OPERATIONAL GUIDELINES REVIEW OF ACCESS WORDING FOR HEARING IMPAIRED

“Hearing loss is not just an ear issue – it is a brain and information processing issue too” η Carol Flexer, 2011

“the focus on sensory coding and acoustic signals has relegated other domains of cognition, learning, memory and attention and inhibition”(D,Pisoni,, W., Kronenberger,,, M.Harris & A.Moberly,,,, \textbf{2017})

Background

The final Joint Standing Committee (JSC) report (ΔJuneμ , ) from an enquiry into the provision of hearing services under the NDIS in November informed the announcement of five new initiatives to improve the NDIS experience for people with hearing impairment. s22(1)(a)(ii)- irrelevant material In June The Operational Guidelines OG for determining access were revised to enable streamlined access to the NDIS for people with hearing loss children young adults requiring early intervention for hearing attachment . Following implementation updated OGS Agency received consistent feedback peaks bodies Department Social Services participants stakeholders about lack clarity OG relation substantially reduced functional impact. On April 2019 AAT heard case Evans vs NDIA determined Ms Evan’s hearing resulted substantial reduced function communicate therefore should be granted access NDIS attachment . Issues dispute whether applicant satisfies s.(c)e ndis Act key findings assessment level functional disability day life case Ms Evans NDIA did not consider evidence regarding impact her hearing result substantially reduced function. The rigid application a decibel threshold would inconsistent statutory question: applicant’s impairment results significantly reduce capacity communicate…… extent thatthe do dictate “threshold” it is submitted they would be inconsistent statutory question under s.c and should disregarded.” \textbf{Evans} &\textbf{NDIA}[AATA754 (April) ] Deafness Forum Australia collaboration Deafblind Audiology Neurosensory Able Senses submission JSC National Disability Insurance Scheme planning September concerns operational guidelines access stating well understood by staff inclusion degree of hearing distinguish levels required support requests misinterpreted criteria access p See separate attachment full submission can also viewed here on website This meeting convened discuss current operational guidelines identify how improved provide greater clarity agency staff constitutes substantially reduced function as benefit early intervention for people with hearing loss Recommended Considerations Operational Guidelines to amended emphasise requirements demonstrate substantially reduced function remove reference dB eligibility criterion.s22(1)(a)(ii)- irrelevant material Because idiosyncratic nature hearing variation amongst individuals due predetermining factors such communication mode device use age onset discussion points listed below. # Page 1of

For Discussion – Functional Impact of Hearing loss

(s.24)

• What constitutes substantially reduced functional impact for hearing loss?

Given variation amongst individuals: how can we measure and report? e.g., audiogram plus functional impact report qualified professional(s), self-report/anecdotal reporting. * What information/evidence will help Agency staff determine whether potential participant has substantial reduced function impact due result in hearing loss? e.g.: combination Audiogram + professional reports. * Who provides evidence about functional impact?: Audiology provide audiograms with pure tone free field thresholds speech discrimination noise etc; however may not cover individual’s perception everyday environments such as work home community). * Can expect audiologicals to provide evidence regarding functional impact? Will be change practice for Audiology and how managed? *Sudden onset hearing pathway?.

Attachment A

Operational Guidelines

s22(1)(a)(ii) - irrelevant material redacted: s22(1)(a)(ii) redacted: s22(1)(a)(ii): irrelevan t material Therefore, adults aged 26 years over are not immediately accepted likely benefit early intervention approach because no requirement support development auditory pathways. Adults age d 26 year over hearing impairment will therefore assessed normally case basis having regard availability all relevan evidence.” note: The text following this appears as a series of redactions without any discernible content beyond what can reasonably inferred from context about sections being removed for relevance reasons under section(s). An Additional Section entitled ‘Additional guidance for hearing impairments’ will added at 8.3*.:* “8:*. *. *Addition guidanc for hearin impairement Hearing impariments may resul reduce funcional capacit undertak communicatio social interaction learning and self managem activities Generally NDIA satisfie that heari ngimpairm ents ≥ decibels better ear pure tone average Hz, kHz, kHz an dB result substantially reduced functional capacity perform one or more activiti This audiometric criterion reflects lower limit constitute substantia reduc functio capacty undertake relevant actiivties” Hearin gimpairemnt <dB deicbels in bette r eard (pure ton averagge of HZ, kHZ,kHzand40k) conjunction with other permanent impairments example vision cognitive iirmpemtions where there is evidenc significantly poorer than expected speech detection discrimination outcomes also be considered to result substantiall yreduced functiona capacit undertaking relevanctivities.”

Attachment B

POTENTIAL IMPACT OF AAT DECISION EVANS VS NDIA – (ACCESS FOR PERSON WITH HEARING LOSS)

Summary of Case On April 25th/June 30th-2019, the AAT heard case Evans vs NDISA determined that Ms Evan’s hearing resulted substantial reduction functionally communicating therefore granted access NDIS.

Ms Evang single mother two teenage daughters ASD received carer payment her daughter employed part-time jobs administrative capacity issues dispute whether satisfies s.(1)c(e). sound measured dB left better ear right as pure tone average or four-frequency average Audiologists Ben Featherston expert applicant Eugene Mougerman respondent provided evidence weight given Mr featherstone’s Evidence in support included significant amplification needed hear sounds between kHz Hz approximately missed speech discrimination decreased negatively impacted background noise evidence provided difficulty understanding other quiet room ability lip-read ineffective conversation more than one person cannot see person’s lips impairment impacts daily interactions work community home environments described Tribunal clear unequivocal evidence Agency argued did not meet decibel guideline different tasks communication interact effectively completely Tribunals findings found significantly poorer expected detection and discrimination outcomes having constantly modify behaviour attempts communicate demonstrates applicants functional life substantially reduced by hearing loss accepted greater capacity to communicate quiet environment considered much spoken interaction does occur quiet where facing speaker test for substantially reduced functional capacity reflect reality community life extent Operational Guidelines dictates threshold agreed with applicant operational guidelines inconsistent statutory question under (c) should disregarded.

FOI 25/26-1019

The Tribunal also agreed with the applicant that the principles of the NDIS Act do not support an interpretation that a person who was unable to understand a significant amount of what is said to them on a daily basis is communicating ‘differently’. The Tribunal considered it would be erroneous to require the Applicant to be completely unable to undertake communication when the NDIS Rules elaboratethatanimpairmentwillresultin asubstantiallyreduced functional capacity whereapersonisunabletoparticipateeffectivelyorcompletelyint heactivity.

Outcome TheTribunalsetasidetheNDIA’sdecisionanddecidedthecandidatsatisfiedtheadaccess criteriaintothenDisforhearing impairment.Whiletheassessmentofanan accessrequestconsidersleveloffunctionalimpactaperson’edisabilityhasontheirdaytodailylife,in thecauseofMsEvans,theNDIDidnotconsiderthaeevidenceregardingthe impactofher hearinglossresulstinsubsantally reducedfunction.

Current NDIA Operational Guidelines

Currently, thenDIIA will besatisfiedthathearing impairments≥65 decibels inbetterear may result insubsantly reducedfunctionalcapacitytoperformoneormoreactivities. This audiometriccriteriareflects therelowerlimitwhatislikelyconstitutesubsantally reducetionalitycapacitorundertakerelevant activities.Hearingimpairments< 65dB decibelsin better ear inconjunctionwithother permanent imperimentsorthere is evidence ofsignificantlypoorer thanexpectedspeech detection and discrimination outcomes,mayalsobe considered to resuultinsubsan tally ducedfunctionalcapacityto undertake relevant activitiess.In contrast the World Health Organisation (WHO) consider a hearin loss40 dB be adisabling heaing losss.See Attachment A for further details.The Hearing Service Program(HSP)fundedbyDepartmentHealthcurrentlytransitioning parttonDisOriginalestimatesclients that would meet NDIS access requirements as per currentOperationalGuidelineswasapproximately 45 ,000.RisksUsing Evans vsNDSAAAT decision reasoningandapplyingthistotutureaccess decisions, tnumberofHSP clientsmaymeetNDIS Disability accesstirequirementswouldincrease by at least22 .,This number does not include Australians with hearinglossgreaterthan redactedthatdo no currentlymettheeligibilityrequirementsfor HSP. AsresultthenDIA may see increasednumberequestsforaccess,and consequently anincreased numbe rinternal review requestsforthoseindividualswhereaccess wasnot met.Up tot%Australians over agehave agedrelated mildhearinglosse( 1-4dB) may result in meeting NDSDdisabilityaccesstruirements therefore scheme could be facedwith increase of peopleover65 remainingthescheme The consequence increasingvolume participants with hearingloss isan increas e funded supports ie: hearing devices Under the HSPHearddevicesareusuallyreplaced everythreeyears.Page of16

Considerations

It is unlikely that the fully subsidised hearing devices available under the HSP will address the functional impact detailed in the Evans vs NDIS case which is likely to result in an increase of requests for premium level hearing aids. While the premium level hearing aids are not likely to meet reasonable and necessary criteria, the increase volume of requests, TAT advice requests, internal reviews and AAT matters are likely to increase. as the HSP will continue beyond the transition period it important ensure Health continues responsible supporting people with mild hearing loss participants able access this mainstream service.

Attachment C

Background

• World Health Organisation (WHO): “Disabling hearing loss refers to hearing loss greater than 40 decibels (dB) in the better hearing ear in adults and a hearing loss greater than 30 dB in the better hearing ear in children. The majority of people with disabling hearing loss live in low-and middle-income countries.”*
• Australian Hearing’s classification of: o Normal: 0–20 dBHL o Mild:21 – 40dBLH o Moderate :41 - 60dBHl o Severe:61—90dBlL o Profound>>81 dBHL
• Incidence as per Hearing Australia website: “In Australia, between nine and twelve children out every ten thousand births will have moderate or worse bilateral deafness at birth. Around another twenty three children for each one hundred thousand born acquire an impairment that requires aids before they are seventeen years old due to accident, illness etc. Deafness can affect learning language development behaviour. It is significantly higher among Aboriginal Torres Strait Islander children who represent serious health educational problems.” The incidence increases over age. Over half population aged sixty seventy has some degree of deafness which rises above seven percent those older eighty eight percent.* Another reference from HCIA report The social economic cost of Hearing Loss In Australia (2017).
• Functional impact on hearing loss how decibels relate real life conversational sounds Reference Australian Hearing Website. o Softest sound young people with normal hearing detect in ideal listening conditions is zero through twenty(0–20)dB HL across the frequency range. o Conversations measured metre away around fifty dBLH though some speech sounds thirty fourty DB HL. o Four metres away quieter about 35dBLH softer speech only measuring approximatelytwentY dBHL. o A functional descriptor mild hearing loss person bilaterally may difficulty hear soft conversations mumbling quiet settings clear voices background noise visual cues recommended depending configuration individual circumstances e.g acknowledgement motivation wear device communication goals acquired sudden gradual use strategies lip reading etc o Moderate bilateral hearing loss forty sixtysixtenyDBHL would have difficulties understanding conversation particularly presence background noise TV radio turned up to be heard aids will likely beneficial depending individual same as previous descriptors. o Severe bilateral hearing loss greater than ninetynineeighteenfour frequencies average >65dB cannot normally converse without visual aid unaided person has significant problems communicating both quiet and noisy environments possibly safety issues. Aid necessary very helpful.*

HSP/NDIS Eligibility Interface Workshop

Date: Monday 2 July 2019, 2:30pm – 4:30pm AEST Venue: redacted - s22(1)(a)(ii) irrelevant material - text code span ATTENDEES:

• Trish redacted Acting First Assistant Secretary, Cancer Hearing and Program Support Division Department of Health Chris redacted Assistant Secretary, Hearing Disability Interface Branch Tony redacted Acting Director, Hearing Policy Section Karel redacted Departmental Officer, Hearing Policy Section Delfina redacted Assistant Director Inter government Strategies Section Ben redacted Departmental Officer Intergovernment Strategies Section Department Social Services Andrew Group Manager National Disablity Insurance Scheme (NDIS) Market Reform Eliza redacted Assistant Secretary Program Transition Branch Human Services Paul Acting Deputy Secretary Health And Care Group Danielle First Asst Secetary Health And Age Car Group Steve Natinal Manger Population Health Branch Health And Care Programes Divison Scott Diretor Australian Hearig And Health Industry Payments Section Industry Programme Brach National Disability Insurace Agency Jacinta Branch Manager Communities Practice Branch Deb Branch Manager Technical Advisory Team Advisry Service Louise Directer Haring Communitie Of Pracice Bran Ingrid Advisor SME Audiology Techinical Adviyce Brench Tori Branch Manager Access Workload Management Branch APOLOGIES: Peter (NDIA) redacted Ron (DSS) sarah (Health) Jessica (Health)

Discussion Items

Temporary conductive hearing loss

s22(1)(a)(ii)-irrelevant material

AAT decision and implications (Evans vs NDIS)

FOI: 25/26-1019

NDIA’s position on Access operational guidelines:

The Tribunal has demonstrated through its decisions regarding access operations under the National Disability Insurance Scheme (NDIS), particularly concerning hearing impairment.

• The current guideline does not set precedent but highlights potential inadequacies within it, specifically focusing more broadly than just early intervention or reduced function benefits from such interventions;
• DSS /DoH are advocating strongly towards adopting an ‘early diagnosis’ threshold; however,
• NDIA maintains their stance against prescriptive measures in this regard;
• For HSP clients transitioning into mainstream services: criteria remain at present as per adults meeting ≥ 65dB, though s22(1)(a)(ii) - irrelevant material is redacted here for brevity.

Further developments planned with OGs:

By September (Jacinta agreed to confirm timeframe) some changes will be completed toward making language of Operational Guidelines functional rather than descriptive.

Population statistics relevant context:

Pertinent population figures indicate that people suffering significant hearing loss outnumber those enrolled directly via HSP programs. This is a key consideration when formulating policy and practice around NDIS eligibility thresholds.redacted: OG – Disability: Hearing losses exceeding 60 dB bilaterally should not necessitate further information beyond demonstrating substantially impaired communication abilities due to conversational speech limitations. Conversely below the same level (i.e., < <60dB) supporting evidence like audiograms may still need confirmation through tests performed by audiology professionals, e.g.: Speech discrimination test results which assesses ability to understand spoken words amidst background noise— poor scores suggest garbled or muffled sounds during conversation can occur. Word recognition scores also help predict effectiveness of potential aids.

Referral Pathway involving Australian Hearing:

The NDIA aims avoid disrupting diagnostic pathways established in cases where children are newly diagnosed as having severe hearing impairments; it suggests initial assessments and fitting procedures related specifically towards these individuals should remain under health funding until they transition into NDIS participant status.

FOI 25/26-1019

s22(1)(a)(ii) - irrelevant material

Next steps and close.

Summary of actions

Ref.	Action	Responsible	Due	Comment
redacted: s22(1)(a)(ii) – irrelevant ma&rdash;i&rdashterial	Operational Guidelines will need to be updated to ensure that eligibility focussed more on ‘substantially reduced function’. There currently no criteria/examples in the guidelines for assessing individuals with less than 4FAHL.db 65d,			`
criteria/exampl
``es ihe Guidelin
```eS foassessing individuallwth lessthan <65dB 4F AHL,\r\nOperational Gudelines wll neeed toupdate te ensurte elgibility is fousced mre oon'substanally reducd functio'. Thre currenlly nno crietia/eamplesintheGuidelinsfor assessing indiviualswithless thant<65Db 4FAHl. `
Operatinal Guide lines wilneed tuo update tonensurethateligibiltyisfocussedmoreonsubsntuallyredusfunction.’TherecurrentlynocriterieexamplesintheguidelineforasseSSingindividualswithlessthann65Db FAhl.
OperationalGidelineswillneedeupdateensurethatelligibiltyisscusedmoresontsustantlyducedunction’
Thererecurrenty nocritierexamplenintheguideLinesforassesSingindividuaLwithlessthan65DB 4A HL.
redacted: s22(1)(a) – irrelevan&rdashterial	Operational Guidelines will need to be updated to ensure that eligibility focussed more on ‘substantially reduced function’. There currently no criteria/examples in the guidelines for assessing individuals with less than <65dB4F AHL.\r\ncriteria/exampl
``es ihe Guidelin
```eS foassessing individuallwth lessthan <65dB,4 F A H L.,`
criteia/eamplesintheGuidelinsfo asse ssing indiviualswithl ess thant<65Db ,4FAHL. `
Criteria/ExamplesInTheGuideLineForAssesseIngIndividualsWithLessThan65db 4fahl,
CriterieExampleSinTHeGuideLinEFoRAsSeSSIngIndiviDualSWitHLeEss ThAnT<65D B 4 FAh l.
OperationalGidelineswillneedeupdateensurethatelligibiltyisscusedmoresontsustantlyducedunction’
Thererecurrenty nocritierexamplenintheguideLinesforassesSingindividuaLwithlessthan65DB 4A HL.
redacted: s22(1)(a) – irrelevan&rdashterial	Operational Guidelines will need to be updated to ensure that eligibility focussed more on ‘substantially reduced function’. There currently no criteria/examples in the guidelines for assessing individuals with less than <65dB4F AHL.`\r\ncriteria/exampl
``es ihe Guidelin
```eS foassessing individuallwth lessthan <65dB,,4 F A H L.,
criteia/eamplesintheGuidelinsfo asse ssing indiviualswithl ess thant<65Db ,4FAHL. `
Criteria/ExamplesInTheGuideLineForAssesseIngIndividualsWithLessThan65db 4fahl,
CriterieExampleSinTHeGuideLinEFoRAsSeSSIngIndiviDualSWitHLeEss ThAnT<65D B 4 FAh l.
OperationalGidelineswillneedeupdateensurethatelligibiltyisscusedmoresontsustantlyducedunction’
Thererecurrenty nocritierexamplenintheguideLinesforassesSingindividuaLwithlessthan65DB 4A HL.
redacted: s22(1)(a) – irrelevan&rdashterial	Operational Guidelines will need to be updated to ensure that eligibility focussed more on ‘substantially reduced function’. There currently no criteria/examples in the guidelines for assessing individuals with less than <65dB4F AHL.`\r\ncriteria/exampl
``es ihe Guidelin
```eS foassessing individuallwth lessthan <65dB,,4 F A H L.,
criteia/eamplesintheGuidelinsfo asse ssing indiviualswithl ess thant<65Db ,4FAHL. `
Criteria/ExamplesInTheGuideLineForAssesseIngIndividualsWithLessThan65db 4fahl,
CriterieExampleSinTHeGuideLinEFoRAsSeSSIngIndiviDualSWitHLeEss ThAnT<65D B 4 FAh l.
OperationalGidelineswillneedeupdateensurethatelligibiltyisscusedmoresontsustantlyducedunction’
Thererecurrenty nocritierexamplenintheguideLinesforassesSingindividuaLwithlessthan65DB 4A HL.

FOI 25/26-1019

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