This post presents the full discussion held at the recent Home Modification forum in Melbourne – where OTs and project managers raised key issues impacting on their industry at this time of rapid reform.
Aaron Stowe from Architecture & Access and Clare Perry from Clare Perry Occupational Therapy Services delivered the opening presentation. A case study of ‘Margie’s Home Modification’ provided the example for looking at five key areas impacting on home modification delivery.
The presentation illustrated how practice standards may be applied to home modification delivery in areas of Client Focus, Collaboration, Compliance, Cost and Quality. A PDF transcript of the presentation is available below. The video of Margie’s Home Modification is linked below.
The panel discussion featured leading specialists from the home modification sector presenting a range of perspectives on opportunities and challenges for OTs and project managers operating in the new insurance environment.
- Chris Porter, Architect, leading access consultant and director of Architecture & Access.
- Bronwyn Stephen, a senior occupational therapist and manager of Quality Lifestyle Solutions – Occupational Therapy in Action, and recently appointed co-convenor of the OT Australia’s Home Modifications Special Interest Group
- Michael Bleasdale, CEO, Home Modification Australia
- Ken Anderson,Injury Management Advisor Worker’s Compensation and home modification subject matter expert, CGU Insurance
- David Brown, Architecture & Access Home Modifications Unit Manager
Following the a brief presentation of the key issues from each panelist, the discussion was opened up to more than 30 professionals who attended the event.
Speaking first, Bronwyn Stephen expressed concern for the enormous challenge facing OTs due to the recent closure of Archicentre.
“Our focus as OTs is on the person. We are assessing the implications of their medical problems both short- and long-term, looking at their cognitive state, any issues they may have in terms of depression or anxiety, the family situation.”
“We have to look at how that physical environment is modified, including the prescribing of equipment, to match the person’s needs and come up with the best solution. For the client, the solution must be achievable, fundable, and have a positive outcome,” she said.
“Considering different options for the design and construction aspects of a home modification by ourselves, without input from an architect, is going to be very challenging because we are not the design or construction experts.”
David Brown said that project managers have a key role to play, taking the lead on the design and specification of home modification along with compliance, cost, and quality control in the overall project delivery.
“We see our role as essential in any insurance project for people with severe and permanent disability living in a home that presents significant barriers to independence.”
“We work collaboratively with the OT and the person with the disability to come up with the best solution — whether the home requires a ramp, a new bathroom and toilet, creating an accessible kitchen, laundry, or paths of travel to any other spaces or outdoor areas right up to the custom home design incorporating specialised equipment and adaptive technology,” he said.
David called for greater clarity in the process of referral, so OTs know when and how to involve a project manager to assist them.
Ken Anderson raised a number of issues that impacted the initiation of home modification projects from the perspective of the insurance agent. These included the complex process of determining the worker’s eligibility for home modification, the requirement to ensure the the best outcome for the most reasonable price, and to determine the best solution compared to other options.
“We are highly reliant on the reports that come in from the OTs, which we then assess and apply the insurer’s framework to decide what will actually be approved to fund,” he said. “Unfortunately, at the moment, some OTs are progressing the process to some extent before it gets to us, so we need to be looking at ways to improve the initial stage.”
Ken proposed that greater clarity about the role of the insurance agent, more hands-on involvement and collaboration with the OT and the project manager, and general timeliness were areas of opportunity for agents.
Michael Bleasdale pointed to the need for evidence in relation to best practice in home modification.
“One of the key activities of MODA is the development of a quality standard capable of increasing our knowledge about what constitutes good practice in areas of client focus, design, construction and so forth,” he said. “A quality standard would also form the basis for home modification service providers to be accredited for aged care, disability, community care, across the range of different program areas.”
“A quality standard should also take into account the best way of procuring and administering home modification services to deliver better outcomes.”
Michael observed that state-based and program-based differences were a major source of stress for professional due to the enormous variation of approaches and costs for home modifications across a disparate number of unconnected programs across the country.
“MODA hopes to coordinate a more consolidated home modification industry, then to be able to get in the door and around the table much earlier with policy-makers and government departments when reforms are taking place and under review.”
|Participant 1: I am unclear about the NDIS and how the home mods are going to work, despite being in the northern suburbs of Melbourne where it is being rolled out, and ringing everyone, nobody can tell me.First of all, will they fund modifications to rental homes? What I’m finding becoming a bigger and bigger problem in my practice, is people coming out of hospital with severe disabilities and not being able get modifications to their rental properties.
I think that is a whole big area that needs to be explored in terms of temporary modifications, modifications that are cheap, modifications that can be rectified when the person moves on, and I think that is something that is being overlooked at present.
I also wonder what is happening when different agencies have overlapping responsibilities and how will that be managed. For example, I have a client who needs a remote opening electric gate. The agency responsible for the property says they can’t do it because they don’t want to set a precedent. The client would most likely be eligible to participate in the NDIS, so I have asked the agency about their relationship with the NDIS, and if they will they cover some of the work, and then we’ll apply for the NDIS funding to cover the rest? They have now told me that they are completely separate and if I think this lady needs the remote opening electric gate, I should go to the Minister. So that seems pretty unsatisfactory.
Another thing that has me concerned is the assistive technologies strategies as well as the home modification. They are a strategy they’re not a goal. I think, too often, it’s decided “I want a home mod or an assistive technology”. This is where OTs are very important because we go in and sort out whether that really is the best answer. I think sometimes a home mod is jumped on as a solution, when different room use or moving in with your daughter or breaking up the fights, really could have solved it.
Educating people about other options is important, and I think sometimes we just look at the home mods as a solution and it’s only a strategy, and it may be right or it may be wrong.
David Brown: I can respond to the home mods in rental accommodation question – The NDIS will fund home modifications in a rental property, but it’s by agreement with the landlord. (See link below to Operational Guidelines – Planning and Assessment – Supports in the Plan – Home Modifications.)
Michael Bleasdale: In relation to the NDIS and other agencies. The NDIS is a national scheme but it is still really reliant on state departments. So there will still be quite a level of reliance on departments of housing across the country which will still need to provide a good deal of accessibility within their homes. I had thought the NDIA was going to be able to be providing specific home modifications to people who are long term residents of the department of housing, and that was the reaction we were hoping for.
There has been no briefing on this generally – this is a source of frustration for the sector; we have been waiting for a year and a half for a strategy. We have been asking to meet and asking to constructively engage with the development of this.
All I can say in terms to the NDIS approach – they have developed different approaches in different trial sites. They are not vastly different but there is tendency in NSW to give the work to a couple of providers that have been brought on as preferred providers, whereas in the ACT it’s a more open market.
You’d know better than I what the Barwon model is; I wouldn’t attempt to describe it. But it is slightly different again. So the NDIS is utilising various mechanisms of procurement of home modifications, different in each state, like using the State Wide Equipment Program (SWEP) here in Victoria, for example. The equivalent agency in NSW doesn’t do home modifications.
The NDIS has to work with these variations as it gradually makes its way towards a nationally consistent approach. And until we get the equivalent of the assistive technology strategy on home modifications we won’t be able to make really serious, critical comment on what will work and won’t work.
|Participant 2: I just want to make comment about including aged care in the plans because it seems like aged care is being left behind as the NDIS comes in. Recently in Victoria, losing the architect in our team has made a huge gap with the closure of Archicentre. We are not sure how we are going to be managing that into the future if we have issues of compliance or if we have a job that isn’t successful. We need that information included into the plan for the future.There is also a lack of confidence on the part of OTs in scoping home mod jobs – how do we differentiate between them as minor or major, and know how to manage the sources for funding, whether it’s public funding, insurance funding or the client paying for some of it.
David Brown: I would think that if an OT feels that they need design and project management support, they will need to request that.
The NDIS will pay for additional costs involved if the NDIA recommends or requires the use of project managers, building certifiers, building assessors and other professionals*, but I can’t say how that applies here.
As project managers, we have the skills to scope up the work, advise on the technical aspects, draw up the design specifications and manage the contracting, but, as I said earlier, we are a bit unclear about how we can get in to provide that assistance at the moment.
(*See link to NDIS Operational Guidelines – Planning and Assessment – Supports in the Plan – Home Modifications below.)
Michael Bleasdale: In terms of aged care – there is a real problem – The Department of Health has been clear to the providers that the home mods provided for under the Commonwealth Home Support Programme (CHSP) are only meant to be small scale because that is the way it has always been done. They have done everything to curtail the availability of higher cost, higher-level home mods.
Which is different from acknowledging, as they have in the UK, that there is a problem with the housing stock and that it is worthwhile to put programs together that will address those particular problems.
I am optimistic that policy-makers in charge of the upcoming reform in the aged care sector will apply insurance principles – that is, why don’t we put money here so we can save money over here. There are things to be optimistic about, but we have to live with what we’ve got for a couple of years.
|Participant 3: I have a current case where a client needs a ceiling hoist. The track is being funded through the Office of Housing but the hoist itself has to go through SWEP with funding by the NDIS. The track will be installed in a couple of months and then the hoist will not be installed for another six months. So that’s what I am currently working with. I’m not sure what the process should be, but that is real life case that’s going on which is frustrating for the client.
Participant 4: OTs in Barwon have a lot to say about the NDIS – because it’s a reality for us not the theory.
From my perspective, it’s important to advocate for the project management technical role. I think the collaborative approach is the right way to go.
In other states the OTs are doing the design, and the NDIS is asking why aren’t we doing it here? It’s not because we’re deskilled, it’s because the collaborative approach to solutions is the way to go.
The thinking we do, and the way we go about it has to be carefully done. We have to be really strong about it – it’s not a reflection of deskilling or poor practice from our perspective.
I think this a really significant thing moving on. When the NDIS hits Melbourne – be ready.
Bronwyn Stephen – If I can just pick up that point and also refer back to a previous one. As OTs our focus is very much on the client. In her presentation, Clare Perry referred to the client-centred approach.
“When we’re looking at home modifications we are very much coming from the point of view of knowledge of the client; the changes, their limitations, their expectations, prognosis, where they fit in the family, what their cultural background is; all of that – we don’t expect to have the understanding of the building itself – what can or can’t be done from a building point of view; what sort of surfaces are better, all that sort of thing. We have had the support of good architects in the past – such as working with Archicentre.”
We are now being told OTs in other states are doing it – it’s a knock around the head to hear that we really aren’t quite so good. But I think the reality is that we are OTs, and our focus is the client. It’s not those environmental design issues apart from obviously understanding the impact of the equipment you’re using in that area and all the rest of it.
So, I think it is really important to move towards a situation where we can work more closely with the architects and the project managers. And through the evolution of the NDIS and those new programs coming in that can be reinforced.
From an OT association point of view, I’ve recently become one of the co-convenors of the home modifications special interest group and what we are aiming to do is to, first off, is to link into really good resources that are set up such as the Home Modification Clearinghouse (see link below) so that people can access information and then go from there.
We need to help OTs with developing skills as relevant to the home modifications area and particularly considering a lot of OTs working, for example, in community health or public hospitals are dealing with a whole range of issues, not just home mods. Home modification is just one area that they are expected to address in their practice.
So our aim will be to assist people in obtaining information, education or mentoring with developing those necessary skills to deliver home mods, or helping them to understand when they do need to refer on to someone else who might have more specialised skills.
David Brown: The NDIS and other insurers need to appreciate the benefits of this collaborative way of working and the technical advisory and delivery role of the project manager. A collaborative approach that gives the right professionals the right roles will allow the NDIS to get projects underway and completed to time, budget and quality requirements. And participants will have the benefits of accessible homes they are happy to live in.
The decision to provide design and project management support to OTs it is not about an arbitrary dollar figure or struggling with a definition of whether you’re doing something minor or major.
Most OTs could expect to manage the installation of a step ramp or a handrail, but where you need to have a building contract, structural work, a building permit – that should not have to be up to OTs to manage. OTs do an amazing job, but design and project management are outside the scope of their role, and they should not be in a position of being embarrassed to ask for the support they need outside their area of expertise.
|Participant 5: I concur with what you have all been saying and certainly with what Bronwyn has been saying. OT Victoria is trying to advocate very strongly for OTs scope of practice within all the changes that have been happening. And saying that, we’re certainly not the design and the structural experts and we do have that participant focus. I would encourage people to join the home mods interest group because we want to have a strong focus in all these different reforms that are happening and be quite adamant about our role, and about the service OTs can offer.
Even to the point of advocating about the excess costs that we are all trying to manage with our clients, which I know is another totally different factor.
There are so many aspects to all these changes in all of these different systems that have to be addressed. From a national perspective, OT Australia has been talking to other stakeholders and has certainly been looking at how we’re going to work at federal and state wide with these systems and changes.
Question from Chris Porter to the participant.
What is the dialogue between the different states on the role and scope of practice for OTs in delivering home modifications when there are these state-based differences?
|Participant 5: In Victoria, the removal of the Archicentre has knocked OTs into gear. And possibly, what we were saying earlier, in terms of OTs not really having such a focus on design because we have had that service and we have worked with Architects to provide this service in the past, has made us take a back step and actually looking at how we are going to focus.We are engaging with SWEP looking at their new framework in terms of home mods prescribing.
We have different reference groups with a focus on the different government reforms relevant to OTs, such as the NDIS. The reference groups all communicate around state-based implementation of the reforms and how they are operating differently in each state and, because they are federal reforms, how we going to coordinate them.
Home modification has come up within those forums, but not as a particular issue in itself from our perspective in Victoria.
OT Victoria is looking at bringing people down from other states to look at our professional development on home mods. By looking at the way people have operated in other states we can provide a revised program.
We are also bedding down what is going to be expected of OTs, as well as what we think is appropriate for OTs.
But it is also important to look at these reforms as opportunities for OTs to have a bit of an entrepreneurial look at their business models, and team up with people like Architecture and Access and other architects.
And for OTs, looking at the fact that when you’re providing a service for a person – just looking at the persons needs and doing a prescription is only one part of that service – and in providing the entire service of home modification, you could be quite entrepreneurial and team up a whole lot of different professionals to provide the entire service.
The way that OTs are going to be providing a service in the future is possibly being quite different to the way it has been in the past.
Participant 6. I have worked across states, across different community health and in-patient care, I’ve been an OT for 30 years. I look at this simply. What happens now, with OTS as professionals, is that many of us (and we have been doing this for a long time for some reason) we don’t value ourselves and what we do. We are underselling and undervaluing of our work.
There needs to be consistency of setting of fees for OT services and consistent scope of services. We have no consistency and we make excuses for the almost 30 years for being inconsistent and insurance companies are capitalising on this – why wouldn’t they.
If I could go to Kmart and get Jimmy Choos instead of Ugg Boots, I would. For me, that sticks out as a problem for my entire career. I think as a group of professionals, and I put this back to OT Australia, we have to stop giving people a lot of stuff for nothing – because it doesn’t give a great outcome for our clients. It gets inconsistent outcomes. Some people get a great outcome and some people get the Ugg Boots.
David Brown – It is more about understanding the requirements for delivering a home modification. Somebody has to engage an architect or designer, a building surveyor, and an engineer, and actively manage the delivery of the project to time and cost and quality requirements. Obviously there are fantastic builders around who work very closely with OTs, and that happens in Victoria as well, but usually they are for smaller modifications.To provide a design or a building service, you must be a qualified and registered practitioner, and aware of the requirements and processes in terms of contracts, certification, the national building code and insurance as just some of the complexities of designing and delivering a home modification.
|Participant 7. What is the experience of people working interstate in comparison to what we do here? If you are not utilising the architect, is it you have stronger relationships with the builder?|
Michael Bleasdale: The NSW model was the OT/builder model – so there are very large organisations that have built themselves around that, so there has been an increased role for the OTs to do a higher spec design.
In NSW, the cultural change is in the concept of introducing the architect and the project manager. The NSW experience is based largely on aged care and disability service delivery, and it’s not the lifetime care and support model of the NDIS. So there is a different bunch of people doing that work, which is all the more confusing.
Ultimately, the job of home modification delivery is the same across the board and there are multiple ways of getting there. I don’t think we need ultimate consistency, but I’d like to see much greater consistency. If I were an OT it would be driving me crazy – working in one state where you could do a drawing, and in another state where it was different.
Which is why part of our role is working much more closely and collaboratively together. I think some kind of national standards applying to home mods for OTs is needed right now.
Without that, I think we’re vulnerable as an industry to the various ways in which these new reforms are being designed, as it is difficult for people in charge of developing these reforms not being mindful of what is going on in the other reforms. So, we could still end up with five or six different ways of looking at the same thing and state-based variations as well. That would be a nightmare for everyone including the client.
Bronwyn Stephen – This situation in Victoria with the disappearance to the access of the services of Archicentre reminded me of a reform we went through some years ago. I was working at a large public hospital in Melbourne where we had a relatively small team of OTs. In other hospitals of similar size, they had larger numbers of OTs. Our tendency was to compare ourselves with them saying we were providing the same number of services using fewer OTs, so we really felt we needed more staff to provide better quality services.
The feedback came through that the other hospitals were asked why they couldn’t they provide the same services using the same amount of staff as us. This is exactly the same situation in a lot of ways. The cost of the Archicentre services were being met elsewhere, and now that has been taken away.
We’ve talked a lot about quality improvement. QA for our clients will be in the right type of knowledge, the right amount of knowledge, being conveyed at the right time in the process.
The sorts of systems we have talked about today, and all of us improving our knowledge, not only of how we work together and also about this area of home modification, hopefully we can get a better system not only for ourselves but our clients.
Michael Bleasdale: You raised the issue of government-funded services earlier. One of the premises of today was whether we are moving to an insurance focus for home mods, and I don’t think we are necessarily. If you said that about aged care, for example, they are not ready to commit to it.
But I think we can say is that we are moving absolutely into an individual focus. The situation of the government funding up front for service are numbered in any reforms. That raises a number of other challenges. It also brings in the biggest constituency – slightly outside but related to home mods – informing and rendering our services to the general community as they undertake renovations in their homes. We need to be actually encouraging people at a time when they are putting vast amounts of money into their renovations – saying to them “Let’s build some accessibility into that.” And I think we all have a role to play in here, and this is something that government is also interested in.
David Brown: In many ways, it comes back to that initial process of assessment and planning and getting the design right from the start. We have seen so many clients go through multiple prescriptions and having to wait such a long time for their modification to get underway. If we can get involved in the whole process earlier, it will alter a lot of people’s lives.
My vision for the future of home modification service delivery is for a workable team-based approach that meets the needs of everyone involved.
We all need clear roles and responsibilities and respect for the roles of each team member.
This will result in high levels of satisfaction from all involved. Project managers can be actively driving project delivery to meet time, budget and quality requirements. We will be preventing delays, costly errors and rectification currently caused by avoidable design issues and variations, and delivering good quality home mods that people are happy to live in, that are practical for the particular home and compliant with the building regulations and accessibility standards.
I think people including insurers, participants and service providers will support the approach that strikes the best balance in giving everyone the outcomes they want, an approach that encourages a sustainable service sector, and results in increased participation and independence for people with disability.
In conclusion, Chris Porter urged all players to support each other and the wider home modification sector as a unique and valuable industry undergoing massive transformation, and encouraged people to unite to strongly advocate for the appropriate scoping of professional practice and appreciation of the service offerings of OTs, project managers, designers and builders.
“More work needs to done on all levels including defining the roles and scope of professional practice, service system development, research and training,” said Chris. “In the future, our industry will be identified by practice standards, requisite specialised knowledge and skillsets, and the unique products we deliver in response to the needs of people with disability.”
He proposed that the form of future services will depend on the entrepreneurial approach taken by service providers in developing new business models and in up-skilling through training and workforce development.
“We will need funding and advocacy to make the transition as service providers in the new marketplace,” said Chris. “Importantly, we need an evidence base to draw upon to support best practice and service development. To achieve this, we will need to lobby insurers to facilitate innovation, research and best practice in the sector.”
The strengthening of interdisciplinary networks and communication at a local, state and national level – between insurers, OTs project managers, designers and people with disability will be key to securing the success of the home modification sector and better outcomes for the consumer.
Links and resources
For more information about the OT Association home modification special interest group, please email co-convenor Bronwyn Stephen firstname.lastname@example.org or contact OT Australia Victoria Division on Email: email@example.com
More information about MODA – Home Modification Australia website.
More information about Architecture & Access Home Modification services.
Margie’s Home Modification (video)