Submission to the Joint Standing Committee on the National Disability Insurance Scheme Inquiry into Assistive Technology

September 2018

Authors:

• Shayna Gavin APAM, physiotherapist, Splash Physiotherapy (VIC)
• Rachel Tosh, speech pathologist, Therapy Alliance Group (QLD)
• Carolyn O’Mahoney APAM, paediatric physiotherapist, Therapy 4 Kids (ACT)
• Kirsty Buhlert-Smith APAM, physiotherapist (VIC)

Answers to inquiries terms of reference:

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

The ACT experience:

The ACT equipment scheme (ACTES) received applications for funding of assistive technology for people with a disability prior to the NDIS. Two separate pro forma existed, one for items less than $2000 and the second for items greater than $2000. Items less than $2000 we generally processed within one month. Items greater than $2000 went to a separate independent panel of therapists for approval. This panel met every 2 to 3 months. Items were approved within a three-month period.

Now that we are in the NDIS, assistive technology items are taking up to 2 years for a decision to be made. If justification report and quotes are all presented at a face-to-face planning meeting, they are generally actioned within one month and if they are approved then the funds are in a participant’s plan between one and 3 months after the planning meeting. If they are presented at any time around this meeting or required within the time period of the plan, there are great delays being experienced.

The Victorian experience:

The State-Wide Equipment Scheme (SWEP) receives applications for assistive technology for people in Victoria. approves the items based on their thorough prescription forms providers are required to provide. However, the NDIS participants’ applications now go through an additional approval process direct with the NDIA. This has created additional delays as:

• Applications approved by SWEP can be listed as ‘pending’ with the NDIA for 11 months and are only looked at during the participant’s next plan review (despite follow ups, attempts to escalate, and requests for plan review). This has occurred both when there is and is not sufficient funding allocated to AT in the participant’s plan. Items have taken up to 2 years total to be provided, which can have devastating consequences to participants. o E.g. A child does not receive a walker and standing frame until they are 3.5 years old and have missed the early intervention window, delaying their development, and allowing onset of secondary complications from their disability such as hip dysplasia, joint and muscle contracture, which all have lifelong consequences in reducing their level of independence and increasing their required level of care. o E.g. An adult does not receive the hoist required, causing their caregivers to engage in unsafe lifting in and out of a bed and wheelchair, injuring themselves, while putting the adult at risk of a fall, with hospitalization an injury reducing their independence and increasing their care needs.
• The NDIA staff can make judgements to reject applications that appear in conflict with the information provided in the prescription. This appears to be due to a lack of understanding of the ICF model, how AT assists in achievement of goals, how risk is managed in AT prescription, what the variety of AT items on the market are and the differences between them (e.g. when a cheaper item is recommended, where this will not meet the participant need). They generally do not communicate with the prescribing therapist before rejecting the application, so there is no room to resolve these issues.

b. whether the estimated demand for equipment to be sourced through the assistive

technology process in each roll out area was accurate;

As therapy service providers we cannot comment directly on this area. However, we are aware from our experiences, and feedback from participants, that the current capacity to deal with equipment requests is under pressure and that there is a significant backlog of applications.

c. whether market-based issues impact the accessibility, timeliness, diversity and availability

of assistive technology;

The ACT experience:

Accessibility, timeliness and availability of assistive technology items for trial is an ongoing issue. Regular attendance of equipment providers to the ACT was available prior to the NDIS, which is likely to be a result of applications being processed more quickly. Extended delays in processing under the NDIS has impacted on the frequency in which they attend the ACT. It is also resulted in fees being applied by some assistive technology providers to therapy centers to attend for a trial and further fee are being charged for any reassessments or re-measures once the items have been approved. These additional fees are proving a barrier for participants who do not have enough funds.

As the number of visits assistive technology providers have to the ACT has reduced, they are performing more trials within one visit. Often this results in insufficient space in their van to bring all the items that enable a complete trial to occur.

With the closure of government therapy services in 2016, there are experienced therapists to prescribed assistive technology items now in private practice and not-for-profit organisations. Currently there seems to be enough experienced therapists to manage the demand, should government therapy services be reintroduced I could foresee NDIS participants finding it more difficult to access an experienced therapist to prescribe assistive technology.

The Victorian experience:

Both AT suppliers and therapists are heavily booked and / or managing waiting lists which is making trials difficult and causing delays to participants. Changes to how travel is reimbursed for capacity building therapists in the 18-19 price guide means that they need to volunteer their time to travel more than 20 minutes to see a participant. The AT application form requires a home visit assessment, and this is certainly best practice to ensure the item will meet the needs of the participant and their family and interact appropriately with other items and the environment in which it will be used. Where a participant requires trial of multiple AT items the supplier can often not fit them all into their van to complete trials on a single visit. Working with NDIS participants requires a specific skill set, that is not held by all local physiotherapists, occupational therapists or speech pathologists. There is often not a skilled therapist to meet the participant’s needs within a 20-minute drive of their home. In metropolitan Melbourne AT suppliers are willing to travel to complete these but are limited by their availability and number of requests. They are also often not able to access the item that needs to be trialed i.e. there are not enough trial items available to be shared for trials. Once approved, some items are in stock and can be delivered within weeks, others need to be ordered and manufactured and shipped from overseas.

d. The Role Of The Ndia In Approving Equipment Requests

There seems to be essentially 2 pathways; equipment requests lodged and considered at plan review, and equipment request lodged during a plan for urgent review. The former pathway seems to have a streamlined approach that is improving in speed and efficiency. The latter pathway does not seem to have a clear way of prioritising and escalating an urgent equipment request.

NDIA processes assess value for money and necessity. Items can be rejected with the suggestion that a cheaper item of similar characteristics should be suitable. An understanding of how an assistive technology item removes a barrier in participation or activity for a participant assists in identifying why an item has been suggested by a therapy provider. Often a similar or cheaper product does not remove the barrier being experienced by the participant and is therefore a meaningless purchase.

Currently therapists write lengthy requests and recommendations based on clinical expertise and judgement as well as direct observation and assessment of the participant and then NDIA approves or rejects the request based on the written report. It appears from a service provider perspective that these reports have been often misinterpreted or not been read by NDIA staff. This is leading to inconsistency in approvals and participants missing out on needed equipment. If NDIA is requesting prescriptions from therapists, then there needs to be wider recognition and acceptance of therapist clinical judgement and expertise in this area to make appropriate recommendations for reasonable and necessary equipment. States such as Victoria have a process for identifying the skill level of prescribers. This means their AT applications can be approved straight away if it matches their prescriber level. They are otherwise referred to a clinical advisor who communicates directly (and in a timely manner) with the prescriber to check and approve the item. Furthermore, there is currently just approval or rejection by NDIA for equipment requests. It might be helpful if NDIA could move from assuming a request is not appropriate unless proven otherwise to assuming a request is appropriate whilst ensuring that all the requirements of the legislation and guidelines are met. We as capacity building therapists understand that NDIA staff generally do not come from a clinical background, and we attempt to communicate the participant needs and clinical justifications in plain language. However, misunderstandings appear to often occur with NDIA staff misinterpreting or missing vital information in the applications and making judgements in conflict with this. It would be extremely beneficial for NDIA staff to consult directly with the therapist if there are questions or aspects of the written application that were unclear or appear not to meet criteria to allow clarification and ensure participants are not missing out on equipment simply because of a difference of terminology or miscommunication.

Several different forms exist, depending on the category of the item being applied for (e.g.

Bedding, mobility, assisted communication).

They are thorough, including diagnosis, information about the client, his caregivers, the equipment item, the home environment, risk assessments, clinical justification of need, relationship of the AT item to goals and removing barriers to participation or independence, imlications of non-provision (including imminent or longer-term risk, and seriousness of the implications, to physical and mental health, independence, and caregivers), and delivery. Depending on the item and the risk factors identified in the application process, (e.g.postural support needs, reduced range of movement, pain, growth, falls risk) the application is categorised as green, yellow, or red. Prescribers are required to register with SWEP, and are categorized as green, yellow, or red. Green level prescribers can prescribe green level applications without needing to go through a clinical advisor. If they need to do a higher level application a clinical advisor checks the application and will contact the prescriber if further information is needed or if they have concerns about the application. Red is the highest level, meaning that red level prescribers can put in applications for higher risk AT needs without the need for a clinical advisor. In this way, SWEP values the skill and workload prescribers put into trial and application processes to meet the individuals’ needs. Now with NDIS, once applications have gone through this SWEP process, they also go to the NDIA for consideration. This delays the process and issues have arisen such as:

• NDIA staff reject an application without the prescriber being contacted. Often there has been a simple misunderstanding that could have been resolved.
• NDIA staff ask the prescriber for information that is already contained within the application.
• NDIA staff reject the application advising that a cheaper item would be appropriate, whereas
• Applications have sat as ‘pending’ with NDIA for 11 months, despite requests and follow up, only to be considered at the next NDIS plan review. Even then, items included on a NDIS plan can still take months to be approved by the NDIA. Participant plans regularly underestimate the cost of AT items, sometimes despite provision of a quote or estimate, requiring a whole plan review and associated delays. One issue in delay in equipment provision is purchase of all items for NDIA brand new. SWEP has a reissue database. Especially for children, items are often used for 4 years due to growth. SWEP’s repairs and maintenance program services the items and makes them available for reissue. Currently NDIS participants ‘own’ the items and are giving them away or selling them after they are no longer needed. Making use of existing state-based infrastructure to reissue AT items would make a difference to times to receive AT in some instances and would be a budget saver for the NDIA. f. whether the regulatory frameworks governing assistive technology are fit-for-purpose, The World Health Organisation’s (WHO) International Classification of Functioning Disability and Health (ICF)i is an effective tool to describe the disability being experienced by a person. The interplay of environmental barriers to a person’s activity and participation can be effectively demonstrated (Figure 1). Assistive technology is a critical requirement to removing barriers for people and to reduce the disability they are experiencing. Disability is described as an incompatibility between what you are able to do and want to do, and the environmental affordances.i

Figure 1. The ICF Framework

If assistive technology requests are lodged during a planning meeting there is the opportunity for a verbal discussion to be had. This is clearly a better form of communication then email, and is a way for planners and participants to ask questions and ensure there is an understanding of the request

When an assistive technology application is made outside of the planning meeting, it can only be lodged via email to the NDIA or through the relevant state based AT program. There is no opportunity for further discussion or questions with the NDIA employee who is actioning the request. It would add value if it was a process that NDIA staff contact the prescriber if they have queries or concerns about the AT request, or are planning on rejecting the application. This would allow for misunderstandings to be resolved during the decision-making process via a phone call.

The communication exchange should be reflective of the impact or associated risk for that assistive technology request. Phone call opportunities should be made available for complex or urgent applications.

Of note, some Victorian therapists have been advised by LACs and ECICs that a new AT process requires all trials and applications to be completed before NDIA planning meetings. Some LACs and ECICs continue to accept well written reports detailing AT items needed and reasoning behind these, with a plan to complete trials and application processes during the NDIA plan. In these instances, AT items are included on the plan based on the price estimates, and listed as ‘to be quoted’. This is reasonable, because many people moving on to the NDIS do not have access to funding to complete assessments, trials and applications. Therapists need to develop a good understanding of the participant need using the ICF model and complete at least one trial in the home before completing an application and being able to submit a quote they are confident will meet the participant need. NDIA capacity building funding should be available for these processes. If participants are required to have all this completed before AT items will be included on a plan, many participants will miss out on AT items vital for their independence, participation in everyday life, and safety.

g. any other related matters

The process for requesting a review of decision is lengthy and can be a source of adverse health events for a participant who continues to wait for an assistive technology item. It would be valuable to have a

• phone conversation with the prescribing therapist added as a step prior to rejection, to allow discussion and a suitable outcome to be explored between therapist and NDIA staff.

As assistive technology providers are now introducing fees for trials and reassessments it may be necessary to consider these increase costs in participants budgets.

Where an assistive technology item has taken longer than 4 months to be actioned, it may be useful to check with the prescriber if a review is required. This will not always be the case, but is required for example when:

• A child has had a growth spurt. Prescribers are required to allow for growth in all AT requests. But where there has been a long delay since the trial, a child may have a growth spurt meaning they could now fit into a larger item size, giving them more room for future growth
• A participant’s ability to use an AT item has deteriorated due to delays in its provision, meaning they now require an AT item that provides more postural supports for their safe use. These are generally more expensive requiring an altered AT budget.
• An AT item has been discontinued by the supplier)

Allowing equipment to be hired using NDIA funding, assuming there is a way for this equipment to be hired, would go some way to reducing further disability occurring for people waiting extended periods of time for the assistive technology application to be actioned. There is potential for this with state- based programs, such as the Independent Living Centre in Victoria who already offer loans for trial pre NDIS, and the SWEP reissue equipment pool.

i How to use the ICF – A practical manual for using the International Classification of Functioning, Disability and Health, World Health Organisation, Geneva, 2013.

ii Using f-words to set goals for children with neurodisability and their families. CRE-CP Education Podcast. Professor Peter Rosenbaum

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