JOINT STANDING COMMITTEE ON THE NATIONAL
DISABILITY INSURANCE SCHEME
Submission from:
Scope (Aust) Ltd
Level 2, 302 Burwood Rd Hawthorn, VIC, 3122
About Scope
Scope (Aust) Ltd (“Scope”) is a leading provider of services to people with disability in Victoria, and one of the largest not-for-profit organisations in Australia. Our origins stretch back to 1948, when a group of parents who wanted better lives and opportunities for their children with disability established the Spastic Children’s Society of Victoria.
Scope’s mission is to enable each person we support to live as an empowered and equal citizen.
Scope provides services including Supported Independent Living (SIL), therapy and individual support across metropolitan and regional Victoria. We also work with corporate and community organisations to improve inclusiveness for people with disability.
SIL provides an opportunity for Scope to enact its mission by supporting customers to live in a home they choose, and a community they value, with a true sense of belonging. We do this by providing services in place, raising awareness and building community capacity to enable the citizenship of people with disability. SIL provides the core foundation for Scope’s future success and sustainability. Last year Scope provided SIL services to 300 customers.
In late 2018, Scope was one of five not-for-profit providers selected, through a formal tendering process, for the transfer of Victorian Government disability accommodation services. Home@Scope is a wholly owned subsidiary of Scope formed to operate the transferring services. The transfer to Home@Scope commenced in May 2019, and by October 2019, we will be delivering our mission to over 1,000 new customers.
Overview
Scope is a strong supporter of the National Disability Insurance Scheme (NDIS). We embrace the benefits the NDIS brings to our customers and actively contribute to its success. We welcome the opportunity to provide a submission to the Joint Standing Committee on the National Disability Insurance Scheme inquiry into Supported Independent Living.
This submission provides a service-provider perspective on key issues related to SIL as reported by our customers and noted by our managers and staff. We have used a de identified case study from Scope to illustrate the possibilities emerging around the co-design of SIL services.
We also draw particular attention to the issues affecting participants with complex needs. For them, the issues associated with SIL cannot be separated from a consideration of the service system as a whole, primarily the interfaces with Specialist Disability Accommodation and mainstream health services. Scope advocates for a more holistic approach to SIL. We describe a service model that has significant prospects to reorient group homes to improve the practice of providers and deliver better outcomes for residents.
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Approval process for access to SIL
The approval process for access to SIL is predicated on determining what is reasonable and necessary for an individual to develop the skills to live as independently as possible. This can be in a shared or individual arrangement. As a SIL provider, Scope’s experience has been with shared living arrangements in group homes. Scope asserts that any review of the approval process for access to SIL must consider the existing service models, including the provision of SIL in group homes, and the way that the SIL market is developing.
For SIL to be included in a participant’s package, the NDIA requires a quote from the selected SIL provider to be submitted for assessment prior to the participant’s budget being approved. This process has the effect of deciding in advance how the budget will be spent – and essentially committing the participant to that particular SIL provider. It would be preferable to create opportunities for participants to exercise choice and control in their selection of SIL provider e.g. the planner is instead authorised to set a price range for the participant and there is no need for further approval so long as the quote from the SIL provider meets the participant’s needs and is within the price range. This would work best for individuals, specifically participants seeking flexible accommodation arrangements outside of Specialist Disability Accommodation (SDA).
While the variety of accommodation options for people with disability is slowly improving, when it comes to people with complex needs, the SIL quote is likely to be for a group home. Moreover, there is an unavoidable nexus between SIL and SDA for people with complex needs. This interdependency should be acknowledged in the approval process for access to SIL for people in this cohort.
Scope commends the recent updates to the SDA Pricing and Payments Framework as endorsed by the COAG Disability Reform Council in February 2019. The Framework establishes a clear vision for the development of SDA over the next 10 years. But the Framework also involves a philosophical shift away from group homes; and the shift may be happening already, as evidenced by the increasing vacancy rate in group homes. This trend is despite there being 3,500 names on the Victorian Disability Support Register.
The objectives of the SDA Pricing and Payments Framework are influencing the development of the SIL market today. Without any transition plan in place for improving (or reducing reliance on) the group home service model, the implementation of the Framework has the potential to threaten the sustainability of existing SIL providers. There needs to be a transition plan in place to ensure the foundations for SIL remain solid into the future.
The SDA market may eventually evolve to supplant group homes with more innovative housing models, but there is no indication as to the timeframe over which this may occur. The service models for SIL/SDA are only now coming into focus. As demonstrated in the following case study from Scope, improving practice in traditional settings, and supporting participants out of group homes into more contemporary settings e.g. three bed homes with advanced technology, is not dependent on the evolution of the SDA market.
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Case study: Transition from congregate care to co-designed SIL
Scope planned and implemented a SIL service redesign project for 11 congregate care residents that was consistent with our strong commitment to co-design. The project team, assisted by skilled, independent facilitators, completed extensive preliminary consultations with residents and families to ascertain their housing and support preferences. Information was also sought from direct employees and key management team members. The final designs for the new homes were determined by a reference group comprised of residents, families, direct and indirect employees and the architect. The residents relocated to four new three-bedroom homes at two sites in a nearby suburb. The homes provide improved accessibility, technology and community access/integration. Post implementation surveys have continued to report high individual and family satisfaction levels.
There are, moreover, many aspects of forward-looking SIL models that should work as well in group homes as they do in more contemporary settings. The adoption of new service models must occur in the context of understanding and responding to the emotional experience of people currently living in group homes. The inference that group homes are always an inferior option may end up influencing the staff working in these settings and impede the changes that need to occur while group homes are in transition. Customers may choose more innovative options over time, but the further evolution of group homes from the current state may ultimately also prove to be a desirable alternative.
The study completed by McConkey, et al (2016)1 contrasted the experience of individuals in Ireland living in personalised rental arrangements, group homes and congregate care respectively. While those people with personalised arrangements achieved the most positive outcomes, the outcomes for people living in group homes were also often positive, and the study concluded that further longitudinal research was required.
Scope believes that in the NDIS context, there are opportunities to modify the SIL/SDA service model so that group homes strengthen choice and control for participants and become an organic part of the communities where they are located. The preferred basis for these arrangements is for participants to choose to live in a house with a shared support model. This includes choice regarding the location and the people with whom the participant lives. Any obstacles related to choosing an alternative place to live if the arrangement does not work out should be minimised by the provider and by the NDIA.
There must also be a genuine and shared decision-making framework in place. The recruitment of staff must be values-based and the team of people focused on delivering service to the customer.
The sustainability of this model is contingent on: The capability of support workers to facilitate group decisions;
1 “Relocating people with intellectual disability to new accommodation and support settings: contrasts between personalised arrangements and group home placements”, Journal of Intellectual Disabilities, v20 n2, pp 109-20
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The appropriate delegation of decision-making authority to staff; A shift to coaching and practice leadership away from operational management; and Performance measures are developed around the team and the participant.
Scope contends that the integration of people without disability into shared living arrangements with people who have a disability would be entirely consistent with participants living an “ordinary life”.
Proposal: Group homes shared by people with and without disability
Scope proposes a service model where one or two people without a disability receive reduced rent in return for providing sleepover duties as a workable option in working toward the transformation of group homes. Taking a five bed group home as an example, two people without a disability would share with three people with a disability. The people without a disability would not carry out personal care as we believe this would be inappropriate.
The preliminary modelling that Scope has conducted demonstrates the economic viability of this model. Cost savings from sleepover are sufficient to fully offset rent for people without disabilities, and therefore, there would be some savings between reduced rent and lower package sizes. Scope is encouraged by recent reforms to the SDA Rules supporting SDA participants to choose living arrangements that include non-SDA participants. There are compelling reasons to explore the potential of these service models, including implications for longer-term scheme sustainability; alignment with the objective of participants living as independently as possible; repurposing the existing housing stock; and offering a clearer pathway toward the future SIL/SDA market.
Vacancy management
SIL vacancies in SDA
Since 1 July 2019, the residential rights of Victorian NDIS participants with Specialist Disability Accommodation (SDA) are protected by new provisions of the Residential Tenancies Act 1997 (RTA), and regulated by Consumer Affairs Victoria (CAV). Amendments to the RTA and the Disability Act 2006 reflect these changes. SDA providers have six months to give participants an information statement and make new RTA or SDA agreements, with completion by no later than 31 December 2019. Existing arrangements will continue until 1 January 2020, when the protections of the Disability Act will cease.
The majority of participants living in SDA in Victoria also have SIL as part of their NDIS package, or else their accommodation provider receives in-kind government funding. This is certainly the case for Scope customers. The current estimate is that 6% of NDIS participants will be eligible for Specialist Disability Accommodation2.
2 Specialist Disability Accommodation: Provider and Investor Brief, National Disability Insurance Agency, April 2018, p.5
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The Department of Health and Human Services (DHHS) currently manages SIL vacancies and the wait list in Victoria. DHHS will continue to offer vacancy coordination until 30 September 2019 and after that providers will need to establish their own processes and ensure there is no negative impact for prospective and current residents. The SDA owner (landlord) has legal control of the tenancy i.e. accepting or evicting a tenant.
There is now a legal requirement for agreements to be developed between NDIS Participants living in SDA, SIL Providers and SDA Owners (Landlords) (see Figure 1 below).
Figure 1: Agreements required for SDA
There is an inherent tension for SIL providers in their being involved with SDA vacancy management. The on-the-ground knowledge of SIL providers in SDA is critical in ensuring there is an appropriate mix of residents. At the same time, it is in the interests of SIL providers to support all of the residents in the house. If a vacancy were offered to a participant who wished to use a different SIL provider, there may be conflict and this has the potential to undermine the principles of choice and control.
The use of technology to match participants to SIL/SDA vacancies would be one way of regulating the subjective elements in vacancy management. This would also obviate the current issues with the Housing Hub in Victoria; the active matching of participants seeking SIL/SDA would be more dynamic and targeted than the passive system of responding to online advertisements.
The current approval and vacancy processes for SIL and SDA operate in parallel and do not always converge in a way that is constructive for participants. This marginalises the support needs and goals of participants; and these are the very concerns that must be the focus of all participant related processes. The poor integration of SIL and SDA at the planning stage also impacts SIL and SDA providers and sends mixed signals to a market seeking to address
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the transition from “heritage” models of supported living to new models in a variety of configurations.
SIL vacancies in non-SDA settings
Shared living environments whether they are family homes, shared housing or SIL, bring additional complexities as people’s choices need to be balanced with the choices and rights of others with whom they live, either permanently or temporarily. The difference between typical shared living arrangements and SIL arise from a range of factors including some people not having chosen to live together but simply having been ‘placed’, perhaps making it difficult for a new resident to feel welcomed.
Delivering and balancing people’s choice and control in SIL is realised by all involved appreciating that this is the residents’ home and like our own homes the preferences of others who do not live in the home (e.g. staff, family members) are secondary considerations. Establishing a genuine and effective shared decision-making framework with provision for the involvement of agreed supportive decision-makers, as required, and ensuring residents, as a group and as individuals assume responsibility for the various decisions that make for an ordinary life at home are also important. The ecosystem that exists around the individual e.g. family and friends who do not live with the participant; other providers; health practitioners; community and other mainstream services; and shops are also crucial to filling SIL vacancies. The home needs to be somewhere that people want to live.
Scope has incorporated this thinking into co-design of our new SIL model. For our distinct customer groups who seek the dignity of an ordinary life, we offer the experience of creating and keeping a real home. Unlike supported accommodation, we do this by repurposing our philosophy, structure and activities to focus on facilitating the experience of home, rather than on the management of a house. The value for our customers will be evident in the degree to which a customer feels at home and improves the quality of an ordinary life. We provide shared support for people with disability to participate meaningfully within their homes no matter where they choose to live.
Funding
Scope believes there is a need for a greater understanding of the cost drivers for SIL/SDA participants with complex needs i.e. people who have additional support requirements due to factors such as concomitant acute, acute or chronic, and chronic disease conditions.
The factors presently considered in allocating high intensity support include the efficacy of a behavioural support plan, need for sleepover/active night and active management of medical support. This funding is based on the skills and experience of the workers supporting the participant rather than on the level of support required. Scope contends that it would be more appropriate for funding related to intensity to be individualised and not linked to worker competencies.
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Further to high intensity supports, there is provision in the NDIS Price Guide 2019-20 for introducing a new worker to a participant through ‘shadow shifts’ in circumstances where complex needs include:
Very limited communication; Behaviour support needs; and/or Medical needs/procedures such as ventilation or Home Enteral Nutrition (HEN).
This is a narrow view of complex needs. 92% (257) of Scope SIL residents have been identified as having needs that are not currently considered as cost drivers by the NDIA3, including:
Co-existing mental illness Age Clients at home during the day Clients that require two people for morning/evening preparations Clients that require a two-person lift Clients that require meal time assistance other than HEN Alternative communication systems Legal orders in place Lack of natural supports
Complexity drives cost in the provision of support in terms of intensity, duration, staff ratios e.g. OHS requirements for safe transfers, training and supervision and the regularity of interface with other service systems e.g. acute health, primary health. This is particularly the case for people with complex physical and multiple disabilities.
Consideration to the additional costs of supporting people with complex support needs, which could be used as cost drivers, include recognition of:
additional staff required due to additional hours of support required additional staff required due to higher support ratios required the higher cost of staff with the skills required to support people with complex needs the cost of providing the required systems and safeguards the cost of providing crises support the cost of facilities and transport required to support people with complex needs n group activities
There is a need for NDIS pricing to make an additional allowance for the cost of support people with complex disability. This allowance could be used to increase support on an as needed basis, including crisis support that would be consistent with organisations’ duty of care obligation.
3 Scope Shared Living Arrangements (2016). Dyson Consulting Group.
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