Parliament of Australia

Joint Standing Committee on the National Disability Insurance Scheme

Inquiry into Assistive Technology

Occupational Therapy Australia (OTA) submission

September 2018

Introduction

Occupational Therapy Australia (OTA) welcomes this opportunity to make a submission to the Joint Standing Committee’s inquiry into the provision of assistive technology (AT) under the National Disability Insurance Scheme (NDIS).

Members of the Committee would be aware that OTA is the professional association and peak representative body for occupational therapists in Australia. As of June 2018, there were more than 20,000 registered occupational therapists working across the government, non-government, private and community sectors in Australia.

Occupational therapists are allied health professionals whose role is to minimise the functional impairment of their clients to enable them to participate in meaningful and productive activities. Occupational therapists particularly work with people with a disability and their families to maximise outcomes in their life domains including daily living, social and community participation, work, learning and relationships. As such, they are key providers of services to many NDIS participants.

The prescription of AT and the design of home modifications is a core function of the occupational therapist, particularly since the roll out of the NDIS has – in theory – opened up unprecedented opportunities for Australians with disability to acquire equipment customised to help them meet their goals.

It is therefore disappointing to report that our members and the NDIS participants they serve experience significant frustrations when trying to prescribe and acquire necessary AT and home modifications. Bureaucratic requirements that have never been satisfactorily justified continue to delay the AT approval process, meaning participants who should be working to achieve their goals are left without any, or with sub-optimal, equipment. In addition to impeding their progress, these delays also put participants at risk of physical injury, heightening the likelihood of avoidable hospitalisations.

This submission outlines some of the key issues relating to AT and home modifications, and proposes effective means of addressing them.

• complexity; identifying potential conflicts of interest; triaging and resolving repairs and maintenance issues promptly; and efficiently achieving value for money.
• The NDIA should develop a process for coordinating repairs and maintenance, and this should be clearly communicated to participants and service providers. As part of this process, provision should be made for the management and prompt resolution of urgent repairs and maintenance requests.
• The NDIA should establish a single contact point to triage and coordinate repairs and maintenance requests for agency managed participants, with self-managing participants choosing to opt in or out.
• The requirement that reimbursement for travel be capped at 20 minutes (in metropolitan areas) and 45 minutes (in regional areas) should be removed.
• The NDIA should immediately intervene to prevent cases of Planners contacting AT suppliers for the purpose of adjusting quotes, without consulting the occupational therapist who prescribed the item of equipment.
• Specific training for prospective NDIS providers should be developed to enable them to adequately understand policies and processes relating to AT and home modifications.
• The NDIA should provide clear examples of what a conflict of interest looks like specific to AT services and supports.
• The NDIA should provide Support Coordinators with guidelines and training to help them navigate AT supports and avoid situations where advantage may be taken of the participant.
• Consideration should be given to the development of a nationally consistent approach to the prescription of aids and equipment.
• The Federal Government should work in partnership with the Victorian Government to address the issues currently affecting the State-wide Equipment Program (SWEP). In particular, consumers must be able to exercise choice and control by not feeling pressured to choose builders appointed to SWEP’s approved panel.
• The NDIA should develop and implement a ‘tracking system’ to enable providers and participants to track the progress of equipment requests and follow up accordingly.
• The NDIA should conduct education sessions and training around the processes underpinning the delivery of complex home modifications. The Agency should also develop national guidelines which clearly outline what will and will not be funded under the NDIS.

Whether the estimated demand for equipment to be sourced through the

assistive technology process in each roll out area was accurate

OTA was not aware that these estimates were accessible. We can only conclude that the lengthy wait times experienced by participants indicate that the NDIA grossly underestimated the demand for AT and home modifications.

Whether market based issues impact the accessibility, timeliness, diversity and availability of assistive technology

It is difficult for participants in areas with a small number of service providers to exercise genuine choice and control. Perhaps in response to this, the NDIA appears to allow the AT supplier to perform the role of funded assessor/prescriber, despite the obvious conflict of interest this involves.

Recommendation

This will likely prevent new providers entering the market, impeding the development of competition and genuine consumer choice, leaving participants at risk of being exploited.

Participants are not always being matched to the most appropriate service provider due to a lack of knowledge on the part of participants and their Support Coordinators.

Recommendation 4:

The NDIA should streamline low complexity and low risk AT.

Recommendation 5:

In areas with few service providers, the NDIA should play a more active role in regulating service provider registrations and behaviour with regard to managing conflicts of interest.

Recommendation 6:

The NDIA should educate Support Coordinators around assistive technology generally and, more specifically, around:

• AT complexity levels;
• matching service providers to need and complexity;
• identifying potential conflicts of interest;
• triaging and resolving repairs and maintenance issues promptly; and
• efficiently achieving value for money.

Repairs and maintenance

There are significant delays in the time taken for urgent and non-urgent repairs and maintenance work to be completed, leading to significant periods of time in which participants must use AT which may not be safe and which is certainly not ideal. This may also leave participants (and carers) housebound, and at risk of injury and hospitalisation.

Contributing factors to this problem include insufficient funds to cover the cost of repairs and maintenance, especially if multiple repairs are required, or if one-off repairs involve complex and high cost equipment.

Too few Support Coordinators are sufficiently experienced in coordinating AT repairs.

The requirement for a Service Agreement when completing an urgent repair is leading to significant delays.

Prior to the NDIS, state equipment schemes provided a central point for participants to report repairs and maintenance issues. These were then triaged and allocated to the most appropriate service provider to resolve. Systems were in place to monitor service providers’ pricing and to ensure that only reasonable and necessary supports were being recommended and funded. This system also ensured that repair versus replacement was appropriately considered.

Recommendation 7:

The NDIA should develop a process for coordinating repairs and maintenance, and this should be clearly communicated to participants and service providers. As part of this process, provision should be made for the management and prompt resolution of urgent repairs and maintenance requests.

Recommendation 8:

The NDIA should establish a single contact point to triage and coordinate repairs and maintenance requests for agency managed participants, with self-managing participants choosing to opt in or out.

Market based issues

Market based issues can be usefully considered from both a provider and supplier perspective.

Provider

In areas where the provider market is thin, participants face lengthy waiting lists to engage with a provider. Recent changes to the way allied health providers can charge for travel is adversely affecting the provider market. Providers can charge either 20 or 45 minutes for travel to a participant, depending on where they are geographically located. Whilst the NDIA recommends that providers attempt to group participants according to geography, this is less practical for those occupational therapists providing a specialised service such as complex home modifications or high end AT. It is most unlikely that these providers can arrange a number of appointments in a particular geographical location. OTA is aware of one large national provider which has indicated it will not provide a complex home modifications service due to inadequate reimbursement for travel. This will only add to the delays being experienced by participants trying to access home modifications and AT.

Supplier

Some OTA members based in rural and remote parts of Australia are reporting great difficulty persuading AT suppliers to visit their areas to trial high end AT. Suppliers are reportedly waiting until they have a number of visits to complete in a given remote area, thereby exacerbating already long wait times.

Recommendation 9:

The requirement that reimbursement for travel be capped at 20 minutes (in metropolitan areas) and 45 minutes (in regional areas) should be removed. These restrictions on claiming have resulted in some providers ceasing to provide support to participants outside the travel constraints, whilst other providers are questioning whether they can realistically provide ongoing support to participants.

The role of the NDIA in approving equipment requests

Occupational therapists are highly skilled at assessing a person holistically and assisting them to trial, select and use the piece of AT most likely to help them achieve their goals. Occupational therapists are also able to implement strategies that may be used in conjunction with the AT to achieve a desired outcome.

In addition to completing a four-year degree, occupational therapists working in disability often have many years of experience working with home modifications and AT. Many of the existing state and territory AT schemes require occupational therapists to meet particular standards and to be credentialed before they can provide certain types of AT. Despite these existing checks and balances, the NDIS currently requires every home modification and AT application to be approved by an NDIA delegate. All too often the delegate is an unskilled Planner who does not have even a rudimentary understanding of disability or the AT options available to address disability. OTA receives regular reports of NDIS Planners questioning the clinical decision making of highly skilled occupational therapists. This is highly unprofessional, as well as the cause of acute and wholly unnecessary anxiety on the part of the participant.

It is with great concern that OTA has been notified of an increasing trend whereby NDIS Planners are, without the knowledge or consent of the prescribing occupational therapist, contacting AT suppliers with requests to adjust quotes of AT such as complex wheelchairs. It is only because the AT suppliers know and value the input of the occupational therapist, that they have alerted the

Occupational Therapists’ Concerns Regarding Assistive Technology (AT) Practices

There are obvious risks to the physical wellbeing of a participant when a wheelchair that has not been prescribed by the occupational therapist, and which does not meet the specific needs of the participant, is supplied. Such a scenario also gives rise to considerations around legal liability and professional indemnity insurance. The NDIA must act immediately to ensure such practices on the part of its personnel cease. If it refuses to so act it must be required to by government.

Whilst there is an increasing number of professional development opportunities being provided by private organisations, OTA is not aware of any that are endorsed by the NDIA. Whilst the Provider Toolkit on the NDIS website is a valuable resource, providers who are new to the NDIS would value NDIS-specific training to enable them to adequately understand the policies and processes that relate to AT and home modifications.

Despite the NDIA being responsible for approving AT and home modification requests, providers continue to find it near impossible to receive a definitive answer to AT-related queries. A call to the 1800 number will yield different answers to the same question, depending on who answers the call. OTA has repeatedly requested to meet with the AT team to discuss the complex home modification process, with no result.

Recommendation 10:

The NDIA should immediately intervene to prevent cases of Planners contacting AT suppliers for the purpose of adjusting quotes without consulting the occupational therapist who prescribed the item of equipment.

Recommendation 11:

Specific training for prospective NDIS providers should be developed to enable them to adequately understand policies and processes relating to AT and home modifications.

Conflict of Interest

There needs to be better management of potential conflicts of interest in the supply of AT services and equipment. State-based equipment schemes have typically required separation between the AT assessor/prescriber and the AT supplier due to the obvious risk of conflict of interest. It would appear that conflict of interest is not well understood under new arrangements as previous boundaries are now being crossed.

OTA is concerned that the new AT/home modifications pathway currently being trialled by the NDIA may give rise to potential conflicts of interest, as the prescriber and supplier can be the same entity.

Recommendation 12:

The NDIA should provide clear examples of what a conflict of interest looks like specific to AT services and supports.

Recommendation 13:

The NDIA should provide Support Coordinators with guidelines and training to help them navigate AT supports and avoid situations where advantage may be taken of the participant.

The Role of Current State and Territory Programs in the Assistive Technology Process

The use of pre-existing state and territory AT programs is a positive development insofar as occupational therapists are already familiar with these systems and they have quality credentialing processes already in place.

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This begs a question, however: If the NDIA has sufficient faith in the pre-existing state and territory equipment programs to incorporate them into the NDIS, why must the NDIA second guess these programs’ approval process, adding an additional layer of bureaucracy to arrangements and further blowing out wait times? Given the NDIA claims it needs more personnel than the 3,000 it is currently allowed, why on earth are they inventing new and completely unnecessary tasks for them?

The use of pre-existing state and territory programs does pose challenges for organisations which provide a national service, as they need to be familiar with more than one program. It is fair to say every program has its unique features.

Some OTA members report that previous state-based AT systems have attempted to retro-fit behind the NDIS. It appears that no consideration was given to the fact that these were different systems, with different needs and offering greater choice and control. It also appears no consideration was given to the number of requests that would be received.

Case study: Victoria

In the case of Victoria, concerns have been raised about the State-wide Equipment Program (SWEP) and its role administering AT requests on behalf of the NDIS.

One OTA member believes there are fundamental issues around SWEP’s vision and approach – which directly influence forms and processes. One such concern is that SWEP, which is the historical model for the Victorian state-funded equipment program, is based on a welfare model. The member states that, as a result of this approach:

• People were on long waiting lists, they had no choice and control and they were considered “fortunate to get what they were given and when they were given it”.

Significantly, this approach has not changed under the NDIS. This has resulted in participants experiencing lengthy waiting times and facing extensive application requirements for AT, which in turn results in increased therapy costs having to be included in the plan to meet SWEP (not NDIS) requirements.

The important distinction between the two models, and the subsequent approach to each individual’s needs, must be addressed.

The NDIS’ social model of disability is outcome focussed, strengths-based, person-centred and addresses environmental barriers and facilitators. In contrast, the more traditional SWEP model focuses on limitations, risks and impairments. This OTA member’s view is that the traditional approach can often be taken at the expense of a focus on participation. The member states that:

• SWEP has not adopted a person-centred or strengths-based approach, is seemingly unaware that the therapist working under the NDIS needs to bill for their time and that this money comes out of the participant’s budget.

In terms of best practice, an AT solution is only one part of the approach to achieve a participation outcome for a client. It is difficult to work towards such outcomes when part of the solution (AT) takes so long and timelines are so unpredictable. Occupational therapists need much greater certainty around the timing of AT solutions so that participants can plan their lives and allocate funds appropriately to achieve their goals.

SWEP’s System Requirements

SWEP’s system requires participants to select AT from the ‘pick list’, and it also effectively requires participants to choose builders from a panel of approved providers. Our members report that this is having the effect of limiting consumer choice.

Occupational therapists are now working in a commercial environment and understand the need to provide an efficient service, offering value for money in the provision of therapy services and the prescription of AT which enables the person to participate more fully in their life roles.

In the Loddon region it is reported that the approach adopted by SWEP has directly resulted in market failure in home modifications. Any work amounting to more than $1300 requires two quotes. One of these has to be from a building provider on the SWEP panel, and SWEP has indicated that the panel provider will be given the job unless the participant expressly indicates a preference for another building provider.

The level of detail that SWEP requires in quotes is well beyond what any commercial builder is prepared to provide, knowing they are unlikely to get the work. Significantly, they are not paid to quote but the panel providers are allowed to bill for their quotes. As a result of these patently unfair – and uncommercial – arrangements, no complex home modifications have been approved since roll out in Loddon. OTA contends that this market failure is largely attributable to the requirements of the NDIS/SWEP system.

Given that NDIS participants have, by definition, already provided evidence of permanent and significant disability, why does SWEP require so much eligibility detail from them?

OTA members report that completing SWEP forms is taking at least twice as long as it used to. Experienced clinicians take at least two hours to apply for a basic piece of AT and must first complete all of their reports as a Word document and then cut and paste in order to save time and address IT problems relating to the regular loss of information. OTA understands that SWEP is attempting to rectify these systems.

Occupational therapists are faced with a system where each agency blames the other for blockages, with the result that the resolution of problems is difficult and delays persist.

Too frequently, when an AT application passes through SWEP’s system it is then delayed while the NDIS submits it to the ‘Reasonable and Necessary’ test. It is not clear why there is this requirement in Victoria for AT requests to pass through two systems of checking, with all of the expensive delay this entails.

An OTA member reports that on one occasion, following long delays in its approval process, the NDIA suddenly approved a substantial number of applications in an attempt to clear its backlog. SWEP then experienced lengthy delays ordering AT items due to the sudden increase in its workload.

The system is challenging at best, and broken at worst. The involvement of two agencies, and the unnecessary duplication of bureaucratic requirements, is adding further delays to an already protracted process. This is frustrating for our members and tragic for their clients.

IT Problems

There have been significant problems around information technology (IT), including information disappearing and being lost from submissions, providers not being able to print the PDF with all of the information showing, IT outages, and no emails relating to validations. While OTA acknowledges

Occupational therapists making AT requests for participants report

that it takes longer to complete a SWEP report than to prescribe the AT – this is plainly unacceptable. There is also no opportunity for providers to detail the participant’s goals that the AT relates to. Suggested headings required to rectify this include:

• Functional abilities relevant to the AT being requested
• What are the features of the AT which are needed to address the participant’s goals?
• How is the recommended AT aligned with the identified features?
• How will the AT enable the person to meet their goals?
• How will the AT impact the level of funded supports or strengthen informal supports?

These headings, and appropriately informative responses from the occupational therapist, making it much easier for delegates at the NDIA to make informed and timely decisions about whether or not a piece of AT is reasonable and necessary.

One occupational therapy practice reports that its clinicians are each having to devote at least one hour a week to following up SWEP applications. The practice does not bill participants for this time, as its clinicians do not believe this is fair. Across this organisation, with more than 50 therapists, it is estimated that AT-related problems amount to 100 hours per week of non-billable time. This is 100 hours that would otherwise be spent helping NDIS participants achieve outcomes. It also, of course, undermines the financial viability of the practice.

Reputational damage

A related and very serious issue for OTA members is reputational. Participants frequently develop a negative view of our members because of delays in the delivery of AT; delays which are attributable to existing arrangements for AT provision, and over which our members have no control. This has also impacted adversely on longstanding business relationships and given rise to a situation where the prescription of AT and home modifications, an integral part of the occupational therapist’s role, has now become a business risk.

While SWEP has highly skilled and experienced technical advisors, a cultural change is required in order to adapt to an individualised funding model, with its focus on the consumer and the commercial viability of service providers. OTA suggests that the bulk purchasing approach, which is SWEP’s traditional practice, should be reviewed and careful consideration should be given to the benefits and outcomes that flow from the individualised approach to AT. It is OTA’s contention that, over time, the economic savings associated with improved consumer outcomes will far outweigh any savings achieved by bulk purchase.

Recommendation 14:

Consideration should be given to the development of a nationally consistent approach to the prescription of aids and equipment. This is in line with recommendations made by other representative bodies such as the National Aged Care Alliance (NACA) and the Council on the Ageing (COTA).

Recommendation 15:

The Federal Government should work in partnership with the Victorian Government to address the issues currently affecting the State-wide Equipment Program (SWEP). In particular, attention should be given to consumers’ ability to exercise genuine choice and control as they choose builders. Commercial builders are clearly disadvantaged under current

Whether the regulatory frameworks governing assistive technology are fit-for-purpose

Too often the NDIA’s regulatory frameworks amount to nothing more than an additional, and expensive, layer of bureaucracy. Navigating these frameworks is time consuming and costly, adding yet more unbillable hours to our members’ workload.

OTA notes that the NDIA is currently developing a regulatory framework which will require those providers who prescribe AT and home modifications to undergo further credentialing. While OTA accepts that some further training may be necessary before less experienced providers can prescribe high end AT and complex home modifications, we remind the NDIA that occupational therapists have all completed at least a four-year university degree, which includes aspects of AT provision and home modifications, and have achieved the competencies required to attain registration with the Australian Health Practitioner Regulation Agency. As such they are fully capable of responsibly prescribing most AT and simple home modifications. Any further credentialing should not involve the repetition of training already undertaken and must not entail excessive bureaucracy or unreasonable expense.

Other related matters

Communication

OTA members report that the fundamental problem with assistive technology, as with all aspects of the NDIS, is one of communication. Requests for assistive technology are made to the NDIS and nothing is heard back. Occupational therapists receive an automatic email but then nothing else. They have no idea where the request is in the system, or how long it will take to be processed. This inability to track a request is particularly frustrating if the occupational therapist needs to be there when the item is delivered in order to ensure that it is correct or to provide the participant with training in its use. Our members are frustrated that they are unable to answer questions from participants about what is happening.

As one OTA member observed:

When I do online shopping and it is being delivered by Australia Post, I know that it has been delivered to the depot, the approximate time it will be delivered to my home address and then a follow-up is sent after the delivery to ensure that I am happy. Surely if we can do this with online shopping we can do this with AT!

Recommendation 16: The NDIA should develop and implement a ‘tracking system’ to enable providers and participants to track the progress of equipment requests and follow up accordingly.

Home modifications

Committee members would be aware that home modifications are provided by the NDIS under its AT program. OTA members report significant difficulties with regard to this aspect of service provision.

Our members in Queensland report that the NDIA offers no training in its complex home modifications processes, leaving occupational therapists to rely on the exchange of information

Issues with Home Modification Processes Under the NDIS

Among themselves via an informal Facebook page. NDIS Planners are claiming it is not their role to provide this training but, rather, it is the role of the NDIA Engagement Teams. The Engagement Teams deny this. Calls for the NDIA to conduct training, or at the very least to offer information sessions on complex home modification processes, have gone unheeded, with NDIA staff saying there are no plans to do any education sessions or training.

This problem is compounded by the fact that there are no national guidelines outlining what complex home modifications will and won’t be funded.

The pricing of home modification items appears to been done in the NDIA head office and is not realistic according to experienced builders. These builders are frustrated by a system notable for the uncertainty of work and long waits for payment once work is completed.

There are reports of builders providing quotes amounting to millions of dollars but only getting the go-ahead for a few low-cost jobs. This is not necessarily the fault of Planners, many of whom report long and frustrating delays in responses from staff at the NDIA’s head office in Geelong. As a result, some builders are withdrawing their services due to a lack of work.

There are also problems around minor home modifications. Work costing relatively small sums is approved without due consideration of more cost-effective solutions recommended by occupational therapists. While some modifications might appear simple, there may in fact be a more appropriate solution, and this may only be apparent to an experienced occupational therapist. OTA is concerned that the current redesign of the AT/home modifications pathway will further contribute to this issue.

There are cases of NDIA Planners asking our members to obtain additional reports from doctors, physiotherapists and other health professionals in support of a home modifications request. These requests are not supported by any documentation on the NDIA website and our members have received no training in this role by any Engagement Team members. However, unless this role is performed, there are significant delays in the approval process or the home modification is flatly refused.

Our members also report a disturbing lack of consistency with regard to Planners’ knowledge of what home modifications have and have not been approved.

Participants are sometimes unaware that they must personally fund building work associated with a home modification which is itself paid for out of their NDIS package. For example, if a bathroom has to have a level access shower, there is a legislated need for safety glass to be installed in the window. While the NDIS package pays for the levelling, the client must fund the safety glass. If a toilet needs to be removed so as a floor can be waterproofed, and the toilet is damaged during this process and cannot be reused, the client must pay for a new one. Participants need to be clearly advised as to what expenses they may personally incur as the result of home modifications approved as part of their plan.

As a result of these problems, and the amount of unbillable work our members must do to address them, some occupational therapists are declining any new NDIS referrals and are considering deregistering from the scheme altogether.

Recommendation 17:

OTA reiterates its call for the NDIA to conduct education sessions and training around the processes underpinning the delivery of complex home modifications. The Agency should also develop national guidelines which clearly outline what will and will not be funded under the NDIS.

Conclusion

OTA is aware that the NDIA has recently revisited the system by which AT and home modifications are supplied as part of the NDIS. This involved consultation with stakeholders, including OTA, and we commend the Agency for this. The new arrangements are currently being trialed and OTA awaits with interest the outcome of this trial. It is to be hoped that many of the problems identified in this submission will be addressed and rectified as part of this process.

OTA thanks members of the Joint Standing Committee on the National Disability Insurance Scheme for this opportunity to address issues around the scheme’s management of AT and home modifications.

Representatives of Occupational Therapy Australia would be happy to appear before the Committee to elaborate on our concerns.

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