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The person- centred rehabilitation lens 3 Personal Rehab Plan Managed conclusion of formal rehabilitation care and support The person, their carer and family in their community Joint, collaborative assessment of need, options, choices, outcomes, incentives, management First single POC Acute / community in-patient rehab plan Complex home rehab plan Home rehab plan Education Re-assessment Monitoring Feedback Incentives Self-management Carer views Innovation Technology Sustainability Continuous assessment and improvement Continuous assessment and improvement