Commonwealth Joint Standing Committee on the NDIS: Inquiry into the provision of services under the NDIS for people with psychosocial disabilities related to a mental health condition
Submission from: Victorian Department of Health and
Human Services
Context
Victoria’s Mental Health Community Support Service (MHCSS) program assists people aged 16-64 years with mental illness or mental disorder and associated psychiatric disability to live independently, maintain the best possible social and emotional wellbeing, meet their personal recovery goals and live satisfying lives in the community.
State funded psychiatric disability support services delivered through the Victorian MHCSS program align with National Disability Insurance Scheme (NDIS) psychosocial supports for people with a mental health condition and associated psychiatric disability. The statewide MHCSS Intake Service, created when the previous Psychiatric Disability Rehabilitation and Support Service program was reformed in 2013, uses the NDIS disability eligibility criteria to determine eligibility for MHCSS programs that will transition to the NDIS. These programs include: Individualised Client Support Packages; Adult Residential Rehabilitation services; and Supported Accommodation Services.
For this reason, MHCSS programs transitioning to the NDIS have been given ‘defined’ program status by the National Disability Insurance Agency (NDIA). This means existing clients are eligible for the NDIS provided they meet the NDIS age and residency requirements.
The MHCSS Intake Service manages a Needs Register for people who have been assessed as eligible for MHCSS but need to wait for a vacancy to arise. While the MHCSS Needs Register itself is not a defined program, Victoria has established an agreed Streamlined Access approach with the NDIA to support people on the Register to collect the required evidence they need to make an NDIS access request.
Preamble
The Victorian Department of Health and Human Services (the department) welcomes the opportunity to provide a submission to the Inquiry into the provision of services under the NDIS for people with psychosocial disabilities related to a mental health condition being undertaken by the Joint Standing Committee on the NDIS.
This submission response identifies how the NDIS interfaces with the state funded mental health service system and key areas where this interface could be strengthened.
When fully established the NDIS will significantly increase access to supports for people with a
psychiatric disability related to a mental health condition. It will also expand the range of supports available and give people with a psychiatric disability choice and control over their supports.
Page | 1
The department is committed to the implementation of the NDIS in Victoria and continues to work collaboratively with the NDIA to support the smooth transition of eligible clients of relevant state funded psychiatric disability support services to the Scheme. A key area of joint focus has been the development of a streamlined access process for people on the MHCSS Needs Register.
This process will provide valuable insights on how the access approach could be refined to make it easier for people with a psychiatric disability to make an NDIS access request.
The department recognises the critical importance of effective interaction between the NDIA and public health services to optimise the opportunities and benefits the NDIS presents for patients and consumers who have a mental health condition and associated psychiatric disability.
The department is working collaboratively with the NDIA and public health services to test, build and strengthen the operational interface between clinical mental health services and the NDIS. This will ensure eligible patients and consumers experience timely access to NDIS supports and coordinated planning, support implementation and plan review. This has already been evidenced during the NDIS transition in Victoria through the streamlined access process for people on the MHCSS Needs Register as this process requires Victoria’s MHCSS Intake Service to directly engage with public psychiatrists to prepare patients and consumers for the NDIS access process.
The government has provided funding to a consortium of health services in North Eastern Melbourne Area (NEMA) through the Commonwealth Government Sector Development Fund to build the evidence and models for effective collaborative practice between the NDIS and health services. This collaborative project will involve three participating health services, the NDIA, the Local Area Coordinator for NEMA, the department, consumers and carers. The project will be conducted over a 16 month period and conclude in June 2018. The department will progressively disseminate the learnings from this initiative to assist all health services across Victoria to prepare for the NDIS. The results will also be provided to the Commonwealth Government and public health services in other jurisdictions.
Eligibility criteria for the NDIS for people with a psychosocial disability
Disability requirements
The NDIS will be available to Victorians who have an impairment that substantially reduces their capacity to do everyday things and participate in the social and economic life of their community, and require support under the NDIS over their lifetime. The NDIA acknowledges that a person’s level of functional impairment and associated disability may be episodic or persistent, debilitating and long lasting.
Consistent with this, a person’s impairment will be assessed as permanent if it is likely they will need support at varying levels over their lifetime.
Determining permanency of functional impairment for people with a mental illness requires expertise which considers the severity, chronicity, history of mental health interventions and impacts on capacity for communication, learning, self-care and self-management. The specialist clinical mental health workforce has long standing experience and expertise in assessing for functional impairment for patients and consumers with a mental illness or mental disorder.
Page | 2
Victoria recognises the opportunity to work with health services to further strengthen the existing capability of the specialist clinical mental health workforce to assess for functional impairment and whether the functional impairment is permanent or likely to be permanent. This work will be progressed through the Sector Development Fund initiative, drawing from the learnings of the Streamlined Access approach for people on the MHCSS Needs Register. These learnings and recommendations will be provided to the Commonwealth Department of Social Services to consider for national application.
The department, through the implementation of the Streamlined Access approach for people on the MHCSS Needs Register, has identified that general practitioners do not consistently have the capability required to appropriately determine functional impairment and its permanency for people with a mental health condition. The MHCSS Intake service will continue to actively engage with general practitioners, private psychiatrists and psychologists to support people on the MHCSS Needs Register to gather the evidence they need to make an NDIS access request.
Eligibility for early intervention
One of the strengths of Victoria’s MHCSS program is its capacity to intervene as early as possible after an acute phase or early in the illness pathway to reduce the burden of disability, assist in stabilising a
person’s mental health condition, optimise recovery outcomes and reduce the risk of social
disadvantage.
It is too early to draw conclusions from Victoria’s NDIS transition on the extent to which the NDIA are applying early intervention approaches to people with a psychiatric condition. Data analysis from the NDIS Barwon trial indicates however that few participants were identified as receiving early intervention supports. On the few occasions where early intervention supports were funded, the average funding allocated through the NDIS plan was higher than other NDIS participants with a psychiatric condition.
As part of the Sector Development Fund initiative the department, in collaboration with health services and the NDIA, will explore and strengthen the early intervention interface between clinical mental health services and the NDIS to ensure consumers who would benefit from early intervention receive individualised funding. Young people with a severe and persistent mental illness will be a key focus.
Transition to the NDIS of all current long and short term mental health state and territory government funded services
Mental Health Community Support Services in-scope for transition to the NDIS
State funded psychiatric disability support services delivered through the Victorian MHCSS program align with NDIS psychosocial supports for people with a mental health condition and associated psychiatric disability. For this reason, MHCSS programs transitioning to the NDIS have been given ‘defined’ program status by the NDIA. This means existing clients are eligible for the NDIS provided they meet the NDIS age and residency requirements.
Page | 3
The continuity of support will be funded by the department for existing clients of MHCSS defined programs who are ineligible for the NDIS on the basis that they do not meet the NDIS age and residency access requirements.
Two MHCSS activity types, Planned Respite and the Mutual Support and Self Help program, are out of scope for transition to the NDIS at this stage and will continue to be funded by the department. The department will actively monitor NDIA decision making, participant access to the scheme and support items within participant plans during the transition period, to determine Victoria’s future delivery of Planned Respite and the Mutual Support and Self Help program. This analysis will include mapping the key elements of these programs to relevant NDIS activity, including the Information, Linkages and Capacity building (ILC) component of the scheme, to identify areas of potential duplication.
Maintaining market expertise in the provision of psychosocial supports to people with a psychiatric disability
Victoria has a highly skilled community managed mental health service sector. If the sector and new providers are unable to sustain delivery of psychosocial disability services within the NDIS operating model and within tolerable levels of medico-legal risk, the depth and quality of the NDIS provider market may be negatively impacted.
There is a risk that over time providers of NDIS funded supports may have a ‘generic’ expertise that is biased to people with (non-mental health) disability and the depth of skill, experience and expertise in Victoria’s MHCSS sector will not be valued and supported by the NDIA. This may have a direct impact on the quality of participant experience and their ability to maintain or improve their psychosocial functioning.
The department will work with the community managed mental health psychosocial disability support sector and the NDIA on strategies to maintain current expertise.
Mental health support to people who do not have a psychosocial disability
Funding of discrete (non-clinical) mental health supports for people with diagnosed mental illness or mental disorder who do not have associated functional impairment (that is, they can undertake activities of daily living, self-manage their mental health condition and engage in community life to a reasonable level) requires a clear understanding of, and differentiation between, mental health specific support needs versus needs that should be met by mainstream health (including clinical mental health treatment services) and social support services (for example, employment, education, homelessness, housing and family support services) as part of the core business of these service systems.
Any consideration regarding the need for continued investment in psychosocial supports for people with a mental health condition who do not require disability support will involve assessment of the role of health services, social support services and the NDIS funded ILC function in supporting this cohort.
Page | 4
The department will focus effort on:
-
Strengthening the capability and capacity of Victoria’s clinical mental health service system to prevent psychiatric disability or reduce the burden of disability, particularly for young people with a mental health condition. This will deliver improved quality of life for people at risk of a
psychiatric disability, reduce preventable demand for NDIS psychosocial supports and
complement the early intervention focus of the NDIS.
As part of this commitment the statewide MHCSS Youth Residential Rehabilitation service will continue to be delivered by the department. This service will focus on supporting young people 16-25 years of age with a mental health condition with complex needs and/or evidence of emerging functional impairment or risk of impairment. Priority attention will be given to eligible young people with a mental health condition and heightened vulnerability associated with engagement with the youth justice, alcohol and drug treatment, homelessness and out-of home care service systems.
- Building the capability of mainstream services to respond to the needs of people with a mental health condition, as part of their core business (for example, building the capability of homelessness services to support people with a mental health condition to access stable, appropriate housing).
This system development will complement the work of NDIA funded Local Area Coordinators who will work with local health and social support services to address barriers people with a mental health condition often experience when trying to access safe, culturally responsive mainstream supports.
The scope and level of funding for mental health services under the Information, Linkages and Capacity building framework
The ILC function is an essential component of the NDIS.
It will play a vital role in building the capacity of people with a psychiatric disability (regardless of their eligibility for individually funded supports under the NDIS), their families and carers, mainstream services and the broader community which, over time, will reduce the demand for, and the level of support required through NDIS Individual Funded Packages (IFP), and thereby reduce the cost of the scheme.
The department is of the view that the scope of the ILC framework is comprehensive and should be delivered as currently scoped. However, given the likelihood of high demand for ILC funded supports and the important benefits that will be generated through ILC, a review of the adequacy of funding currently committed to ILC is warranted.
Of equal importance is how the ILC will be implemented, including the type of delivery arrangements that will be funded and the associated risk of funding low scale fragmented activities. It is suggested careful consideration should be given to the efficacy of one-off grants or small amounts of funding for local information, peer support and capacity building programs. It is the department’s experience that achievement of outcomes in these areas requires sustained investment and adequate scale.
Page | 5
ILC Eligibility and targeting
The department fully supports the use of ILC for people with a mental health condition who:
-
Need one-off, low intensity or episodic supports that are better delivered and managed through funding arrangements other than through an IFP;
-
Need support so that their capacity to live independently does not deteriorate to a point where they would meet the access criteria for the NDIS and require an IFP to participate socially or economically in the community;
-
Need low levels of support to live independently in the community, but are not receiving an IFP, where access to ILC will mean they do not have to test their eligibility for an IFP;
-
Would otherwise meet the access criteria for the NDIS and would therefore be eligible for an IFP, but only require low levels of support that could be provided through ILC; or
-
Access specialist supports through an IFP but also have needs that can (and should) be supported through the mainstream or community sectors, and/or ILC.
The department is of the view that the ILC function should give priority attention to:
-
Building the capacity of carers and families to sustain their caring role that is, linking carers and families to social and recreational activities that provide carers with a break from their caring role and connect them with the community; activities that promote carer wellbeing such as personal development, peer support and mentoring; and linking carers into direct carer support services.
-
Building the individual capacity of people with a psychiatric disability to act for themselves (self-advocacy) and each other, and support families, carers and community members to act for or with people with a mental health condition. This includes facilitating opportunities for peer support that is, support people with a mental health condition or their carers to share their lived experiences with others on similar journeys with the aim of supporting people to effectively exercise choice and control. This capacity building approach acknowledges and respects the lived experience of people with a mental health condition.
-
Supporting the diverse needs of individuals, particularly underrepresented and hard-to-reach groups. These groups may require proactive outreach from ILC and/or the Local Area Coordinators to ensure that they can get the supports they need. The ILC framework notes consideration will be required for people who may not see themselves as requiring support from a ‘disability’ scheme. People with a mental illness are specifically referenced in this context which is supported by the department.
-
Preventative interventions to minimise the likelihood that a person will require an IFP in the future.
Page | 6
Planning process for people with a psychosocial disability, and the role of primary health networks in that process
Streamlined access approach Victoria has established an agreed Streamlined Access approach with the NDIA for people on the MHCSS Needs Register, which is managed by the MHCSS Intake Service. This approach will support people on the Needs Register to collect the required evidence they need to make an NDIS access request. This includes engaging the person’s health professional, on their behalf, to confirm diagnosis and functional impairment (as assessed and recorded by the MHCSS Intake service). Victoria has proposed a joint project with the NDIA to assess the demonstrated benefit of the Streamlined Access approach during transition with the view to enhancing the NDIS access process for people with a psychiatric disability. Notwithstanding this proposed project, Victoria will assess the
effectiveness of the Streamlined Access approach during transition to determine the merit in
establishing a policy position, and formally designing a service model within the specialist mental health service system, to actively identify and support eligible people with a mental illness and associated psychiatric disability to access the NDIS. Access process
The nature of the NDIS access process for people with a mental health condition may create a barrier to entry to the NDIS, particularly for people on compulsory treatment orders, those who are homeless or at risk of homelessness, have little or no informal support network, have complex needs, and/or have reservations engaging with formal service systems.
Collecting evidence of mental health diagnosis and functional impairment is highly administrative and costly for this vulnerable group. The attendant risk is that some people with severe mental illness and associated psychiatric disability will be at heightened risk of not commencing, or disengaging, with the NDIS access and planning processes.
Victoria’s MHCSS Intake Service has advised that:
-
some people on the MHCSS Needs Register do not have a treating health professional and that considerable effort (and cost to the individual) is required to engage the person with a health professional to complete the access request form.
-
General Practitioners have variable understanding of how a mental health condition can impact on their patient’s capability to undertake tasks of daily living or engage in community life and/or the skill and interest in undertaking assessment for functional impairment for this cohort.
It is important that General Practitioners and private psychiatrists and psychologists understand the NDIS access process and their role in providing evidence of functional impairment and confirmation of diagnosis. Primary Health Networks can play a lead role in educating MBS funded health professionals on the NDIS and building their capability to undertake assessments of functional impairment using research validated assessment tools.
Page | 7
Planning and review process
The NDIA will include support coordination as a standard element in the NDIS individual funding package/plan for people with a psychiatric disability.
This is consistent with the Victoria’s MHCSS Individualised Client Support Package program which has an embedded support coordination functionality in the service model. Other core features of this program (which is transitioning to the NDIS) that could be built into, or strengthened in, the NDIS planning and support implementation model include:
Capacity to undertake comprehensive assessment and review of the individual’s support needs
While the NDIS access process does not consider or weight social issues such as poverty, poor physical health, substance misuse problems, homelessness and family violence these issues impact on the person’s resilience and ability to self-manage their mental health condition and subsequent psychosocial support needs. NDIA decision making would be strengthened by taking into account a person’s social, economic and environmental context and (with their consent) including input from treating practitioners or other service providers, in addition to using recovery oriented principles in planning and review processes. This information could then be provided to the participant’s NDIS funded support provider/s (with the participant’s consent) to assist them to better understand the person and provide responsive and safe supports.
Capacity to develop and review support plans face to face with consumers and their
carers/significant others
One of the strengths of Victoria’s current model is its capacity to undertake plan development with people in a range of service settings, such as acute inpatient, bed-based clinical rehabilitation services and prison, prior to discharge. The capacity of NDIA planners to routinely undertake
planning in situ for participants in bed-based settings would facilitate the person’s smooth
transition to the community and continuity of support.
Other features of the MHCSS model that could be built into the NDIS planning model and processes include:
-
development and review of plans face-to-face with participants as part of a person-centred approach; and
-
undertaking plan reviews bi-annually (if not quarterly) as part of standard practice, particularly for participants with high-level psychiatric disability or complex social support needs. Flexibility to respond rapidly to the fluctuating needs of consumers
The psychosocial needs of people with a mental health condition may escalate rapidly and sometimes unpredictably. For example, people may experience heightened need for psychosocial supports after an exacerbation of illness, suicide attempt or a change in living arrangements and informal supports. The MHCSS program has the capacity to rapidly increase support levels in response to these and like circumstances.
Page | 8
Victoria’s clinical mental health service system is dependent on consumers receiving adequate psychosocial supports and the NDIS market having flexibility to appropriately identify and respond to changing or escalating needs. If NDIS providers are unable to respond with adequate agility to participants’ changing support needs this will increase the risk of participants engaging with emergency services (police, ambulance and Emergency Departments) and requiring further tertiary health interventions, particularly inpatient admission. The pricing model should enable NDIS funded providers to develop tailored approaches to the specific needs of participants with changing psychosocial disability support needs. The extent to which this is achieved should be monitored by the NDIA.
Whether spending on services for people with a psychosocial disability is in line with projection
At full scheme, it is estimated that there will be 105,000 NDIS participants in Victoria, and of that the Productivity Commission estimated that 14 per cent of NDIS participants, approximately 15,000 people, would have a psychosocial disability as a primary diagnosis. The NDIS participant numbers in the Barwon area are consistent with this estimate with just under 14 per cent of total NDIS participants having a psychiatric disability as the primary diagnosis. This suggests the rate of eligibility in Victoria of people with a psychiatric disability as their primary diagnosis is on target with the Productivity Commission estimates. Preliminary analysis of NDIS participant actuary data indicates average spending on NDIS supports for people who have a psychiatric condition as a primary diagnosis compares very favourably with the level of supports clients of a state funded MHCSS Individualised Client Support Package currently receive.
Role and extent of outreach services to identify potential NDIS participants with a psychosocial disability
Some people with a mental health condition will find it difficult to navigate the NDIS access and planning process. As indicated previously, the department is considering formally designing a service model within the specialist mental health service system to actively identify and support eligible people with a mental illness and associated psychiatric disability to access the NDIS. This ‘navigator’ model will be tested in the North Eastern Melbourne Area, and focus on identifying and supporting people with a mental health condition who are hard to engage. The results of this trial will be shared with the NDIA and may provide evidence of the value of providing an outreach service to identify and engage potential NDIS participants who have a psychiatric condition.
Page | 9
The provision and continuation of services for NDIS participants in receipt of forensic disability services
Consistent with the NDIS eligibility requirements, as specified in the NDIS Act, all people with a mental health condition and psychosocial disability that meet the disability requirement who are living in the community are eligible for the NDIS support, irrespective of whether they have a forensic history.
Victoria’s forensic mental health service system has relied on the state funded MHCSS program to provide psychosocial support to this cohort as part of an integrated treatment and disability support model. The provision of psychosocial supports should continue to be provided through the NDIS for this cohort.
Other comments
Quality and safeguarding
Under the Bilateral Agreement for Transition to the NDIS, Commonwealth and Victorian Governments made a commitment that existing quality and safeguards would continue to operate during the transition period. This commitment is given effect by the Victorian Quality and Safeguards Working Arrangements for Transition which took effect on 1 July 2016 and will operate until 30 June 2019.
Under these arrangements, the Victorian Government retains responsibility for operating quality and safeguards for disability services transitioning to the NDIS until June 2019 or until the national quality and safeguards framework is implemented.
Under the National Disability Insurance Agency’s Terms of Business for Registered Providers, providers
wishing to deliver NDIS funded supports that are in-scope of Victoria’s quality and safeguarding arrangements must achieve and maintain status as a Victorian approved NDIS provider as a pre-requisite for NDIS registration.
As part of the quality assurance process to become a Victorian approved NDIS provider, all new providers seeking to deliver in-scope NDIS funded psychosocial supports must be accredited against at least one of eight quality assurance standards nominated by the department. Organisations accredited against a standard other than the National Standards for Mental Health Services must also obtain accreditation against this standard within 12 months of receiving Victorian approved NDIS status.
This action has been taken to ensure new providers have adequate capability to deliver good quality, safe psychosocial disability supports to people with a mental health condition.
The Disability Reform Council recently released the NDIS Quality and Safeguarding Framework (the Framework) which will apply when the NDIS is at full scheme. The Framework acknowledges the need for a high level of regulation while markets are developing and growing and as participants build their capability to make informed choices about providers.
One of the regulatory components of the Framework is a NDIS registrar who will have the responsibility for registering providers, managing the NDIS Practice Standards and certification scheme, monitoring provider compliance and taking action as required. The department welcomes the opportunity to discuss the inclusion of mental health specific standards in the NDIS Practice Standards and certification scheme.
Page | 10