NDIA Accountability Project

Impact of Independent Assessments on NDIS clients with psychosocial disability

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Submission to The Joint Standing Committee on the NDIS – INDEPENDENT ASSESSMENTS

Joint Standing Committee on the NDIS PO Box 6100 Parliament House Canberra ACT, 2600

31/3/2021

RE: SUBMISSION TO THE JOINT STANDING COMMITTEE ON THE NDIS – INDEPENDENT ASSESSMENT

  • I am a registered Mental Health Occupational Therapist with over 12 years of clinical experience.
  • I have worked in the NDIS since its roll out in 2018.
  • I hold the position of Allied Health Team Leader with a Community Health organisation working with NDIS clients with a psychosocial disability in the local government areas of Casey, Cardinia and Greater Dandenong.
  • I am also the principal therapist of mOTivations Warragul, a Mental Health Occupational Therapy service covering West Gippsland, and servicing NDS clients with a psychosocial disability.
  • The participants that I work with are significantly impacted by their psychosocial disabilities, such that participation in day to day life is an effort, and sometimes a battle. As such, they have limited or no awareness of the proposed changes to the NDIS and the introduction of Independent Assessments, and how this may impact them. They are unable to advocate for themselves in this regard, so respectfully through this submission, I hope to give them a voice.
  • I also write in support of my profession of Occupational Therapy, which stands to be negatively impacted by the proposed changes.

Quotes provided herein are taken from the “Consultation Paper: Access and Eligibility Policy with independent assessments, November 2020” (herein referred to as “The Consultation Paper”.

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Independent Assessments

Submission 273

Motivations Warragul

  1. An independent assessment has been defined as “an assessment of a person’s functional capacity, which will be used to inform decisions about eligibility for the NDIS and about funding in a participant’s plan”.
  1. It is reported that these assessments be undertaken in most cases, in one sitting, “take around 3 hours on average”, and be conducted by a “suitably qualified allied health professional” who willbe unknown to the participant.
  1. To Occupational Therapists a “Functional Assessment” is a very specific assessment processwhich requires a specific set of knowledge, tools and training. It involves formal observation of aparticipant completing a daily task that collaboratively chosen with the participant. The taskchosen is based on how important the task is to the participant within their daily routine,and towhat degree their disability is impacting on its successful completion. During formaloobservationof the task, the Occupational Therapist completes a task analysis – this involves breaking downthetask and analysing the sensorimotor, cognitive, psychological, interpersonal, educational, cultural and other processes required for effective performance of the task. Allied healthealthprofessionals other than Occupational Therapist are not suitably trained or qualifiedto completefunctional assessments, and to deem them suitable to do so, dilutes a core skillset whichisunique to Occupational Therapy practice. Opening this core OccupationalTherapy skills up toothers professionals threatens the professional identify ofOccupational Therapy, and subjects participants to being exposed to inappropriate,ineffectualor inaccurate assessments.
  1. In addition to formal observation of a functional task, a functionalassessment completedby anOccupational Therapist involves meeting with theparticipant over several sessions, acomprehensive, holisticformal interview taking into accounttheir background, social situationand environmental conditions,a caregiverinterview, and standardised assessment toolsto determine the participant’s self-assessment oftheirdaily functioning and their understandingofthe impact of theirdisabilityonthis. This process may occur over2–3sessions,andt akeup to 15hours tocomplete(including report writing). A once-off assessmenttaking 2–3 hours will clearlynotidentify the same level of information as athorough assessment, limiting aparticipantsaccess tof funds they would be entitled if the full breadthof the functionalimpact of their disability was known.
  1. Assessmentoverseveral occasions necessary for allparticipants tocature relevantinformation, but it is imperativefor participantswithapsychosocial disability – often referredtoasan‘invisible disability’. Psychosocial disabilityisf fluctuant innature,andan d bydefinition,canimpactorperson’sin sight intot heirfunctional capacity. As such, aon ce - off independentassessmen tis

Independent Assessments

Submission 273

Motivations

Warragul

unable to provide a “holistic view of functional capacity”, and will miss significant information about how a person functions, not just on any given day, but whether they can perform required tasks within their daily routine consistently, effectively and appropriately over time.

  1. For clients with psychosocial disabilities in particular, there are significant risks that can emerge if this information is not wholly captured, such as risk of self-neglect, self-harm, harm to others and misadventure.

  2. Self-report tools used as part of the Independent Assessment process are not an appropriate replacement for formal observations from a known therapist over time, because it is a common feature of psychosocial disability that participants overestimate their functional capacity and underestimate the impact of their disability. Due to the symptomatology of mental illness, psychosocial disability can impact a person’s accurate depiction of “how the person manages without any help, how they manage with help and/or supports, over a period of time”. This will significantly impact the quality and accuracy of the information obtained relating to “what good days and bad days look like”..

  3. Similarly, caregiver questionnaires are not an appropriate replacement for observation of a participant’s functional capacity, as caregivers can have different motivations for representing a participant as higher or lower functioning than they are, or present with limited insight themselves into the participants functioning.

  4. Self-report tools and caregiver questionnaires are important aspects of holistic assessments when taken with comprehensive, holistic formal interviews and formal observation of a participant’s functioning over time (functional assessment).

  5. The adult toolkit misappropriates a range of standardised tools that have not been validated for use on the full range of disabilities covered under the NDIS. For example, the Vineland Adaptive Behaviour Scales, Third Edition (Vineland-3) is the NDIS’s preferred tool for psychosocial disability, and yet its online distributor Pearson Clinical reports that it has been validated for “individuals with intellectual and developmental disabilities, autism spectrum disorder, and ADHD”, not for mental illness, or psychosocial disability. Further, it is validated as a tool to assess adaptive behaviour which is not the same construct as functional capacity.

  6. It has been stated that “we will consider all evidence provided in relation to impairment and the permanence, or likely permanence, of that impairment. Where appropriate, this information can be provided by the applicant’s treating health professional”.

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Independent Assessments

Submission 273

motivations Warragul

  1. However, participants from the Independent Assessment pilot have reported that assessment reports from professionals known to them have not been reviewed or allowed to inform the planning process.

  2. Participants who have been involved in the independent assessments pilot have described the process as “dehumanising”, “tick-box assessments” with assessor asking “yes or no” questions with “no context,” with fears that it will result in a “one size fits all model” (quotes taken from print media interviews with pilot participants).

  3. This flies in the face of what we know as best practice in working with people with disabilities: working from a trauma-informed lens and not asking clients to unnecessarily re-tell their stories (especially when they already have existing professionals involved in their care with whom they have a trusting therapeutic relationship). This process can potentially be highly retraumatizing for clients, especially for those with psychosocial disabilities, who are known to have a high incidence of history of trauma.

  4. There are also significant workforce issues that will result from the implementation of independent assessments, in addition to the threat to the professional identify of Occupational Therapy and the dilution of the Occupational Therapy role already mentioned above (point 12).

  5. Participants already experience significant waiting periods to access Allied Health Therapy under the NDIS due to industry-wide shortages of trained Allied Health Professionals (especially for Early Childhood Intervention and Specialist Behavioural Support). Creating a distinct workforce of clinicians to just provide independent assessments diverts clinicians away from provision of intervention / therapy based services, and will only serve to increase staff shortages and therefore the wait-times to access services. For example, we have recently re-advertised a position for an Occupational Therapist at our Community Health Service twice across multiple platforms, and only received one qualified applicant, despite opening the advertisement up to consider full or part-time hours, and Grade 1 or Grade 2 applicants.

  6. Although the Consultation paper states that the Allied Health Professionals undertaking independent assessments will be “qualified health care professionals” and “trained experts,” some of the providers awarded with the contracts for the independent assessments (e.g., Plena) have been encouraging new graduates to apply for these roles. This again exposes participants to being subjected to inappropriate, ineffectual, or inaccurate assessments from inexperienced clinicians.

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motivations

Warragul

  1. Independent assessments may also contribute to increased genericism of allied health roles, leading to a loss of individual skill sets especially for Allied Health Professionals early in their careers.

  2. It is unclear how independent assessors will be appropriately trained to be suitably qualified to assess participants with the broad-range of disabilities covered by the NDIS.

  3. As has been reported in the media, independent assessments also expose inexperienced Allied Health Professionals to the stress of being reported to AHPRA for practicing outside of scope by participants, exposing them to a review of their practice by the Regulation Authority and possible deregistration or conditional registration (for e.g., a physiotherapist completing an independent assessment for a participant with Autistic Spectrum Disorder).

  4. The independent assessment consultation, tendering and pilot process has also raised some ethical issues which I will note herein:

i. Vulnerable and socially disadvantaged participants have been offered $150 to participate in the independent assessment pilot (a substantial amount of money to people with a disability). Participants may feel unduly pressured to give a positive assessment of their pilot experience due to the financial reward.

dd: s47F - Personal privacyii. Participants have not been advised of the true implications of engaging in the pilot process on their existing plan (there have been reports of participants’ funding being changed as a result of the independent assessment despite initial communications expressly advising participants that this would not occur).

jdd: redactediii. There has been no clear or transparent public tender process for the independent assessment contracts. An independent assessor contract was awarded to Allied Care Group, a subsidiary of Zenitas Healthcare, whose chief executive is a former head of the NDIA. A clear conflict of interest. iv. Independent assessment contracts were announced just days after the ‘consultation’ period ended, demonstrating that it was not, in fact, a consultative process.

Recommendations: The Consultation Paper reports on the current challenges to accessing the NDIS: 1. “The current access process requires people with disability to seek information about the impact of their disability from a variety of health professionals, including doctors and specialists. This can often involve long wait times. Appointments to see doctors and specialists can also cost a lot of money. Access to the NDIS should not be determined by a person’s ability to gather and pay for enough evidence to demonstrate reduced functional capacity”. 2. “Inconsistent and inequitable access and planning decisions”.

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Independent Assessments

Submission #273

motivations

Warragul

3. Currently there isn’t one standard way to provide evidence on the impact of a person’s disability or disabilities. This includes how the impact of their environment is considered and how the person’s functional capacity is assessed. This has impacted on participants across the NDIS, and in particular, those with psychosocial disability, due largely to the wide variability in assessment tools used to capture information on mental health conditions. Some assessment tools do not provide enough of the information that is needed, which makes it difficult to achieve consistency and equity in decision making.

Aprovider, I acknowledge these challenges to accessing the NDIS, and witness these inconsistencies on a day-to-day basis. The remedy to these challenges is to adopt the Tune Review’s (2019) recommendation to:

“remov[e] financial barriers to access the scheme by enabling a new functional capacity assessment process funded by the NDIA to be undertaken. This process will provide information to support the NDIA to make clear and consistent decisions about a person’s eligibility for the scheme or the supports provided for in their plan”.

The intention of this recommendations was that independent assessments would operate in conjunction with other forms of evidence to develop a clear picture of participant needs. And not for the assessments to be mandatory.

The NDIS should continue to allow therapists who have existing therapeutic relationships with participants to conduct assessments and provide reports on the functional capacity of their clients. This allows for a trauma-informed approach, consideration of environmental and other psychosocial circumstances impacting functional performance, formal observation of functional capacity and observation of fluctuation over time.

If there is concern regarding the consistency of tools being used by therapists to measure and report on psychosocial disability, provide guidelines for clinicians on standardised tools designed to measure functional capacity that are validated for use with participants with psychosocial disability.

For participants who cannot fund assessments to access NDIS, make funding available for them to engage a known and/or preferred provider to complete an assessment of their functional capacity so their access and eligibility is not disadvantaged.

Sincerely,