DOCUMENT 3
Practice Guide – Psychosocial Disability
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Contents
Practice Guide – Psychosocial Disability ……………………………………………………………………… 1
- Purpose ………………………………………………………………………………………………………. 4
- To be used by ………………………………………………………………………………………………. 4
- Scope ………………………………………………………………………………………………………….. 4
3.1 Recognising psychosocial disability ………………………………………………………………. 4 3.2 Social Model of Health ………………………………………………………………………………… 5 3.3 Diversity and social inclusion ……………………………………………………………………….. 5 3.4 The recovery approach ……………………………………………………………………………….. 6 3.5 Trauma informed support ……………………………………………………………………………. 6 3.6 Recovery based language …………………………………………………………………………… 7
- Pre-planning ………………………………………………………………………………………………… 8
4.1 The planning conversation ……………………………………………………………………… 8 4.2 Psychosocial Recovery Coach …………………………………………………………………….. 9 4.3 Informal supports ……………………………………………………………………………………… 11
- Planning …………………………………………………………………………………………………….. 13
5.1 Planning for episodic conditions …………………………………………………………………. 13 5.2 Supports to consider for participants with psychosocial disability …………………….. 13 5.3 Recovery Coach ………………………………………………………………………………………. 15 5.4 Support coordination…………………………………………………………………………………. 15 5.5 Disability-related health supports ………………………………………………………………… 15 5.6 Forensic patients ……………………………………………………………………………………… 16 5.7 Functional impact of mental health conditions ………………………………………………. 16
- Plan Implementation and Monitoring ………………………………………………………………. 16
6.1 Recovery Coach ………………………………………………………………………………………. 17 6.2 Liaising with clinical mental health services or facilities ………………………………….. 18 6.3 Crisis support …………………………………………………………………………………………… 18
- Case examples …………………………………………………………………………………………… 19
7.1 Billy ………………………………………………………………………………………………………… 19
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7.2 Jane ……………………………………………………………………………………………………….. 20
- Appendices ………………………………………………………………………………………………… 22
8.1 Appendix A: Discharge planning …………………………………………………………………. 22 8.2 Appendix B: Definitions ……………………………………………………………………………… 24 8.3 Appendix C: Table of supports – Guide for decision makers …………………………… 26
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Supporting material ……………………………………………………………………………………… 34
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Process owner and approver ………………………………………………………………………… 34
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Feedback …………………………………………………………………………………………………… 34
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Version change control ………………………………………………………………………………… 34
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1. Purpose
This Practice Guide helps you to understand the support needs of participants with psychosocial disability. Increasing your understanding of psychosocial disability allows you to contribute to a positive planning experience for the participant and encourage effective implementation of participant plans.
2. To be used by
- Plan Developers
- Planners
- Partners in the Community (Local Area Coordinators [LACs])
- NDIA Plan Delegates
3. Scope
Psychosocial disability is the term used to describe the experience of people with impairments and participation restrictions related to mental health conditions. The NDIS considers mental health conditions to be a broad term that describes many different disorders, illnesses, and syndromes. While not everyone with a mental health condition will experience psychosocial disability, those that do can experience severe psychological effects and social disadvantage (National Mental Health Consumer and Carers Forum, 2011).
This Practice Guide focuses on best practice models of psychosocial support, including promoting individual recovery for the participant and person-centred practice to work towards bridging the gap between medical and social models of recovery.
Gaining a better understanding of mental health recovery, recovery language and what recovery oriented means, allows you to:
- promote a culture and language of hope and optimism
- develop your capabilities to support people with psychosocial disability
- encourage participants to recognise and take responsibility for their own recovery and wellbeing to enable them to define their goals, wishes and aspirations.
3.1 Recognising psychosocial disability
Psychosocial disability differs from other disability types in that it is episodic and fluctuating in nature. It may be difficult to identify and understand compared to other disability types because:
- it cannot always be seen or observed
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- there is a strong relationship between mental ill-health and psychosocial disability in which each impacts on or can cause the other. Mental illness describes a broad range of conditions with different symptoms, treatments and recovery journeys
- the experience and impact is different for every individual.
3.2 Social Model of Health
The social model of health examines all the factors that contribute to health, such as social, cultural, economic and environmental factors. It differs from the medical model of health that only considers whether a disease or condition is present or not. Psychosocial disability crosses both social and medical recovery models and affects the participant’s ability to participate fully in life (Report: Psychosocial Capability in the NDIA). People with psychosocial disability are more likely than the general population to experience:
- poor physical health and suicide
- lower levels of employment and education
- limited positive and supportive relationships
- trauma and discrimination that further reduces access to health care, housing and other mainstream services.
The NDIS supports participants to identify what support they need across all areas of their life and maximise their opportunities for social and economic participation.
3.3 Diversity and social inclusion
A socially inclusive society is one where all people feel valued, their differences are respected and their basic needs are met so that they can contribute in a meaningful way.
Understanding diversity, social inclusion and the social model of health will enable you to:
- identify and address the particular socioeconomic barriers faced by the participant with psychosocial disability, and how some of these differ from other disability types
- recognise and address attitudinal barriers including stigma and discrimination
- identify the reasonable and necessary supports that will support the participant to achieve their goals including employment, education, housing and social supports
- support better access to and outcomes from mainstream services for the participant.
Aboriginal and Torres Strait Islander people often perceive their health in the context of the social, emotional and cultural wellbeing of the whole community rather than in terms of their own physical and mental health. They may not accept the language of mental illness and disability. The impact of wellbeing is influenced by their connection to land, culture, spirituality, family and community. Refer to the Practice Guide Aboriginal and Torres Strait Islander Planning Support to develop strategies and consider how you can support Aboriginal and Torres Strait Islander peoples to achieve the best possible outcomes.
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3.4 The recovery approach
3.4.1 What is recovery?
The term ‘recovery’ is used widely throughout the mental health sector and has different meanings for different people. People who experience psychosocial disability may describe themselves as being on a ‘recovery journey’. In the NDIS, recovery is achieving an optimal state of personal, social and emotional wellbeing, as defined by each individual, whilst living with or recovering from a mental health condition.
Clinical recovery and personal recovery are quite different:
- Clinical recovery is based on the medical model of health and is the treatment of impairments and the minimisation of symptoms of mental health conditions
- Personal recovery is based on the social model of health and is living a meaningful life and being able to contribute to a community within the limitations caused by a mental health condition.
When people talk about their mental health recovery they are actively seeking to have a sense of purpose and meaning in their life, despite the symptoms, impairments and disability their condition may bring.
An understanding of the recovery approach allows you to communicate in an appropriate, strengths based manner and use recovery based language throughout the participant’s experience with the NDIS.
Recovery is an individual and unique process. It is defined by the person and driven by their needs and choices. Recovery involves:
- having hope
- being motivated
- feeling optimistic about the future
- having the skills and strategies to manage the challenges the participant may experience.
3.5 Trauma informed support
When engaging with the participant it is important:
- to be aware they may have experienced trauma
- to understand how trauma can impact on their capacity and willingness to participate in planning meetings, particularly discussing their goals and thinking about their progress.
Trauma may not be immediately obvious and can be hidden under the surface and triggered by seemingly normal situations. It is important to remember that many participants with a psychosocial disability have had an experience with trauma. You will need to tailor your communication accordingly.
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The impact of trauma is different for every individual. It can be experienced as:
- a high state of alert emotion
- a sense of numbness and avoidance
- headaches and fatigue
- anxiety and depression
- nightmares
- sleeping and eating issues
- misuse of alcohol or drugs.
It is important to listen to the participant’s experiences and respond to each situation accordingly to recognise where particular discussions or experiences may trigger a trauma response.
3.6 Recovery based language
It is important to use language that conveys hope and optimism to the participant and to support and promote a culture that fosters recovery.
For example use the term ‘person with a mental health condition’ rather than ‘mentally ill person’.
The following resources will help you to understand and use recovery language:
- Recovery orientated language guide (external) produced by the Mental Health Coordinating Council (MHCC)
- Reimagine website (external).
Over 90% of our communication is non-verbal, comprising body language, non-verbal cues such as nods and smiles and tone of voice. When communicating with the participant you should focus on:
- your non-verbal communication as well as the language you use
- the participant’s age, hearing, cognitive or language needs
- being authentic, transparent and sincere.
Note: Suicidal or self-harm related thoughts or statements must be taken seriously and are considered to be a participant critical incident. You should use the Participant Critical Incident Framework to determine the necessary and appropriate actions to undertake if you become aware that the participant is threatening or attempting self-harm.
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4. Pre-planning
When planning with participants who have a psychosocial disability:
- use a whole of person centred approach
- ensure plans are personalised, directed by the participant and recognise their right to exercise control over their own life
- respect the role of any family or significant people in the participant’s life, community and mainstream support networks and strengthen their capacity to support the participant
- find a balance between the concerns and goals identified by the participant and goals identified by the participant’s support networks.
Many participants with psychosocial disability also experience fatigue, disrupted sleep patterns and challenges with organisation due to their psychosocial disability and/or impacts of medication. It may be useful to call the participant the day before the planned meeting and remind them of the time and place the meeting will be held. Record an alert in the NDIS Business System (System) if the participant prefers a phone call the day before a planned meeting.
Note: It is also advised you set a calendar reminder because an alert will only appear if the participant’s record in the System is open.
4.1 The planning conversation
During the planning conversation spend time building rapport with the participant to make the planning conversation seem less formal and make them feel more comfortable. This approach may support the participant to:
- manage any negative emotions they may be experiencing
- pre-empt challenges they may experience
- agree to strategies to put in place rather than wait for them to experience negative emotions
- be more responsive to questioning throughout the planning process.
Before moving into the more formal planning stages check with the participant what supports they may need to comfortably participate in the process. For example, will they need regular breaks, are there topics that are ‘off limits’, what will you do if it appears the participant is struggling with the meeting?
It is important to always:
- be respectful, non-judgemental and genuine
- show empathy in relation to the participant’s life experience
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- try not to pre-empt the participant’s responses
- allow the participant the time they need to think about their needs and responses.
Should the participant appear anxious or disengage during the meeting, implement the agreed strategies. Consider asking them what would make them feel more comfortable. For example, taking a short break or moving to a different room.
The participant may require additional support to identify goals and share relevant information. To help them, summarise and recap back what they have said. This will confirm their needs and further support them to identify their goals. You could also use person centred tools to progress the discussion. For example, discuss what is important to the participant, or ask, ‘what does a good day look like and what supports do you need to have a good day?’
4.2 Psychosocial Recovery Coach
A psychosocial recovery coach (recovery coach) is a qualified mental health worker and through their own experiences and training, understands mental health and its impacts. They can support the participant to build confidence and motivation, foster hope and build capacity to achieve their goals and use their supports to live a full and contributing life. A recovery coach will also support the participant to understand how the NDIS operates within a broader ecosystem of supports including mainstream and community supports.
With support from a recovery coach, it is anticipated that over time, the participant will be able to build their capacity in areas of their life which will then mean they require less support overall to achieve their goals. This could see a decrease in other reasonable and necessary supports in their plan.
4.2.1 Recovery coach types
There are two types of recovery coaches. The participant can decide which type of recovery coach they feel will be the best fit for them. Both types of recovery coach have qualifications, training and experience working in the field of mental health. You should understand and discuss with the participant which type of recovery coach might best suit their individual needs. This may depend on a number of factors:
- the participant’s stage in their recovery journey
- whether they feel more comfortable with a recovery coach who has lived experience of psychosocial disability
- other personal preferences that may influence their decision.
The two types of recovery coach are:
- Lived Experience Recovery Coach – with lived experience competencies.
- Psychosocial Recovery Coach – with learnt experience competencies.
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A lived experience recovery coach, in addition to their formal qualifications has lived through their own experiences with mental health and recovery. They will draw on their personal understanding of mental illness and its impacts when working with the participant. They are able to disclose their lived experience in a purposeful manner to build rapport and a trusting relationship with the participant. This allows them to better understand how the participant may be feeling and they can use that understanding to support the participant on their own recovery journey.
4.2.2 How a recovery coach will work with the participant
As the recovery coach is a new role, the participant may not have had this type of support before. They may ask you about the type of support a recovery coach will provide and what benefits they may get from this additional support. It is important that you understand and discuss the role with the participant so they understand how a recovery coach will support them to achieve their goals and live a full and contributing life.
Discuss the below points with the participant and explain how the recovery coach will support them in their recovery, engagement with the NDIS and other supports. A recovery coach will support the participant to build their capacity and positive relationships in the community, which in turn will reduce the intensity of supports required in the future. A recovery coach will work with the participant to:
- develop a recovery-enabling relationship with them, their families and carers. This relationship will be built on trust and a shared understanding of the participant’s goals and needs so they can work through the ups and downs of a recovery journey together.
- develop and maintain an individual recovery plan. The Recovery Plan will support the participant and optimise available resources (including, their NDIS funding and clinical mental health services).
- provide recovery coaching. A recovery coach will engage with the participant and support them to take more control of their lives. Supporting the participant to better manage the complex challenges of day to day living and articulate and own what a contributing life means for them and their families, and carers.
- coordinate services and support them to access a range of different resources and services in a way that helps them work towards their goals identified in their Recovery Plan.
- complete progress reports to demonstrate that supports are meeting participant expectations and needs. The recovery coach will provide progress reports to the participant and NDIS at agreed times. Progress reports will outline how NDIS funds and other resources are being effectively utilised to progress goals identified in the participant’s Recovery Plan.
- engage with the NDIS by developing their knowledge and skills in navigating the NDIS, self-advocacy and fund management so they become an active participant.
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4.2.3 When to include a recovery coach in a participant’s plan
Generally, if a participant’s primary disability is psychosocial disability then a psychosocial recovery coach should be considered if you identify that the participant requires support to:
- link and maintain engagement with informal, community, mainstream and funded supports
- build capacity, including strengths and resilience.
A recovery coach is available to participants across all service streams – General, Supported, Intensive and Super Intensive. The inclusion of a recovery coach in a participant’s plan must be determined to be reasonable and necessary. The below levels are a guide for reasonable and necessary decision making. There are three indicative levels of funding for a psychosocial recovery coach:
- Level 1 – 100 hours per year
- Level 2 – 50 hours per year
- Level 3 – 30 hours per year.
For further guidance on determining the reasonable and necessary level of funding and how to include recovery coach support in the participant’s plan refer to the Standard Operating Procedure – Include Psychosocial Recovery Coach Support in a Plan.
4.3 Informal supports
4.3.1 Engaging informal supports
With the participant’s consent and where possible it is often beneficial to engage informal supports to assist the participant during the planning process. Informal supports can help to build a whole picture of the participant’s day-to-day life, functional capacity and long-term needs. The participant may not feel comfortable to share information with a planner or LAC about how their functional impairment affects their lives. Their informal supports can support the participant to engage in the planning conversation.
Informal supports may:
- include family members
- include carers
- include friends
- reduce the risk of participants disengaging from the Scheme.
4.3.2 Carers
Over 240,000 Australians provide unpaid care to a friend or family member who is experiencing mental illness. In doing so experience barriers to retain paid work and have reduced education and employment opportunities.
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To help support carers maintain their involvement consider how funded supports can:
- support and sustain relationships
- identify, support and sustain reasonable informal supports by offering respite and a break for carers
- support and acknowledge carers and families own ordinary lives.
4.3.3 Reluctance to engage informal supports
If the participant is hesitant to involve their informal supports in the planning process you should explore this with them. It is important to reassure the participant that, in the end, their decisions and ideas will be what drives their NDIS plan. Always include the participant in conversations, encourage them to participate in decision making and consider ways to support them to build independence.
For example, you could say:
‘Sometimes it’s hard to think of everything you need to consider at a planning meeting. Is there anyone you can think of who you would like to come to your planning meeting? They might be able to remind you about something you’ve forgotten. This information can help make sure we develop a plan for you that meets all of your needs.’
or
‘We usually involve families, or someone who is important to you in planning discussions. Is there someone you would like to be involved? Do you give me permission to contact/include them?’
4.3.4 Discussion topics to have with informal supports
Encourage the participant to talk with their family, friends and support workers about:
- the supports they might need in their plan
- their hopes and dreams
- what reports they may need to provide to the planner or LAC before their planning meeting to feel prepared and in a better position to participate.
4.3.5 Record informal supports
When a participant would like their informal supports involved in the planning process, record their details and the participant’s consent to contact them in the System.
Complete this task as early as possible. Refer to Standard Operating Procedure – Verify and Record Identity and Standard Operating Procedure – Consent and Authority.
4.3.6 Record legal orders
If you identify during the planning process that the participant has a legal order in place (Guardianship, Trustee, Forensic, Treatment or Justice), record details in the System. Where
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possible attach a copy of the order to inbound documents. You should review the orders to be aware of any decisions that other parties may make or any restrictions that will impact in the planning process. For example, if the participant has appointed a financial administrator to manage their money, they are not able to self-manage their NDIS funds. The administrator may agree to engage in this role on their behalf.
Refer to Standard Operating Procedure – Manage Inbound Documents.
A plan and/or correspondence nominee may be appointed by the participant or if the plan developer considers it appropriate.
Refer to Standard Operating Procedure – Record a Nominee Request.
5. Planning
5.1 Planning for episodic conditions
The symptoms of psychosocial disability may be episodic and vary in intensity and need for support. To allow the participant to manage these needs, you should:
- ensure Core support categories are flexible so supports can be increased or decreased as necessary
- explain plan flexibility to the participant and their informal supports so they understand how to use their plan funding flexibly
- explain that if they are hospitalised, some of their NDIS funded supports (for example Core supports) may not be available to them while they are an inpatient. The supports can start as soon as they are out of hospital.
5.2 Supports to consider for participants with psychosocial disability
Funded supports should be considered in the context of:
- A focus on capacity building and individual skill development. Many people with a psychosocial disability have had little or no access to skill-based assessments and supports that build their individual capacity.
- Identifying support needs based on the whole of person. The participant may experience social isolation, and may not have informal support networks to help them engage with mainstream, community or funded supports. The participant will likely need support to implement their plan.
- The impact both regular and irregular supports may have on maintaining the participant’s wellness. Funded supports for domestic assistance, and/or assistance with self-care and community access, could all be integral to supporting the participant to maintain their overall wellness, even if they are only used episodically.
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5.2.1 Supports to consider
| Support | Description |
|---|---|
| Capacity Building | - Improved daily living skills for example assistance with decision making, daily planning and budgeting - Improved Relationships. For example, individual social skills development - Increased Social and Community Participation. For example, life transition planning including mentoring, peer support and individual skill development - Improved Living Arrangements. For example, assistance with applying for accommodation and tenancy obligations. |
| Capacity Building | Support by a recovery coach, who will work with the participant to: - build capacity and resilience - manage the complex behaviours involved in psychosocial disability issues - improve social and economic participation - identify, plan, design and coordinate supports - plan and maintain engagement through periods of increased support needs OR Support by a support coordinator to connect with informal, mainstream and/or funded supports to maintain support relationships and resolve service delivery issues and points of crisis (LAC or support coordination depending on the participant’s individual circumstances). Note: Some participants may already have a support coordinator and may choose to continue working with their support coordinator rather than changing to a recovery coach. |
| Core | Support participant to manage activities of daily living - personal care - community access - attending appointments - shopping, household and health management. |
For a breakdown of supports generally funded by the NDIS, and supports generally funded by other parties refer to the Appendix C: Table of supports – Guide for decision makers.
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Note: The NDIS does not fund supports for clinical treatment related to mental health conditions.
5.3 Recovery Coach
Funding for recovery coach support will sit in the Capacity Building>Support Coordination budget. Hours should be included in the plan at the weekday day time rate using the below support item:
- Psychosocial Recovery Coaching - Weekday Daytime
You must include the support in the plan at the weekday day time rate. It is up to the participant to discuss with their recovery coach when it suits them best to use the support. A recovery coach will be able to claim a weekday daytime, evening, night, weekend and public holiday rate, refer to Price guides and pricing (external) for further information.
To include funding for a recovery coach in the participant’s plan refer to the Standard Operating Procedure – Include Psychosocial Recovery Coach Support in a Plan.
5.4 Support coordination
Generally the participant should not have funding for both recovery coach support and support coordination included in their plan. If the participant has had support coordination in previous plans discuss the recovery coach role with them and the support a recovery coach can provide. Explain that a recovery coach will be able to provide targeted support for the participant in relation to their psychosocial disability and can support them in their recovery journey. If the participant is already linked with a support coordinator they can exercise their own choice and control to decide if they want to use their recovery coach funding to continue receiving support from their support coordinator, or wish to change to support provided by a recovery coach.
Support coordination may be considered reasonable and necessary in addition to funding a recovery coach in limited circumstances. For example, funding for a specialist support coordinator may be considered reasonable and necessary if the participant identifies a goal of finding suitable housing. Refer to the Practice Guide – Identifying Housing Solutions and Standard Operating Procedure – Include Support Coordination in a Plan.
5.5 Disability-related health supports
Reasonable and necessary disability-related health supports can be included in a participant’s plan if they:
- result from the participant’s ongoing functional impairment(s) to which a disability is attributable, and
- are provided in the community, and
- are a regular part of the participant’s daily life.
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The NDIS will not fund disability-related health supports which are more appropriately provided by another service system, such as forensic or secure mental health facilities. Refer to the Practice Guide – Disability-Related Health Supports for further information.
5.6 Forensic patients
In cases where the participant is in hospital or detained in a secure mental health facility there may be further planning considerations you need to take into account. Participants who are in a secure mental health facility may be forensic patients. Forensic patients are people who:
- have been found unfit to be tried for an offence (whether or not a special hearing has been held) and ordered to be detained in a correctional centre, mental health facility or other place
- have gone through a criminal trial or a special hearing and are ‘not guilty on the grounds of mental illness’ (Mental Health Coordinating Council).
Please refer to Appendix A – Discharge planning, Practice Guide – Justice and Practice Guide – Participants Streamed as Intensive or Super Intensive for information related to participants involved with the criminal justice system. For example, incarcerated and pending release.
5.7 Functional impact of mental health conditions
Funded supports must address the impact of the participant’s functional impairments. Supports associated with treating the symptoms of the mental health condition is considered clinical treatment and remains the responsibility of other mainstream service systems.
For example, if a participant experiences symptoms of panic or paranoia when using public transport and accesses Cognitive Behavioural Therapy to address this, the provision of this support would be the responsibility of the health system. The NDIS could fund capacity building supports (Capacity Building – Increased Social and Community Participation) to support the participant to build capacity to use public transport with the aim of independent travel. This may include support with trip planning, understanding transport systems and developing strategies to manage when trips don’t go to plan.
For further examples of symptoms and related functional support needs, please refer to pages 7-8 in NDIA’s Completing the access process for the NDIS: Tips for communicating about psychosocial disability for individuals with psychosocial disability.
6. Plan Implementation and Monitoring
For participants who have funding for a recovery coach or support coordinator you will need to link the participant to their recovery coach or support coordinator.
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To link the participant with a recovery coach or support coordinator the plan delegate will need to complete the Standard Operating Procedure – Make a Request for Service (Support Coordination and Recovery Coach).
Once a provider has been engaged complete a warm handover to the recovery coach or support coordinator. This is necessary so the recovery coach or support coordinator understands how to best support the participant and implement the plan.
Monitor the support coordinator or recovery coach’s reporting requirements. Follow up if necessary to make sure the participant is connected to funded, mainstream and community supports.
If the plan does not include funds for a recovery coach or support coordinator, complete a warm handover with the LAC who will support the participant to implement their plan. They should work collaboratively with the participant and/or their family to help them understand supports in their plan and support them to engage with paid service providers as well as mainstream and community supports. This should also include checking in with the participant to make sure their supports are meeting their needs and troubleshooting any difficult circumstances that arise.
6.1 Recovery Coach
If recovery coach support is included in the plan, you will need to discuss with the participant if they have any preferred providers for this support and gain their consent for the NDIA to make a referral on their behalf.
When a recovery coach is funded in a plan it is critical to introduce, explain and promote the support during the planning, plan review and implementation stages. As it is a new support the participant will not know what to expect from this support and will require information to understand how this support will enable them to work towards their goals. Make sure you discuss the points outlined in the section How a recovery coach will work with the participant, so they understand the new support.
During implementation discuss with the participant that over time a recovery coach will support them to:
- build on their strengths and address barriers to achieving their goals
- engage with the NDIS and exercise greater choice and control
- experience improved physical, social and emotional wellbeing
- experience increased inclusion and participation in relationships, community, work, education and training and housing
- experience greater independence and reduced dependency on formal services and service providers.
Progress reports are required to demonstrate that supports are meeting participant expectations and needs. The recovery coach will provide progress reports to the participant
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and NDIS at agreed times. Progress reports will outline how NDIS funds and other resources are being effectively utilised to progress goals identified in the participant’s Recovery Plan.
6.2 Liaising with clinical mental health services or facilities
With the participant’s consent, the LAC, recovery coach or specialist support coordinator will participate in case meetings or conversations with the participant’s treating clinician/case manager and undertake the following:
- develop an agreed understanding of the responsibilities of the parties
- ensure the participant understands who they should contact under what circumstances for example, crisis management
- ensure the participant understands how the funded support providers are to respond to their episodic or variable support needs
- share information on the individual’s current plan
- ensure the participant’s NDIS plan, treatment plan and recovery plan complement each other and optimise outcomes for the individual
- identify how access to clinical mental health supports will be maintained, including health services available at times of crisis or escalation of need
- advise the participant’s clinical specialist mental health service if the individual ceases to be a participant.
6.3 Crisis support
In the participant’s service agreement they can specify what supports should continue if they experience a period of significant deterioration in their mental health. Funded supports should be used flexibly and increased and decreased as needed. It is the responsibility of the mainstream health system to support the participant and their informal supports around recovery/relapse planning and support in relation to the participant’s mental health condition.
The recovery coach or support coordinator should work with the participant and their family to develop a plan to support the participant if they experience a significant deterioration in their mental health. This may include a list of key contacts and authority to liaise with the participant’s family, friends, GP or other treating mental health professionals to ensure the participant is well supported during times of crisis. This is not to be confused with a therapeutic plan including strategies or medications to manage symptoms. This is the responsibility of allied health and medical professionals. The recovery coach or support coordinator should notify the Agency of these plans in the next progress report or sooner if required.
Where a recovery coach or support coordination is not funded and the participant experiences a deterioration in their mental health, LACs can support the participant to access appropriate mainstream and informal supports. If a change in the participant’s circumstances
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means additional streaming factors are met the LAC may recommend a change in streaming, refer to the Standard Operating Procedure – Update Participant Streaming.
Note: The term crisis support is used internally and may not be reflective of the terminology used with the participant or in the mental health sector.
7. Case examples
7.1 Billy
7.1.1 Meet Billy
Billy has met access requirements, has been hospitalised for four months in a mental health facility and is on a forensic order. The forensic order is a community based order, as opposed to a custodial order, and states that he must continue to access treatment and attend all appointments made in relation to his mental health condition as recommended by his treating psychiatrist.
7.1.2 Discussion
Funded supports should not be provided while Billy is residing in the facility. While Billy is an inpatient, the health system is responsible for meeting the day to day care and support needs including those related to his disability. This includes any supports required to access the community as part of rehabilitation.
In this case, the mental health system retains responsibility for providing:
- clinical treatment related to the participant’s mental health condition
- rehabilitation/recovery treatment
- residential care where the primary purpose of the care model is for time limited support following inpatient treatment (for example Step Up/Step Down programs).
7.1.3 Planning
Before developing Billy’s plan, the plan developer requests information regarding discharge planning from the mental health facility and records the following information in the System:
- planned timeframes for discharge
- confirmation that the participant’s mental health condition has stabilised and the participant is well enough to live safely in the community
- details of where the participant will be living after discharge including what informal supports are available to them
- details of the mental health and health clinical supports, that will be put in place to support the participant post discharge
- information about what other supports will be required post discharge to support the participant with daily activities
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- any other information available.
When discharge is planned for within 12 weeks, a plan is developed following the normal planning process. Refer to Practice Guide – Determine Reasonable and Necessary Supports. Once the plan is approved, a warm handover is completed with the recovery coach or support coordinator. The recovery coach or support coordinator starts working with Billy and facility staff to progress transition planning.
If Billy requires a plan prior to 12 weeks before the scheduled discharge date, the plan can be approved without including funded supports, with the details of his mainstream and informal supports. Refer to the section ‘No reasonable and necessary supports identified’ in Practice Guide - Determine Reasonable and Necessary Supports. A plan review should be completed prior to discharge once the discharge date is known, to include funding in the plan for supports required when the participant leaves the mental health facility.
The planner attaches a copy of the forensic order to the participant’s record in the System and adds an alert related to the order. The planner referred to Standard Operating Procedure – Manage Inbound Documents and Standard Operating Procedure – Alerts in the NDIS Business System.
Note: Refer to the TAB Requesting Advice intranet page for information about mandatory advice requests when planning decisions may need to consider forensic orders.
7.2 Jane
7.2.1 Meet Jane
Jane is 41 years old and lives in public housing. Jane was studying to become a vet before her education was interrupted by the onset of mental illness. Jane experiences high levels of anxiety when she leaves her home. She has previously been hospitalised following a decline in her mental health.
7.2.2 Access to Informal, Community and mainstream supports
Jane receives support from a support worker funded through her NDIS plan. However Jane reports having no friends and that she rarely sees her family.
Jane lives alone and has a number of bird cages and pet accessories. The public housing authority asked Jane to reduce the clutter in her house so that it can be cleaned, but she refused. Jane has been threatened with eviction.
7.2.3 Engagement with the NDIS
Jane has a plan review meeting with her NDIS planner and they discuss the new recovery coach support available to participants with psychosocial disability. Jane’s planner includes level 1 funding for recovery coach support in Jane’s NDIS plan as she is currently not linked to clinical supports and has little informal or community supports in place.
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The recovery coach helps Jane to develop a recovery plan. They identify what’s important to her, exploring her values and interests and link this to her NDIS goals of maintaining her current housing and getting a job.
Jane identified caring for animals as an interest. The recovery coach supported Jane to:
- identify the barriers to achieving her goals
- identify the skills she needed to help her take steps toward these goals
- to link with a psychologist to work with her to develop strategies for managing anxiety and building up emotional strength to spend time out of the house
Jane sought out reassurance and encouragement from her recovery coach to engage with her psychologist. She initially felt that her sessions with her psychologist was not a good use of the psychologist’s time. She discussed her concerns with her recovery coach who reassured her that the psychologist was there to support her.
The recovery coach helped Jane to develop the confidence to begin volunteering at an animal shelter.
Jane, having practiced self-advocacy and negotiation skills with her recovery coach, is working with a housing support officer to reduce the clutter of pet accessories in her house. She has successfully negotiated the sale of several items through Gumtree. Jane has managed to avoid eviction and her housing is stable.
7.2.4 What’s happening for Jane now
It has been several months since Jane began receiving support from a recovery coach. She has increased her volunteering hours over this time and she hopes to increase to two days a week in the future. Through her volunteering Jane has made a number of friends and has taken up swimming and joined a walking group which are helping her physical strength, energy and sense of wellbeing.
Jane has updated her goals in her recovery plan with her next goal being to learn computer and other digital skills so she can study an online certificate in animal care. Jane, with the help of an employment service hopes to apply for a job at the local animal shelter.
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8. Appendices
8.1 Appendix A: Discharge planning
This overview is of hospital/secure mental health facility discharge processes and includes considerations for planning if a forensic order is in place and when a discharge date has been set.
The NDIS and the mental health system work together to plan and coordinate streamlined care for individuals requiring both health and disability services. Planners, recovery coaches, support coordinators and LACs consult with their State or Territory’s relevant specialist mental health discharge planning guidelines. The guidelines are used to engage the responsibilities of specialist mental health services during a participant’s transition from rehabilitation or hospital settings.
Keep lines of communication open, and provide clear information to the participant, and all parties involved in planning for discharge. For advice on reasonable and necessary transitional supports during the discharge processes from either mental health or justice facilities TAB advice can be sought.
Note: Advice may be mandatory in some circumstances. Refer to the TAB Requesting Advice intranet page.
When determining NDIS supports for participants who are involved with the justice system, refer to Practice Guidance – Justice for information related to pre-release planning and Practice Guide – Participants Streamed as Intensive or Super Intensive.
8.1.1 Health Liaison Officers
Health Liaison Officers are represented in all states and territories and work within the Complex Support Needs (CSN) Pathway Branch of the NDIA. They provide a single point of contact for health staff to facilitate support for participants (prospective and current) in hospital settings.
For more information refer to the Health Liaison officer factsheet on the CSN intranet page.
8.1.2 Transition supports
The NDIS is responsible for working with the mental health system during discharge planning to support participants with psychosocial disability who require disability-related functional supports following discharge.
NDIS involvement in transition planning should commence when a participant has stabilised and there is a need for ongoing disability-related supports to maintain or manage functional capacity once the participant returns to living in the community.
The health system is responsible for general discharge planning to support participants through the discharge process and during transition to post-discharge care provided in the community. For example, referral to community mental health team and housing supports.
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NDIS plans for participants in hospital or mental health facilities should be developed when a discharge date is available and this date is within 6-12 weeks’ time. However, prior to this time, a plan including only mainstream and informal supports may be developed. If required refer to No reasonable and necessary supports identified in Practice Guide - Determine the Reasonable and Necessary Supports.
If the participant has a current NDIS plan, the funding remains active and is available to support the participant to reintegrate into the community and day-to-day living activities following discharge.
Note: The participant or representative may request a plan review or the Agency may commence a plan review when there is a change in the participant’s circumstances that requires a change in their ongoing support needs.
Effective joint discharge planning ensures:
- the participant’s psychosocial support needs are appropriately identified
- NDIS supports are in place at the time of discharge
- smooth service delivery during transition
A planning meeting involving the recovery coach, specialist support coordinator or LAC, the participant and clinical mental health service should be held before discharge. As part of this meeting the treating mental health representative should be asked to provide information about what treatments will be put in place post discharge.
Service providers/recovery coaches/support coordinators/LACs should provide supports so the participant is supported through the change, as well as supports that assist participants to develop self-care and self-management capacities.
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