Response to NDIS (SEN) Committee Parliamentary Inquiry into NDIS Independent Assessments

ermha | 22 Mental Health 365 and Disability Services

APRIL 2021

Response to NDIS (SEN) Committee Parliamentary Inquiry into NDIS Independent Assessments

Contact

Karenza Louis-Smith, Chief Executive Officer ermha365 1st Floor, Building G, 45 Assembly Drive Dandenong South VIC 3175

Acknowledgements

ermha365 acknowledges the contribution of staff from the organisation’s intensive services and complex client’s teams, our Senior practice leaders as well as Executive Management in the preparation of this submission. ermha365 also acknowledges the importance of maintaining privacy and client confidentiality.

To that end, the organisation seeks the opportunity to be consulted prior to the reproduction or publication of any content arising from case studies featured in this submission.

ermha365 acknowledges Aboriginal and Torres Strait Islander people as the Traditional Owners and Custodians of this country, their connection to land, water and community. We also pay our respects to their cultures and customs, and to Elders both past and present. ermha365 is committed to contributing to the Closing the Gap initiatives by improving health outcomes for Aboriginal and Torres Strait Islander people.

About ermha365

ermha365 is a company limited by guarantee operating across Victoria and the Northern Territory that provides a range of NDIS supports including supported independent living (SIL), support coordination, and specialist behaviour support.

We are known for our work with people who have significant mental health and cognitive disabilities, and who may have additional complex needs including behaviours of concern. Our participants’ background is likely to include trauma and lengthy institutional care, high contact with the service system (with little success), and a range of complex needs and diagnoses.

We are one of a very small number of specialist service that work with complex participants with co-occurring mental health needs who present with dual disability, autism spectrum disorder, alcohol and drug issues, and contact with the forensic/criminal justice system. As a result, ermha365 is a lifeline for people who often feel like “a square peg in a round hole”, many of whom have experienced stigma and discrimination, and been ostracised or excluded from the simple things that most of us take for granted.

At ermha365, we believe it is a fundamental human right to live in the community — not in prison, or a locked hospital ward, just because there is nowhere else for you to go. We are

a erm ha ermha365 would appreciate the opportunity to be consulted prior to the

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experienced in successfully transitioning high-risk, high-needs participants from SECUs, in- patient units, prison and forensic facilities, and are a go-to source for the NDIA when there has been a market failure in relation to supporting people with extreme behaviours of concern and high support needs.

Our purpose is to be a unifying voice for people with mental disability, giving them the voice, choice and support to thrive in a vibrant supportive community.

Our vision is for progressive reform, advocating for all people living with a mental disability to be able to reach their personal potential.

Our mission is to work side by side with the people we work with, providing them with the compassion, care, advocacy and support they need to live the lives they want within a supportive community.

To illustrate key themes, ermha365 highlights challenges though the use of case studies where possible. Pseudonyms are used to protect the identity of individuals and maintain client confidentiality in accordance with the NDIS Code of Conduct for Service Providers and statutory privacy obligations. The case study included in this submission has been de- identified, and the client has given written consent for it to be published in any Parliamentary Reports arising from this Inquiry. Page 3 of 14

ermha365 understands that the new NDIS Access and Eligibility Policy will include mandatory independent assessments for prospective participants to assess the impact of their disability on their day-to-day life (functional capacity). We further understand that this policy, and independent assessments, will come into effect in the middle of 2021 for all applicants over 7 years of age.

In February 2021, we made a submission to the NDIA’s Request for Consultations on this issue.

Because we work with NDIS participants with significant mental health and cognitive disabilities, and who may have additional complex needs including behaviours of concern, we focused our NDIA submission on how the Agency can successfully support the introduction and delivery of independent assessments specifically to this cohort.

The majority of ermha365’s NDIA consultation paper submission is reproduced within this submission to the NDIS (SEN) Parliamentary Committee, to assist Parliament’s Inquiry into Independent Assessments.

However, this Executive Summary has been replaced and rewritten to address the Committee’s Terms of Reference. We also acknowledge and appreciate the assistance of redacted (Senior Research Officer, Joint Standing Committee for the National Disability Insurance Scheme) in granting ermha365 an extension of time to 16 April in order to finalise client permission for the case study included.

While you will find that this submission touches on many areas that the Committee is looking into, it specifically addresses the following in detail:

(c) the human and financial resources needed to effectively implement independent
  assessments;

The NDIA can reduce the risk of market failure for complex participants by ensuring that there is funded support for disability support providers to do the necessary groundwork and behind-the-scenes work that will need to happen to support an independent assessment. This includes facilitating access for the assessor, preparing the participant, and minimising behaviours of concern and risk. This additional layer of risk management in the independent assessments process will require an appropriate level of funding for the disability support provider – not just funding for the independent assessor – as it is additional unfunded work that disability support providers will be unable to absorb.

(d) the independence, qualifications, training, expertise and quality assurance of
   assessors;

Our recommendation as a provider of complex psychosocial disability supports is that the NDIA establishes a Complex assessment panel, prequalified with assessors who have 10+ years’ experience working with complex clients. This will not only deliver the right functional assessment, but also help streamline engagement in the independent assessment process for Page 4 of 14

participants with complex needs. Specialised assessors are more likely to be known to the participants and their care teams, making the choice of assessor easier and the assessment more likely to proceed without incident.

 (f) the implications of independent assessments for access to and eligibility for the
  NDIS;

(g) the implications of independent assessments for NDIS planning, including decisions
   related to funding reasonable and necessary supports;

This submission contains a case study demonstrating that complex participants often ‘fall through the cracks’, are difficult to engage in single or even multiple sessions of assessment, and require ongoing advocacy from support providers and other agencies to achieve the right level of funding to deliver reasonable and necessary supports. These challenges will be exacerbated under the proposed Independent Assessments model.

(h) the circumstances in which a person may not be required to complete an
  independent assessment;

Our submission to the NDIA consultation flagged a process concern regarding the abolition of pre-qualified access lists as part of the move to the independent assessments model.

• While we understand that these lists were intended to be used during the trial and transition period to manage the large volume of people transitioning from state and territory service systems to the NDIS, in practice many of ermha365’s participants will have been part of these access lists. Like many other providers, we would like to understand the rationale for new functional assessments to re-prosecute a case for NDIS eligibility, where this is likely to be disruptive to routine-dependent people whose eligibility is not likely to change.

• We are also concerned that, due to the small sample sizes, complex participants are unlikely to have been included in the pilot programs for independent assessments, and their needs may not yet have been taken into consideration.

   This could be resolved with a complex-specific pilot prior to rollout, with the results
   published and shared with stakeholders for comment and feedback.
  

  (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;

  (k) the appropriateness of independent assessments for people with particular disability types, including psychosocial disability

Psychosocial disability is episodic and difficult to determine at a ‘point in time’. In addition, complex participants with psychosocial disability can be difficult to engage, and need to have new people who are not part of their care teams introduced to them over time in order for these interactions to proceed safely and without incident. Page 5 of 14

The hazards of occupational violence for support providers also need to be considered in the introduction of independent assessments:

e Risk planning is an important precursor to participant engagement, to mitigate risks to the assessor and participant

e Some participants are routine-dependent and changes to routine (such as the introduction of unfamiliar assessors that are not part of their care teams) can have a long-term effect on disability support providers that have worked hard to stabilise routines and behaviours of concern.

The remainder of this submission reproduces our February 2021 Response to NDIS Access and Eligibility policy with Independent assessments (as provided to the NDIA in response to consultation requests), with the exception of one case study where we were unable to obtain client permission for publication.

a ermha ermha365 would appreciate the opportunity to be consulted prior to the

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ermha365’s three-point plan to successfully introduce Independent Assessments for complex participants

In introducing independent assessments for complex participants with significant mental health and cognitive disabilities, and who may have additional complex needs including behaviours of concern, we believe the key elements for the NDIA to consider include:

1. The need for a Complex assessment panel, prequalified with assessors who have 10+ years’ experience working with complex clients.

   This will not only deliver the right functional assessment, but also help streamline engagement in the independent assessment process for participants with complex needs. Specialised assessors are more likely to be known to the participants and their care teams, making the choice of assessor easier and the assessment more likely to proceed without incident.

2. Building a process that considers and allows for cultural differences – such
   

   as flexible timeframes and processes to build rapport with Aboriginal and CALD participants.

   Without this, over time, the NDIA may find that independent assessors may elect not to work with complex participants, when they find they cannot engage successfully with the participant during the limited time window the independent assessor is funded for. A flexible independent assessment process that considers these differences will reduce the risk of longer-term market failure for complex participants, and reduce the likelihood of appeals.

3. Involving complex disability support providers before, during and after the
   

   assessment, to reduce incidents and ensure safety for the participant and the assessor.

   The NDIA can further reduce the risk of market failure for complex participants by ensuring that there is funded support for the necessary groundwork and behind-the- scenes work that will need to happen to support an independent assessment. This includes facilitating access for the assessor, preparing the participant, and minimising behaviours of concern and risk. This additional layer of risk management in the independent assessments process will require an appropriate level of funding for the disability support provider – not just funding for the independent assessor – as it is additional unfunded work that disability support providers will be unable to absorb. Page 7 of 14

We also recommend further consideration and clarification around:

Assessment tools - We note that the validity and overall effectiveness of suite/battery of proposed assessment tools is yet to be determined, as this was not done as part of the pilot. The Policy accounts for this by noting a period of review and evaluation of the suite. However, given the impact on participants, this is less than ideal and raises the question of accuracy of assessments in the first instance. In addition, although cross- cultural validity is mentioned, we were unable to locate any information on the populations included to evaluate this.

The need to ensure equitable and fair access to the Scheme - We would also like to flag a process concern regarding the abolition of pre-qualified access lists as part of the move to the independent assessments model.

While we understand that these lists were intended to be used during the trial and transition period to manage the large volume of people transitioning from state and territory service systems to the NDIS, in practice many of our participants will have been part of these access lists. Like many other providers, we would like to understand the rationale for new functional assessments to re-prosecute a case for NDIS eligibility, where this is likely to be disruptive to routine-dependent people whose eligibility is not likely to change.

We are also concerned that, due to the small sample sizes, complex participants are unlikely to have been included in the pilot programs for independent assessments, and their needs may not yet have been taken into consideration.

This could be resolved with a complex-specific pilot prior to rollout, with the results published and shared with stakeholders for comment and feedback.

CASE STUDY CONFIDENTIALITY

The case studies in this submission have been de-identified. However, ermha365 would appreciate the opportunity to be consulted prior to the reproduction or publication of any content arising from such case studies

a ermha ermha365 would appreciate the opportunity to be consulted prior to the

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1. A Complex assessment panel – prequalified with assessors who have 10+ years’ experience working with complex clients – will make the choice of assessor easier, and the assessment more likely to proceed without incident.

It is our recommendation that the NDIA should specifically seek to recruit independent assessors who have at least 10 years’ experience working with people with complex psychosocial disabilities.

This could be achieved by actively approaching specialists who have a proven track record in this area. ermha365 is happy to assist by providing introductions to such specialists within our network.

Because this part of the market is so small, a panel of Complex assessors is more likely known to the participants and their care teams, making the choice of assessor easier and the assessment more likely to proceed without incident.

In our experience, it can take weeks to introduce a new person to one of our participants if they are not an existing part of their support network, and care teams must carefully consider whether it is best to have a functional assessment in their home, and who needs to be there for safety and risk.

Without this, we foresee a potential market failure for our participants if the NDIA is unable to attract people to actually do the assessments – for example because a pre-visit risk assessment identifies that it is too risky for the independent assessor to attend. The market may use this is a further reason to opt out of providing supports to complex participants, at best reducing choice and control and at worst, leaving people without support. Other options include:

 1.  The NDIA might want to consider funding complex support providers such as ermha365
   to act as a referral source, giving us the assessment requirement, and we can make
  recommendations as to who we believe would be appropriate assessor in that instance;
   or

2.  In the case of complex participants, support providers such as ermha365 have
    significant collateral information on file that can be utilised as an alternative to
   extensive and disruptive assessments where safety or risk assessments indicate this is
   preferable; or

3. The NDIA could consider achieving the overall objective of this change within existing
  processes/mechanisms (for example, for participants with BSP funding, a review of
   funding/supports post-completion.)

In addition to these suggestions, we also recommend that the NDIA actively seeks to grow the pipeline of assessors in all categories, because this area of allied health is already stretched for capacity.

This leaves an open question as to who is actually going to support essential day-to-day work to change peoples’ lives, should a significant portion of the allied health market decide that independent assessments are an easier or more profitable way to spend their time. Page 9 of 14

Case Study “John”

John, male and in his early 40s, has been trying to get access to the right level of NDIS supports for just over two years after transitioning from a State Funded individual support package. At that time, John was assessed for a very small package of NDIS support.

John has a number of clinical diagnoses, including schizophrenia and intellectual disability, as well as a high level of physical and mobility issues. He recently had a hip replacement and requires a walking frame.

John’s functional needs are almost exactly the same now as when he was first assessed for this small NDIS package. However, at that time his physical health (including his hip) was slightly better.

Over the past 20 years, John has experienced many periods of insecure housing. The only place John could find to live was in Supported Residential Accommodation (SRS), where he struggled to maintain tenancies due to aggression towards other residents. This aggression arose from behaviour-related incidents stemming from John’s auditory and visual hallucinations. This pattern of aggression and subsequent eviction resulted in John cycling through almost 20 SRS placements.

Because John was assessed for such a small initial package of support, John’s housing situation was made even more stressful with the introduction of the NDIS. Over the past two years, extensive care team meetings have taken place to try to secure an increase in support funding for John, including behavioural support assessments and SDA housing. This involved at least eight people in each meeting including the NDIA.

In the second half of 2020, John voluntarily admitted himself to hospital after his latest SRS placement broke down. With his long history of homelessness, and lack of formal supports, John relied on funded supports to exit hospital back into the community. This was the latest in a frustrating ‘revolving door’ of inpatient admissions where John was unable to obtain support funding without a housing model in place, and unable to obtain housing without support.

Since John’s latest admission to hospital, the care team has worked around the clock to secure six months of 24/7 2:1 transition support, and now 1:1 support funding for John, which is about to be reviewed.

ermha ermha365 would appreciate the opportunity to be consulted prior to the

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In our organisation alone, we estimate that two days a week of unfunded work over a period of three months have gone into securing this result for John — a result that still needs review to secure ongoing support in the community.

We would welcome independent assessment as a circuit-breaker to this type of lengthy extended process of obtaining appropriate support for complex participants like John — however it is important to acknowledge the complexity and risk inherent in this work.

A point-in-time assessment may have delivered a shorter road to support for John, however the risk is that John would end up with the same result he had at the beginning — a small and inadequate package leading to years of insecure housing placements, and cycling in and out of hospitals, creating costs in other parts of the service system.

ermha ermha365 would appreciate the opportunity to be consulted prior to the

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2. Building an independent assessment process that considers and allows for cultural differences – such as flexible timeframes and processes to build rapport with Aboriginal and CALD participants – reduce the risk of market failure for complex participants and the likelihood of appeals.

In total across our operations, 11% of ermha365’s NDIS participants are Indigenous and at least the same number hail from culturally and linguistically diverse backgrounds. In Darwin, 100% of our participants are Indigenous Australians.

Engagement with participants from different backgrounds is a cultural issue, where language is only one consideration. In our experience it takes a very long time to build these relationships – far longer than the independent assessor is funded for.

Should the independent assessments process fail to consider these realities, this sets up the potential for inequities in access to the Scheme. It may also exacerbate market failure for complex participants and increase the likelihood of appeals.

Simply mandating a limited number of hours for the process of independent assessments will not make the process more efficient – and risks making it significantly less effective for complex, marginalised and vulnerable groups, leaving the Agency open to avoidable criticism and complaints. Page 12 of 14

3. Involving complex disability support providers before, during and after the independent assessment will reduce incidents, and ensure safety for the participant and the assessor – but this work must be funded by the NDIS.

The NDIA can further reduce the risk of market failure for complex participants by ensuring that there is support for the participant to engage in an independent assessment.

This includes funding disability support providers to facilitate access for the assessor, prepare the participant, and to minimise behaviours of concern and risk.

This additional layer of risk management in the independent assessments process will require an appropriate level of funding for the disability support provider – not just funding for the independent assessor – as it is additional unfunded work that disability support providers will be unable to absorb, in addition to existing unfunded activities.

For example, in our response to the NDIS Review of Supported Independent Living price controls (September 2020) we noted many areas where disability providers are currently having to step in to make the system work, without any direct or indirect funding to do so.

Unfunded activities and risks currently incurred by providers like ermha365 include:

• The lack of a complex loading that prices in the additional cost and risk of working with high complex needs participants who are more likely to assault staff, impact community, damage property, have high contacts with justice and clinical settings or have fluctuations in engagement

• The cost of clinical governance to oversight complex needs, including o Provision of progress notes, reports and summaries to Care Teams o Attendance at care team meetings to review complex client requirements o Reflective practice with behaviour support practitioners, or other clinical specialists o Shift handovers o Development and monitoring of risk mitigation plans and High Risk Register panels

• Unfunded operational needs assessment (we estimate that for people with complex requirements we complete up to 30 hours minimum of assessment per client for SIL)

• Pathway planning: it is not unusual for transitions to be planned over a period from 3-9 months requiring constant contact with care teams, liaison with planners and supporting stakeholders.

While we are supportive of the move to independent assessments if they deliver greater access and equity for complex participants, and the opportunity to use flexible funding for life skills capacity building, upskilling and improvements in practice, providers like ermha365 cannot do the work of facilitating the independent assessments that precede this funding without being able to charge it back to the Scheme. Page 13 of 14

(ermha is) one of a small number of providers who will not walk away from people, and will not shy away from the very, very real challenges of providing support to the people coming to the complex support pathway. (There is) value in a willingness not to give up on people.

Senior stakeholder, NDIS

(ermha is) one of the few organisations that will actually take our clients.…if we took ermha completely out of the equation … There’d be a massive void in the service sector.

Psychologist working with complex clients

I see ermha’s willingness to work with complex clients and have been able to observe some of the fantastic outcomes as a result of that intensive work.

Senior stakeholder, DHHS

Thank God for ermha!

Senior stakeholder, DHHS Page 14 of 14