Mental Health

365 and Disability Services

OCTOBER 2021

ermhAs365 Response

Submitted by ermhAs365

ermha365 submission Parliamentary Inquiry into the future of the NDIS

Contact

Karenza Louis-Smith, Chief Executive Officer ermha365 1st Floor, Building G, 45 Assembly Drive Dandenong South VIC 3175 1300 376 421 | redacted | www.ermha365.org

Acknowledgements

ermha365 acknowledges the contribution of staff from the organisation’s mental health and complex client teams, as well as Executive Management in the preparation of this submission. ermha365 also acknowledges the importance of maintaining privacy and client confidentiality. To that end, the organisation seeks the opportunity to be consulted prior to the reproduction or publication of any content arising from case studies featured in this submission.

About ermha365

ermha365 is a company limited by guarantee, operating across Victoria and the Northern Territory, providing a range of NDIS support services as well as mental health, forensic and community programs and services.

We are known for our work with people who have significant mental health and cognitive disabilities and who may have additional complex needs, including behaviours of concern. Our participants’ backgrounds are likely to include trauma and at times lengthy institutional care, high contact with the service system (with little success), and a range of complex needs and diagnoses.

We are one of a very small number of specialist services working with complex participants who have co-occurring mental health needs who present with dual disability, autism spectrum disorder, alcohol and drug issues, and contact with the forensic/criminal justice system. As a result, ermha365 is a lifeline for people who often feel like “a square peg in a round hole”. Many of our clients have experienced stigma and discrimination, often ostracised or excluded from the simple things that most of us take for granted.

At ermha365, we believe it is a fundamental human right to live in the community – not in prison, or a locked hospital ward, just because there is nowhere else for you to go. We are experienced in successfully transitioning high-risk, high-needs participants from Secure Extended Care Units (SECUs), in-patient units, prisons and forensic facilities to community living and we are a go-to source for the State government and the National Disability Agency (NDIA) when the system has failed people with extreme behaviours of concern and high support needs.

Our purpose is to be a unifying voice for people with mental disability, giving them the voice, choice and support to thrive in a vibrant supportive community.

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ermha365 submission Parliamentary Inquiry into the future of the NDIS

Our vision is for progressive reform, advocating for all people living with a mental disability to be able to reach their personal potential.

Our mission is to work side by side with the people we work with, providing them with the compassion, care, advocacy and support they need to live the lives they want within a supportive community.

Case studies

To illustrate key themes, ermha365 highlights the challenges our clients face though the use of case studies. Pseudonyms have been used throughout this report, to protect the identity of individuals and maintain client confidentiality in accordance with the NDIS Code of Conduct for Service Providers and statutory privacy obligations. The case studies in this submission have been de-identified. However, ermha365 would appreciate the opportunity to be consulted prior to the reproduction or publication of any content arising from such case studies.

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ermha365 submission Parliamentary Inquiry into the future of the NDIS

Contact ………………………………………………………………………………………………………………… 1

Acknowledgements …………………………………………………………………………………………………. 1

About ermha365 ……………………………………………………………………………………………………. 1

Case studies …………………………………………………………………………………………………………. 2

1. Executive Summary ………………………………………………………………………………………. 4

2. Background briefing: Complex Care needs clients and the case for change …………. 8

Complex Care needs clients ………………………………………………………………………….. 8

Limited providers delivering supports to clients with Complex Care needs ……………. 9

Unsuitable housing options exacerbate negative client circumstances …………………. 9

3. Observations and recommendations in respect of the interfaces of NDIS service provision with other non-NDIS services provided by the States, Territories and the Commonwealth ……………………………………………………………………………………………. 11

4. Observations and recommendations in respect of the how the NDIS is funded, including the current and future funding sources for the NDIS, the division of funding between the Commonwealth, States and Territories, and the need for a pool of flexible and reserve funding particularly to support people with complex needs who are transitioning from custodial settings and hospital settings into the community. ………………………………………………………………………………………………… 14

5. Case studies: Complex care needs clients and the NDIS experience ……………………. 18

“John” ……………………………………………………………………………………………………… 18

“Nigel” ………………………………………………………………………………………………………. 19

“Bridget” ………………………………………………………………………………………………….. 20

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ermha365 submission Parliamentary Inquiry into the future of the NDIS

Thank you for your invitation to make a submission to Parliament’s Inquiry into the future of the NDIS.

We understand that the purpose of this Inquiry is to inquire into and report on current scheme implementation and forecasting for the NDIS, with particular reference to:

• a. The impact of boundaries of NDIS and non-NDIS service provision on the demand for NDIS funding
• b. The interfaces of NDIS service provision with other non-NDIS services provided by the States, Territories and the Commonwealth, particularly aged care, health, education and justice services
• c. The reasons for variations in plan funding between NDIS participants with similar needs
• d. How the NDIS is funded
• e. Financial and actuarial modelling and forecasting of the scheme
• f. The measures intended to ensure the financial sustainability of the NDIS (e.g. governance, oversight and administrative measures)
• g. The ongoing measures to reform the scheme, and
• h. Any other related matters.

ermha365 has focused this submission on the areas of particular interest to us within these terms of reference, specifically:

• b. The interfaces of NDIS service provision with other non-NDIS services provided by the States, Territories and the Commonwealth, particularly aged care, health, education and justice services; and

• d. How the NDIS is funded, including:

  • the current and future funding sources for the NDIS,
  • the division of funding between the Commonwealth, States and Territories, and
  • the need for a pool of reserve funding

The people we support sit at the intersection between multiple service systems, particularly Justice, Disability and Mental Health.

Over the past three years, ermha365 has made a significant number of submissions to the NDIS directly and to the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability in respect of challenges in implementing the scheme when it comes to the support of people with multiple and complex needs.

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ermha365 submission Parliamentary Inquiry into the future of the NDIS

These submissions responded to:

• The Issues Paper on Violence Abuse Neglect and Exploitation of People with Disabilities in the Criminal Justice System;
• The Issues Paper on Group Homes, with particular reference to people with psychosocial disability living within group home settings;
• NDIS SIL (Supported Independent Living) pricing controls discussion paper
• NDIS Support Coordination discussion paper
• NDIS Independent Assessments discussion paper (we also provided a response to the Parliamentary Inquiry into NDIS Independent Assessments)
• NDIS Provider and Sector consultation paper on Improving Outcomes for people who require Supported Independent Living (SIL)

We have also separately provided submissions to the Royal Commission into Mental Health (Victoria) and to the Victorian Government in respect of changes to the Mental Health & Wellbeing Act, as well as to the Victorian Government Legislative Council Inquiry into Victoria’s Justice System.

This is unfunded work for our organisation, which we pursue because of our passion, mission and drive to find a way to get the best possible outcomes for the people we support.

The NDIS represents a ground-breaking and life-changing opportunity for people with disabilities to get the supports they need to live an ordinary life in the community.

However, it creates significant challenges for providers like ermha365 to make NDIS funding work for complex participants with psychosocial disability, for whom the Scheme does not appear to be designed to provide an adequate and sustainable level of support.

This submission covers:

1. A background briefing on Complex Care needs clients and the case for change, particularly the lack of suitable housing and its impact on providers’ ability to provide quality supports that uphold participants’ human rights;
2. Observations and recommendations in respect of the interfaces of NDIS service provision with other non-NDIS services provided by the States, Territories and the Commonwealth, and the need for a ‘third’ system that considers people with complex needs; and
3. Observations and recommendations in respect of how the NDIS is funded, including the current and future funding sources for the NDIS, the division of funding between the Commonwealth, States and Territories, and the need for a pool of flexible and reserve funding particularly to support people with complex needs who are transitioning from custodial settings and hospital settings into the community; and
4. Case studies that highlight the issues.

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ermha365 submission Parliamentary Inquiry into the future of the NDIS

Within this Inquiry’s terms of reference, we would like to see the Committee inquire into and report on the following issues relating to current scheme implementation and forecasting for the NDIS as it relates to in-scheme support that recognises complex needs:

1. The need for a Complexity loading within the NDIS pricing structure that supports providers to pay for the cost of additional quality and safeguarding required for the ongoing support of very complex NDIS participants, in addition to their individual day-to-day support package which is mostly consumed in paying for direct expenses, particularly wages for support staff. Very few quality providers are currently prepared to work with complex participants, affecting choice and control.
2. A requirement for the NDIS Price Guide Overhead section to reflect the cost of transitioning extremely clients from institutional settings to a supported life in the community. This can often take up to 12 months and involves considerable discussion and planning to design and deliver a suitable placement. ermha365 is often approached to facilitate such placements, and the time spent is at our cost, as we do not have NDIS funding until the client commences. There is no allowance in the NDIS Price Guide Overhead section for this type of work. In recognition that this transition work is an essential part of establishing an efficient and effective service, providers should be able to charge a client’s package (or the NDIA directly) as soon as we commence these discussions.
3. Incentive payments for providers who can prove an ability to work successfully with people with complex and episodic psychosocial disability to improve and maintain their quality of life, rather than the current ‘penalty’ for quality supports, whereby NDIS packages of support are automatically reduced once improvements are made, until the person’s situation deteriorates and they can prove they are once again in crisis.
4. Adequate funding, time and consideration given to SIL providers who are currently being required to manage community support for participants whose are now receiving (or stand to receive at their next review) much smaller funding packages than in the past. This includes the (currently unfunded) work that will be required to transition participants with complex needs to shared accommodation and support arrangements – when most complex participants will currently be living in separate homes – while also managing significant behaviours of concern and impacts to the participant and the community. At the same time, the removal of the previous method of SIL payments is another layer of disincentive to providers such as ermha365. SIL rates are being significantly reduced, and this directly impacts on support levels for extremely vulnerable and complex clients, which in turn places the community and individuals at greater risk.

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ermha365 submission Parliamentary Inquiry into the future of the NDIS

5. In addition to in-scheme support that recognises complex needs, the Committee should also consider whether there is a need for a ‘third system’ that sits above the NDIS, Mental Health and Justice systems and enables collaboration and cooperation in designing and funding pathways for individuals with complex needs.

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ermha365 submission Parliamentary Inquiry into the future of the NDIS

Complex Care needs clients often have extended histories of self-harm, property damage and violence, placing at risk; staff, family members and the wider community. Clients with multiple, complex and challenging needs (‘Complex Care needs clients’), are at significant disadvantage due to a combination of the nature and severity of their mental illnesses, disability status, persistent criminal offending behaviour, traumatic backgrounds and social isolation. They require multi-agency support to assist with their health, housing, social participation and personal function. This cohort have been found to be more likely to use alcohol and other drugs and be homeless or marginally housed in insecure or inappropriate arrangements.

Appropriate housing choices for people living with Complex Care needs are currently very limited - even more so for NDIS participants^1. When housing is provided that is not fit for purpose, there is often significant property damage and an increased safety risk to the individual and community. It is not unusual, therefore, for delayed or inappropriate provision of support to lead to long-term hospitalisations or incarcerations, which present severe infringements on an individual’s human rights and significantly compromise their ability to achieve life goals. These prolonged admissions and detentions are often not clinically or legally justified, but are a result of these clients having “nowhere else to go”. Once trapped in these circumstances, clients with complex and challenging support needs can enter a vicious criminal justice cycle, putting significant pressure on emergency services, prisons and hospitals^2. The costs to the person, their family, and the agencies who provide services to these groups are estimated to be very high. ^3

According to the Office of the Public Advocate’s Report (2018)^4 there are a range of factors that characterise clients with Complex Care needs. They usually:

• have multiple and/or severe disabilities requiring various forms of support, often compounded by experiences of trauma
• experience issues with interpersonal engagement, such that they have limited family support and/or are unable to live with others
• engage in challenging behaviours that can put themselves or others at risk of harm
• are or have been engaged in multiple government service systems
• have exhausted (or are at risk of exhausting) service providers and workers

^1 Office of the Public Advocate (2018), ‘The illusion of ‘choice and control’’ available at: https://www.publicadvocate.vic.gov.au/ourservices/publications-forms/research-reports/ndis/519-the-illusion-of-choice- and-control (accessed 29 April 2019).

^2 Baldry et al (2006), ‘Ex-Prisoners, Homelessness and the State in Australia’ Available at: https://journals.sagepub.com/doi/abs/10.1375/acri.39.1.20 (accessed 19 April 2019).

^3 Burt 2003; Edwards et al 2009; Flatau et al 2008; Gulcur et al 2003; Mental Health Coordinating Council 2008.

^4 NDIS (2018), ‘Improving the NDIS participant and provider experience’ available at https://www.ndis.gov.au/media/1068/download (accessed 15 April 2019).

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ermha365 submission Parliamentary Inquiry into the future of the NDIS

• have a history (or are at risk) of unstable accommodation, homelessness and/or periods in detention in the criminal justice and/or mental health systems and, as a consequence of the above. Fit for purpose, stable housing plays a critical role in the prevention of exacerbating existing conditions.

Limited providers delivering supports to clients with Complex Care needs

The Productivity Commission’s Report found the NDIS utilisation rate in 2016-2017 was approximately 70%. This underutilisation results from several factors, including insufficient market supply. The Productivity Commission’s Report further states that Thin Markets will persist for participants ‘with complex, specialised or high intensity needs, or very challenging behaviour’ in the absence of government intervention and will ultimately result in poorer participant outcomes.^5

For too many people with disabilities, quality of life is dependent on the commitment of families. The crisis in accommodation means that few are able to plan effectively, and transitions out of the family home are often traumatic experiences. When accommodation cannot be found, sometimes extended family members are pressed into service. Alternatives to group homes are few and far between and for some clients this can lead to a restricted lifestyle and poor quality of life with limited opportunities for independence.^6

The ‘Shut Out’ report published in 2009 proposed an injection of funds to increase the availability of accommodation options, in particular on the development of more creative models that were more responsive to individual need and lifestyle.

At present, ermha365 is one of only a very small handful of SIL service providers in Australia specifically catering for the multiple and complex needs of the Complex Care client cohort. Most providers operating in this space operate distinct models, e.g. either provide a mix of aged care and disability services or focus on different cohorts (e.g. lower levels of mental illness / care).

Unsuitable housing options exacerbate negative client circumstances

One of the biggest problems for people with complex needs is the absence of adequate, affordable and secure accommodation. In ermha365’s experience it is the single most important factor in the success or failure of those who live with chronic mental illness. In the past, clients who have been provided public housing are vulnerable due to neighbours’ complaints or demands on emergency services, for example, clients with multiple fire service callouts.^7

^5 Productivity Commission (2017), ‘National Disability Insurance Scheme (NDIS) Costs’ available at https://www.pc.gov.au/inquiries/completed/ndis-costs/report (29 April 2019).

^6 National People with Disabilities and Carer Council (2009), ‘Shut Out: The Experience of People with Disabilities and their Families in Australia’ available at: https://www.dss.gov.au/our-responsibilities/disability-and-carers/publications- articles/policy-research/shut-outthe-experience-of-people-with-disabilities-and-their-families-in-australia?HTML (accessed 8 May 2019).

^7 Hamilton (2009), ‘The report on the Five Years of the Multiple and Complex Needs Panel’ available at: https://dhhs.vic.gov.au/publications/multiple-and-complex-needs-review-reports (accessed 16 April 2019)

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ermha365 submission Parliamentary Inquiry into the future of the NDIS

They are unable to live sustainably with others because of their behavioural presentation and low thresholds for frustration and distress. As a result, many of these clients have been bounced back and forth between the mental health system and disability system over many years with neither system wanting to accept responsibility for their support.^8

The Multiple And Complex Needs Initiative (‘MACNI’) run by the Department of Health and Human Services identified that Complex Care needs clients are often unable to sustain fit for purpose accommodation because they require a level of and type of support that ‘the contemporary service system structure, with its usual emphasis on targeted, time-limited, specialist interventions, does not readily allow’. ^9

Only a very small number of specialist disability accommodation (SDA) recipients will receive sufficient funding for a single resident dwelling that may be able to cater to these specific needs.^10

^8 Office of the Public Advocate (2018), ‘The illusion of ‘choice and control’’, available at: https://www.publicadvocate.vic.gov.au/ourservices/publications-forms/research-reports/ndis/519-the-illusion-of-choice- and-control (accessed: 29 April 2019). 16 Hamilton (2009), ‘The report on the Five Years of the Multiple and Complex ^9 ‘Multiple and Complex Needs Panel’ review available at: https://dhhs.vic.gov.au/publications/multiple-and-complex-needs- review-reports (accessed 16 April 2019);The Office of the Public Advocate (2018), ‘The illusion of ‘choice and control’’, available at: https://www.publicadvocate.vic.gov.au/ourservices/publications-forms/research-reports/ndis/519-the-illusion- of-choice-and-control (accessed: 29 April 2019).

^10 NDIA (2018), ‘Specialist Disability Accommodation Provider and Investor Brief’ available at: https://www.ndis.gov.au/providers/essentials-providers-working-ndia/specialist-disability-accommodation#sda-provider- and-investorbrief (accessed 29 April 2019).

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ermha365 submission Parliamentary Inquiry into the future of the NDIS

Many clients with Complex Care needs are caught in the justice or forensic mental health system or may be homeless; leading to negative impact on peoples’ lives, potential breaches of their civil and human rights and high costs to Government.

The lack of suitable housing for Complex Care needs clients leads to:

• suboptimal therapeutic outcomes for individuals, despite the best endeavours of all stakeholders
• poor quality of life (or at worst suffering inadvertent human rights abuses) as people get caught in a cycle they cannot break
• community concern and pushback around housing these individuals – the ‘nimby’ effect
• additional costs being incurred across services systems that may be avoidable, including property damage, incarceration, lengthy hospital stays and other forced detention costs
• Additional strain on emergency services, police, ambulance and emergency departments
• Potential political implications in the event of incidents that may attract negative press
• Increased costs of SIL

In many instances, delayed or inappropriate provision of support leads to avoidable detention under the Mental Health Act 2014 as well as other infringements on an individual’s human rights and significantly compromises their ability to achieve life goals. The Mental Health Council of Australia stated the over-representation of people with mental illness in the criminal justice system is due to a failure of the health system to provide adequate support for those at risk of incarceration.^11

The denial of treatment of mental health patient in prison often leads to further offending, longer incarceration (at greater cost) and aggravation of mental health conditions. It is vital for the successful community reintegration of people with a mental illness on being released from prison that they have access to stable accommodation.

^11 Parliament of Australia Senate Estimates (2006), ‘Mental Health and the Criminal Justice system’ available at: https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Former_Committees/mentalhealth/report/c13 (accessed 26 April 2019).

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ermha365 submission Parliamentary Inquiry into the future of the NDIS

Prisons and mental health services are increasingly being treated as accommodation options for people with challenging presentations^12 and often include harmful and restrictive practices.^13 Complex Care needs clients may also be admitted to seclusion (‘SECU’ - the confinement of a patient in a room from which free exit is prevented) merely due to a lack of appropriate supports. While seclusion can be used to provide safety to protect the patient, staff and others, it can also be a source of distress for the patient, fellow patients, staff, family and visitors.

Such prolonged admissions are rarely clinically or legally justified. The consequences of prolonged detention and the entailing trauma can contribute further to challenging behaviour patterns and compromise the ability of a person to engage with and benefit from support upon release. When they are released, Complex Care clients are often restricted to isolative arrangements in the community. Such circumstances significantly compromise a client’s ability to achieve life goals as well as leads to infringements on an individual’s human rights.

The cost on health and justice systems for emergency services and extended confinement (both State and Federal Government) is very high. Delays in accessing appropriate accommodation may result in people entering or remaining in detention or the forensic mental health system due to the risks arising from unmet support needs leaving them cycling through unstable and inappropriate forms of accommodation at tremendous human cost.

We are fast approaching the point where if the needs of Complex Care clients do not receive serious and dedicated attention, extremely vulnerable people’s dignity and human rights will be significantly compromised. This is an untenable situation in a country like Australia.

If the NDIS cannot or will not step in to provide leadership on this issue, in partnership with States, Government must urgently create and fund a “third system” that safely and humanely provides for the needs of people with complex needs.

This can sit outside of both the NDIS and state-funded mental health systems in order for those systems to focus on the 95% majorities that their policies and funding streams are currently aligned to.

This “third system” is especially essential for people exiting the forensic system, where current structures simply cannot accommodate the number of people with mental illness and disability who are being unfairly kept in prison and who do not have the right mechanisms in place to enable them to transition safely into the community.

^12 Office of the Public Advocate (2018), The illusion of ‘choice and control’, available at: https://www.publicadvocate.vic.gov.au/ourservices/publications-forms/research-reports/ndis/519-the-illusion-of-choice- and-control (accessed 29 April 2019).

^13 Human Rights Watch (2018), ‘I needed help, instead I was punished’: Abuse and neglect or Prisoners with disabilities in Australia. Available at: https://www.hrw.org/report/2018/02/06/i-needed-help-instead-i-was-punished/abuse-and-neglect- prisoners-disabilities (accessed 29 April 2019).

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ermha365 submission Parliamentary Inquiry into the future of the NDIS

A “third system” would consider the needs of the small but significant number of Complex Care needs clients who present with significant behaviours of concern (often an extreme nature) who are unable to live (initially) with others, and where support from untrained staff may not be appropriate. Fundamentally, an NDIS service design that supports transition from Institutionalised settings as a step down into the community, and ultimately to shared living options, must exist. This is currently individual (stand-alone) SIL, which is considered to be expensive. We believe there are better ways to design this aspect of the service model and have discussed this in the next section.

A third system would also acknowledge that Complex Care needs clients do not have the strong informal supports and social connections/networks upon which more mainstream NDIS supports rely. Such participants have specialist support coordination and a broader care team network that may include state departments (e.g. MACNI, Justice, Disability, Office of the Chief Practitioner and Office of the Chief Psychiatrist, guardians and advocates).

In the long term, NDIS policies for Home and Living should consider principles and frameworks that are more fit-for-purpose for Complex Care needs clients who can “fall through the cracks”, in particular in circumstances where it is difficult to distinguish between their disability or criminal needs.

This was highlighted in the recent Royal Commission Public Hearing 11, where the Commission explored the NDIS-justice interface. The Chair suggested it was difficult to distinguish a person’s disability and criminal needs, and that this was evidence that the Principles weren’t fit for purpose. The panel agreed it was difficult, but said the Principles work well for the majority of participants. ^14

In respect of housing issues more broadly, the NDIA should consult with other entities that provide and support housing the States, Territories and the Commonwealth to expedite and improve accessibility to a wider variety of housing stock for Complex Care needs clients so they do not stay incarcerated or remain in hospitals longer than they should.

^14 https://disability.royalcommission.gov.au/public-hearings/public-hearing-11)).

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ermha365 submission Parliamentary Inquiry into the future of the NDIS

We appreciate the need to reassess how the NDIS is funded to ensure long-term sustainability of the scheme.

However, ermha365 remains extremely concerned that the narrative of the NDIS continues to push towards Individualised Living Options (ILO) as a replacement for Supported Individual Living (SIL). Our understanding is that it is primarily cost that is driving this narrative, but believe there are better ways to ensure scheme sustainability without replacing SIL with ILO.

Our concerns centre around the high and unacceptable risks that participants, our staff, and the community will face if complex participants are unable to access 24/7 support via quality providers.

Some solutions include:

• Market settings that encourage innovative housing models that include a mix of SDA accommodation and private rental space that opens up housing opportunities for a wider range of NDIS participants and Complex Care Needs clients. (See highlight box on ‘Congregate living for people with complex needs’). This would not only increase opportunities for better housing options for complex care needs clients, improving quality of life for participants, but also have a long-term positive impact on reducing costs and support needs over time.
• Policy settings that encourage and incentivise State Government agencies to partner with NDIS providers to develop small non-SDA group congregate living options that can specifically house people with Complex Care needs. This will open up options for participants, and reduce pressure on (and demand for) SDA, which cannot be met by the Scheme’s constraints.

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• Incentives to enhance Complex Care needs clients’ ability to access Social/Affordable housing and the private rental market. Although Social and Affordable housing providers have a duty to make reasonable adjustments in providing accessible housing stock to people with disability, there is still a significant shortage. In addition, our clients are often ‘overlooked’ as a suitable tenant because of their background, history of property damage and neighborhood disturbance, risk of eviction, hostile neighbors, and being in an unsafe area (due to affordability). In addition, policies designed to allow access to private rental exclude the additional downstream barriers faced by the people we support, who often do not pass the ‘review’ as a suitable tenant (e.g. cannot demonstrate 100 points of identification, and lack networks and employment to provide references for rental agents).

• Changing the NDIS policy settings to support providers to subsidise rent specifically for complex care needs clients as part of a client’s funded package of support. To deliver on our mission, organisations like ermha365 often have to ‘step in’ and support the tenancy, creating a perceived closed system of supported independent living (SIL) homes. What is not acknowledged is that in doing so, ermha365 bears unfunded costs including supporting participants to identify suitable properties; bearing liability risk on damage to properties; and taking on unfunded corporate overheads to manage these properties.

• Flexible Home & Living transition funding arrangements (housing and support) that extend for more than 90 days should be made available for complex participants, and be adaptable in acute situations when needs or circumstances change. Transitional support is essential for every complex care needs client who is currently incarcerated or in secure hospital settings. From our experience, when a person has not lived in the community for some time, we know it is essential that funding is in place for a comprehensive assessment process that enables a full understanding of the participant and their needs in order to develop an appropriate NDIS plan.

• Incentive payments for providers who can prove an ability to work successfully with people with complex and episodic psychosocial disability to improve and maintain their quality of life, rather than the current ‘penalty’ for quality supports, whereby NDIS packages of support are automatically reduced once improvements are made, until the person’s situation deteriorates and they can prove they are once again in crisis.

• Adequate funding, time and consideration given to SIL providers who are currently being required to manage community support for participants whose are now receiving (or stand to receive) much smaller funding packages than in the past. This includes supporting such participants with complex needs to transition to shared accommodation and support arrangements – where most participants will currently be living in separate homes – potentially managing significant behaviours of concern and impacts to the participant and the community.

ermha365 submission ermha Parliamentary Inquiry into the future of the NDIS i B65

Congregate living for people with complex needs

ermha365 has identified and developed the concept for a new accommodation model aimed at achieving better client outcomes and relieving pressure on the NDIS and public system as an alternative to individual SIL packages: a “Therapeutic Village” that delivers better care and integrated services, specifically catering to the needs of Complex Care clients could be introduced into the scheme. This would be a specialist congregate living model — not a group home.

This first-of-a-kind village model would enable independent living within a communal setting, that supports the delivery of the full range of services required for each client. It is envisaged that the Therapeutic Village will initially provide a transitional step-down home for particularly vulnerable Complex Care needs clients. Key benefits include:

• Improved quality of life - Clients should be accommodated in a safe and therapeutic environment oriented toward rehabilitation and community reintegration. The ability of clients to live in their own homes, safely and with appropriate support has been demonstrated to improve the quality of life of clients and minimise many of their harmful behaviours.

• Compliance with human rights laws - It is highly likely that some of the current situations clients find themselves in result in a breach of their civil and human rights, which inadvertently are a direct result of alternative solutions to housing these clients not being viable or available.

• Significant cost savings — bringing together a number of complex care needs clients together in one location will also deliver a significant cost saving when compared to individualised SIL packages of support that the agency is currently funding.

ermha365 recommends that Government, via the NDIA, funds and pilots a therapeutic village in each state as part of a new model of stepped care, creating a pathway for Complex Care needs clients to be able to move into a range of other accommodation options.

Further evidence for this model in terms of public investment in housing — particularly for those transitioning from forensic settings — is now available.

A brand-new study from the University of New South Wales” also shows that the evidence strongly supports the need for much greater provision of social housing to

8 Martin, C., Reeve, R., McCausland, R., Baldry, E., Burton, P., White, R. and Thomas, S. (2021) Exiting prison with complex support needs: the role of housing assistance, AHURI Final Report No. 361, Australian Housing and Urban Research Institute Limited, Melbourne, https://www.ahuri.edu.au/research/final-reports/361, doi10.18408/ahuri7124801 - 23 Aug 2021

ermha365 submission ermha Parliamentary Inquiry into the future of the NDIS /B65

people exiting prison, particularly for those with complex support needs. Headline take-outs from this report include that: e Imprisonment in Australia is growing and ex-prisoner housing need is growing; but at the same time, housing assistance capacity is declining.

e Without real options and resources, prisoner pre-release planning for accommodation is often last-minute. Insecure temporary accommodation is stressful, and diverts ex-prisoners and agencies from addressing other needs, implying desistance from offending.

e Ex-prisoners with complex support needs who receive public housing have better criminal justice outcomes than comparable ex-prisoners who receive private rental assistance only.

e Public housing ‘flattens the curve’ of average predicted police incidents (down 8.9% per year), time in custody (down 11.2% per year), justice system costs per person (down $4,996 initially, then a further $2,040 per year).

In dollar terms, housing an ex-prisoner in a public housing tenancy generates, after five years, a net benefit of between $5,200 and $35,000, relative to the cost of providing them with assistance in private rental and/or through homelessness services.

Parliamentary Inquiry into the future of the NDIS B65

Case studies: Complex care needs clients and the NDIS experience

The following case studies illustrate a range of Complex Care needs clients who we support at ermha365 to convey the challenges outlined in this submission. They have been de-identified to protect individuals’ privacy. All case studies represent people with significant mental health and cognitive disabilities and additional complex needs including behaviours of concern, presenting their journey through lengthy institutional care, and the significant support they have required to access a reasonable level of community-based supports. ermha365 would appreciate the opportunity to be consulted prior to the reproduction or publication of any content arising from such case studies.

Case Study

“Joh n ry”

John, male and in his early 40s, has been trying to get access to a level of NDIS supports to help him live in the community for just over two years after transitioning from a State Funded individual support package. At that time, John was assessed for a very small package of NDIS support.

John has a number of clinical diagnoses, including schizophrenia and intellectual disability, as well as a high level of physical and mobility issues. He recently had a hip replacement and requires a walking frame. John’s functional needs now are almost exactly the same now as when he was first assessed for this small NDIS package. However, at that time his physical health (including his hip) was slightly better.

Over the past decade John has experienced insecure housing. The only place John could find to live was in Supported Residential Accommodation (SRS), where he struggled to maintain tenancies due to aggression towards other residents. This aggression arose from behaviour-related incidents stemming from John’s auditory and visual hallucinations. This pattern of aggression and subsequent eviction resulted in John cycling through almost 20 SRS placements.

Over the past few years, extensive care team meetings have taken place to try to secure an increase in support funding for John, including behavioral support assessments and SDA housing. This involved at least eight people in each meeting including the NDIA. In the second half of 2020, John voluntarily admitted himself to hospital after his latest SRS placement broke down. With John’s long history of homelessness, and lack of formal supports, John relied on funded supports to exit hospital back into the community.

This was the latest in a frustrating ‘revolving door’ of inpatient admissions where John was unable to obtain support funding without a housing model in place, and unable to obtain housing without support. Since John’s latest admission to hospital, the care team has worked around the clock to secure six months of 24/7 2:1 transition support, and now 1:1 support funding for John, which is about to be reviewed.

Parliamentary Inquiry into the future of the NDIS

Case Study

ermha365 submission ermha

Nigel’s Background:

• Nigel is a young man in his mid-20s.
• Originally referred to ermha365 as a Victorian DHHS Disability client with an individual support package.
• Identified as a Multiple and Complex Needs Initiative (MACNI) client due to complexity of needs.

Diagnoses & Behaviours:

• Diagnosed with several mental disorders: autism, oppositional defiant disorder, antisocial personality disorder, intellectual disability.
• Assessed to be substance dependent.
• Engaged in violent behaviours that placed himself and others at risk; deemed requiring intensive supervision.

Custody History:

• Substance use and offending behaviour have led him to spend periods in custody.
• Transitioned to the NDIS in 2018 while held in custody.

Housing Challenges:

• Due to nature of disability and presenting behaviors it became impossible for Nigel to remain in family home.
• Involved with DHHS services since youth including out-of-home care placements.
• Transient, homeless, spent time in/out of prison.

Housing has been one of most significant issues. Strain on service sector accommodating his needs. Unstable housing history across multiple settings:

• Properties under ‘out of home care’ arrangements,
• Community agency properties,
• Own property,
• Shared accommodation,
• Supported disability accommodations. Some involved presence of multiple staff, e.g., a 2:1 model (staffing ratio) providing support around-the-clock.

At time of writing this submission, Nigel is incarcerated as recent accommodation option broke down leading to breach of bail conditions. Period of incarceration extended due to lack of suitable residential address available for release.

NDIS package totals almost $300k. Family frustrated that no supports can be provided if nowhere to go; unable return home or fund private rental despite Centrelink benefits received by Nigel which provide limited income & little prospect employment immediately so securing appropriate/affordable accommodation problematic. Qualifies for NDIS but currently not receiving any support from program.

Unclear whether would qualify for SDA.

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(ermha is) one of a small number of providers who will not walk away from people, and will not shy away from the very, very real challenges of providing support to the people coming to the complex support pathway. (There is) value in a willingness not to give up on people. Senior stakeholder, NDIS

(ermha is) one of the few organisations that will actually take our clients.…if we took ermha completely out of the equation … There’d be a massive void in the service sector. Psychologist working with complex clients

I see ermha’s willingness to work with complex clients and have been able to observe some of the fantastic outcomes as a result of that intensive work. Senior stakeholder, DHHS

Thank God for ermha! Senior stakeholder, DHHS