Submission to the Joint Standing Committee on NDIS

Develop Therapy Services is a private practice that provides occupational therapy, physiotherapy, podiatry and aquatic therapy services to children and adults in metropolitan and rural/remote South Australia. We have been a registered provider of the NDIS in South Australia, since the inception of the NDIS providing services since the initial early intervention trial site to the state in 2013. We continue to be a registered provider of early intervention services, home modifications, therapeutic supports and behavioural supports. We employ approximately 20 FTE Therapists, with , and then to additional paediatric age groups from July 2016. During then since the rollout to the present time, we have expanded services in to all ages under 65 years. Therapists in our practice, with experience ranging from 30 + years to new graduates. We provide support to individuals with a range of physical, psychological and developmental disabilities, their families and carers. As a outine intervention, assistive technology (AT) is frequently recommended, prescribed, and reviewed.

We welcome the opportunity to provide this joint committee with response to the terms of reference:

a. The transition to the NDIS and how this has impacted on the speed of equipment
   provision:

The provision of equipment to participants is significantly slower with respect to all clients. These delays appear due to:

• the number of steps and complexity of NDIS paperwork to be completed at every step of the process
• ensuring equipment is anticipated by the family in advance of a planning meeting, to increase the chance of the equipment being put into the plan in the first instance
• significant difficulties having plans altered if it was not appropriately anticipated before a planning meeting or misunderstood by a planner at this meeting
• having changes to equipment needs in plans when a clients condition unexpectedly changes during the plan period,
• having equipment needs recognised as a requirement associated with access to family and community life of a child.
• the approval of items to go into plan, and once in plan, approval to proceed
• clarification of what may be deemed ‘reasonable and necessary’ by NDIS staff for an individual participant.

• Repetition of tasks, eg waiting time for approval and inclusion into plan results in quotes being out of date and needing to be requoted before provision.
• Respecting that quotes may vary from the initial paper work due to childhood growth, the complex needs of some participants, largely related to he delay in gaining approval. This leads to another round of paper work/reapplications to apply the variation in funding to be approved before the item can be supplied results in additional delays.
• Waiting for higher level approval within NDIS delays final decisions and approvals being placed on plans.
• Once approvals have been given, prescriptions provided, and item ordered, supply may also be delayed if item is coming from interstate or overseas.
• Participants or their parents are communicated with when items are rejected and told that appeal is possible. This is a necessary step, but often distresses families, who are unsure what to do, and it puts them in the middle of negotiations with NDSI and therapists. An example is one family was told that the ramp that had been prescribed by the therapist to meet AS 1428, for a rise of 340mm was “too expensive” and would not be funded.
• The prescribing therapist is rarely consulted, if at all, yet he/she frequently could answer any questions about the reasons and specifications for AT item they have prescribed.
• There is no way to contact NDIS in urgent and dangerous situations, such as for bed and sleep safety. Emails that are sent, take days, weeks or months to gain a reply. We have a number of specific examples where there have been delays in responding to emails or phone calls., and in enabling funding to be released to enable services to be provided. In at least one of these situations the result was a breakdown in the therapeutic relationship with anger and mistrust leading to carers choosing to discontinue services despite the high risk situation continuing Thus, urgent AT needs due to safety or suddenly changing high risk situations have not been able to be addressed.

b.

whether the estimated demand for equipment to be sourced through the assistive technology process in each area was accurate: No comment can be made as we are unaware of the given estimations for demand.

c. whether market-­‐based issues impact the accessibility, timeliness, diversity and availability of assistive technology There are more suppliers coming onto the market which may be able to provide AT directly. However, the inherent inefficient practices required by NDIS for submitting paperwork, having items on plans, waiting for approval of plans, and approval of items, still exist.. d. the role of the NDIS in approving equipment requests: AT prescription is a skilled role that requires:

• clinical knowledge of the range of disabilities, the expected and variations in typical presentations, how they change over time, short and long-­‐term prognosis, and the current and future functional implications for the individual and primary carers;
• clinical knowledge of the particular client in the context of their home and community, as well as their disability.
• experience in AT prescription with product knowledge to know the potential range of options, the methods of use, cost-­‐benefit for long term use, safety implications for specific participants and environments, future needs, and progression to future equipment items
• problem solving to know what can be managed by off-­‐the-­‐shelf solutions, and what will need customisation. How safety risk, both immediate and long-­‐term, for the participant and their carer/s, can be minimised.
• grief counselling to support participants and their families to accept AT items into their home, and to cope with the continual grief related to loss of hopes, and dreams.
• Ability to see the whole picture of the impact of the disability, not just the presenting problem. Therapists may spend many hours with participants and their families before reaching a decision with them about an AT solution

Planners do not always have the appropriate skills to decide to approve or not approve specific items. Approval seems to be based largely around the cost of the recommended AT when there are multiple factors to consider, as we have listed above. It is false economy to provide a cheaper alternative if it results in injury or lost opportunity to the participant.

NDIS Staff are making decisions and questioning the therapeutic decision making of the treating and prescribing therapists. They do not have the regular contact with the participant and their carers, and are requesting more information to be provided, thus increasing the complexity, costing, and time delays of equipment provided.

example a treating therapist was requesting a new supportive shower chair for a boy with severe physical disabilities as he had out grown his previous chair. The request was for the next size up with matching supports. The request from NDIS was for the prescribing therapist to justify why each of the additional supports were needed.

It is completely inappropriate for planners to have a role in AT selection. One participant submitted an AT request for a new bath seat, as she had outgrown in size and development the previously supplied item. Although the child was still within the weight limit of the reclined support, she was now wanting and able to sit with support in the bath, and was a health, bonny girl who no longer fitted within the sides so was rolling out of the frame. After trial / consideration of a number of options, the OT completed a request for a new item to which the parents had agreed. The parents were told that the AT request was not approved as the child was still within the weight range. No consideration was given to the changing abilities of the child, nor the increased risk related to rolling out of the support and being at risk within the water.

-e. the role of current state and territory programs in the assistive technology process: In South Australia, we previously had an AT service provided by the Domiciliary Equipment Service that had evolved over the years to be reliable, responsive, effective, and user friendly. They had:

• Systems to enable consultation and communication with clinical consultants where additional support / clarification of prescriptions was needed. For example, only one assessment form had to be completed for submission. Therapists were trusted to have completed the necessary assessments, and trial and consideration of options in collaboration with clients with this information kept in the client’s file as working notes.
• Maintenance service for clients for equipment had been provided. It was acknowledged that equipment requires repair, and some items require regular servicing. This was automatically done without the need to get approval in a plan with a monetary amount attached.
• Methods for ensuring equipment that was issued (either new or recycled) was safe, in working order, and fit for the purpose required.
• Had a store that enabled recycling of equipment, and a way for alternative items to be considered and trialled easily, following consultation with treating therapists. Children frequently grow out of equipment before it becomes worn out.
• Enabled short term trial of equipment times that then could continue into use. Trialling is essential particularly with individuals with complex physical disabilities for whom it is necessary for them to have time over a period of days as their physical status varies on daily or even hourly basis. Carers also need time to use the equipment.

Recommendations:

1. Simplifying process and paperwork requirements by NDIS

   • AT items are mostly able to be predicted in advanced and included on plan. However, it is not always possible to predict the rate of change for some individuals (development of skills or loss of abilities) that require sudden adjustment of AT needs.

   • There needs to be a simple way for extraordinary requests to be placed onto plans at short notice. Some people are only just coming to terms with the disability and the prognosis this may mean. For example, parents may not be ready to hear or think that their infant of under 2 years may need a standing frame or walker to be upright to walk, but the extent of the disability will be obvious to the therapist. The therapist would be advocating for standing with support from 12-15 months of age to be important for bone growth, development of hips, and to aid in digestion. The infant may also need supports for seating in baths, pushers, high-chairs. Waiting another year for the next plan misses critical developmental time periods. Another example is an individual with a complex condition may be stable for many months/ years, but then suddenly change, either acquiring or losing abilities that suddenly place them and their carers at high risk for injury, e.g. suddenly learning how to roll onto your tummy without having the strength to roll back creates a high risk of suffocation in bed unless positioned with appropriate equipment; suddenly not being able to stand to take own weight in transfers then requires carers to provide total assistance in transfers, with hoist lifters, hi/lo beds now required.

   • AT Application to be a total of 1-2 pages, with additional information only when detailed specifications are needed, e.g. for complex home modifications, complex seating/mobility. The Individual clinical records for each client should contain all of the necessary information about how AT will assist the participant to meet their goals, and what has been considered / trialled / discussed / decided in line with best practice standards. Therapists should be trusted that this has been undertaken, and not wasting time and NDIS money documenting this again on the detailed application form. This should be able to be audited if required.

   • More than one item to be submitted on the one application, eg DVA application process.

   • Common risk assessment / evaluation / prescription procedure to be used to enable consistent priority ratings across Australia

• Items that are for replacement due to growth of the participant, or the item wearing out, with same prescription of previous features be automatically approved and funded. This is to include where the ‘next size up’ is required.

• Maintenance of existing AT items for participants, where prescription needs have not changed to be automatically funded without the need to apply for a variation to the plan, and the awaiting of funding.

2. Clinical consultants of each discipline within NDIS are able to be contacted directly by therapists prior to submission of paper work

   • DVA have a system where clinical advisers are able to be contacted by phone / email to discuss complex issues, provide advice prior to prescribing AT items regarding procedures, clinical decision problem solving. They also have a role in approving high cost or complex items.

3. Recognition of skill set of therapists. NDIS providers have undergone an approval process, and to be able to provide AT supports. Organisations and Private Practices have a responsibility to train and support staff to have the appropriate skills and knowledge to gain and maintain competencies for AT prescription to maintain NDIS Accreditation.

4. Continued use of state systems to enable recycling of AT equipment, particularly for children Children will often out grow equipment before it is worn out. Low cost items / customised items may not be cost effective to recycle,

5. Have a method for urgent AT requests to be dealt with quickly.

6. Prior approval for set items Low cost / high volume / non-­‐customised AT items to have set criteria and automatic approval with therapist prescription.

   Suppliers for items can quote for provision of these items annually, and participants then can have the choice of which approved supplier to contact to provide the item/s.

Submitted by: Alison Copley and Sonya Murchland, Directors