Regulations on habilitation and rehabilitation, individual plans and coordinator


Date FOR-2011-12-16-1256


Ministry of Health and Care Services


Published in 2011 Booklet 13


Commencement 01/01/2012

Edited


Changes

FOR 2001-06-28-765, FOR-2004-12-23-1837

For
Norway

Legal

LOV-2011-06-24-30-3-2, LOV-2011-06-24-30-§7-1, LOV-2011-06-24-30-§7-2, legislation 2011-06-24-30-§7-3, LOV-1999-07-02-61-§2-1a, LOV-1999-07-02-61-§2-5, LAW-1999-07-02 -61-§2-5a, LOV-1999-07-02-61-§2-5b, LOV-1999-07-02-62-4-1

Promulgated
19.12.2011 kl. 15.15

Short Title
regulation on habilitation and rehabilitation

Chapter Overview:

Chapter 1. Purpose and scope (§§ 1-2)
Chapter 2. General habilitation and rehabilitation (§§ 3-4)
Chapter 3. Habilitation and rehabilitation in the community (§§ 5 - 9)
Chapter 4. Habilitation and rehabilitation specialist health (§§ 10-15)
Chapter 5. Individual plan and coordinator (§§ 16-23)
Chapter 6. Commencement (Section 24) || |
Adopted by Royal Decree. 16 December 2011, pursuant to Act 24 June 2011 no. 30 relating to municipal health services, etc. (health and care Act) § 3-2 second paragraph and § 7-2 second paragraph. Promoted by the Ministry of Health. Other parts of the regulations established by the Ministry of Health on 16 December 2011 pursuant to Act 24 June 2011 no. 30 relating to municipal health services (health and care Act) § 7-1, third paragraph, and § 7-3 third subsection, the Act of 2 July 1999 no. 61 of the specialist health Services (specialized health Services Act) § 2-1a seventh paragraph, § 2-5 second paragraph, § 2-5A third paragraph, and § 2-5b, second paragraph and law 2 July 1999 . 62 mental health care (the mental health Act) § 4-1 second paragraph.
Changes: Changes in regulations August 29, 2016 No.. 1030 (effective September 15, 2016).

Chapter 1. Purpose and scope

§ 1. Purpose of the Regulations The purpose of the regulation is to ensure that people who need social, psychosocial or medical training and rehabilitation, offered and provided services that can contribute to the stimulation of their own learning, motivation, better functioning and coping ability , equality and participation. The purpose is also to strengthen the interaction between the service provider and the patient and user and any dependents, and between service providers and agencies within an administrative or across administrative levels.
Regulations shall further ensure that the services offered and rendered

1.
From a patient and user perspective,

2.
In or as close as possible the patient's and the user's usual environment,

3.
Coordinated, interdisciplinary and systematic,

4.
In one for patient and operator meaningful context.

§ 2 Scope These regulations apply to habilitation and rehabilitation services offered and rendered by health and care law and Specialized Health Services Act.
In addition, these regulations apply individual plan to be developed by health and care Act § 7-1, Specialist Health Service Act § 2-5 and the Mental Health Act § 4-1 and appointment of the coordinator for health and care Act § 7-2 and Specialized Health Services Act § 2-5A.

Chapter 2. General habilitation and rehabilitation

§ 3. Definition of habilitation and rehabilitation Habilitation and rehabilitation are ACCR, planned processes with clear targets and measures, where several actors working together to provide the necessary assistance to the patient and the user's own efforts to achieve the best possible functioning and coping ability, independence and participate in social and community.

§ 4. Patient and user municipality and the regional health authority shall ensure that the individual patient and user can participate in the implementation of their own habilitation and rehabilitation cf. Patient and user Rights Act § 3-1. The implementation means planning, designing, practicing and evaluation.
The municipality and the regional health authority should facilitate the patient and user representatives participating in the planning, development and evaluation of re- / habilitation activities.

Chapter 3. Habilitation and rehabilitation in the municipality

§ 5. The municipality's responsibility for habilitation and rehabilitation municipality shall plan their habilitation and rehabilitation activities and a general overview of the needs for training and rehabilitation of the municipality. Services included in the municipal health and care services to be integrated into an overall multidisciplinary re- / habilitation services.
Municipality shall ensure that all persons residing in the municipality, provided the required reports and follow-up by social needs, psychosocial or medical training and rehabilitation, ref. § 1 and § 3
Re / habilitation offer should be given independent the patient and the user's living arrangements.

The municipal health and care services will occasionally collaborate with other agencies.

§ 6. Coordinating Unit for habilitation and rehabilitation of the municipality shall be a coordinating unit for habilitation and rehabilitation activities in the municipality, ref. Health and care Act § 7-3. The coordinating unit will help to ensure comprehensive services to patients and users with social needs, psychosocial or medical training and rehabilitation.
Coordinating Unit will have overall responsibility for work on individual plans and for the appointment, training and supervision of coordinator. Overall responsibility for individual plans means that the device shall inter alia:

A)
receive messages about the need for an individual plan, cf. § 23

B)
ensure that it is prepared routines and procedures for working with individual plans.

§ 7. Notification of possible needs for social, psycho-social and medical rehabilitation and rehabilitation municipality shall create conditions so that personnel in the municipal health and care services should be able to report possible re- / habilitation needs that personnel are familiar with the service . The message given to the coordinating unit or wherever the municipality decides.

§ 8. Exploration and evaluation municipality shall ensure the necessary examination and assessment, and if necessary refer to a specialist, before habilitation and rehabilitation is started.

§ 9. Utilities and ergonomic measures municipality shall ensure provision of essential utilities and for facilitating environment around the individual. The municipality should consider aids as one of several alternative actions based on the patient and operator's overall needs. If necessary, the municipality must request assistance from NAV or from other relevant bodies.

Chapter 4. Habilitation and rehabilitation specialist health

§ 10. The regional health entity responsible for training and rehabilitation The regional health authority shall ensure that persons with a permanent domicile or residence in the health region offered and given the necessary training and rehabilitation in specialized health services within and outside the institution, cf. § 1 and § 3 .

§ 11. Coordinating Unit for habilitation and rehabilitation in specialized health services should be a coordinating unit in each health should have a general overview of habilitation and rehabilitation measures in the health region, see. Specialist Health Service Act § 2-5b. The coordinating unit will help to ensure comprehensive services to patients in need of social, psychosocial or medical training and rehabilitation.
Coordinating Unit should have an overview of and the necessary contact with habilitation and rehabilitation activities in the municipal health and care services. In addition, the device having such a responsibility as responsible as stated in § 6, second paragraph.

§ 12. Notification of possible needs for habilitation and rehabilitation specialist health The regional health authority shall facilitate such personnel in the specialist should be able to report possible need for training and rehabilitation that personnel are familiar with the service. The message given to the coordinating unit or wherever the regional health authority decides.

§ 13. Tasks that require specialized adaptations etc. The regional health authority shall ensure necessary survey and investigation of patients who need habilitation and rehabilitation in specialized health services.
The regional health authority shall also ensure offer

A)
training and improving students function and various individual skills that require specialized facilitation and guidance

B)
intensive training as part of the individual habilitation / rehabilitation plan, or as a necessary, specialized offerings finishing

C)
educational for patients who need it, and prepare a framework that can contribute to increased mastery.

§ 14. Particularly for advice, guidance and cooperation The regional health authority shall ensure

A)
advice and guidance to local authority plans for individual patients

B)
cooperation with the municipality plans for individual patients and the development of individual plans

C)
generic advice and guidance to employees in the municipality

D)
cooperate with other agencies when required for investigation, adaptation and implementation of services for the individual.

§ 15. Ambulatory service habilitation and rehabilitation services in the specialist should be given outpatient if such services are not most appropriately can be provided in an institution.

Chapter 5. Individual plan and coordinator


§ 16. Patient and user rights Patient and user need long-term, coordinated health services have the right to an individual plan drawn, cf. Patient and user Rights Act § 2-5. The person has the right to participate in the work with their plan, and it shall be made for this, cf. Patient and user Rights Act § 3-1. Relatives should be included in the work to the extent that the patient and the user and relatives wish.
If a patient does not have to consent, the person's next of kin is entitled to participate along with the patient or user, cf. Patient and user Rights Act § 3-1 third paragraph.
Individual plan does not give the patient and the user greater right to health and care than that provided by the other regulations.
Provisions of the first paragraph, second and third sentence, and the rules in the second paragraph apply correspondingly to the appointment of the coordinator.

§ 17. Consent An individual plan should not be drawn up without the consent of the patient or user or to give consent on their behalf. The same applies to the appointment of the coordinator.
For patients applies patient and user Rights Act Chapter 4 for consent to medical care.

§ 18. Responsibility for preparing individual plan Commune health and care services and health authorities have a duty to ensure that the individual plan under § 1 are prepared for patients and patients who need long-term, coordinated services, cf. Health and care law § 7-1, Specialist health Service Act § 2-5 and the mental health Act § 4-1.
Coordinating Unit for habilitation and rehabilitation has overall responsibility for individual plans, ref. § 6 and § 11
If a patient or user needs both offered by health and care law and Specialized Health Services Act or the Mental Health Act, shall municipality ensure that it becomes an individual plan, and that planning is coordinated. The health authority shall as soon as possible notify the municipal coordinating unit for habilitation and rehabilitation when it sees the need for an individual plan that includes services from both the specialist and the municipality, and shall in such cases contribute municipalities work with individual plan.
Have the patient or the user needs for services from other service providers or agencies shall municipal health and care services and health authorities cooperate with them.
The planning must be coordinated, and it should only be produced individually for each patient or user.

§ 19. Contents of individual plan Individual plan's content and scope should be adapted to the needs of the individual patient or user. It should be preparing the plan taking into account the person's ethnic, cultural and linguistic assumptions. The plan must contain the following main points

A)
an overview of the patient and user goals, resources and needed services

B)
a list of who participates in the work plan

C)
an indication of who is coordinator

D)
an overview of patient and user, service and contributors and any dependents will contribute in the planning process

E)
an overview of what measures are appropriate and the extent of them, and who should be responsible for these

F)
a description of how the measures will be implemented

G)
a statement of the plan period and the timing of any adjustments and revisions of the plan

H)
patient and the user's consent to the plan drawn up and any consent that participants in planning given access to confidential information

I)
a list of necessary or desirable cooperation with other service providers, institutions and agencies.

§ 20. The implementation of the individual plan The general responsibilities and function division between the various service providers shall apply to the implementation of the plan, unless otherwise agreed.

§ 21. The coordinator of the municipality patients and patients who need long-term, coordinated services for health and care law, the municipality shall provide Coordinator, ref. Health care services law § 7-2. This applies regardless of whether the patient or the user wants individual plan.
Coordinator shall ensure the necessary follow-up of the individual patient or user. Coordinator shall also ensure coordination of services and progress in work on individual plans.

§ 22. coordinator in the specialist For patients requiring complex or long-term, coordinated services for Specialized Health Services Act, shall be offered Coordinator, ref. Specialist Health Service Act § 2-5A. This applies regardless of whether the patient wants an individual plan.

Coordinator shall ensure the necessary follow-up of individual patients. Coordinator shall also ensure coordination of services related to residential care and to other service providers and ensure progress in work on individual plans.
The coordinator should be a doctor, but other medical staff may be coordinator when deemed appropriate and justifiable.

§ 23. Responsibility for reporting on the need for an individual plan and coordinate health professionals must immediately notify patients and clients need for individual plans and Coordinator, ref. The Health § 38a. The same applies to other personnel who provide health care services for health and care law, cf. Health and care Act § 2-1.

Chapter 6. Commencement

§ 24. Commencement This regulation enters into force on 1 January 2012.
From the same date, the Regulations on 28 June 2001 no. 765 on habilitation and rehabilitation and Regulation of 23 December 2004 no. 1837 concerning individual plans for health legislation and Social Services Act.