Reflections from neuropsychology
When the National Disability Insurance Scheme (NDIS) was launched in 2013 it provided a ray of hope for people with a disability and those working in the disability sector. The scheme enables individualised support for those with permanent disability and offers the chance to improve quality of life for those affected, as well as give their family and carers, the potential for some well-deserved reprieve. As a neuropsychologist with an interest in disability and rehabilitation I have navigated, and assisted others to navigate, the NDIS system. I share here some of my thoughts about how psychologists and neuropsychologists can engage with the NDIS to provide much-needed services.
The Barwon region was chosen as the Victorian trial site for the NDIS rollout. At the time, in both the public and private sector, there was much excitement about the possibilities afforded by this model. In many respects, the concept of clients being able to have choice and control over their supports and to determine how and by whom they wanted their funding and supports to be managed, reflected the goal-directed therapeutic practice employed in the rehabilitation sector as well as more broadly, in psychological practice. However, it quickly became apparent that transitioning to the scheme was going to prove more of a challenge than initially anticipated.
The beginning of the scheme
In the public health service, once the NDIS was in place there was a shift in the nature of referrals received whereby there was an influx of referrals from general practitioners and community health providers solely for the purpose of cognitive assessment and diagnosis of disability. This placed considerable pressure on the Neuropsychology Department to whom most of these referrals were directed. Initially, this was considered to be a fantastic means by which to put forward a business case for increasing the psychology staff ratio within the department. That dream was quickly deflated when informed that these referrals could not be accommodated within our division.
“Psychologists who are NDIS registered providers have the fantastic opportunity to solidify a place for our profession within the disability sector, particularly in the realm of behavioural intervention and support”
As we navigated the eligibility and application procedures for NDIS, we realised there was no funding for neuropsychological assessment in the scheme. The justification for this is that individuals needed to have a demonstrated disability and it was not the place of the NDIS to provide assessment or make such a determination. This led to a conundrum given that, as a rehabilitation service, these referrals did not fall within our scope of practice, and referring clients for private assessment was simply out of reach for many financially constrained clients. Unfortunately, bridging this gap remains an ongoing challenge for many and as different health services come under the scheme, each has had to generate their own means by which to address this matter.
The second challenge faced was determining whether a public health service could charge NDIS approved clients for services, or was this considered ‘double dipping’ in the Victorian and Federal Government public health fund. This required our health service to develop more clearly defined parameters around service provision. Essentially, clear parameters needed to be established to clarify what supports fell under the ‘disability’ umbrella (i.e., case management) and hence, should be managed external to our service as opposed to those that were readily delivered by the health system yet still required by the affected individual to improve function or independence (i.e., hydrotherapy or fall/balance clinics).
The NDIS plan
The NDIS provides a benefit for non-compensable clients with established acquired brain injuries, neurological conditions, early-onset neurodegenerative disorders, and so on. These clients are now able to access services and interventions that had previously eluded them without independent funding. Furthermore, they are given a fantastic sense of agency and choice in their supports and interventions thus, promoting self-efficiency and independence. Essentially, if they chose to self-manage their plan, they can choose what supports they want and who they want to be their providers.
Only a small number of clients take up the option for self-managed plans; a likely consequence of the complexities of navigating the NDIS system (i.e., knowing what services were required or available) as well as the level of higher order decision-making required to do so effectively, including requesting and paying invoices. Many of the clients chose Agency Managed Service Providers of which there simply weren’t enough during the planned rollout. Agency Providers were heavily understaffed and, in many respects, out of their depth given that unskilled staff were often hired to bridge this gap. With clients that had high care needs and considerable cognitive, physical or communicative complexities, this was simply insufficient and left both clients and carers feeling disillusioned with high rates of carer turnover. Thankfully, the dust is beginning to settle and this is becoming less of an issue as Agency Providers become more accustomed to the systems, clients and associated demands.
While directing one’s own NDIS plan and care needs is a fantastic forward step, it does require a level of insight and awareness on the client’s behalf which for many clients (particularly those with early onset dementia or acquired brain injury) is not present – or at least not to the degree necessary to ensure appropriate services are sought. In many instances, family members and carers are often left despairing given that inappropriate or inadequate services were often sourced if the client was not suitably directed by healthcare providers when applying for the scheme. In this instance, family and carer needs can tend to be ‘put on the backburner’ or considered less of a priority and avenues by which carer’s can receive support are dependent somewhat on the client having awareness of their family member or carer’s needs or the presence of a suitable healthcare provider or advocate to include respite/carer support as part of the plan.
Access challenges
Advocacy and support is required more broadly when attempting to complete the NDIS Access Form given that, even those without cognitive impairment, can struggle ‘knowing where to start’. In line with the NDIS application being directed by the client, the requests for service and access are generally required to be completed by the client. This often proves a significant challenge for those with intellectual disability or other cognitive impairments that impair decision-making, as well as for those with poor literacy or from non-English speaking backgrounds. More often than not, without support from staff who are accustomed to completing NDIS applications, many requests for access and service were, and still are, initially rejected. All of this prolongs the process and increases frustration for all involved. Clients with disability often require support to:
- generate goals
- establish how those goals can be supported and by whom
- provide evidence of the impact of their disability upon their daily life (including a rating of severity), and
- justify how the requested service would reduce that impact and result in improved quality of life or independence.
How can psychologists help?
Once established within the service, there are many ways in which psychologists can be effective, particularly in private practice. Psychologists who are NDIS registered providers have the fantastic opportunity to solidify a place for our profession within the disability sector, particularly in the realm of behavioural intervention and support. Much of my private work has been for those with significant disability and associated behavioural problems, working with them and care staff to provide a plan to manage challenging behaviours and finding appropriate community-based programs to enable more meaningful engagement in daily life. Psychologists can register to provide a range of NDIS supports including Specialised Positive Behaviour Support, Early Intervention Supports for Early Childhood, Support Coordination and Therapeutic Supports. Targeted therapeutic interventions that psychologists readily provide are well supported by the scheme. However, approval from the client’s NDIS Support Coordinator always needs to be sought prior to any intervention commencing.
| Neuropsychological reports specifically are often used as a therapeutic tool within NDIS for those clients lucky enough to have had these completed prior to applying. In writing reports for clients who are considered eligible the following report inclusions are recommended to expedite the application process. |
- Clearly outline the disability, including the nature and extent and provide opinion about the stability and permanency of the disability.
- Clearly outline the impact of the disability; specifically, in what way does the disability impact the client’s day to day function (including evidence and corroborative reports). The use of behavioural observations, occupational therapy reports, etc., should be used as a means of justification for your opinion.
- Always reference eligibility criteria and how you consider they apply to the individual (i.e., the person is under 65 years of age, is an Australian citizen/resident/permanent visa holder, lives in an NDIS catchment area and meets the disability or early intervention requirements. For details refer to the NDIS website (bit.ly/2MpAOiA).
- Clearly outline the supports required and consider the broad guide given by NDIS, whereby supports need to be ‘reasonable and necessary’. Hence, justification needs to be very clear regarding what is required and why this form of support is required as opposed to an alternative method. Where possible, suggest the agencies, intensity and type of intervention you feel would be most suitable.
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A closing note
The vision of the NDIS is a grand one – allowing people with disability to become the driver’s in their own lives with goal-directed and person-centred care at the forefront. While the implementation of this vision has not been without its teething problems, any service that enables a wider array of supports and access to clients with varying forms of disability is a fantastic health-care progression.
As a profession, psychologists have a great skill set to provide evidenced-based and goal-directed interventions to clients within the NDIS. However, as a collective, more concerted efforts need to be made within our profession to position ourselves as a suitable ‘disability based’ provider. One suggestion in progressing toward this objective would be placing a stronger emphasis in our post-graduate teaching and training on therapeutic intervention for clients with disability and cognitive impairment. The current emphasis in postgraduate training is directed towards enhancing clinical and diagnostic skills. However, experience in supervising students and registrars over many years has highlighted that this can be to the detriment of rehabilitation or therapeutic intervention teaching, which is necessary to work in this, as well as many other settings. Consideration needs to be given to incorporating or mandating more therapeutic practices into student and registrar training – a move which will enhance the work undertaken by psychologists overall, rather than just those working within the NDIS.
The use of neuropsychological assessment as a therapeutic tool as opposed to the primarily consultant capacity that many clinicians operate is also a necessary step in garnering more support for the need for the profession within the NDIS sphere. The breadth of information that a neuropsychological assessment provides for individuals with cognitive disabilities is a means by which NDIS providers can develop a clear strategic and therapeutic plan for clients. This is an avenue that requires further exploration and greater advocacy. As psychologists, we have a specialist skill set that can enhance the care for affected individuals and contribute significantly to the NDIS into the future.
The author can be contacted at [email protected]