Complex Support Needs Branch Monitoring Framework

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dis.gov.au

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Contents

• Complex Support Needs Branch (CSN) Monitoring Framework ………………………….. 3
• 1. Purpose …………………………………………………………………………………………………….. 3
• 2. Monitoring Cycle ……………………………………………………………………………………….. 4
• 3. Monitoring Activities and Check-in Definitions ……………………………………………. 6
• 4. Monitoring Activities and Check-in Approaches ………………………………………….. 9
  • 4.1. Initial Contact …………………………………………………………………………………….. 10
  • 4.2. Implementation Meeting ………………………………………………………………………. 11
  • 4.3. Check-in Types ………………………………………………………………………………….. 12
• 5. Record Management for Monitoring Activities …………………………………………… 14
• 6. Feedback …………………………………………………………………………………………………. 14
• 7. Version Control ……………………………………………………………………………………….. 15
• Appendix A …………………………………………………………………………………………………….. 15
  • Justice Interface ………………………………………………………………………………………… 15
  • Justice Planning Team Monitoring ……………………………………………………………….. 15
  • Justice Liaison Team Monitoring ………………………………………………………………….. 16
• Appendix B …………………………………………………………………………………………………….. 18
  • Specialised Resolution Team (SRT) Monitoring Guidance ………………………………. 18
  • Specialised Resolution Team (SRT) Monitoring ……………………………………………… 18
  • Short Term Response (STR) Team Monitoring ………………………………………………. 19
• Appendix C …………………………………………………………………………………………………….. 21
  • Stages of Monitoring and Check ins From Plan Approval ………………………………… 21

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Complex Support Needs Branch (CSN) Monitoring Framework

1. Purpose

This Framework will guide you to:

• Understand the CSN approach to plan monitoring.
• Understand the different types of monitoring activity that a planner is to complete and record appropriately on PACE.
• Consider the participant circumstances to be addressed during monitoring.
• Determine how to document the monitoring activity.

The Framework should be used by:

• Delegates, including CSN Planners, Resolution Officers
• Liaison Officers
• CSN Participant Support Officers (PSOs)

This document should be read in conjunction with the CSN Monitoring Work Instructions document on CSN SharePoint, CSN Service Model.

CSN supports participants with unique and significant needs arising from personal and situational factors as well as ensuring these participants receive tailored, coordinated, and responsive service delivered through a caseload management approach. One of the key components of the CSN service offer is regular monitoring of a participant’s plan from initial allocation.

Monitoring in CSN is a proactive, structured, and participant-centred process designed to ensure that individuals with complex needs receive the right supports at the right time. It is a core function of the CSN service offer and is essential for safeguarding participant outcomes, identifying emerging risks, and ensuring that NDIS plans are implemented effectively.

The purpose of monitoring is to ensure that participants with complex needs are receiving the right supports, at the right time, in the right way. Monitoring is not just about oversight—it’s a proactive, participant-focused process that helps maintain the quality, safety, and effectiveness of funded, community and mainstream supports. It is also important for ensuring that:

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You ensure plan implementation aligns with the participant’s goals and needs.

You identify and respond to changes in the participant’s circumstances.

You foster collaboration among stakeholders, including support coordinators, guardians, other government services and service providers.

You facilitate timely responses and changes to supports where necessary.

You evaluate the need for transition to other planning teams, such as Service Delivery, MND or Justice Planning teams.

2. Monitoring Cycle

The CSN Monitoring Cycle is a continuous process designed to ensure consistent oversight and support throughout the duration of a plan. It is recommended that a monitoring activity occurs at least every six weeks and a Scheduled Check-in occurs every 6 months, while a participant is supported within CSN. A delegate or liaison officer’s engagement may be more frequent based on the participant’s level of risk, involvement with the justice system, child protection, health, or other situational factors.

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[Image not converted to Markdown – “Image of CSN Monitoring Cycle” – check the source PDF page for the actual content]

Image caption: The CSN Monitoring Cycle for a Participant where 6 weekly monitoring activities are performed. The cycle follows a structured, clockwise sequence of steps that repeat over time.

Where the Participant is engaged with an alternate pathway in CSN, the following advice should be considered:

Justice Interface

The Justice Planning and Liaison Teams within CSN provide a specialised service for participants involved in the justice interface, incorporating a tailored and responsive approach to monitoring. For more information on monitoring and check-in approaches for participants supported by the Justice Liaison and Planning teams, please refer to Appendix A.

Specialised Resolution Team (SRT)

The Specialised Resolution Team (SRT) is a dedicated team that provides a divisional response for at risk participants. For more information on SRT monitoring and check-in approaches please refer to Appendix B.

Child Protection Liaison (CPL)

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The Child Protection Liaison (CPL) is a time limited pilot initiative aimed at enhancing outcomes for children, young people and their families. The project will test the concept of CPL roles within selected cohorts in Western Australia (WA) and Victoria (VIC). The initial trial period will commence in August 2025 and run for a 12-month period before an evaluation phase. If successful, the intention would be to expand the service offer across other states and territories.

The CPL will not undertake participant check-in activities as outlined in Check-in Approaches. The role of the CPL is to provide an important link between external stakeholders supporting people with disability interfacing with the child protection system and the NDIA. This support is provided regardless of the pathway the participant is aligned to. The CPL will work collaboratively with internal staff to ensure all relevant information and contact is recorded in line with PACE Knowledge Articles.

3. Monitoring Activities and Check-in Definitions

Monitoring is not a single action but a range of purposeful engagements that provide insight into how well a participant’s plan is providing support to achieve goals and improve the quality of their life.

These may include:

Activity	Key Purpose
Initial Contact	Establishing rapport and understanding the participant’s immediate needs upon entry into the CSN pathway.

Initial contact is the foundational part of the monitoring framework because it marks the beginning of active oversight and engagement with the participant (and/or their guardian). While it may seem introductory, it plays a critical role in setting up expectations of support and to inform of the regular monitoring activities that will occur throughout the participant’s journey in the CSN pathway.

For more information on participant allocations, please refer to Knowledge Article manage a new participant allocation.

| Implementation Meeting | This is a structured opportunity to review plan implementation activity and set the scene with stakeholders on the expectations of |

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Activity

Key Purpose

services and, will also identify any risks that may be present. A plan implementation meeting allows for coordination among stakeholders to ensure supports are effective and aligned with the participant’s goals.

It is also an opportunity to inform stakeholders of the monitoring activities that will occur as part of the CSN service offer and arrange for any required assessments or progress reports to be submitted within required timeframes.

The meeting should be offered within 7 calendar days of plan approval. For further information relating to plan implementation processes refer to Knowledge Article understanding implementation meetings.

Scheduled Check-in

Is a planned and regular point of contact between CSN and the participant (or their support network) to monitor how their NDIS plan is progressing and, to assess participant wellbeing.

A Scheduled Check-in can be conducted via phone, Ms Teams call, or in person, depending on the participant’s needs and preferences. They may involve the participant directly, or their guardian, plan nominee, or Support Coordinator.

It is a requirement of the monitoring framework that a Scheduled Check-in occurs every 6 months.

Discretionary Check-in

A Discretionary Check-in (including system generated risk flag) is flexible, unscheduled engagement initiated in response to specific concerns, changes in a participant’s circumstances, or through your own judgment where additional contact is needed. A discretionary check-in may be required to respond quickly to emerging risks or issues (e.g. a breakdown in supports, hospitalisation, housing instability).

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Activity	Key Purpose
Transition Suitability Reviews	Assessing whether the participant’s support needs have stabilised and, whether they are ready to move from CSN to a different support model such as Service Delivery.
	This can occur at any stage within the CSN Monitoring Cycle and at a minimum at every scheduled check-in. When it is assessed that a participant may no longer meet the criteria for the CSN planning pathway, it may be appropriate to consider a transition back to Core Service Delivery. Refer to transition referrals for more information.
Desktop Review	A desktop review is a type of monitoring activity that involves reviewing a participant’s information and progress without direct contact with the participant or their support network. It can typically be conducted by examining available documentation and PACE records to assess the participants current plan and goal progression. For more information on how to perform a desktop review.
Stakeholder Engagement	Usually intentional, collaborative communication between CSN staff and key individuals or organisations involved in a participant’s support network. This can include Support Coordinators, guardians, plan nominees, service providers, other government agencies and other relevant professionals.

What Monitoring is Not

It’s important to recognise monitoring activities from administrative or procedural activities that do not directly provide information of a participant’s progress. These activities are important for the participant to access supports and are not counted as monitoring activities:

• Processing claims or payments
• Creating a Request for Service (RFS)
• Internal escalations or consultations
• Receiving or reviewing quotes

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Monitoring Activities and Check-in Approaches

Throughout the CSN monitoring process a CSN planner will be required to undertake monitoring activities and check-ins. Below is a table summarising the differences.

Feature	Monitoring Activity	Scheduled Check-in
Frequency	Every 6 weeks	Every 6 months
Formality	Can be informal	Formal and structured
Contact Required	Not always	Yes, direct contact
Purpose	Ongoing oversight	Comprehensive review
Documentation	Required (PACE Enquiry case and / or Activity Log)	Required (PACE Check-in case)
Examples	Desktop review, stakeholder contact	Phone/Ms Teams/in-person check-in

Guidelines for Engagement

To support meaningful and effective engagement, staff undertaking monitoring should consider the following when speaking with the participant and their support network:

• Be Participant Centred - this approach focuses on the individual’s needs, preferences, and goals, rather than just their disability or diagnosis. By placing the

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individual at the centre of the care planning process, person-centred practice empowers participants to take an active role in decision-making and ensures that the support services provided are tailored to their unique needs and circumstances. • Promote Self-Advocacy by providing participants (or if a child their child representative) with the knowledge, skills, and confidence to advocate for themselves, this can assist participants to take control of their lives and make informed decisions about their care. This, in turn, promotes autonomy, self-esteem, and overall well-being. • Review the participant’s PACE record and supporting documents before making contact (complete a desktop review). Familiarise yourself with their circumstances and supports. • Introduce yourself to the participant and their informal/formal supports. • Confirm your understanding of the participant’s background and existing information held by the NDIS. • Discuss the participant’s individual circumstances, including informal, community, and mainstream supports. • Ask how the funded supports in the participant’s plan are helping them pursue their goals. • Enquire how the participant is managing their plan budget. • Ensure the participant and their support network understand and can access the supports in the plan. • Respond to any open queries or outstanding requests from the participant. • If needed (or applicable to the participant), request that the Support Coordinator or Specialist Support Coordinator assist in linking the participant to appropriate services. • Advise the participant that regular check-ins will occur and that their Support Coordinator will provide ongoing updates to the NDIA. • Take a multi-disciplinary approach with the participants consent, collaborate with the participants support ecosystem, both informal, formal and mainstream. By working together with a range of professionals, including healthcare providers, therapists, and support workers, support coordinators can ensure that individuals with disabilities receive comprehensive and coordinated care that address their complex needs and ensure everyone involved understands their roles and responsibilities. Collaborative case conferencing.

4.1. Initial Contact

When a participant is allocated or re-assigned to a CSN Planner, initial contact must be made:

• Within 2 business days for priority allocations, or

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• Within 5 business days for standard allocations. This contact ensures the participant is aware they have a new My NDIS contact (CSN Planner) and understand the role of the Complex Support Needs (CSN) Branch. The interaction must be recorded in PACE as an enquiry case.

For more information on participant allocations, please refer to manage a new participant allocation.

To request assistance from CSN Operations or Participant Support Team (PIT) in booking a meeting, please follow the steps outlined in request a meeting booking in PACE.

Preparation Prior to Contact

Delegates are expected to conduct a desktop review before initiating contact. Critical to the desktop review is reading through the CSN Suitability Checker which gives a holistic overview of the participant’s personal and situational factors. This review helps guide the conversation and ensures the planner is informed about the participant’s background and current supports.

4.2. Implementation Meeting

After a plan is approved, participants can start using the funding outlined in their NDIS plan to access supports. This stage is called implementation, and it helps participants understand and make the best use of their plan.

An implementation meeting should be offered to support the participant (or their guardian) in:

• Gaining a clear understanding of their plan
• Learn how to begin utilising their funded supports
• Understand how their plan is managed and how payments are made
• Connect with service providers of their choice
• Understand the purpose and function of service agreements This meeting also provides an opportunity to identify any risks the participant may face when using their funding.

Once a plan approval case is finalised, a plan implementation case is automatically generated in PACE. Where appropriate, the implementation meeting may be conducted at the same time as the plan approval meeting. If not, the meeting should be offered within 7 calendar days of plan approval.

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To request assistance from CSN Operations or Participant Support Team (PIT) in booking a meeting, please follow the steps outlined in request a meeting booking in PACE.

If the participant advises that an implementation meeting is not required, this decision must be recorded in the implementation case on PACE. The next scheduled check-in should be booked within six months.

For more information relating to the stages of monitoring within a participant’s plan, please refer to Appendix C.

4.3. Check-in Types

Check-in Overview

There are different types of Check-ins in PACE, which are explained below. For more details, see the Knowledge Article understand types of check-ins.

A Check-in is a direct conversation with a participant or their authorised representative. It is a requirement that direct contact is made with the participant (or their authorised representative) to complete a Check-in. This ensures the conversation is meaningful, participant-led, and supports accurate and up-to-date information gathering. It’s a chance to build a strong relationship and have a meaningful, participant-led discussion.

Check-ins help make sure the plan is working well, and that the participant has the right supports in place. They also help keep the participant’s information up to date.

To request assistance from the CSN Operations or Participant Support Team (PIT) in booking a meeting, please follow the steps outlined in request a meeting booking in PACE.

Types of Check-ins	Purpose of Check-in
Scheduled Check-in	A Scheduled Check-in is a key component of ongoing
engagement with participants in CSN. They help ensure
participants continue to receive appropriate supports and
that their plans remain effective.

At the initial contact the date for the first Scheduled Check- in is to be arranged for six months time. Depending on the duration of the plan, it is recommended that a Scheduled Check-in occurs at least every six months, however if the

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Types of Check-ins | Purpose of Check-in

plan end-date is less than six months a Plan Reassessment Check-in will automatically generate.

Refer to the Knowledge Article explaining the purpose and outcomes of a check-in to assist you in communicating the purpose and expected outcomes of check-in conversations with participants or their authorised contacts.

Discretionary Check-in

Discretionary Check-ins can occur as needed and are manually created in PACE. These Check-ins are typically prompted by a specific reason, which will guide your conversation with the participant, their plan nominee, and/or Guardian. The reason may stem from an enquiry or an identified risk or vulnerability.

If a delegate identifies a welfare and/or funding risk to the participant during a monitoring activity, they are required to create a Discretionary Check-in case. This ensures that all relevant information is captured and recorded appropriately.

Discretionary Check-in with system generated risk flag

If a participant’s situation meets the risk criteria, a system generated risk flag will create an automatic check-in case. This Check-in case will be assigned to the CSN Planner.

Check-ins play an important role to help safeguard the participant. It is an opportunity to sensitively talk about any risks or concerns with the participant.

Further information can be found in the Knowledge Articles identified risk or vulnerability and understand types of check-ins.

Reassessment Check-in

If you are completing the last Check-in before a plan reassessment, this is called a Reassessment Check-in.

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Types of Check-ins

Types of Check-ins	Purpose of Check-in
	During this Check-in, you’ll support the participant to prepare for an upcoming plan reassessment. You’ll record detailed information and upload any new evidence.
	The information you record will assist the participant to make informed decisions based on what they want and prefer for their next plan. This will help create a plan which meets their needs. It also means the participant does not have to retell their story or repeat information.
	A Check-in for the purpose of reassessment will automatically generate 116 days from the plan end date.

Check-in to determine suitability for transition

During the participant’s journey in CSN, the CSN planner will be responsible for regularly reviewing a participant’s suitability to remain in the CSN pathway during a Scheduled Check-in. Transition reviews should consider the participant’s stability, progress toward their goals, the effectiveness of current supports, and any emerging risks or needs.

If a participant is assessed as ready to transition to Core Service Delivery, a transition referral must be completed and submitted to the CSN Operations Triage Team for assessment and realignment.

5. Record Management for Monitoring Activities

Recording of all interactions related to a participant is mandatory. It is essential for information gathering, record keeping and a nationally consistent approach. Please refer to Knowledge Articles on PACE for further details about how to document discussions with participants.

6. Feedback

If you wish to provide any feedback, please complete Monitoring Framework Feedback Form.

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7. Version Control

Version	Amended by	Description of Change	Status	Date
V2.1	QVERHJ	Approved Version	APPROVED	2025-07-08
2.0	QVERHJ	Review of Monitoring and Check-ins	DRAFT	2025-05-29
1.4	GP	Review of Monitoring and Check-ins	DRAFT	2025-04-24
1.1	AH0030	Updated to include Justice Liaison Monitoring	DRAFT
1.0	AH0030	New CSN Monitoring Framework	DRAFT	31-07-2024

Appendix A

Justice Interface

The CSN Branch provides a Justice service offer to participants that interface with the justice system, delivered by both the Justice Planning Team (JPT) and Justice Liaison Team (JLT). Not all participants who have a justice interface are eligible for JPT, and on these occasions, will continue to be supported by CSN or Core Service Delivery and JLT.

The JPT consists of Justice Planners who undertake planning activities using available information and have a high-level of contact with internal and external stakeholders. This includes a close working relationship with Justice Liaison Officers (JLO) related to participant matters.

The CSN Justice service offer aims to support successful transition for participants from a custodial environment in collaboration with all stakeholders, ensuring a considered approach of NDIS funded supports.

Justice Planning Team Monitoring

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The Justice Planning Team (JPT) is a dedicated team in CSN supporting participants that have met the JPT Eligibility Criteria.

Justice Planners work with Participants and their stakeholders to ensure the appropriate mainstream and NDIS funded supports are engaged, particularly when transitioning from a custodial setting into the community.

The Justice Planner will also undertake all check-in activities as outlined in the Monitoring and Check-in Approaches.

The Justice Planning Team includes Intensive, Super Intensive and Complex streamed Participants, with check-in frequencies occurring for each stream as outlined in table 1 below:

Table 1

Streaming	Required Check-In Frequency
Intensive	6-Monthly
Super Intensive	12-Weekly
Complex	12-Weekly

Justice Liaison Team Monitoring

The Justice Liaison Team is a national team that provides support to internal and external stakeholders working alongside people with disability who intersect with the justice system. This support is provided by the Justice Liaison Officers (JLO) in each state and territory.

The JLOs operate from both NDIS Offices and onsite at prisons, youth detention centres and forensic hospitals.

The JLOs do not undertake participant check-in activities as outlined in Check-In Approaches. The role of the JLO is to provide an important link between external stakeholders supporting people with disability interfacing with the justice system and the NDIA. This support is provided regardless of the pathway the participant is aligned to.

The Justice Liaison Officers will support internal and external stakeholders with:

• The NDIS Access process for applicants intersecting with the justice system.
• Informing planners of any changes or updates regarding the participant’s legal orders and/or status for transition to the community.

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• Submitting referrals to the complex support needs pathway after collaboration with the national delivery planner. • Supporting the planning, reassessment, and monitoring process by ensuring the planner has the most up to date information regarding situational factors. • Monitoring planning, reassessment and home and living decisions and providing support by removing barriers and requesting escalations as required.

For further information and a full overview of the Justice Liaison Officer role, visit the Justice Liaison Team intranet page.

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Appendix B

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Specialised Resolution Team (SRT) Monitoring Guidance

The below guidance will support SRT staff to complete the required monitoring activities and inform enabling teams of the SRT monitoring process. This document should be read in conjunction with the above Complex Support Needs Branch Monitoring Framework information.

Specialised Resolution Team (SRT) Monitoring

The Specialised Resolution Team (SRT) is a dedicated team providing a divisional response to participants in the Complex Support Needs (CSN) and Aged Care Hospital Interface (ACHI) Branches, supporting participant safeguards and promoting a positive participant experience.

A small percentage of participants in the CSN Branch will require monitoring to be undertaken from a deidentified inbox due to the participant risk factors that may impact the health, security and wellbeing of staff.

Monitoring activities will include:

• 3 monthly monitoring will be set up to identify participant risks and safeguards.
• Monitoring will be deidentified from the SRT Communications Inbox.
• Engagement will be in the form of email only with third party representatives, noting consent to share information will be obtained.
• Scheduled or unscheduled planning tasks will be actioned. This may include requesting technical advice and submitting new home and living applications.
• Action any Participant Critical Incident (PCI) reports and undertake welfare checks as required.
• Commission specialised services to undertake specific assessments as required. This may include appointing a Specialised Support Coordinator and Occupational Therapist.
• Provide education, advice and guidance to third party representatives as required.

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Short Term Response (STR) Team Monitoring

The STR team aims to provide participants time sensitive, intensive support and close monitoring over a short period (16 weeks) to stabilise the participants circumstances as a short-term early intervention mechanism. The STR team is a dedicated planning team of skilled planners working with specific complex support cohorts such as justice, psychosocial and /or with allied health experience.

The STR Planner plays a crucial role in responding and stabilising a participant supports during this time of crisis.

Once a participant is allocated the following activities will be required:

1. Complete a desktop file review and conversation with referrer
2. Make an assessment of possible issues /risks
3. Make initial contact with the Participant (or guardian) and their Support Coordinator (SC) within 3 business days of allocation for: a) Introductions b) Discuss expectations c) Role of the STR Planner d) Discuss and identify challenges/barriers e) Develop a Short-Term Response Case Plan (STRCP) f) Document all engagement in the business system through an activity log in the enquiry case. Refer to Knowledge Article [log an activity or internal note](/foi-library/releases/23fb25e35a95-foi-24-25-0519-decison-document/document-001__log-an-activity-or-internal-note/) for more information.
4. Implementation of agreed activities a) Connect with Participant on a regular basis to manage risk and confirm safety. b) Connect with SC on a regular basis to monitor participant situation, ensure stability of supports and build SC capability. c) Assess if circumstances have changed or if there are concerns, and request Plan Variation or Reassessment if required. d) Conduct Plan Variation if required or amend the goals while making recommendations to include specific supports.

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e) Seek appropriate advice from enabling services e.g. TAB, Home and Living, Director case conference, HDD, JLO.

f) Complete a comprehensive implementation meeting which aligns with the Request for Service (RFS). Document in the business system through an activity log in the enquiry case. Refer to Knowledge Article log an activity or internal note for more information.

g) Gather information, evidence-based reports for planning, and coordinate assessments as stipulated in plan and RFS.

h) Perform desktop monitoring on (1–2 weekly basis) regarding participant situation, outcomes, and utilisation of funds.

i) Check-in with SC and Participant (fortnightly or as required) to check progress against goals and identify transition readiness.

j) Request an 8-week update on participant progress from the SC.

k) Update the STRCP with finalised outcomes and your recommendation to transition back to National Delivery (ND)/Partners in the community (PIC) or ongoing support from CSN.

l) Complete handover back to ND Planner/PIC or CSN planner and provide guidance on monitoring and continued support (where applicable).

5. Build Capability of Support Coordinator

a) Build capability of SC in responding to crisis and acting as first point of contact for Participant and SC.

b) Provide education and guidance to ensure evidence collected is appropriate to meet justification framework.

c) Provide accurate and specialised advice and ensuring knowledge of and compliance with relevant legislation and policy frameworks.

d) Monitor quality of service provision to ensure they are personalised and tailored to the circumstances.

e) Prior to transition, a discretionary check-in will be completed, and the next scheduled check-in will be set for 3 months. This ensures that ND or CSN can connect in a timely manner following the transition out of the STR pathway.

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Appendix C

Stages of Monitoring and Check ins From Plan Approval

The diagram is a timeline that outlines key activities during two main stages of a plan:

1. Plan Approval and Implementation Stage

This initial phase spans the first eight weeks:

• Weeks 1 to 2: The plan is formally approved, and an implementation meeting is conducted to initiate the process.
• Week 8: A monitoring activity is carried out, and a report is submitted by the Support Coordinator to assess early progress.

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2. Plan Usage Stage

This phase covers the remainder of the plan’s duration, from Week 14 to Week 50, and includes regular monitoring and scheduled check-ins:

• Week 14 and Week 20: Monitoring activities are conducted to track ongoing progress.
• Week 26: A scheduled check-in is held to review the plan’s effectiveness and make any necessary adjustments.
• Week 32, Week 38 and Week 44: Additional monitoring activities are performed. The later monitoring activities can be used to prepare the participant and stakeholders with preparing for upcoming reassessment check-in.
• Week 50: Dependent on length of plan a Scheduled Check-in or Reassessment Check-in is completed.

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