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Practice Guide – Disability-Related Health Supports

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Practice Guide – Disability-Related Health Supports

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Contents

Practice Guide – Disability-Related Health Supports …………………………………………. 1 Contents ……………………………………………………………………………………………………… 2

  1. Purpose …………………………………………………………………………………………… 4 To be used by ………………………………………………………………………………….. 4 Scope ……………………………………………………………………………………………… 4 3.1 Policy position ……………………………………………………………………………….. 5 3.2 Guiding statements ………………………………………………………………………… 5 3.3 The disability-related health supports arrangements are likely to apply to 6 3.4 The disability-related health supports arrangements are not likely to apply to 6 3.5 Younger People in Residential Aged Care (YPIRAC) ………………………….. 6 3.6 Liaison Officers ……………………………………………………………………………… 7 Disability-related health supports ………………………………………………………… 7 4.1 Principles to consider when deciding to include disability-related health supports in a plan …………………………………………………………………………………… 8 4.2 When a support moves from being regular to acute ………………………….. 10 Pre-planning …………………………………………………………………………………… 10 5.1 Information for ECEI - Children under 7 …………………………………………… 10 5.2 Streaming …………………………………………………………………………………… 11 5.3 Planning conversation …………………………………………………………………… 11 Planning ………………………………………………………………………………………… 12 6.1 Advice for plan developers and delegates ……………………………………….. 12 6.2 Relating a health support to the participant’s functional impairment …….. 12 6.3 Air conditioning and/or heating (Climate control) ………………………………. 13 6.4 Medical equipment ancillary costs ………………………………………………….. 14 6.5 Oxygen ………………………………………………………………………………………. 14 6.6 Determining if a disability-related health support is not reasonable and necessary ……………………………………………………………………………………………. 14 6.7 Determining funding for disability-related health supports ………………….. 15

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6.8 Mandatory advice from the Technical Advisory Branch

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6.9 How to include funding in plans

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6.10 Nursing supports

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6.11 Plan comments

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Implementation and monitoring

19

Plan review

19

Case examples

19

9.1 Example 1 – Amanda

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Appendices

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10.1 Appendix A: Registered nurse (RN) delegation of care

21

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10.3 Appendix C: TAB mandatory advice list

38

10.4 Appendix D: Table Summary of Jurisdictional Power Subsidies

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Supporting material

41

Feedback

41

Version change control

41

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1. Purpose

The purpose of this Practice Guide (PG) is to support plan developers and delegates to consider disability-related health support arrangements in line with the National Disability Insurance Agency’s (NDIA’s) legislative framework. That is:

  1. Determine whether a health support is reasonable and necessary, that is, it meets all the criteria in section 34 of the National Disability Insurance Scheme Act 2013 (NDIS Act).
  2. Determine whether the support is most appropriately funded or provided by the National Disability Insurance Scheme (Scheme), or whether it is more appropriately funded or provided by the health system, section 34(1)(f) of the NDIS Act.
  3. Determine whether a support is most appropriately funded or provided by the Scheme, and apply the National Disability Insurance Scheme (Supports for Participants Rules) 2013 (Rules) which requires planners to take into consideration the matters set out in Rules 7.4 and 7.5.
  4. Have regard to the disability-related health supports policy, which will provide additional guidance and considerations relevant to determining whether the support is most appropriately funded by the Scheme (s 34(1)(f)) having regard to the Rules.

2. To be used by

  • Plan Developers – Planners and NDIS Partners in the Community (Early Childhood Partners and Local Area Coordinators [LACs])
  • NDIA Plan Delegates.

3. Scope

This PG outlines the disability-related health supports that may be considered for participants who are involved with the health system. These participants may also have involvement with other mainstream interfaces such as justice, child protection, or mental health.

Planning for participants who are involved with the health system generally follows the same process as for other participants. However, there is additional information to consider as outlined in this PG.

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3.1 Policy position

The Agency takes a whole of person approach when funding supports in a participant’s plan. This means that funding is based on the reasonable and necessary criteria in section 34 of NDIS Act and Rules and is not limited to the impairments which satisfy the criteria for accessing the Scheme. Specifically, in accordance with section 34(1)(f) of the NDIS Act, the Agency needs to determine whether a disability-related health support for a participant is most appropriately funded or provided by the Scheme. The Scheme is responsible for supports relating to a person’s ongoing functional impairment that allows the person to undertake activities of daily living. This includes maintenance supports delivered or supervised by clinically trained or qualified health practitioners, where these are linked to the care and support a person requires to live in the community and participate in education and employment (NDIS (Supports for Participants) Rules).

3.2 Guiding statements

Consider the following guiding statements when determining whether disability-related health supports are funded by the Scheme:

  1. The participant experience is central to all decisions.
  2. The nature of an eligible participant’s disability, and the functional impacts, determines what NDIS supports are most appropriate to achieve desired outcomes.
  3. The NDIS views a person as a whole and allows participants to choose and control the supports that allow them to reach their goals.
  4. A person-centred allocation is optimal; however, it is recognised that until the NDIS matures, guidance is sometimes required at a support and service level.
  5. The NDIS aims to take an outcomes focus to the way disability and health supports are funded. Health and disability supports wrap around the participant’s needs so they receive seamless support from multiple service systems.
  6. Consistent with the Council of Australian Governments (COAG) agreed Principles to Determine the Responsibilities of the NDIS and Other Service Systems (including the Applied Principles and Tables of Support (APTOS)), health supports that are not a regular part of the everyday life of a person with disability remain the responsibility of health systems.
  7. The supports provided to a participant will be in the context of appropriate Quality and Safeguarding frameworks.

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  1. Participants can choose the most appropriately qualified person to provide their supports, within the funding available in their NDIS plan.
  2. NDIS funded services should be provided by the most appropriate and cost effective service provider.

Any participant that requires disability-related health supports as outlined in this PG. These supports will most often be required by people whose disability affects multiple or whole of body systems, such as significant acquired brain injury, cerebral palsy, neurological conditions or spinal cord injury. Disability-related health supports can be required because of a wide range of disability types and funding for these supports should be explored for all participants in accordance with the criteria in section 34 of the NDIS Act and the NDIS Rules.

Generally, disability-related health supports will not meet reasonable and necessary criteria when funding is more appropriately provided by another service system. For example, (this is not an exhaustive list):

  • people in hospital
  • emergency or clinical care in community settings such as hospital in the home
  • participants in custody (in a correctional facility, for example prison, remand centre or youth detention centre), on remand, awaiting or following sentencing. In these circumstances, a participant’s day-to-day care and support needs, including personal care are more appropriately funded by the justice system (see Rule 7.25(a)).

Note: In a rural, remote, or regional location, there may be times where disability-related health supports might be provided in a health centre due to thin markets or for ease of delivery. In these circumstances, please refer to your team leader for advice.

3.5 Younger People in Residential Aged Care (YPIRAC)

Typically, disability-related health supports will be provided by the residential aged care facility in an aged care setting for YPIRAC participants. However, if a participant identifies a health support need which is not currently being met by the residential aged care facility, please refer to the Technical Advisory Branch (TAB) for advice.

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3.6 Liaison Officers

Liaison Officers are represented in all states and territories and are part of the Complex Support Needs (CSN) Pathway Branch. Liaison Officers provide a single point of contact for health and/or justice staff to facilitate support for participants (prospective and current) in health and/or justice settings. The Liaison Officer role is non-participant facing with a focus on support for hospital and justice staff, NDIS plan developers (planners and LAC’s), engagement staff and support coordinators. For more information refer to the Health Liaison and Justice Liaison Officer factsheets on the CSN intranet page.

Disability-related health supports must be considered reasonable and necessary under s34 of the NDIS Act and may include:

  • planning, care and training for specific health tasks provided by a support worker, allied health professional, and/or nurse
  • purchase of some consumables
  • maintenance and cleaning of some specific equipment
  • purchase or lease of some equipment.

Disability-related health supports are expected to assist in the following areas (this is not an exhaustive list):

  • Dysphagia: for participants who have trouble eating, drinking or swallowing on a daily basis.
  • Respiratory: for participants who require support or any associated care and planning to maintain respiratory health and comfort to help them breathe.
  • Nutrition: for participants requiring help with the way they eat or understanding the food they need.
  • Diabetes: for participants who have daily problems with how much sugar is in their blood.
  • Continence: for participants who need daily assistance with toileting (bladder and bowel).
  • Wound and Pressure Care: for participants who need daily wound and pressure care (resulting from pressure wounds or swollen limbs).
  • Podiatry: for participants who require help looking after their feet, ankles and lower limbs.

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• Epilepsy: for participants who need daily help managing the effects of epilepsy on their life. • Botox and associated splinting: It is unlikely Botox and associated splinting supports will be reasonable and necessary to include in a plan, as these are generally provided in a clinical setting.

When determining if you can include disability-related health supports in a participant’s plan you must consider the following principles and decide if a support is most appropriately funded by the Scheme (NDIS [s34(1)(f)]) having regard to the specific matters set out in the NDIS Support for Participants Rules (see Rule 7.4 and 7.5).

The decision to fund reasonable and necessary disability-related health supports should not only be based on the primary and/or secondary disability as recorded in the NDIS Business System (System).

In making this decision, you will also need to consider whether the support:

• directly relates to a person’s ongoing functional impairment, and • is a regular part of daily life, and • is most appropriately funded or provided by the NDIS, and • is evidenced, meaning supporting information can generally be obtained.

When determining if a disability-related health support is directly related to the participant’s disability, consider whether:

• the purpose is the provision of maintenance supports delivered or supervised by clinically trained or qualified health practitioners where these are integrally linked to the care and support the person requires to live in the community and participate in social activities, education and employment • the participant would not require the health support BUT FOR his/her functional impairment.

Regular part of daily life

When determining if a disability-related health support is a regular part of daily life you must determine if the support is required on:

• a habitual basis such as daily, weekly, monthly or yearly

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• a repeated or fixed pattern of need or • an ongoing basis and is not time limited or a one off requirement.

4.1.3 Is most appropriately funded by the NDIS

You must determine if a support is most appropriately funded by the NDIS. In the following situations (see NDIS Rules), supports will remain the responsibility of the healthcare system:

• Acute services: these services are generally provided by public and private hospitals and may require a short stay in a hospital. Acute conditions are those that come on sharply and are often brief, intense and/or severe. • Post-acute services: these services provide follow-up care after a person’s hospital stay, often by allied health services, and can include admitted or community-based rehabilitation. • Diagnosis and treatment of chronic health conditions for example, diabetes, cancer, heart disease. • Palliative care: treatment, care and support for people living with a life-limiting illness. • Diagnostic services: diagnosis decisions and advice provided by a practitioner using clinical judgment to determine a person’s symptoms and the possible condition causing these symptoms.

4.1.4 Is evidenced - supporting information can be obtained

You may need to ask the participant to provide supporting information to justify your decision making when including disability-related health supports in a plan. You may also require information about the recommended amount of support required and type of worker needed.

Supporting information may be:

• an expert opinion in the form of a written report from a suitably qualified health care practitioner detailing clinical reasoning and justification for the proposed disability-related health support, including the type of support recommended, the frequency and duration this support is required, and how the support is related to the participant’s functional impairment • literature • lived experience of the participant • anything the Agency has learnt through the delivery of the Scheme.

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This information may include:

  • type and availability of support recommended (including information about all supports considered and why the support is required)
  • frequency and duration of the support (including whether or not the support is for the diagnosis, acute management, rehabilitation or maintenance of a health need)
  • care and maintenance of the support
  • whether the delivery of the support can be delegated (for example, by a nurse to a disability support worker)
  • the relationship of the support to the participant’s functional impairment
  • outcomes that will be achieved through delivery of the support
  • most appropriate setting for the delivery of the support.

Ideally the Agency requires supporting information to be current. Currency is dependent on the type of support, relevant risks, changing needs of the participant and good practice in delivery of the support.

4.2 When a support moves from being regular to acute

If the participant has an acute episode, (see definition above) this support is more appropriately provided by the relevant State or Territory health care system or private health system. The NDIS is not the most appropriate funder for supports during an acute episode (See Rule 7.5(c)(ii)). The NDIS will recommence funding when the support ceases to be acute, but continues to be regular as defined above.

5. Pre-planning

5.1 Information for ECEI - Children under 7

In Early Childhood Early Intervention (ECEI), families/carers are responsible for their child’s support needs consistent with what would be required for children of a similar age. If a child’s disability-related health support needs require significant support, the plan developer would first need to consider the family’s/carer’s capacity and the informal mainstream and community supports available. It is important to understand each family’s individual circumstances to identify where additional support may be required. Where ECEI participants require a level of s \upport with daily activities, significantly beyond the level usually required for children of the same age, funded supports in a plan may be required.

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5.2 Streaming

So that participants receive appropriate assistance to engage in the planning process, participants involved with the health system and/or other systems such as mental health, justice, child protection etc. may be streamed Intensive or Super Intensive. Make sure the correct streaming decision is recorded in the System. Refer to Standard Operating Procedure - Update Participant Streaming, for further information. Note: The term streaming is for internal use only.

5.3 Planning conversation

The planning conversation allows you the opportunity to gather detailed and concise information regarding the participant’s functional impairment and disability-related health support needs.

The following points can support you to have a high quality conversation:

  • Be aware this is a sensitive conversation and you are asking very personal questions. You may feel resistance. Build rapport with the participant and display empathy, make sure they understand this is a confidential conversation and they can choose who does and does not attend the meeting.
  • Encourage the participant to explain how their disability-related health support needs relate to their functional impairment.
  • Ask the participant to explain who their current disability-related health supports are provided by (support worker, registered nurse, family member etc.). If the support is provided by a family member, ask if this is the participant’s choice or if they would rather this support be provided by someone else.
  • Ask the participant what equipment or consumables they currently use in relation to their disability-related health supports.
  • Where appropriate, explore with the participant whether they have any capacity building goals in relation to their disability-related health support needs, or whether there is any assistance that could be provided to help increase their independence. You may need to explain the delegation of care guidelines (see Appendix A) to the participant, especially if the type or level of worker to be funded by the NDIS is likely to be different from the worker currently delivering their disability-related health supports.

Note: Make sure supporting information is provided to support decisions related to delegation of care. If you need further assistance, please refer to the Technical Advisory Branch (TAB) for advice.

Planning

6.1 Advice for plan developers and delegates

All plan developers and delegates should use the following resources to assist in making reasonable and necessary decisions:

  • Reasonable and necessary supports – Section 34 of NDIS Act
  • NDIS (Supports for Participants) Rules 2013
  • Planning Operational Guideline
  • COAG Applied Principles and Tables of Supports (APTOS)
  • Practice Guidance
  • Published TAB Guidance
  • Standard Operating Procedures

6.2 Relating a health support to the participant’s functional

impairment

When considering if a disability-related health support is directly related to the participant’s impairment, you must determine whether:

  • the primary purpose is the provision of maintenance supports delivered or supervised by clinically trained or qualified health practitioners where these are integrally linked to the care and support the person requires to live in the community and participate in education and employment. If a support meets this description, it is most appropriately funded by the NDIS
  • if a part of early intervention for children, the provision of the support is likely to reduce the child’s future support needs, which would otherwise require support from the NDIS in later years, including through a combination and sequence of supports
  • the health support need is directly related to the participant’s functional impairment
  • the participant would not require the health support BUT FOR his/her functional impairment
  • the participant does not require disability-related health supports on a regular basis. Their health needs will continue to be supported by the health system.

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Example 1: A participant with autism falls over, breaks their leg and has an open

wound. On release from hospital the participant’s wound care is not most appropriately funded by NDIS because it is not related to the participant’s ongoing functional impairment and not required on a regular basis (as part of the person’s everyday life). Example 2: A participant with an intellectual disability that does not affect their mobility, falls and cuts their hand, which requires wound care. Wound care is not most appropriately funded by the NDIS because the injury is not related to the participant’s ongoing functional impairment. The participant’s wound would be cared for by his GP, health care centre or hospital.

Pharmaceutical Benefits Scheme (PBS) and Medicare Benefits

Scheme (MBS)

Several of the consumables that would be funded by the NDIS as a disability-related health support are already funded through the PBS. For consumables currently funded under the PBS, this will continue to be most appropriately funded by the health system through the PBS. Where a consumable product is considered reasonable and necessary and is not currently funded under the PBS, a referral to the TAB should be made for further advice. Several of the supports provided by allied health professionals, which may also be funded as a disability-related heath support, are also funded under certain MBS programs. Where a participant is accessing supports through a MBS program, this will continue to be the most appropriate program to fund the supports. Where the maximum amount of MBS services under a MBS program have been reached and ongoing support is required, a referral to the TAB should be made for further advice. A participant factsheet is being developed to support participants to understand the options for supports covered under the PBS and MBS programs. In the interim seek advice from the TAB.

6.3 Air conditioning and/or heating (Climate control)

For people who have a disability that affects their ability to regulate their body temperature (thermoregulation), air conditioning and/or heating (climate control) may be funded as a disability-related health support if considered reasonable and necessary. All requests for air conditioning and/or heating must to be referred to the TAB for advice.

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6.4 Medical equipment ancillary costs

Generally, the NDIA does not fund electricity costs that are ancillary to a disability- related health support assistive technology on the basis that these costs are already funded through existing Commonwealth and State/Territory schemes (s34(1)(f)). Therefore, it will not be considered ‘value for money’ (s 34(1)(d)) for the NDIS to duplicate funding that is already provided through another government scheme. Refer to Appendix D for a list of the subsidies available. Where a participant feels they are still disadvantaged and request further support this may be considered on a case-by-case basis, but must be referred to TAB for advice.

6.5 Oxygen

State and Territory governments provide oxygen tanks and subsidies for persons requiring them. This remains most appropriately funded by the existing state or territory Scheme. The participant should check with the relevant state or territory oxygen scheme prior to any request being made to the NDIS to fund oxygen supports. If the requirement for oxygen is over and above what the state or territory provide and is required due to a disability-related health condition then it may, for some participants be considered a reasonable and necessary support by the NDIS. In order to consider the request, assessment information is required from a treating physician indicating the prescriptive need for oxygen, including delivery method (mask or nasal specs) and flow required. All requests should be referred to TAB for advice prior to including in a plan.

 reasonable and necessary

A disability-related health support will not be reasonable and necessary where it does not meet s.34(1)(a)-(f) of the Act. When considering s.34(1)(f), the requested supports may not be most appropriately funded by the NDIS where: • the support is not directly related to the participant’s ongoing functional impairment (see 4.1.1) ­ the nature of the support is not required as a regular part of the participant’s daily life and required on a habitual basis (see 4.1.2) • the support relates to the diagnosis and clinical treatment of health conditions, including ongoing or chronic health conditions including health supports delivered by a medical practitioner (Rule 7.5 (a) Supports for Participant Rules)

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• The support relates to other activities that aim to improve the health status of Australians, including general practitioner services, medical specialist services, dental care, nursing, allied health services including acute and post-acute services, preventative health, care in public and private hospitals and pharmaceuticals (Rule 7.5 (a) Supports for Participant Rules) • Medical or pharmaceutical services which have been claimed through Medicare or the Pharmaceutical Benefits Scheme • The supports are time-limited, goal-oriented services and therapies predominantly aimed at restoring health and improving function after recent medical or surgical treatment. This includes episodic treatment and rehabilitation • The support relates to sub-acute services (e.g. palliative care, aged care, etc.) including in-patient and out-patient services delivered in the person’s home, hospital or clinical settings • The support relates to newborn follow-up provided in the health system, including child health services (Rule 7.10 (c) Supports for Participants Rules) • The support duplicates other support delivered under alternative funding through the NDIS (Rule 5.1 (c) Supports for Participants Rules) • The provision of the support is contrary to: · a law of the Commonwealth; or · a law of the State or Territory in which the support would be provided (Rule 5.3(a) Supports for Participants Rules) • The support need is unknown at the time the plan is approved (i.e. contingency funding).

Supports funded by the NDIS, including disability-related health supports, must be considered reasonable and necessary and appropriately funded by the NDIS under the NDIS Act and Rules. The guidance below will support you to determine how much funding to include in the plan so the disability-related health supports assessed as reasonable and necessary can be fully funded by the NDIS. See also Plan review below.

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6.7.1 Type/Level of worker – Delegation of Care

Disability-related health supports may include supports delivered by registered nurses and allied health professionals, as well as enrolled nurses and disability support workers. The type or level of worker required will depend on the person’s individual needs, the nature of the support and the setting in which the support is being provided.

Initially, it is anticipated that participants will transition their delegated or other disability-related health supports using the same level of worker as previously provided. For new, or scheduled review participants, if they are receiving delegated care consider what evidence/supporting information is available to support this continued level of worker. If there is no evidence or this is a new support, consider if delegated care should be included at the registered nurse level and review as part of monitoring and implementation.

Type and level of worker will be a key aspect to review as part of implementation and monitoring of the plan. To assist in determining the type and level of worker that should be funded in a participant’s plan please refer to Appendix A: Registered nurse delegation of care.

6.7.2 Frequency of support

The frequency of the support will depend on the person’s individual needs and the nature of the support. For guidance about typical support hours for different support types see How to include funding in plans. You will need to consider evidence/supporting information provided by the participant and any relevant health professionals in order to determine the reasonable and necessary frequency of funded supports.

6.7.3 Assistive Technology (AT), Equipment and Consumables

Funding can be included in a participant’s plan for a range of disability-related health supports AT, equipment and consumables. The criteria described in Section 4.1 applies to AT, equipment and consumables.

6.8 Mandatory advice from the Technical Advisory Branch

You will need to seek advice from the Technical Advisory Branch (TAB) prior to including some disability-related health supports in a participant’s plan, even if you consider the support to be reasonable and necessary. This will help to:

  • ensure Scheme financial sustainability
  • confirm the support is most appropriately funded by the NDIS
  • monitor risk to the participant.

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First, you must consider if the support meets the reasonable and necessary criteria and is directly related to a participant’s functional impairment. Then, check if the support requires referral to TAB for advice prior to including in the participant’s plan. To check if the support requires referral to TAB, refer to Appendix C. If the support requires advice refer to the TAB DRHS Intranet page for the process to follow. Once you have received the advice from TAB, use this in your considerations when determining the reasonable and necessary funding for the disability-related health support to include in the participant’s plan.

6.9 How to include funding in plans

To maximise funding flexibility for participants, where possible combine funding for reasonable and necessary disability-related health supports to avoid funding multiple small items/services at the line item level. Detailed guidance is available for a number of specific disability-related health supports. Refer to the PGs below when developing plans involving these support types:

  • Practice Guide - Dysphagia Supports
  • Practice Guide - Epilepsy Supports
  • Practice Guide - Wound and Pressure Care Supports
  • Practice Guide - Respiratory Supports
  • Practice Guide - Continence Supports
  • Practice Guide – Diabetic Management Supports
  • Practice Guide - Nutrition Supports
  • Practice Guide - Podiatry and Foot Care Supports.

6.10 Nursing supports

The plan developer/delegate should make sure there are sufficient funds included in the plan to cover a participant’s reasonable and necessary nursing support needs. It is the responsibility of the service provider to assign the most appropriately qualified nurse to provide the health related support i.e. has appropriate competencies for that task:

  • If the level of nursing is not known at the time of planning, include all nursing hours together using the line item - Composite Funding For Delivery Of Health Supports By A Clinical Nurse Consultant.

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• If the participant can provide clear supporting information detailing their current level of nursing, include like for like supports using the relevant composite line item/s from the following list:

Composite Funding For Delivery Of Health Supports By An Enrolled Nurse

Composite Funding For Delivery Of Health Supports By A Registered Nurse

Composite Funding For Delivery Of Health Supports By A Clinical Nurse

Composite Funding For Delivery Of Health Supports By A Clinical Nurse Consultant

Composite Funding For Delivery Of Health Supports By A Nurse Practitioner. Note: Nursing supports should not be stated so a participant can access all levels of nursing support for the duration of their plan. Refer to Appendix B: Summary of disability-related health supports for a summary of the supports to be considered in each budget for each type of health support including nursing supports.

6.11 Plan comments

Include clearly worded comments in the plan to: • explain the funding in each category for each disability-related health support • facilitate choice and control to allow for plan funding flexibility • ensure participants understand what funding has been provided to meet their goals and disability-related health support needs • assist providers in identifying funding available for disability-related health supports • support implementation and monitoring. Example: Includes funding for <describe health supports – for example, development of an oral eating and drinking plan>. So the participant is supported and remains at the centre of decision making include your justifications for any included or excluded disability-related health supports to support reasonable and necessary decision making. Note: Generally to support flexibility, supports should not be stated.

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7. Implementation and monitoring

The implementation and monitoring of plans including disability-related health supports will generally follow the same process as with all plans. However, be mindful that funding for disability-related health supports in NDIS plans may be new to participants and stakeholders. You may need to take time to explain the new items in plans and ensure participants can link to appropriate supports.

You should explain comments in the plan to the participant so they understand the funding allocated for health supports. Plan comments can also be used when monitoring utilisation, effectiveness of funding and achievement against goals in subsequent plan reviews. It will be a critical review point for considering level of nursing care including delegation of care.

Refer to Practice Guide – Implementation and Practice Guide – Monitoring for more information.

8. Plan review

Review the disability-related health supports previously included in the participant’s plan, to determine if they still meet the reasonable and necessary criteria as set out in this PG.

To ensure continued access to supports have a conversation with the participant, their nominee or child representative to assist them to engage with local mainstream health services.

This assistance may be provided by an LAC or support coordinator. Transitional funding may be considered reasonable and necessary so participants are not without critical health supports while alternative arrangements are made. Participant safety should be a key consideration. Additionally, consider use of your local escalation processes so any participants in this circumstance are supported.

Refer to Review Practice Guides and Standard Operating Procedures.

9. Case examples

9.1 Example 1 – Amanda

Amanda has multiple sclerosis (MS) and lives at home with her partner, Megan. She lives in Adelaide, where summer temperatures are often 40 degrees Celsius or over. She receives the disability support pension and has a low income health care card. She has requested a plan review (redacted: s48) to see if funding for medical related air conditioning can be included in her plan.

Plan discussion

Amanda discusses the impact MS has on her everyday life with her plan developer. She mentions that her symptoms are significantly worse during summer when the temperatures exceed 25 degrees Celsius. When it is hot, she experiences increased pain, fatigue, blurred vision, muscle weakness, walking and memory dysfunction. She asks her plan developer if the NDIS can fund air conditioning (climate control) so that she can maintain her functional capacity during summer and continue to pursue her goals. She is a home owner and would like funding for an air conditioner at home as she does not currently have one and would prefer a ducted system. She would also like NDIS funding to cover her air conditioning bill. She has provided a certificate from her GP that states her medical condition is severely worsened by hot weather. Her occupational therapist (OT) has also provided a report stating that while Amanda has tried thermoregulation using other methods, she has not been successful. Her OT report also stated she has significantly worsened mobility and functioning due to heat.

Reasonable and necessary supports

Capital supports

  • split system air conditioner x2 (one in the bedroom and one in the living area)

Amanda has provided medical evidence that she has thermoregulation difficulties directly related to her disability and has trialled other means of cooling without success. Requests for any air conditioning/heating supports requires mandatory contact with TAB to seek advice before including in a plan. The plan developer contacted TAB through the Technical Advice Phone Support (TAPS) line and sought advice prior to including it in Amanda’s plan. The NDIS will fund split system air conditioners for Amanda. A ducted system does not meet the National Disability Insurance Scheme Act 2013 criteria for reasonable and necessary supports as it does not represent value for money.

Supports provided by another service system

Some funding for Amanda’s air conditioning bills is provided by the South Australian state government through a medical heating and cooling concession. Amanda is eligible for this concession as she has a low income health care card. She is responsible for part payment of the energy bill.

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Appendices

10.1 Appendix A: Registered nurse (RN) delegation of care

Registered nurse (RN) delegation of care allows an RN to delegate high level care to another suitably trained person. When an RN delegates their care they remain responsible for:

  • conducting an initial health assessment with the participant
  • developing the participant’s care plan including decisions relating to delegation of any part of the care to another person
  • training and assessment of the support worker/s to deliver the delegated support based on the participant’s care plan
  • reassessment of the participant’s care needs as required
  • connecting the participant with their health support worker/s
  • environmental assessment including at different locations for example, the home, community settings, (including camps and excursions)
  • accountability for delegated aspects of the nursing care plan which includes:
    • making sure the participant has a support worker with the appropriate level of education, knowledge, experience, skill and assessed competence to perform participant specific delegated care tasks (this does not include basic competency training as this is the responsibility of the provider)
    • making sure the support worker/s is competent, confident of their ability to perform the task safely, is ready to accept the delegation, and understands their level of accountability for performing the activity
    • making sure the care plan clearly outlines the delegated care tasks to be undertaken by the support worker
    • training the support worker in the individualised needs of the participant (this is above basic competency training)
    • monitoring and reassessment of the care plan and additional training as the participant’s needs change.

Important: The NDIS is not responsible for training support workers in initial skill and knowledge development. The NDIS funds training for specific support where relevant to the participant’s individual care needs and are above the entry level competency standard.

10.1.1 Tier levels

Tier levels describe the level of support required. This is determined according to the complexity of the health support need, the number of skills and credentialing staff require and the number of services the participant requires.

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FOI-23.24-0538

10.1.1.1 Tier 1

Participants who require a very high level of support or have a very complex health support needs such as:

  • respiratory supports which are part of daily support requirements:
    • ventilator dependent, tracheostomy
    • Non-invasive Positive-Pressure Ventilation (NPPV) or Bilevel Positive Airway Pressure (BiPAP) ventilation for full 24/7
    • any Tier 2 or Tier 3 supports
  • supports which require training and delegation in four or more different skill areas
  • participants who require disability-related health supports for the first time (may move to Tier 2 at plan review)
  • three or more health service providers.

Note: Meeting the requirements for Tier 1 is an indicator for including high intensity level 3 personal care supports in the plan.

10.1.1.2 Tier 2

Participants who require an intermediate level of support such as:

  • Constant Positive Airway Pressure (CPAP) or non 24 hour BiPAP support
  • diabetic management
  • development of an oral eating and drinking plan
  • epilepsy management supports including administration of medication and implementation of an Emergency Medication Management Plan (EMMP)
  • supports which require training and delegation in up to three different skill areas
  • wound care support (if treatment management required)
  • any Tier 3 supports
  • up to three health service providers.

Note: Meeting the requirements for Tier 2 is an indicator for including high intensity level 2 supports in the plan.

10.1.1.3 Tier 3

Participants who have low level support needs such as:

  • continence support (includes catheter and bowel care)
  • Percutaneous Endoscopic Gastronomy (PEG) and Home Enteral Nutrition (HEN) support

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Podiatry Care Support

  • podiatry care support
  • skin integrity maintenance (if indicated per risk assessment)
  • supports which require training and delegation in one skill area
  • up to two service providers.

Note: Meeting the requirements for Tier 3 is an indicator for including high intensity level 2 supports in the plan.

High Intensity Supports

A support is considered high intensity if the participant requires assistance from a support worker with additional qualifications and experience relevant to the participant’s support needs. The high intensity price limits may be considered when:

  • support is frequent (at least 1 instance per shift) where assistance is required to manage challenging behaviours that require intensive positive behaviour support; and/or
  • continual active support is required due to high medical support needs (such as unstable seizure activity or respiratory support).

Including RN Delegation of Care in Plans

Refer to Table 1 when calculating the number of delegation of care hours to include in a plan. When including hours for training of support workers, make sure you include support worker hours at the relevant high intensity level (2 or 3) for each health support worker attending training.

Provisions for Shadow Shifts

Shadow shifts may be considered where the participant has complex support needs that are best met by introducing a new worker to the participant before they commence providing the support independently. Consider where the specific individual support needs include:

  • very limited communication
  • behaviour support needs
  • medical needs/procedures such as ventilation or HEN.

Where shadow shifts are required to introduce the participant to new support workers, up to 6 hours of weekday support per year may be funded. Introducing new workers is not designed to replace formal, recognised training that will be provided by an employer to their workforce, such as shadowing (or buddying) less experienced staff or new staff with experienced workers or informal carers.

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10.1.3.2 Other Considerations

Additional hours may be required for either Tier 1 or Tier 2 participants if they:

  • are under the care of Department for Child Protection: up to 20 hours
  • require interpreter services for assessment and training: up to 10 hours
  • have additional service providers (indicated by multiple settings, for example, shared care arrangements): up to 10 hours/provider.

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10.1.4

Client support provided by RN

Table 1 - RN Delegation of care hours

Tier 1 Tier 2 Tier 3
ihr — 1 per year ihr - 1 per year ihr - 1 per year
2hrs - 1 per year 2hrs - 1 per year thr - 1 per year
Thr — 3 per year thr - 1 per year thr - 1 per year
2hrs — 3 per year 2hrs - 1 per year ihr - 1 per year
3hrs - 1 per year ihr - 1 per year thr - 1 per year
30mins — 6 per year 30mins — 3 per year 30mins — 2 per year
90mins — 1 per year 90mins — 1 per year N/A
3hrs - 1 per year 2hrs - 1 per year thr - 1 per year
1hr — 5 per year 30mins — 3 per year N/A
2hrs — 1 per year 2hrs — 1 per year thr - 1 per year
Add skill 1hr per year Add skill 30mins per year

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Client support provided by RN

Tier 1 Tier 2 Tier 3
Delivery of training 2hrs — 1 per year 1.5hrs — 1 per year
(2 skills/2-4 support worker staff) — Competency Add skill 1hr per year Add skill 30mins per year
Delivery of training 2hrs — 1 per year 1.5hrs — 1 per year
(2 skills/2-4 support worker staff) — Reassess Add skill 1hr per year Add skill 30mins per year
Environmental Assessment 1hr — 4 times per year 1hr — 4 times per year

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Refer to Table 2 as a guide when including disability-related health supports in a participant’s plan. The table lists the estimated hours and frequency of supports for each of the individual health items where this is the only support need for the participant. Please consider all of a participant’s needs when determining the number of hours to include for a specific type of support. Refer to each individual disability-related health support Practice Guide for details regarding hours and frequency of support.

You should take into account all hours required to meet a participant’s reasonable and necessary whole of person needs. Combine the hours required for different health support categories so there is no duplication of hours for a provider type (for example, nurse, speech pathologist, dietician, podiatrist, and physiotherapist).

Example: John has a C3 spinal cord injury, is medically stable and is receiving services from personal care workers for his daily care. He requires routine monitoring visits and clinical intervention by an appropriately skilled nurse including, but not limited to, catheter changes, skin integrity checks, trachea tube changes and identifying and addressing training needs. This would be estimated as 2-5hrs at a registered nurse level per week.

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10.2.1 Table 2 — Summary of disability-related health supports

Continence Supports for consideration

Core

  • Personal care hours for assistance with continence care as part of the participant’s daily personal care for example, maintenance and care of a catheter (see RN delegation of care).
  • Continence consumables.
  • Membership of a stoma association - $50 concession or $60 full rate, if requiring stoma consumable products from Stoma Appliance Scheme.

Capacity building

  • Composite nursing hours for:
    • continence assessment plans and reviews from a continence nurse (CNC level nurse) which includes identification of continence consumable/AT support needs — up to 3hrs per year
    • catheter changes for suprapubic and indwelling catheters — up to 12hrs per year. For full guidance when including disability-related continence supports in plans refer to Practice Guide – Continence Supports.

Capital

N/A

Diabetes Supports for consideration

Core

  • Personal care hours to support the participant to implement the diabetic management plan and assist with the administration of routine, non-complex insulin when the participant is unable to perform the tasks due to their ongoing functional impairment.
  • Hours for personal care worker to attend training specific to the implementation of the participant’s management plan.

Note: additional hours required will depend on other disability support needs, where support workers are already required to support the participant in everyday life activities.

  • The NDIS does not fund diabetic medication and consumables.

Continence Supports for consideration

  • Nursing hours to develop a participant specific diabetic care plan including initial consultation, development of the plan and re/assessment — up to 5hrs per year (including 1 reassessment).
  • Where there is evidence the complex health and disability care needs of the participant exceed the skill set of a trained support worker, nursing hours may be included to administer insulin. Hours required will depend on other disability support needs.

For full guidance when including disability-related diabetes supports in plans refer to Practice Guide — Diabetic Management Supports.

The NDIS does not fund diabetic equipment.

Dysphagia Supports for consideration

  • Personal care hours to support implementation of an oral eating and drinking care plan (OEDCP) or mealtime management plan and/or any recommended swallowing therapy strategies as delegated by a speech pathologist.

Note: Additional hours considered to attend participant specific training in regards to mealtime plan or eating and drinking plan. Up to 2 hours per year per support worker.

  • Low cost assistive technology such as adaptive cutlery.
  • Thickeners to prevent aspiration and promote safe swallowing.

Capacity building - Delivery of health supports by a speech pathologist including:

  • re/assessment, development of OEDCP or mealtime management plan — 14hrs per year (based on assessment in 2 locations)
  • swallowing therapy intervention, usually included as part of the OEDCP or mealtime management plan

Continence

Supports for consideration

  • training family and support workers in the specific implementation of the participant’s management plan — 8hrs per year (based on training in two locations).

For full guidance when including disability-related dysphagia supports in plans refer to [Practice Guide – Dysphagia Supports](Dysphagia Supports).

Capital

N/A

Epilepsy

Supports for consideration

Core

  • Personal care hours for a support worker to:

    • attend training to implement an Epilepsy Management Plan and/or Emergency Medication Management Plan - up to 90 minutes every 2 years
    • implement, shop for and cook a participant specific Ketogenic diet plan. Training to implement plan — 1hr per year. Support hours will vary (see [Practice Guide – Epilepsy Supports](Epilepsy Supports))
    • monitor seizures where the level and risk of seizure are high due to the severity of the participant’s epilepsy — hours dependant on participant’s other disability support needs.

  • Low cost assistive technology (up to $1500 per item) such as seizure monitor alarm systems, seizure mats for beds, and oximeters, to measure a person’s oxygen saturation.

Important: Any requests for 24/7 or 2:1 support related to epilepsy monitoring should be referred to the TAB for advice.

Capacity building

Where there is evidence the complex health and disability care needs of the participant exceed the skill set of a trained support worker, nursing hours may be included to monitor seizures. Hours will vary depending on participant’s other disability-related support needs.

For full guidance when including epilepsy supports in plans refer to [Practice Guide – Epilepsy Supports](Epilepsy Supports).

Continence Supports for consideration

Capital N/A

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Nutrition

Supports for consideration

Core

  • Personal care hours for a support worker to:

    • administer HEN, and assist PEG maintenance and care where a participant is unable to independently manage due to their functional impairment
    • assist where a participant has cognitive difficulties to implement a nutritional meal plan.

    Note: hours will vary depending on the participant’s other disability-related support needs.

  • PEG and HEN equipment and consumables including:

    • enteral feeding tube
    • administration reservoir such as a feed bag or bottle
    • giving set
    • syringes
    • enteral pump.

  • HEN formula when the cost of formula exceeds what is deemed more than standard food costs for the average Australian and is not currently funded under the PBS.

Capacity building

Dietitian hours for:

  • re/assessment and development of a standard or complex meal plan — up to 5-10hrs per year (based on one reassessment)
  • training (for family members, support workers) specific to the participant’s individual nutritional needs — 1-6 hrs per year.

For full guidance when including nutrition supports in plans refer to Practice Guide — Nutrition Supports.

Capital

N/A

Nutrition

Podiatry and foot care

Core

  • Personal care hours for a support worker to assist a participant with the implementation of a home exercise program which has been prepared by a podiatrist - as a general guide 15 minutes per day additional to the participant’s normal daily care routine.
  • Training in the specific needs of the participant - 1hr per support worker.
  • Low cost AT (up to $1500 per item) such as orthotics and wearable technology.
  • Repairs and maintenance of podiatry related AT.

Capacity building

Podiatrist hours including:

  • Podiatry assessment and development of podiatry care plan including reassessment — up to 9hrs per year.
  • Training support workers in the individual needs of the participant - 1hr per support worker.
  • Cutting toe nails and other foot care - 20 - 60min per visit, every 6-8 weeks.

Note: Where there is evidence the complex health and disability care needs of the participant exceed the skill set of a trained support worker, podiatrist hours may be included to implement the podiatry care plan.

Capital

The following AT items over $1500 per item:

  • custom foot orthoses
  • medical grade footwear
  • custom footwear.

For full guidance when including Podiatry and Foot Care Supports in plans refer to Practice Guide — Podiatry and Foot Care Supports.

Respiratory Supports for consideration

Core

  • Personal care hours for a support worker:
    • where a registered nurse (RN) has delegated care for the support worker to administer the proper use of medical equipment (see [RN Delegation of care])
    • attend training in the individualised needs of the participant
    • support a nurse with tracheostomy changes.
  • Consumables related to tracheostomy, suctioning, air humidifiers CPAP and BIPAP machines and Oximeters
  • Disability-related health equipment and consumables delivery
  • Disability-related health equipment and consumables - Set up/training
  • Repairs and maintenance - Disability-related health machines
  • Filters and/or humidifiers for ventilators.

Capacity building

Nursing hours for an RN to delegate work to a health support worker or enrolled nurse (see [RN Delegation of care]). Includes training support workers in the individualised needs of the participant.

Capital

Purchase or lease of:

  • Constant Positive Airway Pressure machine (CPAP)
  • Bilevel Positive Airway Pressure machine (BIPAP)
  • Ventilator
  • Oxygen (Note: this requires TAB referral)
  • Air humidifier
  • Portable suction machine
  • Cough assist machine.

For full guidance when including respiratory supports in plans [Practice Guide — Respiratory Supports].

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Respiratory, Wound and Pressure Care

Supports for consideration

Supports for consideration

  • Personal care hours for support workers to assist with the implementation of a wound prevention plan and to attend training provided by Nurse, physiotherapist or occupational therapist (see RN Delegation of care).
  • Consumables for prevention and dressing of wounds such as PH wash, moisturiser and barrier creams, gauze, bandages, dressing, tape and cotton wool to dress wounds. (Note: for participants with Epidermolysis Bullosa (EB), all wound care consumables/dressings are provided through the EB dressing scheme).

The following should be considered when including consumables related to wound prevention and management:

*   Tier 1 - Wound Prevention kit for participants at risk of pressure injury — i.e. $1000 per year
*   Tier 2 — Additional $1000 per year for management of 3-4 simple wounds (dressings for wound care 2-3 days for each wound for 2-6wks) — i.e. $2000 total per year
*   Tier 3 — Additional $2500 per year for management of ongoing chronic wound care, i.e. $3,500 total per year. Any additional funds will be quotable following assessment by CNC.
  • Pressure care garments
  • Pressure supports (AT) up to $1500 per item
  • Disability-related health equipment and consumables delivery
  • Repairs and maintenance - disability-related health machines.

Capacity building

  • Nursing hours for:

Respiratory

Supports for consideration

— specific pressure care and wound management plan. Including initial consultation and re/assessment, development of the plan and ongoing clinical intervention support - up to 5hrs per year (based on one reassessment)

— ongoing clinical intervention support as identified by assessment (treatments range from one hour per day to 3 hours weekly as identified by the practitioner and level of nurse).

Capital

Purchase or lease of pressure supports (AT) over $1500 per item including:

  • pressure cushions
  • mattress
  • lymphoedema machine if required for maintenance.

For full guidance when including wound and pressure care supports in plans Practice Guide — Wound and Pressure Care Supports.

Botox and Splinting

Supports for consideration

While Botox and splinting supports are unlikely to be funded by the NDIS, funding needs to be assessed case by case and may be provided when it is a regular part of the participant’s daily life and results from the participant’s functional impairment.

  • The NDIS is unlikely to fund the purchase of Botox Neurotoxin type A.*
  • Serial casting, whether it is post-Botox or done independently from Botox treatment, is a time-limited episodic treatment.
  • As such, Botox and post-Botox rehabilitation for children aged under seven years with developmental delay and disability is considered a health system responsibility.
  • The NDIS will fund splinting to maintain a participant’s function once the post Botox rehabilitation is completed.

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Respiratory Supports for consideration

*Botox must be administered in a clinical setting, and in Australia, therapeutic Botox injections for spasticity are only given by doctors. They usually do so in private rooms or as part of a hospital spasticity clinic. It is unlikely that Botox will be provided out of a clinical setting and cannot be delegated.

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10.3 Appendix C: TAB mandatory advice list

The following supports require you to seek advice from TAB prior to including in the participant’s plan.

Assistive Technology Supports requiring TAB advice
CPAP Devices New CPAP machines
BIPAP Devices All BiPAP machines
Climate control All requests for air conditioning and/or heating
Cough Assist Machines All new requests (excluding like for like replacement)
Life Support Ventilators (IPPV) All requests, including replacement requests
Negative pressure wound therapy pump (NPWT) Pneumatic compression pumps for lymphoedema management
Oxygen All requests for additional oxygen supply above state or territory scheme supply
Respiratory Device Consumables
  • Request for more than 4 masks, straps and tubing sets per year for Non-invasive ventilator devices (# see definition below) — BiPAP or CPAP
  • Consumable requests for use with invasive ventilator and BIPAP devices (## see definition below)
Seizure response mats, monitors, Apple watch All requests for devices above $2,000
VAC Dressings and VAC Machines New requests for VAC Dressings and/or Machines

Capacity Building supports

Supports requiring TAB advice

Support Requirement
Continence More than 18 hours for RN supports per year for direct management of participant’s continence needs
Diabetes Requests for RN nursing supports for direct management of diabetes where there is evidence that the diabetes is stable

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Assistive Technology - Supports requiring TAB advice

  • More than 35 hours/year for high cost/intensive feeding programs due to dysphagia/sensory aversion
  • More than 15 hours/year direct speech therapy support for 1-2 assessments per year of swallow safety and risk due to dysphagia

Epilepsy

More than 38 hours per year for direct support from RN for management of epilepsy / seizure monitoring

RN direct care — not RN Delegation of Care model of support or training

RN for direct in-home nursing support for a function that otherwise sits with health e.g. RN funding for in-home blood testing due to behaviour/anxiety

Nutrition

More than 20 hours/year for assessment and development of a meal plan

Nutrition (PEG/HEN)

More than 3 hours per day for RN direct care for PEG/HEN maintenance

Podiatry/Foot Care

More than 25 hours/year of Podiatry Care Program (PCP) and/or foot care and maintenance from podiatrist or nurse

Respiratory

More than 14 hours per week for RN supports for direct management of participant’s respiratory needs

RN Delegation of Care

Requests for RN Delegation of Care hours exceeding those in Table 1: RN Delegation of care hours.

Tier 1 — Above 62 hours per year Tier 2 — Above 31 hours per year Tier 3 — Above 12 hours per year excluding travel

Wound and Pressure Care

  • More than 7 hours per week of RN support to attend dressings for the duration of plan
  • Request for RN support to attend to dressings immediately post discharge from Hospital

Core supports - Supports requiring TAB advice

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Assistive Technology Supports requiring TAB advice

  • Ancillary Power: Any requests for additional NDIS funding of disability- related health supports AT ancillary power costs over and above Commonwealth, State or Territory subsidies and payments

  • Continence consumables: All requests above $10,700 per year

  • 24/7 and/or 2:1 Monitoring for Epilepsy: Requests requiring this level of support for exclusive monitoring /management of epilepsy

  • Wound Dressings: Above $3,500 per year.

Non-invasive ventilation (NIV) is the use of breathing support administered through a

face mask, nasal mask, or a helmet. Air, usually with added oxygen, is given through the mask under positive pressure; generally the amount of pressure is alternated depending on whether someone is breathing in or out. CPAP and BiPAP are types of non-invasive ventilation.

Invasive ventilation is breathing support administered via an endotracheal or

tracheotomy tube to deliver air and oxygen.

10.4 Appendix D: Table Summary of Jurisdictional Power Subsidies

Jurisdiction Subsidy
Commonwealth Essential Medical Equipment Payment
Western Australia Life Support Equipment Electricity Subsidy Scheme
Thermoregulatory Dysfunction Energy Subsidy Scheme
Queensland Electricity Life Support
Medical Cooling and Heating Electricity Concession Scheme
New South Wales Life Support Rebate
Medical Energy Rebate
Northern Territory NT Concession Scheme (NTCS)
NT Seniors Recognition Scheme (NTSRS)
Tasmania Annual electricity concession
Life support concession

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Jurisdiction Subsidy

Jurisdiction Subsidy
Victoria Annual electricity concession \
Life support concession \
Medical cooling concession
Australian Capital Territory Life support rebate \
Home haemodialysis rebate
South Australia Medical heating and cooling concession \
Energy bill concessions

11. Supporting material

  • NDIS Act 2013
  • NDIS Rules
  • Disability-Related Health Supports Operational Guideline

12. Feedback

If you have any feedback about this Practice Guide please email Service Guidance and Practice Branch. In your email, remember to include the title of the resource you are referring to and to describe your suggestion or issue concisely.

13. Version change control

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Version Amended __ Brief Description of Change Status

No Amended by Brief Description of Change Status Date
5.0 EMN960 Minor updated to TAB APPROVED 2020-08-21
Mandatory advice table. Inclusion of case example.
6.0 EMN960 TAB have updated the list of supports that you will need to obtain advice from TAB before including those supports in a participant’s plan. Requests for respiratory support devices must be referred to TAB before your decision as to what supports should be included in the plan. APPROVED 2020-09-29