Evidence of Functional Impairment

Providing NDIA with evidence of a person’s functional impairment has proven challenging for many health professionals. The NDIA has developed its own guidelines, which outline the evidence it requires, how it should be presented, and the language in which it needs to be written. This has called for a major re-think for many health professionals as it deviates from a lot of the professional training they have received in report writing and from reports required under other legislation such as Medicare, Workcover, and TAC. However, all is not lost, and piecing together bits of the NDIS Act, the NDIS Operation Guidelines, and information on the NDIS website helps clear up the picture. 

Let's start with the NDIS Act

Section 24 of the NDIS Act lists the disability requirements a person who is at least seven years old needs to meet in order to access NDIS. If we drill down to Section 24(c), the Act states that the impairment must  result in substantially reduced functional capacity to undertake, or psychosocial functioning in undertaking, one or more of the following activities:

(i)  communication;

 (ii)  social interaction;

 (iii)  learning;

 (iv)  mobility;

 (v)  self‑care;

 (vi)  self‑management.

The six areas mentioned above are often referred to as the six functional domains. 

What is a substantial functional impact?

Section 8.3 of the Operation Guidelines provides a bit more insight into what functions and activities are considered under each of the six domains. For example, under communication, the guidelines tell us that this “includes being understood in spoken, written or sign language, understanding others and expressing needs and wants by gesture, speech or context appropriate to age”.

The Guidelines also provide advice as to when the NDIA considers an impairment to result in substantially reduced functional capacity:

• the person is unable to participate effectively or completely in the activity or perform tasks or actions required to undertake or participate effectively or completely in the activity, without assistive technology, equipment (other than commonly used items) or home modifications (rule 5.8(a) of the Becoming a Participant Rules); or

• the person usually requires assistance (including physical assistance, guidance, supervision or prompting) from other people to participate in the activity or to perform tasks or actions required to undertake or participate in the activity (rule 5.8(b) of the Becoming a Participant Rules); or

• the person is unable to participate in the activity or to perform tasks or actions required to undertake or participate in the activity, even with assistive technology, equipment, home modifications or assistance from another person (rule 5.8(c) of the Becoming a Participant Rules).

The guidelines make further notes on this subject – for example, reliance on commonly used items like walking sticks, non-slip mats, and the like do not constitute proof of a substantial functional impairment. Another interesting point involves doing tasks more slowly or differently than others, which also may not be considered a substantial functional impairment. Click here to see the full list in the guidelines.

Who can provide the NDIA with evidence of a functional impact?

The website outlines who can provide evidence of functional impairment in relation to the six domains listed in the NDIS Act and what assessments are deemed best practices for a range of disabilities. I suspect these guidelines often missed participants, prospective participants, and providers alike. For example, the professions the NDIA considers most appropriate to provide evidence of a psychosocial disability are psychiatrists, general practitioner (GPs), psychologists (in limited circumstances), and a few others. The NDIA then provides a list of standardised assessments in order of preference to be conducted by the treating health professional. Another example is hearing impairments, in which the treating professional is listed as an audiologist and is again followed by a list of assessments in order of preference. 

There is a chance that the assessments listed on the webpage will not provide enough information to prove that a person’s disability meets Section 24 (c) of the NDIS Act. Before rushing out and spending thousands on further assessments, Part E of the Access Request Form (Evidence of Functional Capacity) can be completed by the treating health professional. 

What ongoing evidence of functional impairment does the NDIA require?

This is the million-dollar question! There are some NDIS participants who have never had a full assessment of their functioning. These participants are likely to have transitioned to NDIS from a defined program or have a List A diagnosis. On the other side of the coin, I have observed some participants using their NDIS funding to have a full assessment of their functioning completed each year. The NDIA, however, has provided some clues as to what they require that lie in the bungled roll-out of Independent Assessments (IAs). The NDIA outlined two purposes for the IAs, one for access to NDIS and the second for current participants. It is the second purpose of the IAs that is of interest here. The NDIA was requesting that IAs be conducted approximately every five years or when a person has a significant change of life circumstances, such as leaving school. The IAs also had very similar guidelines to the NDIS website as to who and what assessments are considered best practices when providing evidence of functional impairment. This is great news as it gives current participants flexibility as to which health professional to engage to complete this work for them. This will change depending on the person’s disability and the allied health team required to best meet their capacity-building needs. Therefore, can we safely say that participants only need to have an assessment of their functioning done every five years unless their circumstances change? Possibly, but to date, the NDIA has not provided further guidance on this matter.

Where do we go from here?

It is not that straightforward, as there are some answers we just don’t have. What we do know is that

a) The NDIA provides guidelines as to what it does and does not consider a substantial functional impairment;

b) Evidence of functional impairment can be provided to the NDIA by a range of treating health professionals;

c) The NDIA provides guidelines as to which assessments it believes are best suited to individual disabilities.