Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697629295825.pdf (Australia)
THE AUSTRALIAN ORTHOTIC PROSTHETIC ASSOCIATION Submission to the Joint Standing Committee Inquiry: NDIS Independent Assessments 2021 NDIS JMF Grant Submission: 9A4STJB | AOPA 1 Independent AssessmentsSubmission 255 Orthotics and Prosthetics in Australia Orthotist/prosthetists assess the physical and functional limitations of people resulting from disease, illness, trauma and disability, including limb amputation, diabetes, arthritis and neuromuscular conditions, such as stroke.
Orthotic and prosthetic services may involve the provision of orthoses and prostheses to restore function, prevent deterioration, and improve quality of life.

Orthotist/prosthetists are commonly employed in Australian hospitals, private clinics, research institutions as well as rural and remote regions, working independently and as part of multidisciplinary healthcare teams to support the Australian community.

Orthotist/prosthetists are tertiary qualified allied health professionals.
An Australian Qualification Framework level 7 is required to practice as an orthotist/prosthetist in Australia, consistent with education standards for other allied health professions.

Orthotic/prosthetic students complete training alongside physiotherapy, podiatry and occupational therapy students.

The Australian Orthotic Prosthetic Association (AOPA) is the peak professional body for orthotist/prosthetists in Australia, with certified practitioners comprising 89% of the practicing profession.
AOPA is responsible for regulating the profession and is a founding member of the National Alliance of Self Regulating Health Professions (NASRHP) in partnership with other professional organisations, including Speech Pathology Australia, the Australian Association of Social Workers and Exercise and Sports Science Australia.

AOPA is recognised by the Commonwealth Government as the assessing authority responsible for conducting migration skill assessments for orthotist/prosthetists.
2 AOPA | 2021 JSC Inquiry into NDIS Independent Assessments Independent AssessmentsSubmission 255 Contents Executive Summary Recommendations 4 5 The independence, qualifications, training, expertise and quality assurance of assessors (D) The appropriateness of the assessment tools selected for use in independent assessments to determine plan funding (E) The implications of independent assessments for access to and eligibility for the NDIS (F) 6 8 11 The implications of independent assessments for NDIS planning, including decisions related to funding reasonable and necessary supports (G) 13 The circumstances in which a person may not be required to complete an independent assessment (H) A potential solution: supplementary orthotic/prosthetic assessments 14 16 3 AOPA | 2021 JSC Inquiry into NDIS Independent Assessments Independent AssessmentsSubmission 255 Executive Summary Orthotist/prosthetists are tertiary qualified allied health practitioners who assess, prescribe, manufacture, fit and review orthoses and prostheses.
The population accessing the essential services of orthotist/prosthetists may require restoration of function, pain management or alignment and support of a body segment achieved through the use of an orthosis/prosthesis.

The vast majority of people accessing orthotic/prosthetic services have a disability.
The Australian Orthotic Prosthetic Association (AOPA) is peak professional body for orthotist/prosthetists and is pleased to provide this submission to the Joint Standing Committee (JSC) to support the inquiry into NDIS independent assessments.

The NDIS is a social insurance scheme designed to take a lifetime approach and fund reasonable and necessary supports.

The proposed independent assessment structure threatens these principles.
Independent assessments have been introduced to support equitable and consistent decisions regarding scheme access, planning and funding decisions.

Independent assessments place a significant responsibility on assessors to understand, interpret and convey vital information that impacts scheme access, planning and funding decisions for people with disabilities.

Participants who access the NDIS may have a psychosocial, physical or intellectual disability.
Those who access orthotic/prosthetic services are likely to have a physical disability (e.g., lower limb amputation) that impacts their mobility (e.g., how they access their home, workplace and community) and activities of daily living (e.g., getting dressed, cooking, toileting).
Independent assessments would be used to determine whether people needing mobility and activities of daily living supports, as described, are eligible for scheme access, identify the required supports (e.g., an amputee will require a transtibial prosthesis), describe the supports in their plan and allocate funding for the determined supports.
concerns regarding independent assessments in respect of orthotic/prosthetic services:  To our knowledge, orthotist/prosthetists are the only practitioners with the necessary entry-level competencies and scope of practice to complete a safe and effective orthotic/prosthetic assessment.

 The current independent assessment format and choice of tools may not be sufficiently specific to determine scheme access for people with orthotic/prosthetic needs.
 Independent assessments may lack the required details to inform plans budgets, leading to plan reviews and delayed access to reasonable and necessary supports.

 Independent assessments may not be required for all participants, such as those with stable conditions without fluctuations in their functional capacity and therefore provide a barrier to timely access to vital supports.
Any independent assessment process should sufficiently cover all aspects of an individual’s support needs, including an orthotic/prosthetic assessment.

We recommend the inclusion of a supplementary orthotic/prosthetic assessments, which will require time to develop and trial.

The supplementary system should also be overseen by an allied health expert advisory group with representation from the participant sector and the orthotic/prosthetic workforce.
AOPA therefore calls upon the JSC to pause the roll-out of independent assessments until an evidenced and independent review is completed and unintended consequences of the independent assessment process have been fully explored.

AOPA is available for further comment and would be most pleased to provide further support to the JSC on request.

The JSC provides 11 terms of reference for the inquiry, of which this submission focusses on five, as outlined in the heading sections.
AOPA highlights four primary Please note the following submission has used fictional examples.

Effort has been made to ensure these examples reflect real-life scenarios 4 AOPA | 2021 JSC Inquiry into NDIS Independent Assessments Independent AssessmentsSubmission 255 Recommendations AOPA call upon the JSC to pause the roll-out of independent assessments until an evidenced and independent review is completed and the unintended consequences of the independent assessment process are fully explored.
Any independent assessment process should include supplementary orthotic/prosthetic assessments and will require time to develop and trial.

The supplementary system should also be overseen by an allied health expert advisory group with representation from the participant sector and the orthotic/prosthetic workforce.

AOPA is pleased to provide the JSC with the following recommendations.

1.
1.

The JSC call upon AHPRA to clarify that the listed professions for conducting independent assessments will be within their scope of practice and have the appropriate competencies to provide a holistic assessment, including orthotic/prosthetic assessment.

2.

The findings of the second independent assessment pilot are made public.

3.

The JSC call for an allied health expert advisory group with representation from the participant sector and orthotic/prosthetic workforce.

4.
4.

Independent assessments are offered as an option for participants with stable and fixed conditions.

5.

The JSC call for the roll-out of independent assessment process to pause.

6.

Supplementary orthotic/prosthetic assessments are introduced into the independent assessment process.

7.

The independent assessment process, along with supplementary orthotic/prosthetic assessments is tested to ensure it is fit for purpose.

.
.

AOPA | 2021 JSC Inquiry into NDIS Independent Assessments 5 Independent AssessmentsSubmission 255 The independence, qualifications, training, expertise and quality assurance of assessors (D) The independent assessment process requires assessors to understand, interpret and convey important information.

Independent assessments for orthotic/prosthetic supports have not been tested.
Assessor experience and expertise The role of the independent assessor is to gather information with the intention to describe an NDIS applicant/participant’s1 functional capacity.

The functional capacity information is subsequently communicated to an NDIA delegate to support decision/s on scheme access, supports listed within the plan and how the plan is funded.
Independent assessors may be psychologists, occupational therapists, physiotherapists or speech pathologists and are required to have a minimum one year of clinical experience and a broad clinical background, but are not required to have specialist knowledge commensurate with the applicant/participant’s disability.

They are also not required to possess a minimum level of competency to conduct safe and effective assessments.
An orthotic/prosthetic assessment is a holistic assessment specific to the orthotic/prosthetic device and associated services, taking into account an individual’s personal, environmental, physical and resource factors.

Certified orthotist/prosthetists provide orthotic/prosthetic assessments within their professional and personal scope of practice2 and this task is described within the orthotist/prosthetist entry-level competency standards3.
To our knowledge, no other profession maintains equivalent entry-level competency standards, or scope of practice as orthotist/prosthetists for the purpose of orthotic/prosthetic assessment.

Based on the required assessor experience and expertise, AOPA calls into question the scope of practice and entry-level competencies of independent assessors.
It is unlikely that an independent assessor in the proposed assessor model (e.g., a psychologist) will have sufficient expertise to inform scheme access, plan development and funding decisions in relation to orthotic/prosthetic supports, nor provide a safe and effective assessment to the same degree as a certified orthotist/prosthetist.
Recommendation 1: The JSC call upon AHPRA to clarify that the listed professions for conducting independent assessments will be within their scope of practice and have the appropriate competencies to provide a holistic assessment, including orthotic/prosthetic assessment.

Currently, there is no understanding of the impact or unintended consequences of independent assessments for participants that use orthoses/prostheses.
Independent assessments have been tested through two pilots; one in 2018 that was limited to participants with intellectual disability, psychological disability and autism spectrum disorder, the other currently open to all participants.

This means there is no current data on 1 We note that an NDIS applicant is a person who is applying to become a participant in the NDIS, and a participant is a person who is in the NDIS.
Care has been taken to ensure reference is made to the correct population 2 https://www.aopa.org.au/publications/scope-of-practice 3 https://www.aopa.org.au/publications/competency- standards 6 AOPA | 2021 JSC Inquiry into NDIS Independent Assessments Independent AssessmentsSubmission 255 how the experience and expertise of the independent assessors has influenced scheme access, plan development and funding for participants requiring orthotic/prosthetic supports.
As there is no relevant data available, the NDIA is unable to comment with certainty on the suitability of independent assessor’s experience, expertise and training, for people who use orthoses/prostheses.

It is vital that the findings from the second pilot are made public, and the experiences and outcomes of orthotic/prosthetic users are analyzed.

Recommendation 2: The findings of the second independent assessment pilot are made public.
Oversight and review Independent assessments place significant responsibility on assessors to understand, interpret and convey vital information that impacts scheme access, planning and funding decisions for people with disabilities.
In other disability sector roles, allied health practitioners are required to:  demonstrate how they meet their profession’s scope of practice and competency standards,   supported with training that would equip them with the clinical skills required for the task, required to have experience and expertise commensurate to the applicant/participants disability and needs,  undergo regular performance review or evaluation.
AOPA call upon the JSC to recognize these requirements and recommend the NDIA consider establishing an allied health expert advisory group.

The group would oversee the implementation and evaluation of independent assessments, and review of the adequacy and effectiveness of the assessment tools, workforce, and overall assessment process.

For the group to effectively inform independent assessments they would need representation from the participant sector and the orthotic/prosthetic workforce.
Recommendation 3: The JSC call for an allied health expert advisory group with representation from the participant sector and orthotic/prosthetic workforce.
·- -- -- ---· -- -- _ , _ .=.-...:=..-- -=-==-=-= ~ ""- -=--=--=-==== 7 AOPA | 2021 JSC Inquiry into NDIS Independent Assessments Independent AssessmentsSubmission 255 The appropriateness of the assessment tools selected for use in independent assessments to determine plan funding (E) Plan funding should be informed by knowledge of a participant’s orthotic/prosthetic potential and the costs to meet this potential.

The independent assessment tools are unable to determine these factors.
Capturing a participant's orthotic/prosthetic potential orthotic/prosthetic potential.

This can be seen in example one.

When an orthotist/prosthetist establishes the likely level of function that can be restored through the use of an orthosis/prosthesis, they have assessed a person’s orthotic/prosthetic potential.

For example, an orthotist/prosthetist will assess an individual’s current functional capacity and likely future functional capacity when using a prosthesis.
A participant’s orthotic/prosthetic potential can be difficult to identify using generic, non-specific instruments.

Often a practitioner would use a specific tool like the Amputee Mobility Predictor (AMP).

A tool like this, combined with specific orthotic/prosthetic competencies, helps practitioners identify likely outcomes and the potential functional level.

Independent assessments focus on a participant’s current functional capacity.
None of the tools in the independent assessment toolkit assess a participant’s The NDIA have chosen broad and non-disability specific tools to be used in independent assessments.

Because of this, the tools are unable to identify the orthotic/prosthetic potential of a participant.

Example one: missing the orthotic/prosthetic potential for a participant with rheumatoid arthritis Milly has rheumatoid arthritis.

She experiences pain, swelling, reduced range of motion and inflammation in her feet.
She cannot predict when her rheumatoid arthritis ‘flares up’.

When she does have a flare up, Milly’s pain is so severe she cannot stand for long periods and can only walk short distances.

An extreme flare up also prevents Milly from working and her ability to care for herself.

When Milly underwent an independent assessment, she was asked about her pain and how this impacts her.

She was asked to complete a survey called the WHODAS.

The WHODAS use a frame of reference of 30 days.


Milly's flare ups in the past 30 days have been sporadic and not representative of what she normally experiences.

This meant her WHODAS scores indicate her rheumatoid arthritis does not impact her work and home life greatly.

Furthermore, there was no investigation into how she may benefit from orthoses.

As a result, her plan includes supports like cleaning services and home modifications, but it does not include a pair of foot orthoses.
8 AOPA | 2021 JSC Inquiry into NDIS Independent Assessments Independent AssessmentsSubmission 255 Capturing a participant's future orthotic/prosthetic needs There are participant groups that experience dramatic changes in their functional capacity over a short period of time.

As a result, these populations will experience a change in their orthotic/prosthetic support needs as their clinical situation changes.
For example, people with degenerative conditions like multiple sclerosis, rheumatoid arthritis and muscular dystrophy may experience substantial changes in their ability to walk and stand over a period of months.

This change in their functional capacity means they may start with using simple ankle orthoses that assist with balance but may progress quickly to needing knee-ankle-foot orthoses that prevent falls and assist with standing transfers.
A participant may experience this substantial change in their orthotic/prosthetic support needs over a short period of time.

The independent assessment tools focus only on current functional capacity and do not seek to predict or assess for future needs.

As seen in example two, there is no way to explore a participant's future needs using the proposed tools.

Example two: a participant with multiple sclerosis needs to access new orthoses Costa has multiple sclerosis.
This degenerative condition is affecting Costa’s legs and he is experiencing a decline in strength.

He was able to walk long distances in the community a year ago using ankle-foot orthoses (AFOs).

Costa had an independent assessment three months ago.

At that time he was only managing to walk short distances in the community when using his AFOs.

The assessment acknowledged he used AFOs to ambulate.

A new pair of AFOs were included in his new NDIS plan.
Unfortunately, Costa’s strength and coordination has deteriorated fast.

Now, only three months after his independent assessment, Costa is beginning to feel unsafe using his AFOs when completing standing transfers.

Costa is experiencing a change in his orthotic support needs based on his changing clinical situation: a change that could have been predicted.

Costa will need knee-ankle-foot orthoses (KAFOs) in the very near future to ensure his standing transfers are safe.
Costa’s future orthotic/prosthetic needs were not assessed in his independent assessment.

The tools were too broad and were not able to investigate how quickly his condition was likely to deteriorate.

As a result, he does not have funding for KAFOs.


9 AOPA | 2021 JSC Inquiry into NDIS Independent Assessments Independent AssessmentsSubmission 255 Capturing the costs of providing orthotic/prosthetic supports An accurate budget and plan require a thorough and complete understanding of the costs to meet a participant’s orthotic/prosthetic support needs.
There are numerous factors to consider to determine the cost of an orthotic/prosthetic support, including:  The clinical time to assess for, prescribe, review orthoses/prostheses.

 The technical time to manufacture orthoses/prostheses (capital and labour costs).

 Specific components or features of an orthosis/prosthesis that link to the participant’s goal, e.g., a goal to swim, run or participate safely in sport will require different orthotic/prosthetic components and designs.
 Availability and appropriateness of orthotic/prosthetic devices and/or components e.g., weight limitations on components or appropriateness in wet or dirty conditions.

 Travel costs to fit, supply and review orthoses/prostheses (particularly for participants in rural and remote areas).

Without knowledge of these factors that contribute to the cost of an orthotic/prosthetic support, it is unclear how independent assessors will allocate funds to a plan.
We anticipate that the proposed independent assessment process will result in an increase in plans that are underfunded and require plan reviews.

We highlight the travel and access related issues for orthotic/prosthetic services as an example.

The NDIS uses the Modified Monash Model to calculate provider travel costs.

However, numerous discrepancies exist between the MMM and orthotic/prosthetic workforce distribution.
For example, Launceston (Tasmania) is classified as MM2 (Regional Centre) and has an orthotic/prosthetic service provider within the area.

In contrast, Rockhampton (Queensland) which is also an MM2 (Regional) location, is serviced by a single part- time clinic operating only two days per month, servicing prosthetic clients only.

The closest orthotic service is a part-time clinic located in Bundaberg, 288km away, which also operates only 2 days per month.
Without knowledge of these nuances, which will not be captured in an independent assessment, an NDIA delegate will be unable to accurately budget for the likely orthotic/prosthetic support costs.

Workforce distribution, provider travel costs, and the orthotic/prosthetic componentry needs of a participant are not captured in any of the independent assessment tools, nor specified in the independent assessment process.

These factors are vital when developing a plan and determining funding.
Example three: two participants with the same functional capacity but different NDIS budgets Kumiko and Doug are NDIS participants.

Both use a knee-ankle-foot orthosis (KAFO) and have been assessed as having the same level of function.

Kumiko lives in a major city, has an office job and her main goal is to continue working and spending time with her friends.

Doug lives rurally, four hours drive from the nearest orthotic/prosthetic service provider.
Doug is a warehouse manager and spends most of his day standing.

Further to this he has an extensive garden on a large sloping block.

Doug's goal is to continue working and gardening.

Although Kumiko and Doug have the same diagnosis, level of function and same goals to participate in their work, their respective work locations, environment and access to orthotic/prosthetic providers, will mean that Doug's budget must account for his additional access and context-specific needs.
Doug’s budget needs to accommodate orthotic/prosthetic provider travel costs and his KAFO will need to tolerate humid weather conditions, long distance walking and hard labour tasks.

The current independent assessment tools focus on functional capacity and do not allow factors like provider travel and context-specific needs to be explored.
10 AOPA | 2021 JSC Inquiry into NDIS Independent Assessments Independent AssessmentsSubmission 255 The implications of independent assessments for access to and eligibility for the NDIS (F) Independent assessments may lead to some applicants being incorrectly denied scheme access, and some experiencing functional deterioration The use of an orthosis/prosthesis may impact independent assessment outcomes The independent assessment process aims to collect participant data via standardised tools and participant interactions.
The tools have been specifically chosen for their ability to provide a broad measure of function and are not disability or profession specific.

Unfortunately, as there is no clear mandatory requirement to indicate the use of an orthosis/prosthesis it may also be unclear to what extent the orthosis/prosthesis contributes to the observed functional level.
Furthermore, it is unlikely that the scope and competency of an independent assessor facilitates the exploration of how an orthosis/prosthesis impacts the results of an independent assessment.

The use of an orthosis/prosthesis during an independent assessment may substantially change the outcome of the broad measure of function and the independent assessment broadly.
The participant interaction sheet allows for an assessor to record if orthoses/prostheses were used during the interaction component of the assessment, but it is not mandatory.

The combination of using tools that are not orthotic/prosthetic specific, and not having a means to clearly identify the impact of an orthosis/prosthesis on functional capacity, may increase the risk of NDIS applicants being denied scheme access or of supports being overlooked.
Example four: An applicant who uses an ankle foot orthosis (AFO) may be denied scheme access Glen is in remission for his cancer treatment.

His treatment included chemotherapy.

Unfortunately, the chemotherapy damaged a nerve in his leg.

This nerve damage is permanent and increases the chance of falls.

Glen uses a simple AFO to ensure his foot does not drop when he is walking.

He will always need an AFO.

Glen does not have difficulty with any other tasks and does not require any other supports.
Glen is wanting to become an NDIS participant.

He is undergoing an independent assessment.

When reaching question D2.3 in the WHODAS “In the past 30 days, how much difficulty have you had in: moving around inside your home” Glen records 'none' as he considers he uses his AFO for this activity.

During the participant interaction, the independent assessor watches Glen carry shopping bags from inside his car into the kitchen.

Glen is wearing his AFO underneath his pants.


The assessor cannot see the AFO and is not prompted to inquire if Glen uses an AFO for this activity.

Glen’s functional capacity has been overestimated.

As a result, Glen is at high risk for being denied scheme access.
AOPA | 2021 JSC Inquiry into NDIS Independent Assessments 11 Independent AssessmentsSubmission 255 Failure to assess an applicant's potential using an orthosis/prosthesis Failure to recognize potential for functional deterioration Without measuring an NDIS applicant’s potential when using an orthosis/prosthesis, an applicant may be incorrectly denied scheme access.

This is because independent assessments measure current functional capacity.
The independent assessments in their proposed form do not assess the potential for improved functional capacity with access to an orthosis/prosthesis.

Example five highlights this as a particular concern for applicants with adaptive behaviours.

Independent assessments comprise of standardised tools and participant interactions.

Both of these components are overseen by an independent assessor.
Even if an assessment tool seeks to recognise adaptive behaviours, the assessor must understand the typical behaviour.

Many of the listed professions for the independent assessor role are unlikely to have this knowledge.

This represents a risk for applicants who use adaptive behaviours not explored by the independent assessment tools or known by the assessor.

Independent assessments only measure current functional capacity.
They do not consider an applicant’s potential for decreased functional capacity when access to orthoses/prostheses is delayed or denied.

Timely access to orthoses/prostheses is vital for applicants with degenerative and progressive conditions.

For these applicants, a delay in access to an orthosis/prosthesis may pose a threat to safety and/or future needs.

Orthoses/prostheses have the potential to prevent a future decline in function.
The NDIS grants access to supports that may reduce an applicant's future needs for supports.

Once again, the independent assessment tools are too broad and the competency and scope of the assessor is unlikely to capture and communicate future orthotic/prosthetic needs.

Example six shows how this is unable to be captured in the proposed independent assessments.

Example five: a child with congenital limb loss is at risk of being denied scheme access Jane is five years old.
She was born without her right index and middle fingers.

She does not currently access any supports.

Jane's mother Cheryl would like Jane to become an NDIS participant.

Jane is undergoing an independent assessment.

Cheryl is completing the Vineland 3 on behalf of Jane.

When asked if Jane "holds a crayon/pen/pencil properly for drawing, etc?"

Cheryl considers that Jane does.

The independent assessor is not familiar with hand range of motion, strength and anatomy and does not clarify this answer.
The assessor is also not familiar with the increased risk of injury to tendons and muscles when a person with congenital limb loss does not have access to a prosthesis.

Jane is assessed as having high functional capacity.

The independent assessment has failed to measure the positive impact a prosthesis may have on Jane's functional capacity and future needs.

Example six: a person with a partial foot amputation is at risk of deterioration Clive has diabetes.
All five toes on his right foot were amputated due to complications from his diabetes.

Clive wants to prevent further amputation which is unfortunately common.

To prevent a further amputation, Clive wants to gain access to various supports including a foot orthosis that offers stabilisation, protection of his foot and restores his balance.

Clive is undergoing an independent assessment.

He notes that he has very little difficulty with activities.
Both the tools and the independent assessor are unable to explore what would happen if Clive were denied scheme access.

He is assessed as having high function and is ineligible for NDIS access.

Clive is unable to access the foot orthosis he needed.

He is likely to have a secondary amputation.
12 AOPA | 2021 JSC Inquiry into NDIS Independent Assessments Independent AssessmentsSubmission 255 The implications of independent assessments for NDIS planning, including decisions related to funding reasonable and necessary supports (G) Independent assessments will leave participants who use orthoses/prostheses at great risk of underfunding We have raised concerns of the impact of the independent assessment tools and the broader assessment process on the funding outcomes for NDIS participants in section E. The following section provides a further summary.
Capturing a participant's orthotic/prosthetic potential For a participant to truly exercise their choice and control, they must be able to make informed decisions.

An informed decision can only be made when all options are explored.

Independent assessments in their current format do not explore a participant's orthotic/prosthetic potential.

This means participants may not be aware of all of their support choices as demonstrated in example seven.
When a participant's orthotic/prosthetic potential is not explored, their plan is likely to only include supports they currently access.

If a participant is not currently accessing an orthotic/prosthetic support, then they are unlikely to receive funding for this support, even if it will improve their functional capacity and quality of life.

Capturing a participant's future orthotic/prosthetic needs The proposed independent assessment tools measure current functional capacity.
The participant interaction overseen by the independent assessor is used to validate the outcomes from the tools.

The independent assessment process is not designed to identify the future orthotic/prosthetic needs of a participant.

This means a participant’s plan is at risk of not having all the required supports and funding, resulting in unnecessary plan reviews.

Plan reviews are yet another barrier to timely access to vital orthoses/prostheses.
For many participants waiting only a matter of weeks before they access their orthosis/prosthesis may increase the risk of:  Falls,  Escalated care needs,  Health interventions,  Deterioration, such as reduced range of motion or strength Capturing the costs of providing orthotic/prosthetic supports There are various factors included in the cost to safely provide orthoses/prostheses.
If these factors are not taken into consideration, participants are at risk of receiving a plan that is underfunded and does not meet their needs.

Participants who live in rural and regional areas, are not likely to access an orthotist/prosthetist easily.

When a plan does not include adequate provider travel, a participant will be unable to access their orthosis/prosthesis and services in a timely manner.
This is a significant issue for participants who are at risk of their orthosis/prosthesis critically failing.

As seen in example nine, a participant is at risk of falls when their orthosis/prosthesis critically fails.
AOPA | 2021 JSC Inquiry into NDIS Independent Assessments 13 Independent AssessmentsSubmission 255 The circumstances in which a person may not be required to complete an independent assessment (H) Participants with stable and fixed conditions are unlikely to experience fluctuations in their functional capacity.

As such, independent assessments are likely to be a barrier to timely access.

A barrier to timely access The proposed independent assessments aim to improve scheme access and plan development.
Once eligibility has been confirmed, the primary reason for an independent assess is to assist with plan development and funding allocation into a plan.

Amputation is a permanent and, in many instances, a stable clinical presentation.

As such, the prosthetic support requirements are more likely to be stable and only change in alignment with a change in life circumstances.
It would be appropriate for independent assessments to be waived for participants in this situation, and only be required where a change in life circumstances has occurred.

This is not only efficient but reinforces the lifetime approach (e.g., reflecting changes in life circumstances) and choice and control principles (e.g., offering a choice for participants to have an independent assessment).
Having participants with stable and fixed conditions undergo routine independent assessments is not financially viable to the scheme.

In many cases people living with amputation have come to understand their own needs and preferences.

An independent assessment is just another barrier for the participant to overcome before an assessment can take place.
Recommendation 4: Independent assessments are offered as an option for participants with stable and fixed condition 14 AOPA | 2021 JSC Inquiry into NDIS Independent Assessments Independent AssessmentsSubmission 255 Example ten: when a person living with an amputation does not need an independent assessment Qin has an amputation and uses a transfemoral (above the knee) prosthesis to ambulate safely.

Qin has been an amputee for 15 years and an NDIS participant for six years.
Qin's current prosthesis in nearly two years old.

Both she and her prosthetist recognise a new prosthesis is required to keep Qin at her current functional level.

She is also due for a new plan.

As independent assessments have just been introduced, Qin must also undergo one of these.

Previously Qin was able to have a discussion with her prosthetist who completed an assistive technology quote.

The quote would contain all of the details of Qin's prosthesis, including clinical justification.
This would take only a week.

Under the new system, Qin must undergo an independent assessment.

This takes two weeks to organise.

After the independent assessment has been conducted, the NDIA delegate notices a lot of information is missing including how much her new prosthesis is likely to cost and how many hours of clinical services she is likely to need.

The NDIA contacts Qin's requesting more detail.

Now Qin must contact her prosthetist to obtain more details.
This means Qin will be waiting longer before she can obtain a new prosthesis AOPA | 2021 JSC Inquiry into NDIS Independent Assessments 15 Independent AssessmentsSubmission 255 A potential solution: supplementary orthotic/prosthetic assessments Supplementary orthotic/prosthetic assessments offer a solution to many of the issues associated with the proposed independent assessments The value of supplementary orthotic/prosthetic assessments Independent assessments threaten scheme access, plan development and funding for applicants and participants who use or would benefit from orthoses/prostheses.
It is unlikely to be in the scope and competency of an independent assessor or NDIS delegate to conduct safe and effective orthotic/prosthetic assessments.

Orthotic/prosthetic assessments are the only way to understand an applicant/participant's orthotic/prosthetic needs and the cost to meet these needs.

AOPA call upon the JSC to pause the roll-out of independent assessments until an improved system is established.
AOPA recommends a new system acknowledge the role an orthotic/prosthetic assessment and offer a supplementary orthotic/prosthetic assessment as a solution.

An orthotist/prosthetist can conduct a supplementary orthotic/prosthetic assessment.
This would provide a complete picture of the applicant/participant's;  Function and how their orthoses/prostheses may impact their independent assessments, Recommendation 6: Supplementary orthotic/prosthetic assessments are introduced into the independent assessment process.

How a supplementary orthotic/prosthetic assessment may be triggered A clear workflow will be required to successfully trigger a supplementary orthotic/prosthetic assessment.
AOPA puts forward the following workflow for the JSC to consider; 1.

Participant information sheets clearly identify if an applicant uses orthoses/prostheses.

If the applicant uses orthoses/prostheses, then a supplementary orthotic/prosthetic assessment is triggered.

2.

If an applicant has a disability that may benefit from orthotic/prosthetic intervention (e.g., congenital limb loss, rheumatoid arthritis), then a supplementary orthotic/prosthetic assessment is triggered.

3.
3.

Before using each instrument, independent assessors explicitly mention if the applicant should/should not consider the use of their orthoses/prostheses in their answer.

 Future orthotic/prosthetic needs, 4.

The independent assessor explicitly  Potential for improved functional capacity when using orthoses/prostheses,  The likely costs to provide these supports.

Recommendation 5: The JSC call for the roll-out of independent assessment process to pause.
communicates to the NDIA delegate which assessments were conducted with/without considering the applicant's orthoses/prostheses.

5.

A supplementary orthotic/prosthetic assessment is conducted, and standardised tools are used.

The orthotist/prosthetist reports to the NDIA delegate on the applicant's 16 AOPA | 2021 JSC Inquiry into NDIS Independent Assessments Independent AssessmentsSubmission 255 potential for functional capacity improvement/decline, if access to orthoses/prostheses is granted/declined.
To achieve the NDIA's goal for independent assessments to improve equity, the tools and processes need to be standardised.

Supplementary orthotic/prosthetic assessments could be standardised by using templates and guidance documents.

Supplementary orthotic/prosthetic assessments can work to improve scheme access and planning decisions.
By having these assessments completed by a certified orthotist/prosthetist, the assessments will be able to provide sufficient detail to inform scheme access, required orthotic/prosthetic supports and funding for these supports.

Recommendation 7: The independent assessment process along with supplementary orthotic/prosthetic assessments, is tested to ensure it is fit for purpose.
17 AOPA | 2021 JSC Inquiry into NDIS Independent Assessments Independent AssessmentsSubmission 255 THE AUSTRALIAN ORTHOTIC PROSTHETIC ASSOCIATION 18 AOPA | 2021 JSC Inquiry into NDIS Independent Assessments Independent AssessmentsSubmission 255