NDIA Accountability Project

Independent Assessments for NDIS Participants Transitioning from Hospital Care

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Proposed Submission

Joint Standing Committee on the National Disability Insurance Scheme PO Box 6100 Parliament House Canberra ACT 2600

March 2021

The introduction Eastern Health provides a comprehensive range of high quality acute, sub-acute, palliative care, mental health, drug and alcohol, residential care and community health services to people and communities that are diverse in culture, age, socio-economic status, population and healthcare needs. We deliver clinical services to more than 775,000 people in our primary catchment area. Our services are located across 2,800 square kilometres in the east -the largest geographical catchment area of any metropolitan health service in Victoria. Eastern Health is not an NDIS provider but rather interfaces with existing and future NDIS participants to rehabilitate and support people with existing or recent onset disability leave hospital and return to their community.

The following is the Eastern Health Allied Health Services response to the Joint Standing Committee’s inquiry into NDIS Independent Assessments. Our response is aligned to the various elements of the Committee’s Terms of Reference as follows and pertains to people who are inpatients (residing in hospital-based beds) in our healthcare services.

Response Aligned To Terms Of Reference

a. The development, modeling, reasons and justifications for the introduction of independent assessments into the NDIS;

The NDIS Act review conducted by David Tune was reported on in November 2019. This report indicated that NDIS to fund independent assessments would be useful for people who could not afford or access them. This report did not recommend that all NDIS applicants should be subject to an Independent Assessment ( (1)). b. The impact of similar policies in other jurisdictions and in the provision of other government services; There is substantial evidence to suggest Independent Assessments for disability does not reflect best practice. People with disabilities in the UK have been subject to Independent Assessments since 2013. Many people with disabilities have reported losing benefits that they previously had, many are living below the poverty line, and the suicide rates have been steadily increasing for this population ( 2,3,4,5). The evidence from the UK is that the Personal Independence Payment (PIP) has cost the government considerably more than anticipated, whilst simultaneously depriving people with disabilities of essential funded supports ( 6). c. the human and financial resources needed to effectively implement independent assessments; Given the current NDIS market failures and concerns about the quality of existing NDIS providers, it can be predicted with some certainty that there will be a lack of suitably qualified Independent Assessors if this change becomes mandatory for all NDIS access requests and plan reviews ( 7,8). A lack of suitably qualified assessors with expertise in the participant’s primary disability, hospital process and transitions from hospital to community will lead to significant delays in transition to the community and essential disability supports. The costs of employing Independent Assessors for all future/existing NDIS participants (henceforth referred to as NDIS participants) is likely to far exceed current costs, as many individuals who are hospital inpatients currently provide professional assessments from expert hospital-based teams to the NDIA to support access.

Recommendation on Exemption from Independent Assessment Process

and planning. For hospital inpatients, it is important that a longitudinal approach to assessment with a consistent team of experts in the participant’s disability and transition from hospital is available. The professional assessments are part of standard care for NDS participants who are inpatients at Eastern Health and require new/additional NDIA supports (henceforth referred to as NDIA supports) to transition into the community. These assessments are intertwined within a continuum of care where participants are part of the team who engage in comprehensive planning to understand a participant’s goals and readiness for transition into the community, in addition to environmental and resource constraints. Independent assessments for hospital inpatients reflect a significant duplication in this clinical assessment process and an unnecessary additional cost to the NDIA.

We recommend that all inpatients who require NDIA to enable transition into the community be exempted from the Independent Assessment process. This will support a reduction in duplication of assessment, a cost saving for the NDIA, assessment completed by clinicians with appropriate expertise and most importantly reduce the impact of participants having to re-tell their story to external stakeholders who they share no history or relationship with. To support NDIA processes, Eastern Health’s highly qualified teams are willing and able to adapt the content of assessments and reports to reflect the assessment needs of the NDIA.

d. the independence, qualifications, training, expertise and quality assurance of assessors; The population of NDIA participants residing in hospital who require NDIA supports to enable transition into the community is significantly heterogeneous. No single qualification or set of experiences would meet the needs of this heterogeneous population. A high-quality assessment involves an assessor with expertise in the participants’ disability, hospital policy and procedures and the process of supporting transition from hospital into the community. Given the known market failure issues associated with NDIS, it is unlikely that all NDIS participants residing in hospital will be assessed by someone with suitable expertise in the participants’ disability, hospital policy/procedures and the complex process of supporting transition from hospital into the community.

Quality assurance can be maintained by ensuring assessors with appropriate expertise and system knowledge are engaged in the assessment process. One such process would be to implement an ‘opt-in model’ for Independent Assessment where NDIA participants with access to a team of experts (appropriate to the participant and their disability) can choose to use their existing team to complete the required assessment processes. For NDIA participants currently admitted to hospital and requiring NDIA supports to transition into the community, this would reflect engaging the expertise of healthcare staff in providing high quality assessment to support access and planning. Eastern Health is a large organisation with significant expertise in health and disability domains across the continuum of care. As such Eastern Health can ensure NDIA participants who require supports to transition into the community are provided with the highest quality care by teams with specialist skills and expertise in the NDS and the participant’s specific health and disability needs. Consistent with Eastern Health’s Allied Health credentialing and scope of practice program, we will ensure all allied health staff participating in this process are suitably skilled, capable and credentialed.

e. the appropriateness of the assessment tools selected for use in independent assessments to determine plan funding; The assessment tools identified provide a generic assessment of health and disability and are targeted to individuals who have a lived experience of stable disability (rather than new onset, fluctuating or deteriorating disability). These assessments reflect significant duplication in the assessment process completed within hospital settings for NDIA participants who require NDIA supports to facilitate transition into the community. If these assessments are the basis of Independent Assessor recommendations, Eastern Health Allied Health teams have the expertise to embed these assessments as standard practice for NDIA participants (should the assessment tools be provided). Whilst these assessments provide a basic description of a participant’s disability, level of function and environmental barriers to participation they do not identify:

  • The appropriate community residence/destination to transition to (for example interim housing, SDA, own home, family members home).
  • The amount and type of support, assistive technology and/or environmental modifications required to transition to this specific environment. It is the scope and responsibility of the healthcare team to work with an NDS participant to identify the most appropriate residence/destination to transition into the community (9,10). An NDIS participant who requires NDIS support to transition into the community will have engaged in these complex and sensitive conversations with members of their healthcare team. The selected assessment tools cannot replicate these sensitive conversations with a risk that Independent Assessors will identify an alternative plan to support transition into the community that does not align with that of the participant and the healthcare team. This will place NDIS participants at an unfair disadvantage, and potentially leave them residing within a hospital (unable to transition into the community) and without vital NDIS supports whilst they lodge appeals.

f. the implications of independent assessments for access to and eligibility for the NDIS; Eastern Health Inpatient Services provide support to people with new and existing disabilities along the NDIS pathway. Routine audit data reveals that at any given time Eastern Health staff are supporting an average of 13 hospital inpatients access NDIS supports to transition into the community. As such, since the introduction of the NDIS to our region in November 2017, our inpatient allied health staff have supported in excess of 500 NDIS applications by providing clinical evidence of permanent functional incapacity and diagnosis. The skills of our clinicians have excelled in adapting to the assessment and reporting needs of the NDIA to support access and planning with this evidence provision readily achieved as part of the NDIS participants’ healthcare journey. In Eastern Health inpatient services there is an average of 62 days from new diagnosis of permanent disability until patients’ care needs plateau where support needs for transition into the community can be identified and an NDIS access request completed. We anticipate a model for mandatory Independent Assessment will result in significant delays to a participant transitioning into the community. This delay will be reflected in the need to book an Independent Assessment, complete the lengthy Independent Assessment process, collaborate with healthcare teams, compile the assessment findings, and submit a report to the NDIA. It is our opinion, that potential NDIS participants who are inpatients in hospital settings and require NDIS support to transition into the community should be offered the choice of: provision of evidence by their treating team in support of their NDIS application; or an independent assessment.

h. the implications of independent assessments for NDIS planning, including decisions related to funding reasonable and necessary supports; An NDIS participant and the health care team engage in complex and sensitive conversations and assessments over many weeks or months to identify the most appropriate environment to transition from hospital to the community. There is a complex interplay between the identification of an appropriate community residence (for example interim housing, SDA, own home, family member’s home) and the reasonable and necessary supports required to facilitate this. It is the responsibility and expertise of healthcare services to complete the planning and support required to enable transition of care from hospital to the community and ensure reasonable and necessary supports are in place to support this (9,10). Under a mandatory Independent Assessment model, hospitals will be reliant on NDIS funded external stakeholders (Independent Assessors) with a potential conflict of interest to access appropriate NDIS supports to enable ransition of care from hospital to the community. Use of Independent Assessors in hospital transitions is not in alignment with existing healthcare policy and procedures. There is significant risk to the healthcare sector should the hospital team and the Independent Assessor, disagree on the location for transition to community living and/or the reasonable and necessary supports required to achieve this.

Eastern Health Allied Health Services would recommend the following:

  • An ‘opt in model’ for Independent Assessment where NDIS participants (including those admitted to hospital) can use their existing team to complete the required assessment processes.
  • Should an NDIS participant admitted to hospital choose to ‘opt in’ for an Independent Assessment,
  • The scope and responsibility of inpatient healthcare teams and Independent Assessors are established and clearly articulated prior to the commencement of any Independent Assessment.
  • There is a clear and timely process for decision escalation.

development of trust in a consistent team which includes the patient as a team member, and continuity of

care and information sharing via clinical handover between professionals and the patient to reduce the

burden on participants to retell and repeat their personal story.

k. the appropriateness of independent assessments for people with particular disability types, including psycho-social disability; Psychosocial disability is a specialised area of assessment, requiring a longitudinal approach to assessment and planning. A good assessment involves collateral information from family, carers, and current supports. Given the known market failure issues, it is unlikely that all people with mental illness will be assessed by someone with suitable expertise in this area.

Conclusion

Eastern Health and NDIS share a common goal in supporting NDS participants residing in hospital to transition into the community. At Eastern Health we support the implementation of an ‘opt-in’ model for Independent Assessments which would enable: - NDIS participants with access to a team of heath care experts to use their existing team to complete the required assessment processes - Equity in access to the NDIS for individuals who cannot afford or do not have a qualified team available to support access or planning for NDIS supports.

The implementation of mandatory Independent Assessments reflects a significant duplication of work where NDIS participants have access to qualified health clinicians who can provide this evidence. For hospital inpatients who require NDIS to support their community transition, this duplication reflects a significant cost burden to the NDIS, the risk of inappropriately experienced clinicians completing the assessments, sufficient plan funding and an anticipated delay in community transition for participants.

Prepared by Bianca Summers Endorsed by Gayle Smith, Chief Allied Health Officer, Eastern Health

References

  1. Tune (2019) Review of the National Disability Insurance Scheme Act 2013: Removing Red Tape and Implementing the NDIS Participant Service Guarantee. Australia.
  2. https://www.theguardian.com/society/2020/feb/07/dwp-benefit-related-suicide-numbers-not-true-figure-says-watchdog-nao
  3. https://www.nao.org.uk/wp-content/uploads/2020/02/Information-held-by-the-DWP-on-deaths-by-suicide-of-benefit-claimants.pdf
  4. https://www.independent.co.uk/news/uk/home-news/disability-benefit-assessment-complain-uk-government-a8894341.html
  5. https://www.leonardcheshire.org/our-impact/stories/my-experience-applying-pip
  6. https://inews.co.uk/news/pip-reform-george-osborne-disability-benefits-cost-government-money-246403
  7. Office of the Public Advocate (2019) Safeguarding the rights and interests of people with disability: Submission to The NDIS Thin Markets Project. Melbourne, Australia.
  8. Joint Standing Committee on the National Disability Insurance Scheme (2018) Market readiness for provision of services under the NDIS. Commonwealth of Australia.
  9. Victorian State Government (2014) Discharge and transfer of care. https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/acute-care/acute-medicine/discharge-and-transfer
  10. National Disability Insurance Scheme (2020) NDIS and other Government Services: Health. https://www.ndis.gov.au/understanding/ndis-and-other-government-services/health
  11. Australian Commission on Safety and Quality in Healthcare (2017) AUSTRALIAN CHARTER OF HEALTHCARE RIGHTS. nsW, Australia.
  12. Garrubba & Yap (2019) Trust in Health Professionals. Centre for Clinical Effectiveness, Monash Health, Melbourne
  13. Harrison R, Walton M, Manias E. 2015. Patients’ experiences in Australian hospitals: an Evidence Check rapid review. Australian Commission on Safety and Quality in Health Care.