PARLIAMENT OF AUSTRALIA
JOINT STANDING COMMITTEE ON THE NATIONAL
DISABILITY INSURANCE SCHEME
INQUIRY INTO NDIS PLANNING
OCCUPATIONAL THERAPY AUSTRALIA (OTA)
SUBMISSION
SEPTEMBER 2019
1
Introduction
Occupational Therapy Australia (OTA) welcomes the opportunity to provide a written submission to the Joint Standing Committee on the NDIS Inquiry into NDIS Planning.
OTA is the professional association and peak representative body for occupational therapists in Australia. As of June 2019, there were more than 21,000 registered occupational therapists working across the government, non-government, private and community sectors in Australia.
Occupational therapists are allied health professionals whose role is to minimise the functional impairment of their clients to enable them to participate in meaningful and productive activities. Occupational therapists particularly work with people with a disability and their families to maximise outcomes in their life domains including daily living, social and community participation, work, learning and relationships.
While OTA has long been a strong supporter of the NDIS, it is fair to say that our members and the participants they serve continue to experience significant challenges and barriers when trying to navigate the scheme.
OTA welcomes this inquiry, as it has long been the view of the occupational therapy profession that inappropriate plans are the root cause of the delays that so frustrate occupational therapists and place their clients at real risk. But poor plans are themselves symptomatic of a deeper problem: the relative inexperience of many NDIS Planners.
Feedback from members raises concerns about the impact of planning on participants’ access to timely and appropriate services. Wait times for initial NDIS plan meetings are too long and wait times for plan reviews are too long. And, of greatest concern, these wait times leave highly vulnerable people without necessary supports, exposing them to unacceptable risks.
The failure of plans to anticipate and make allowance for changes in a participant’s condition is an ongoing concern as it gives rise to the need for a long and frustrating review process. And members report that, having waited an unacceptable amount of time for a review of a client’s plan, they are sometimes given just a day’s notice that the review is to occur.
OTA also notes that there are differences between the states and territories with respect to providers’ and participants’ experience of NDIS planning.
The role of occupational therapists in the NDIS
Occupational therapists are highly skilled in assessing the degree to which a person’s disability affects their level of function in daily tasks. Based on these assessments, occupational therapists make recommendations for interventions that enhance and maintain an individual’s functional
2
capacity. As a result of these assessments and interventions, occupational therapists are well placed to document the level of formal and informal supports the participant requires to live a meaningful life. Given their expertise and area of practice, many occupational therapists deliver NDIS funded services to participants. These services include, but are not limited to, functional capacity assessments, interventions to promote participation in daily living skills and independence, minor as well as complex home modifications, and prescribing assistive technology.
Occupational therapists are frequently asked to complete a functional capacity assessment and/or to provide an update on a participant’s level of function prior to a plan review to enable the Planner to fully understand the level of supports required.
Experience, expertise and qualifications of Planners
OTA members report that the experience, expertise and qualifications of Planners are highly variable. One member likened planning meetings for participants to a lottery, with the quality of outcomes dependent on whether the Planner was experienced and able to facilitate a positive meeting experience, or had little knowledge of disability and the planning process.
This variability in the experience, expertise and qualifications of Planners is reflected in plan variability; some participants have high-quality plans and others have plans with fundamental gaps.
Members have advised OTA that participants often experience difficulties as a result of Planners who do not understand their needs or conditions. One occupational therapist practice reported that participants who have had a difficult experience at their last plan review often turn to staff in that practice for assistance in articulating their needs at upcoming plan reviews. Occupational therapists have therefore found themselves providing participants with the type of assistance that Support Coordinators, Planners and LACs are supposed to provide, despite the participant having access to these. Unfortunately, participants are using therapy support funding for services that other professionals in the scheme are meant to provide. This would not be the case if the expertise and qualifications of Planners were appropriate and consistent.
A key issue is the professional background of many Planners. Too many lack any experience in the health or allied health sectors. As a result, they often recommend highly inappropriate assistive technology; for instance including manual wheelchairs in plans for people with rheumatoid arthritis who have reduced hand function and are unable to self-propel a wheelchair.
Some Planners include major home modifications in plan budgets where the client would be equally well served with a less costly alternative. For instance, one occupational therapist reported that a plan included a bathroom modification for an accessible shower when a bath board would have met the participant’s needs. Another example of a Planner’s knowledge gap is a client being told that adaptive clothing was not appropriate for their condition of rheumatoid arthritis.
3
The variability in experience and knowledge of Planners is reflected in the hours allocated to supports in plans. Some plans allocate excessive hours to deliver a particular support, while others allocate plainly inadequate time for the same support.
Measures are needed to enhance and standardise the experience, expertise and qualifications of Planners. OTA has identified a number of possible avenues to achieving this end. First, requiring Planners to hold a relevant tertiary level qualification, or equivalent skills, would improve the planning experience of participants.
Alternatively, establishing a national basic practice principles framework for Planners would address the inconsistencies noted. Such a framework would ideally align with existing practice frameworks employed by health and allied health professionals who deliver services to clients with disabilities (e.g. using an evidence-based, strengths-based, person- centred approach). Such a framework could be incorporated into the design of the NDIS Participant Service Guarantee, or serve as a stand-alone framework specific to NDIS planning practice.
Additionally, enhanced collaboration between Planners and allied health professionals would allow knowledge sharing and improved planning processes. Embedding a ‘care-team’ approach within the culture of NDIS planning, one that would facilitate closer collaboration between Planners and other NDIS provider professionals with respect to individual participants, could improve planning.
OTA’s offer to help train Planners has been repeatedly rebuffed by the National Disability Insurance Agency (NDIA), on the questionable grounds that occupational therapists are somehow “conflicted”. Being trained in the management of disability, and eminently qualified to recognise the likely progression of disability, occupational therapists are ideally suited to train and encourage newcomers to this often highly complex field. Given many Planners have no experience of disability or disability services, they would surely benefit from such assistance. Thanks to an insular, and at times mistrustful agency, however, occupational therapists willing to help train Planners are currently a wasted resource.
As we have pointed out to the NDIA, this training need not be elaborate or expensive; it could simply take the form of a series of webinars. Once a new CEO is in place at the NDIA, we will renew our offer to do whatever we can to enhance and expedite the NDIS planning process.
Recommendation 1: Consideration should be given to requiring Planners to hold a relevant tertiary level qualification, or equivalent skills.
Recommendation 2: A national basic practice principles framework for Planners should be developed. Such a framework would ideally align with existing practice frameworks employed by health and allied health professionals who deliver services to clients with disabilities and could be incorporated into the design of the NDIS Participant Service Guarantee, or serve as a stand-alone framework specific to NDIS planning practice.
4
Recommendation 3: The NDIA should pursue and promote enhanced collaboration between Planners and allied health professionals to enable knowledge sharing and improved planning processes, and consider ways of embedding a ‘care-team’ approach into planning practices.
Recommendation 4: The NDIA should accept OTA’s offer, repeatedly made, to help train NDIS Planners in the nature, likely progression, and optimal management of disability.
Ability of Planners to understand and address complex needs
The capacity of Planners to address complex needs is sub-optimal. Accordingly, those participants with complex conditions and/or circumstances who are developing their first NDIS plan may benefit from an initial, short-term plan incorporating a professional needs assessment. On occasions when this has occurred, it is reported that it has proved highly successful, with the participant ultimately receiving a quality plan that reflects their needs.
OTA understands that there are specialist assessor panels within the NDIA who review complex assistive technology and home modification reports provided by occupational therapists. However it appears there are inconsistencies around the skill level of these assessor panels, resulting in some panel decisions clearly being made by skilled staff, and others appearing to be made by unskilled staff (as evidenced by incorrect details, the omission of important details, and misused technical language).
OTA is of the view that there would be greater consistency of decision making on the part of these panels if panel members had facilitated access to clinical supervision and support.
Recommendation 5: The NDIA should have the scope to implement initial short-term plans that incorporate professional needs assessment, including comprehensive functional assessment, particularly for clients with complex needs and/or challenging circumstances.
Recommendation 6: The NDIA should ensure members of specialist assessor panels have facilitated access to clinical supervision and support.
Ongoing training and professional development of Planners
Occupational therapists are highly skilled in assessing a person’s level of function, their capacity to improve their function and ultimately how this affects the supports they require. As such, they are well positioned to contribute to the education of Planners.
With regard to assistive technology, given that Planners are now responsible for approving funding to participants who need ‘replacement’ items, participants would be well served by Planners who possess an understanding of the role of occupational therapy in assistive technology and environmental modifications prescription. This knowledge would inform decision making around the
5
funding of occupational therapy advisory services, and would enable Planners to explain the role of occupational therapists to participants.
OTA is concerned by reports of participants being advised they do not need an occupational therapist to advise them on the replacement of complex assistive technology. OTA believes it is imperative that NDIS participants are provided with clear and accurate information about the importance of accessing an allied health professional’s advice around assistive technology replacements.
Participants who do not seek a suitably qualified and experienced allied health professional’s advice run the real risk of acquiring the wrong piece of assistive technology. In the absence of a professional’s advice, participants may also rely heavily on the advice of an assistive technology salesperson which, although useful, should not replace the expertise of a qualified and experienced allied health professional.
OTA is aware that some assistive technology suppliers refuse to sell certain items of equipment to NDIS participants without appropriate prescription, out of fear of negligence claims. In thin assistive technology markets this is problematic for those participants without funding for occupational therapy or other prescribing allied health professionals in their plans, or those wishing to purchase complex replacement assistive technology independently. It is imperative that the NDIA address this problem, ensuring that those in need of AT have the necessary professional support to make informed decisions around the acquisition of this equipment, regardless of where they live.
Of further concern is that, too often, Planners seem unaware of the fact that disability can change over time. For those participants with a progressive condition, a plan can be out of date before it is even approved. As already noted, OTA would be delighted to collaborate with the NDIA in an effort to better acquaint Planners with the nature and likely progression of certain disabilities.
Recommendation 7: The NDIA should ensure that Planners do not downplay, or seek to circumvent, the role of appropriately qualified and experienced allied health professionals in the replacement of assistive technology.
Recommendation 8: The NDIA should ensure that those in need of assistive technology have the necessary professional support to make informed decisions around the acquisition of this equipment, regardless of where they live.
Overall number of Planners relative to the demand for plans
OTA is advised by its members that there is an insufficient number of Planners relative to demand, and that this problem is exacerbated by the amount of time Planners have to devote to process related, rather than clinical, issues. As a result, effective participant planning is being compromised.
6
It is difficult, of course, to identify the number of Planners required to meet the demand for plans until such time as the planning process is functioning in an optimal manner. Accordingly, there should be increased investment in the design and operation of the planning process, and a commitment to the professional development and training necessary to ensure Planners are well placed to meet the needs of participants in a timely manner.
Planners are often involved in unscheduled plan reviews that might have been avoided if the plan was fit for purpose in the first instance. There must be a renewed effort to ensure first plans do not fail the participant. As OTA wrote in a letter dated 18 October 2018 to the then CEO of the NDIA:
In the medium to long term, a commitment to getting plans right in the first instance will improve the lives of thousands of NDIS participants and save the scheme hundreds of millions of dollars.
Recommendation 9: The NDIA should invest in the design and operation of the planning process, and in the professional development and training of Planners. to balance considerations of the need for increased planners with the need for enhanced operational processes pertaining to planning.
Recommendation 10: The NDIA must make a renewed effort to ensure first plans do not fail the participant.
Participant involvement in planning processes and the efficacy of draft plans
Other issues raised by OTA members include the relatively low number of NDIS plans for Aboriginal and Torres Strait Islander peoples in certain parts of Australia, despite Aboriginal and Torres Strait Islander peoples being overrepresented with respect to the incidence of disability. This may indicate the need for a greater focus on the cultural safety of Aboriginal and Torres Strait Islander peoples accessing NDIS support. Some participants may require the support of family members and community to access NDIS supports and planning; working with community partners, such as social or health service providers, to engage family members in participants’ planning could prove a valuable exercise on the part of the NDIA.
OTA is aware of calls for the introduction of draft plans by the NDIA. Draft plans should aim to involve participants in the active appraisal of how their plan is likely to meet their needs, and should allow for easy adjustment of the plan to accommodate any changes identified as reasonable, necessary and/or desirable.
In cases where only part of a plan requires adjustment, Planners should have the capacity to review that section; this would be more effective than generating a draft plan, and is clearly preferable to undertaking a full plan review.
7
Recommendation 11: The NDIA should consider how community-based organisations and local providers of social and/or health services can be engaged to support participants’ families and carers, particularly those with specific cultural needs.
Recommendation 12: Draft plans should aim to involve participants in the active appraisal of how the plan is meeting their needs, and should allow for easy adjustment of the plan to accommodate any changes identified as reasonable, necessary and/or desirable.
Incidence, severity and impact of plan gaps
Plan gaps can occur for a number of reasons, including unavailability of Planners, unavailability of participant or support coordinators, or delays in plan approval following a planning meeting. OTA has been advised by one member that the incidence of plan gaps is around 75 per cent, and that the gaps are usually of two to six weeks’ duration. In cases where there are added complexities or staffing issues, gaps can last even longer. Generally speaking, providers will seek to continue delivering services during the gap period if that is at all feasible and in the interests of the client, but they do so in the hope that payment issues will be resolved once the new plan is in place.
Pausing services that may have been established over the course of months, and after a client might have been on a waiting list for months prior to that, is not in the participant’s best interest. Pausing a service in such circumstances is clearly counter to best practice principles and to many providers seems unethical. Plan gaps can result in participants losing hard won gains, which is personally disappointing and has obvious financial consequences for the scheme.
Plan gaps can also have a significant negative impact on providers’ workflow. Providers report that more often than not they are paid for services delivered during a plan gap, however these payments often come at an additional administrative expense to providers.
Reassessment process, including the incidence and impact of funding changes
OTA members report significant concerns around the reassessment process. Participants are having funding abruptly and substantially cut for no clear reason, and this is a frequent occurrence. Further, there appears to be significant inconsistency between what is funded for different clients with similar needs and goals. The assessment methodology appears to be based on participants’ capacity to articulate their needs, which will vary according to the individual, the impact of their condition and, perhaps most significantly, their socioeconomic circumstances. A client’s plan should be driven by their disability, not the quality of their advocacy.
8
Review process and means to streamline it
Increasing the flexibility of the planning process to allow for reviews of a section of a participant’s plan could enhance timely access to services and reduce administrative burden. OTA understands that under the current planning process, it is usual for a plan review to be triggered if there is a change required to the plan. Participants could be spared the onerous and lengthy process of a full review if plans had the capacity for additional supports to be considered and included via a review of just a section of the plan.
While OTA understands that light touch plan reviews are possible, some participants report that they are being advised by Planners not to ask for plan changes until plan review time, and are being discouraged from submitting unscheduled plan review requests. This suggests that Planners are also concerned about the negative flow-on effects of unscheduled plan reviews, and lends further weight to calls for a system that allows for partial plan reviews that do not disrupt continuity of access to supports.
Plan review meetings are often scheduled with minimal time being afforded to the therapist to finalise interventions relevant to a particular goal and to submit a plan review report. Again, this indicates that the current review process is far from ideal. Providers are not always able to arrange service delivery around a plan review date, due to a number of variables including assistive technology providers’ availability and participant availability. Arranging services at short notice to meet the demands of a plan review is a suboptimal situation. Ideally, the very opposite should apply: the timing of plan reviews should be determined by the timing of service delivery to the participant.
Unscheduled or delayed plan reviews are an ongoing concern, as providers are obviously unable to plan for these. If providers were aware of a pending plan gap, they could discuss this with the participant and try to adjust their service delivery accordingly.
Moreover, a service such as a complex home modification can take months to deliver and complete, and a plan review occurring in the middle of such a service can give rise to complicated payment issues for all providers involved.
OTA supports improved communication between NDIA Planners and the members of a participants’ care team, particularly service providers, in relation to plan reviews. Improved communication would be a first step to ensuring minimal disruption to participants’ support services during plan reviews. This should be a standardised element of the planning function.
Recommendation 13: The NDIA should improve communication between NDIS Planners and the members of a participants’ care team, in relation to plan reviews. Such communication should be a standardised element of the planning function.
9
Incidence of appeals to the AAT and possible measures to reduce the number
While OTA does not collect data on the number of appeals to the Administrative Appeals Tribunal (AAT) made by participants who have accessed occupational therapy supports, we are aware that such appeals occur regularly.
Members have reported that the variety of reasons for appeal is diverse, but they often involve claims that the NDIA has failed to understand the participant’s needs. This is particularly concerning given the amount of assessment and planning participants undergo. OTA understands that some of the appeals to the AAT are made by participants with longstanding and complex medical or chronic health issues, or mental health issues. Further, OTA understands that some of the appeals are made by those who have more idiosyncratic functional capabilities, for instance someone with post-polio syndrome or a pain disorder, including participants who report persistent pain but whose condition is poorly defined. These factors indicate that a lack of understanding of participants’ conditions may be contributing to the incidence of appeals to the AAT.
Participants’ conditions would be better understood if there were an initial and thorough functional assessment (such as that provided by occupational therapists) of all participants presenting with these types of complex or poorly defined conditions. Comprehensive functional assessment would assist NDIA staff to understand the functional impact of a participants’ condition from the outset of their engagement with the scheme. Clear definition as to the functional impairments covered by the NDIS is necessary for these assessments to be most useful.
Under the current funding arrangements, however, there is no dedicated remuneration stream available for occupational therapists to undertake a functional assessment for persons seeking access to the NDIS. Education and training for allied health and medical professionals working with the NDIS as to the definitions of functional impairments covered by NDIS would support appropriate assessments.
OTA understands that the NDIA must reconcile the principles of ‘choice and control’ and ‘reasonable and necessary’, and that this tension may manifest itself in participants’ appeals to the AAT. Clarification around the operation of these principles, and clearer communication regarding their practical application, could help reduce the number of appeals to the AAT.
Recommendation 14: In line with Recommendation 5 of this submission, the NDIA consider implementing initial short-term plans that would provide for comprehensive functional assessment, particularly for clients with complex needs, challenging circumstances and/or poorly defined conditions.
10
Circumstances in which plans could be automatically rolled-over
In some instances, automatic roll-over of a participant’s plan may be appropriate. OTA members report that some participants with stable physical conditions/function, and without cognitive or fluctuating mental health concerns, would benefit from automatic plan rollover. Having said this, participants whose plans roll over automatically should still be able to request an unscheduled plan review with ease. A participant should always be able to request a plan review when they experience a significant change in their circumstances, such as a reduction in the availability of informal supports or a significant life event.
Recommendation 15: Consideration should be given to the automatic roll-over of plans for participants with stable physical conditions/function, and without cognitive or fluctuating mental health concerns.
Circumstances in which longer plans could be introduced
A variety of circumstances lend themselves to the implementation of longer plans. For example, plans lasting longer than 12 months may be beneficial to clients with additional complexities, clients in rural and regional settings, and those affected by thin markets. Clients in thin markets are impacted by typically slower access to capacity building supports. A person may spend months on a waitlist, then wait for home modification diagrams and report, wait for builders to visit the site of the proposed modification, then wait months for quotes. The application to the NDIS and subsequent processing often takes a significant amount of time. As such, the process for a client living in a thin market to access a home modification can exceed 12 months. Similarly, the time taken for a client to access an assistive technology trial in a thin market is likely to exceed that of other areas. For participants experiencing such circumstances, longer plans would better meet their needs.
Recommendation 16: Consideration should be given to longer plans being allowed for participants in thin market areas.
Adequacy of the planning process for rural and regional participants
Occupational therapists working with clients in rural and regional areas often find their work entails the additional role of researching available assistive technology for clients, liaising with equipment providers, and arranging trials of equipment. This is further complicated by the relatively limited selection of local products and services. While participants’ funding is supposed to provide for the additional demands faced by providers in these areas, OTA members report that this is not always the case.
11
Any other related matters Including travel in a participant plan The NDIA should ensure greater transparency, consistency and fairness around decisions relating to the number of hours of support included in a plan. In particular, attention should be paid to the participant’s geographical location, as this plays a significant part in these decisions. For instance, a participant may receive 10 hours for a functional capacity assessment. A participant living in a region where they can access an occupational therapist locally may have access to the full 10 hours, while a participant who lives 30 minutes away may lose up to 3 hours on travel expenses.
Plan Implementation
While the NDIA regularly reports statistics around the number of plans that have been developed, OTA would like to have access to the statistics around plan implementation, particularly with regard to plans with provisions for assistive technology and complex home modifications.
Conclusion
OTA thanks the Committee for this opportunity to comment on the National Disability Insurance Scheme’s planning arrangements, and to suggest ways in which these arrangements might be improved. Representatives of OTA would be pleased to appear before the Committee and expand on these observations if Committee members were to deem that helpful.
Please find at, Attachment A, a case study illustrating the NDIS planning process at its most effective.
12
Attachment A
Planning Case Study
Ben - 13-year-old boy who has Cerebral Palsy
Lives with single father
Severe disability – uses wheelchair for mobility, hoist for transfers, full support required with all daily tasks, significant allied health input
Planner Attributes Participant Outcome
Allied health background - an In initial planning review meeting, Planner very quickly excellent understanding of disability understood the complexity of the participant’s disability – particularly complex and and the extensive supports that are involved. progressive conditions Planner ensured plan included adequate funds for repairs and maintenance of numerous AT items – this minimises need to replace items unnecessarily or to hire items for long term while awaiting replacement funding decision.
Planner understood that following installation of a ceiling hoist formal supports could be reduced.
Understanding of how complex Planner had advanced communication skills to manage social situations impact on informal father’s anxiety around his son’s support needs. supports
A thorough understanding of what Planner was able to clearly articulate what could be supports are NDIS and what are not funded by NDIA and what would need to be funded by other funding sources.
For example, Ben required an oral suction unit – Planner was able to identify that the NDIA was not the most appropriate funder for this item.
Note- this will require a much greater understanding when the 1/10/19 changes are implemented as the oral suction machine will be funded by NDIS.
A thorough understanding of NDIS Planner had excellent knowledge of AT procedures and policy – e.g. replacement AT policies. He identified that a replacement hi lo bed did not require an AT application and that the funds could be incorporated directly into the plan.
Timely plan reviews – Planner contacted support coordinator to book plan communication of plan review dates review meeting, with adequate time provided for all allied to all involved health professionals to submit reports and to ensure no plan funding gaps.
13
Continuity – makes for a more Same Planner completed the subsequent plan – the plan streamlined subsequent review meeting was streamlined, and the Planner was readily able to see what supports would be required ongoing.
Due to the experience of Planner, the plan did not require higher delegate approval and was subsequently provided to the family the following day.
Ability to perform light touch review The first plan (set up by an inexperienced Planner) included community, social and recreational activity supports and core daily adaptive equipment as self managed. Ben’s father did not have adequate financial resources to make this work, therefore Ben was not able to access some of the supports and services that he required.
Planner completed a light touch review to change funding to plan managed – this enabled purchase of a low-cost AT item that reduced further skin breakdown.
14