A survey of occupational therapists writing functional assessment reports for NDS participants

October 2022

FOUNDAION lhema DyAustralia 4

PREPARED BY

Summer Foundation, ABN 90 117 719 516 PO Box 208, Blackburn 3180, Vic Australia

Telephone: +613 9894 7006 Fax: +613 8456 6325 info@summerfoundation.org.au www.summerFoundation.org.au

© 2022 Summer Foundation Ltd. A copy of this report is made available under a Creative Commons Attribution 4.0 Licence (international)

CITATION GUIDE

Winkler, D., D’Cruz, K., Minter, E., Mulherin, P. (2022). Providing an evidence base for Home and Living decisions: A survey of occupational therapists writing functional assessment reports for NDIS participants. Summer Foundation.

DISCLAIMERS

The Summer Foundation and Occupational Therapy Australia have contributed information towards this report and believe it to be accurate and reliable. The Summer Foundation and Occupational Therapy Australia do not make any warranty, expressed or implied, regarding any information, including warranties to accuracy, validity or completeness of information. This guide is for educational purposes and the Summer Foundation and Occupational Therapy Australia cannot be held responsible for any actions taken on the basis of information outlined in this guide.

Providing an evidence base for Home and Living decisions 2

Contents

Executive summary

The survey

4

Key findings

5

Recommendations

6

Introduction

7

The role of OTs in supporting requests for SDA

8

Aims of the survey

9

Method

10

Results

11

Elements of exemplary OT reports

11

Concise and rigorous reports

11

Holistic approach

12

Clinical justification of recommendations

12

Exemplary OT reports versus mediocre ones

13

Standardised assessments and OT reports

13

Participant perspectives and preferences in OT assessments

15

Comprehensive evidence to support SDA funding decisions

16

NDIA staffing and processes

17

Building the capacity of OTs

18

Recommendations

19

Conclusion

20

Appendix A

21

Providing an evidence base for Home and Living decisions

Executive summary

Occupational therapists need to know what the NDIA thinks a ‘good’ functional assessment report looks like to help NDIS participants provide evidence for Home and Living decisions.

Funding to live in specialist disability accommodation (SDA) can be life changing for eligible participants of the National Disability Insurance Scheme (NDIS). In order to receive SDA funding, participants must provide evidence of their ‘extreme functional impairment and/or very high support needs’ to the NDIA, where a Home and Living panel will determine the participant’s eligibility.

The evidence that participants submit to the NDIA usually includes a functional assessment completed by an allied health professional. Results of an assessment are written up as a report and are a key piece of evidence to inform Home and Living decisions. Most of these reports are written by an occupational therapist (OT), or a multidisciplinary team which includes an OT.

Clear, concise and rigorous OT reports have the potential to help NDIS participants with the highest levels of needs secure adequate funding for housing and support. However, there is currently very limited information about what evidence the NDIA needs from OT reports to make informed, timely and accurate decisions.

Up to 30,000 participants are expected to be eligible for SDA, but as of June 2022 just under 20,000 were receiving this funding. Nearly 1,500 NDIS participants are stuck in hospital, and over 3,000 people under 65 live in residential aged care. Many of these people are likely eligible for SDA. The new Federal Government has committed to addressing issues with hospital discharge and housing, and wants to strengthen the SDA market. These are welcome commitments. But they must be informed by the needs of people with disability and the sector, and matched with concrete actions. The Summer Foundation and Occupational Therapy Australia are ready to work with the NDIA to explore issues with the SDA funding and find solutions.

OT reports that do not meet the Agency’s opaque evidence threshold should not be the reason a person’s request for SDA is denied. Increasing the quality, rigour and conciseness of the evidence provided to the NDIA with an SDA request has the potential to support the NDIA to make faster and more accurate SDA decisions. This would support the SDA market to make the best use of the over 1,000 vacancies in new SDA and reduce the number of NDIS participants going through long and bureaucratic internal and Administrative Appeals Tribunal (AAT) reviews of funding decisions. But in order to do this, OTs need to know what the NDIA thinks ‘good’ reports and rigorous evidence look like.

The survey

We conducted a survey in July 2022 to explore the role of OTs in helping NDIS participants request SDA funding. The aim was to understand the functional assessment and report-writing process from the OT perspective, and provide actionable insights to the NDIA. In total, 206 OTs responded to the survey. Over 95% had at least 3 years of experience, and between them they had completed over 1,000 assessments and reports for participants seeking SDA funding.

Key findings

• The report-writing process can be long and complex with many OTs feeling like their professional expertise is sometimes undervalued

• There is a lack of clarity among OTs about the NDIA’s expectations of a ‘good’ functional assessment report

• OTs identified that exemplar reports must present a holistic understanding of a participant’s support and housing needs, preferences and goals and provide clear recommendations with clinical justification.

• Application of assessment recommendations to NDIA and SDA eligibility was described as a crucial step in the reporting process.

• OTs use a wide range of standardised and non-standardised assessments in order to fully understand a participants’ needs and preferences

• OTs seek more feedback on reasoning for Home and Living decisions and best-practice examples to build their capacity around NDIA processes and expectations.

• Clearer timeframe expectations and templates for more concise assessment reporting are needed

• OTs would like to see the employment of more NDIA staff with disability/allied health knowledge, citing lack of disability knowledge as a barrier to NDIA staff applying the content of OT reports to Home and Living decisions

• Co-design of solutions and improved processes is important for restoring trust in the system

“ [We need] consistent information from the NDIA regarding their expectations from an OT report and what information they want in the report … Planners’ decisions vary dramatically and frequently will come back with questions which have already been clearly outlined in the report. “ – OT

Recommendations

OTs recognise the need for change in the way that some assessment reports are prepared in support of participants requesting SDA funding. However, they also need to know what information the Home and Living Panel needs to make funding decisions. Recommendations for improving the evidence collection and report-writing process have been derived from the reflections of OTs. These actions will help improve the capacity of OTs, shorten decision timelines, and provide greater transparency and confidence to NDIS participants requesting funding for SDA.

1. Produce written guidelines and best-practice examples – Written guidelines from the NDIA on the evidence needed for a SDA and support decision will help OTs provide concise and relevant information aligned with legislation.

2. Develop a template for OT reports – The NDIA should produce a template in collaboration with the industry with a clear outline of the evidence required for the agency to make an informed decision about SDA. This would assist occupational therapists to provide more concise and rigorous reports for the Home and Living Panel. This template could also reduce timeframes and eliminate the need for NDIS planners to spend hours summarising lengthy reports.

3. Employ more staff with an allied health background – The Home and Living Panel should include more NDIA staff with a background in allied health, to help improve the capacity of the NDIA to use the content in OT reports to make an evidence based decision regarding SDA.

4. Consider a broader range of evidence to inform decisions – The NDIA should welcome a holistic approach to assessments, including accepting written or video evidence from participants outlining their support and housing needs, preferences and goals.

5. Provide detailed reasoning for SDA decisions – When a request for SDA funding is denied by the Home and Living Panel, detailed and individualised reasoning behind the decision needs to be provided to the NDIS participant.

6. Develop a list of objective measures relevant to SDA decisions – The NDIA should collaborate with Occupational Therapy Australia and the Summer Foundation to determine a list of relevant objective measures that may assist the Home and Living Panel to make timely and accurate decisions.

7. Provide more education on SDA to OTs – The NDIA could collaborate with Occupational Therapy Australia and the Summer Foundation to develop a training program for OTs completing reports for SDA and support requests.

8. Collaborate to agree on standardised assessments list – There is an opportunity for the NDIA, in partnership with Occupational Therapy Australia and the Summer Foundation, to develop a list of key standardised assessments for SDA funding requests.

Introduction

The National Disability Insurance Agency (NDIA) decides whether a person with disability is eligible to receive funding for support. Funding is only approved by the NDIA when it decides that the NDIS participant’s request is ‘reasonable and necessary’. Funding requests for housing and associated supports are determined by the NDIA Home and Living Panel. These include requests for home modifications, supported independent living (SIL), individualised living options (ILOs), short and medium term accommodation, and specialist disability accommodation (SDA). In the last quarter, there were 6,412 new requests for funding to the Home and Living Panel.

The Panel’s decision must align with the NDIS legislation and the participant’s stated needs and preferences, which are often informed by the expert advice of allied health professionals. When providing evidence for why they need a certain type of funding, participants often submit a report from an Occupational Therapist (OT). This report documents the functional capacity assessment completed by the OT and is evidence to support the participant’s funding request.

An estimated 6% of NDIS participants with ‘extreme functional impairment and/or very high support needs’ will be eligible for SDA, which is housing designed to maximise their independence and meet their needs. Despite the approximately 30,000 participants likely eligible for SDA funding, as of June 2022 only 19,358 had SDA funding allocated in their plans. Most of the people receiving SDA are living in old stock built prior to 2016. An estimated two thirds of this stock does not meet contemporary standards in terms of maximising independence and allowing the efficient delivery of paid supports. At the same time, while the Agency has set aside $700m annually for SDA payments, in the last year it spent $186m.

This SDA underspend is not due to a lack of demand. There are 1,430 NDIS participants stuck in hospital due to a lack of suitable housing, and 3,163 people under 65 in residential aged care. Many of these people likely meet the NDIA’s eligibility criteria for SDA. Despite this demand, the Housing Hub lists over 3,000 vacancies in disability housing nationally. Therefore, problems in the SDA market are not simply due to insufficient funding, weak demand, or low supply of housing. Rather, many of the problems can be traced back to thick bureaucracy and opaque decision-making at the NDIA.

Much of the potential demand for SDA remains inactivated: thousands of people who are likely eligible for SDA are not aware that it might be an option for them. In 2021-22 only 39 younger people in aged care moved into SDA. This number is lower than in 2020-21, when 72 people moved into SDA from aged care. In order to get younger people with disability out of aged care, to prevent further admissions, and to facilitate timely hospital discharge, these participants need

Providing an Evidence Base for Home and Living Decisions

Expert support and capacity building to understand their options, document their needs and preferences to help secure an appropriate level of funding for SDA and support.

In the last 12 months evidence regarding issues with the NDIA’s decision-making for SDA has been documented.8 The Summer Foundation works with hundreds of NDIS participants with complex needs who have goals related to housing. Many of these people use the Housing Hub’s Tenancy Matching Service to assist them on the pathway to requesting SDA funding. However, participants are experiencing long delays and frustrations when trying to access SDA funding, leading some to appeal NDIA decisions to the Administrative Appeals Tribunal (AAT). 9

The new government has promised to investigate the ‘underspend’ in SDA and address the reasons for participants pursuing AAT reviews.10 Minister for the NDIS, Bill Shorten, has agreed to address issues with hospital discharge and housing.11 The Summer Foundation and Occupational Therapy Australia welcome these commitments, and want to work with the new government and NDIA to streamline the process of applying for SDA funding.

One piece of the puzzle is the evidence that allied health professionals – often OTs – provide to the NDIA in support of a participant’s request for SDA funding. There is insufficient guidance and information to deliver consistent and concise reports that include all of the evidence that the NDIA requires. The consequences of this are significant. It could mean that a person who might otherwise have been approved for SDA is denied the funding due to insufficient evidence in an OT report. The type of standardised assessment an OT uses, or the way they write-up the evidence, may make the difference between SDA funding being approved or denied. This situation is unsatisfactory, and may see some people with disability slip through the cracks through no fault of their own. It is this issue that this report addresses.

[We need] more transparency from the NDIA regarding exactly what information is required/not required. What constitutes evidence in the eyes of the NDIA? What guidelines are they using to make decisions? … I understand they don’t just want people writing to tick their boxes, but it wastes a lot of time all round trying to guess what they need from us – OT

The role of OTs in supporting requests for SDA

Funding for SDA is only granted to NDIS participants who provide evidence of their needs. Like all NDIS funding, participants need to justify why they need a certain type of support. Participants will only receive the funding they request if the NDIA is satisfied that it meets certain criteria, and is based on the expert evidence of health professionals.

Participants requesting funding for SDA normally provide the following information to the NDIA in order for their eligibility to be determined:

• A housing goal in their NDIS plan
• A Participant Housing Statement
• A Home and Living Supporting Evidence Form
• A functional capacity assessment by an allied health professional (such as an OT)
• Additional assessments to support the application if needed

Based on the evidence received from NDIS participants and allied health professionals, the NDIA’s Home and Living Panel then determines a participant’s eligibility for SDA funding, including the design category, building type, location and supports.12 If the Panel rejects the participant’s application for funding, or chooses to fund a different type of SDA, the participant may ask for that decision to be reviewed internally at the NDIA. If the participant disagrees with the outcome of the internal review, they then may appeal the decision at the AAT.13

Anecdotal evidence suggests that there may be a lack of quality, consistency, and rigour in some OT reports submitted to support participants’ requests for SDA funding. This in turn may be contributing to the numerous slow and inconsistent funding decisions being made by the NDIA’s Home and Living Panel.14 The flow-on effects of these decisions are not only detrimental to the participants involved, but also the wider SDA market which needs confidence that Agency decisions will be consistent with legislation and previous decisions.15

OTs need to know what information the NDIA requires to make an informed decision. Improved guidance, detailed templates, and greater transparency about what quality evidence looks like will help streamline the SDA funding process and improve outcomes for all stakeholders.

12 NDIA (2022). Specialist Disability Accommodation: Operational guideline. National Disability Insurance Agency. hhttps://ourguidelines.ndis.gov.au/supports-you-can-access-menu/home-and-living-supports/specialist-disability-accommodati on 13 NDIA (2022). Reviewing our decisions: Operational guideline. National Disability Insurance Agency. hhttps://ourguidelines.ndis.gov.au/home/reviewing-decision/reviewing-our-decisions. In the case of an SDA funding decision, the AAT will look at all the evidence in front of it and decide about the kind of SDA that a person should be funded for. As part of its deliberations, the AAT may request further evidence from both the NDIA and the participant. This may include further evidence from OTs, in form of reports on the participant’s housing and support needs. 14 Skipsey, M., Winkler, D., Cohen, M., Mulherin, P., Rathbone, A., & Efstathiou, M. (2022). Housing delayed and denied: NDIA decision-making on Specialist Disability Accommodation. Public Interest Advocacy Centre and Housing Hub. hhttps://apo.org.au/node/317588 15 Wellecke, C., Robertson, J., Mulherin, P., Winkler, D., & Rathbone, A. (2022). Specialist Disability Accommodation provider experience survey. Housing Hub and Summer Foundation. hhttps://apo.org.au/node/318315

Aims of the survey

The Summer Foundation and Occupational Therapy Australia developed a survey to understand the assessment and report-writing process from the perspective of OTs. The survey was targeted at OTs who have experience writing reports for NDIS participants seeking funding for SDA. In order to participate in the survey, OTs had to have completed a functional capacity assessment for an NDIS participant requesting funding for SDA in the previous 2 years.

The survey consisted of 15 questions, with an emphasis on short-answer responses asking OTs to comment on the ways they prepare assessments, as well as suggestions for how the quality of evidence provided to the NDIA by OTs could be improved.

Providing an evidence base for Home and Living decisions

Method

A survey was conducted in July 2022, and shared with the Summer Foundation and Occupational Therapy Australia’s professional networks. All data was collected anonymously. Data analysis involved descriptive quantitative analysis for demographic variables, and open-ended questions were analysed using descriptive qualitative analysis to identify key themes capturing recommended changes.

In total, 206 OTs completed the survey. Of these:

• 95.6% (n=197) had at least 3 years of experience, including 64.1% (n=132) who had 11+ years of experience

• Between them, OTs had completed 1,033 functional capacity assessments for participants seeking SDA funding, with a median of 5 assessments per OT (range = 1-300).

• 6.3% (n=13) had attended an AAT hearing to provide evidence specific to an SDA funding need

• 66.5% (n=137) had received guidance or training specific to writing reports for participants seeking SDA funding

• 57.3% (n=118) always asked a colleague to review their OT reports prior to finalising

Results

OTs were asked to select the disability types of the participants for whom they had written an SDA and support-related report. The question did not specify ‘primary’ disability type to allow for participants with more than one significant disability. Most common responses were psychosocial disability (12.2%, n=97); acquired brain injury (12.2%, n=97); autism (11.8%, n=94); other neurological disability (9.9%, n=79); and other physical disability (7.2%, n=57).

Figure 1 - Disability types of participants for whom OTs had written an SDA and support-related report

Providing an evidence base for Home and Living decisions 12

Elements of exemplary OT reports

OTs were asked to identify the essential elements of excellent reports. There was a range of elements described across all 206 respondents, with a quorum centering around 3 key areas:

• Concise and rigorous reports
• The need for a holistic approach
• Clinically justified recommendations

Concise and rigorous reports

Respondents described a level of confusion around reporting expectations from the NDIA. Some responses emphasised the importance of a ‘thorough’ assessment, while most respondents urged for more concise reports, citing concerns with long reports that take a lot of resources and may not be read by the NDIS. The use of a good template to guide reporting was a key recommendation.

“It would be good to have NDIA guidance on information required, to avoid excessive report writing and details that are not required. Report writing in the NDIS is becoming ridiculously arduous, taking up excessive therapist time and using a considerable amount of a participant’s NDIS plan budget.” – OT

Respondents also noted the importance of using easy to read, non-OT specific language that is understood by NDIS staff without disability experience or allied health qualifications. The use of practical examples was also encouraged.

“Guidance for language for reports. OT clinical reports can be technical and are often read by people with no clinical background who make these determinations. Our c临ical reasoning can be very clear as to why someone needs support - to another OT. However, clients often miss out on support with NDIA limited understanding of the nature of mental health treatment” – OT

Holistic approach

Excellent reports were described as reports that communicate a holistic understanding of the NDIS participant and their housing and support needs. Respondents identified the importance of including a functional assessment, capturing the voice of the participant, and demonstrating an understanding of the NDIS criteria.

Typically respondents described the use of standardised and non-standardised functional assessments that include the observation of activities of daily living (ADLs), instrumental ADLs, mobility and transfers. Other important elements include an evaluation of the environment and access/sensory needs, equipment and support needs, carer impact, psychosocial assessment and behaviour/risk assessment. Respondents also emphasised documenting support needs over a typical 24 hours, noting past and future needs.

“The report should cover all the participant’s physical, cognitive and pyscho-social skills and relate this back to their ADL and IADL status. What supports that they have in place now and why SDA is being sought. The sort of supports that will be needed for the person to relocate and this includes both the physical environment, supports on a day to day basis as well as supports that need to be accessed as the need arises.” – OT

Capturing the voice of the NDIS participant was identified as key to excellent reports.

Suggestions included the use of a participant profile, quotes and photographs. Respondents emphasised the importance of communicating the unique needs of each participant, including a description of their disability, and reference to the NDIS participant’s goals and preferences.

“The report should always have photographs!!! [Half of] the battle is bringing the NDIA decision makers into the room with us. Photos assist to do this.” - OT

Overwhelmingly, respondents identified the importance of OTs having a very good understanding of the NDIS legislation, as well as knowledge of SDA housing types and availability. Responses suggested linking functional assessment and report recommendations back to NDIS criteria, and housing needs described in the context of SDA eligibility, with a clear justification of why their current housing is unsuitable or not sustainable.

Clinical justification of recommendations In describing the features of an excellent report, respondents identified the importance of including a list of recommendations at the end of the report supported by a clearly articulated clinical justification. In other words, respondents emphasised the importance of a clear statement of what support is needed and a description of why this support is needed. In doing this, respondents suggested tailoring the recommendations to the unique needs and goals of each participant, as well as explicitly linking the recommendations to the SDA eligibility criteria. Some suggested justification as to why other housing options are not suitable, a statement of how the recommendations will improve a participant’s outcomes, and reference to potential risks to the participant and/or others if the recommendations are not funded.

“Clearly defined need for SDA (i.e. why current living situation is unsuitable to support a participant with their current NDIS goals and why SDA is recommended, including why alternate housing options are not suitable).” - OT

Providing an evidence base for Home and Living decisions 14

Exemplary OT reports versus mediocre ones

In addition to the above description of the essential elements of exemplary reports, respondents shared suggestions as to what differentiates an exemplary report from a mediocre one. Overwhelmingly, respondents indicated that an exemplary report is one that successfully communicates the assessment and recommendations of the OT, contextualised to the personalise needs and preferences of the NDIS participant.

   "Personalisation: what are the details specific to the participant, not just support needs but the personal differences that will impact their quality of life. Outlining the risks of what can happen if the person's holistic needs are not met, not just physical risks but social and functional." – OT

Respondents suggested specific reference to the benefits of SDA for the participant, as well as identification of potential risks (physical, social and functional) if housing needs are not met. Documentation of a participant’s housing history was also suggested, along with evidence of exhausting all other housing options. Opportunities for capacity building in line with NDIS goals, as well as consideration of the trajectory of a persons disability, especially in the context of degenerative conditions. In some instances, respondents also suggested input from the multidisciplinary team to communicate a personalised and holistic understanding of the participant.

Respondents also identified factors that assist OTs to produce an exemplary report:

• Experience in report writing

• Strong knowledge of SDA criteria

• Knowledge of previous AAT decisions

• Having good knowledge of the participant gained from multiple assessment sessions

• Clear clinical reasoning

In addition, respondents identified barriers to writing quality reports such as:

• Lack of clarity regarding what the NDIS wants/needs from reports

• Inconsistency in approvals

• Lack of feedback from the NDIS and examples of the information required

Standardised Assessments and OT Reports

OTs were asked to comment on the standardised assessments they thought might be included in reports. OTs could mention 1 or more assessments, as well as provide further comments. There was a large range of assessments recorded by participants, including both standardised and non-standardised assessments. The 5 most commonly listed assessments were:

• World Health Organization Disability Assessment Schedule (WHODAS 2.0 or WHODAS) (n=140)

• Care and Needs Scale (CANS) (n=107)

• Functional Independence Measure (FIM) (n=66)

• Adaptive Behaviour Assessment System 1st, 2nd and 3rd edition (ABAS-1, ABAS-2, ABAS-3) (n=53)

• Vineland Adaptive Behavior Scale 1st, 2nd and 3rd edition (Vineland-1, Vineland-2, Vineland-3) (n=50)

Despite the popularity of these assessments, 111 different assessments were mentioned in total, including various versions and modifications (see Appendix A). Over 60 of these were mentioned by only 1 OT.

As 1 respondent commented, this variety is necessary since:

“No 2 [NDIS] participants are the same, and no 2 participants should undertake the same standardised assessment. Standardised assessments do NOT replace an occupational therapist’s expert knowledge and skills in completing [a] functional assessment.” – OT

While the reason for the large range of potential assessments may be attributed to the need for a tailored approach to assessment, and use of disability specific assessments, a number of respondents indicated some confusion and conflict in their reasoning. Some respondents identified being influenced by discipline or disability specific reasoning for assessment selection, while others described being influenced by what they perceive the NDIS wants.

“Really depends - I usually just give them what they want whether it is relevant or not. For my SDA report I included: Lawton Instrumental Activities of Daily Living (IADL) Scale, World Health Organization Disability Assessment Schedule 2.0 (WHODAS) and the Care and Needs Scale (CANS). I included these not because I think they are overly good at reflecting the person’s needs but the NDIS likes them and often the client doesn’t score well so it helps. Do I think they are better than a well thought-out clinical justification? Nope, but they love it. “ – OT

Some respondents indicated that they use the list of standardised assessments on the NDIS website that are identified as ‘best practice’ in evidence.$^{16}$ In comparing this list of assessments to the top 5 assessments listed by the OTs surveyed, only 3 were listed on the NDIS website (WHODAS/WHODAS 2.0, CANS, and Vinelands).

$^\text{16}\ $NDIA. (2022). Types of disability evidence. National Disability Insurance Agency. hhttps://www.ndis.gov.au/applying-access-ndis/how-apply/information-support-your-request/types-disability-evidence

Participant perspectives and preferences

in OT assessments

Respondents noted the importance of including participant perspectives and preferences in the OT assessment and report. They recognised this to be aligned with a person-centred approach to practice, consistent with the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) and NDIA policies.

Respondents described ways that OTs can support participants to express their perspectives. Establishing rapport and supportive communication were identified as crucial in this process, as well as spending time with the participant. In addition, respondents emphasised the role of the OT in selecting appropriate standardised assessments, templates, and supportive documents (housing needs and preference tool, housing options document, home and living form) that capture the preferences of participants. As well as ensuring that participants receive adequate capacity building about housing options, for some participants, the opportunity to trial housing options would be ideal. Assessments and observations could then occur over multiple sessions and in different settings to fully capture the functional capacity of participants. Other suggestions included the use of goal setting tools such as the Canadian Occupational Performance Measure (COPM) and the Goal Attainment Scaling (GAS).

“Ask them their preferences, include them in conversations (where possible) about future accommodation, get feedback about what they want and need (they can be different things), include a participant statement, use the Home and Living form.” – OT

While respondents identified the value in OTs documenting the participant perspective within the report, overwhelming respondents encouraged the inclusion of a written/verbal/video statement from the participant. More specifically, it was suggested that participants share their goals in their own voice and clearly demonstrate their preferences. In instances where this may be difficult for participants, respondents suggested asking them or their family or carers some simple questions about where they would like to live (location), who they would like to live with (alone, with others) and to include this information in the report. Co-design was identified as a useful process in ensuring a collaborative approach to compiling a report. Respondents also recognised the importance of participants reviewing the information collated and ensuring that the report adequately describes their preferences and perspective.

“I will ensure they complete their own statement in their own words as to why they are seeking a SDA. I will also provide them with references and resources around the SDA process and what living options they can consider. I will provide them with a draft of my report and go through it with them to ensure that I am representing their application as best as possible.” – OT

“Ensure that the report is discussed with them prior to finalising. Ensure that it matches their goals and aspirations in line with the Home and Living Supports form. I always include a section on the person’s housing goals and highlight why SDA, the location, etc is important to them.” – OT

Supporting evidence from informal networks was also identified as crucial to showing a holistic view of participants’ needs and preferences. OTs also reported the potential for differing perspectives of OTs, NDIS participants and close others, emphasising the importance of acknowledging these differences in the report.

“When providing my recommendation, I generally include both my recommendation and the client’s perspective or preference regardless of whether these are consistent.” – OT

“We also sometimes use things such as Carer Burden assessments to highlight the potential strains placed on carers when they are not equipped to support a client” – OT

Providing an evidence base for Home and Living decisions 18

Comprehensive evidence to support SDA funding

decisions

OTs were asked to comment on additional evidence or reports they considered essential to provide to the Home and Living Panel as part of a request for SDA funding. The most common responses were multidisciplinary team (MDT) reports (62.5%, n=213); client/family/carer impact statements (14.1%, n=48); and behaviour support plans/positive behaviour support plans (13.5%, n=46).

Figure 2 – Essential evidence or reports provided in support of a request for SDA funding. Note: OTs could select more than one response.

Improving NDIA staffing, processes and the capacity of OTs Respondents recognised the potential to improve the capacity of OTs to provide the NDIA with objective evidence, while also identifying areas for improvement in NDIA systems and processes. More specifically, respondents communicated significant frustration with the amount of time required to write reports, coupled with a lack of consistent and appropriate SDA funding decisions. Many respondents raised concerns as to whether reports are read in full by the NDIA, citing a lack of disability and allied health knowledge as a barrier to NDIA staff understanding the content of reports. Overall respondents expressed a loss of trust in the system and a devaluing of their professional judgement.

Providing an evidence base for Home and Living decisions 19

“Without being arrogant, I believe my reports are to an exceptional standard and I don’t believe my department could provide a better report. I think the NDIS’s ability to fund and read our reports is what is lacking. It is not the OTs fault. It is the NDIS who are tightening their belts and it is frustrating when it leads back to us. I have had lawyers note that they wouldn’t change my reports and yet, decisions still come back as not conclusive enough.” – OT

“… as a sole provider I have now made the decision to no longer provide these reports. This is despite 20 years experience in OT, strong clinical skills, adequate report writing skills for other funding bodies and purposes including accident insurance schemes and medico-legal. however I have found that the confusing and conflicting requirements for NDIS with the extended process of appeals etc, makes this not worth my time, effort and energy - for self-care and an attempt at burnout prevention I have ceased these. “ – OT

In response to these concerns, respondents suggested changes at the NDIA that would assist the capacity building of OTs. Many of these changes related to either staffing, or Agency processes.

NDIA staffing and processes A key change that could be considered is for the NDIA to employ more staff with an allied health background. Staff also need more education about disability, mental health conditions, and OT assessments.

“OTs would have enhanced capacity if the NDIS were more timely in their responses and if they had staff who had a basic understanding of disability so that they could understand OT reports and therapists weren’t required to write 60 page reports when the information could be accurately depicted within 20 pages - quality over quantity should suffice but not when it comes to NDIS.” – OT

“Getting a mandate adopted that stops the unqualified NDIA staff from questioning OT recommendations and getting qualified AHPs to review the reports and making those decisions. General admin staff do not have the clinical knowledge to decline an OTs’ recommendation.” – OT

In addition to the recommendations around NDIA staff, there were also numerous suggestions regarding Agency processes, and in particular the Home and Living Panel. These changes included:

• Clear and objective assessment processes and transparency in decisions

• Specialist support coordinators and NDIA staff available for discussion and feedback on OT reports

• More accessible information for OTs on the NDIA website

• Clearer definitions of SDA and supported independent living (SIL)

• Guidelines on the minimum requirements/standards of individuals completing reports

• Clear timeframe expectations for OTs completing reports and NDIA response times

• Communication of legislation changes to OTs

• Adequate funded time to gather information and write a comprehensive report

Providing an evidence base for Home and Living decisions 20

OTs reflected on the need for:

“Clearer guidelines for OTs delivering this service. More openness and transparency within the process on the NDIA’s behalf. In my practice I do not see any consistency between 1 determination to the next and I clearly believe this is unfair and some people are missing out on opportunities they deserve just as much as the ones who are receiving them.” – OT

“Simplified templates without excessive repetition, removing the repeated burden of proof - these are people with severe permanent disabilities already accepted onto the scheme, we should not have to prove this each time, nor have to endlessly justify to NDIS staff with NO health background or understanding, the recommendations we are making based on our degrees, ongoing CPD [Continuing Professional Development] and years of experience.” – OT

“The NDIS website is very geared toward consumers, without much guidance for providers. Feedback on reports and reasons for decisions (not just cutting and pasting the reasonable and necessary criteria) or a provider panel who can offer feedback would be helpful. Decisions seem so random.” – OT

“Having the opportunity to understand what was missing for the reader, we know the situation and are assuming that we have communicated the detail we think is important but we are guessing really. It will depend on the person’s experience and understanding of the disability but the response provided back is ‘it doesn’t meet reasonable and necessary…’ But how? I would love to interview panel members to understand what they want as we interpret things so differently.” – OT

Building the capacity of OTs

Respondents also made suggestions for building the capacity of OTs. These suggestions centred on collaboration between OTs, Occupational Therapy Australia and the NDIA:

• Occupational Therapy Australia training, mentoring, templates and communities of practice

• Supervision and mentoring for junior OTs

• More focus on objective assessments/reporting/language in university training

• Research evidence/journals readily accessible to clinicians to include in reports

• Education regarding NDIS/SDA funding

• Co-design development of resources such as guidelines, templates, an NDIS language guide, required standardised assessments and case examples

Providing an evidence base for Home and Living decisions 21

OTs stated that:

“NDIA need to explicitly include OTs and [Occupational Therapy Australia] in the\n> co-design process for Home and Living supports. Currently we are not included. Our\n> expertise is not valued and recognised.” – OT

“Free education from the likes of [Occupational Therapy Australia] and Summer\n> Foundation, ensure all OTs are aware that the SDA reports should be reviewed and\n> ask for minimum length of time working in NDIS to complete SDA reports (e.g. 12\n> months or 2 years)” – OT

“I would not recommend OTs being ‘accredited’ or requiring additional training to\n> provide this work. OTs are already qualified and regulated. Market forces have\n> increased the number of new practitioners, and the complexity of the work they are\n> expected to do. NDIA should support staff development, but not limit the scope of\n> new practitioners. This would limit the availability of clinicians required to do this\n> work. It would also substantially reduce job satisfaction and therefore risk workforce\n> retention, for those staff required to ‘specialise’ in this complex and often frustrating\n> practice area.” – OT

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Recommendations

OTs recognise the need for change in the way that report writing for SDA funding is executed. However, they also need to know what information the NDIA requires to make informed decisions. Recommendations for improving the evidence collection and report-writing process have been derived from the reflections of OTs. These actions will help improve the capacity of OTs, streamline Home and Living Panel decision-making, shorten decision timelines, and provide greater transparency and confidence to NDIS participants requesting funding for SDA.

1. Produce written guidelines and best-practice examples - Written guidelines from the NDIA on the evidence needed for a SDA and support decision will help OTs provide concise and relevant information aligned with legislation.

2. Develop a template for OT reports - The NDIA should produce a template in collaboration with the industry with a clear outline of SDA eligibility criteria. This would assist occupational therapists to provide more concise and rigorous reports for the Home and Living Panel. This template could also reduce timeframes and eliminate the need for NDIS planners to spend hours summarising lengthy reports.

3. Employ more staff with an allied health background - The Home and Living Panel should include more NDIA staff with a background in allied health, to help improve understanding between the Agency and OTs, as well as to understand and be familiar with a broad range of standardised and non-standardised assessments.

4. Consider a broader range of evidence to inform decisions - The NDIA should welcome a holistic approach to assessments, including accepting written or video evidence from participants outlining their support and housing needs, preferences and goals.

5. Provide detailed reasoning for SDA decisions - When a request for SDA funding is denied by the Home and Living Panel, detailed and individualised reasoning behind the decision needs to be provided to the participant and OT who wrote the report.

6. Develop a list of objective measures relevant to SDA decisions - The NDIA should collaborate with Occupational Therapy Australia and the Summer Foundation to determine a list of relevant objective measures that may assist the Home and Living Panel to make timely and accurate decisions.

7. Provide more education on SDA to OTs - The NDIA could collaborate with Occupational Therapy Australia and the Summer Foundation to develop a training program for OTs completing reports for SDA and support requests.

8. Collaborate to agree on standardised assessments list - There is an opportunity for the NDIA, in partnership with Occupational Therapy Australia and the Summer Foundation, to develop a list of key standardised assessments for SDA funding requests.

Conclusion

Demand for SDA is strong. For thousands of NDIS participants stuck in hospital or aged care, SDA is the solution to increasing their choice, control, and long-term health and social outcomes. There are also thousands of people with disability living in old disability housing stock that does not meet contemporary standards. These dwellings are not designed to maximise independence and leave NDIS participants more dependent on paid support than they need to be. Many factors underpin NDIA funding decisions. This study addressed 1 crucial piece in the puzzle of requesting SDA funding: the evidence provided to inform Home and Living decisions.

OTs play a key role in supporting NDIS participants request funding for life-changing SDA. Their c临ical expertise is necessary to assess the functional capacity of people with disability, and write evidence-based reports to inform NDIA decision-makers. However, the policy context in which they work is difficult and can lead to confusion and frustration for OTs, as well as the people with disability who they are supporting.

This survey has revealed that for OTs, the goal of writing functional assessment reports may be clear, but the way of reaching it is complex. Much of this problem stems from poor communication from the NDIA in clarifying what information they need to inform their decisions. To OTs, exemplar reports must present a holistic understanding of a participant’s support and housing needs, prefences and goals and provide clear recommendations with clinical justification. Some OTs believe that a lack of disability knowledge and allied health experience within the Home and Living Panel is a barrier to decision-makers understanding the content of OT reports. OTs demonstrate an interest in partnering with the NDIA to co-design solutions, improve processes, and ensure NDIS participants are better supported to live well. This will help to restore trust in the system and ensure best outcomes for participants.

The Summer Foundation and Occupational Therapy Australia want to progress the findings and recommendations in this report by working collaboratively with the NDIA. The knowledge and expertise that exists in the allied health sector is a valuable source of information for the NDIA about what works, what issues need to be addressed, and what possible solutions might be. Greater collaboration will improve the SDA-funding request process from the perspective of participants, which will benefit all stakeholders.

Providing an evidence base for Home and Living decisions 24

Appendix A

Table 1 - List of assessments selected by OTs

*designates assessments listed by the NDIA as ‘best practice’ evidence17

Providing an evidence base for Home and Living decisions

Providing an evidence base for Home and Living decisions

Providing an Evidence Base for Home and Living Decisions

Pain Impact Questionnaire (PIQ-6)

Patient Competency Rating Scale (PCRS)

Patient-Specific Functional Scale (PSFS)

*Paediatric Evaluation of Disability Inventory revised as a computer adaptive test (PEDI-CAT)

Perceive, Recall, Plan & Perform (PRPP)

Physical Mobility Scale (PMS)

Powered Mobility Device Assessment Training Tool (PoMoDATT)

Professional Learning Community Assessment-Revised (PLCA-R)

Psychosocial Impact of Assistive Devices Scale (PIADS)

Recovery Assessment Scale (RAS)

Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)

Residential Environment Impact Scale (REIS)

Rivermead Behavioural Memory Test (RBMT)

Routine Task Inventory (RTI or RTI-E)

Rowland Universal Dementia Assessment Scale (RUDAS)

Safe Functional Motion Test (SFM)

Saint Louis University Mental Status exam (SLUMS)

Satisfaction with Life Scale (SWLS)

Sensory Processing Measure 1st and 2nd edition (SPM and SPM-2)

Sensory Profile 1st and 2nd edition (sp-2)

Spinal Cord Independence Measure (SCIM)

Stroke Drivers Screening Assessment (SDSA)

Talking Mats

Test of Everyday Attention (TEA)

Timed Up and Go Test (TUG)

Tinetti Gait and Balance Assessment Tool

Upper Extremity Functional Scale (UEFI)

*Vineland Adaptive Behavior Scale 1st, 2nd and 3rd edition (Vineland-1, Vineland-2,

Vineland-3)

Waisman Activities of Daily Living Scale (W-ADL)

Waterlow Pressure Sore Risk Assessment Tool and Waterlow Scale (Waterlow score)

Wechsler Adult Intelligence Scale | Fourth Edition (WAIS-IV)

Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)

Westmead Home Safety Assessment (WeHSA)

Wide Range Assessment of Visual Motor Abilities (WRAVMA)

*World Health Organization Disability Assessment Schedule (WHODAS 2.0 or WHODAS)

World Health Organization Quality of Life (WHOQOL)

Zarit Burden Interview (ZBI)