Cairnmillar
INSTITUTE | Treatment | Education | Research
09 April 2021
Joint Standing Committee on the National Disability Insurance Scheme
PO Box 6100
Parliament House
Canberra ACT 2600
Dear Joint Standing Committee on the National Disability Insurance Scheme
Inquiry into Independent Assessments
We welcome the opportunity to provide our submission to the National Disability Insurance Agency (NDIA) inquiry into independent assessments under the NDIS.
About the Cairnmillar Institute
For over 60 years the Cairnmillar Institute (Cairnmillar) has been providing both mental health educational and treatment services that are evidence-based and that work. The latter claim is demonstrated by our clinical governance protocols, which show that we maintain effective results in our care of our clients. Moreover, being linked to an educational institution ensures that our practice is contemporary, evolving and evidenced based. Cairnmillar, a NFP organisation, is now the largest trainer of post graduate psychologists nationally. Conducting assessments is a core part of our work and training and as such we have created an “Assessment Hub” staffed with Assessment coordinators and a variety of endorsed psychologists.
Our commitment to the NDIS was displayed when we hosted a conference in January this year on the NDIS and assessment “Understanding and Demystifying Neurodevelopmental Disorders” which was designed to enhance the capacity and capability of provisional psychologists working in this space and NDIS assessors. Almost 100 people attended this one-day low cost ($20) conference. It is from this experience that we base our comments below.
For several years, Cairnmillar Institute students (provisionally registered psychologists) have been conducting NDIS assessments in a variety of settings while on work placements. Moreover, we also conduct assessments at our Cairnmillar Clinics which are offered at low cost.
We only comment on the Terms of Reference aligned to our expertise and experience.
Our response to selected Terms of Reference:
- a. the development, modelling, reasons and justifications for the introduction of independent assessments into the NDIS
An assessment can achieve more than ‘understanding the impact of a person’s impairment on their functional capacity’. A high-quality assessment assists in understanding a person’s strengths and weaknesses, identifying potential problems with cognition and emotional reactivity, and enables recommendations to be made back to the treating practitioner (in light of the information gathered) for treatment/remediation and
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intervention. Recommendations/findings and assessment selection should be defensible and can only be as accurate as the assessment process allows.
Our provisional psychologists have stated that they feel that the current model of assessment by assessors is very inadequate and does not always map onto the needs of the participant, given assessors frequently lack psychological knowledge of the participant and have very little engagement with the clinical services with whom they are involved. Consequently, it is vital that additional comprehensive testing is completed to provide the appropriate information for the participants ongoing needs. This is appreciated by the participants’ plan manager and medical practitioner, and other professionals working with the participant, and ensures an ethically and legally defensible assessment, with appropriate information and recommendations targeting the participants’ individual needs. It is in our experience that current assessments do not always address the additional mental health and wellbeing aspects of having a disability (of any sort) and, yet again, participants need to be put through further testing to garner this information. As you are aware, mental health/ psychological capacity and a range of emotional wellbeing issues are associated with having functional capacity deficits – and this is regardless of the disability that has been determined is the ‘primary’ disability. Typically, a participant has multiple challenges, and a single label cannot adequately represent the individual needs they face on a daily basis.
More discretionary, broader, evidenced-based and aligned measures, complementary to functional areas, will provide participants and plan managers with fit-for-purpose assessment findings/ recommendations for consideration and therefore set up the client for success, increasing the rate of skill attainment and improving outcomes in the short and longer terms. Assessments that address the biopsychosocial needs of each participant ensure that diagnosis and intervention are addressed concurrently, which helps to improve outcomes for participants.
While the intention may be to individually tailor and case manage plans, the assessments themselves need to be tailored in order to discern the exact client needs. Therein, a sense of provisional ‘working’ diagnosis is important. This scientist-practitioner model/approach is fundamental to the assessment process. It leads to a more accurate, ethical and defensible assessment and informs recommendations, and it provides best service delivery.
The independent assessment scheme needs to be funded appropriately, engaging assessors who have assessment knowledge and can undertake appropriate quality assurance and assessment testing and process. See next comment.
- c. the human and financial resources needed to effectively implement independent assessments
There would be many independent agencies equipped to effectively implement independent assessments. However, one under-utilised and low-cost resource is psychology interns who are post graduate, closely supervised provisional psychologists. Interns have vast knowledge and experience of assessment being minimally in their 6th full time year of psychology. They have previously conducted these assessments but, as an under-utilised asset, could do more through specifically constructed clinics for this purpose. Provisional psychologists are registered psychologists who are registered provisionally – meaning that they are already registered (not just students).
- d. the independence, qualifications, training, expertise and quality assurance of assessors
We appreciate being able to be involved in, and able to conduct, the assessments required. We are concerned, though, that the use of generic assessments is constraining, given that they provide only limited information to assessors. Ideally, participants’ assessment needs should be targetted in such a way that the participants see the right assessors with the right tools (chosen from a vast array of evidence-based tests) and knowledge to provide a quality assessment service. Our Assessment Hub has specifically trained
registered psychologists with broad ranging endorsements (Clinical, Educational and Developmental, Neurological) to support and inform various assessments.
Ideally independent assessors need to cross-refer. For example, the requirements of Autism Spectrum Disorder assessment (even at the functional capacity level, i.e. not diagnosis) is very different from those of Intellectual Disability. Therefore, different expertise is required to assess a person’s functional capacity for Autism Spectrum Disorder as opposed to Intellectual Disability.
At the Cairnmillar Institute, we have staff trained in best practice. We have robust monitoring and Quality Assurance for reports, where reports are systematically reviewed. This is another competency in itself. Within our Clinics we have informed policies and practice guidelines that are embedded within a coherent clinical governance system which ensures we are effective in our services that we provide to the community.
- e. the appropriateness of the assessment tools selected for use in independent assessments to determine plan funding
Some of the current assessments do not align to the functional category, nor are they broad enough in scope. For example, the Vineland and the NDIS areas do not match up. Not all assessment tools are appropriate for every disability, and many functional assessment tools may be taken out of context if given inappropriately or administered by assessors without the appropriate experience. If the best assessments are not selected, the assessment may be compromised and lead to inferior outcomes.
The experience of some of our clinicians and students working across other government funding programs (e.g. Department of Education Program for Students with Disabilities) is that when independent assessments are completed, they are typically seen as a “funding assessment” determining eligibility only. This results in assessors being asked to use assessment tools that are not appropriate for the participant, nor do they take the time required to really understand the participant’s needs. Such assessments focus on the participants’ potential negatives and deficits, and organisations have a tendency to pay independent assessors a minimal fee for the service which does not account for the workload required to do a thorough assessment. The assessment tools chosen become more about eligibility for funding, rather than determining needs.
You are welcome to contact us for discussion around a relevant comprehensive list of assessments that provisional psychologists do, and the assessment tools that provisional psychologists undertake/administer with clients in all our clinics.
- g. implications of independent assessments for NDIS planning, including decisions related to funding reasonable and necessary supports
Quality decisions (e.g. planning, funding, treatment) stem from quality independent assessments. Currently, the assessment suite should be broadened, strengthened and made inclusive for all individuals. Independent assessments mean that participants are required to repeat their story multiple times and waste money as each clinician has to ask similar questions to ascertain the information they need. A standardised assessment, completed by ethical practitioners who are working with the participant, provides more than a diagnosis, it provides the participant an opportunity to develop a working relationship with the clinician. Research regarding transdisciplinary practice is clear that participants prefer to work with a minimum number of practitioners, rather than trying to juggle multiple services. Independent assessors increase the number of practitioners a participant needs to work with, which adds financial and emotional stress, as well as increased costs for travel, time etc.
- h. the circumstances in which a person may not be required to complete an independent assessment
Clear indicators, for example, of poor communication or poor cognitive ability that were determined in a previous assessment would mean that assessments may not be appropriate. Ethically it is inappropriate for
participants to be put through multiple assessments without a good clinical reason. Moreover, it is seldom that a reassessment provides any further information to what has already been gleaned from other processes and sources. This is particularly challenging when independent assessors are utilised, as the assessor does not have a detailed history of the participant and needs to ‘start from scratch’ in many cases. This wastes money and time for both participants and the NDIA more broadly.
- i. opportunities to review or challenge the outcomes of independent assessments
There would also need to be a trigger – or a reason – to enable the challenge. Ideally, all assessments should be defendable. Clients should be able to challenge their assessment findings. Subsequently, it is important that the assessments are practical, accountable and evidence based.
- j. the appropriateness of independent assessments for particular cohorts of people with disability, including Aboriginal and Torres Strait Islander peoples, people from regional, rural and remote areas, and people from culturally and linguistically diverse backgrounds
Ideally, independent assessments are reviewed on a case by case basis, and test selection or categories of tests should be decided based on individual need. This is aligned with our argument about not being constrained by particular assessment tests. Funding processes such as the NDIS are designed to reduce the costs for people who struggle to afford what is needed. However, systems put in place – such as independent assessors – decrease the ability of people with these needs to be able to access the service. Being comfortable with the person who is doing an assessment is vital for participants. Independent assessors create challenges and ultimately end up supporting those with higher education who have the capacity to negotiate the system, and therefore already have a higher income. Cultural research on generational poverty makes it clear that people who come from diverse backgrounds value different things and can navigate their own communities well but can struggle in broader society. Government processes need to provide clear, efficient and simple strategies for participants to share their information in a way that ensures the funds are distributed to people who really do need the services.
- k. the appropriateness of independent assessments for people with particular disability types, including psychosocial disability
It is against our ethical obligations if we use inappropriate assessments, or if we are limited to basic, generic assessment tools that are not aligned to the needs of the client. Assessments are confronting and overwhelming for people in many situations, without the added burden of funding processes. NDIS assessments using independent assessments create an additional workload, increasing costs and stress not only on the system but on the participants, and the professionals who work with them. Participants may not always be able to connect and engage with people with whom they do not already have a relationship, and they may miss out on funding as they are unable to communicate their needs appropriately or feel comfortable saying things to people they do not know.
In Summary:
For independent assessments to be appropriately implemented, there need to be clear guidelines and expectations around conducting types of assessments. Interpretation is a skill that requires expertise. The advantage of using appropriately trained psychologists is that they are able to assess subtle nuances which may have significant ramifications for the client, and if these nuances are missed, they can result in suboptimal outcomes.
Recommendations:
Our recommendations are as follows:
- Increase the psychological/emotional/cognitive assessments be added to the assessment suite
- Align assessments with functional areas identified by the NDIS
- Introduce an assessment system where the provisional or confirmed diagnosis is aligned to the skill set of the assessor undertaking the assessment
- Consider utilising provisional psychologists based in low cost clinics (e.g. psychology university settings) for psychosocial, mental health and a range of other functional assessments.
- Provide participants with the ability to choose an assessor who can understand their specific needs and with whom they feel comfortable to engage.
- Should independent assessments become legislation:
- Allow for participants to advocate for individual circumstances that they may include assessments from professionals currently working with them, and
- Ensure a high level of quality control is incorporated within the process so that organisations cannot take advantage of participants or professionals in the field.
- Review and critique other state and federal government funding programs to ensure the concerns of participants and practitioners do not filter into the NDIS.
Thank you for your time spent considering our response.
Yours sincerely
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Professor Kathryn von Treuer, CEO
(on behalf of the Cairnmillar Institute - Assessment Hub)