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DOCUMENT 1
Practice Guide – Complex Support
Needs Pathway
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Contents
Practice Guide – Complex Support Needs Pathway ..................................................................
1.
Purpose ...................................................................................................................... 3
2.
To be used by ............................................................................................................. 3
3.
Scope .......................................................................................................................... 3
4.
Complex Support Needs (CSN) Pathway ................................................................... 3
5.
Referring to the CSN ................................................................................................... 4
6.
Behaviours of Concern ............................................................................................... 4
7.
Risk of inappropriate entry into Residential Aged Care ............................................... 5
8.
Younger People in Residential Aged Care (YPIRAC) ................................................. 5
9.
Children living in a voluntary agreement outside the family home .............................. 6
10.
Homelessness ............................................................................................................ 6
11.
Justice interface .......................................................................................................... 7
12.
Liaison officers ............................................................................................................ 7
13.
Supporting material ..................................................................................................... 7
14.
Feedback .................................................................................................................... 8
15.
Version change control ............................................................................................... 8
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1. Purpose
This Practice Guide will introduce the Complex Support Needs (CSN) Pathway. It will
describe the reasons participants are referred to the CSN Pathway and how to refer a
participant in need of specialised support.
2. To be used by
Plan Developers:
-
Planners
-
Partners in the Community (Early Childhood Partners and Local Area
Coordinators [LACs])
NDIA Plan Delegates.
3. Scope
This practice guide has been developed to provide you with an overview of the CSN Pathway
and the cohorts they work with. This is not detailed planning guidance. Where a link is
provided to another resource, you must refer to that resource for full guidance.
4. Complex Support Needs (CSN) Pathway
The National Disability Insurance Agency (NDIA) is committed to ensuring all participants of
the National Disability Insurance Scheme (NDIS) have an experience which meets their
needs and delivers a fit for purpose plan. However, a single pathway approach is not
appropriate for all participants. Because of this, the NDIA has introduced the CSN Pathway.
The CSN Pathway aims to provide specialised support for people with disability who
experience personal and situational factors that are beyond the scope of the typical NDIS
Pathway. The CSN Pathway has dedicated planning teams and a network of skilled planners
with experience working with specific complex support cohorts such as justice, psychosocial
and/or with allied health experience.
The CSN Pathway acknowledges the range of primary and secondary situational and
personal factors contributing to the complex support needs of a participant. This may include
voluntary or involuntary involvement in other government service systems and transitional
supports for returning to the community, for example, exiting incarceration or an acute
rehabilitation environment.
The NDIA defines complex support needs as:
‘A situation where a person has extraordinary support needs based
on the presence of situational and personal factors that require a
comparatively greater need for coordination of multiple services to
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assist the participant in the development and implementation of their
plan’.
For the purposes of the CSN Pathway, the definition of complexity does not describe the
complexity of the participant’s disability, rather the interaction of the personal and situational
factors, level of intensity and how these impact the participant’s ability to navigate the NDIS
Pathway.
At access, or throughout ongoing engagement with the NDIS, participants may be identified
as suitable for the CSN Pathway based on factors such as:
Behaviours of Concern (BoC)
Younger People in residential Age Care (YPIRAC) and those returning to the
community from living in residential aged care
children living in a voluntary agreement outside the family home
involuntary or voluntary involvement with particular government systems, such as
justice or mental health
homelessness.
Participants may move between the typical NDIS Pathway and the CSN Pathway depending
on their situational or personal factors at any given time.
5. Referring to the CSN
During the planning process you may identify the participant has complex support needs. The
decision to refer the participant to the CSN Pathway is made by National Delivery.
The decision to stream the participant in or out of, the CSN Pathway is made by the CSN
Branch.
Note: Being streamed as Intensive or Super Intensive does not mean a participant needs to
be referred to the CSN Pathway. The criteria and process to consider when to refer to this
pathway can be found in Standard Operating Procedure - Referral for Complex Support
Needs.
6. Behaviours of Concern
Behaviours of Concern (BoC) refers to a wide range of behaviours of an intensity, frequency
or persistence that threatens the quality of life, physical safety of the individual and/or others.
BoC may include:
physical or verbal aggression
property damage
inappropriate sexual behaviour
disinhibited and impulsive behaviour
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self-injurious behaviour also referred to as self-harm.
The NDIS Commission has oversight of behaviour support plans and restrictive practices.
The NDIS Commission is operating in all states and territories except for Western Australia.
Current state requirements for quality and safeguards continue to apply in Western Australia
until the NDIS Commission commences operating from 1 July 2020.
Behaviour support practitioners must lodge any positive behaviour support plans including
restrictive practices with the NDIS Commission.
Behaviours of concern alone are not an indicator for referral to the CSN Pathway. A referral
should only take place if the participant’s complex needs are unable to be met by a planner in
the NDIS Pathway.
Refer to the Standard Operating Procedure – Behaviour Intervention Supports and the NDIS
Quality and Safeguards Commission for further information.
7. Risk of inappropriate entry into Residential Aged
Care
Participants who are considered at risk of inappropriate entry into residential aged care are
supported by the CSN Pathway to help them to identify current and future support needs and
appropriate, alternative housing options.
Factors that may indicate if the participant is at risk of inappropriate entry into residential
aged care include, but are not limited to:
homelessness, or at risk of homelessness
a lack of adequate and readily available housing and supports
a recent or unexpected loss of a sole carer or guardian with no known alternative
care options
exposure to domestic violence and/or
palliative care needs.
8. Younger People in Residential Aged Care (YPIRAC)
Younger people who reside in a residential aged care facility on a permanent basis, who
have been approved under the Aged Care Act for residential aged care and are NDIS
participants are considered to have complex support needs.
YPIRAC participants are supported within the CSN Pathway due to their complex living
arrangements, support needs and interface with the aged care system.
Refer to the Practice Guide – Medium Term Accommodation, Practice Guide - Younger
People in Residential Aged Care and Standard Operating Procedure – Younger People in
Residential Aged Care.
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9. Children living in a voluntary agreement outside the
family home
Voluntary out of home care arrangements are the provision of care outside the family home
when a child’s parent/s or primary care giver are no longer able to continue to care for their
child in the family home due to the child’s significant disability support needs.
Under these circumstances the voluntary arrangement is jointly coordinated and overseen by
the relevant state or territory authority and the NDIA. Under this arrangement, parents or
primary care givers continue to be responsible for the decision making relating to their child.
A child who is not currently living in a voluntary arrangement, but who is at risk of requiring
accommodation outside the family home should be referred to the CSN Pathway. This will
ensure the child has supports in place to increase the capacity of both the child and their
family to remain living together as a family and reduce or remove the risk of requiring living
arrangements outside the family home.
Refer to Practice Guide - Children and Young People with Disability Living in a Voluntary
Agreement Outside the Family Home.
10. Homelessness
The NDIA provides reasonable and necessary disability supports to all eligible Australians
including people who are homeless. A person is homeless if they:
do not have conventional accommodation, such as sleeping rough or in improvised
dwellings
frequently move from one shelter to another, such as emergency accommodation or
“couch surfing”
live in accommodation that falls below minimum community standards, such as
boarding houses and caravan parks.
Representatives from the NDIA and LACs will engage in face to face meetings with
participant’s who are homeless. These meetings can be at any of the NDIA offices, Service
Australia Service Centres, LAC offices or any safe location in the community.
A person experiencing homelessness can provide a postal address to receive mail from the
NDIA. This could be the address of a support agency, church or a representative.
A support coordinator can be included in the plan to support the participant to engage with
local homelessness services and makes sure they are receiving any services and supports
they are entitled to.
Refer to Homelessness Australia for information on available supports in your state or
territory.
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11. Justice interface
Planning for participants who are involved with the justice system generally follows the same
process as for other participants.
A participant interfaces with the justice system when they are:
in custody (in a correctional facility for example, prison, remand centre, or youth
detention centre), on remand, awaiting or following sentencing
on bail, probation or parole and required by a Court order to report to a correctional
or community correctional agency
serving a community based order
under forensic orders, which may include restrictions on their movements and/or
other requirements, for example, drug testing, attending prescribed treatment.
Interfacing with the justice system alone is not an indicator for referral to the CSN Pathway. A
referral should only take place if the participant’s complex needs are unable to be met by a
planner in the NDIS Pathway.
Refer to the Practice Guide – Justice for further information.
12. Liaison officers
Liaison Officers are represented in all states and territories and are part of the Complex
Support Needs (CSN) pathway Branch. Liaison Officers provide a single point of contact for
health and/or justice staff to facilitate support for participants (prospective and current) in
health and/or justice settings. The role of a Liaison Officer is a non-participant facing role with
a focus on support for hospital and justice staff, NDIS plan developers (planners and LACs),
engagement staff and support coordinators.
Refer to the Health and Justice Liaison officer factsheets on the CSN intranet page for further
information.
13. Supporting material
NDIS Act 2013
NDIS Rules
NDIS Operational Guidelines
Planning Operational Guideline.
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14. Feedback
If you have any feedback about this Practice Guide please email Service Guidance and
Practice. In your email, remember to include the title of the resource you are referring to and
to describe your suggestion or issue concisely.
15. Version change control
Version Amended Brief Description of Change
Status
Date
No
by
2.0
CS0074
New definition for homelessness.
APPROVED 2020-03-17
Added section to address
participants at risk of inappropriate
entry into residential aged care.
Update to include guidance on
Liaison officers. Replace OHS with
Services Australia
Class 1 approval
3.0
CRG656 Class 1 approval
APPROVED 2020-07-24
Practice Guide strengthened to
incorporate advice that children at
risk of requiring accommodation
outside the family home should be
referred to the CSN Branch.
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DOCUMENT 2
Referral for Complex Support Needs
Previous Step: The
participant is identified as having complex support needs or has
experienced a crisis situation and is referred by the Exceptionally Complex
Support Needs Program.
Next Step:
The participant either enters the Complex Support Needs Pathway for
planning or is referred back to National Delivery for planning as they do not
meet the criteria.
1.
Purpose
This Standard Operating Procedure (SOP) will guide you to:
consider if the circumstances of the participant require the Complex Support Needs
(CSN) Pathway
refer the participant to the CSN Branch
understand the participant will be assessed by the CSN Branch and either enter the
CSN Pathway or remain in the General Pathway.
Note: Enhancements to the CSN Pathway processes are underway. It will be important to
check back for updated guidance in the future.
2.
Index
6.1 Refer the participant to the CSN Pathway
6.2 CSN Branch assess the participant and advise outcome
6.3 The participant exits the CSN Pathway and is referred to National Delivery for
planning
7.1 Appendix 1 - Workflow diagram
7.2 Appendix 2 – Workflow diagram alternative text
8 Supporting material
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3.
To be used by
National Access Workload Management Branch Delegates
Plan Developers
- Planners
- Partners in the Community (Early Childhood Partners and Local Area
Coordinators [LACs])
National Delivery Directors and Assistant Directors
Complex Support Needs Planners and Business Support Officers
Exceptionally Complex Support Needs Program.
4.
Scope
During the planning process you may identify the participant has complex support needs.
Complex support needs are where the participant has extraordinary support needs requiring a
greater need for coordination of multiple services to assist the participant in the development
and implementation of their plan. Table 1 lists the factors which may contribute to the
participant requiring this more tailored approach.
The decision to refer the participant to the CSN Branch can be made by:
the National Access Workload Management Branch (NAWMB)
National Delivery
the Exceptionally Complex Support Needs Program (ECSNP).
As with any streaming decision, Partners in the Community will need to make a request for the
CSN Pathway via National Delivery.
The decision to move a participant in, or out of, the CSN Pathway is made by the CSN Branch.
Only CSN authorised officers can complete the CSN Suitability Checker assessment and
update the participant’s stream to Complex. For more information regarding streaming, refer to
the Standard Operating Procedure – Participant Streaming.
5.
Prerequisites
Generally, National Delivery will have determined the participant's streaming as
Super Intensive in the NDIS Business System (System).
There is sufficient documented evidence attached to the participant record indicating
the need for referral to the CSN Pathway.
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The participant is identified as requiring referral to the CSN Pathway by the ECSNP
team after experiencing an unexpected crisis due to a sudden change in
circumstances.
6.
Procedure
6.1 Refer the participant to the CSN Pathway
1.
Consider the participant circumstances and the factors in Table 1. To refer to the CSN
Branch there should be
one or more situational or personal factors. In addition, a
significant level of intensity or impact must be demonstrated in relation to each factor,
which results in the participant requiring an extraordinary level of support and liaison
across mainstream interfaces for them to be able to achieve their outcomes.
6.1.1 Table 1: Situational and personal factors indicating complex support needs
s47E(d) - certain operations of agencies
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s47E(d) - certain operations of agencies
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2.
When referring to the CSN Pathway, consider the CSN Checklist below. You must be
satisfied of the following:
The situation cannot be handled through changes such as a new provider or plan
review.
The participant cannot be adequately supported by an experienced LAC or planner in
conjunction with an appropriate support coordinator.
It is not in the best interests of the participant to stay with the current planning team.
An active Section 48 or Section 100 review is
not currently underway by the National
Review Team or Internal Review Team. This is because it may be in the best interests
of the participant to continue with a particular process, or staff member, to complete a
review process. However, if during the process of a Section 48 or Section 100 review
you identify circumstances that critically require the CSN Pathway, speak to a National
Delivery Director or Assistant Director (AD) regarding the appropriateness of a referral.
There is not an active Administrative Appeals Tribunal (AAT) case underway.
Agreement to refer to determine suitability has been provided from a National Delivery
Director or AD.
Participant has exceptionally complex support needs if referred via the ECSNP.
Referrals to the CSN Pathway should be submitted at the Assistant Director or Director
level, so it is clear that there is endorsement for the referral.
3.
Create an open
Interaction in the System, using the category -
CSN Assessment
Required and assign to the CSN inbox
CR SDP Return to CSN. Refer to Interactions
Template – Planning for how to complete the interaction. Set the interaction status to
Open. Include the login ID of the referrer so advice on the outcome can be returned to
the right person.
Note: If the open
Interaction remains in your inbox, go to
Internal Use and reassign it
from
Open Activities.
4.
The participant remains with National Delivery until the CSN Branch makes the
decision.
6.2 CSN Branch assess the participant and advise outcome
1.
The CSN Branch receives the referral via an
Interaction.
2.
The CSN Suitability Checker assessment is completed within five business days of the
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referral interaction.
3.
The CSN Suitability Checker assessment to be completed within two hours of the
referral interaction if a crisis referral has been undertaken for the participant
(categorised as
Extreme under the Escalation Prioritisation Matrix).
4.
The CSN Suitability Checker is uploaded to
Inbound Documents in the System.
5.
A new
Interaction is created and assigned to the referrer with the category
Outcome
of CSN Assessment.
6.
If the outcome is the participant does not meet the CSN Suitability Assessment,
planning will continue with National Delivery.
7.
If the participant is suitable for the CSN Pathway, the CSN Branch will update the
participant’s stream to Complex and organise a warm handover with the staff familiar
with the participant’s circumstances. The CSN Branch will take over the planning
process where there is CSN planner capacity.
Note: The streaming value Complex is
only for use by the CSN Branch and the decision to give a participant the streaming
value of Complex can only be made by the CSN Branch.
8.
If the participant enters the CSN Pathway resulting from a crisis referral, the CSN
Branch may organise a warm handover with the staff familiar with the participant’s
circumstances. The CSN Branch will take over the planning process; and undertake a
plan review the same day of the referral interaction.
6.3 The participant exits the CSN Pathway and is referred to National
Delivery for planning
The referral and warm handover to National Delivery will occur when the participant is already
receiving support in the CSN Pathway and their circumstances change to the extent they are
determined to no longer require this Pathway.
1.
The CSN Branch will complete the Suitability Checker Assessment prior to each
participant plan review. When the participant is assessed as no longer requiring the
CSN Pathway, the participant’s stream will be updated and they will be referred back to
National Delivery for planning.
2.
The CSN Branch will discuss the referral with a National Delivery AD in the geographic
area of the participant. The AD will facilitate the identification of an appropriate plan
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developer to plan with the participant.
3.
The CSN Branch will create an open
Interaction in the System with the category of
CSN handover to SD&P for planning and assign to the nominated plan developer.
Refer to Interaction Templates – Planning for how to complete the interaction.
4.
The CSN Branch will conduct a warm handover with the plan developer in National
Delivery, and identify outstanding or ongoing matters to consider during the planning
process.
5.
The plan developer in National Delivery will support the participant in the NDIS
Pathway.
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7.
Appendices
7.1 Appendix 1 – Workflow diagram
For alternative text to the diagram, go to Appendix 2.
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7.2 Appendix 2 – Workflow diagram alternative text
7.2.1 Steps for National Access Workload Management Branch (NAWMB)
Start.
NAWMB delegate identified participant has sufficient evidence of complexity.
Approval required from NAWMB AD.
If
No, follow standard process.
End process.
If
Yes, NAWMB AD will use the CSN Checklist found in the Standard Operating
Procedure - Referral for CSN.
If
No, follow standard process.
End Process.
If
Yes, NAWMB AD creates interaction and assigns to CSN inbox -
CR SDP Return to
CSN. Flow on to Steps for CSN Branch.
7.2.2 Steps for Service Delivery
Start.
Plan developer identified participant needs indicate CSN Pathway.
Approval required from National Delivery AD.
If
No, follow standard process.
End Process.
If
Yes, National Delivery AD will use the CSN Checklist found in the SOP - Referral for
CSN.
If
No, follow standard process.
End Process.
If
Yes, National Delivery AD creates interaction and assigns to CSN inbox-
CR SDP
Return to CSN. Flow on to Steps for CSN Branch.
7.2.3 Steps for CSN Branch
CSN inbox (
CR SDP Return to CSN) receives interaction.
Complete CSN Suitability Checker and determine suitability for Pathway within 5
business days.
Complete CSN Suitability Checker assessment within 2 hours of the referral interaction
if a crisis referral has been undertaken for the participant (categorized as
Extreme
under the Escalation Prioritisation Matrix).
BSO allocates participant to planner within the CSN Pathway, to occur within 2 hours of
the referral interaction, if the participant has undergone a crisis referral via the ECSNP.
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Referrer advised of outcome.
If
Not Suitable, referrer will follow standard process.
End Process.
If
Yes, CSN reach agreement with referred on appropriate handover process and
participant is reassigned to CSN.
End Process.
Warm handover of participant between National Delivery and CSN Pathway to occur
the same day; if the participant has undergone a crisis referral via the ECSNP.
7.2.4 Steps for Exceptionally Complex Support Needs team – not in workflow diagram.
Receipt of crisis referral assessment report by 9am each morning.
ECSNP team create interaction into CRM.
ECSNP assign interaction to inbox in the system; either National Delivery or CSN
branch (according to the participant’s current plan).
Participant’s individual needs will be considered for CSN Pathway, example crisis
referral interaction recorded, and a sudden severe change in circumstance.
Flow on to Steps for National Delivery/Complex Team according to participant’s
current plan.
8.
Supporting material
National Disability Insurance Scheme Act 2013
Practice Guide - Complex Support Needs Pathway
9.
Process owner and approver
Process Owner – CSN Branch.
Approver – General Manager Participant Experience Design.
10. Feedback
If you have any feedback about this Standard Operating Procedure, please email Service
Guidance and Practice. In your email, remember to include the title of the product you are
referring to and describe your suggestion or issue concisely.
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11. Version control
Version Amended Brief Description of Change
Status
Date
by
7.0
KN0014 Class 1 Approval
APPROVED 2020-03-25
Inclusion of complex streaming process and
information.
Replaced Service Delivery with National
Delivery.
8.0
CRG 656 Class 1 Approval
APPROVED 2020-07-23
Guidance updated to highlight that young
people at risk of entry into an aged care
facility should be referred to Complex
Support Needs Pathway and that children in
voluntary or statutory out of home care, and
children at risk of requiring accommodation
outside the family home should be referred to
CSN.
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