia)

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Completed 8 February 2022

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