Operational Guideline – Planning and
Assessment – Supports in the Plan – Interface
with Health
Legislation
1.
Read ss. 4, 5 and 34 of the National Disability Insurance Scheme Act 2013 (NDIS Act) and the
National Disability Insurance Scheme (Supports for Participants) Rules 2013 (Supports for
Participants Rules).
General principles
2.
People with disability should be supported to participate in and contribute to social and economic
life to the extent of their ability.
See s.4(2) of the NDIS Act
3.
People with disability should be supported to receive supports outside the NDIS and be assisted to
coordinate these supports with the supports provided under the NDIS.
See s.4 (14) of the NDIS Act
4.
Reasonable and necessary supports for people with disability should:
a.
Support people with disability to pursue their goals and maximise their independence,
b.
Support people with disability to live independently and to be included in the community as
fully participating citizens, and
c.
Develop and support the capacity of people with disability to undertake activities that enable
them to participate in the mainstream community and in employment.
See s.4(11) of the NDIS Act
5.
The preparation, review and replacement of a participant’s plan should so far as reasonably
practical be individualised; directed by the participant; where relevant consider family, carers and
significant others; consider availability of informal support, access to mainstream and community
supports; and build individual capacity to increase participation and inclusion in community with the
aim of achieving individual aspirations.
6.
Plans should maximise choice and independence of the participant and facilitate tailored and
flexible responses to individual goals and needs.
See s.31 of the NDIS Act
7.
The statement of participant supports specifies the general supports (if any) and the reasonable
and necessary supports (if any) that will be funded. In deciding whether to approve a statement the
delegate must:
a.
Have regard to the legislation and rules, participant statement, relevant assessments,
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b.
Be satisfied that all clauses of s.34 of the NDIS Act on reasonable and necessary are met
including that the support is most appropriately funded by the NDIS and offers value for
money,
c.
Have regard to the principle that a participant should manage their plan to the extent they wish
and the operation and effectiveness of any previous plans of the participant.
See ss.33, 34 and 35 of the NDIS Act
Reasonable and necessary supports
8.
Before specifying any general support, or reasonable and necessary support, in a participant’s plan
the delegate has to:
a.
Be satisfied that all the criteria set out in s.34(1) of the NDIS Act are met in respect of each
funded support before it is included in a participant’s plan;
b.
Ensure the support:
i.
Will not cause harm to the participant or pose risk to others,
ii.
Is due to the effect of the disability on the participant and does not duplicate supports
available from other systems,
iii.
Does not relate to day to day living costs (e.g. rent, groceries, utility fees) unless directly
attributable to the impact of the disability on the participant, and
iv.
Is not illegal or consist of income replacement
See Operational Guideline – Planning and Assessment – Supports in the Plan
See rs.5.1, 5.2 and 5.3 of the Supports for Participants Rules
c.
9.
Consider the additional guidance for delegates provided by the National Disability Insurance
Agency (the NDIA) set out in this operational guideline in relation to the interface with Health
systems.
This operational guideline lists the matters that delegates are to consider under headings which
refer to the paragraphs of s.34(1). For example, value for money (s.34(1)(a)) and effective and
beneficial having regard to current good practice (s.34(1)(b)). Delegates are to note that the
matters to be considered may fall across more than one paragraph of s.34(1) and need to be
considered in relation to more than one paragraph of s.34(1).
Guidance on when supports relating to health are
most appropriately funded
10. The principles that determine whether or not the NDIS is more appropriate to fund a support for a
participant are outlined in Schedule 1 of the Supports for Participants Rules.
11. The NDIS will be responsible for necessary and reasonable supports related to a person’s ongoing
functional impairment and that enable the person to undertake activities of daily living, including
maintenance supports delivered or supervised by clinically trained or qualified health practitioners
where these are directly related to a functional impairment and integrally linked to the care and
support a person requires to live in the community and participate in education and employment.
See r.7.4 of the Supports for Participants Rules
12. The NDIS will not be responsible for:
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a.
The diagnosis and clinical treatment of health conditions, including ongoing or chronic health
conditions, or
b.
Other activities that aim to improve the health status of Australians, including general
practitioner services, medical specialist services, dental care, nursing, allied health services
(including acute and post-acute services), preventive health, care in public and private
hospitals and pharmaceuticals or other universal entitlements, or
c.
Funding time-limited, goal-oriented services and therapies:
d.
i.
Where the predominant purpose is treatment directly related to the person’s health
status, or
ii.
Provided after a recent medical or surgical event, with the aim of improving the person’s
functional status, including rehabilitation or post-acute care, or
Palliative care
See r.7.5 of the Supports for Participants Rules
Further guidance on funding supports related to
health
13. The table below provides guidance on whether a support is more appropriately funded or provided
through the NDIS or by other parties. Other parties can include other government departments and
agencies, independent organisations funded by governments to provide services, individuals and
families.
A. The NDIS is generally more appropriate to fund the following necessary and reasonable supports:
1.
Assistance to coordinate supports and assistance with daily personal activities –
assistance to engage with the health system such as decision making support and making
appointments, (except where this is provided as part of a coordinated health care package),
including a continuation of any support for complex communication needs or challenging
behaviours while accessing health services, including hospitals
2.
Prosthetic limbs, orthotics or splints for ongoing functional performance (but not any
medical or surgical procedures) – see separate Operational Guideline Planning and
Assessment – Supports in the Plan - Prosthetic Limbs.
3.
Community re-integration – which enables the participant to live in the community such as
personal support and home modifications and delivery of routine, non-clinical care to enable
activities of daily living
4.
Training of NDIS funded support staff on a participant’s individual needs by nurses or allied
health professionals, including training for new service providers and retraining as the
participant’s needs change (with service providers being responsible for training new staff)
5.
Assistance with transport – specialist transport to and from medical appointments required
as a result of the participant’s disability (where no other transport option is appropriate and not
including emergency or in patient transport or substituting for parental responsibility)
B. Depending on their purpose the following supports can be more appropriately funded by either the
NDIS or other parties:
1.
Assistance in managing life stages, transitions and supports, can be funded by the NDIS
or by the health/mental health system. In determining which system is more appropriate, the
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system that is delivering the majority of supports is usually more appropriate to assist in the
coordination of these supports.
2.
a.
NDIS: assistance where the majority of the coordination and transition supports relate to
supports funded by NDIS, or to non-clinical supports,
b.
Other parties: assistance where the majority of the coordination and transition supports
relate to supports funded by the health system.
Therapeutic support, including assistance by allied health professions such as speech and
language pathology, physiotherapy, occupational therapy, audiology and therapy delivered by
a therapy assistant under the supervision of the therapist:
a.
b.
3.
4.
5.
NDIS:
i.
Maintenance care where the primary purpose is to provide ongoing support for a
participant in order to maintain a level of functioning including long term
therapy/support required to achieve small incremental gains or to prevent functional
decline,
ii.
To improve functioning in an early intervention context
Other parties: where it is a time limited intervention to improve functioning following an
acute event, medical treatment or accident (e.g. to improve functioning immediately
following a stroke or acquired brain injury)
Care and supervision by clinically trained staff, including delegated care
a.
NDIS: where this is required because of the participant’s functional impairment and
integrally connected to the participant’s support needs to live independently and to
participate in education and employment (e.g. supervision of delegated care for ongoing
high care needs, such as PEG feeding, catheter changes, skin integrity checks or
tracheostomy tube changes) (see Decision Tree below)
b.
Other parties: where the primary purpose is to treat or manage a medical condition or
recovery after medical treatment
Assistance with daily personal activities and participation in community activities
a.
NDIS: where the assistance is related to an ongoing functional impairment (however not
in hospitals, except where a continuation of any assistance for communication and
challenging behaviours),
b.
Other parties: where the participant’s need is temporary to recover from a medical
condition or event through post-acute care
Aids and equipment
a.
NDIS: aids and equipment which are permanent and for the purpose of improving
functioning and related to a participant’s self-care needs (including continence aids and
catheters), except for medical or surgical procedures (e.g. the NDIS would not be
responsible for providing continence aids and catheters for participants undergoing
treatment within hospital settings),
b.
Other parties: aids and equipment which are for the permanent or temporary purpose of
regulating or treating a medical or health condition or aids and equipment associated with
medical or surgical procedures and post-acute recovery
C. Other parties are generally more appropriate to fund the following supports:
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1.
Diagnosis and assessment of health conditions, including ongoing or chronic health conditions
(e.g. aged care, developmental delay)
2.
Clinical treatment and supports, including:
3.
a.
Acute and emergency services, general practitioner, medical specialists, dental care,
b.
Care as an admitted patient in public and private hospitals,
c.
Medicines and pharmaceuticals including items listed and not listed on the Pharmaceuticals
Benefits Scheme (PBS) and oxygen and Botox,
d.
Services listed on the Medicare Benefits Schedule, and
e.
Temporary or interim prosthetics.
Subacute care services that are delivered under the management of a clinician, including:
a.
Palliative care where the primary clinical purpose or treatment goal is optimisation of the
quality of life of a patient with an active and advanced life-limiting illness,
b.
Geriatric evaluation and management which aims to improve the functioning of a patient with
multi-dimensional needs associated with medical conditions related to ageing, such as
tendency to fall, incontinence, reduced mobility and cognitive impairment,
c.
Psychogeriatric care where the goal is improvement in the functional status, behaviour and/or
quality of life for an older patient with significant psychiatric or behavioural disturbance,
caused by mental illness, an age-related organic brain impairment or a physical condition
4.
Post-acute care – including clinical supports that are delivered to a participant in their home
following an acute episode (such as nursing care and medical supplies).
5.
Assistance to increase functioning (rehabilitation) specialist allied health, rehabilitation and
other therapies for people with recently acquired conditions such as newly acquired spinal cord
injury or brain injury, until the participant has achieved the maximum level of achievable functioning
and the remaining allied health support is for the purpose of maintenance
6.
General hearing, vision and podiatry services where these are unrelated to the participant’s
disability as determined in the NDIS access requirements and/or required by other Australians of a
similar age without a disability (e.g. prescription glasses, orthotics to realign posture)
7.
Preventive health designed to improve general health or prevent illness, injury and chronic
disease through education, promotion and incentives, including addressing obesity, smoking and
alcohol use.
8.
Private health insurance fees
9.
Medical costs normally met through disposable income such as gap fees with doctors or chemist
costs or prescription medicines.
Assistance available where the NDIS is not more
appropriate to fund a support
14. It may be appropriate to refer a participant to a Local Area Coordinator to support the participant in
accessing mainstream supports.
15. A Local Area Coordinator may be able to provide a range of general supports such as:
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a.
When requested, provide local/ relevant information to the participant and their support
networks regarding mainstream services to facilitate independence, participation and inclusion
identified with a participant’s plan,
b.
When requested, support the participant and family’s access and inclusion to service settings,
and
c.
When requested, facilitate coordination of specialised supports between the NDIA and service
settings.
16. A Local Area Coordinator can also work on a broader level with mainstream service systems to
enhance access, participation and inclusion of people with disability. This includes by building the
inclusion capacity of mainstream service providers in the local region.
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Decision tree for participants with complex care
needs
Planner’s name:
Date:
Participant’s name:
NDIS:
The NDIS is responsible for ‘maintenance supports delivered or supervised by clinically trained or
qualified health practitioners where these are directly related to a functional impairment and integrally
linked to the care and support a person requires to live in the community and participate in education
and employment’.
This is intended to provide support to participants who have a functional need and also a complex
healthcare need. The health system is responsible for clinical supports and the treatment of health
conditions, including post-acute care. In some instances the education system may also be responsible
for attending to the clinical care needs of students while in attendance at school.
Requirements to have complex care funded by
the NDIS
Considerations
Criterion 1
The support need relates to the participant’s
functional impairment
Note: The support need must relate to the participant’s
functioning to enable them to live independently, participate in
education or employment etc. (e.g. without the support the
participant would not be able to undertake activities of daily
living)
Criterion 2
The complex care is integrally connected to the
participant’s general support needs
Note: It is not practicable or appropriate to separate the
participant’s complex care needs from their day to day support
for activities of daily living (e.g. while participating in school the
student requires a person trained in suctioning to prevent
choking)
Criterion 3
The support need is not for medical or acute
treatment;
Note: The health system and/or education system (for students
attending school) are responsible for funding supports for
participants to treat a medical condition or for acute care (e.g. a
nurse to visit the participant in their home or at school to
undertake wound management or post-acute follow-up)
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Requirements to have complex care funded by
the NDIS
Considerations
Were all of Criterion 1 and 2 and 3 met?
Yes ☐ No ☐
If the participant meets Criterion 1 and 2 and 3, continue to criterion 4 to establish which system is the
most appropriate for complex care provision.
If the participant does not meet Criterion 1 or 2 and 3, it is likely that the health system is more
appropriate to fund the support for the participant, not the NDIS.
Approach to determining what support model
is appropriate for participants with a complex
care need
Considerations
Criterion 4
The participant’s care needs require specialisation
and expertise which is not reasonable to expect
from a standard attendant carer
Note: This means that the participant’s care needs require
someone with highly specialised skills in order to safely or
effectively support the participant. This would be only where it is
beyond what could be expected from a standard attendant carer
(e.g. specialised knowledge of how to change a trachea)
Criterion 5
The participant’s care needs require ongoing
supervision by a clinically trained professional
Note: A participant’s carer or attendant carer may require
supervision by a clinical professional such as a nurse in order to
ensure the person is appropriately supporting the participant
with their complex care (e.g. a fortnightly visit from a nurse or
suitably trained professional to monitor colostomy bag changes
by the attendant carer)
Criterion 6
It is safe and appropriate to train an attendant
carer to provide the support, including with
supervision from a medical profession
Note: In many cases strong evidence supports a delegated care
model where attendant carers are provided with training and/or
ongoing supervision by a medical professional, such as a nurse,
in order to support a participant’s complex care needs. If this is
the case, the NDIS will provide funding at the rate of ‘complex
care’
Were all of Criterion 4 and 5 and 6 met?
Yes ☐ No ☐
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If the participant meets Criterion 4 and 5 and 6, their plan should include funding for ‘complex care’ and
any associated training and supervision by a medical professional (however not for any medical or acute
treatment as outlined above in ‘Criterion 3’).
If the person does not meet Criterion 6, this should be discussed with National Office to explore options
and available evidence for a delegated care model. In exceptional circumstances the NDIS may fund
support above the ‘complex care’ rate in order to purchase appropriate expertise and qualifications. This
is on a case by case basis and only where there is evidence that a delegated care model is not
appropriate.
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