Ratios of support

FOI 25/26-1343 DOCUMENT 15

Ratios of support

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Research question: Is there research (national and international) available that can inform best practice in applying Ratios of Support to participant care in group programs and supported employment? Are there guidelines available in other insurance type schemes (national and international)?

Date: 14/12/2021 Requestor: Tiffany redacted: s22(1)(a)(ii) - irrelevant material Request endorsed by (EL1): Jane redacted: s22(1)(a)(ii) - irrelevant material Cleared by: Illya redacted: s22(1)(a)(ii) - irrelevant material

1. Contents

Ratios of support ………………………………………………………………………………………………………… 1

1. Contents ………………………………………………………………………………………………….. 1

2. Summary ………………………………………………………………………………………………………. 2

3. Assessment Tools…………………………………………………………………………………… 2

4. Guidelines ……………………………………………………………………………………………………… 5

5. Factors that can influence ratios of support ………………………………………………… 6

5.1  Manual Handling ........................................................................................................ 7

5.2  Behaviours of concern ............................................................................................... 8

6. Social service analogues …………………………………………………………………………………. 8

7. Appendix – Correspondence ……………………………………………………………………………. 9

7.1 Royal College of Occupational Therapists ……………………………………………………… 11

7.2   Icelandic Occupational Therapy Association .................................................          11

7.3  American Occupational Therapy Association .................................................         12

7.4  Occupational Therapy Australia ............................................................................... 13

7.5  Swedish Association of Occupational Therapists .................................................   16

7.6  Council of Occupational Therapists for the European Countries ............................. 17

7.7  NDIS Quality and Safeguards Commission researchers ......................................... 17

8. References ………………………………………………………………………………………………….. 19

9. Version control ……………………………………………………………………………………………… 21

10. Summary

Occupational Therapists (OT) use clinical judgement in determining ratios of support required by clients for employment, community and social activities. OTs appeal to a wide variety of considerations covering personal, environmental and institutional factors. No guidelines have been developed by any organisation that offer clear guidance or rules for determining ratios of support. Different assessment tools are used to inform clinical decision making depending on the individual circumstances of the person requiring support.

3. Assessment Tools

Members of Occupational Therapy Australia (OTA) advised that the types of assessments they use to assist with determining support ratios varies between participants. OTs employ their clinical reasoning in determining which assessment tool will provide the best information. Some tools and strategies that were mentioned include:

  •   informal interview and history taking
  •  observing and analysing skills of formal and informal supports
  •  Overt Behaviour Scale
  •  manual handling plans
  •  observing rosters and scheduling
  •  Care and Needs Scale
  •  Community Integration Questionnaire [7.4 Occupational Therapy Australia].

Previous research completed by the TAB Research Team in March 2021 identifies one systematic review noting that only two assessment tools have been used for both individualised support planning and resource allocation. They are the Support Intensity Scale

(SIS) and the Instrument for the Classification and Assessment of Support Needs (I- CAN) [1,2,3,4]. These two scales are the most widely researched support needs assessment scales [2]. Both are in use in Australia [2,5]. I-CANS is based on the World Health Organisation’s International Classification of Functioning, Disability, and Health. SIS uses the American Association on Intellectual and Developmental Disabilities functioning model [2].

The SIS records frequency, duration and type of support required for specific activities. The assessor rates activities according to the following scales:

FREQUENCY – How frequently is support needed for this activity?

 0 = none or less than monthly

 1 = at least once a month, but not once a week

 2 = at least once a week, but not once a day

 3 = at least once a day, but not once an hour

 4 = hourly or more frequently

 DAILY SUPPORT TIME – On a typical day when support in this area is needed, how
 much time should be devoted?

 0 = none

 1 = less than 30 minutes

 2 = 30 minutes to less than 2 hours

 3 = 2 hours to less than 4 hours

 4 = 4 hours or more

 TYPES OF SUPPORT: What kind of support should be provided?

 0 = none

 1 = monitoring

 2 = verbal/gestural prompting

 3 = partial physical assistance

 4 = full physical assistance [6].

The I-CAN records frequency and type of support required on a scale of 0 – 5 to then calculate intensity of supports required:

FREQUENCY – how often support is needed

 5 = Continuously

 4 = Frequently

 3 = Daily

2 = Weekly

 1 = Occasionally

 0 = Never

 TYPE – how much support is needed

 5 = Pervasive

 4 = Extensive

 3 = Moderate

 2 = Minor

 1 = Managed

 0 = Independent

COMBINED SUPPORT INTENSITY – sum of Frequency and Type scores

 10 = Continuous / Pervasive

 8 = Frequent/ Extensive

 6 = Daily / Moderate

 4 = Weekly / Minor

 2 = Occasionally / Managed

 0 = No support [7].

Paying particular attention to the Type scores in both assessment scales, a suitably qualified clinician may be able to interpret these scores in such a way as to suggest ratios of support or at least suggest something about possible ratios of support. For example, a person with a SIS Type score of 1 or 2 (monitoring, verbal/gestural prompting) for community access or employment activities may thrive with a higher ratio environment compared to a person with a SIS score of 4 (full physical assistance). Similarly, a person with an I-CAN Type score of 1 or 2 (managed, minor) may benefit from group social activities with a shared support worker while a person with a score of 4 or 5 (extensive, pervasive) may require direct individual support at a 1:1 or 2:1 ratio. However, the assessment tools do not specifically recommend ratios of support and any conclusions about ratios would be significantly based on clinician’s expertise or judgement.

It is also worth noting that these assessment tools do not determine support needs but are based on the assessor’s observations of support needs. Both tools record support needs based on the assessor’s understanding and then quantify and aggregate scores to indicate overall support needs. In that sense, the contribution of these assessment tools to determining ratios of support may be limited.

4. Guidelines

Previous research completed by the TAB Research Team in March 2021 states that there are no available professional or governmental guidelines that can be used to support determining personal care hours required for a range of tasks, disabilities and severity levels [1].

ICARE NSW has produced guidance relevant to people with Spinal Cord Injury. This document estimates support needs for different levels of spinal cord injury. Considerable clinical judgement is required to determine appropriate support hours. Ratios of support are not explicitly mentioned. However, the estimates do appeal to the following scale:

O = no assistance	person completes the task
X = standby assistance	person completes task with monitoring, supervision
+ = needs some/set-up support	person completes more than 75% of the task
++ = needs moderate support	person completes approximately 25-75% of the task
+++ = needs full support	person completes 25% or less of the task

[8]

As reasoned in 3. Assessment Tools, it may be possible to interpret this scale as implying something about support ratios, however this would need to be done carefully and with individual clinical justification.

I have not found any professional or governmental guidelines that could assist with determining appropriate ratios of support for community access or group social activities. I reached out to 13 professional Occupational Therapy organisations. I received replies from 6. All 6 of the groups (Occupational Therapy Australia, Royal College of Occupational Therapists in the UK, the Icelandic Occupational Therapy Association, American Occupational Therapy Association, Swedish Association of Occupational Therapists, Council of Occupational Therapists for the European Countries) confirmed that there were no overall guidelines and that determination of support ratios occurs at a local or individual level [7. Appendix – Correspondence].

Members of the OTA NDIS reference group have advised:

Guidelines could be useful. However, information must be triangulated including person’s own statement of performance, with observation, other clinical and care information, client environment, and other relevant contextual factors. Any inconsistencies need to be sorted out. Each client’s social and community participation levels are different. What is reasonable and ordinary for their age, relationships, skill set and social needs should be considered [7.4 Occupational Therapy Australia].

Sarah Jones, the Professional Practice Advisor from OTA, also referred me to a member of their NDIS Reference group for further advice. Leanne Healey, OT and founder/director of Everyday Independence, is in the process of developing and trialling a support measure aimed

at informing NDIS planning decisions. Discussions regarding this project are pending [7.4 Occupational Therapy Australia].

5. Factors that can influence ratios of support

OTA members advised the following factors can influence decisions about determining support ratio:

• level of risk to self, others and property damage
• past incident reports
• manual handling risk plans
• self-report around comfort, confidence
• cognition
• safety risks
• vulnerability within the community
• public transport confidence/ability/ability to be trained
• level of supervision required
• maximum benefit – do they participate/benefit with number of people around
• compatibility with others, e.g. issues participating with other genders precluding group ratios
• opportunities/abilities to learn from others and form natural relationships
• unpredictable or ad hoc support needs such as behavioural support or toileting support [7.4 Occupational Therapy Australia].

Relevant considerations can include personal, environmental and institutional factors. Personal factors can include:

• goals and lifestyle
• physical features of the person (height, weight etc.)
• functional capacity of the person (e.g. capacity to assist with transfers or to self-mobilise)
• the behaviour and personality of the person (e.g. presence of behaviours of concern, how well they get on with the staff)
• the person’s capacity to engage in social activities (need for prompting, active inclusion etc.)
• need for assistive technology / availability of assistive technology

Environmental factors can include:

• risk of the activity (e.g. swimming, operating tools/equipment)
• complexity of the activity (e.g. complex employment tasks, navigating crowded event)
• duration of the activity (e.g. travel time, short trip to the shops, day trip out of town)
• risk in the environment (e.g. beach, busy urban streets, crowded events)

Institutional factors can include:

• consideration of the needs of all individuals in a group
• manual handling policy of the organisation
• availability of assistive technology, accessible vehicles etc.
• availability of trained staff
• other staffing needs (e.g. scheduled breaks, support for staff with a disability)
• legislative requirements, codes of practice, professional guidelines

This list is not exhaustive. The complexity and interdisciplinarity of determining support ratios may provide a clue as to why there is very little research directly focussing on the topic.

5.1 Manual Handling

Safe Work Australia and state-based work safety organisations have codes of practice relating to manual handling tasks [9,10,11]. The Safe Work Australia Code of Practice for Hazardous Manual Tasks suggests that, to maximise worker safety, transfer equipment should be preferred to team handling. In other words, where possible a single person should assist a patient or client using suitable assistive technology rather than two or more people assisting a patient or client manually. There are of course exceptions for equipment that is designed to be operated by two people [9]. A 2011 Work Safe Victoria guideline suggests that two people may be required to operate an electric hoist where the patient or client is not able to assist [10]. A 2006 manual handling guideline from the NSW Department of Ageing, Disability and Home Care (now the Department of Community and Justice) states that clients with uncontrolled movement may require two carers for personal care tasks. The guideline also recommends the development of a Client Manual Handling plan for risk management and support planning [12].

Phillips, Mellson and Richards emphasise the importance of individual risk assessments rather than just assuming that one or two carers are appropriate for transfers [13]. Thornton observes that two carers are often required for floor hoists, while a single carer is required for ceiling hoists. The latter is safer and generally more cost effective [14]. Determining whether 1:1 or 2:1 is required for transfers depends on the suitability of available equipment with implications for funding of ceiling hoists or floor hoists.

5.2 Behaviours of concern

Behaviours of concern are a frequent reason for requesting higher staff ratios. I could not find any research directly investigating the relationship between staff ratios and behaviours of concern. A 2021 Cochrane review completed by researchers at the NDIS Quality and Safeguard Commission investigated organisational interventions for reducing use of restrictive practices. They listed 11 potential interventions but did not explicitly consider staffing numbers or staff-client ratios as a factor in use of restrictive practices [15]. Correspondence with the author of this review suggested other potential sources (refer to redacted: s22(1)(a)(ii) - irrelevant NDIS Quality and Safeguards Commission researchers). A 2009 report from the Victorian government summarises the relationship between staffing levels and restrictive practices:

Staffing factors have been identified as critical, though there is a lack of consensus in the literature as to how best to determine optimum staffing numbers. Higher staffing ratios have been suggested as a means of enabling early intervention and prevention of escalation. However, the availability of higher levels of staff have also been associated with a greater likelihood of staff using physical interventions, if for no other reason than they have the person power available to do so. Similarly, while lower staffing ratios make it practically more difficult to use restraint, lower staffing levels can also contribute to staff feeling anxious and consequently more likely to deploy restrictive practices earlier than they might otherwise do so had they the support (reassurance and security) of other staff close by who could offer assistance if required. Further research into these issues is necessary [16].

Relating specifically to staff-client ratios, the report refers to a study in which the researchers found higher staff to patient ratios resulted in increased use of restrictive practice when the staff in question were nursing assistants. However, there was a decreased use of restrictive practices when the staff in question were registered nurses [16]. This finding could not be corroborated as the reference appears to be incorrect, however it does coincide with other research that suggests training has a greater effect than staff numbers. Singh et al found that training staff with mindfulness techniques reduced staff interventions for aggression and this was true at low, moderate and high staff-client ratios [17].

6. Social service analogues

I looked into the literature related to ratios of support in aged care and childcare. Unfortunately, the literature did not add much to the considerations already raised above.

There is inconsistent evidence that ratios of support affect children’s learning and developments in early learning environments. A 2016 study by Iluz, Adi-Japha and Klein found some association between ratios of support and positive peer interactions [18]. A later systematic review found “child-staff ratios for pre-school aged children classrooms have small, if any, associations with concurrent or subsequent child outcomes” [19]. Though ultimately the standard of evidence in the reviewed papers was low.

In the context of aged care, a study by Baker et al found that abuse is more likely to occur in situations where there is not sufficient staff to complete all the work [20]. A study by Karimi-Shahanjarini et al found that insufficient staff in a hospital setting leads to lack of organisation and ‘ad hoc’ shifting of tasks [21]. In both these cases, it is not clear what counts as ‘insufficient staff’. While the findings might be relevant to determining the importance of proper ratios, they do not support planning for what those ratios might be.

7. Appendix – Correspondence

I sent an initial inquiry to 13 professional occupational therapy organisations via email on 30th September 2021 (refer to table below). With minor variations for individual organisations, the message read:

I am completing some research for the National Disability Insurance Agency, the organisation that administers Australia’s National Disability Insurance Scheme (NDIS). The NDIS provides support to eligible people with intellectual, physical, sensory, cognitive and psychosocial disability.

I am currently compiling existing research on how occupational therapists determine ratios of support for community access and group social activities. I am interested in how this is achieved internationally.

It is common practice for Occupational Therapists to recommend support ratios required by their clients. For example, while one person may require 2:1 direct assistance for certain tasks, another person might thrive with 1:7 supervision for the same task. My questions are:

• What considerations go into determining the appropriate ratio of individual support (i.e. 1:1 or 2:1)?
• What considerations go into determining a safe and effective ratio of group support (i.e. 1:3 versus 1:7)?

I’m hoping you might be able to provide some information on how your members determine the appropriate ratio of support. If possible can you please provide any:

• recommendations you make to your members regarding ratios of support
• best practice guidelines you may have developed or refer to in order to determine appropriate ratios of support
• existing research you appeal to in making recommendations / developing guidelines for ratios of support
• contacts you believe may be able to assist with my inquiry.

Thank you very much for your time and all the best

Organisation	Email	Replied (Y/N)
Canadian Association of Occupational Therapists	practice@caot.ca	N

7.1 Royal College of Occupational Therapists

From: Library library@rcot.co.uk Sent: Thursday, 7 October 2021 1:04 AM To: redacted: s22(1)(a)(ii) - irrelevant material, Aaron redacted: s22(1)(a)(ii) - irrelevant material Cc: redacted: s22(1)(a)(ii) - irrelevant material Subject: RE: Research inquiry: best practices for determining ratios of support [SEC=OFFICIAL] Dear Aaron, Thank you for your enquiry. RCOT produced two Member briefings last year that may be of interest: Workforce planning and Managing caseload - workload weighting. I attach these for your reference. As far as contacts are concerned, you may find the RCOT Independent Practice Specialist Section directory of help. The directory’s search page, and links to more information about the Specialist Section, can be found here: https://rcotss-ip.org.uk/. Moving further afield, an NHS provider directory can be viewed at https://www.england.nhs.uk/publication/nhs-provider-directory/. It gives an overview of all NHS trusts. You may, however, find contacting individual library services a better first step. The Health Library & Information Services Directory (https://www.hlisd.org/libraries/search) would help with this. Keying “foundation”, for example, in the ‘Library or Organisation Name’ box will give many results. I hope this helps. I’m ccing Anne Keen in here in case she wishes to add anything to the above. Best wishes, Alice redacted: s22(1)(a)(ii) - irrelevant material (she / her) Librarian (Collections & Access) Royal College of Occupational Therapists redacted: s22(1)(a)(ii) - irrelevant material W: www.rcot.co.uk E: redacted: s22(1)(a)(ii) - irrelevant material

From: redacted: s22(1)(a)(ii) - irrelevant material Sent: 01 October 2021 16:43 To: redacted: s22(1)(a)(ii) - irrelevant, materialAaron redacted: s22(1)(a)(ii) - irrelevant material Subject: RE: Research inquiry: best practices for determining ratios of support [SEC=OFFICIAL] Dear redacted: s22(1)(a)(ii) - irrelevant material Thank you for contacting the Royal College of Occupational Therapists (RCOT). RCOT does not provide guidance to its members regarding patient: therapist ratios as this is decided at a local level depending upon the needs of each individual receiving occupational therapy. I have found the following information, but it is not occupational therapy specific: Resources NHS evidence search workload weighting https://www.evidence.nhs.uk/Search?q=workload+weighting Social Care Institute for Excellence http://www.scie.org.uk/publications/guides/guide01/managing-work/workload.asp You may wish to contact library@rcot.co.uk to see if my colleagues could assist you further. Kind regards, redacted: s22(1)(a)(ii) - irrelevant material Professional Adviser - Professional Practice Enquiries Service Royal College of Occupational Therapists redacted: s22(1)(a)(ii) - irrelevant material www.rcot.co.uk

7.2 Icelandic Occupational Therapy Association

From: redacted: s22(1)(a)(ii) - irrelevant material Sent: Friday, 1 October 2021 7:56 PM To: redacted: s22(1)(a)(ii) - irrelevant, materialAaron redacted: s22(1)(a)(ii) - irrelevant material Subject: Re: research inquiry: best practices for determining ratios of support [SEC=OFFICIAL]

You are most welcome - best of luck with your project! redacted: s22(1)(a)(ii) - irrelevant material

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

www.ii.is

From: redacted: s22(1)(a)(ii) - irrelevant material, Aaron redacted: s22(1)(a)(ii) - irrelevant material Sent: 30 September 2021 22:30 To: redacted: s22(1)(a)(ii) - irrelevant material Subject: RE: research inquiry: best practices for determining ratios of support [SEC=OFFICIAL]

Hi redacted: s22(1)(a)(ii) - irrelevant material Yes it was a very specific request. It sounds like you’ve understood perfectly. I have found that some OT organisations develop guidelines for use by their members. From your description it sounds like things work at more of a local level in your jurisdiction. Thanks very much for taking the time to reply. I really appreciate it. All the best

From: redacted: s22(1)(a)(ii) - irrelevant material Sent: Thursday, 30 September 2021 11:08 PM To: redacted: s22(1)(a)(ii) - irrelevant, materialAaron redacted: s22(1)(a)(ii) - irrelevant material Subject: RE: research inquiry: best practices for determining ratios of support [SEC=OFFICIAL] Hi Aaron, I´m not sure if I understand your request – it seems very specific. We, as an association and a union do not have any information on how OT´s decide on support in their different workplaces. People with disabilities are a very diverse group and those decisions are made on multiple levels of the services an mostly within the different municipalities in the country. Although we have laws and procedures on support for people with disabilities but that is measured in a specific way and just for a part of the disabled population. Sorry for this Yours sincerely redacted: s22(1)(a)(ii) - irrelevant material OT, MPM President Icelandic Occupational Therapy Association redacted: s22(1)(a)(ii) - irrelevant material

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

7.3 American Occupational Therapy Association

From: redacted: s22(1)(a)(ii) - irrelevant material (AOTA Customer Service Support) customerservice@aota.org Sent: Thursday, 7 October 2021 7:39 AM To: redacted: s22(1)(a)(ii) - irrelevant, materialAaron redacted: s22(1)(a)(ii) - irrelevant material Subject: [AOTA Customer Service] Re: Research inquiry: Best practice for determining ratios of support [SEC=OFFICIAL] Hello, AOTA does not have data or publications regarding this. I would say that clinicians use their clinical and professional reasoning. Typically if AOTA does not have specific knowledge about a topic I refer members to ask questions in CommunOT. Follow the link and feel free to post any questions, concerns, etc. https://communot.aota.org/home CommunOT has a general forum, as well as several communities that one can post in, and they may be found here: https://communot.aota.org/communities/allcommunities Academic Education Admin and Mgt

AOTA Elections Children and Youth COVID 19 Developmental Disabilities Home and Community Health Mental Health Private Practice and Entrepreneurship Productive Aging Rehab and Disability Sensory Integration and Processing Students Technology Work and Industry

Thank you for your email. AOTA Practice Division Approved Provider Program

7.4 Occupational Therapy Australia

From: Practice Queries Practicequeries@otaus.com.au Sent: Wednesday, 6 October 2021 5:25 PM To: redacted: s22(1)(a)(ii) - irrelevant, materialAaron redacted: s22(1)(a)(ii) - irrelevant material Subject: RE: Best practice for determining ratios of support [SEC=OFFICIAL] Hi Aaron, A few more responses have come through from our reference group which I have collated below. What factors do you consider when determining ratio of support for community and social activities?

• Level of risk to self, others and property damage.
• Past Incident Reports.
• Manual Handling Risk Plans.
• Self-Report around comfort, confidence.
• Cognition.
• Safety risks.
• Vulnerability within the community.
• Public transport confidence/ability/ability to be trained.
• Level of supervision required.
• Maximum benefit – do they actually still participate/benefit with number of people around
• Compatibility with others e.g. issues participating with other genders precluding group ratios
• Opportunities/abilities to learn from others and form natural relationships – would indicate higher group ratio
• Unpredictable or ad hoc support needs i.e. behavioural support or toileting support – that would unsafely leave others in group without direct support for significant period What assessments would you complete to contribute to decision making, are there any standard assessments that you use? Responses varied between clinicians- selection of appropriate tools would involve clinical reasoning to ensure the most appropriate assessment is used for the clients needs and to get the most useful information to safely achieve work towards the clients goal, however, some assessments that were mentioned included: Initial interview and history taking. Behavioural scales (Overt Behavioural Scale) for behaviours of concern. Lifting and handling assessments (manual handling plans). Rosters of Care (e.g. from day programs, SIL). CANS. OBS, and writing actual times spent undertaking activities to determine level of care and ratio of supports and number of hours for same. Completion of Community Integration Questionnaires. Analysis of skills of formal and informal supports. Are there any specific guidelines that you follow when determining ratio of support and how do you consider these? All responses were No – individually tailored to each individual. Guidelines could be useful. However information must be triangulated including person’s own statement of performance, with observation, other clinical and care information, client environment, and other relevant contextual factors. Any inconsistencies need to be sorted out. Each client’s social and community participation levels are different. What is reasonable and ordinary for their age, relationships, skill set and social needs should be considered.

What factors do you consider when recommending hours of support recommended? how might NDIS clients differ from clients accessing other types of funding? Risk assessments around when, how often, and what time of day the person is out in the community. Environmental assessments. Consideration as to when should the supports be reviewed and graded up or down- Reassessment of improved functional capacity using self-reports, WHODAS, self-efficacy scales in social and community participation. Time taken to complete activities / receive benefit from activities Comparison to time a person without disability would spend on these activities / opportunities they would have Person’s goals i.e. if they want to go out in community often or not Tolerance of these activities e.g. if significant disability and fatigue/ medical needs at play If informal supports are also providing anything History of accessing supports, importance of meaningful activities, importance of routines e.g. if they have gone to bowling on a Thursday night for ten years would want to keep those hours the same I hope this helps Regards, redacted: s22(1)(a)(ii) - irrelevant material

Professional Practice Advisor Occupational Therapy Australia redacted: s22(1)(a)(ii) - irrelevant material

From: redacted: s22(1)(a)(ii) - irrelevant Healey redacted: s22(1)(a)(ii) - irrelevant material Sent: Wednesday, 6 October 2021 10:32 AM To: redacted: s22(1)(a)(ii) - irrelevant, materialAaron redacted: s22(1)(a)(ii) - irrelevant material Subject: Participation and support needs

Hi Aaron OTA passed your details onto me. I was so excited that you reached out to OTA in relation to support needs. I wanted to share with you the work that I am doing in relation to participation and support needs. Following years of study and liaison with international experts, I have developed an Everyday Participation and Support Needs Measure. I have worked with a research company, ORIMA, to develop this measure and planning tool. At Everyday Independence we are starting trial of the tool in the next few weeks and have a MVP (using soft tech) for the trial but intend to build this into an expert management system in the next 6 months that will enable us to do some predictive planning (service bundling of hours of therapy, hours of support to achieve personal goals that reflect the person’s values and preferences, but is also based on objective assessment of personal capacity and potential). Aligned with evidenced based guidelines and “good” practice, the measure is administered and the data gathered using a collaborative approach with the person and their supporters. The measure also has a component of personal capacity assessment, so it is not only a measure using direct observation and self-report. To be honest, this was the key reason for failure of the Independent Assessment model. As a therapy organisation it is clear to us that we are a long way from being the dominant narrative which underpins support decisions by the NDIA. I want to challenge this. The provision of a budget for supports and services is currently not based on the person’s assessed support needs. The way the NDIA currently determines support budgets is not aligned with internationally recommended evidence based guidelines and on the ground, the core budget rarely reflects the person’s needs, we see a lot of people over supported, and the delivery of support is not aligned with enabling the person to achieve personal outcomes. We are often seeing people NOT achieving their potential and growth due to the core budget and the way supports are delivered. We want to work towards a future where people with a disability can be supported more by community members, colleagues, peers etc – as you and I are. The reality now is that NDIA participants just get 1:1 person to person support when in the community which often prevents the person from building real social capital. Yet as therapist we have no way to influence support budgets. I am very passionate about a person getting the right intensity and type of support and I am concerned about the current state of support allocation and implementation. This is the sole reason I have embarked on developing this measure – so that people get every chance to build their best life and supports are only there to bridge the gap that may exist when there is a mismatch between the person- task and environment. I would be very keen to share my work with you. Given that social and community participation is a key component to building a good everyday life, much of the measure is focussed on this area – which is relevant to your study.

Best wishes redacted: s22(1)(a)(ii) - irrelevant redacted: s22(1)(a)(ii) - irrelevant material | materialFounder & Director Everyday Independence redacted: s22(1)(a)(ii) - irrelevant material

Work days: Monday to Friday www.everydayind.com.au

From: redacted: s22(1)(a)(ii) - irrelevant materialAaron redacted: s22(1)(a)(ii) - irrelevant material Sent: Wednesday, 6 October 2021 9:30 AM To: Practice Queries Practicequeries@otaus.com.au Subject: RE: Best practice for determining ratios of support [SEC=OFFICIAL] Hi redacted: s22(1)(a)(ii) - irrelevant material Yes, that would be wonderful if you passed on my details. Thanks very much. All the best

From: Practice Queries Practicequeries@otaus.com.au Sent: Wednesday, 6 October 2021 8:57 AM To: redacted: s22(1)(a)(ii) - irrelevant, materialAaron redacted: s22(1)(a)(ii) - irrelevant material Subject: RE: Best practice for determining ratios of support [SEC=OFFICIAL] Hi Aaron, Following on from our phone discussion yesterday. A member of our NDIS reference group has been working on an expert management system for the past 12 months to assess and measure participation and support needs. She has done extensive international searches and liaised with every expert in this area. The system has been built and they are entering trial next week. She is happy to get in contact with you to discuss her work. Are you happy for me to pass on your details to her so she can get in touch? Kind regards, redacted: s22(1)(a)(ii) - irrelevant material

Professional Practice Advisor Occupational Therapy Australia redacted: s22(1)(a)(ii) - irrelevant material

From: Harrison, Aaron Aaron.Harrison@ndis.gov.au Sent: Friday, 1 October 2021 11:41 AM To: Practice Queries Practicequeries@otaus.com.au Subject: RE: Best practice for determining ratios of support [SEC=OFFICIAL] Hi redacted: s22(1)(a)(ii) - irrelevant material Thanks so much for getting back to me. It would be great to talk to you next week. We have a public holiday in NSW on Monday but I am free on Tuesday. 1pm would be perfect. You can reach me on 0434 886 465. Thanks again

From: Practice Queries Practicequeries@otaus.com.au Sent: Friday, 1 October 2021 11:34 AM To: Harrison, Aaron Aaron.Harrison@ndis.gov.au Subject: FW: Best practice for determining ratios of support [SEC=OFFICIAL] Hi Aaron, Thank you for reaching out to OTA to support the research that you are completing. It would be helpful to have some additional context from you before I put this to members. This will help ensure that the information we provide is most useful to you. Is there a time on Monday that would be suitable for me to give you a quick call? I am also available Tuesday after 12.30pm

Hopefully speak with you soon Kind regards, redacted: s22(1)(a)(ii) - irrelevant material

Professional Practice Advisor Occupational Therapy Australia redacted: s22(1)(a)(ii) - irrelevant material

From: Occupational Therapy Australia info@otaus.com.au Sent: Thursday, 30 September 2021 11:39 AM To: Practice Queries Practicequeries@otaus.com.au Subject: FW: Best practice for determining ratios of support [SEC=OFFICIAL] Hey team, Please see enquiry from NDIS below. Kind Regards, redacted: s22(1)(a)(ii) - irrelevant material

Marketing and Membership Administrator Occupational Therapy Australia redacted: s22(1)(a)(ii) - irrelevant material

| W www.otaus.com.au

From: redacted: s22(1)(a)(ii) - irrelevant, materialAaron redacted: s22(1)(a)(ii) - irrelevant material Sent: Thursday, 30 September 2021 11:33 AM To: Occupational Therapy Australia info@otaus.com.au Subject: Best practice for determining ratios of support [SEC=OFFICIAL] Good morning I am currently compiling existing research on how occupational therapists determine ratios of support for community access and group social activities. It is common practice for Occupational Therapists to recommend support ratios required by their clients. For example, while one person may require 2:1 direct assistance for certain tasks, another person might thrive with 1:7 supervision for the same task. My questions are:

• What considerations go into determining the appropriate ratio of individual support (ie. 1:1 or 2:1)?
• What considerations go into determining a safe and effective ratio of group support (ie. 1:3 versus 1:7)? I’m hoping you might be able to provide some information on how your members determine the appropriate ratio of support. If possible can you please provide any:
• recommendations you make to your members regarding ratios of support
• best practice guidelines you may have developed or refer to in order to determine appropriate ratios of support
• existing research you appeal to in making recommendations / developing guidelines for ratios of support
• contacts you believe may be able to assist with my inquiry. Thank you very much for your time and all the best

7.5 Swedish Association of Occupational Therapists

From: redacted: s22(1)(a)(ii) - irrelevant material Sent: Thursday, 4 November 2021 8:27 PM To: redacted: s22(1)(a)(ii) - irrelevant, materialAaron redacted: s22(1)(a)(ii) - irrelevant material > Subject: Sv: Research inquiry: best practices for determining ratios of support [SEC=OFFICIAL]

Dear Aaron,

The Association of Occupational Therapists are not able to provide you with this specific information. But please read about Professional duties for OT’s in Sweden. Occupational Therapist in Sweden are trying to follow National Guidelines, provided by The National Board of Health and Welfare.

Hope this was to any kind of help.

Kind regards, redacted: s22(1)(a)(ii) - irrelevant material

redacted: s22(1)(a)(ii) - irrelevant material Educational coordinator and developer International Secretary Swedish Association of Occupational Therapists

7.6 Council of Occupational Therapists for the European Countries

From: redacted: s22(1)(a)(ii) - irrelevant material Sent: Saturday, 9 October 2021 11:51 PM To: redacted: s22(1)(a)(ii) - irrelevant materialAaron redacted: s22(1)(a)(ii) - irrelevant material Subject: Re: Research inquiry: best practices for determining ratios of support [SEC=OFFICIAL]

Dear Aaron,

Thank you for your email and please accept our apologies for not replying to you earlier.

Unfortunately, COTEC as an organisation, does not have any published material on this topic. However, we would suggest that you get in touch with our Members who might have some in-house material related to your questions. Their contact details can be found on our website - https://www.coteceurope.eu/membership-2/

Let us know if we can be of any further help,

Kind regards,

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

Office Administration

7.7 NDIS Quality and Safeguards Commission researchers

From: redacted: s22(1)(a)(ii) - irrelevant material Sent: Wednesday, 15 December 2021 4:38 PM To: redacted: s22(1)(a)(ii) - irrelevant material, Aaron redacted: s22(1)(a)(ii) - irrelevant material Subject: RE: Interventions for reducing restrictive practice [SEC=OFFICIAL]

Hi Aaron,

The review about organisational interventions to reduce restrictive practices (or behaviours of concern) showed the lack of studies looking at organisational-level interventions for people with a disability. Almost all the studies in our review looked at staff training.

The categories of interventions we listed were based on some common themes that were mentioned in papers. The paper I’ve attached is one of the papers the categories are based on and references some studies regarding staff ratios.

I’ve also attached a report by the Victorian Government that has a section referring to staff ratios, and a section on barriers to reducing restraint. The references they’ve listed also look relevant.

You might also find some other resources on websites such as

https://restraintreductionnetwork.org/

I hope that’s useful and all the best with your project.

Kind regards,

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

Senior Research Officer Senior Practitioner Division redacted: s22(1)(a)(ii) - irrelevant material www.ndiscommission.gov.au

From: redacted: s22(1)(a)(ii) - irrelevant material Sent: Wednesday, 15 December 2021 10:02 AM To: redacted: s22(1)(a)(ii) - irrelevant material, Aaron’ redacted: s22(1)(a)(ii) - irrelevant material Cc: redacted: s22(1)(a)(ii) - irrelevant material Subject: RE: Interventions for reducing restrictive practice [SEC=OFFICIAL]

HI Aaron,

Apologies on being so slow to get back to you.

redacted: s22(1)(a)(ii) - irrelevant material Senior Research Officer here at the Commission, is the Primary author of this review. Michelle may be able to tell you whether this was a consideration in some of the included literature. Michelle will email back to let you know.

Regards redacted: s22(1)(a)(ii) - irrelevant material

redacted: s22(1)(a)(ii) - irrelevant material (PhD) Director Research and Practice Evidence Senior Practitioner Division redacted: s22(1)(a)(ii) - irrelevant material www.ndiscommission.gov.au

From: redacted: s22(1)(a)(ii) - irrelevant material, Aaron redacted: s22(1)(a)(ii) - irrelevant material Sent: Friday, 10 December 2021 2:17 PM To: redacted: s22(1)(a)(ii) - irrelevant material Subject: Interventions for reducing restrictive practice [SEC=OFFICIAL]

Hi redacted: s22(1)(a)(ii) - irrelevant material

I have just read your Cochrane review of interventions to reduce restrictive practices and was wondering if you can assist me.

I am currently completing a research project for the Technical Advisory Branch of the NDIA looking primarily at best practice for determining ratios of support (staff/carer to participant ratios) for employment activities and social / community participation.

Evidence is pretty thin to support best practice. However, one reason that clinicians often recommend higher ratios for our participants is to assist with managing behaviours of concern or managing risk to the participant, staff or others. I’ve not been able to find any published research pertaining to this directly. For instance, I did not see staff ratios mentioned as a potential intervention to reduce use of restrictive practices in your review.

Did you come across any consideration of staff ratios in your research? If so, can you point me in the direction of any published research that might inform my project?

Thanks and all the best

Aaron redacted: s22(1)(a)(ii) - irrelevant material

Research Officer, Enabling Services Technical Advisory Branch Operations and Support Division National Disability Insurance Agency

8. References

[1] Scheetz J. Resource to Assist with Determining Personal Care Hours. TAB Research Team paper 2021.

[2] Verdugo MA, Aguayo V, Arias VB, García-Domínguez L. A systematic review of the assessment of support needs in people with intellectual and developmental disabilities. Int J Environ Res Public Health. 2020;17(24):9494.

[3] Giné C, Font J, Guàrdia-Olmos J, Balcells-Balcells A, Valls J, Carbó-Carreté M. Using the SIS to better align the funding of residential services to assessed support needs. Res Dev Disabil. 2014;35(5):1144–51.

[4] Arnold SRC, Riches VC, Stancliffe RJ. I-CAN: the classification and prediction of support needs. J Appl Res Intellect Disabil. 2014;27(2):97–111.

[5] International SIS Use [Internet]. American Association on Intellectual and Developmental Disabilities. [cited 2021 Oct 6]. Available from: https://www.aaidd.org/sis/international.

[6] Profile Form. Supports Intensity Scale [Internet]. American Association on Intellectual and Developmental Disabilities. [cited 2021 Oct 6]. Available from: https://www.aaidd.org/docs/default-source/sis-docs/sis_form_do_not_copy.pdf?sfvrsn=2.

[7] I-CAN [Internet]. Centre for Disability Studies. [cited 2021 Oct 6]. Available from: https://www.i-can.org.au/.

[8] Lukersmith S (ed.) ICARE (Insurance and Care NSW). Guidance on the support needs for adults with spinal cord injury. 2017. Sydney, Australia.

[9] Code of Practice for Hazardous Manual Tasks [Internet]. Safe Work Australia. [cited 2021 Oct 6]. Available from: https://www.safeworkaustralia.gov.au/system/files/documents/1905/model-cop-hazardous-manual-tasks.pdf.

[10] A health and safety solution – assisting people who have fallen [Internet]. WorkSafeVictoria. [cited 2021 Oct 6]. Available from: https://content.api.worksafe.vic.gov.au/sites/default/files/2018-06/ISBN-A-health-and-safety-solution-assisting-people-who-have-fallen-2011-05.pdf.

[11] Code of Practice for Hazardous Manual Tasks [Internet]. Safe Work NSW. [cited 2021 Oct 6]. Available from: https://www.safework.nsw.gov.au/__data/assets/pdf_file/0020/50078/Hazardous-manual-tasks-COP.pdf.

[12] Best Practice Guidelines for Manual Handling [Internet]. Department of Ageing, Disability and Home Care. [cited 2021 Oct 6]. Available from: http://disabilitysafe.org.au/sites/default/files/DADHC_Best_Practice_Guidelines_MH.pdf.

[13] Phillips J, Mellson J and Richardson N. It takes two? exploring the manual handling myth. 2014. University of Salford. Available from: http://usir.salford.ac.uk/id/eprint/43619/.

[14] Thornton S. An ergonomics approach to managing transfers from two handed to single handed care [Thesis]. Loughborough University. [cited 2021 Oct 6]. Available from: https://iosh.com/media/4403/sarah-thornton.pdf.

[15] Iffland M, Xu J, Gillies D. Organisational interventions for decreasing the use of restrictive practices with children or adults who have an intellectual or developmental disability. Cochrane Libr [Internet]. 2021; Available from: http://dx.doi.org/10.1002/14651858.cd013840.

[16] McVilly K. Physical restraint in disability services: Current practices, contemporary concerns, and future directions [Report]. State Government of Victoria 2009.

[17] Singh NN, Lancioni GE, Winton ASW, Curtis WJ, Wahler RG, Sabaawi M, et al. Mindful staff increase learning and reduce aggression in adults with developmental disabilities. Res Dev Disabil [Internet]. 2006;27(5):545–58. Available from: http://dx.doi.org/10.1016/j.ridd.2005.07.002.

[18] Iluz R, Adi-Japha E, Klein PS. Identifying child–staff ratios that promote peer skills in childcare. Early Educ Dev [Internet]. 2016;27(7):1077–98. Available from: http://dx.doi.org/10.1080/10409289.2016.1175240.

[19] Perlman M, Fletcher B, Falenchuk O, Brunsek A, McMullen E, Shah PS. Child-staff ratios in early childhood education and care settings and child outcomes: A systematic review and meta-analysis. PLoS One [Internet]. 2017;12(1):e0170256. Available from: http://dx.doi.org/10.1371/journal.pone.0170256.

[20] Baker PRA, Francis DP, Hairi NN, Othman S, Choo WY. Interventions for preventing abuse in the elderly. Cochrane Database Syst Rev [Internet]; 2016(8):CD010321. Available from: http://dx.doi.org/10.1002/14651858.CD010321.pub2.

[21] Karimi-Shahanjarini A, Shakibazadeh E, Rashidian A, Hajimiri K, Glenton C, Noyes J, et al. Barriers and facilitators to the implementation of doctor-nurse substitution strategies in primary care: a qualitative evidence synthesis. Cochrane Database Syst Rev [Internet]. 2019;4:CD010412. Available from: http://dx.doi.org/10.1002/14651858.CD010412.pub2.

9. Version control

Version	Amended by	Brief Description of Change	Status	Date
1.0	AHR908	Research paper to investigate evidence base for determining ratios of support.	Approved	21-12-2021