NDIA Accountability Project

Dietitians Australia submission on the impact of independent assessments on nutrition and dietetic supports for people with disability

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Joint Standing Committee on the

National Disability Insurance Scheme:

March 2021

Dietitians Australia is the national association of the dietetic profession with over 7500 members, and branches in each state and territory. Dietitians Australia is the leading voice in nutrition and dietetics and advocates for food and nutrition for healthier people and healthier communities. Dietitians Australia appreciates the opportunity to provide feedback to the Joint Standing Committee on the National Disability Insurance Scheme on the independent assessments.

Dietitians Australia and the associated logo is a trademark of the Dietitians Association of Australia.

Dietitians Australia interest in this consultation

As the leading organisation of nutrition and dietetic professionals in Australia, Dietitians Australia supports reforms to the National Disability Insurance Scheme to improve the health and wellbeing of people with disability.

The Accredited Practising Dietitian (APD) program provides an assurance of safety and quality and is the foundation of self-regulation of the dietetic profession in Australia. Accredited Practising Dietitians have an important role to play in the disability sector including providing person-centred nutrition care for NDIS participants, in contributing to integrated care in the context of NDIS and training of disability sector staff.

This submission was prepared by the Dietitians Australia following the Conflict of Interest Management Policy and process approved by the Board of Dietitians Australia. This policy can be viewed on the Dietitians Australia website.

Recommendations

  1. Immediately cease the roll out of the independent assessments program
  2. NDIA to conduct a robust and transparent evaluation of the current independent assessment program including the impact on participants, funding, access and outcomes
  3. If NDIA continues to progress the independent assessments, ensure that: a. Dietitian reports are incorporated when determining eligibility to access NDIS, funding allocation and during subsequent NDIS planning arrangements b. Add nutrition risk screening to the assessment phase

Key message

Dietitians Australia is concerned about the Federal Government’s planned changes to the NDIS.

Independent assessments do not consider food and nutrition, failing to recognize the presence or risk of malnutrition and the corresponding impact on function. Nutritionally vulnerable Australians with a disability may miss out on access to the NDIS, with the potential to further increase the number of potentially avoidable deaths experienced by people with a disability in Australia.

Discussion

Dietitians Australia (DA) endorses the disability sector’s joint statement on the Australian Government’s planned reforms to the NDIS1. We join with Professor Bruce Bonyhady (key architect of the NDIS)2 and the Ombudsman, Michael Manthorpe, in their calls to halt the roll out of Independent Assessments3 and start again “based on strong, transparent and accessible evidence and co-design”.2

Additional concerns on the impact of independent assessments on participants access to nutrition supports

The assessments in their current form will not identify individuals who are at risk of malnutrition or those who require nutrition and dietetic supports to optimise function and enhance their physical, mental and social wellbeing. Furthermore, the independent assessments are not able to

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differentiate between self-reported ability to eat and drink with risk taking behaviours specific to food and drink.

There is no current evaluation that assesses the impact of the independent assessments on access to the NDIS or funding, for nutritionally vulnerable individuals. Below we outline hypothetical examples that demonstrate the potentially detrimental impact of these assessments on access to the NDIS and support services for people with disability who are nutritionally vulnerable.

Example 1: “Sarah” 30 y.o. with Cerebral Palsy

Situation

  • Sarah has an impaired swallow; she needs texture modified food (puree) and drinks (thickened)
  • The texture modified diet increases Sarah’s risk of malnutrition. Sarah requires medical nutrition therapy to support her to choose foods that are the right texture or can be pureed safely. Many of these need to be fortified to ensure she gets all the nutrition she needs without having to eat excessive volumes
  • Sarah has reduced mobility and dexterity; she uses adaptive equipment.

Assessment

Vineland assessment asks, “can use a spoon to feed themselves”. Sarah’s answers “yes”. However, this does not encapsulate the services required to achieve this function, which include:

  • Speech pathologist input to assess safe swallow
  • Dietitian to plan menu and train carers to prepare fortified and texture modified food and drink
  • Physio to provide adaptive and supportive seating
  • OT to provide adaptive cutlery

Outcome

  • The functional assessment fails to recognise the extent of the support required.
  • Resulting funding does not cover nutrition therapy to support function and optimal outcomes.

Example 2. “David” 50 y.o. man with Downs Syndrome living in supported accommodation

Situation

  • David has multiple missing teeth and refuses to wear dentures. He can only eat softer foods as a result
  • People with Downs Syndrome also have an Intellectual disability. David has a reduced ability to understand complex concepts, impacting his ability to make appropriate food choices
  • 20+ years of poor diet has resulted in weight gain, high cholesterol, high blood pressure and diabetes. David needs medical nutrition therapy to manage his diabetes and reduce his risk of having a heart attack or stroke.

Assessment

  • Vineland assesses whether David “shows awareness of healthy and unhealthy foods”.
  • David nor his support person understand how to manage his health with food, they rely on medications.

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  • The assessor is not a dietitian and not qualified to determine David’s level of awareness of healthy and unhealthy foods in the context of a complex relationship between food, David’s disability and the surrounding personal, social and environmental factors.
  • The assessor is also not qualified to understand the impact of David’s level of awareness of healthy/unhealthy food on subsequent food intake behaviour, health, social or economic outcomes.
  • Awareness of healthy and unhealthy food does not necessarily predict subsequent food intake behaviours and is not an appropriate screening question to determine need for nutrition and dietetic support.

Outcome

  • The functional assessment fails to recognize the need for nutrition and dietetic supports.
  • David is deemed ineligible for NDIS funding or
  • Insufficient funding is allocated to David to prevent further adverse health effects as a result of David’s disability.

Summary of concerns

The proposed Independent Assessment Toolkit is unable to identify individuals who are at risk of malnutrition or those who require nutrition and dietetic supports to optimise function and enhance their physical, mental and social wellbeing. The proposed assessment tools are inappropriate for the purpose of malnutrition/nutrition screening and they do not assess the complex relationships between practical knowledge of food, meal planning, cooking and swallowing on a persons’ capacity to complete activities of daily living and participate fully in their community.

The examples provided reflect people with disability who are nutritionally vulnerable and at immediate risk of death, e.g. choking or aspiration due to impaired swallow and medium to long term risk of malnutrition or cardiometabolic changes related to diet and lifestyle. The current proposal risks limiting access to the scheme for similar people. The application of Independent Assessments to determine funding may further reduce the capacity of participants to access reasonable and necessary disability related nutrition supports.

When Troller and Salomon4 synthesised data from reports of reviewable deaths in Australia, it was found that many potentially avoidable deaths experienced by people with disability, were attributable to inappropriate management of their food, fluid and nutrition care needs. Despite the directive and intention of the NDIA to address this significant concern, the proposed independent assessments present an additional barrier to appropriate management of the food, fluid and nutrition care needs of people with disability, within the context of the NDIS.

Dietitians Australia’s call to action is congruent with Salomon and Troller4 recommendations to implement nutrition screening and carer training to reduce the risk of deaths related to aspiration and choking in people with disability.

References

  1. Disability sector statement on the Australian Government’s planned reforms to the National Disability Insurance Scheme (NDIS). Published March 2021. Available from: https://everyaustraliancounts.com.au/ndis-sector-statement/
  2. Bonyhady, B. An analysis of the NDIA’s proposed approach to Independent Assessments. Published Feb 2021. Available from: https://disability.unimelb.edu.au/__data/assets/pdf_file/0011/3623987/Independent-

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Functional-Assessment-An-Analysis-of-the-Proposed-Approach-by-the-NDIA-Final-22-February- 2021.pdf 3. Manthorpe, M. Independent Assessments submission 4: Inquiry into Independent Assessments. Published: Feb 2021. Available from: https://www.aph.gov.au/DocumentStore.ashx?id=d8b59bf9-62c1-476b-b8c0- 40149e5b9917&subId=703977 4. Salomon C, Troller J. A scoping review of causes and contributors to deaths of people with disability in Australia Findings: University of New South Wales, Sydney; 2019.

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