wa ndis trials evaluationdisability.wa.gov.au/global/publications/wa ndis/repo… · web viewthe...

2016

WA NDIS Trials

Evaluation

FINAL REPORT

Executive Summary and RecommendationsPurpose

This report presents the key recommendations of the evaluation of the two trials of the National Disability Insurance Scheme (NDIS) in Western Australia - the National Disability Insurance Agency (NDIA) trial in the Perth Hills region and the WA NDIS trial (formally My Way) managed by the Disability Services Commission WA (DSC) in the Lower South West and Cockburn Kwinana areas.

The evaluation has compared and contrasted the two models to assess the sustainability and effectiveness of the models, the experience for individuals and the outcomes for people with disability, their families and carers. Finally, the evaluation has sought to identify the implications for the future of the disability reform agenda in Western Australia and nationally.

It is important to note that the evaluation has been conducted during a period when neither trial site model is fully operational. The NDIA model and the WA NDIS model have been progressively implemented during the period July 2014 to June 2016.

The Evaluation has been undertaken using an industry standard “cross-functional business model” analysis, used to generate a comprehensive business model combining all the processes for both NDIA and WA NDIS operations in the WA trial sites. This approach is inherently independent of factors such as geographical, cohort and population levels and provides a sound basis for comparing the rules and practices of the two NDIS models in Western Australia.

The evaluation draws on multiple sources of information from public, government and trial site operations supported by workshops conducted with staff from the NDIA and WA NDIS, comprehensive surveys of over 69 Disability Service Providers with follow-up interviews, over 600 individual Participant Plans and 21 Participant detailed follow up interviews. The multiple data sources were used to validate the business model and form the basis of the recommendations of this report.

Delays experienced outside the control of the evaluation reduced the Participant conversation program and Providers survey. However, although the sample of Participants and Providers interviewed was small, consistency in the responses combined with the structured approach provided useful confirmation of trial site processes, practices and experiences that were not isolated or unrepresentative.

Executive Summary

There are many similarities between the two models that are being trialled in Western Australia. Both operate within the key nationally consistent parameters of the NDIS that is set out in the

WA NDIS Trial Evaluation – Final Report 30 September 2016 of 127

Commonwealth legislation and rules. The NDIA trial site operates under the NDIS Act 2013 and the WA NDIS model operates under the Disability Services Act 2014 (Western Australia) that mirrors the relevant definitions and rules in the national legislation. The models therefore utilise common eligibility requirements and employ the same definition of “reasonable and necessary” supports. Most importantly both models use individual Participant Plans to enable maximum choice and control by individuals over their services.

The Participant Plan is fundamental to both models. All Participants have a Plan that embodies the agreement between the Participant and their respective trial site operator (agency). It describes their life, situation, personal goals, need for assistance and the unfunded and funded supports that are to be provided. The Plan has the central role in the description, funding and method of access to services and supports for an individual and their family.

The two models are derived from different start-points. The WA NDIS model is based on over 20 years of reform and refinement of a well-established base in WA whereas the NDIA model is newly developed to meet the specific needs of the NDIS at a national level. Both models are evolving and adapting to the roll-out of a new scheme.

The business model analysis, including comparison of the lifecycle of the Participant Plan under each model, clearly establishes the policy and practice differences between the trial site models and their respective evolutionary changes. Influencing factors related to implementation and ramp up in the trial sites have been excluded from the business model which reflect agency policies and practices as of July 2016. Given the progressive implementation of the trials and that a Participant Plan requires a year before review, comparative assessment of Participant outcomes was not viable.

The evaluation comprehensively analysed Participant Plan preparation, activation, operation and review processes and practices that accurately reflect the acceptance and effectiveness of Plan outcomes from the Participant’s and Provider’s perspectives. The dependency between the preparation of the Plan, its quality and accuracy, and the subsequent activation and delivery of the services clearly impact Participant satisfaction, experiences and their Plan outcomes.

Plan quality was confirmed in the surveys, interviews and observations to be closely correlated to the outcomes for people with disability, their families and carers. Whilst a good Plan improves the likelihood, it is not a guarantee of a good outcome for a Participant. Conversely, a poor Plan causes negative impacts on Participants, their families, Providers and agency operations. Thus Plan quality is regarded as a strong indicator of a good Participant outcome.

The use of performance indicators based on compliance with “Norms” was observed to compromise “Reasonable and Necessary” criteria and objectives for “Individualised Assessment” and to lead to “standardisation” of a Participant’s disability assessment, less effective planning of support services and Participant dissatisfaction with their Plan.

Each report recommendation is identified as requiring changes to either policy or process for each trial model. Changes to trial model policy are expected to require more agency investment


and lead time than improvements to operational practices. Where the recommendation is “In Place”, benefits may be expected from additional process improvements.

The key recommendations address gaps in either or both trial models necessary to meet the core requirements of future disability reform in WA. These core requirements are:

A sustainable and effective service model, able to meet diversity, intensity, disability, location and volume of demand;

A positive service experience for individuals, able to effectively assist individuals and their families engage with supports from community, mainstream and disability services;

Optimal outcomes for people with disability, providing individuals, their families and carers responsive choice and control, safeguards against vulnerability and contribute to their life goals; and

Address implications of future disability reform in Western Australia, ensuring the capacity to scale up to state-wide services, while maintaining effective quality management of Plans, services and operations and nurturing a capable and competent disability services sector to meet demand.

Key Features of an Effective Model for WA

The evaluation has identified five key features of an effective model for future disability reform in WA. These are not unique to WA and may be considered relevant for wider national application of the NDIS.

The five key features with associated key recommendations are:

Key Rec# Recommendation

Action Section RefWA NDIS NDIA

KR-1 Early engagement of Providers in Plan development and services commitment is to form part of the ongoing WA model.

In Place Policy Change

3.4.A

KR-2 Promote full three-way engagement between the Planner/Coordinator, Participant and Provider to ensure maximum service value, minimal operational overheads and optimal Plan outcomes.

In Place Process Change

4.2.C


1. Effective engagement of all parties involved in supporting an individual. A strong and collaborative relationship between the agency, Participant and Providers is essential for achievement of a quality Plan and successful outcomes for people with disability, their families and carers.


Action Section RefWA NDIS NDIA

KR-3 Implement and maintain a robust and sustainable, decentralised and scalable communication and relationship process involving Participants, their Providers and the agency.


4.3.B


Action Section WA NDIS NDIA Ref

KR-4 Ensure processes are in place to provide prompt response, negotiation, resolution of issues and safeguarding vulnerabilities of Participants during Plan operation.


3.6.A

KR-5 Implement processes that support “rolling” adjustments for service and Provider changes to a Plan during operation, together with greater flexibility in setting Plan review periods.

Policy Change

Process Change

3.7.A

KR-6 Enable responsive access to agency and Provider support, operational flexibility and adaptability of Plans in order to enable and maintain ongoing, responsive Participant choice and control.

Policy Change

Process Change

4.3.A


Action SectionWA NDIS NDIA Ref

KR-7 The viability of all funded services in a Plan is to be proven prior to approval.


3.4.B

KR-8 The activation of Provider services, following Plan endorsement, is to incur a minimal delay in Participant access to supports.


3.5.C


2. Effective choice and control for the participant over their services whilst safeguarding the vulnerability of the individual. Active monitoring by the operating agency with responsive support at all times including flexible Plan adjustment for changing circumstances.

3. Accurate assessment of Participant needs with service descriptions and funding agreed by all parties. Ensure prompt service delivery, lowest operational overheads and optimal value from the investment in Participant supports.



KR-9 Implement processes to ensure all committed services in a Plan are effectively and fully delivered to the Participant with appropriate incentives and monitoring procedures.


3.6.C


Action Section WA NDIS NDIA Ref

KR-10 Engage with the WA disability services sector to ensure adequate availability and capacity of services for WA rollout and a healthy relationship that fosters good-will and cooperation.


4.1.A

KR-11 Adopt an “open pricing” approach whereby price book components are negotiated in an open industry consultation process, inclusive of WA.


4.1.D



KR-12 Ensure a reliable, functional, scalable and sustainable financial system is implemented.

Process Change

Process Change

4.3.E


4. Capable and sustainable disability services sector able to meet the demands of a state-wide rollout of the NDIS scheme. Agreed service price baselines (for WA) with capacity to negotiate individual needs and supports.

5. Efficient and reliable financial management of service costing and delivery. A sound financial operational system accessible by Providers and Participants.

The degree of change required by the respective trial models to comply with the key features of an effective model for future disability reform in WA is summarised in Table 1.

Table 1 – Summary of Key Recommendation Action Types

Action Type WA NDIS NDIA

Policy Change Required 2 4

Process Change Required 1 8

In place (No Action) 9 0

Total Key Recommendations 12

The WA NDIS model is the closest fit to the key features of an effective model for WA, requiring the least modification. However, the WA NDIS model needs to continue to change and evolve in addition to adoption of the two key recommendation policy changes and a process change.

General Recommendations

These general recommendations include enhancement of positive elements of both the NDIA and WA NDIS models that will contribute to further improvement of the delivery and operation of disability reform in WA.

General Rec# Recommendation Action Section

RefWA NDIS NDIA

GR-01 Performance indicators used to monitor Plan quality are to reinforce the primary purpose of a Plan and not promote conformity.

Process Change

Process Change

3.4.C

GR-02 Endorsement of all Plans and changes to Plans to require signed acceptance by the Participant.


3.5.A

GR-03 Version control and endorsement of new and modified Plans to meet applicable (state) government document management standards.


3.5.B

GR-04 Self-Managed Participants are to have explicit provision for employment liabilities (superannuation, worker’s compensation) in the Plan and procedures are to be in place to ensure that responsibilities have been effectively communicated to the Participant.


3.5.D

GR-05 Participants granting Provider access to their service category accounts is to be controlled so that budget and service claim management processes meet accepted financial standards.

Not Applicable

Process Change

3.5.E

GR-06 Compare Provider - Participant service agreements with the corresponding Plan service descriptions and budgets to identify variations affecting the value of services.

Process Change

Policy Change

3.6.B

GR-07 Payment of Participant expense claims to be prompt and effectively escalated for issue resolution as required and provide accessible and up-to-date account status.

Process Change

Process Change

3.6.D


General Rec# Recommendation Action Section

RefWA NDIS NDIA

GR-08 Payment of Providers for services to be timely with effective escalation and negotiation procedures for issue resolution, including effective means of monitoring and managing allocated Participant accounts.


3.6.E

GR-09 Implement processes to ensure continuity of Participant funded services during the period between Plan expiry and the replacement Plan commencement


3.7.B

GR-10 Implement processes to facilitate synchronisation of Participant Plan service budgets with corresponding accounts used for processing claims from the Participant and their Providers.


3.7.C

GR-11 Establish negotiation and escalation procedures for resolution of marginal viability of services to ensure continued access to vulnerable service categories.


4.1.B

GR-12 Group homes accommodation support pricing, support grades and facility allowances be negotiated for a sustainable future.

(Currently under active negotiation between commonwealth and state governments)


4.1.C

GR-13 Maintain an active presence in monitoring Participant and community trends on-line to ensure responsiveness to changing needs and attitudes.

In Place In Place 4.2.A

GR-14 Adopt a pro-active agency program for Participant relationship development that monitors trends in Participant’s perception of service value, Plan satisfaction, Provider interaction and agency support.

Process Change

Process Change

4.2.B

GR-15 Implement a program to address Participant concerns and minimise anxiety regarding their ongoing dependency on continuity of NDIS based supports.

Process Change

Process Change

4.3.C

GR-16 Implement Plan development processes aimed at measurable Plan quality improvements delivering optimised service value with reduced Plan operational issues and support overheads.

Process Change

Process Change

4.3.D

GR-17 Reassess existing Performance Indicators to provide greater emphasis on measuring viability of services, achievement of reasonable and necessary criteria, individualised funding, and responsiveness to Participant choice and control.

Process Change

Process Change

4.3.F

GR-18 Performance measures be put in place to reward Plan development for achieving robust, viable and accurate Plans.

Process Change

Process Change

4.3.G

GR-19 Resolve any legal issues with respect to tax liabilities for proxy/guardian receiving funds on behalf of Participants.

Policy Change

Policy Change

3.6.F


The degree of change required by the respective trial models to implement the recommended improvements into the effective model for future disability reform in WA is summarised in Table 2.

Table 2 – Summary of General Recommendation Action Types

Action Type WA NDIS NDIA

Policy Change Required 1 3

Process Change Required 8 15

In place (No Action) 9 1

Not Applicable 1 0

Total Recommendations 19

Further improvement of the delivery and operation of disability reform in WA by either model will benefit from change and evolution and adoption of these general recommendations.

The WA NDIS model requires fewer modifications with one of the recommendations requiring a policy change, eight requiring process improvement and nine requiring no action. The NDIA model requires three policy changes and fifteen process improvements.


WA NDIS Trial Evaluation

Final Report

Table of Contents1.0 OVERVIEW AND OBJECTIVES.............................................................................................15

1.1 Overview.....................................................................................................................................15

1.2 Objectives....................................................................................................................................16

1.2.1 Study Focus......................................................................................................................................16

1.2.2 Study Objectives..............................................................................................................................16

1.3 Terms of Reference......................................................................................................................16

1.3.1 Evaluation Focus (Compare and Contrast).......................................................................................17

1.3.2 Evaluation Focus (Experiences)........................................................................................................17

1.3.3 Evaluation Focus (Outcomes)...........................................................................................................17

1.3.4 Evaluation Focus (Sustainability)......................................................................................................18

2.0 HOW THE EVALUATION WAS APPROACHED..........................................................................19

2.1 Evaluation Approach....................................................................................................................19

2.2 Caveats and Constraints..............................................................................................................20

2.3 Key Dates.....................................................................................................................................21

2.4 Sources of Information................................................................................................................22

2.5 Action Assessment......................................................................................................................23

2.6 The Business Model.....................................................................................................................24

2.6.1 Business Model Overview................................................................................................................24

2.6.2 Assessing the Activities....................................................................................................................25

2.6.3 Comparing Trial Model Processes....................................................................................................26

3.0 PLAN LIFECYCLE STAGE FINDINGS......................................................................................27

3.1 Participant Plan Overview...........................................................................................................27

3.2 Participant Plan Lifecycle.............................................................................................................29

3.3 Engagement Overview.................................................................................................................29

3.4 Plan Development.......................................................................................................................32

3.4.1 Plan Development Overview............................................................................................................32


3.4.2 Plan Development Delay..................................................................................................................33

3.4.3 Business Process Comparison..........................................................................................................34

3.4.4 Developing a Plan............................................................................................................................36

3.4.5 Service Management Options – Overview.......................................................................................40

3.4.6 Organisation Managed (WA NDIS)...................................................................................................42

3.4.7 Self-Directed (NDIA).........................................................................................................................44

3.4.8 Self-Management (Both Agencies)...................................................................................................46

3.4.9 Use of “Norms” for Plan Assessment...............................................................................................47

3.4.10 Plan Development Summary............................................................................................................49

3.4.11 Plan Development Recommendations.............................................................................................50

3.5 Plan Endorsement and Activation................................................................................................51

3.5.1 Plan Endorsement and Activation Overview....................................................................................51




3.5.5 Self-Managed (Both Agencies).........................................................................................................57

3.5.6 Continuity of Participant Support during Plan Rollover....................................................................59

3.5.7 Plan Endorsement and Activation Summary....................................................................................60

3.5.8 Plan Endorsement and Activation Recommendations.....................................................................62

3.6 Plan Operation.............................................................................................................................63

3.6.1 Plan Operation Overview.................................................................................................................63




3.6.5 Self-Managed (Both models)............................................................................................................71

3.6.6 Plan Operation Summary.................................................................................................................74

3.6.7 Plan Operation Recommendations..................................................................................................76

3.7 Plan Review and Adjustment.......................................................................................................77

3.7.1 Plan Review and Adjustment Overview...........................................................................................77


3.7.3 Plan Review Timing and Gaps..........................................................................................................79

3.7.4 Initiating a Plan Review....................................................................................................................80


3.7.5 Request Change of Service...............................................................................................................81

3.7.6 Request Provider Change.................................................................................................................83

3.7.7 Plan Review and Adjustment Summary...........................................................................................84

3.7.8 Plan Review and Adjustment Recommendations.............................................................................85

4.0 TRENDS AND MODEL SUSTAINABILITY................................................................................86

4.1 Disability Services Sector.............................................................................................................86

4.1.1 Provider Marketplace.......................................................................................................................86

4.1.2 Service Provider Adaptation to NDIS................................................................................................89

4.1.3 Pricing of Services............................................................................................................................90

4.1.4 Group Homes Supports....................................................................................................................91

4.1.5 Disability Services Sector Trend Summary.......................................................................................94

4.1.6 Disability Services Sector Trend Recommendations.........................................................................95

4.2 Participant and Community.........................................................................................................96

4.2.1 Provider Survey................................................................................................................................96

4.2.2 Community Trends...........................................................................................................................96

4.2.3 Plan Quality......................................................................................................................................98

4.2.4 Value of Service.............................................................................................................................100

4.2.5 Participant and Community Trend Summary.................................................................................102

4.2.6 Participant and Community Trend Recommendations...................................................................103

4.3 Agency Policies and Operations.................................................................................................104

4.3.1 Communication and Relationships.................................................................................................104

4.3.2 Financial Systems...........................................................................................................................107

4.3.3 Process Improvement....................................................................................................................108

4.3.4 Agency Trend Summary.................................................................................................................110

4.3.5 Agency Trend Recommendations...................................................................................................111


Table of Figures

Figure 1 Business Model Sample

Figure 2 Plan Structure Overview

Figure 3 Participant Plan Purpose

Figure 4 WA NDIS Plan Funding Sample

Figure 5 NDIA Plan Funding Sample

Figure 6 The Plan Lifecycle

Figure 7 Plan Lifecycle Stages

Figure 8 Engagement Overview

Figure 9 Plan Development Contribution

Figure 10 Plan Development Engagement

Figure 11 Plan Development Period

Figure 12 Plan Development Process Assessment

Figure 13 Plan Building Steps

Figure 14 Plan Life Description Comparison

Figure 15 Plans per Planner/Coordinator

Figure 16 Plan Categories

Figure 17 Plan Formal Supports

Figure 18 Plan Informal Supports

Figure 19 Plan Management Options

Figure 20 Organisation Management

Figure 21 Self-Directed (NDIA)

Figure 22 NDIA Support Coordination

Figure 23 Self-Managed

Figure 24 WA NDIS WC Plan Sample

Figure 25 Plan Endorsement and Activation

Figure 26 Plan Endorsement and Activation Engagement


Figure 27 Plan Endorsement Process Assessment

Figure 28 Plan Operation

Figure 29 Plan Operation Engagement

Figure 30 Plan Operation Process Assessment

Figure 31 Plan Review and Adjustment

Figure 32 Plan Review Engagement

Figure 33 Plan Review Process Assessment

Figure 34 Provider Business Impact Comparison

Figure 35 Provider - Participant Comparison

Figure 36 Plan Productivity Comparison

Figure 37 Provider - Agency Comparison 104

Figure 38 Relationships 105


Definitions used in this Document

Term Description

Act Disability Services Act 1993 together with Disability Services Amendment Regulations 2014. National Disability Insurance Scheme Act 2013

Agency Refers to the scheme operators in the WA trial sites Disability Services Commission (WA NDIS) National Disability Insurance Agency (NDIA)

AQS Agency Quantitative Survey. Surveys conducted during the evaluation collecting specific information required to support the analysis and compare and contrast of the trial models

BSO NDIA Business Support Officer

Coordinator Short form for the WA NDIS Coordinator.

DSC Disability Services Commission (WA)

DSO A registered Disability Services Organisation under the DSC panel. In this document, the term Provider has been used that includes DSOs.

Formal Support Participant supports provided under the NDIS funding provisions specified in their Plan. Examples include services from registered service providers such as care, orthotics and therapy.

Informal Support Participant supports provided without funding provisions under the NDIS. Examples are community services and family based contributions.

In-kind Existing Commonwealth or State/Territory government programs delivered under arrangements separate to the NDIS.

JSC NDIS Joint Steering Committee (WA)

Mainstream services Services received by participants from other government sources. Mainstream services may contribute to the support of the Participant (eg. Occupational Therapy provided by Department of Health) Mainstream services may or may not receive funding according to a Participant Plan under the NDIS.

NDIA National Disability Insurance Agency. Operates the NDIA trial site in Western Australia.

NDIS National Disability Insurance Scheme

Observation The term “observation” is used to refer to items of information provided from surveys, workshops and other verified sources to the evaluation. Observations do not include added interpretation from the evaluation process.


Term Description

Organisation Managed Applicable to WA NDIS. A registered disability services organisation is engaged via an agreement with the Disability Services Commission to provide designated services in accordance with one or more Participant Plans. The services are covered by a Schedule Variation Agreement under the panel contract for Registered Service Providers (Provider)An individual or their representative chooses the (registered) service provider to manage the funded strategies in their Plan.

Participant Experience The experiences of the participant throughout all stages of their Plan with all supporting parties such as: Service Providers, the trial site operator, local community etc.

Participant Outcome Participant outcomes based on the contribution to their life goals from supports itemised in their Plan.

Plan Outcome Plan outcomes based on the degree to which Plan contents, Provider engagement, services delivery and agency support meet the expectations of a Participant.

Plan Refers to the Participant Plan. The Plan details for a Participant the background, goals, supports and service funding for a period, usually 12 months.

Plan adjustment Modification of a Plan during operation that is not part of a formal Plan review. Usually limited to support service arrangements specified in the Plan. An example may be minor adjustment of a service allowance or change of a service provider.

Pricebook NDIA NDIS Support Clusters Definitions and Pricing for Western Australia.WA NDIS My Way Support Clusters and Pricing Framework.

Planner NDIA Planner with primary responsibility for liaising with the Participant. Counterpart to the WA NDIS Coordinator.

Provider A Registered Service Provider or Disability Services Organisation. A Provider of services to the disability sector in WA registered with the DSC (panel contract). A Provider also registers with NDIA to operate in the NDIA trial site in WA.

Self-Directed An NDIA form of Self-Management where the Participant is responsible for selection of the Registered Services Provider (Provider) who is to deliver one or more services in their Plan where the method of payment is direct to the Provider by the agency (NDIA). The Participant authorises access to their service account for the Provider claim process and is able to monitor activity on this account.

Self-Managed Applicable to both trial models. A Participant is responsible for the operation of strategies and associated support services designated as self-managed in their Plan. It requires the participant to select the (registered or non-registered) supports provider for each self-managed service. This involves either receipt of advances or submission of claims for reimbursements.The definition of self-management is agreed between the NDIA and DSC on 18 February 2015 (for the purposes of the Joint Steering Committee)

Services Services are described in a Participant Plan and are provided to a Participant and their family by a service provider that may or may not be a Registered Service Provider (Provider). Services as described in this report are all funded and paid for and claimed via the methods specified in the Plan.


Term Description

Supports Supports received by a Participant or their family include funded services described in the Plan together with all other informal and mainstream supports that may be mentioned directly or indirectly in the Plan.

Trial Sites NDIA trial model operates in the Perth Hills area for people with disability living in the local government areas (LGAs) of Kalamunda, Mundaring and Swan.WA NDIS trial model operates in the Lower South West region for people with disability living in the LGAs of Augusta-Margaret River, Boyup Brook, Bridgetown-Greenbushes, Busselton, Donnybrook, Balingup, Manjimup and Nannup (for the whole trial period 2014-2016) as well as the Kwinana and Cockburn LGAs (for 2015-16 only).

Trial Site Operator The operator of the respective trial site, either NDIA or WA NDIS. (See agency)

WA NDIS Coordinator WA NDIS Coordinator with primary responsibility for liaising with the Participant. Counterpart to the NDIA Planner.


1.0 Overview and Objectives

1.1 Overview

The National Disability Insurance Scheme (NDIS) was introduced in 2013 to ensure that across Australia people with disability get the support they need. Changes are being made to existing systems to deliver a fairer and more comprehensive range of services to people with disability and to provide support for their families and carers.

The NDIS is being rolled out gradually to achieve a smooth transition, with agreements for trials in every state and territory in Australia. The majority of states and territories commenced the trials within their jurisdictions on June 2013, testing the service model and scheme arrangements over a two-year period. Subsequently, states and territories commenced negotiations to finalise agreements for a full rollout of the NDIS in their jurisdiction.

Western Australia joined the two-year trial of the NDIS in June 2014. A unique agreement between the Commonwealth and Western Australian governments provided for comparison of the two different models of the NDIS. One model is managed by the National Disability Insurance Agency (NDIA) in the Perth Hills region. The alternative model, WA NDIS, is managed by the Disability Services Commission WA (DSC) in two trial regions: the Lower South West which commenced in July 2014; and the Cockburn Kwinana region which commenced a year later in July 2015. Together the trials aim to provide services to 8,383 participants by the end of the two-year trial – 4,133 participants in WA NDIS and 4,250 participants in NDIA NDIS.

There are similarities and differences between the models. Both operate within the NDIS legislation and rules that set out nationally consistent parameters. The NDIA trial site operates under the NDIS Act 2013 and the WA NDIS model operates under the Disability Services Act (Western Australia) that mirrors the relevant definitions and rules in the national legislation. The models use different pricing structures. The models have common eligibility requirements, employ the same definition of “reasonable and necessary” supports, and use individual Participant Plans to enable maximum choice and control by individuals over their services.

A fundamental approach to this evaluation, and its underlying methodology, is “that it is not sufficient to identify differences without confidently being able to explain the reason for these differences”.

The evaluation has developed the basis to compare and contrast the respective models and to separate policy and practice differences influenced by the environmental, cohort and implementation effects.

This Final Report accurately points to the cause of differences in participant experiences and in their Plan outcomes with the NDIA and WA NDIS trial models. It points to areas of improvement to inform the full NDIS national rollout with consideration of future sustainability factors.


1.2 Objectives

The evaluation objectives for this study and the staging of the evaluation were agreed between the Commonwealth and Western Australian governments.

1.2.1 Study Focus

The evaluation will focus on the extent to which the individual trials achieve a sustainable and effective service model and a positive experience for individuals and outcomes for people with disability, their families and carers. The report will need to explicitly identify these and future implications for disability reform in Western Australia

1.2.2 Study Objectives

The purpose of this study is to provide evaluation reports which will inform decision making about the future of disability reform in WA.

The objectives of the evaluation study are:

Objective 1 Compare and contrast the two trial site models.

Objective 2 Identify any implementation issues for each model which will require attention during the two-year trial (formative perspective).

Objective 3 Monitor and track modifications that are made to both models during the trial period and determine the reasons for the changes.

Objective 4 Provide information on the processes and outcomes of each model to the extent possible within the available timeframe.

Objective 5 Identify and discuss the implications of the evaluation findings for the future of the disability reform agenda in Western Australia and nationally.

1.3 Terms of Reference

Four Terms of Reference were identified for the evaluation:

a) a sustainable and effective service model;

b) a positive service experience for individuals;

c) outcomes for people with disability, their families and carers; and

d) implications of future disability reform in Western Australia.

Each Term of Reference included a list of questions or topics that characterised the range, purpose and objectives to be considered.


1.3.1 Evaluation Focus (Compare and Contrast)

Term of Reference a): A sustainable and effective service model

The key focus of this evaluation was to compare and contrast the trial service models in operation at the two trial sites in Western Australia. In particular, to examine and compare the preparation and operation of a Participant Plan, its policies, procedures, roles, responsibilities and relationships with other bodies that influence delivery of an effective Plan.

The common elements together with the minor and major differences in the way the models are implemented and operated in the trial sites have been identified. Importantly, the observed differences between the business policies, procedures and practices of both trial models have been isolated from the environmental, cohort and implementation factors so that the findings and opportunities identified in this report may be applied to the broader implementation of the NDIS across Australia and contribute to its future sustainability.

Without such separation it is not possible to reliably establish the cause of differences affecting observed experiences and outcomes.

Points to consider include: operational flexibility, staff involvement, complaints processing, policy factors, capacity to meet demand, cost effectiveness, Provider capacities and service delivery.

1.3.2 Evaluation Focus (Experiences)

Term of Reference b): A positive service experience for individuals

The experience of agency staff, Providers and Participants is an important gauge as to the effectiveness of the trial models, their similarities, differences, strengths and weaknesses.

Points to consider include experiences with: Participant planning and funding, coordination support, engagement with Providers and inclusion of mainstream and community supports.

1.3.3 Evaluation Focus (Outcomes)

Term of Reference c): Outcomes for people with disability and their families and carers

A key aspect of the outcomes for Participants is the effectiveness of the operation of their Plan that includes responsibilities for the services and Plan outcomes, the effective value of the services and how well the descriptions in the Plan address their needs.

Points to consider include: accessibility to supports, equity of funding, synergy of informal and formal supports, effective choice and control, safeguards, unintentional side effects and workload on Participants.


1.3.4 Evaluation Focus (Sustainability)

Term of Reference d): Implications for future disability reform in Western Australia

The compare and contrast focus of this evaluation provides a unique opportunity to identify changes that will improve the effectiveness of the processes and associated Plan outcomes for each trial model and the NDIS in general. In addition, the indicators and processes for measuring progress toward these improvements are important to achieving beneficial changes. This report includes consideration of the importance of quality control, quality assurance and quality management and how such processes may be better used to support the ongoing implementation of the NDIS.

Points to consider include: financial operations stability, scalability to state-wide service, trends in experience and Plan outcomes for people with disability, sustainability of informal support networks, allowance for diversity and ongoing capability of specialist disability Providers.


2.0 How the Evaluation was Approached

2.1 Evaluation Approach

The first stage of the evaluation focussed on a series of surveys and workshops to form a baseline for the evaluation. The second stage built on the baseline evidence and findings, updating them with current practices, identifying changes in response to lessons learned and integrating the experiences of people with disability participating in the trials. These multiple and separate information sources inform the analysis of governance arrangements, policy, procedures and work practices of both scheme trial sites and the service providers. The WA NDIS trial site of Cockburn – Kwinana commenced in July 2015 and was included in the second round of workshops and surveys.

This Final Report brings information from all stages of the evaluation together, enabling full comparison between the two models.

The core focus of the evaluation to “compare and contrast” the trial models was enabled using a comprehensive business process model that clearly identified the similarities and differences at a detailed level. In this way, a comprehensive understanding of the fine processes and practices of each trial model was developed. This understanding was used to prepare detailed and focussed questionnaires and interview programs targeting the objectives of the evaluation and refining the business model.

An overview of the independent surveys and workshops is provided under Sources of Information on page 26 and more details are included in the attachments. The survey and workshop attendees included Participants, NDIA Planners and WA NDIS Coordinators engaged in the day to day work of plan development and operation, and Providers currently working and providing services in the trial sites. Other interviews and workshops were held with staff from the DSC and the NDIA on subjects such as business process, risk and quality management and financial operations.

The surveys and workshops were carefully prepared with extensive research and reference to the business model to produce comprehensive sets of topics and questions structured for grading and grouping the responses. This approach made it possible to collate and analyse the emerging patterns across multiple sources of information characterising similarities and differences between the trial models. The accuracy of information from a source could then be “triangulated” to ensure the highest confidence was maintained for “compare and contrast” purposes.

A set of 20 case studies was prepared, each combining material from multiple sources. A summary of each case study and the contributing sources in in the attachments. Extracts from these case studies are used throughout the report to illustrate the observations.


Throughout the report, the term “observation” is used to refer to items of information gathered from surveys, workshops and other verified sources for the evaluation. The observations do not include added interpretation from the evaluation process.

2.2 Caveats and Constraints

Cohorts and Diversity

The application of the trial model processes by each agency is individual in nature and subject to many considerations including disability cohort, ethnicity, location, family and community etc. The evaluation focusses on the processes themselves, how they are practiced and the outcomes and dependencies of each process that are characteristics of the respective trial models. Hence the comparison of the trial models is independent of the types, extent and diversity of individuals participating in the respective trial sites.

However, one aspect of this approach is that where special consideration is given to select groups it does not show up in the evaluation. An example is the streaming approach used in NDIA for complex and intensive care situations that modifies the prevailing policies of agency engagement during Plan operation. It is not the intention of the evaluation to suggest that because particular processes and practices are compared, that there are not exceptions or special cases in both trials.

Survey Samples

Due to delays experienced with responses to the Agency Quantitative Surveys and other factors outside the control of the evaluation, two variations to the study schedule were made that reduced the period available for the Participant conversation program, the second survey of Providers and the final report preparation. The detailed impact is provided in the attachments.

However, although the sample of Participants and Providers interviewed was small, consistency in the responses combined with the structured approach provided useful confirmation of trial site processes and practices and that these results were not an isolated or unrepresentative situation.

Participant Outcomes

One of the evaluation terms of reference includes the assessment of Participant outcomes to the extent possible in the timeframe. Given the progressive implementation of the trials and that a Participant Plan requires a year before review, comparative assessment of Participant outcomes was not viable. Additionally, this is a cohort dependent assessment that is outside the scope of this evaluation and both trial sites have alternative sources of comprehensive actuarial and other satisfaction surveys.


However, the evaluation has comprehensively analysed Participant Plan preparation, activation, operation and review processes and practices that accurately reflect the acceptance and effectiveness of the Plan outcomes from the Participant’s and Provider’s perspectives. Whilst a good Plan improves the likelihood, is not a guarantee of a good outcome for a Participant. Conversely, a poor Plan causes many negative impacts on Participants, Providers and agency operations. Thus Plan quality is regarded as a strong indicator of a good Participant outcome.


2.3 Key Dates

The evaluation study key dates:

16th June 2014 Study Stage 1 commenced

30th June 2015 Data collection closed for Interim Report

8th September 2015 Variation #1 Reschedule Interim Report & Stage 2 start

22nd October 2015 Original Interim Report release date

4th December 2015 Rescheduled Interim Report Draft date1

18th January 2016 Interim Report released to Joint Steering Committee

18th January 2016 Study Stage 2 commenced

31st March 2016 Interim Report publication version

9th May 2016 Variation #2 Reschedule Final Report2

18th July 2015 Data collection closed for Interim Report

2nd September 2016 Final Report Preliminary Draft

30th September 2016 Final Report release to Joint Steering Committee

Changes to the study timeline due to factors outside the control of the evaluators impacted the time available for stage 2 surveys, causing a reduction in the numbers of Participants and Providers from those originally planned.

Survey and workshop dates are provided separately under Sources of Information.

1 The original schedule for the Interim Report, due on 22nd October 2015, was modified in Variation #1 to 18th January 2016 in order to provide for delays associated with responses from the NDIA NDIS to the Agency Quantitative Survey #1 in Apr-Aug 2015. The due date for the Final Report was not changed.

2 The original schedule for the Final Report due on 22nd August 2016 was modified in Variation #2 to 30th September 2016 in order to provide for the deferred start to Stage 2, revision of the Interim Report for publication in March 2016 and delays with responses to the Agency Quantitative Survey #2 in Feb-May 2016.


2.4 Sources of Information

An extensive set of reference materials has been collated and together with information from workshops and surveys has been incorporated into the data warehouse.

Each category of source information includes multiple individual component sources.

Source Source Description

S1 Agency Policies and Business Practice

Rules and Guidelines applicable to the formulation and operation of Participant Plans published by the agencies (including relevant Acts)Agency business process workshops were held Oct-Dec 2014 and ongoing interviews to Jul 2016.

Up to Jul 2016

S2 Agency Risk Workshops Agency operational management risks and issues workshops

Mar 2015

S3 Agency Planner & Coordinator Workshops #1

Agency Planners and Coordinators operational staff interviews and workshop records

Feb 2015

S4 Service Provider Survey #1 Responses to the Service Provider survey in April 2015. (Initial interviews in Nov 2014)

Apr-May 2015

S5 Agency Quarterly Reports Agency management and actuarial Quarterly Reports Sep14 to Jul16

Jun 2016

S6 Bilateral Agreements Trial Site scheme agreements between WA State & Commonwealth Governments

Up to Jul 2016

S7 Agency Quantitative Survey #1

Responses to Agency Quantitative Survey in August 2015

May-Aug 2015

S8 External Sources Other sources including JSC NDIS inquiries and Senate hearings held in WA and Canberra in 2015.Published articles.

Up to Jul 2016

S9 Participant Plan Survey 300 Participant Plans sampled from each trial site for Nov 2014, Feb 2015 and Nov 2015.

Feb 2016

S10

Agency Planner & Coordinator Workshops #2

Agency Planners and Coordinators operational staff interviews and workshop records

Feb 2016

S11 Agency Quality Management Workshops

Review of Agency quality management approach and practices in the trial sites

Mar 2016

S12

Agency Quantitative Survey #2

Responses to Agency Quantitative Survey #2 completed in May 2016

Feb-May 2015

S13

Participant Conversation Program

Structured interviews with selected Participants from each trial site.

Jun 2016

S14

Service Provider Survey #2 Structured interviews and Service Provider survey updates in July 2016.

Jul 2016


Further information regarding the survey based sources is provided in the attachments.

The information was collated into a database repository and associated with the detail elements of the business model. The business model was also used to identify specific information required to fully understand how the agencies were performing detail processes.

The surveys and workshops were carefully prepared to clarify points of difference and highlight different experiences and outcomes where appropriate.

2.5 Action Assessment

The recommendations in the respective sections have been assessed as to the action required by the respective trial models in order to adopt each one.

The action indicators are:

In Place Evidence from the evaluation indicates that the recommendation is largely in place. However, benefits may be obtained through further refinement of process and policy.

Process Change Evidence from the evaluation indicates that the recommendation may be implemented by review and modification of business processes without policy change.

Policy Change Evidence from the evaluation indicates that the recommendation may require modification of trial model policies, rules and guidelines as well as process changes in order to progress implementation.

Not Applicable The recommendation applies to processes that do not form part of the agency’s trial model.


2.6 The Business Model

2.6.1 Business Model Overview

We used an industry standard “cross-functional business model” analysis as a basis for the “Compare and Contrast” objective of the evaluation. Using this approach, it was possible to generate a comprehensive business model combining all the processes for both NDIA and WA NDIS operations in the WA trial sites. In this way, the business rules and processes for the trial sites could be compared at a detail component level.

This approach is inherently independent of factors such as geographical, cohort and population and provides a sound basis for comparing the rules and practices of the two NDIS models in WA.

In its final form, the business model identified 20 responsibilities, 78 activities, 100 documents and 293 connecting information flows. A sample section of the business model is in Figure 1Business Model Sample showing some of the activities for four of the responsibilities. Each element of the model is associated with an extensive database repository containing categorised evidence and observations from the information sources.

Figure 1 Business Model Sample


2.6.2 Assessing the Activities

Each activity in the business model was assessed for each agency as to how well it met the needs and expectations of persons involved with the business processes. A simple rating process was used as follows:

Rating Description

OK The activity performed acceptably and met expectations

Benefit from Improvement The activity performed below expectations and requires improvement

Process Review Required The activity performed unacceptably and requires review

Not Applicable The activity is not applicable to the trial model

The surveys, workshops and interviews were carefully structured to probe how effective the business model activities were in practice and how well they met the expectations of those persons using them in their role within the model.

A characteristic of a cross function business model is that each activity is performed by a single responsibility. Also, since many activities are used in more than one of the Plan lifecycle stages, each one could be tested against multiple situations as to how well it met the expectations of its responsible role.

An activity is not isolated, it receives outputs from other activities and generates outputs for yet other activities. So assessing how well an activity is meeting its expectations means also checking if it is getting what it needs, when it needs it and is what it gets OK. Then checking if those activities needing something from it are also getting what they need, when they need it and is it OK for what they need to do next.

The rating method involved taking each activity in turn and using feedback from all the various sources that made use of the activity, or have a connection with it, for each of the trial site operations. Where the people involved in using the activity or had a dependency on it were satisfied it was operating sufficiently well it was rated as “OK”. If there were minor issues with how it was working in practice such as causing some delay or inconvenience, then it was rated as “Benefit from Improvement”. Where there were major delays, rework or unplanned costs or its outputs were not meeting the needs of other dependent activities, the activity was rated as “Process Review Required”. Some activities are not relevant to one or other of the trial site business operations in which case it was rated as “Not Applicable”.


2.6.3 Comparing Trial Model Processes

In addition to rating acceptability of activities for each trial model, a comparison was made as to how differently each activity was performed for each trial model.

Information from the surveys, workshops and interviews was used to assess each activity and the different business process characteristics of each trial model and how it was practised.

Comparison Description

Common or Minor Business rules and practices are the same or similar in both trial models.

Medium Business rules and practices are noticeably different between the trial models

Major Business rules and practices are substantially different

Using the association of activities to business work flows, such as Plan development, it was possible to “compare and contrast” at a detail level the differences between the two trial models.

The results of the activity rating and comparison are included in the sections covering each of the Plan lifecycle stages.

An extra feature of the business model that can be seen in Figure 1 Business Model Sample is the colour coding on the activities to show their comparison rating: Green for Common, Orange for Medium and Red for Major difference between trial models.


3.0 Plan Lifecycle Stage Findings

3.1 Participant Plan Overview

The Participant Plan is a document that describes the services agreed in discussion between the Participant and their family and their Planner/Coordinator. It includes some background and the life goals of the individual that are used to prepare the approach and describes the services that are to be used to engage with selected service providers. The purpose of a Participant Plan is itemised in Figure 3 Participant Plan Purpose.

The Plan structures used by the two models are similar but with one key difference 3: The WA NDIS model combines all informal and formal service strategies together under each Plan goal, whereas NDIA has separate groups for informal and formal service strategies that are not associated directly with a Plan goal. (See Figure 2 Plan Structure Overview).

The Participant’s goals and objectives are clearly stated in Plans from both agencies, albeit in a different way due to the way the strategies are structured in the document.

Each funded strategy identified for the Plan is described in terms of the services it covers.

Figure 2 Plan Structure Overview

The WA NDIS Plans provide the method of calculation and the Provider who has agreed to deliver the services. They also include in the funding summary the funding contribution from in-kind and mainstream supports where the costs are known. This provides an overall picture of the financial supports received by the individual. See

3 From August 2015, NDIA introduced a major revision to the structure of their Plans. Some information was removed (such as the name of the NDIA Planner) and the number of strategies reduced in accordance with the revised service category structures and codes. The observations in this document are based on the Plan structure adopted from August 2015.


Error: Reference source not found.

The NDIA sample in Error: Reference source not found shows the “Reference Number: 0014" which is the Support Coordination service discussed later.

Figure 3 Participant Plan Purpose


The purpose of a Participant Plan is to: record the desires and needs of the participant;

define the journey for the participant;

describe the desired outcomes for the participant;

describe the relationship between the participant and the various support providers assisting in achieving the objectives in the Plan;

describe the involvement of community in the participant journey;

describe how the supports funded under the NDIS will work with mainstream services for the participant;

provide guidance on how the participant can exercise choice and control;

rationalise the interpretation of and agree on what is reasonable and necessary;

describe how the participant is involved in the operation of the Plan and engagement of supports;

describe the respective responsibilities of all parties involved in operation of the Plan strategies and its services;

determine the level of investment in providing supports to the participant; and

describe the particular services that are required for complex needs and challenging behaviour.

3.2

Participant Plan Lifecycle

All Participants have a Plan that embodies the agreement between them and the agency. It describes their life, situation, personal goals, need for assistance and the supports that are to be provided.

The Plan has the central role in the description, funding and method of accessing services and supports to an individual and their family.

A Participant Plan progresses through six stages of its lifecycle as shown in Error: Referencesource not found


Figure 4 WA NDIS Plan Funding Sample Figure 5 NDIA Plan Funding Sample

Figure 6 The Plan Lifecycle

It has been useful for this evaluation to look at the trial models as to how they work and compare them for each of the Plan stages. This report presents the results in four groups as shown in Error: Reference source not found:

Plan Development – covers Participant eligibility and Plan development,

Plan Engagement - covers Plan endorsement and activation,

Plan Operation – covers Plan operation, and

Plan Review and Adjustment – covers the Review stage which performs adjustments and initiates Plan re-development.

3.3 Engagement Overview

Each stage of the lifecycle is characterised by different levels of engagement between the participant, agency staff and service providers. Figure 8 Engagement Overview provides an overview of the different engagement approaches practised within the two trial models.

The horizontal bars represent the degree of engagement of each of the principal roles (Participant, Planner etc.) in each stage.


Figure 7 Plan Lifecycle Stages

Figure 8 Engagement Overview

Full bar Engaged in the lead role. A lead role has the key responsibility for the outcomes of the stage.

Shaded bar Engaged in a supporting role. A supporting role has a significant part in contributing to the outcomes of the stage.

Empty bar Not engaged. The role may provide a low level part and contribute to the outcome of the stage in a minor way or not be involved at all.

Mixed bar Indicates that for the stage, the role may have either a lead or supporting role depending on the management responsibilities specified for a particular Plan strategy.

The participating roles for NDIA NDIS and WA NDIS are briefly described below.


NDIAService Provider

Provides formal and informal services to the participant

Finance Officer Provides financial monitoring and services for the participant

Business Support Officer

First point of contact for agency support for the participant.

NDIA Planner Provides Plan development and review support.

Participant Self-manages the operation of the Plan and service providers

WA NDISService Provider

Provides formal and informal services to the participant

Technical Officer

Provides financial monitoring and services for the participant.

WA NDIS Coordinator

First point of contact for Plan development, ongoing participant support and Plan review.

ParticipantSelf-manages their Plan or participates in an organisation managed arrangement with a Provider.

The WA NDIS and NDIA differ in their approach to engagement and responsibilities.

WA NDIS: The trial model provides continuity of support throughout the process with a Coordinator assigned to the Participant and their family from the time of eligibility request throughout all stages of the lifecycle. During the Plan operation stage, the participant, together with their family, leads their own self-managed strategies and services and receives Organisation Managed supports from Providers. Their Coordinator proactively monitors the Participant and their services and provides assistance as required.

NDIA: The trial model assigns a Planner to the participant and their family once access is granted following the eligibility request. The Planner leads the Plan development and is responsible for the successful endorsement and handover to the Participant for Plan activation and operation. During Plan activation and operation, the Participant has primary responsibility for directing and managing their supports with assistance from NDIA finance officer, business support officer and their Support Coordination Provider (where the Plan provides funding for this) 4. NDIA assign a Planner for Plan review and adjustments when required.

4 NDIA provide additional levels of monitoring of Participants by the Intensive Support Team where identified as part of their Plan.


3.4 Plan Development

3.4.1 Plan Development Overview

Following successful assessment for eligibility, an individual is granted access to the NDIS and starts development of their Plan.

The main contribution for Plan development is shown in Figure 9 Plan Development Contribution.

Figure 9 Plan Development Contribution

The overall engagement across the full Participant lifecycle is shown in Figure 8 Engagement Overview on page 35. An extract of the engagements associated with the Plan development stage is in Error: Reference source not found.

The approach by WA NDIS and NDIA to Plan development have some key differentiating factors. With respect to the engagement with the individual and their family:

The WA NDIS Coordinator remains involved from eligibility consideration through Plan development and continues providing support and assistance for the individual and family onwards through later Plan lifecycle stages.


Figure 10 Plan Development Engagement

The NDIA Planner involvement commences after access is granted and ceases after Plan approval.

With respect to engagement with Providers during Plan development:

The WA NDIS Coordinator assists the Participant to choose Providers and discusses with them and the Providers the necessary and required supports, optimisation of support strategy grouping and validation of support service descriptions and budgets.

The NDIA Planner does not identify or associate Plan supports with a Provider during Plan development. Service descriptions and budgets are only discussed with the Participant.

3.4.2 Plan Development Delay

Period between Access approval and first Plan approval.

The initial delays from the backlog of new individuals entering the NDIS scheme for both agencies was effectively cleared by April 2015 and as of December 2015 the typical time between granting access to the scheme and approval of the first Plan is around 50 days for both trial sites.

Figure 11 Plan Development Period

The different approach to Plan development between the models does not appear to influence the elapsed time between when a Participant becomes eligible and approval of their Plan where the trial implementation backlog is not a factor.


3.4.3 Business Process Comparison

The business process model allowed for detail recording and analysis of the component activities as performed by each agency in the trial sites. In particular, it is emphasised that these assessments are based on observations of how the processes are actually applied in practice and not necessarily the intentions of the respective agencies. This section presents findings from the business model from two perspectives:

Business Process Assessment – For each trial site, information from all sources was used to assess issues, constraints and opportunities associated with the practice of the individual processes. A simple assessment method was applied indicating the process is OK, would benefit from improvement or needs review of the process to address inadequacies.

Model Process Comparison – The “compare and contrast” objective of the evaluation identified the degree of difference in the way the business model activity is practiced within each of the two trial sites. This is independent of the business process assessment and the process comparison was noted as common to both schemes, or to have minor, medium or major differences.

Plan Development Business Process Assessment

All

surveys, workshops and other sources of information were used to assess how the two schemes perform the 17 business model processes that support Plan Development. The results are in Error: Reference source not found.

WA NDIS:

No activities were identified to require process review.

4 of the business model activities as practiced by WA NDIS associated with Plan development were assessed to benefit from improvement. These activities relate to efficiencies associated with issue resolution, Plan internal reviews and quote preparation by Providers.

NDIA:

3 of the business model activities as practiced by NDIA associated with Plan development were assessed to benefit from review of business processes in order to remediate


Rating NDIAWA

NDIS

OK 5 13

Benefit from Improvement 7 4

Process Review Required 3 0

Figure 12 Plan Development Process Assessment

constraints and issues associated with current practices. These activities relate to expense account operations, issue escalation and Participant relationship.

7 business model activities were assessed to benefit from improvement in efficiencies associated with preparation of Plan content, service costing, funding descriptions, Participant and Provider interactions and Plan internal reviews.

Model Process Comparison

The degree of difference as to how each agency implemented and practised each process was assessed as shown in the following table.

Comparison

Activity Difference Count %

Common or Minor 4 24%

Medium 776%

Major 6

Total 17 100%

Areas of major difference in Plan development include 6 activities associated with operating option processes, interaction with Participant and Providers, service costing and escalation processes.

Areas of medium difference include 7 activities associated with funding and expense provisions, internal Plan reviews, Plan structures and planning liaison.

4 activities were considered to be the same or have minor differences.

This demonstrates that 76% of the processes involved in Plan development under the two models are significantly different to each other and leads to the observed differences described in this section.


3.4.4 Developing a Plan

Plan Development Steps

Developing a Plan for an individual and their family is a skilled process that benefits from experience. Knowledge of the nature and nuances of various disabilities in different cohorts is essential to make accurate assessments of the “necessary and reasonable” supports in order to prepare an effective Plan.

Building a Plan involves a number of steps and associated skills. The three steps are shown in Figure 13 Plan Building Steps and both trial models employ the same steps, although the results of each step differ in terms of the Plan structure and content.

Figure 13 Plan Building Steps

A Plan describes how the services are to be accessed and managed, either directly by the individual or their family, or through a Provider. These basic options are shown in Error: Referencesource not found. Both models include similar methods for informal supports from mainstream and family where NDIS funding is not included.


WA NDIS Plan Development Approach

The WA NDIS approach is focussed on negotiation and engagement of the parties that will have roles in delivering the supports specified in the Plan for the determined budget. This is a three-way interchange between the individual, the Coordinator and the Provider and may include other clinical, allied health and mainstream advice. The effectiveness of this three-way collaborative consultation approach was endorsed at Coordinator workshops, Service Provider surveys and interviews, and discussions with Participants.

The level of content, specification and style across all the 300 WA NDIS Plans surveyed was consistent.

The broader consideration of informal mainstream, family, community and verified formal supports from Provider quotes lead to high levels of confidence that the developed Plan will be effective and quickly activated.

The outcome of the three-way cooperation and negotiation process was observed to promptly activate Plans and run smoothly with a low level of problems during Plan operation.

NDIA Plan Development Approach

The NDIA approach is focussed primarily on engagement between the Planner and the individual and their family. Observations with Participant experience on the consultation process and resolution of “reasonable and necessary” supports varied and the 300 NDIA Plans surveyed showed a consistently low level of detail about the individual and limited informal support information. The formal funded supports were specified and budgeted primarily on the basis of the Planner’s experience, Participant conversations and agency guidelines.

The individual endorses Plans where the viability of services has not been tested. Subsequently, activation may be delayed due to Provider rejection of services considered to be not financially viable. (This is covered in the PlanEndorsement and Activation section of this report.)

Life Planning

Differences in the degree of consultation and understanding of the individual’s situation were evident from the Plan Survey. The WA NDIS Plan life descriptions were more comprehensive than NDIA as shown in Error: Reference source not found.5

5 The comparison is based on 100 Plans from each trial site sampled for November 2015 provided for the Plan survey.


Figure 14 Plan Life Description Comparison

The average number of lines describing the life situation of the Participant and family in NDIA is 15.2 compared to WA NDIS with 33.5 lines.

To further illustrate the difference in the investment in understanding the individual that is reflected in the Plan life story, the data in Error: Reference source not found shows that 5% of NDIA Plans contain over 25 lines of Plan life description compared to 66% of WA NDIS Plans.

Position of Power

Perceptions were commonly held by individuals that the agency, through their Coordinator or Planner, was in a strong position of power in determining their future by way of how the Plan was developed and the supports that were to be included. A high level of anxiety was expressed as to the uncertainty that current supports would be continued in following years. This was common to both models although to a lesser extent with WA NDIS Participants, attributable to the ongoing relationship with their Coordinator.

Collaboration

Differentiation between these different Plan development engagement approaches is most evident where complex needs require assessment. Each model uses sliding scales to determine the level of support that is deemed reasonable and necessary in each circumstance. The three-way collaborative approach used by WA NDIS was seen to better optimise the required supports and the Provider surveys, interviews and Participant conversations provided evidence as to the disparate Plan outcomes and experiences resulting from the different model approaches to Plan development.

Provision for transport for access to participant services is a factor that may benefit from the negotiation process during Plan development and in consultation with the Provider. It can take into account whether a participant can travel to a service point to receive services, the suitability of public transport or whether the service provider will need to travel to the Participant’s home. Under NDIA Self-Directed Plans, insufficient travel facilitation has been observed as a reason for a Provider to reject Plan services during activation, or to negotiate with the Participant for a reduced effective service time in order to provide for travel time as part of the service.

Plan Development Effort

The effort put in to planning and optimisation of Plan strategies and services was observed to have an effect on the ease of activation and operation of a Plan. This is a consultative process and the two models approach this differently in terms of business process and practice:

For both agencies, resources assigned to Plan development are not subject to the scope of services or associated budgets in the Plan. However, agency performance indicators are applied to the preparation of Plans that impacts the content and quality of Plans and the level of engagement, consultation and contribution to the Plan.


Data from the Agency Quantitative Survey covering the number of Planners or Coordinators and number of Plans approved per month of the trial average number of Plans per was used for the following table. The actual graph is shown in Figure 15 Plans per Planner/Coordinator

Agency Average Plans per Month

WA NDIS Coordinator 3.6

NDIA Planner 4.8

WA NDIS Coordinators spend some of their time in ongoing support of their portfolio of Participants. WA NDIS do not have information breaking down the proportion of Coordinator time spent on general Participant operational support compared to Plan development and review. It appears reasonable to assume the 25% fewer Plans produced by WA NDIS Coordinators compared to NDIA Planners is due to these other duties.

Based on these observations and assumptions, the time and effort to prepare a Plan for both agencies would seem to be the same, notwithstanding the differences noted between their contents and preparation methods. (4.8 Plans per month equates to about 33 hours per Plan)

Figure 15 Plans per Planner/Coordinator

The cost of Participant Plan preparation is quarantined from the cost of support services that are described in the Participant Plan6. Performance measures put in place to manage the cost and productivity for Participant Plans need to consider any consequential impact on the experience and outcomes for Participants. A few dollars saving in Plan preparation cost may compromise a

6 All the costs associated with the trials are set out in the bilateral agreement (Schedule G of the Intergovernmental Agreement and the National Partnership Agreement). The trial site operations and administration costs of the NDIS (which include the cost of Participant Plan preparation) are quarantined from the cost of support services that are described in the Participant Plan


much greater cost in operation of the Plan which typically, according to actuarial data, averages in excess of $30,000.


3.4.5 Service Management Options – Overview

Service management is the term used to describe how the formal supports in a Plan are managed. In particular it covers methods for engaging and receiving funded services from Providers and other sources.

Figure 16 Plan Categories

There are two fundamental categories of supports covered in a Plan (Figure 16 Plan Categories):

Informal Supports (Error: Reference source not found) are those not funded by the NDIS. They include all supports provided by the family, friends and the local community. Informal supports are managed by the Participant and their family, with some assistance from the agency or covered in their Plan where their circumstances require it. To simplify model comparison, Mainstream sources such as Department of Health, local Doctors, Hospitals etc. are grouped with ono-NDIS funded services under informal supports.

Formal Supports (Error: Reference source not found) are those funded (through either agency) from NDIS funds. These supports are managed by one of the Service Management options available from the respective agencies.

WA NDIS Trial Evaluation – Final Report 30 September 2016 of 127Figure 18 Plan Formal SupportsFigure 17 Plan Informal Supports

The models differ substantially when it comes to obtaining services from a Provider. Each trial model includes two basic options for service management as shown in Error: Reference source notfound

Self-Directed (NDIA)

NDIA have a method called “Self-Directed” where the individual, after getting their approved Plan, chooses the Provider and then arranges to receive specific services that the Provider then claims from NDIA.

Organisation Managed (WA NDIS)

WA NDIS have a method called “Organisation Managed” where the individual chooses the Provider during the development of their Plan and then, after Plan approval, the Provider is contracted and paid by DSC to deliver the specific services in the Plan to the individual.

Self-Managed

Both models have a “Self-Managed” method where the individual looks after obtaining and paying for the services by themselves. This involves receiving an advance or claiming for reimbursement of the costs.

The key difference between the models is that WA NDIS select and engage with the Provider during Plan development whereas NDIA defer selection until after the Plan has been approved and responsibility has been transferred to the individual to perform the selection and engagement. This difference has many consequences, discussed further throughout this document.


Figure 19 Plan Management Options

3.4.6 Organisation Managed (WA NDIS)

The Organisation Managed supports option is part of the WA NDIS model and is based on the DSC approach that has been in operation for over 20 years. A Plan may have multiple Providers delivering Organisation Managed services.

The main features include:

The choice of Provider is made by the Participant during Plan development,

Supports are grouped together for a chosen Provider,

Plan support specifications and costings are negotiated between the Coordinator, Provider and Participant,

Agreement of all three parties (Provider, Coordinator and Participant) is required for Plan approval, and

Following Plan approval, a contract Schedule Variation Agreement is enacted between the Provider and DSC covering conditions and responsibilities for operation of the agreed components of the Plan.

The payment and service methods for WA NDIS Organisation Managed are summarised in Error:Reference source not found.

A Shared Management service option is offered under the Organisation Managed support. Under this arrangement between the Provider and Participant, the Provider takes on the overall responsibility and liabilities associated with supports that would usually be handled under the Self-Management option by the individual. The Provider assists the individual in choosing and engaging local services for support as and when required while safeguarding their liabilities and handling the funding associated with the Plan supports.


Figure 20 Organisation Management

Provider experience with Organisation Managed option processes during Plan development noted that:

The process has not changed from previously established DSC arrangements in order to allow for differences in the way the WA NDIS trial model operates,

The multi-step process includes:

Participant and Coordinator choose Provider,

DSC issues request for quote from nominated Provider,

Provider meets with individual, reviews and negotiates specifications,

Provider submits quote to Coordinator to incorporate into draft Plan, and

Coordinator arranges 3-way signing of agreement for Plan approval.

The processes associated with Organisation Managed option are subject to delays and would benefit from revision to reduce unnecessary overheads and effort.

In some cases, an Individual’s experience with the existing Organisation Managed arrangements with a Provider has led to an intention to change to a Shared Management approach in their next Plan to enable greater freedom in choice of supports provider during Plan operation.

CS02: (WA NDIS) XXX said: “Shared Management offers me the ‘best of both worlds’”

CS12: (WA NDIS): Participant XXX said: “Because of where we live, we do not have access to the same services as other places. We choose to Self-Manage so we can use local services for support.”

CS12: (WA NDIS): A Coordinator said: “We need to use Self-Management as an option in Plans so that local services can be used where registered services are not available.”

CS03: (WA NDIS): Provider PPP talking about the efficiency of quoting for WA NDIS: “We have agreed with DSC to a fixed rate example to simplify our response process”. The ability to negotiate the service requirements with the Coordinator was considered an integral part of the quote process.

CS03: (WA NDIS): Provider PPP commented: “We recognise the value of involvement but it needs to be more efficient. The mandatory Participant contact often causes delay in getting the quote completed”

CS03: (WA NDIS): Provider PPP commented that although the quote process was onerous for WA NDIS, it provided an opportunity to negotiate on the services and to meet the Participant.

CS03: (WA NDIS): Participant XXX moved to the trial site from Perth with their parents. XXX needed intensive and ongoing support that was not available in supported accommodation at the time. The discussions were escalated to the Regional Director who with the family identified a Service Provider willing to develop the facilities in the group home together with training of support staff to meet the needs of XXX. Discussion and negotiation between the provider, XXX and family together with the WA NDIS team took 6 months.


3.4.7 Self-Directed (NDIA)

Self-Directed supports under NDIA are similar to Self-Managed except that the supports are sourced from a Provider who is reimbursed directly by NDIA via their portal claims process. The individual does not need to manage the funds for supports under the Self-Directed option.

Similar to Self-Managed option (but different to the Organisation Managed option under WA NDIS), in that the Provider is not identified during Plan development but deferred until after Plan approval.

The choice between Self-Directed and Self-Managed is by the Planner in discussion with the individual although NDIA guidelines prevail.

The Self-Directed option requires that there are Providers available at the Participant’s location for the Plan services. Otherwise, the Self-Manage option is required in order to allow access to local non-registered providers. Evidence that this is considered during Plan development was not observed and has been a factor in Plan activation delay.

The payment and service methods for NDIA Self-Directed services are summarised in Error:Reference source not found.

Grouping of supports for delivery by a Provider is not performed during Plan development. This is the responsibility of the individual during activation of their Plan as part of the selection and negotiation with Providers.

The category of Support Coordination has increasingly been applied in Plans since July 2014. This support category provides assistance to the individual to administer Self-Managed and Self-Directed supports, choose providers (local and Providers) and coordinate supports from multiple sources. As in the case of other Self-Directed supports, the choice of Provider to provide Support Coordination is also up to the individual, following Plan approval.

The specification and budget for the Support Coordination is included in the Plan. The use of Support Coordination category support has increased from 41% of Plans in November 2014


Figure 21 Self-Directed (NDIA)

Figure 22 NDIA Support Coordination

to 53% in November 2015. By way of example, in November 2015 of the 100 Plans sampled, (see Error: Reference source not found) the average allocation was $1,830 pa which is equivalent to 20 hours support over the year. This also means that 47% of Participants have no Support Coordination7.

The viability of Plan services is not tested during Plan development and establishing the feasibility of activation and delivery of the Plan supports is not required for Plan approval. 8.

CS10: (NDIA) Participant comment about allowing Service Providers to attend a Plan development meeting: “I knew that bringing them with me was not appreciated so I did not say they would be coming. The planner was not impressed, listened to each one then asked them to leave straight away”

CS01: (NDIA) Examples of Plans considered unsuitable to the needs of the individual by experienced therapists were provided by PPP as evidence of inadequate consideration of the Participant needs by the Planner during Plan development. Evidence pointed to the Planner superimposing their assessment over evidence provided by the individual’s parent.

CS10: (NDIA) Participant XXX said “They don’t want anyone there because they know what our rights are” when referring to being told not to bring their Provider representative to the meeting.

CS10: (NDIA) In regard to level of understanding about the disability support needs; the Provider said: “They don’t want us there because they think we know too much”

CS08: (NDIA) Participant XXX stated: With transport funding removed, the family and XXX tried to negotiate alternative arrangements with the Service Provider but was unsuccessful as the Service Provider would not do it for the cost. XXX’s family stated that her network of families with disability were having similar experiences with the same Service Provider due to loss of their transport supports. XXX family stated “… they told us that we would have individualised funding, how is removing everyone’s transport ‘individual’?”

CS11: (NDIA) Participant XXX stated in relation to current plans: Plans contain poor support details, are difficult to interpret and lead to confusion with delivery of services and upset families.

CS19: (NDIA) Participant YYY said: “… preparing the plan was a negative experience because the Planner did not listen to me or want to understand XXX support needs” “… requests to remove supports that XXX would not use were ignored”.

CS04: (NDIA) Participant XXX commented on the effectiveness of XXX’s Plan on XXX’s life: “It (the Plan) is a waste of words”

7 The role of Support Coordination within WA NDIS is provided by the Coordinator and not subject to Plan specification or budget and has ready access to (internal) peer and escalated support.

8 NDIA provide additional levels of monitoring of Participants by the Intensive Support Team where identified as part of their Plan.


3.4.8 Self-Management (Both Agencies)

Both models provide for Self-Management where the individual has some funds they are able to spend on services and providers of their choosing as and when required, within the bounds described in their Plan. These services tend to range from allowances for travel such as cab fares to employment of casual labour for care support.

Self-Management requires that the individual be able to manage the spending of the allocated money and record and claim for reimbursement of these expenses and be aware of the budget. In some cases, small advances are made to simplify minor costs such as admission fees and local travel.

The payment and service methods for NDIA Self-Directed services are summarised in Error:Reference source not found.

The main positive factors for the Self-Management option are:

The ability to access local support services as and when required and not be constrained to registered Providers. This has been observed to be a significant factor where the Providers do not have a local presence and consequently influenced the decision to take on Self-Management.

The ability to exercise choice and control during Plan operation by engaging service providers as and when required. There is no constraint to activate services promptly after approving a Plan and local services can be changed to suit the individual’s preferences.

The main negative factors for Self-Management are:

The need to effectively manage the budget, receipts and claims. For WA NDIS, this means a strong receipting regime for submission of monthly, paper-based claim forms. For NDIA, this means using the MyGov computer access to the NDIA Portal to lodge claims.


Figure 23 Self-Managed

Figure 24 WA NDIS WC Plan Sample

Where employment of casual labour is involved, there are liability issues associated with superannuation and worker’s compensation that fall on the individual. WA NDIS explicitly provide for these items in the Plan. The 300 Plans provided by NDIA for review did not include explicit provision for these requirements.9

Responsibility falls on the Participant to find and engage suitable service providers. This can be challenging where there is either a shortage of the appropriate services or the services are not provided locally or the funding provided in the Plan is considered by providers to be insufficient to justify the provision of the services.

The decision as to what services may be Self-Managed is agreed between the agency Planner and the individual, although the agency Planner has a final say. The decision includes consideration of a variety of factors, including: supports availability, ability to manage the funds, level of family support and the individual’s disability (such as psychosocial).

CS12: (NDIA) Participant XXX. “…It will be their responsibility, I will only employ sole traders”. When it was explained that a sole trader was not able to access worker’s compensation, XXX stated “they [the NDIA workshop] didn’t explain that one”.

CS12: (NDIA) Workshop attendee commented: “a Participant can make additional one-off claims for insurances not provided for in their Plan”

(See also comments on page 80)

3.4.9 Use of “Norms” for Plan Assessment

Both models employ comparison of the Plans with “Norms” as part of their quality management programs.10 Plans that lie outside what is considered normal for the statistical expectation for the cohort are flagged for checking.

9 NDIA state that the cost of superannuation and worker’s compensation are included in the base rate costings for the service in the Plan.

10 The Quality Management workshops confirmed the use of a “Please Explain” to clarify Plans considered to be outliers from the “Norm”.


However, in practice the application of this has other implications and impacts each trial site differently.

WA NDIS:

Plans are peer reviewed prior to approval processes,

Draft Plans are compared to a Norm for the cohort, and

Coordinator explains reasons for outliers to peers and Area Manager and adjustments negotiated.

NDIA:

When completed, Plans are compared to a Norm for the cohort,

A “Please Explain” is issued to the Planner if an outlier is detected. A detail assessment justifying support specifications and budgets in the Plan is required,

Planners are intimidated by getting a “Please Explain” and the work involved in the review process, and

Pressure to conform to the Norm has the result that Plans are developed using acceptable, easily justified levels for each support, avoiding what may be “reasonable and necessary supports” that are different to the “standard”.

The use of Norms is a valid approach to mapping the range and diversity of individual needs and Plan investments. However, it is not an indicator of Plan Quality, suitability for activation or the acceptability of service outcomes from Plan operation and appears inconsistent with the NDIS commitment to individualised funding.

CS01 (WA NDIS) Coordinators commented that all Plans are peer reviewed as part of the development procedures for Plan consistency and Coordinator training purposes. This included comparison with “Norms” for cohort consistency assessment and consideration of any appropriate adjustments. Clarification may be sought from the regional director as required.

CS01: (NDIA) Planners commented that they made efforts to avoid getting a “Please Explain” when putting a Plan together. A “Please Explain” involved a time consuming detail review to justify the assessment and pricing of every component of a Plan and implied they had made an error in the assessment of the Participant and their needs.

CS01: (NDIA) A Participant case was cited by Provider PPP where a severely autistic individual was assessed to have a low level of disability by the Planner on the basis that XXX had “a happy demeanour”. Provider PPP’s therapist asserted that this “demonstrated a gross lack of understanding of the characteristics of the autistic disability”. The situation was compounded by the family not having English as a first language and feeling intimidated at the meeting and agreeing to any support they could get. Comprehensive information from XXX’s therapists was available but not accessed by the Planner.

CS09: (NDIA) Participant XXX’s podiatry supports were removed from the new plan. The funding of podiatry was transferred to Medicare. However, complications with XXX’s disability caused XXX’s GP to insist that treatment for the complication took priority over XXX’s podiatry needs. Because the family has limited


capacity to pay the total gap payments under Medicare, a family member stated “we have to wait ….which is causing a major problem for XXX”.


3.4.10 Plan Development Summary

1. Development of a Plan that meets Participant expectations and agency guidelines:

a) The relationship with the Planner/Coordinator is the key factor in generating a successful Plan that meets Participant expectations and agency guidelines.

b) Restricted consultation, limited experience of the Planner/Coordinator with the disability and preconceptions lead to poor Plan acceptance by the Participant and inappropriate services with reduced outcome satisfaction.

c) Understanding complex needs are better resolved together between the Planner/Coordinator and Participant to best assess required services.

d) Incorporation of Provider experience with the Participant and in delivery of identified services is a valuable contribution to Plan robustness and acceptance by the Participant.

e) The power balance between Planner/Coordinator and Participant requires careful attention to avoid compromising the Participant’s Plan and supports.

2. Confirmation of the viability of a Plan prior to approval:

a) The viability of Plan service descriptions and budgets is best established using a three-way process involving the Planner/Coordinator, Provider and Participant in information sharing, service negotiations and planning the strategies during Plan development.

b) Plan feasibility and viability should be established prior to submitting a Plan for approval.

3. Plan quality performance indicators:

a) Compliance with “Norms” compromises Reasonable and Necessary criteria and objectives for Individualised Assessment. Pressure by the agency on Planners/Coordinators to comply can lead to “standardising” of Participant’s disability assessment, less effective planning of support services and Participant dissatisfaction with their Plan.

b) Inappropriate performance indicators may work counter to Plan quality objectives and have a negative impact on service activation and Participant outcomes.


3.4.11 Plan Development Recommendations

No. RecommendationAction

WA NDIS NDIA

3.4.A Early engagement of Providers in Plan development and services commitment is to form part of the ongoing WA model.Evidence from the evaluation clearly demonstrated using a three-way engagement process (including Providers as in the WA NDIS Organisation Managed approach) is the most effective way of optimising Plan services and producing better experiences for Participant and Providers and Plan outcomes.


3.4.B The viability of all funded services in a Plan is to be proven prior to approval.Evidence shows that where a Plan includes services that have not been proven as viable contributes to Participant’s stress, rejection by Providers and delays in Participants receiving Plan supports.


3.4.C Performance indicators used to monitor Plan quality are to reinforce the primary purpose of a Plan and not promote conformity. Evidence shows that pressure to conform to “Norms” leads away from the principle of individualised assessment and compromises Participant’s experiences and Plan outcomes.

Process Change

Process Change


3.5 Plan Endorsement and Activation

3.5.1 Plan Endorsement and Activation Overview

The main contribution for Plan development is shown in Figure 25 Plan Endorsement and Activation.

Figure 25 Plan Endorsement and Activation

The lifecycle stages of Plan Endorsement and Plan Activation represent the engagement process of a Plan with the Participant and with Providers to commence the supports and services. There are differences in the way the two trial models approach each of these stage processes, however, the start point is a draft Plan and the end-point is an approved Plan with “activated” services agreed with one or more service providers.

An extract of the engagements associated with the Plan development stage is in Error:Reference source not found


Figure 26 Plan Endorsement and Activation Engagement

Endorsement

The Endorsement stage of the Plan lifecycle is where the draft Plan prepared during Plan development, or adjusted in the Plan review stage is presented to the Participant for their agreement and endorsement.

For NDIA, this is where responsibility for Self-Managed and Self-Directed supports is accepted by the Participant and the new Plan endorsed:

The NDIA Planner is responsible for successful transfer of responsibility and endorsement of the Plan.

It is noted that NDIA do not require the Participant to endorse or approve their Plan explicitly. It is assumed that the Plan as prepared by the Planner and sent to the Participant is agreed and endorsed unless the Participant requests an internal review.

NDIA can change a Participant’s Plan at any time. Plan changes are common and specification and budget changes to the Plan do not require endorsement by the Participant.

Reissued (updated) Plans are not identified as different to other previously issued Plans with release dates or other means of version identification.

At this point, the Plan budgets are implemented into the MyGov NDIS accounts for each support service in the Participant Plan.

The MyGov NDIS Participant portal budget is often different to the Plan budget for no apparent reason, and unattributed payments (such as “catch-up” and “handling fee”) were noted.

For WA NDIS, this is where responsibility for Self-Managed supports is accepted by the Participant.

The WA NDIS Coordinator is responsible for successful transfer of responsibility for the Self-Managed supports, assisted by the Technical Officer for associated accounting processes.

Changes to a Plan are rare except for emergency strategy additions

Endorsement of changes is almost exclusively due to Plan review.

CS10: (NDIA) Participant XXX has received five versions of their Plan in twenty months, each with varying services and amounts of funded dollars. When XXX has changed needs [eg. therapeutic aids] the process has been to contact the supports coordinator who then negotiates any changed needs with the agency. The modified Plan is then emailed to XXX. The family and XXX have been requested by the Planner not to contact them until the annual review of the plan.


Activation

The Activation stage of the Plan lifecycle is where providers are engaged to deliver formal services specified in the Plan. This includes NDIA Self-Directed and WA NDIS Organisation Managed services.

For NDIA, activation is the responsibility of the Participant and involves choosing the Provider for one or more Self-Directed services in their Plan and setting up a service plan with the selected Provider. The Participant then provides permission for the Provider to access their NDIA account for the identified Plan service categories. Where the Plan provides for a Support Coordinator, this is usually the first step in engaging a Provider in order that assistance is available in selecting and engaging additional Providers for Plan services.

For WA NDIS, the Coordinator oversees activation of the Organisation Managed supports which involves issuing the contract Schedule Variation Agreements to the respective Providers according to the quotes provided during the Plan development. The Providers then contact the Participant to finalise their service plan.


The business process model allowed for detail recording and analysis of the component activities as performed by each agency in the trial sites. In particular, it is emphasised that these assessments are based on observations of how the processes are actually applied in practice and not on the intentions of the respective agencies. This section presents findings from the business model from two perspectives:


Model Process Comparison – The “compare and contrast” objective of the evaluation identified the degree of difference in the way the business model activity is practiced within each of the two trial sites. This is independent of the business process assessment and the process comparison was noted as common to both schemes, minor, medium or major differences.

Endorsement and Activation Business Process Assessment

All surveys, workshops and other sources of information were used to assess how the two schemes perform the 17 business model processes that support Plan endorsement and the 23 that support Plan activation. The results are in Figure 27 Plan Endorsement Process Assessment.


WA NDIS:

No processes were identified as requiring process review.

7 of the business model activities as practiced by WA NDIS associated with Plan endorsement and activation were assessed to benefit from improvement. These activities relate to efficiencies associated with Plan adjustments, escalations and document management.

NDIA:

12 of the business model activities as practiced by NDIA associated with Plan endorsement and activation were assessed to benefit from review of business processes in order to remediate constraints and issues associated with current practices. These activities relate to expense account operations, issue escalation, service activation with providers and Participant relationship and support.

14 business model activities were assessed to benefit from improvement in efficiencies associated with Provider engagement, Plan adjustments and account implementation.

Activation Rating

NDIAWA

NDIS

OK 8 18



Figure 27 Plan Endorsement Process Assessment


Endorsement Rating NDIAWA

NDIS

OK 5 14




The degree of difference as to how each agency implemented and practised each process was assessed.

Comparison Endorsement Processes

Activation Processes

Activity Difference Count % Count %

Common or Minor difference 3 18% 4 17%

Medium difference 782%

1083%

Major difference 7 9

Total 17 100% 23 100%

Areas of major difference in Plan endorsement and activation include 16 activities associated with expense processes, Provider engagement, Participant support, service coordination, Plan adjustments and escalation processes.

Areas of medium difference include 17 activities associated with Plan administration and approval, self-management initiation, Participant responsibilities and handover monitoring and Plan quality assessment.

This demonstrates that 82% of the processes involved in Plan endorsement and Plan activation under the two models are significantly different to each other and leads to the observed differences described in this section.


The Plan contains all required information to complete activation of the services for Organisation Managed supports. The Participant involvement is to inform the Provider that the Plan has been approved and meet to complete the service plan.

Providers reported the following issues:

Delays were experienced with notification of the Plan approval either by the Coordinator or Participant,

Uncertainty as to the service commencement date based on different dates in the SVA and actual Plan activation dates arising from various delays with endorsement, and

Often only part of Plan (related to the Quote in the SVA) was accessible. Providers felt a full understanding of the Plan supports was beneficial in planning and delivering most effective supports to the Participant.


Services usually start promptly following notification of the Provider of the commencement date.

CS02: (WA NDIS): Provider PPP said: “We have delays in starting services because of problems getting the PCSS signed”. “we are not always informed of the commencement date and it doesn’t match the date we put in the quote”


Once the Plan is endorsed (accepted by the Participant), the Participant commences the process of choosing a Provider for each Self-Directed service in their Plan (these are designated as pay direct to provider).

The Planner may give a short list, or assist with getting in touch with a Provider, to expedite the activation process. Evidence was provided that that this is Influenced by familiarity between some Planners and Providers. This appears to be more prevalent in choosing a Provider qualified for Support Coordination where assistance with decisions then became available to the Participant for subsequent selection of additional Providers for other services in the Plan.

Activation of a service can occur at any time after the Plan is endorsed. This is up to the Participant to decide and arrange and may be assisted by a Provider Support Coordinator (where the Plan provides for one and the service is engaged with a Provider service plan).

Grouping of Plan services to be sourced from one Provider is also up to the Participant to decide. The “One Stop Shop” approach simplifies the job for the Participant and the Providers report that this is beneficial to their service delivery. A “One Stop Shop” approach is where a Participant selects one Provider to perform as many of the Plan services that they are qualified for, thereby minimising the number of Providers they need to manage, provide personal information to and allow access to their home. From a Provider perspective, they are able to gain a better understanding of the individual through greater contact that better informs them of the most effective way to provide the services.

Availability of a suitable Provider local to the Participant is not tested during Plan strategy development and is left to the Participant to resolve during activation. The Participant needs to contend with:

A Provider has “right of rejection” to not take up the offer to provide services,

A suitable Provider may not be available or not able to provide local services (at this time), or

The Provider may negotiate a proportion of the service to be allocated to cover transport or other factors.


Support Coordination is becoming a special case for activation11. The Provider providing Supports Coordination assists the Participant with choice of other Providers or local services in the Plan.

There is strong self interest in promoting their own service offerings,

The “One Stop Shop” simplification appeals to both the Provider and the Participant,

The amount of Supports Coordination is regulated by the budget allocation in the Plan and Providers report that this is insufficient to be viable as a stand-alone service.

The Provider meets with the Participant to set up the service plan between them for the designated services for the specified period in the Plan. All Providers use their own service agreement form.

As part of activation of a Provider, a Participant grants access to their service category account for the Provider to claim via the NDIA Provider Portal for services rendered. It was commonly reported that multiple Providers were allocated access to the same service account, leading to claim difficulties and rejections. It was also commonly reported by Providers and Participants that the portal budget frequently differed from the Plan budget.

CS08: (NDIA) With transport funding removed, Participant XXX tried to negotiate alternative arrangements with the Service Provider who had a lifetime relationship with XXX and family. XXX was unsuccessful due to the service delivery costs not being acceptable. XXX negotiated with a different provider who provided the service and recovered the cost of the transport by reducing the effective support time to include travel.

CS14: (NDIA) Provider PPP stated that they need to combine Support Coordination with other better margin services (such as therapy) to be a viable business.

CS14: (NDIA) Provider PPP observed that a Participant was “walked across the road to get started with a Supports Coordinator” by their Planner. PPP’s comment was that this was not fair to their business or other providers and was an unacceptable influence on the choice supposed to be made by the individual.

CS07: (NDIA) Provider PPP stated that “40% of services were not activated”. PPP believed that a substantial proportion of the lack of activation was due to rejection by the Provider because the service was not financially viable.

3.5.5 Self-Managed (Both Agencies)

Endorsement of a Plan with Self-Managed services enables a Participant to access services from any chosen provider or local service. The Participant may proceed to access the services and claim via the respective agencies procedures.

Activation of a Self-Managed service can occur at any time after the Plan is endorsed. This is up to the Participant to decide and arrange.

11 As of November 2015, 47% of Plans did not include provision for Support Coordination.


Self-Management may involve advances paid to the Participant bank account, typically for incidentals such as taxi or admission fees. Access to local services is based on local knowledge of the Participant and reported to be generally effective.

For both agencies, setting up the banking arrangements was not a problem, although some Participant reported issues with access to MyGov.

A key differentiator between the models is the claim process set up for Self-Managed services.

NDIA require claims to be made using a computer to access the MyGov NDIS site account for the Participant. Claims may be lodged at any time and receipt evidence is not required to submit the claim. It was observed that Participants at times had difficulty with the MyGov site and access to their online portal account.

WA NDIS is a manual approach where claim forms with receipts are submitted in person or by post to their area Financial Officer.

The handover to the Participant to manage their responsibilities also was different between the agencies.

For NDIA:

Training workshops are available,

Planner assistance in principle finishes at Plan endorsement although In practice, the Planner may assist for a short period at their discretion (Soft handover),

Participants are advised to call the general office for help (Experience reports the same access issues as for Plan operation), and

Where Self-Directed services include Supports Coordination, the Provider may assist according to the provisions in the Plan.

For WA NDIS:

The coordinator provides ongoing assistance as required,

Where the Organisation Managed services include Shared Management, the Provider assists according to the provisions in the Plan.

Delays in activating Self-Managed services may occur for many reasons. Finding a provider for Self-Managed services was reported to be less of an issue for a Participant than with other Plan management options. Reasons for delays in Participants activating their Self-Managed services include:

The Participant may not be active (not doing anything about it),

The Participant may be having difficulties in successfully engaging with local services, or

The viability of the service has not been tested prior to endorsement of the Plan.


CS07: (NDIA) Participant XXX (In developing their first Plan) commented the Planner influenced the management method [self-management] saying, “I did not understand the consequences of my decision …. I signed it straight away (the Plan)”. XXX commented, “I found it difficult to find a service provider willing to travel to my home … they said it wasn’t viable”.

CS02: (WA NDIS) Participant XXX commented “we have to self-manage here because there isn’t a registered service provider in the area, ….it’s not perfect but I chose to live here I suppose”

CS05: (NDIA) Family member YYY was previously with DSC and decided to self-manage the plan for Participant XXX. When asked about YYY’s experience and understanding of what had to be done, YYY said that in the beginning “I felt I understood what was needed to be done” and “…I had the confidence to get started”. After starting the exercise, YYY realised “…I didn’t understand, it was so difficult – there was no LAC” and “I had problems with the computer access and the instructions I was given were not that good”.

CS12: (WA NDIS) Participant XXX related how the Coordinator had paid particular attention to ensuring that the public liability insurance had been paid before XXX employed the local care worker.

CS12: (NDIA) In relation to handover training for Participant self-management: XXX said, “they [the NDIA workshop] didn’t explain that one”.

3.5.6 Continuity of Participant Support during Plan Rollover

There are key differences in the degree of impact on Participants between the models as a result of delays in rolling over from one Plan to the next (the review process). This is most evident in the services where payment is direct to the Provider.

WA NDIS make advance payments for the following 3 months:

Quarterly advances are withheld pending Plan approval.

The Provider usually continues support. This was evidenced by Participant comments.

Subsequent advances usually cover the gap in arrears to preserve continuity albeit at any revised service funding conditions.

NDIA reimburse approved claims on demand:

Services delivered after the Plan expiry date and prior to the new Plan commencement date are not able to be claimed.

Participant supports are usually suspended

- Unless the Provider opts to carry the loss, or

- The Participant opts to pay for the services from their own pocket.

Claims may be made for services delivered after the new Plan commencement date.

For Self-Managed supports, there are also differences between the models.


For WA NDIS, claims are placed at the end of the month with full receipt information. There are usually no payments withheld or delayed during Plan rollover given that the Technical Officer is able to discuss the Plan status with the Participant’s Coordinator.

For NDIA, The Participant portal rejects claims for services delivered after the Plan expiry date. Participants may elect to pay for the services out of their own pocket to continue support until the replacement Plan commencement is enabled on the portal.

The severity of the rollover impact has not been examined in detail. However, the Plans reviewed show that delays of 2 to 6 weeks are not uncommon for NDIA during which time services are not claimable by Participant or Provider. WA NDIS delays are typically less than 2 weeks and generally transparent to Participants as far as support continuity is concerned.

CS13: (NDIA) Provider PPP had provided services after a Plan expiry date in expectation that when the new Plan was in place, services provided in the intervening period would be reimbursed. However, after several months attempting to have claims paid for these services and continued rejection and failure to negotiate, PPP is considering that in the future, they will unfortunately have to cease providing services after Plan expiry.

3.5.7 Plan Endorsement and Activation Summary

1. Effective engagement of all parties in endorsing a Plan:

a) WA NDIS Plan endorsement uses a three-way involvement approach. Delays arise from getting all signatures associated with endorsement of a Plan (Providers, Participant and Coordinator). This may be remedied by improvements to the efficiency of this process.

b) NDIA Plan endorsement uses a two-way involvement approach. Participants are under pressure to accept Plans they consider deficient. NDIA assumes a Participant accepts the Plan unless they request an internal review.

c) The WA NDIS Coordinator ensures effective handover of responsibility from Agency to Participant for Self-Management for acceptance of risks and liabilities and that necessary insurances are in place as required.

d) NDIA Planner handover of responsibility from Agency to Participant for acceptance of Self-Management risks and liabilities has limitations, may be incomplete and leave Participants vulnerable with respect to risk of non-compliance with employment provisions.

2. Plan (document) Integrity:

a) Where a full history of NDIA Plans for a Participant was reviewed, it was common for there to be multiple copies of a Plan with the same approval date and different


service descriptions and budget allocations. There was no evidence in the Plan document itself of any version information, endorsement dates and agreements or endorsement obligations so that it was not possible to determine which Plan document was current.

b) NDIA Participants reported they were not involved in endorsing or approving changes made to their Plan. (NDIA do not require a Participant to endorse their Plan to indicate agreement)

3. Prompt activation of Provider services for a Plan:

a) WA NDIS Providers implement Organisation Managed services promptly using agreed (Provider quoted) service specifications and budgets in place ready for activation.

b) WA NDIS Organisation Managed Plan services have no inherent delay in activation. However, minor delays were experienced with notification of the commencement date, following approval of the Plan. This may be remedied by improvements to this process.

c) WA NDIS processes for set up of Schedule Variation Agreements (SVA) would benefit from improvements and timeliness.

d) NDIA Self-Directed activation is dependent on the Participant choosing and engaging with one or more Providers. Delays are primarily due to the Participant taking on responsibility, understanding what needs to be done and agreeing a service plan with the chosen Provider.

e) Providers may reject NDIA Plan services they consider not to be viable. This causes activation delay while the Participant shops around.

4. Assistance with activation:

a) NDIA. Once selected and activated, the role of Provider Support Coordination can be of assistance in activating other services in a Plan. However, Support Coordination provisioning in Plans can be limiting (eg average 20 hours per year) and not all Plans include Supports Coordination (Observed to be around 53% in November 2015). Providers also consider Support Coordination services to not be viable financially without cross subsidisation from other services. The Provider Supports Coordinator may influence the Participant when selecting Providers for other services in their Plan.

b) WA NDIS. Activation of Organisation Managed services is done by the Provider in the Plan, assisted by the Coordinator as required.

5. Impact of Plan delays on Participant support:

a) Under NDIA, the gap between the Plan expiry date and new Plan commencement date is not covered and Participant support services cease during this period, causing varying degrees of Participant hardship. This is covered in section 3.7.3 PlanReview Timing and Gaps.


b) WA NDIS Organisation Managed Providers generally cover gaps associated with Plan review delays.

6. Financial activation of a Plan:

a) NDIA Participants may grant multiple Providers concurrent access to a Plan service category account. This increases claim rejections and difficulties with account status monitoring during Plan operation.

b) WA NDIS require completion of the SVA with the Provider to activate the services.

7. Group services (shared accommodation):

a) WA NDIS resolve group services (accommodation) with care needs and service budgets during Plan development negotiation, including consideration of Plans and strategies for co-located Participants.

b) NDIA operation of group home accommodation services is discussed under financial discussions in chapter 4.0 Trends and Model Sustainability.

3.5.8 Plan Endorsement and Activation Recommendations


WA NDIS NDIA

3.5.A Endorsement of all Plans and changes to Plans to require signed acceptance by the Participant.Assumption that a Plan is agreed based on a Participant not requesting an internal review creates unacceptable pressure to accept Plans considered to be deficient by the Participant.


3.5.B Version control and endorsement of new and modified Plans to meet applicable (state) government document management standards.Evidence shows that a Participant may have multiple Plans where there is no indication as to which of them is current and they have not been required to accept changes to a Plan.


3.5.C The activation of Provider services, following Plan endorsement, is to incur a minimal delay in Participant access to supports.Evidence shows the activation under the WA NDIS Organisation Managed services is prompt. However, the NDIA Self-Directed services incur delays under the responsibility of the Participant to select and engage Provider services and resolve service viability issues.




WA NDIS NDIA

3.5.D Self-Managed Participants are to have explicit provision for employment liabilities (superannuation, worker’s compensation) in the Plan and procedures are to be in place to ensure that responsibilities have been effectively communicated to the Participant. Evidence shows that where there is no explicit provision in a Plan and Participants are not adequately informed as to their legal obligations and are at risk of non-compliance.


3.5.E Participants granting Provider access to their service category accounts is to be controlled so that budget and service claim management processes meet accepted financial standards. Evidence shows that individual Participant accounts are accessed by multiple Providers causing budget exceptions and rejection of valid service claims.

Not Applicable

Process Change


3.6 Plan Operation

3.6.1 Plan Operation Overview

The main contribution for Plan development is shown in Figure 28 Plan Operation.

Figure 28 Plan Operation

Operation of a Plan follows activation of the specified services with the selected Providers, usually in accordance with the service plan agreed between the Provider and the Participant. It also includes Self-Managed services arranged by the Participant directly with Providers or local services as required.

An extract of the engagements associated with the Plan development stage is in Error: Reference source notfound.

All services are tracked by either the Provider or Participant in order to acquit them against the Plan budget service category items. In the case of NDIA, the acquittal process is progressive with each service claim lodged by either the Provider or Participant using their respective portals. For WA NDIS, the Provider


Figure 29 Plan Operation Engagement

performs the acquittal at the end of each quarter against their quarterly advance, and the Participant lodges monthly claims manually.






Plan Operation Business Process Assessment

All surveys, workshops and other sources of information were used to assess how the two schemes perform the 37 business model processes that support Plan operation. The results are in Error: Reference source not found.

WA NDIS:

No processes were identified as requiring review.

7 of the business model activities as practiced by WA NDIS associated with Plan operation were assessed to benefit from improvement. These activities relate to efficiencies associated with Plan service compliance, Provider expense operations, Plan adjustments and Provider administration.

NDIA:


19%

35%

46%

0%

19%

81%

Review

Improve

OK

NDIA

WA NDIS

Operation Rating NDIAWA

NDIS

OK 17 30



Figure 30 Plan Operation Process Assessment

7 of the business model activities as practiced by NDIA associated with Plan operation were assessed to benefit from review of business processes in order to remediate constraints and issues associated with current practices. These activities relate to expense account operations, services coordination, issue escalation and Participant relationship.

13 business model activities were assessed to benefit from improvement in efficiencies associated with Plan service compliance, self-managed expenses and service engagement, Plan adjustments and Provider service delivery.



Areas of major difference in Plan operation include 10 activities associated with expense processes, escalation processes, Participant monitoring, self-management service engagement, Plan adjustments and Provider changes.

Areas of medium difference include 16 activities associated with budget monitoring, incident reporting, service quality, self-managed expenses, informal and mainstream services and off-Plan support.

This demonstrates that 68% of the processes involved in Plan operation under the two models are significantly different to each other and leads to the observed differences described in this section.


The Provider is responsible for delivery of all agreed Organisation Managed services to the Participant in accordance with a Schedule Variation Agreement to their DSC panel contract set up during Plan activation. The Provider and Participant have a service plan that covers their agreed components of the Plan.

Supported accommodation services may be part of the responsibility and these have significant differences between the trial models in levels of funding, grading of support requirements and coverage of vacancies. These supported accommodation factors are discussed under trends and sustainability later in this report.

The Provider receives a quarterly advance for the services and acquits for these at the end of the period in a report to DSC. Any emergency strategies added to a Plan during operation are covered in a quarterly adjustment.

The WA NDIS Organisation Managed approach restricts change of Service Provider during operation. The use of binding SVAs has advantages for accountability for service delivery but


Comparison



Medium 16 68%

Major 10

Total 38 100%

brings impediments to ease of Provider change processes. Where a Provider change is desired, it is usual to initiate a Plan review process to re-quote and reset the arrangements.

Shared Management

WA NDIS incorporate a Shared Management option within Organisation Managed arrangements. Shared Management allows for the Participant and the Provider to work in partnership and engage individual service supports during Plan operation according to Plan budget but without predefined providers.

The level of management exercised by the Participant may be adjusted as required to suit circumstances,

The services may come from the Provider’s resources or be sourced from other Providers or local services as required,

The Provider takes on responsibility for administering the financial aspects of the services,

Liability is the responsibility of the Service Provider and covers insurances, worker’s compensation and taxes associated with casual employment.

Shared Management was introduced to address difficulties experienced by Self-Managed Participants in administering their financial and liability obligations, yet wishing to retain flexibility in accessing local services.

It was observed that Participants had, or were planning to change to Shared Management in their next Plan to make changing Providers during Plan operation easier.

Experiences

Participants, Coordinators and Providers all reported that grouping of services in discussions during Plan development led to minimal issues during operation and contributed to better utilisation of Plan service allocations.

Moderation is provided by the Coordinator as required. The Coordinator also monitors Provider service activities for the Participant and gathers reports from the Provider regarding progress to goals and any issues with services. Participants and Providers were strongly supportive of the role of the Coordinator for advice and resolution of issues as required.

Participants reported that operations were smooth and in most cases they had a good relationship with their Providers. However, in one instance, difficulties arose between a Participant and the care worker assigned by the Provider. The Coordinator negotiated for a change of care worker with the Provider and the Participant is moving to Shared Management in their next Plan.


Financials

All Providers involved with Organisation Managed agreements were satisfied with the overall processes for quarterly advances and acquittal processes. There have been changes to accommodate the NDIS acquittal processes that have added overheads with respect to time based services accounting.

Providers reported that negotiation on financial issues was effective in reaching mutually acceptable and timely resolutions with WA NDIS. This was typically facilitated by the Coordinator or escalated to the regional director. This included situations where services were provided to a Participant when a Plan review was delayed and there was a gap between expiry of one Plan and commencement of the replacement Plan.

CS02: (WA NDIS) In 2016 the relationship between Participant XXX and their Service Provider became irreconcilable. XXX found it difficult to find a replacement Service Provider registered in the local area. Options to self-manage were rejected due to the obligations related to employment. It was agreed with the Coordinator to continue with the current Service Provider and to explore a shared management option. XXX negotiated a Shared Management agreement that used local non-registered services to support XXX that were employed by the Shared Manager and the day to day direction would be the responsibility of XXX. The new Plan reflected this arrangement.

CS05: (WA NDIS) Participant XXX had multiple children with disability, each with a Plan under WA NDIS. XXX expressed total dependency on their Coordinator.


A Participant receives services from a Provider they choose during Plan activation. Each Provider has a service agreement with the Participant that covers the delivery conditions for the agreed services under the Plan.

The Participant has full responsibility for the request and acceptance of services and may add (activate) additional Providers for Plan services during Plan operation. In this manner, a Participant may receive the same service in the Plan from more than one Provider either concurrently or at different times over the Plan period. This allows for easy change of Provider during a Plan although problems arise:

Integrity and claims issues are created with concurrent service account access by multiple Providers, and

Service agreements with existing Providers may have conditions attached.

As of 1 July 2016 the process for requesting services from Providers was to change to a service booking system. As of August 2016 when the evaluation investigation was closed, this new process was not fully operational due to technical issues and was not evaluated.


Support Coordination

A Support Coordination is a Plan funded service engaged by the Participant from a Provider to assist with choice and control of Self-Directed and Self-Managed services in their Plan. Support Coordination assists with selection of additional services (including Providers) and may also assist with administration of Self-Managed services.

It is common for the Provider chosen for Support Coordination to also provide other services in the Plan.

The Support Coordinator may act as a “go-between” in operational matters between the Participant and the agency and may have better access to a Planner during operation to resolve issues and facilitate changes to Plan services.

A key difference between a Support Coordinator in NDIA and a Shared Manager in WA NDIS is that the NDIA Support Coordination does not assume responsibility for liability, insurance and tax arising from casual employment services.

Participant Experiences

Participants reported that they did not fully understand all of their Plan service provisions, in particular those that were to be sourced from Providers. Participants on average scored the NDIA Plan at 4.0 out of 9 for ease of understanding. (This may be compared to a score of 8.5 out of 9 for WA NDIS).

A Participant has full responsibility for the “Choice and Control” operation of their services under the specifications of their Plan. A Participant may get assistance by contacting the agency offices, or if their Plan includes Support Coordination, from the Provider selected for this service (up to the budget limit for Supports Coordination services in the Plan).

In general, as is the case with WA NDIS, it was observed that a good relationship usually exists between the Provider and the Participant.

Training for Participants taking on responsibility for their services is available through NDIA workshops and information material. However, Participants reported they still felt unprepared and unsure of what was required or expected of them.

The Participant experience in obtaining assistance from NDIA was, in all instances, condemned as ineffective:12

The contact point was the general phone number for reception. In most cases, a message was left with NDIA reception as the necessary person was not available.

12 Although only a small sample was involved, it is concerning that all reported the same experience and level of dissatisfaction with access to assistance from NDIA. All Providers also reported similar dissatisfaction. It is considered that these are not isolated instances of the issue and are representative of access difficulties with NDIA for assistance.


In Participant conversation, all Participants said that they no longer attempted to make phone calls to NDIA because of the lack of response.

Messages and phone calls were not returned.

The only way to get assistance was to attend in person.

Access to a Planner took days to months to achieve.

They felt they were “on their own”.

Experience with Support Coordination varied widely. It ranged from the Participant not being aware of the service (although evidence showed fees for the service were being claimed), through to proactive support for changes to their Plan covering variations to their services and technical aid requirements.

CS15: (NDIA) Participants stated that where a phone call (to NDIA) was left unanswered they were asked to leave a message, never to have someone return their call. In cases where they did get through it was not unusual to be told to call someone else to resolve their enquiry. Many Participants and their families claimed to have “given up” with trying calling anyone.

CS14: (NDIA) On inspection of Participant XXX’s Plan, it showed support coordination as a service item. XXX was clearly “surprised” and stated that they were not aware they had that support. Additionally, XXX was also shown evidence of claims paid to a provider that they were not aware of.

CS15: (NDIA) Participant XXX stated, “you have to go in, no point calling them. I am lucky because I live close by”.

CS15: (NDIA) Participant XXX tried to contact the agency to get better control of what was happening with the Service Provider and drawings on XXX’s portal account. XXX commented they did not have a relationship with anyone in the agency but tried to call someone and said the response was very poor. After repeated attempts, XXX said: “I gave up” and “you get your plan and you are on your own…there’s no LAC” (In comparison with XXX’s previous experience with DSC support) .

Provider Experience

Pricing of services is considered in chapter 4.0 Trends and Model Sustainability and claims processing is discussed under financials in the next section below.

In the Provider surveys, all Providers reported when issues arose relating to Participant services, that contacting a suitable person in NDIA was problematic. Access to a Planner was a case of leaving a message at reception for a call back. Return calls were days later if at all, and in many cases by a Planner with little or no knowledge of the Participant.

In surveys and interviews, Providers reported that deficiencies in the Plans contributed to difficult situations where the assessed services and funding allocations were inconsistent with the needs of the individual’s disability. This was particularly evident with psychosocial and complex need situations.


Negotiation over the service or Plan issues was generally rejected and not an option. This was a common observation in the first survey in May 2015 and the follow-up interview program in June 2016 the providers reported that the situation was the same or had degraded further.

CS15: (NDIA) Provider PPP commented that trying to contact a Planner was difficult. “nothing has changed” with reference to the situation at the time of the first Provider survey (May 2015)

Financials

A number of flaws in the Provider portal for processing claims for services were consistently reported by Providers and also by Participants regarding their account management.

The replacement service booking and claim processes designed for 1 July 2016 implementation were aimed at addressing some of these flaws. However, this new process was not available for assessment for inclusion in this report and was not operational by early August 2016 when investigation closed. Providers had unpaid claims up to 2 months as of this report date.

The observations presented here apply to the processes in place up to 30 June 2016. It is possible the capabilities of the new processes have addressed some of these issues.

1. Multiple Provider Access: A Participant is able to grant access to their service account to more than one Provider to claim for delivered services. A Provider sees only the balance for the service account and not claims made by other Providers on the account. This leads to claim rejections due to unexpected and unattributed deductions from the account budget balance.

2. Plan and Portal Budget Mismatch: Both Providers and Participants reported that the portal service account budget did not correspond to the budget allocated in the Plan.

3. Mysterious Deductions: Participants have noted “mysterious” deductions from their account by Providers not knowingly granted access permission.

4. Mismatched Claim Payments: Providers report that claim reimbursements do not match the claim value and NDIA are unable to explain the difference.

5. Cross Claims: The Support Coordination account was being used by a Provider to cover another service to the Participant.

Most claims are processed expediently (80%) and paid within a couple of days. The bulk claim submission process causes a high rate of rejection and Providers prefer to lodge claims individually to reduce and localise rejection issues. Rejected claims take weeks to months to resolve with large unpaid amounts and require excessive effort to engage in resolution process. The escalation process is regarded as ineffective.

Providers express concern over the impact on Participants from withholding supports after Plan period end prior to commencement of the new Plan. NDIA does not pay for services provided in


this period or, even negotiate extenuating hardship cases. It was observed that in many cases, the Providers continue supports at their own cost.

CS13: (NDIA) Provider PPP stated, “we recently claimed $297k on the NDIS and received $408k in cash! Despite numerous requests we are unable to get from the NDIS what the money paid is in respect of.” “…but you can imagine how out of control we feel with this process.” The NDIS helpdesk have tried to respond but it seems as though “there is either no skill to understand or simply no capacity to do the work”.

CS10: (NDIA) On the subject of the budgets in the Plan and the portal, Participant XXX said: “…the budget in the portal has never balanced for 18 months.”

CS10: (NDIA) Participant XXX said, “there are transactions occurring that both I and NDIA cannot explain”. XXX said the NDIA explained it “was probably a ‘catch-up’”. XXX went on to say that they have become “anxious and frustrated” by the whole process.

CS13: (NDIA) In the May 2015 survey, providers identified major frustrations on outstanding unpaid claims. The follow up interviews in June 2016 confirmed that unpaid claims that varied from $60,000 to as much as $240,000.

CS13: (NDIA) Provider PPP’s attempts to resolve unpaid and rejected claims experienced months of delay and substantial effort. Examples of outstanding claims over 12 months old were given.

CS13: (NDIA) Provider PPP said that they had claims rejected due to other “invisible” claims on the account unexpectedly depleting the budget.

CS13: (NDIA) Provider PPP stated that “NDIA do not negotiate” and “It has deteriorated since 2014 … It was bad to start with…”.

3.6.5 Self-Managed (Both models)

A large proportion of budget allocation for Self-Managed Participants is for incidentals such as travel, admissions and other community services and may involve actual advances for these expenses. This works well for both trial sites.

Where funded services are involved, assistance may be provided by either the WA NDIS Coordinator or the NDIA Provider Supports Coordinator in selecting and engaging the Participant’s services. This approach regarding assistance was considered effective by Participants although it was dependent on the degree of need and experience of the Participant in taking on their responsibilities.

After an initial swing to Self-Management in both trial sites, Participants reported that the effort involved in managing the services influenced them to move to alternative service management methods. (The use of Shared Management in WA NDIS and Provider Supports Coordinator services in NDIA is discussed in section 3.4 Plan Development.)

In both trial sites, Participants reported that locating suitable local providers for Self-Managed services was easy.


Insurance

Where support is sourced from casuals or sole traders, the Participant becomes an “Employer” and has liabilities for appropriate insurance, superannuation, worker’s compensation and tax. It is important that the Participant be well advised as to how to properly manage this situation. This exposure was commented on by Participants as a significant factor in choosing to reduce the degree of Self-Management.

The two models approach this differently:

NDIA: The insurance and related expenses may be covered under additional unspecified expense claims (that were not observed in the Plan survey)13. In addition, it was observed that the Participant was not fully or accurately briefed on liabilities associated with employment (and the associated tax, insurance and safety obligations) as part of the handover to operation responsibility.

WA NDIS: Specific provision is made in the Plan for superannuation and worker’s compensation expenses and the Coordinator ensures that these are effectively in place.

Tax Liability Issues

It was also brought to the attention of the evaluators that there may be legal issues with respect to tax liabilities for proxy/guardian receiving funds on behalf of Participants. This is common to both models and is the subject of further legal determination outside the scope of this evaluation.

For example, a Participant and their guardian were unable to be accommodated within the present WA NDIS self-managed service delivery policy framework. The reasons given were:

The (DSC) policy framework only allows for the reimbursement of the Worker's Compensation element of employer's liability. The policy framework does not allow for re-imbursement of premium or other costs employers liability insurance covering in particular vicarious liability.

The (DSC) policy framework does not recognise employment of carers as permanent part or full time employees. The policy framework only recognises casual employment and sub-contractor arrangements.

It was noted that there are various review processes in place involving DSC and the GST Technical Product Leadership Indirect Tax, Perth, Australian Taxation Office.

Financials

Both models require periodic claims to be made for reimbursement although they differ in detail.

13 NDIA report that the employer related on-costs such as worker’s compensation and superannuation are included in the base hourly rates for the Self-Managed services.


NDIA:

Claims may be made at any time.

Claims are made using a computer accessing the MyGov NDIS portal.

Receipts evidence is not required for claim.

Receipts should be retained for possible check at a later date (No evidence of checks being performed was observed).

Claim rejections are rare although the resolution process suffers from the agency contact issues covered elsewhere.

WA NDIS:

Claims are typically monthly.

Claim are made using the WA NDIS claims form.

Claim submissions require comprehensive receipt evidence.

The Claims submission is provided to the area Financial Officer.

Issues are resolved by the Coordinator.

Both models have a mechanism for advance payments.

NDIA pay the first month instalment in advance with claims in arrears for following months.

WA NDIS provide monthly advances for incidental expenses.

CS13: (NDIA) Participant XXX commented that they had trouble getting the MyGov portal access to work. When XXX sought help from NDIA, XXX said “it took weeks to get it sorted”.

CS13: (NDIA) At the financial workshop, it was demonstrated that receipts are not required for Participants to submit claims for Self-Managed services via the online MyGov NDIS portal process.

CS13: (WA NDIS) Participant XXX stated: “….I keep a record of everything, ….I get paranoid because if I miss something and they find out they think I’m ripping them off”


3.6.6 Plan Operation Summary

1. Operational response to the need for changes to a Plan

Discussion of the processes for handling requests for change of service or Provider during Plan operation are considered under the section 3.7 Plan Review and Adjustment.

2. Responsibility for operation of a Plan:

a) WA NDIS transfer all liability, risk and responsibility for service quality to either the Provider for Organisation Managed services or the Participant for Self-Managed services. Operation of Organisation Managed services is agreed with the Service Provider prior to operation and responsibilities are specified in the SVA.

b) NDIA transfer all liability, risk and responsibility for service quality to the Participant for operation of all Self-Directed and Self-Managed services. These may be subject to further service plans set up between the Provider and the Participant. The consequences of poor activation or Provider delinquency during operation can leave the Participant vulnerable to receiving substandard support services. Participants are then required resolve the issues by themselves.

3. Monitoring service operations and service value:

a) The WA NDIS Coordinator safeguards Participant vulnerability by monitoring service delivery and value. Negotiation on issues is usually promptly resolved by the Coordinator with the Participant and Provider or escalated to the area manager.

b) NDIA do not routinely monitor Participant services and access to agency assistance is constrained. The Provider Support Coordinator may assist the Participant where a conflict of interest does not occur.

c) NDIA. Services may have reduced value or effectiveness as a result of compromises made between the Participant and Provider in their service plan.(The viability of Plan services has not been checked prior to operation.)

4. Support for Participants and Providers during Plan operation:

a) WA NDIS: All support is channelled through the Participant’s Coordinator. Escalation through to the area manager is generally effective and prompt. Some Providers have received inconsistent advice from different sites on similar subjects.

b) NDIA Participants may be assisted by a Supports Coordinator from one of their Providers. (Provider Supports Coordination is funded and budgeted in the Plan. In November 2015, 53% of Plans included provision of Supports Coordinator services.)


c) NDIA: Limited resources and access is provided by the agency to assist with resolution of operational service or financial issues. Phone contact is effectively impractical for Participants and Providers alike and attendance in person is the adopted usual procedure.

d) Comparative assessment of the cost of providing Participant operational support via internal staff (WA NDIS Coordinator) compared to Provider contracts (Supports Coordinator) was not possible due to lack of data from DSC and variability of the NDIA inclusion of Provider Supports Coordination in Plans.

5. Self-Management:

a) Self-Management is most effective for incidental cash based services such as public transport and community fees. This aspect of Self-Management works well for both trial models.

b) Access to local services suits non-metro localities where Provider presence is not strong. (Both trial models)

c) Self-Management for both trial models places responsibility for employment and associated insurance, safety, superannuation and worker’s compensation on the Participant.

d) Legal issues with respect to tax liabilities for proxy/guardian receiving funds on behalf of Participants exist and the resolution may result in changes to the service delivery model for the self-managed model.

6. Financial Operations:

a) Service acquittal processes for both trial models require a change to time based service delivery and staff timesheet methodologies. This has had a major impact on Provider business management processes with staff training and culture implications.

b) Participant claiming processes are adequate for both trials although rigorous receipting manual process in WA NDIS contrasts to lower level of validation procedures and account discrepancies with NDIA.

c) Participant access to their current account status is supported via the Participant portal in NDIA. WA NDIS Participant account status is not currently available through a self-serve process (A WA NDIS Participant portal is not available).

d) WA NDIS Organisation Managed services are well established with effective DSC panel contract based processes. The quarterly advance and acquittal processes operate satisfactorily.

e) NDIA Self-Directed services lodged on the NDIA portal are processed promptly, once approved.

f) NDIA Provider individual claims via the portal localise any rejection issues. The batch process was not favoured due to higher rates of batch rejection.


g) NDIA Provider claims that are rejected require contact with the agency that is frustrating, time consuming and takes weeks or months to complete.

h) Access to an appropriate NDIA person is difficult and opportunity to negotiate is minimal.


3.6.7 Plan Operation Recommendations


WA NDIS NDIA

3.6.A Ensure processes are in place to provide prompt response, negotiation, resolution of issues and safeguarding vulnerabilities of Participants during Plan operation.Evidence shows that Participants are highly dependent on support from the agency during Plan operation. Where access to support is constrained, Participants are vulnerable and experience reduced choice and control, stress leading to disaffection with the agency and an adversarial situation.


3.6.B Compare Provider - Participant service agreements with the corresponding Plan service descriptions and budgets to identify variations affecting the value of services.Evidence shows that Participants have agreed to reduced value or effectiveness in their Provider service plans by trading off support hours.

Process Change

Policy Change

3.6.C Implement processes to ensure committed services in a Plan are effectively and fully delivered to the Participant with appropriate incentives and monitoring procedures.Evidence shows that where a formal responsibility for delivery of services is not in place, the Participant may not receive their full Plan service commitment.


3.6.D Payment of Participant expense claims to be prompt and effectively escalated for issue resolution as required and provide accessible and up-to-date account status. Evidence shows that for the majority of Participant claims there is prompt payment. However, access to agency assistance for resolution of rejection issues, or to check account status can be difficult for Participants.

Process Change

Process Change

3.6.E Payment of Providers for services to be timely with effective escalation and negotiation procedures for issue resolution, including effective means of monitoring and managing allocated Participant accounts.Evidence shows there are numerous flaws with the NDIA Provider portal account processing exacerbated by difficulties with access, negotiation and escalation for issue resolution.




WA NDIS NDIA

3.6.F Resolve any legal issues with respect to tax liabilities for proxy/guardian receiving funds on behalf of Participants. Evidence pointed out a number of legal and tax issues (including GST) with respect to the Self-Management model applicable to both schemes that may result in changes to the service delivery model.

Policy Change

Policy Change


3.7 Plan Review and Adjustment

3.7.1 Plan Review and Adjustment Overview

The main contribution for Plan development is shown in Figure 31 Plan Review and Adjustment.

Figure 31 Plan Review and Adjustment

A Plan review is normally scheduled for 12 months after the approval of a Plan. This may be changed on request by the Participant or through an agency initiated process. A Plan review builds a new Plan based on the existing one by initiating a Plan development process.

An extract of the engagements associated with the Plan development stage is in Error: Reference source notfound.

Adjustments may be requested for a Plan during operation. These requests may be raised by various methods by either the Participant, Provider or agency person. The response to the request for adjustment depends on the nature and circumstance of the request. Once an adjustment has been agreed, the modified Plan is endorsed by the Participant and the changes activated as per the normal Plan lifecycle.14

14 NDIA do not require a Participant to endorse changes to their Plan. If a Participant does not agree to the changes, they can request an internal review.


Figure 32 Plan Review Engagement





Plan Operation Business Process Assessment

All surveys, workshops and other sources of information were used to assess how the two schemes perform the 16 business model processes that support Plan review and adjustment. The results are in Error: Reference source not found.

WA NDIS:

2 of the business model activities as practiced by WA NDIS associated with Plan review and adjustment were assessed to benefit from review of business processes in order to remediate constraints and issues associated with current practices. These activities relate to Plan services and Provider changes.

3 business model activities were assessed to benefit from improvement in efficiencies associated with Plan service compliance and Plan adjustment requests.


Operation Rating NDIAWA

NDIS

OK 4 11



Figure 33 Plan Review Process Assessment

NDIA:

4 of the business model activities as practiced by NDIA associated with Plan review and adjustment were assessed to benefit from review of business processes in order to remediate constraints and issues associated with current practices. These activities relate to service expenses and Participant relationship.

8 business model activities were assessed to benefit from improvement in efficiencies associated with Plan service adjustments, Plan service compliance and Participant engagement in the Plan review.



Areas of major difference in Plan review and adjustment include 9 activities associated with Plan adjustments and Provider changes, Participant progress and Plan need reconciliation, Provider selection and Participant engagement in the review process.

Areas of medium difference include 5 activities associated with claims history, services experience and Plan administration.

This demonstrates that 87% of the processes involved in Plan review and adjustment under the two models are significantly different to each other and leads to the observed differences described in this section.

3.7.3 Plan Review Timing and Gaps

Delays sometimes occur with scheduling and completing a Plan review prior to expiry of the current Plan. In some cases, an extension is applied to the expiry date but this is not always the case.

NDIA:

Evidence of delay was common in the surveys conducted. In many cases an extension of the Plan expiry date was put in place. Instances of delays over 6 weeks were observed with no extension in place.

The portal budget did not necessarily get updated for the extended claim period and caused claim rejection.

Where extension was not put in place, services were not able to be claimed after the expiry date, leading to suspension of the service to the Participant until the new Plan


Comparison



Medium 587%

Major 9

Total 16 100%

commenced. Any rejection of claim (by Participant or Provider) for services provided during this period was not negotiable.

WA NDIS:

Delays in completing a scheduled review were typically less than 2 weeks. This was facilitated by an early (3 month) alert to the Participant’s Coordinator regarding the pending review.

Participants did not lose service support during these delays due to coverage provided under the Provider Organisation Managed quarterly cycle provisions and engagement with the Coordinator in the monthly Self-Managed claim cycle.

CS16: (NDIA) Participant XXX stated that due to the Planner being absent, for 6 weeks XXX was not able to claim for any services after the current Plan had expired. XXX paid from their own pocket for some reduced level of services during this period until the new Plan commenced.

CS16: (WA NDIS) Participant XXX mentioned that there was a 6 week delay with the Plan review over Christmas. XXX stated that their services continued as normal while waiting for the new Plan to be finished.

CS13: (NDIA) A situation was described by Provider PPP where a Participant was given an extension on the Plan review but the portal account expiry date was not adjusted accordingly. The Provider provided services in good faith expecting to be able to claim when the portal status was corrected. When the new Plan was activated, claims for services during the intervening period were not accepted and not negotiable. This experience was corroborated by multiple Providers during the interviews.

CS13: (NDIA): Provider PPP stated that in the past, the Participant was put first and money second. In addition, that negotiation was part of the services arrangements. They have continued to provide services to Participant even knowing that they will not be able to claim under the new NDIA rules. However, PPP said this is not sustainable and will need to cease soon.

3.7.4 Initiating a Plan Review

Early Review

Setting a Plan review date is part of the Plan development process. Evidence from the Plan Survey showed that no periods other than 12 months were set.

For WA NDIS, an early review is agreed between the Participant and their Coordinator. Plan adjustments are generally not an option.

For NDIA, the Participant needs to request access to a Planner and explain the need for a review. In some cases, the Provider Support Coordinator may act on behalf of the Participant. The Planner may agree to the new review or commence a Plan adjustment as an alternative.


Starting a Review

The method of starting a review differs between the models.

WA NDIS:

The Participant’s Coordinator gets advance notice (90 days) to gather Provider and Participant progress information.

The Coordinator contacts a Participant in person to assess the extent of likely changes.

The current Plan may be extended for a further (12 month) period if the Participant agrees.

A full review (Plan development) is commenced.

NDIA:

An alert is raised that a Plan review for a Participant is due.

A Planner is allocated from the Plan Review team.

The allocated Planner contacts a Participant by phone or in person to assess the extent of likely changes.

The Planner may extend the current Plan for a few months or the full 12-month period.

An adjustment to the Plan may be agreed with the Participant and the modified Plan endorsed. When approved, the service account budgets and expiry dates are updated on the portals.

A full Plan review (Plan development) is commenced.

CS02: (NDIA) Participant XXX complained that on getting a phone call from a Planner, XXX had agreed to an extension of their Plan. Subsequently XXX felt that this was not what they really wanted but was not able to contact the Planner to change the decision. “It was too late”.

CS02: (WA NDIS) Participant XXX wanted an early review so they could make changes to their services and providers. The request was rejected on the basis that it was “only 6 months to the scheduled review”.

CS13: (NDIA) A situation was described by Provider PPP where a Participant was given an extension on the current Plan but the portal account expiry date was not adjusted accordingly.

3.7.5 Request Change of Service

NDIA provide a more flexible Plan adjustment process than WA NDIS, where the Provider Organisation Managed services are difficult to change.

These processes were confirmed at workshops with the respective agencies.


WA NDIS:

The Participant’s Coordinator discusses the need for a service change with the Participant and also the Provider as required.

Preference is given to deferring the change to the next scheduled Plan review or an early Plan Review may be scheduled.

Some Plans have a contingency provision. If so, updates to the current Plan contingency changes may be made.

An emergency strategy may be created for the Plan

- Prepare the new service specification, budget and chosen Service Provider.

- Approval is escalated to the Regional Manager.

- The updated Plan is endorsed by the Participant, Coordinator and Provider.

- The Provider SVA for Organisation Managed services is updated.

- Responsibility is transferred to the Provider to implement the changes and update their service plan with the Participant.

NDIA:

The agency passes the request to the Plan Review team15.

A Planner is allocated from the Plan Review team to assess the request with the Participant. The Provider Support Coordinator may assist with the assessment.

The change may be deferred to the scheduled Plan review date or an early Plan Review scheduled.

Adjust the service specification and or budget:

- Update the Plan.

- Issue updated Plan.

- Initiate an internal review if Participant does not accept the Plan change.

- Update Participant service account portals.

- Responsibility is transferred to Participant to update the service plan with the Provider.

WA NDIS have limited provision for making changes to a Plan during operation. This is restrictive and as a consequence causes more effort to be made on a full review compared to making an adjustment. The SVA provisions for Organisation Managed services would benefit from process

15 High intensity or complex needs are referred to a special group of Planners.


changes making adjustment of services and budgets more flexible and responsive to a Participant exercising choice and control.

The NDIA adjustment process is flexible and efficient However, in practice it falls down due to difficulty in accessing a Planner and understanding of the reasons for the change. The delays and difficulties with this are a deterrent to the Participant to continue with requests for change and compromise effective choice and control. Additionally, changes to Plans are made without Participant endorsement and issued Plans bore no indications as to applied changes or document version and had the same (retrospective) approval date. The portal service accounts fail to match Plan budgets and contain unattributed account adjustments.

CS10: (NDIA) Participant XXX has received five versions of plans in twenty months, each with varying services and amounts of funded dollars. Each time, the Provider’s Support Coordinator arranged for the adjustment and the revised Plan with the change was emailed to XXX and did not require XXX to endorse the change.

CS10: (NDIA) When XXX has changed needs [therapeutic aids] the process has been to contact the Supports Coordinator [who is also the Service Provider]. It is the Supports Coordinator that negotiates any changed needs with the agency. (The family and XXX have been requested by the Planner not to contact them until the annual review of the plan). The family have stated that adjustments to the plans have been positive. The current approved plan has had two adjustments. Each time an adjustment occurs the plan reflects the change and is emailed to XXX. XXX is not required to endorse the change and the original approval date is unchanged.

CS13: (NDIA) The management and control of funding through Participant XXX’s portal account has been frustrating where the family stated “it hasn’t balanced in 18 months, there are transactions occurring that both I and NDIA cannot explain”. She went on to say that they have become “anxious and frustrated” by the whole process.

CS02: (WA NDIS) Participant XXX had support services delivered under an Organisation Managed arrangement. Whilst the relationship at times became difficult due to service delivery and quality issues, they were resolved with the assistance of the Coordinator.

3.7.6 Request Provider Change

NDIA provide a more flexible Provider change process than WA NDIS where the commitments for Provider Organisation Managed engagements are difficult to change. These processes were confirmed at workshops with the respective agencies.

For WA NDIS, a change of Provider effectively requires a Plan review in order that the contractual arrangements and responsibilities covered under the SVA can be addressed. There is a case for updating the SVA contract terms to include provision for early release supporting transfer of service responsibilities to another Provider where the service needs of the Participant do not require a Plan review. This would improve Plan flexibility and responsiveness to Participant choice and control.

For NDIA, a Participant may select and activate the remaining period of service with a new Provider at their discretion. This is effective choice and control. However, in practice this


introduces problems with the claims process by allowing multiple Providers to access the same service account at the same time. (Claims issues are discussed under Plan operations.) Remedies for this situation have been planned for the new service booking process from 1 July 2016. However, this process is not operational as of early August 2016 and assessment is outside the timeframe of this evaluation.

CS02: (WA NDIS) Participant XXX found it difficult to find a replacement provider when the relationship with XXX’s current provider became unworkable. With 6 months to Plan review, XXX spoke with the Coordinator who advised XXX that they must wait until the annual Plan review to change provider. XXX agreed to continue with the current Service Provider and to explore a Shared Management option as part of their new Plan.

CS13: (NDIA) When Provider PPP was questioned about their experience with claims on Participant accounts, the situation where the balance was less than expected due to other unknown deductions was common. Claims were rejected due to insufficient funds in the account and were not negotiable and not paid.


3.7.7 Plan Review and Adjustment Summary

1. Flexibility in setting the Plan review date and supporting a more flexible Plan adjustment process:

a) Both agencies could improve Participant support by being more flexible in setting the Plan review date and supporting a more flexible Plan adjustment process. This would improve responsiveness to Participant choice and control and reduce overheads involved with full Plan reviews.

2. Change of service or Provider during Plan operation:

a) WA NDIS provides well proven but rigid arrangements under the contract SVA for Organisation Managed services. However, this restricts change of service or Provider during Plan operation. WA NDIS would benefit from changes to the contract SVAs to better support early release during Plan operation and to facilitate variation of Plan services.

b) NDIA have a flexible process for changing services or Provider during Plan operation that supports choice and control by the Participant. Also, where a Provider Supports Coordinator is available, they are able to assist the Participant in having changes made to services in the Plan.

c) NDIA allow multiple Provider access to a Participant service account that causes claim rejection and needs remediation. Access to a Planner needs improvement to be more responsive to Participant needs.

3. Period gap between Plan expiry and the replacement Plan commencement:

a) NDIA inhibit claims by Participants and Providers for services rendered during this period. Revision of portal and Plan dates and budgets also need to be synchronised.

b) NDIA loss of Participant services during the gap between Plan expiry and the replacement Plan commencement needs to be addressed. Improved provision for service continuity during Plan review delays needs to be implemented to avoid hardship for Participants.

c) NDIA would benefit from improvements to the financial management of Participant service accounts to better support multiple Provider access to a Participant service account and synchronise changes to Plan and portal budgets and dates.

d) WA NDIS Organisation Managed arrangements are able to provide service continuity during Plan rollover where delays occur.


3.7.8 Plan Review and Adjustment Recommendations


WA NDIS NDIA

3.7.A Implement processes that support “rolling” adjustments for service and Provider changes to a Plan during operation together with greater flexibility in setting Plan review periods.Evidence showed that Participant choice and control in reaction to changing needs was best served by responsive changes to their Plan services supported by synchronised budget and account management. Also, that the practice of deferring changes until the next review increased Participant stress and hardship.

Policy Change

Process Change

3.7.B Implement processes to ensure continuity of Participant funded services during the period between Plan expiry and the replacement Plan commencement.Evidence showed that disallowing Provider claims for services provided after the Plan had expired and before a replacement Plan was put in place (with no negotiation) caused suspension of Participant supports and degrees of hardship. Periods of up to six weeks were noted.


3.7.C Implement processes to facilitate synchronisation of Participant Plan service budgets with corresponding accounts used for processing claims from the Participant and their Providers.Evidence showed that Participants and Providers commonly experienced mismatch between the Plan service budget and the portal account figures for which explanations were not available and rejection of claims occurred.



4.0 Trends and Model SustainabilityThis section addresses factors that contribute to the sustainability of the trial models for the coming years and suitability for extension to other areas of WA. Whereas preceding sections have considered the trial models in the context of the Plan lifecycle, this section focuses more holistically on influencing factors and trends.

The trends and sustainability are considered in three sections:

Disability Services Sector,

Participant and Community, and

Agency.

4.1 Disability Services Sector

Success of disability service delivery into WA requires that services are available to the Participant wherever they are and that they are sufficient to meet the nature of the needs specified in their Plans.

Information gathered from the two Service Provider surveys (May 2015 and June 2016) and from the Participant Plans, Participant Conversations and Agency Workshops has been collated into this discussion on trends and sustainability of the Disability Services Sector under the following topics:

Provider marketplace,

Adaptation to NDIS,

Pricing of Services, and

Group Home Supports.

4.1.1 Provider Marketplace

Provider Survey

The “Your Business” section of the second Provider survey provided a total of 198 responses to the 22 questions from the 9 Providers.

Each Provider’s response assessed the subject change since the first survey in May 2015 as being: Much Better, Better, No Change, Worse or Much Worse. In addition, they also assessed the trend for the next year on the same basis.


The Providers’ assessment of the changes to their business over the past year are shown in Error:Reference source not found.

The majority of responses assessed the Participant experience as “No Change” – 46% for NDIA and 66% for WA NDIS.

Where the WA NDIS scored 31% for “Worse” or “Much Worse”, NDIA scored 54%.

Of particular note is the trend showing that 60% of the question responses expected that the situation for that subject to become worse or much worse in the coming year.

Rejection of Plan services

Participants and Providers reported that the trend is for increasing consideration of margins involved with costs of service delivery. As a result, some categories of services for a Participant are being rejected based on cost recovery and operating margins and this is expected to increase as the opportunity to cross-subsidise from non-NDIS areas reduces (See below for more on cross-subsidisation).

As a consequence, the trend is for reduced market availability of some low margin service categories accompanied by reduced quality of service. This is evidenced by:

Rejection of requests for service by Participants (NDIA),

Difficulty for Participants to activate some services in their Plan,

Increasing use of inexperienced care workers and high turnover of these staff.

The special case of group home services is considered under the pricing topic below. However, the threat to loss of accommodation service capacity is real and presents a major issue to be resolved in order to maintain sustainability of this service to people with a disability, their families and carers.

Consolidation of Service Providers

Acquisition and mergers of smaller organisations is happening. At this time, the impact of this on local services is not clear, however comments from the Provider interviews have included:

Major players are getting stronger voices and political connections,

Providers are accessing alternative funding channels,


Figure 34 Provider Business Impact Comparison

Management of influencing service channels and choice to better suit their own business needs.

There is also a polarisation of services into those with better margins. This change in service accessibility affects the trial models differently.

WA NDIS perform the engagement with Provider during Plan development and fully resolve service access and budgets by the time the Plan is ready.

NDIA defer the engagement with the Provider until after the Plan is completed when responsibility is passed to the Participant to resolve service access within set budgets. This increases activation delay and impacts service value.

CS08: (NDIA) The existing provider declined on the basis of insufficient funding for the service. Participant XXX found an alternative service provider that negotiated to provide the service with recovery of the cost of the transport being taken from support hours prescribed in the Plan.

Commitment to “Mission”

The Providers responding to the surveys and interviewed have consistently expressed a high level of commitment to their clients. This is evidenced by continuing support for Participants even when claims for the services are not accepted (such as under NDIA after a Plan expiry date or for Off-Plan episodic support).

In the June 2016 Provider survey, it was commented that they were undergoing a hardening of business approach under the stress of new regulations, negotiation difficulties and reduced operating margins. Specific observations from the survey include:

Loss of dedication to “Mission”:

Corporate survival is becoming more important than individuals,

Reduction of their services portfolio to more sustainable categories (such as therapy).

Tighten employee conditions, including:

Loss of company vehicle fleet,

Reduced employee benefits,

Reduced training.

Play by the rules:

Comply with (WA) employment and HSE conditions and regulations,

Manage safety exposures (Participant and staff) more closely.


Heightened risk management around viability of services:

Reduce risk associated with unpaid work caused by claim rejection,

Use of reserves and cross-subsidisation for services.

CS11: (NDIA): Provider PPP said “We are a charitable organisation and are facing a loss of ‘Mission’ through the impact of changes introduced by NDIS”. “…scaling for complex needs is not sustainable within the margins.” “Voice of complex disabled advocacy is totally ineffective” “… impacts the most needy the most”.

Sector Engagement

The policies and practices of the two models differ substantially in their level of engagement with the disability services sector.

DSC facilitates the relationship with Service Providers through the procurement and registration processes for the Service Provider panel and through industry forums and CEO roundtables. In addition to DSC panel registration, NDIA require service providers to also register for specific services in the NDIA Perth Hills trial site16.

The DSC engagement approach benefits both WA NDIS and NDIA as a local source of qualified Providers for the trial sites.

The NDIA uses a national coordinated approach for development of the disability services sector. This approach focusses on national peak body relationships with Providers reporting there is limited direct engagement with the local (WA) services sector.

The sustainability of effective services delivery for both trial sites in WA is currently dependent on the sector engagement policies and practices of the DSC.

4.1.2 Service Provider Adaptation to NDIS

Corporate Change

To operate effectively under the new NDIS services model, Providers need to have sophisticated Finance, Human Resource and Customer Relations Management systems. The first Service Provider survey established that all the respondents were planning substantial investments in corporate changes in order to make their services scheduling, delivery, tracking and billing systems. These are high level corporate investment initiatives that cost millions, funded from corporate reserves and cross-subsidisation where available. This is a primary driver for consolidation with other Providers.

16 There is provision for nationally registered Providers to operate in the NDIA trial site in WA.


The second survey in June 2016 highlighted these major investments in management practice and information systems. Key factors coming from the survey were:

Cultural impact of service time management practices,

Financial management planning and reporting,

The cost and lead time for major Finance, CRM and HR systems change,

Line management overheads and training in new procedures.

While some Providers were well advanced in updating their information management systems and introducing modern mobility-enabled service delivery administration and monitoring capabilities, others were “making do” with manual processes until a decision was made as to the WA commitment. Given the lead time to implement the scale of these changes, it is likely the “Late Adopters” may be at a disadvantage to others in their sector.

Services Cross-Subsidisation

All Providers in the second survey were cross-subsidising services in the trial sites in one way or another. The most common cross-subsidisations declared by Providers were:

From outside the trial sites, such as other DSC disability services regions in WA,

From services with better margins (such as therapy) to those at or below cost recovery (such as Supports Coordination).

This type of cross-subsidisation is not sustainable. The ability to access reserves and other income is being used to cover the cost of change to the new NDIS models. The pricing model is key in assuring sustainability and guarding against loss of some service categories to the sector.

Other sources of cross-subsidisation available to some of the larger Providers included:

From alternative business activities such as production workshops and employment,

From other funding sources such as investments and charities.

4.1.3 Pricing of Services

Feedback from Providers was that the pricing methodology is acceptable but that the parameters used in some areas are not considered realistic, such a zero provision for fixed overheads. A often repeated request by Providers was for an open price setting process.

The WA NDIS approach for setting a service budget in a Plan is negotiated as part of the Plan development quote process between the Provider and the Coordinator. A limited range of rates for the service category applies.


For NDIA, the service budget in a Plan is determined by the Planner using standard service category price rates and the assessed quantity required.

Specific mention was made by these Providers that the following factors need to be considered during price setting for WA:

Plan Services need to provide for WA industry and award standards and conditions:

Sunday minimum attendance periods (eg 2 hour minimum),

Compliance with WA safe work practices (eg need for 2 care workers for some services),

Participant safety (Appropriately experienced or capable care worker)

Cost of service delivery:

Improved negotiation for time lost for travel to the service point,

Cost of travel. (including viability of Participant use of public transport)

Recognition of regional rates and awards (for services at a distance from Perth)

Additional remote factors on pay rates and employment,

Regional awards and safety conditions,

Regional factors for staff turnover and cost of retention,

Distance factors in maintenance of relationships,

Training at a distance,

Relief staff for service continuity.

CS08: (NDIA) Provider PPP gave the example of a NDIA Plan that specified weekend service attendance for 1 hour. When NDIA was challenged that the WA awards required minimum callout on a Sunday to be 2 hours, PPP was told “you figure it out”

CS08: (NDIA) : With respect to the nature of the disability of a large proportion of Provider PPP’s Participants, public transport is considered an unacceptable risk. PPP commented that “their policy to ‘force’ to use public transport is not viable for many of our clients”.

4.1.4 Group Homes Supports

The observations in this section were gathered in July 2016. At the time of this report, discussions on group home supports between the state and commonwealth regarding support categorisation and pricing are in progress so parts of these considerations may be out of date at the time of publication.


Group home accommodation services are subject to several key differences between the two models and trial site operations. A number of Providers that provide accommodation support were included in the surveys and have provided information used with the case studies in this report.

The grading of supports differs with respect to Low, Medium and Complex needs:

WA NDIS grading is in consultation between the Provider, Coordinator and others such as allied health during the service quote process for Plan development,

NDIA grading is determined by the Planner and used to determine the Plan budget. This is not negotiable.

Allowance for (modified) vehicles for transport of persons with disability:

WA NDIS include provision for subsidised modified vehicles for Participant transport use in a group home facility as part of the support with the Provider,

NDIA do not include support for vehicles used for Participant transport in a group home.

Compensation for temporary vacancies. (Where staffing requirements remain the same for 24/7 supports and safe working compliance.)

WA NDIS include coverage for temporary occupancy vacancies. (This has been reduced from 6 months to 3 months but is subject to negotiation.)

NDIA do not provide compensation for income loss due to temporary vacancy.

Provision for industry awards and safe working compliance:

WA NDIS rates recognise WA industry awards and safe working conditions,

NDIA rates do not meet all provisions in the WA industry awards and safe working conditions.

Group homes within WA currently accommodate over 1,800 Participants. This service category within the sector represents a major investment in facilities and trained staff providing support for Participants with low, standard and complex needs.

The WA NDIS approach involving negotiation between informed parties during Plan development allows for a more accurate individualised assessment of reasonable and necessary supports and includes generation of an agreed quote for the supports.

The NDIA approach is not negotiated with the Provider and the Planner prepares the budget in accordance with standard NDIA guidelines for the supports. The Plan services are not confirmed as viable prior to handover to the Participant to manage.

The NDIA pricing structure for low, standard and complex needs is significantly lower than WA NDIS rates and does not have an equivalent for the WA NDIS “high” needs.


Comparative funding per annum by Agency for group home support Group Home Case Study Provider-AAA

Based on Provider assessments of agency price lists July 2016

Agency Low NeedsStandard

NeedsHigh

NeedsComplex Needs

DSC $124,489 $161,660 $188,559 $215,458NDIA $94,350 $118,246 $134,667 $151,089Funding Impact (per Participant) ($30,139) ($43,414) ($53,892) ($64,369)

Group Home Case Study Provider-BBB

Based on actual Participants in each home operated by BBB and Provider assessments of agency price lists July 2016

HomeAverage per person $ pa17

WA NDIS NDIAHome A 187,855 145,418Home B 165,024 130,406Home C 159,280 130,406Home D 188,569 130,406Home E 188,569 130,406Home F 215,458 130,406Home G 201,129 130,406Overall Average 190,755 131,526

The observed actual average cost per person lies between High and Complex needs pricing.

Based on WA supporting over 1,800 Participants in group homes, and a sample of 70 Participants receiving accommodation support funding, the difference in funding (as understood and used by Providers for financial planning) was between WA NDIS and NDIA of $59,229 per person represents a shortfall of $106m per annum.

For the group home accommodation sector to remain viable in WA, substantial top-up funding is likely to be necessary. Otherwise, those homes without major alternative funding and cross-subsidisation will face closure.

There is the opportunity to seek additional funding for special needs on a Participant by Participant basis. However, this additional allocation is for supports for individual Participants separate to their group accommodation.

17 WA NDIS: Accommodation only. Plans for 15 individuals in Home G are currently in negotiation. It is assumed that maximum pricing under the model ($215k) will not apply for all individualsNDIA: Accommodation only, pricing guidelines assumes that shared benefits accrue from homes with 6 or more people. Maximum levels ($130k for homes with 6 or more individuals) have been applied for all individuals.


CS11: (NDIA) : Provider PPP stated: “Clearly, … I have to believe I (we) have missed something on the NDIS funding and it may be other supports in their pricing framework is available, however the overriding conclusion is that we simply could not continue to operate the group homes under NDIS pricing as currently published and as currently understood”. PPP followed by saying: ”… under NDIS (as interpreted), we would be required to return the group homes back to DSC as it will result in a $Y.Ym shortfall of funding, which is wholly unsustainable.”

CS11: (WA NDIS) Provider PPP said: “The ZZZ home gets better funding (than NDIA) just for the accommodation, but still not enough. If the specialist care element is assessed objectively I do get the sense funding under WA NDIS will be acceptable.”

CS11: (NDIA) Provider PPP stated “under NDIS you can be creative and claim extra funding under different pricing categories, in addition to accommodation. For instance, with YYY we also applied for $$k for hours to be used for ‘assistance with daily life in the home and community, education and work’ – this enabled us to bump up YYY’s accommodation amount to $$$k per year. However, this took a lot of negotiation over 4 months and cannot be guaranteed with everyone.”


4.1.5 Disability Services Sector Trend Summary

1. Sector engagement, relationship and negotiation:

a) Providers place a high value on the relationship with the agency and an ability to negotiate on sector issues, services and Participant interests. Providers were supportive of the WA NDIS negotiation and accessibility but critical of the NDIA “no negotiation” practices and restricted access

b) A good agency – Provider relationship assists effective service optimisation, engagement and service delivery for best Participant experience and outcomes and reduced agency operational support overheads.

c) The WA NDIS process for Plan quote involvement for Organisation Managed services is important for Provider negotiation of viable services and relationship with their clients and the agency.

d) A loss of “Mission” and hardening of corporate attitude impacts Participant hardship via reduced service viability and reluctance to provide voluntary coverage for non-claimable services.

2. Service availability and viability:

a) Proven service availability and viability avoids rejection, activation delay and loss of service value to Participants.

b) Providers are at various states of systems readiness for state-wide NDIS rollout. Some have advanced investments in setting up their new Financial, HR and CRM systems whereas others are deferring their changes until a decision is made as to how the NDIS will operate in WA.

c) Consolidation of Provider marketplace and impact of the cost of change, (particularly on late adopters and their business readiness) inhibits capacity for expanded services into new areas.

3. Group homes accommodation support is not sustainable:

a) Group homes accommodation support in is not sustainable at the current NDIA pricing levels. Based on Provider understandings of July 2016, a shortfall for WA under NDIA is estimated to be up to $106m per annum. Existing group home accommodation providers will either close or return the homes to the State to operate without a major increase in existing prices set by NDIA to match WA NDIS negotiated levels.

4. Adoption of an “open pricing” process:

a) NDIA adoption of an “open pricing” process to ensure viability of Participant Plan services and sustainability of the sector. The disability services sector in WA needs to be involved in order to establish a sustainable service category pricing and acceptable provision for regional factors for rollout to additional WA areas.


4.1.6 Disability Services Sector Trend Recommendations


WA NDIS NDIA

4.1.A Engage with the WA disability services sector to ensure adequate availability and capacity of services for WA rollout and a healthy relationship that fosters good-will and cooperation.Evidence showed that Providers are subject to major expense and adaptation to the new service model. These changes are being funded from reserves, other business activities and cross-subsidisation from non-NDIS trial site areas. Some Providers are better placed than others to effectively transition putting at risk the net capability of the sector to respond to the increased level of demand.


4.1.B Establish negotiation and escalation procedures for resolution of marginal viability of services to ensure continued access to vulnerable service categories.Evidence showed that a refusal to negotiate with a Provider on price for a service category with marginal viability led to unsustainable cross-subsidisation of the service and risk of withdrawing service categories.


4.1.C Group homes accommodation support pricing, support grades and facility allowances be negotiated for a sustainable future.Evidence was provided of major NDIA pricing shortfall in group home accommodation that is in the order of $106m pa for WA. Current operators stated they would either close or return the homes to DSC. (This was based on Provider understandings in July 2016 and is currently under active review between commonwealth and WA governments.)


4.1.D Adopt an “open pricing” approach whereby price book components are negotiated in an open industry consultation process.Evidence was provided of inadequacies in the service pricing method with assumed values and “no negotiation”. Service prices in Plans are considered by Providers to be below acceptable level or not allow for WA awards.



4.2 Participant and Community

4.2.1 Provider Survey

The “Participant Experience” section of the second Provider survey provided a total of 144 responses to the 16 questions from the 9 Providers.

Each Provider’s response assessed the subject change since the first survey in May 2015 as being: Much Better, Better, No Change, Worse or Much Worse. In addition, they also assessed the trend for the next year on the same basis.

The Providers’ assessment of the changes experienced by Participants under their care over the past year are shown in Error:Reference source not found.

The majority of responses assessed the Participant experience as “No Change” – 63% for NDIA and 78% for WA NDIS.

Where the WA NDIS scored 21% for “Worse” or “Much Worse”, NDIA scored 35%.

The response to the trend showed that 30% of the subject responses related to Participant experiences are expected to worsen further in the coming year.

4.2.2 Community Trends

Providers

The increased competition in the service provider market has changed the way Providers interact with their clients. Increased marketing and “Shop Front” presence is part of this. Web site expansion and commitment to social media as a vehicle for influence and building expectations is either active now or part of short term plans for all Providers contacted. As an example, one Provider attributed a 17% increase in new business to their expanded social media program and a 2-5% swing from traditional marketing channels.

The importance of a good Customer Relationship Management system to link marketing with Participants, services and business planning was noted with several Providers.


Figure 35 Provider - Participant Comparison

Significantly, a Provider relationship program was noted to include teaching clients “How to be a good customer”.

Participants

Observations from both the Participant conversations and Provider interviews confirmed that Participants are also active with social media and sharing of experiences. In particular, Participants have expectations from talking with other persons with similar disability and circumstance about what services and supports should be in their Plan.

Participants are actively sharing methods that contribute to obtaining a more favourable result in their Plan review. This is most prevalent where the relationship with the agency is not strong and the Plan review process is viewed by the Participant as being somewhat adversarial.

Providers observed that online collaboration among Participants is an increasing trend and expect it will gather force as more Participants with more experience apply pressure to the Plan review process.

Agencies

NDIA and WA NDIS have extensive web sites promoting their services and providing information for Participants and the community.

The Participant conversations and Provider surveys reinforced their need for a good relationship with the agency.

Where a poor relationship was observed to exist between the Participant and the agency, evidence showed there were resulting problems with the Plan, poor service outcomes and the Participant experienced stress and degrees of hardship. This was observed within both WA NDIS and NDIA trial sites.

A poor relationship with the Provider resulted in delays with service activation, service compromises and financial issues that in turn affected Participant support.

The WA NDIS Coordinator long term commitment to a Participant usually builds a sound relationship between the agency and the Participant. Specific instances observed where the relationship between the Coordinator and Participant broke down clearly demonstrated the negative impact on the Participant experience and outcomes.

The NDIA relationship with the Participant varies over the Plan lifecycle. After developing the Plan, the Planner transfers the operational responsibility to the Participant. At this point, agency support that may be required during Plan operation is up to the Participant, or their Provider Supports Coordinator, to initiate. Participant conversations and Providers interviews consistently reported the operational relationship between NDIA and its Participants was difficult and was cited as a key factor in the increasingly adversarial nature of Plan reviews and adjustment


situations. (NDIA relationship practices with a Participant during Plan operation are noted under the Plan operation discussions.)

WA NDIS also have a strong relationship with most Providers through the negotiation processes during Plan development and quoting, ongoing work with the Coordinators and often their long association with DSC in the past. The Organisation Managed service method also reinforces this longer term relationship.

NDIA operate differently with Providers in that the Participant has the key responsibility for the relationship. NDIA operational engagement with the Provider is primarily through the financial side and service claim processing. Engagement with the disability services sector is primarily with the peak national bodies and was observed by the Providers in the surveys as having little effective presence in WA. Maintenance of the relationship between the NDIA and the WA Provider community was credited to the work of specific individuals at the Midland office.

CS09: (NDIA) Participant XXX had a close relationship between their family and other families in their network group for mutual support. Conversations often explored each other’s Plans and the supports they had access to and which Planner was involved. This included advice that “… you should get them to change your Planner because PPP always says no”.

CS20: (WA NDIS) Participant XXX was not happy that the Plan did not properly address the child’s unusual needs and that the Coordinator was not supportive of XXX’s requests to have the situation improved. XXX sought advice (source withheld) on how to obtain an early Plan review that would result in a better fit to the child’s needs.

4.2.3 Plan Quality

Plan Development

Long term sustainability requires that Plan quality is managed and optimised for Participant experience and outcomes. Both agencies have Participant satisfaction surveys, either by phone or online questionnaire, that contribute indirectly to Plan quality assessment.

For WA NDIS, the three-way negotiation and quoting processes associated with developing the Organisation Managed services contribute directly to shared confidence in the “reasonable and necessary” nature of the services, and the cost effectiveness and viability of the Plan moving into operation.

For NDIA, the two-way negotiation approach to developing the Self-Directed Provider services had a low level of confidence by the Participant from their perspective that the “reasonable and necessary” objectives had been met. There was concern that cost effectiveness or viability of the Plan had not been established and that understanding what they had to do and obtaining the services was challenging.


An example of the benefit of WA NDIS three-way negotiation was where consideration of service grouping for more effective delivery and Participant outcome was resolved during Plan development. This approach to Plan development contributes to effectiveness of service investment, meeting expectations and was strongly supported by Participants, Providers and Coordinators. This is a more sustainable approach in that it reduces operational difficulties and increases the quality of experiences and outcomes and the value of service investment.

CS19: (NDIA) The family stated that during the meeting with the Planner, that service YYY was not required as “ it would never be used. ZZZ does not want it”. When the Plan was received, the unwanted service was included in the Plan. XXX accepted the Plan as provided as it was less trouble than trying to get it fixed. XXX did not activate the service with a Provider and was anxious about not spending the money.

Plan Production

In NDIA, the Planner role is focussed on development and review of Plans.

In WA NDIS, as well as the development and review of Plans, Coordinators also provide ongoing support for Participants during Plan operation.

On this basis, it is expected that the overall number of Plans produced by a NDIA Planner would be higher than the number prepared by a WA NDIS Coordinator. This is confirmed from data provided in the agency surveys. The graph in Error: Reference source not found shows the history of Plan productivity for two trial sites. The average is shown for the period from July 2015 to February 2016 (after the erratic effects of the implementation period). As expected, the NDIA average Plans per month per Planner is 4.8, higher than for WA NDIS where it is 3.6 Plans per month.

WA NDIS Coordinators produce 25% fewer Plans than NDIA Planners. This reflects primarily the additional duties of a Coordinator for Participant support during Plan operation but also includes the more time consuming WA NDIS Plan three-way negotiation process and more comprehensive Plan content.


0.0

2.0

4.0

6.0

8.0

10.0

12.0

Plans Approved per Planner/Coordinator

WANDIS

Avg WANDIS

NDIA

Avg NDIA

Figure 36 Plan Productivity Comparison

Use of “Norms”

Both agencies have a process for evaluating Plans by comparing the services and budgets with a “Norm” derived from a similar cohort sample. This process identifies those Plans that are considered to be atypical and seeks an explanation for the deviation from the expected normal service provisions.

This process is at odds with application of individualised assessment and the “reasonable and necessary” criteria. Planners and Coordinators reported during the workshops that they felt under pressure to produce Plans that conform to the “Norm” in order to avoid scrutiny of assessments.

Evidence of avoiding a “please explain” by applying a standard assessment to a Participant’s needs was noted in the agency workshops, Provider interviews and Participant conversations. The methods used to monitor the consistency and quality of Plans should not intrude on the determination of Participant “reasonable and necessary” needs and lead to less effective Plans and unsustainable business practices.

Consideration of the difference between the investment in Plan development and Plan operation emphasises the substantial return in Participant benefit and service effectiveness through commitment to developing the best quality Plans. From Error: Reference source not found it can be seen that the average cost of developing (or reviewing) a Plan in Planner or Coordinator time (3.6 to 4.8 Plans per month) is approximately $2,000. 18 In comparison, the average committed cost for a Plan for both trial sites is in excess of $35,000 (December 2015 actuarial reports) 19 so the Plan represents about 6% of the total investment in a typical Participant. A change in the investment in Plan development can significantly affect the value and effectiveness of the operation of a Plan and the outcomes for the Participant, yet it is a small part of the overall investment.

4.2.4 Value of Service

The value of the service as received by the Participant is dependent on the effectiveness of the service configuration and planning during Plan development and how the service is delivered by the providers. From the Participant Interviews there was a close correlation between Participants that were dissatisfied with the value and appropriateness of their services and who were also dissatisfied with their Plan and the way it was developed.

Parents of Participants who were Self-Managing services were highly committed to obtaining the maximum value of every dollar for their child. Their most particular annoyance was where service funds were used to cover travel or seen as unreasonable, such as charging an hour for a 15 minute visit.

18 Based on a notional Planner or Coordinator employment cost of $100,000 pa.

19 Note the average committed cost per Plan varies between the three trial sites considerably due to the different locations, and cohorts (age and disability type) and group home supports. For further up to date information on these costs, refer to the actuarial reports covering the trial sites.


Provider managed services under both trial models had similar levels of acceptance by Participants. Providers all have their own service plans mutually agreed with their Participants that conform to the Plan service descriptions and budgets.

The perceived value of the services was heavily influenced by how the Plan specified that they be delivered, the allocated funds and the experience and capability of the persons providing the care and support. Factors raised most often included:

Inappropriately experienced or trained care worker,

Percent of active service time versus total time charged,

Time lost to travel.

The trend for Providers to use less experienced persons in order to lower the cost of service was observed by Participants. The price setting process needs to consider the relationship between service pricing and expected training and competency levels for the service category.

CS06: (NDIA) The family of XXX stated “a twenty minute drive to attend a meeting at school [Therapist] and they charge for an hour and the same going back to the office”. She added “I want every cent to go to supporting XXX. XXX needs it more than they do”. When the mother challenged the Provider regarding the changes, she reported they said “… that’s the way we charge NDIA”.

CS11: (NDIA) It was reported by multiple Providers that their care workers spend more time interpreting what Plans required and addressing gaps in support needs that reduced the effective time spent with the Participant.


4.2.5 Participant and Community Trend Summary

1. Trends in value of services to Participant:

a) Increasing trend to commercialisation of the Provider-client relationship and client retention.

b) Participants and their families are highly committed to achieving the best value from their dollar. This highlights the need for flexible and responsive Plan adjustment facilities that allow Participants to exercise control over their services and Providers.

c) The influence of reduced service prices becomes evident to Participants through lower skilled and trained care workers, reduced value of services and more opportunistic charging by Providers to offset costs.

d) Participants are actively working together to prepare for and influence results in their Plan reviews. Providers are actively using social media for their marketing and engagement with the community, Participants and families.

2. Importance of a good agency - Participant relationship:

a) A good agency - Participant relationship generates better a Participant experience. The WA NDIS Coordinator continuity and accessibility is a positive factor. A breakdown in this relationship causes Participant anxiety and additional work for the agency in order to repair issues with Plans.

3. Plan development sustainability

a) The WA NDIS three-way negotiation during Plan development contributes strongly to the quality of the Plan, its viability and effectiveness in services delivery. This approach has greater stability and sustainability in delivering to expectations.

b) The NDIA two-way negotiation leads to a compromised Plan without proven service viability that is passed to a Participant to activate and take charge of service delivery and resolve problems as they arise.

c) Plan development quality indicators are summarised in section 3.4.10 Plan DevelopmentSummary.

d) Production rate for the two agencies (i.e. hours per Plan) is about the same allowing for the additional Participant support time spent by WA NDIS Coordinators. (Data was not available to this evaluation to quantify this observation)

e) There is a close correlation between Participants dissatisfied with the value and appropriateness of their services and who were also dissatisfied with their Plan and the way it was developed.


4.2.6 Participant and Community Trend Recommendations


WA NDIS NDIA

4.2.A Maintain an active presence in monitoring Participant and community trends on-line to ensure responsiveness to changing needs and attitudes.Evidence showed that social media is playing a greater role in collaboration between Participants, Providers and their communities with reported on-line marketing responsible for up to 17% of new Participants.

In Place In Place

4.2.B Adopt a pro-active agency program for Participant relationship development that monitors trends in Participant’s perception of service value, Plan satisfaction, Provider interaction and agency support. Evidence of increasing collaboration between Participants and sharing of expectations of their Plans, agency support and Providers has led to an increasingly adversarial attitude at Plan review.

Process Change

Process Change

4.2.C Promote full three-way engagement between the Planner/Coordinator, Participant and Provider during Plan development to ensure maximum service value, minimal operational overheads and optimal Plan outcomes.Evidence showed a three-way negotiation during Plan development contributes strongly to the quality of the Plan, its viability and effectiveness of the service delivery, Participant acceptance and reduced operational issues.



4.3 Agency Policies and Operations

The “Agency Experience” section of the second Provider survey provided a total of 333 responses to the 37 questions from the 9 Providers.

Each Provider’s response assessed the question subject change since the first survey in May 2015 as being: Much Better, Better, No Change, Worse or Much Worse. In Addition, they also assessed the trend for each subject for the next year on the same basis.

The Providers’ assessment of the changes experienced in working with the agency over the past year are shown in Error:Reference source not found

For WA NDIS, 81% were assessed as “No Change” and 11% as “Worse” and 6% as “Better”.

For NDIA, 51% scored “No Change” but 43% were scored as “Worse” or “Much Worse” although 6% were also scored as “Better”.

The response to the trend showed that 24% of the subjects are expected to worsen further in the coming year.

4.3.1 Communication and Relationships

The agency has the roll of coordinating and channelling information and fostering the relationships between all parties supporting the delivery of services to Participants their families and carers.

The differences observed between the agencies partly relate to differences in the trial models and also to different business practices. The key difference between trial models is the role of the WA NDIS Coordinator who takes on and retains a Participant in an ongoing relationship. In contrast, NDIA allocate a Planner from a pool as required for development of new Plans and again when a Plan review or adjustment is required.

The difference in practice is also marked. The WA NDIS Coordinator is the primary contact at all times and easily accessed by either the Participant or Providers associated with their Plan.

Both Participants and Providers consistently rated accessibility and cooperation of the WA NDIS Coordinator highly in sorting out all Plan related and other operational issues that arise.


Figure 37 Provider - Agency Comparison

In contrast, Participants and Providers were consistently critical of the difficulty of accessing assistance of NDIA staff for services or financial matters. It was commonly reported by both Participants and Providers that they had committed to attending the NDIA office in person, having given up on phone access.

NDIA have increased the number of Plans that include Provider Supports Coordinator services to better support Participants with their operational responsibilities.

Based on the Plan survey information, the use of Support Coordination category support has increased from 41% of Plans in November 2014 to 53% in November 2015.

In practice, Support Coordination was observed to have mixed outcomes. Some Participants reported effective support for their Plan and adjustments, whereas others reported it to be of no assistance. The outsourcing of Participant assistance to a Provider Supports Coordinator has some issues not experienced with the WA NDIS Coordinator. These are:

The Provider Supports Coordinator is not independent of Providers,

The amount of assistance is limited to the budget allocated in the Plan (in November 2015, the average Plan allocation was $1,830 - refer to the sample data in Error: Reference source not found on page Error: Reference source not found), and

The Provider Supports Coordinator is not internal to the agency and faces similar access issues with NDIA as other Participants and Providers.

For Participants to exercise choice and control, the service support environment needs to be responsive to their needs. As the NDIS scheme grows in WA, a robust and sustainable communication and relationship development process is essential to provide responsiveness to its Participants and Providers.

Evidence gathered from multiple sources suggests that the existing centralised NDIA communications and relationship facilities in WA cannot cope with the current load. In contrast, the distributed and personalised access model practised by WA NDIS was commended and has proven sustainability and scalability.


Figure 38 Relationships

There was also a difference reported in the way the respective agencies responded to resolution of issues, especially when escalation was required. With NDIA, most Providers in both surveys commonly reported excessive delays (months) and that generally negotiation was not an option. However in contrast, two Providers reported effective escalation based on personal association with NDIA Midland staff.

Issue resolution with WA NDIS was generally expedient and facilitated by the Coordinator and escalated to the area manager or regional director for negotiation as required. However, it was reported that inconsistent advice was occasionally received from different sites or staff that required further investigation by the Provider.

Participants expressed concern regarding the extent of their increasing dependency on the supports and commitments to ongoing support into following years. This was common to both models.

Participants were wholly dependent on the WA NDIS Coordinator or NDIA Planner for development of their Plan. Where a good relationship was established, the Participant had greater confidence in the outcome.

The following observations were made by Participants relating to Plan development and review that were commonly experienced with NDIA and not with WA NDIS:20

There was a power imbalance strongly on the side of the agency,

The Participant yielded to pressure from the agency regarding interpretation of “necessary” supports,

The Participant accepted compromises to what they believed was reasonable and necessary,

The Participant accepted Plans they considered not to meet their needs,

The agency superimposed their assessment of the disability over specialist advice,

Historical information was disregarded and Provider’s representatives discouraged from meetings,

Access to escalation for clarification and redress was not understood to be available.

The conclusion from these Participant responses is that good Plans require a good relationship between the Agency and Participant:

WA NDIS: most Participants reported a strong relationship with their Coordinator and difficulties were rare.

NDIA: most Participants reported difficulties and some felt it was adversarial. In particular, instances were noted where a Participant had prepared evidence specifically to avoid being

20 One WA NDIS case was reported where the Participant was not satisfied with their Plan due to relationship issues they had with their Coordinator.


compromised during a Plan review. This was a reaction to lessons learned from their previous Plan development experience.

In summary, Provider relationships were reported from surveys in May 2015 and July 2016:

WA NDIS has been generally good over many years. However, the trend has been for progressive degradation due to many changes in process. (see Error: Reference source not found)

NDIA relationship was assessed as poor in 2015 and has further degraded since then. Poor online facilities for claims and lack of communication accessibility, refusal to negotiate on issue resolution and ineffective escalation processes. Excessive delay in resolving outstanding debts (many months).

4.3.2 Financial Systems

Problems with the NDIA claims processing are discussed under Plan operation. The WA NDIS quarterly advance and acquittal process is accepted as reliable although the DSC web site sometimes came in for criticism and performance improvements may be required to address scalability.

From a sustainability perspective, evidence from Providers and Participants requires that the NDIA need to improve their account integration with Plan budgets and integrity of the claims process for Providers. All Providers provided examples of flaws with the processes up to 30 June 2016. The replacement process intended to operate from 1 July 2016 was not operational as of early August when this report was prepared. Providers expressed considerable concern over the viability of the proposed service booking procedures and the ability of Participants to comply with the changes. Further assessment of this new system is out of the scope of this evaluation.

A reliable, scalable and sustainable financial system needs to be implemented without delay. The summary of the issues be resolved in the replacement system includes:

Integrity issues with Participant service accounts,

Multiple access by Providers to Participant service accounts,

Budget correlation between Plan and Participant account,

Claim rejection procedures and resolution:

Transparency of decisions,

Expedite resolution of issues and anomalies.

Plan transitions and rollover account management:

Continuity of support for Participants when Plan review is delayed,

Account adjustments to comply with Plan extensions,


Claim processing for gap periods between Plan expiry and recommencement.

Exception handling where Participant services are disrupted.

CS13: (NDIA) Provider PPP said “The old system had issues. … The replacement is not cause for optimism”.

CS13: (NDIA) Provider PPP tried for 7 months to have claims paid that were lodged for services provided for a Participant after their Plan expired and before the new Plan was commenced. PPP said “after all this time they finally said no, it is not negotiable”

4.3.3 Process Improvement

The Plan lifecycle stages in this document cover the assessment of business processes that can benefit from improvement and those where a process review is necessary.

This section addresses areas where overall improvements may be made in the interest of Plan quality, improved choice and control for Participants and cost effective services by Providers.

Process flexibility and improvement

Greater use of flexible Plan durations to suit observed stability or rate of change of Participant requirements.

Improved and more responsive processes for minor adjustments to Plan service specifications and budgets during Plan operation.

Service initiation and Provider engagement efficiencies:

WA NDIS: more streamlined quoting and commencement processes,

WA NDIS: Timely access to Participant Plans by Providers with approved services in the Plan.

Collaborated services across multiple Participants

Aggregate service delivery overheads to a Participant group,

Service delivery coordination across co-located Participants:

Co-located Participants use a rationalised travel schedule,

Co-located Participants with a common Provider,

Coordinating multiple Providers for one or more Participants.


Training of agency staff

Consistent advice to Providers,

Consistent advice to Participants,

Consistent approach to Plan quality,

Balance of quality versus volume KPIs.

Agency use of Performance Indicators to support primary goals

Demonstrated Reasonable and Necessary services in Plans,

Demonstrated Choice during Plan development and Provider engagement,

Demonstrated Control through flexibility and responsiveness during Plan operation,

Demonstrated value of services to Participants,

Demonstrated effectiveness and sufficiency in choice and availability of provider services to meet Participant Plan specifications,

Demonstrated feasibility of activating a Plan in a timely manner consistent with the responsible party’s resources and abilities,

Published Plan quality indicators that favour Plan quality over volume to avoid poor Plans with low value and poor outcomes for Participants,

Participant assessments of the planning process. Phone and surveys are not sufficient due to “power” imbalance.

Procedures and resources supporting Choice and Control for Participants

Plan development practices supportive of Participant exercising “Choice”:

Influence of power over decision making,

Avoid premature assessment of needs based on limited contact or understanding of cohort factors.

Plan to be tested as viable for activation by a Participant:

Availability of designated services in the Plan,

Minimise likelihood of Provider rejection,

Local factors affecting service access are covered.

Operational response and flexibility:

Ability to adjust Plan services responsively,


Multiple levels of Plan review:

- Expedite review processes,

- More responsive to changing needs,

- Less agency resource intensive.


4.3.4 Agency Trend Summary

1. Access to information and negotiation:

a) Early resolution of emerging issues is a strong contributor to the improved sustainability of the WA NDIS over the NDIA models. The distributed and personalised access model practised by WA NDIS with the ease of access to negotiation for Participants and Providers afforded by the ongoing Coordinator relationship is the major factor in the marked difference in experience and Plan outcomes observed in the surveys and workshops.

b) The current centralised NDIA communications and relationship approach in WA cannot cope with the current level of activity. Difficulties experienced with NDIA access compromises effective control by Participants and Provider services. A robust and sustainable communication and relationship process is essential to provide responsiveness to its Participants to exercise choice and control.

2. Continuity of support into the future:

a) Participants from both trial sites expressed anxiety from a lack of confidence in the continuity of support from the scheme after their current Plan period expired as a result of the annual Plan review process.

3. Participant Relationship:

a) Participant evidence was that good Plans require a good relationship between the agency and Participant. For WA NDIS, this was the normal situation and difficulties were rare and Participants were generally pleased with their Plan. However, for NDIA, most Participants reported difficulties with their relationship with the agency (some felt it was adversarial) and generally were not satisfied and accepted Plans they considered inadequate.

4. Plan flexibility:

a) Trial model processes that would benefit from improvement include provision for flexible Plan durations and responsive processes for minor Plan adjustments.

b) For WA NDIS, improvements to the Provider quoting and Plan commencement processes would minimise minor delays.

5. Financial System:

a) The WA NDIS quarterly advance and acquittal process is reported by Providers to be acceptable.

b) For NDIA, it is critical that a reliable, scalable and sustainable financial system be implemented without delay. The systems in place up to 30 June 2016 had many flaws and the replacement systems from 1 July 2016 was not effectively operational with unproven processes by early August 2016.


6. Continuity of Participant services:

a) Participant services under NDIA are suspended during the gap between Plan expiry and commencement of a replacement Plan. NDIA need to ensure continuity of Participant services during this Plan rollover period to mitigate Participant hardship. This is covered under section 3.7.8 Plan Review and AdjustmentRecommendations.

7. Performance Indicators:

a) Pressure to comply with Plan “Norms” was observed to lead to compromised assessment of individual needs in order to produce conforming Plans and avoid a “Please Explain”.

b) Review of Performance Indicators to provide greater emphasis on quality and viability of Plans and Participant outcomes such as demonstrated achievement of reasonable and necessary criteria.

c) Review of Performance Indicators to monitor Participant and Provider experiences, and achievement of choice and control through being responsive to meeting needs for Plan and service changes at all stages of the Plan lifecycle.

4.3.5 Agency Trend Recommendations

RecommendationAction

WA NDIS NDIA

4.3.A Enable responsive access to agency and Provider support, operational flexibility and adaptability of Plans in order to enable and maintain ongoing responsive Participant choice and control.Evidence showed deterioration of Participant choice and control caused by difficult access to agency support, excessive time to resolve issues and inflexible procedures for changing Plans. The evidence showed the trend was for further degradation.

Policy Change

Process Change

4.3.B Implement and maintain a robust and sustainable, decentralised and scalable three-way communication and relationship process involving Participants, their Providers and the agency. Evidence showed that Participant experience, Plan outcomes and operational overheads were markedly better where Plan development and operation was based on the three-way collaboration process. There were fewer issues and viable solutions were quickly put in place.




WA NDIS NDIA

4.3.C Implement a program to address Participant concerns and minimise anxiety regarding their ongoing dependency on continuity of NDIS based supports.Evidence was received from Participants expressing deep anxiety about their dependency on the annual review process and the consequence that their supports may be reduced or removed next year.

Process Change

Process Change

4.3.D Implement Plan development processes aimed at measurable Plan quality improvements delivering optimised service value with reduced Plan operational issues and support overheads.Evidence showed that better quality Plans were better accepted by Participants, easier to implement and fewer issues during operation. Participant’s experience and outcomes were more positive. Plans with low acceptance by Participants were difficult to implement, caused disputes with Providers and reduced value of service and outcomes, and elevated stress on Participants.

Process Change

Process Change

4.3.E Ensure a reliable, functional, scalable and sustainable financial system be implemented without delay.Evidence showed the NDIA claims processing financial system to have many faults. The new system implemented on 1 July 2016 exhibited problems to Providers and Participants and a low level of confidence was expressed. Further assessment of the new system was outside the time frame of this evaluation. The WA NDIS systems are adequate for the current two trial areas but the scalability for rollout of the paper based claims process requires attention.

Process Change

Process Change

4.3.F Reassess existing Performance Indicators to provide greater emphasis on measuring viability of services, achievement of reasonable and necessary criteria, individualised funding, and responsiveness to Participant choice and control. Evidence was noted regarding the quality management programs at the agencies. However, the observations throughout this evaluation indicate that areas requiring remediation or improvement will benefit from increased visibility from a strategic commitment to improved performance indicators.

Process Change

Process Change



WA NDIS NDIA

4.3.G

Performance measures be put in place to reward Plan development for achieving robust, viable and accurate Plans. Evidence shows that incentives for Plans to comply with cohort “Norms” led to preparation of Plans that were considered by Participants to be inaccurate and inadequate for their needs. Provider specialists expressed similar assessments. Agency staff experienced stress balancing the pressure to conform to the “Norm” with their Participant assessments. (Avoiding “Please Explain” requests)“Normalisation” of Plans runs counter to the purpose of a Plan that requires adherence to principles of individualised assessment.

Process Change

Process Change


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