NDIS Practice Standard 3: Provision of Support #
1.0 Purpose #
The purpose of this policy is to ensure that every participant has access to responsive, timely, competent and appropriate supports that meet their needs, desired outcomes and goals.
iSeekSupport will provide program design, individual planning, coordination and support management to all participants.
2.0 Scope #
iSeekSupport will ensure our staff are trained to act professionally and appropriately when developing plans that empower the participant to achieve their needs, goals and aspirations.
We will keep each participant informed of their plan while undertaking a holistic approach that incorporates strength-based and person-centred strategies.
3.0 Policy #
All services and support plans are developed and delivered in collaboration with the participant and their advocate.
All participants, family members, representatives or advocates must be included in any decision-making process, selection of strategies or activities, and approval of all aspects of their support plan.
Support management will consist of delivery, monitoring, review and reassessment, promptly.
The CEO or their delegate will ensure that the least intrusive options are planned, using contemporary evidence-informed practices.
Reasonable efforts will be made to match the participant’s key worker requirements to our current frontline workers.
iSeekSupport will collaborate with all relevant parties, including other service providers, and only share information with the consent of the participant. Our team will consult to ensure that we meet individual needs.
The CEO will ensure that only appropriately trained staff work with the participant. The process of allocation will incorporate a skill and knowledge review of a potential frontline worker.
iSeekSupport will utilise this policy to ensure the organisation maintains a contemporary approach to support management services.
4.0 Procedure #
4.1 Support management principles #
Support management includes screening, comprehensive assessment, support planning and support plan implementation, monitoring, review and case closure. Staff must keep up to date with best practices and collaborate and develop strengths-based techniques to build and develop the participant. The participants support members must be kept informed as per the participant’s requirements.
4.1.1 Consulting with participants #
Staff must be aware of the power imbalance between the participant and our organisation; therefore, our staff must communicate and inform them about all aspects of their support. Our staff who are working with the participant in the development of their plan are required to:
- Ask the participant about what they need and learn about their other supports to understand how they interact with each other
- Be alert to participants’ general state of health and challenge assumptions that could result in their health needs not being identified or adequately addressed
- Explain clinical information, terminology and prepare reports in ways that participants and others in the support team can understand
- Support others in the participant’s support team to understand their support plan, how it supports goals and to check their capacity to implement it
- Find ways to allow the participant to contribute to the coaching and supervision of their supports
- Identify and discuss with participants the specific health or allied health support that could be appropriate to achieve goals combined with other plans and supports
- Assist the participant in understanding and co-design health and allied health supports
- Provide the participant with current information and be open to new approaches during service provision
- Provide opportunities to practice and build my capacity to make informed choices
- Look for opportunities to build health and allied health supports that fit day-to-day routines and preferences and are least restrictive or intrusive
- Consider participant’s circumstances, networks and the support context when identifying options and designing my supports
- Involve participants in understanding and designing health and allied health-related safeguards to keep them safe while supporting their right to take risks and build independence.
- Consult about developing an agreed way to respond to health and allied health-related emergencies and crises
- Support participants to communicate with their team about what to do to manage health and allied health-related problems and respond to a crisis
4.1.2 Creating a support plan #
The CEO or their delegate will:
- Verify that consent was received for assessment and services and is recorded in the participant’s file
- Review the participant’s referral information and confirm eligibility and suitability for a ISeekSupport service
- Contact the participant and arrange a suitable time for a comprehensive assessment
- Arrange interpreters, advocates, guardians, or other service providers, with the participant’s consent, to attend the assessment
- Determine, if possible, whether a clinical assessment of the participant’s health condition is required and arrange for the appropriate staff to attend the assessment, i.e. registered nurse or allied health professional
- Ensure representatives identified by the participant (e.g. family, advocate and carers) are contacted and, if necessary, participate in the assessment
- Assess as per the organisation’s appropriate policies and procedures and base the assessment on the participant’s needs and situation
- Contact the referrer and any existing providers, within five (5) days after a comprehensive assessment, for further information that may be required
- Arrange additional specialised assessments, if indicated
- Collaborate with the participant and their supports (refer to 4.1.1 Consulting with participants)
- Match available resources (i.e. staff to the needs of the participant)
- Work across service boundaries to ensure that participants with complex care needs are provided access to a full range of required support services such as allied health, health and social support services
- Provide a single point of contact for participants who require a complex range of services or require intensive levels of support
- Ensure ISeekSupport’s service is screened for eligibility and suitability as per the applicable program guidelines and our Access to Supports Policy and Procedure
- Investigate potential options for sourcing support, including the availability of iSeekSupport staff/resources and the use of brokerage resources
- Arrange, if necessary, a case conference with relevant services and individuals to discuss the participant’s situation
- Ensure outcomes from support management are documented within the support plan
- Inform the participant that their coordinator will continually review and assess their services for effectiveness
- Provide the support plan, where appropriate, to the participant’s general practitioner or representative, with the participant’s consent
- Develop a support plan that includes a plan of action that meets the participant’s needs, requirements and aspirations and includes:
- Participant information, e.g. personal and health details, cultural and spiritual requirements, sexual identification, Aboriginal and Torres Strait Islander, etc.
- Participant goals
- Advocate details
- Interpreter requirements
- Consent forms
- Active engagement planning
- Strategies to develop, sustain and strengthen independent life skills
- Integrated health therapeutic and other supports are part of natural routine
- Medical information, including conditions, doctors, medications, use and management
- Risks to participant and staff (include management of the risk if required)
- Emergency and disaster plan – Personal Emergency Preparation Plan
- Any financial budget requirements (if applicable)
- Details of the participant’s involvement in any planning and decision-making process
- Provide a copy of the support plan to the participant to review and agree to the provided strategies and service.
- Monitor the relevancy of the support plan through regular contact with the participant and other representatives and service providers involved in the participant’s wellbeing (refer to 4.1.1 Reviewing the support plan)
The support review is an essential element in providing focused and relevant supports, occurring at various points in the support continuum, depending on the needs of the participant or family, urgency and complexity of the family’s needs, and changes in family circumstances.
Support plan reviews may be held to:
- Determine if the current roles and responsibilities of our staff and organisation are meeting the needs of the participant
- Assess if the frontline workers are meeting participant’s goals
- Review the purpose, intent, and direction of the intervention
- Evaluate the service currently being supplied against the participant’s strengths, needs, goals and aspirations
- Consider previous assessments and to determine if any more are required
- Reassess the participant, using the relevant assessment tool
- Re-evaluate using evidence gathered during work with the participant
- Review the current risks and Personal Emergency Preparation Plan
- Examine the status of the support plan
- Make decisions relevant to the participant; ensure all parties are informed
- Review goals and actions
- Schedule a case conference with the participant and all relevant stakeholders to ensure their active involvement and to discuss any changes in service
- Plan towards transfer or closure, if relevant
- Record any changes to a support plan in the participant’s notes or file
- Assess the need to change the service agreement.
4.1.1 Reviewing the support plan #
Consulting with the participant is an essential element of the support plan review. During the review process, staff will:
- Work with the participants to identify meaningful outcome measures and support them to monitor their progress against their goals and expectations
- Support participants to review their crisis management and safeguarding arrangements and request adjustments as needed (e.g. Personal Emergency Preparation Plan
- Support the participant to navigate NDIS supports and report to the NDIA on implementation, as required
- Support in identifying opportunities for increased independence and reduced reliance on service systems at participant’s pace
- Support participants to make sure their views and interests are heard in formal and informal review processes
- Ascertain the current risk levels and adjust plan and strategies to suit the current status
- Support participants to find and access channels they are comfortable with to raise concerns, complaints and incidents when they arise.
4.2 Exiting the service #
When the participant’s needs begin to exceed program resources, or should the participant change to another service provider, the CEO or their managers will:
- Refer to the transition and exit notes in the Participant Support Plan
- Follow the guidance of the Transition or Exit Policy and Procedure
- Inform the participant of any potential risk of transferring or exiting
- Negotiate participant handover arrangements with the new service provider
- Advise participants of risks related to leaving the service.