Joint Standing Committee on the National Disability Insurance Scheme
General issues around the implementation and performance of the NDIS Submission 74
About HammondCare
Established in 1932, HammondCare is an independent Christian charity specialising in dementia care, palliative care, rehabilitation and older persons’ mental health services. HammondCare is acknowledged as Australia’s leading dementia-specific service provider and is dedicated to research and supporting people who are financially disadvantaged. HammondCare’s mission is to improve quality of life for people in need, with the ambition to set the global standard for relationship-based care for people with complex needs and for those who others won’t or can’t.
In FY20, HammondCare cared for approximately 9,800 people in the home and in the community, 2,000 people in residential aged care services and 5,100 people through HammondCare’s sub-acute hospitals. HammondCare’s Dementia Centre is recognised in Australia and internationally for its high-quality research, consultancy training and conferences in the area of best-practice dementia care, having specialised in the area for more than 30 years. It is now the largest and most experienced provider of dementia-specific services in Australia.
HammondCare has residential aged care facilities (RACFs) across New South Wales and Victoria. Within these homes, HammondCare has approximately 57 NDIS clients across 16 of our care homes. The vast majority of our NDIS clients have a diagnosis of dementia.
Contact
Angela Raguz Chief Operating & Risk Officer HammondCare 2
General issues around the implementation and performance of the NDIS Submission 74
Implementation and Performance of NDIS in
Residential Aged Care
Introduction
HammondCare welcomes the opportunity to provide feedback to the Joint Standing Committee on some of the general issues encountered in the implementation and performance of NDIS. We recognise the importance of the NDIS in ensuring the protection and support of Australians living with a disability.
To support a more efficient and streamlined implementation of NDIS requirements into residential aged care, HammondCare recommends:
* an exemption for accredited dementia services to have externally developed Behaviour
Support Plans;
* a single reporting system through the aged care portal, removing duplication; and
* a single clearance check for onboarding staff to limit delay times and costings.
HammondCare supports the government’s decision to transition younger people out of residential aged care, with no person under the age of 65 entering such services by 2022.1 However, HammondCare recommends that dementia-specific residential aged care services should be an exemption to this rule. The expertise required to support someone living with dementia resides in an aged care setting and should therefore be treated as an “exceptional circumstance”2 to this transitioning process. This submission is put forward on the assumption that this ‘exceptional circumstance’ is accepted by the NDIS Quality and Safeguards Commission (NDIS Commission).
Behaviour Support Plans
HammondCare is Australia’s largest provider of dementia-specific services and is currently funded by the Australian Government to deliver the Dementia Support Australia programs: Dementia Behaviour Management Advisory Service (DBMAS) and Severe Behaviour Response Team (SBRT). Through these programs and with HammondCare’s long history in caring for people with dementia, we have developed a deep knowledge, understanding and capability on how best to care for those
1 Department of Social Services, Younger people in Residential Aged Care: Strategy 2020-25, Commonwealth of Australia (2020): 5. 2 Department of Social Services, Younger people in Residential Aged Care: Strategy 2020-25, Commonwealth of Australia (2020): 9. 3
General issues around the implementation and performance of the NDIS Submission 74
with dementia. Despite this, under NDIS requirements HammondCare must either register as a Specialist Behaviour Support Provider (SBSP) or use an external Behaviour Support Practitioner, who would not have the knowledge of HammondCare’s model of care, design or expertise.
The NDIS Behaviour Support Plan (BSP) process suggests that unless registered as a SBSP, a provider cannot create an appropriate plan for behaviour management to NDIS clients. This overlooks any in- house knowledge and capability that the provider might have and instead mandates that they seek out additional documentation which only replicates what is already in place through Aged Care Behaviour Management Plans (as required by the Aged Care Quality and Safety Commission (ACQSC)). In contrast with Behaviour Management Plans that provide relevant information on how to care for an individual in an accessible 1-2 page document, a BSP is on average 28 pages and generally reports on the assessment of an individual and provides recommendations on behaviour management. For many NDIS clients who live at home or have informal care, a BSP is the only documentation for their care. However, these assessments are already conducted in residential aged care – from lifestyle and social through to clinical issues – and a BSP only replicates what is already largely covered.
Below is an example of a BSP which was created for an NDIS client at HammondCare’s Waratah RACF, prior to HammondCare taking over the site.
Example:
> Sarah3 had an alcohol-related acquired brain injury and dementia. Included within her external
> Behaviour Support Practitioner’s 30-page BSP is the recommendation that “the best way to reduce
> intensive behaviours is to teach and train an individual better communication or coping skills as a
> replacement function for challenging behaviour”.4
While the BSP above recognises Sarah’s brain injury, it fails to acknowledge or understand her cognitive impairment and its impact on her reasoning and cognitive functioning (which would enable such recommended training and positive behaviour support). The focus of BSPs is positive behaviour support, using training and positive reinforcement to eliminate behaviours. This may not be achievable for people living with dementia, therefore making BSPs an inappropriate document to support people living with dementia.
Drawing on our expertise as a dementia specialist residential aged care provider, we urge the committee to acknowledge the unique context of people living with younger onset dementia (YOD) in residential aged care. The Royal Commission5 acknowledged HammondCare’s expertise in dementia care and behavioural and psychological symptoms of dementia (BPSD). Despite this, we must still register a SBSP in order to maintain our approach to care and dementia support.
3 Names of residents have been changed within this submission. 4 Direct quote from the NDIS Behaviour Support Plan. 5 Royal Commission into Aged Care Quality and Safety, “In the matter of the Royal Commission into Aged Care Quality and Safety”, (Auscript: May 17, 2019), 1946. 4
General issues around the implementation and performance of the NDIS Submission 74
We recommend that existing Aged Care Behaviour Management Plans be accepted as an alternative to BSPs in special circumstances, such as for NDIS clients funded under a diagnosis of YOD in accredited dementia-specific services.
HammondCare’s Recommendation:
If an NDIS client is funded through a diagnosis of YOD, an Aged Care Behaviour Management Plan should be an acceptable alternative for a BSP when the provider is an accredited dementia-specific service.
Reporting
Aged care and disability support work may appear similar, as both provide services to vulnerable people. However, the needs of both cohorts differ greatly, as do the goals of care. While many NDIS clients may enter the system in early or mid-life and receive long term support, aged care recipients arrive later in life and for a shorter period of time. This is compounded by their greater range of comorbidities as a result of being later in life. Therefore, treatment and goals of care must also take into account a far greater spread of medical diagnoses with often poor prognosis.
Registered residential aged care providers are concurrently monitored by both the NDIS Commission and the ACQSC. Both bodies have their own regulatory systems, including incident reporting through separate portals, creating a legislative burden for RACFs. Currently providers must report quarterly on the national quality indicators to the ACQSC and monthly to the NDIS Commission regarding restraints. The mandated quarterly reporting provides the ACQSC with an organisational summary while the monthly reporting is in regard to the individual NDIS clients. Furthermore, incidents involving a resident funded through the NDIS must also be reported to both the ACQSC and NDIS Commission. Although effectively providing the same information to both bodies, two separate evaluation and investigation processes can take place at different times, causing undue administrative burden for RACFs. These separate lines of reporting put unnecessary pressure and responsibility on aged care staff. Reporting should be conducted through a single portal.
The NDIS Commission has clear definitions and high standards regarding restrictive practices, setting a precedent for how reporting should be conducted. This is recognised in the Aged Care and Other Legislation Amendment (Royal Commission Response No. 1) Bill 20216, which aims to streamline aged care restrictive practice reporting with NDIS standards. HammondCare recommends that this is extended to support a singular reporting framework, similar to the National Framework to
6 Aged Care and Other Legislation Amendment (Royal Commission Response No. 1) Bill 2021: Explanatory Memorandum (Cth), https://www.aph.gov.au/Parliamentary_Business/Bills_LEGislation/Bills_Search_Results/Result?bId=r6723, 1. 5
General issues around the implementation and performance of the NDIS Submission 74
Restrictive Practice7 – removing the current duplicative process for aged care providers and standardising reporting requirements nationally by improving information sharing between the NDIS Commission and aged care. With this approach in mind, RACFs should report through existing aged care reporting mechanisms.
The current monthly reporting takes HammondCare’s Clinical Care Managers a cumulative, average total of 56 hours across all sites supporting NDIS clients. This is because the current system is not user friendly – described by staff as “clunky”.
Challenges we have identified include:
* error messages repeatedly appearing throughout the process with no relevance to the
reporting;
* non-sequential ordering of restraints, forcing Managers to enter multiple tabs for each
resident’s restraints; and
* no ability to change medication doses for residents.
HammondCare’s Recommendation:
The existing aged care portal should allow aged care providers to disclose if a report relates to an NDIS client. When this is indicated, a copy of the report is automatically forwarded to the NDIS, rather than providers reporting directly to both, separately.
Workers Screening Check
Relevant aged care staff must currently undergo two separate worker clearance checks in order to engage with NDIS clients: an aged care police certificate (CRC) and an NDIS Worker Screening Check (WSC). While CRCs capture criminal offences, they do not provide the in-depth screening of a WSC. For example, unless legal charges are brought against an individual for elder abuse, the offence will not be captured in a CRC. In comparison, a WSC will examine the individual’s entire history of employment in the sector, including any complaints or non-legally actioned problems. Therefore, HammondCare recommends that the WSC replace the CRC for the aged care sector – rather than mandating residential aged care providers complete both.
In addition, the WSC does present challenges which must urgently be resolved. In particular, HammondCare has experienced the following major difficulties when navigating the WSC:
7 Department of Social Services, National Framework for Reducing and Eliminating the Use of Restrictive Practices in the Disability Service Sector, Commonwealth of Australia (2013): 1. 6
General issues around the implementation and performance of the NDIS Submission 74
1. Significant cost burden
The requirement for a WSC is a costly upfront, out-of-pocket expense for staff – $80 in New South Wales and $120 in Victoria. With an already understaffed and underpaid workforce, this is an unnecessary and additional barrier in attracting well-skilled people into the aged care sector.8 While providers are able to reimburse staff for the check, it is an additional cost on top of the $40 which providers must pay for the CRC. HammondCare has made the decision to reimburse our staff who must undertake the WSC, with an approximate cost of $57,000 per year for new staff and $30,000 for existing staff. Such costs disincentivise providers from accepting NDIS clients in the future, even in ‘exceptional circumstances’ where dementia specialist residential aged care may be an appropriate accommodation option for those living with YOD.
2. Lengthy delays exacerbating the workforce gap
HammondCare has also experienced difficulties in obtaining WSCs, with long delays in clearances of up to four (4) weeks; in comparison, a CRC takes a maximum two (2) weeks. Until this clearance has been fully granted, staff are not legally allowed to work with NDIS clients. The recent Federal Budget outlined that by 2050 an additional 3,600 Registered Nurses and 34,200 personal care workers are needed to meet the increasing demand for aged care services.9 This workforce gap is already felt by staff, described by the Royal Commission as “trying to do their best in extremely trying circumstances where there are constraints on their time and on resources available to them”.10 These delays continue to disincentivise potential employees from engaging with the sector, as well as aged care providers from taking on NDIS clients.
3. Complications for Non-Australian Citizens delaying recruitment of key workers
Additional delays have been experienced for those who are not Australian citizens who do not have an Australian ID or drivers licence. In these cases, a paper version of the check must be completed with a clearance time of four (4) to six (6) weeks. The University of New South Wales found that in 2016, 37% of aged care workers were born overseas; a 5% increase from 2011.11 With an expanding proportion of migrant employees in aged care, HammondCare recommends that the WSC be amended to better cater for the prominent migrant workforce.
HammondCare’s Recommendation:
A streamlining of the clearance check process which decreases the current delay times felt under the Workers Screening Check.
8 Royal Commission into Aged Care Quality and Safety. Volume 1: Aged Care Royal Commission Final Report: Summary. Commonwealth of Australia (2021): 76. 9 Department of Health, ‘Workforce – Growing a skilled and high quality workforce to care for Senior Australians’, Budget 2021-22, 134, accessed June 23, 2021. 10 Royal Commission into Aged Care Quality and Safety, Interim Report: Neglect, Commonwealth of Australia (2019): 8. 11 Christine Eastman, Sara Charlesworth & Elizabeth Hill, “Fact Sheet 3: Aged and Disabled Carers,” Markets, Migration & the Work of Care, accessed June 21, 2021, https://www.arts.unsw.edu.au/sites/default/files/documents/Aged_and_Disabled_Carers_Final.pdf 7
General issues around the implementation and performance of the NDIS Submission 74
Summary
HammondCare supports the NDIS Commission’s goal to ensure NDIS clients receive quality care. However, when residential aged care providers were automatically registered as NDIS providers in December 2020, existing aged care infrastructure and frameworks governing quality control were not fully taken into consideration. NDIS clients living in residential aged care are supported through reporting and clearance systems under the Aged Care Act. Where NDIS clients choose to stay in dementia-specialist residential aged care, it is recommended that Aged Care Behaviour Management Plans are an acceptable substitute for BSPs. Recognition of these plans should be accompanied by a streamlined reporting process through the aged care portal. Finally, a single clearance system for NDIS and aged care staff should be implemented across both sectors, decreasing delays in clearance and additional costs of the WSC. HammondCare’s recommendations seek to support the NDIS Commission to build upon on their processes in aged care; creating an efficient and streamlined approach while maintaining quality of care and transparency. 8