Best practice functional capacity assessment for people living with psychosocial disability

Muriel Cummins and Malitha Perera

The vision for Australia’s social model of disability – the National Disability Insurance Scheme (NDIS) – promised equitable opportunities for people with psychosocial disabilities to live “ordinary” and meaningful lives through the provision of tailored, individualised support. Psychosocial disability is an internationally recognised term under the UNCRPD, used to describe the experience of people with impairments and participation restrictions related to mental health conditions1 .

The dawn of the NDIS represented a welcome paradigm shift for cohorts whose care was previously dominated by medical models. Mental health occupational therapists aim every day to honour the original vision of the NDIS by working with participants towards their goals, drawing on a substantive toolbox of evidence-based approaches. Occupational therapists engage in policy advocacy and are committed to building an equitable NDIS.

As defined within the NDIS Act (2013), to be eligible for the NDIS a person must demonstrate “substantially reduced functional capacity” in at least one functional area or domain2. The assessment of functional capacity is therefore a critical aspect of both testing eligibility for the NDIS and ensuring support packages correlate with functional needs identified.

Evidence suggests that people with psychosocial disabilities are more than twice as likely to have their initial NDIS applications rejected relative to other disability types3. A recent change to the NDIS Act (2013), titled the National Disability Insurance Scheme Amendment (Participant Service Guarantee and Other Measures) Bill 2021, means there will be clearer eligibility for cohorts who experience episodic conditions where functional capacity fluctuates4 .

Occupational therapy enables everyday life participation5, and assessment approaches identify barriers to full participation and supports needed. The assessment of functional capacity is a core focus of the work of occupational therapists.

The Joint Standing Committee (JSC) on the NDIS is a multi-partisan parliamentary committee appointed to oversee and conduct inquiries into specific aspects of the NDIS. During 2021, the JSC undertook a detailed inquiry into independent assessments – of a person’s functional capacity – used to inform decisions about NDIS eligibility and funding in a participant’s plan.

The JSC inquiry sparked a national debate on functional assessment, receiving almost 400 written submissions from people with disabilities and their carer representatives, peak bodies, legal professionals and many more6. It culminated in a report7 which, together with the OTA Submission to the Inquiry8, are essential reading for anyone aiming to understand the current public policy debate on functional assessment and the NDIS.

The JSC inquiry report issued a clear set of recommendations for functional capacity assessment within the NDIS, including recommending that functional assessment be completed by allied health professionals with appropriate credentials, and that functional assessment be co-designed in collaboration with

people with disabilities and their representatives, and the disability sector.

The JSC cautioned against assessment processes that may disadvantage cohorts within the NDIS, and the need to tailor assessment processes. This recommendation is particularly relevant for people with psychosocial disabilities.

The JSC further recommended a bulkbilled Medicare Benefits Schedule model of assessment to ensure greater equity, suitably accredited assessors to provide holistic and multidisciplinary assessment, and assessment processes that consider medical reports and other contextual information as appropriate.

Drawing on the evidence base, occupational therapy practice wisdom and the JSC inquiry report described above, this article identifies the following seven essential elements of functional capacity assessment for people with psychosocial disabilities. 1. Evidence-based assessment approaches

Functional capacity assessment for people living with episodic conditions, where capacity fluctuates over time, require an assessment approach that can capture and contextualise fluctuation.

The legislative framework underpinning the NDIS states that assessment tools must “… have reference to areas of activity and social and economic participation identified in the World

Health Organisation International

Classification of Functions, Disability and Health” 12. In addition, assessment tools must hold validity and reliability; and be standardized for use with particular impairment-types. Best -practice approaches incorporate the perspective of the person and those of their family, carers and clinical and other care-providers. Generic measurement tools are limited in their capacity to detect and/or predict individual functional capacity and support needs

because the characteristics and impact of disability are uniquely variable9 . 2. Assessment identifies individualised support needs

A comprehensive approach to functional capacity assessment informs tailored recommendations outlining reasonable and necessary support needs – thereby ensuring support plans are appropriately funded. The Productivity Commission (2011) recommended the NDIS be “needs based assessment” for this reason.

3. Skilled assessors

Assessments need to be delivered by skilled and experienced assessors with disability-specific expertise. It is essential that assessors are skilled health professionals with a clear understanding of functional capacity as outlined in the NDIS Act (2013), and are able to fully assess the impacts on all six functional domains: self-care, communication, social interaction, learning, mobility and self-management. 4. Recovery-oriented assessment practice

Valuing a participant’s lived experience is critical to understanding their strengths, challenges and impact of their disability.

Assessment processes must recognise the person as experts on their own functional

capacity. The NDIS psychosocial recovery framework identifies the need for practice to be responsive to fluctuating and episodic conditions (Principle 5)10 . 5. Trauma-informed assessment

Mental health occupational therapists recognise the impact of trauma on the individual, group and community, and its impact on mental health.

A trauma-informed approach recognises trauma within vulnerable populations11. Assessment processes that focus on impairments can be inherently distressing for people living with psychosocial disabilities. 6. Co-design

Co-design principles have been further embedded in the NDIS through recent legislative changes4. The JSC report recommended the co-design of assessment processes with people with lived experience of disability.

Honouring co-design principles in designing functional assessment means including people with disabilities in decision-making, thereby ensuring

Australia continues to meet its obligations under the UNCRPD. 7. Impartiality

In addition, assessment approaches

need to be conducted with integrity and impartiality. The assessment approach, model and process must uphold the highest principles of best practice. Contractual models constrained by performance management or quotabased frameworks, or incentives or mandates to depersonalise or reduce funded supports, clearly compromise these principles. The bulk-billed Medicare Benefits Schedule model of assessment has potential to uphold them.

During 2022, the NDIS psychosocial recovery framework is due for roll-out, aiming to ensure greater recognition of the unique needs of people with psychosocial disabilities10. Australians living with psychosocial disabilities have a right to best-practice functional capacity assessment informing tailored, individualised support packages that can be delivered within a recovery framework. This is in tune with the recommendations set out by the JSC Parliamentary Inquiry into Independent Assessment. Occupational therapists, who play a key role in advocating for this, are uniquely placed to contribute to the co-design of a fit-for-purpose NDIS functional capacity assessment process. About the authors Muriel Cummins is an occupational therapist and holds a Master of Public Health. She graduated in Dublin 2001 and has worked in mental health and disability in Australia since 2005. She is passionate about working in close partnership with those with lived experience, and promoting co-design in service development. Muriel’s previous roles span the clinical, not-for-profit, peak body and private practice sectors.

Malitha Perera is an occupational therapist who has worked in various operational, clinical and strategic leadership roles in mental health. He is passionate about addressing inequities that impact on our collective health and wellbeing. He holds a Bachelor of Occupational Therapy, Bachelor of Psychological Science and Master of Public Health.

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