Roberto has infected wounds from a recent operation that was not related to his disability. The wounds won’t heal but his disability doesn’t affect how his community nurses manage his sores. Roberto asks us to fund the at-home care supports recommended by his doctor.
Would we fund this?
No, we don’t typically fund hospital-in-the-home (HITH) care to support participants with medical conditions. We can only fund supports where we are the most appropriate funding body, rather than other general systems. This includes supports the health system provides as part of a universal service obligation. The health system is responsible for hospital and post-acute care services, including HITH services. Further, these supports are unlikely to relate to Roberto’s disability.
Why wouldn’t we fund this?
We don’t fund supports not related to your disability. This includes supports for medical injuries not caused by your disability support needs.
We also don’t fund supports more appropriately funded or provided through other service systems, including the health system.
We have to think about a number of things when we decide if the NDIS, rather than the health system, is the most appropriate funding agency for a support. We are not responsible for:
- activities that aim to improve the health status of Australians, including allied health services such as acute and post-acute services, and care in public and private hospitals
- funding time-limited, goal-oriented services and therapies that treat your general health, or that you get after a recent medical or surgical event, including rehabilitation or post-acute care, with the aim of improving your function.
This means we won’t fund community nursing or hospital-in-the-home supports:
- that don’t relate to your disability or your ongoing functional impairment, or where the purpose of the support is not related to your daily living
- while you are being treated in hospital; a clinical setting, such as hospital in the home; or in custody
- that are used to treat acute wounds or injuries, such as surgical wounds, likely to heal or resolve within 12 weeks.
To work out whether a support is reasonably and necessary for you, we look at the information you give us against the NDIS Funding Criteria.
What else do we think about?
If your disability means you can’t treat your injury or illness, and you don’t need clinical care through another system of support, such as the health system, we may consider including funding in your plan for a support worker.
This worker would help you manage activities related to your:
- daily living
- ongoing functional impairment.
For example, we may fund a support worker if, as a result of an intellectual disability, you keep removing the dressing from your wound. However, we are highly unlikely to fund the treatment or consumables, such as dressings or medication, you need for your injury or illness. These are not related to your disability.
Jemma has Parkinson’s disease, as well as obesity and diabetes. She lives at home with her husband and has an NDIS-funded care worker twice a week to help with some of her daily activities. Jemma recently had surgery on her knee. Several days after the surgery, the hospital discharged her with a wound-treatment plan. As part of this plan, a community nurse from the hospital-in-the-home program will visit Jemma every day for 2 weeks to care for her surgery wound.
Shortly after coming home Jemma develops an infection in the surgery wound, most likely due to her diabetes. The hospital-in-the-home clinician changes Jemma’s wound treatment plan to provide support for the infected wound. This includes daily injections to stop the infection from spreading. The plan indicates it’s likely to take at least 3 months before the wound will heal.
Reviewing her treatment plan, Jemma finds out that the health system only funds the first 2 weeks of the plan. After that, Jemma must pay for the community nurse and her wound care costs. Using her treatment plan for evidence, Jemma asks for funding to be included in her NDIS plan for the treatment of her infected wound. Her request includes funding for:
- 3 months of community nurse visits
- the wound care consumables and daily injections
- 3 extra visits each week from her NDIS care worker as, due to the infected wound, Jemma needs more carer support. Her husband isn’t able to continue providing extra care to Jemma and he needs respite.
When working out whether the funding for wound care support and extra NDIS support from a care worker is reasonable and necessary, the planner looks are the information Jemma provides against the NDIS Funding Criteria.
The planner thinks about whether the wound treatment support:
- relates to Jemma’s disability, her ongoing functional impairment and disability support needs,
- is most appropriately funded by the NDIS and not by other another service system or support service, such as the health system.
The planner also thinks about whether it is reasonable to expect that Jemma’s family provides extra carer support.
In Jemma’s case, the planner decides the following:
- There is no evidence that the wound care supports relate to Jemma’s Parkinson’s disease. This means the costs for the community nurse and wound care consumables are not related to her disability support needs.
- The wound care support is not related to Jemma’s ongoing disability care needs. It relates to a time-limited service and post-acute care provided after Jemma’s recent surgery. As such, the support is more appropriately funded or provided through the health system and not the NDIS.
- Jemma’s existing daily living funding for the NDIS care worker takes into account the level of support that is reasonable to expect families, carers, informal networks to provide Jemma for her disability while she was mobile. It doesn’t cover the level of support Jemma needs to manage her disability in her current condition. It’s not reasonable to expect Jemma’s family to provide all the extra care she currently needs for daily activities. Taking this into consideration, the planner decides that 3 extra care worker visits a week for 3 months are reasonable and necessary based on the NDIS funding criteria.
The planner assesses Jemma’s funding request and:
- declines funding for the community nurse and consumable items requested specifically to support Jemma with her infected wound
- approves funding for 3 extra care worker visits per week for 3 months to give Jemma extra help to meet her disability support needs until she regains her mobility
- arranges to check-in with Jemma in 3 months’ time to make sure her NDIS supports are meeting her needs.
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