SUBMISSION
SUBMISSION TO THE JOINT STANDING COMMITTEE ON THE NATIONAL DISABILITY INSURANCE SCHEME
About Access Care Network Australia (ACNA)
Access Care Network Australia (ACNA) is Australia’s largest not for profit, specialist supplier of assessment, support planning and case management services in Australia. In FY22 ACNA will deliver more than 150,000 assessments on behalf of State and Commonwealth Governments to:
- Older Australians, both in the home (Regional Assessment Service) and as the largest provider of assessments to determine individualised funding for residential aged care services;
- People awaiting hospital discharge (NSW Ministry of Health), and
- People with disability to determine whether they require wage support (Dept of Social Services).
ACNA had also been appointed to the NDIS Independent Assessment Panel.
ACNA has invested millions in academic-led R&D to find better ways to deliver government services. It has applied its 10+ years of data and operational insights gained from delivering more than 405,000 assessments to the design of robust, sustainable social services systems including a particular focus on hospital avoidance and aged care. For example:
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In 2015, ACNA shared its assessment model with Government (along with a range of operational insights and sensitive financial data) to provide the foundations for the design of the Regional Assessment Service.
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In 2018, as part of a $29 million Budget initiative, ACNA was engaged to roll out its Reablement Method on a national scale. ACNA trained and mentored over 130 assessors across five organisations.
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In 2020/21, ACNA continues to work closely with the Department of Health, providing operational advice on the design of the unified system of home care.
Why this submission?
ACNA acknowledges and fully accepts the decision by the Minister for the National Disability Insurance Scheme and the Disability Reform Minister’s Meeting of 9 July 2021 not to proceed with Independent Assessments. While not diminishing the significant differences between the lives and challenges of people living with disability and older Australians, we believe our insights, based on supporting over 30,000 people each year to access social services, will assist government in its consideration of how to approach NDIS access and planning in the future.
What we have heard and our observations
Before the decision was made to cease the introduction of Independent Assessments, the ACNA executive team consulted with people living with disability and those providing support; not on the components of IA, but on how we, as a panel member, could ensure the experience was a positive one. What we learned, together with our observations based on operating in other service systems, follows.
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The current access process requires the person to ‘prove how disabled they are’
It is deficit based, requires significant investment (time and money) and is perceived by prospective Participants as a ‘test’ that they will either pass or fail, with the answer determining whether they are accepted into the scheme and a flow on effect on their lives.
Irrespective of how well trained or helpful Agency or Partner staff are, the process immediately sets the prospective Participant and the Agency as combatants, not collaborators. It puts the power in the hands of the treating professional and the Agency. Importantly, it focuses on function, not the impact of the disability on a person’s goals and aspirations.
In other social service contexts, such as aged care or disability employment services supported wages, determining eligibility for support does not take place via a telephone assessment or through the evaluation of documentation. Rather, it takes place in a more appropriate environment such as their home or workplace, where the person is more comfortable and feels more in control (as the planner is the invited guest, not the person seeking support).
The current planning process relies on the traditional assessment model
Multiple researchers (and our own evidence based on a review of more than 2,000 older Australians) have found a weak relationship between what people say and what they can do. This results in people being directed to the wrong kind of care, or care that is beyond what is needed.
Our method of assessment reinvented the traditional approach to planning. Instead of focusing on what a person can’t do, we focus on what they can do. Instead of asking questions we have them demonstrate tasks; it is an ‘active assessment’. We offer practical advice throughout the assessment and go as far as providing follow-up encouragement after the assessment. The results have been remarkable.
ACNA’s audited Client Satisfaction Score is 98.7% (against a contractual requirement of 85%) and in an academic trial of ACNA’s Reablement Method, 16.4% of clients did not need ongoing Government-funded services.
ACNA’s method focuses on the whole person (not just their functional deficits) to identify goals that build on their strengths and capabilities and contribute to their overall wellbeing.
Importantly, the method can be trained and is replicable. ACNA trained and mentored five competitor organisations and over 130 of their staff. An independent report¹ on the outcome of the initiative was recently released. It concluded;
- Our method of assessment – specifically the ‘active assessment’ component, increased reablement opportunities and client follow-up and amounts to a substantial shift away from the traditional model of assessment.
- Our method of assessment – is superior to the traditional assessment approach – it is more appropriate, more effective at identifying reablement opportunities and is cost-neutral.
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We need to capture a person’s story
One of the frustrations stated by people dealing with government is that they must tell their story over and over again. Every interaction has them repeating the same information to a new audience. So too with the current NDIS process.
A prospective Participant must first provide information either to a Local Area Coordinator and/or their treating health professional so he or she can complete their parts of the application form. Interestingly, the prospective Participant only provides very basic information in the application form (identifiers and type of disability). Most of the form is completed by the health professional who not only provides medical information but provides an opinion on the impact of the disability on the prospective Participant’s life.
In our experience, based on completing more than 400,000 assessments, no one is an expert in a person’s life – except the person themselves. Two people can have the same diagnosis or disability but with dramatically different impacts; based on their home environment, their family situation, their financial position and their attitude. It is difficult to determine impact sitting in a medical office. A far better model is that a person’s story is captured by a person skilled on building rapport and on eliciting information without taking a ‘tick box’ approach. Importantly, the person should be able to document the prospective Participant’s story in a way that:
- Ensures a Participant’s voice is not only heard, but the Participant themself, feels heard, and
- Enables multiple readers (Participant, family, LACs or Agency personnel) to share a common understanding of the Participant and enables robust benchmarking across Participants.
Goal orientated planning builds capability and independence
Once through the first gate (eligibility), the prospective Participant has a planning meeting. The NDIA provides some good information on its website to assist Participants to prepare for their planning meetings by asking a series of questions. The questions are designed to create a picture of the Participant, to understand their goals, their current capabilities and support networks. While there is nothing wrong with the questions as such, the setting and skill of the assessor can have a big impact on the outcome of the planning session.
A good planning meeting is essential to the proper functioning of the NDIS and as explained earlier, the identification of strategies and supports that will assist someone to live a rich and full life should focus on the future, be goal-oriented and seek to find solutions.
The approach that ACNA uses in other social services contexts is based on two assumptions; every person knows what they need to have a better life and has the skills to create solutions for themselves – they just may need some structure to guide their thinking, or the confidence to see possibilities.
This discussion should take place in the Participant’s home environment where they are most comfortable, in charge and in control. Importantly, the Participant should own the goals and strategies. At ACNA we believe the plan (which encompasses goals and strategies) should be owned by the person. It is written in their words, signed by them and summarised into a one-page action plan they can put in a prominent place to enable them to monitor their progress towards the achievement of their goals. Yes, this is captured on a portal which they and their carers can access, but there is something to be said for the simplicity of a daily reminder and its impact on a person’s motivation to achieve.
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Great planners share several traits
In the aged care system, the role of the assessor and planner are combined, with only high-level plans requiring a review by a delegate. This is efficient, reduces the need for a person to tell their story more than once, and reduces the Participant’s stress. We have refined our recruitment criteria and process over our ten years of operations and have concluded the characteristics of a great assessor/planner are:
- Their ability to work inclusively – to respond appropriately to diversity by having a person- centred approach, understanding the impact of historical context, being aware of any unconscious bias and respecting cultural beliefs.
- Self-efficacy and self-awareness – to ensure planners operate within their scope of practice and seek the input of others when it is beneficial to the person requesting support.
- Flexibility – to adjust their approach in response to the needs of the Participant based on the input of significant others and referrers and observed activities in the home.
- Solution focused – developing strategies by observing the environment, abilities and challenges and listening to the person’s story to suggest ways to overcome problems and challenges.
- Safety focused – having the ability to recognise signs of emotional, psychological, physical or financial abuse, harm or neglect and act in accordance with legislation and best practice.
- Ability to identify hazards and risks as they relate to the person and communicate mitigation strategies while ensuring dignity of risk is maintained.
While qualifications may assist in identifying a potential workforce that use clinical reasoning skills, it is the aforementioned criteria that differentiates a good experience and outcome (for both Participants and funders) from an algorithmic, ‘tick a box’, poor experience.
Quality must be defined and measured regularly
ACNA’s integrated quality and audit system triangulates data from a range of sources for each assessor/planner to measure not only compliance, but quality of interaction. Each assessor/planner is assessed quarterly as follows:
Observation
Team Leaders evaluate the interaction against five criteria:
- Establishes rapport, shows respect, places the person at ease, clearly explains purpose of meeting and how information will be used.
- Uses strengths-based language and demonstrates focus on identifying opportunities to build on strengths, improve functional capacity and participate in social and community activities.
- Obtains the required consent and informs the Participant and/or representative of information handling process, privacy and confidentiality.
- Process and documentation is consistent with standard operating procedures.
- Clearly communicates outcomes, next steps, contact details and feedback/complaints process.
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Documentation Audit
Team Leaders audit a sample of each assessor/planner every quarter considering:
- Completeness of data and information.
- Clear and concise sentences without errors in grammar or spelling.
- Strengths based and non-judgemental descriptors.
- Completeness of each part of the documentation and its ability to inform the other parts of the report.
Triangulation
- The observed practice was consistent with the quality of the written report.
- The documentation is consistent with dual assessment results
- Client satisfaction survey results meet the standards.
- Assessor/planner’s self-reflection is consistent with the observations, written reports and client satisfaction surveys.
The triangulation findings are discussed with each assessor every quarter, enabling Team Leaders to identify and action improvement plans in a timely manner.
Finally, our impact extends well beyond the assessment
While we may be funded to gather information, develop support plans and facilitate access to government subsidised services, our clients constantly reinforce that our impact is so much greater.
We are the motivators, myth busters, the people who open minds to possibilities.
Over the years we have surveyed more than 5000 people in order to understand what makes up a good assessment experience for them. A common theme is our clients say it is the first time in their aged care journey that they “really felt listened to”.
The ability to listen is central to the skills of our assessors, as is the need to:
- Show a genuine interest in a person’s story,
- Reserve judgment on people who are ageing,
- Talk plainly about ageing and its effects, and
- Treat clients like people and not obligations.
These skills ensure our assessors consider the views and opinions of our clients in the decision- making process. This empowers clients and numerous studies have shown this shared decision-making not only increases client satisfaction but also leads to improved health and well-being outcomes.
Dr Ricki Smith CEO