033 Specialist Support Coordination Policy and Procedure
1. Purpose
The purpose of this policy is to ensure that participants receiving specialised support coordination:
- are provided tailored support to implement, monitor and review their support plans to reduce the risks associated with the complexity of their situation
- exercise meaningful choice and control over their supports
- maximise the value for money they receive from their supports
- receive transparent and factual advice about their support options that promote choice and control.
2. Scope
This policy guides all SSCs and administrators who assist to provide specialist support coordination services to our participants.
3. Definitions
In this policy, Support coordination is funded under the National Disability Insurance Scheme (NDIS) to strengthen the participant’s ability to design and build their supports, emphasizing linking to broader support systems.
Support Coordinator means person whose role is to assist a participant to build capacity and co-ordinate their supports
SSC (SSC) aids clients with disabilities or mental health concerns in navigating the support system. They collaborate with clients to determine their requirements, link them up with services that are suited to their needs, and coordinate care between various providers.
Participant means a client or potential client who is receiving supports or services from Proactive Support
4. Rights and Responsibilities
Management
It is the responsibility of management to
- Ensure that specialist support coordination is delivered by an appropriately qualified and experienced practitioner (e.g., a psychologist, occupational therapist, social worker or mental health nurse), who uses an expert or specialist approach, to meet the participant’s needs.
- Provide the supports and access to supervision that a SSC requires to fulfill their role
SSCs
It is the responsibility of the SSC to
- Identify the specific high complex needs or high-level risks relating to a participant’s situation.
- Take appropriate steps to address the needs and risks
- Use a collaborative approach to manage the situation
- Assist participants reduce complexity in their support environment
- Address barriers to connecting with supports
- Build capacity and resilience
- Ask for assistance where required
5. What is the Difference?
Support coordination involves a tiered, capacity building approach of three levels:
Level 1 – Support Connection
Assists a participant to implement their plan by strengthening their ability to connect with the broader systems of supports and understand the funded supports' purpose.
Level 2 – Support Coordination
Aims to support participants to direct their lives (not just their service). It is focused on assisting participants in building and maintaining a resilient network of formal and informal supports.
Level 3 – Specialist Support Coordination
Helps participants reduce complexity in their support environment and overcome barriers to connecting with broader systems of supports and funded supports. SSCs negotiate appropriate support solutions with multiple stakeholders and seek to achieve well-coordinated plan implementation. SSCs will help stakeholders resolve crisis points for participants and ensure consistent service delivery and access to relevant supports during crises. Support challenges may include health, education, housing or justice services. Specialist support coordination is generally delivered over an intensive and time-limited period, necessitated by the participant’s immediate and significant plan implementation barriers.
6. Providing a Service
When providing specialist support coordination, Proactive Support will ensure:
- The focus is on clearly identified aims, goals and benefits
- Planning and coordination will include mainstream, informal, community and funded supports
- The need for specialist support coordination decreases over time
- Participants are genuinely allowed to exercise choice and control
- Information provided to the participant regarding their options and plan is in a communication mode and language that they are most likely to understand
- Information should include transparent and factual advice about the participant’s support options
- Any conflicts of interest are made clear
- Funded supports are used effectively and efficiently
7. Procedure
7.1 Overview
Specialist support coordination will be provided in line with the principles documented in other Proactive Support policies and procedures, including:
- person-centered supports
- support for individual values and beliefs
- individual privacy and dignity
- independence and informed choice
- support planning
- responsive support provision
Accordingly, specialised support planning will ensure that each participant is actively involved in developing their specialist support plans. Proactive Support will provide all participants, carers and/or nominees with sufficient and appropriate information to promote choice and control.
7.2 Specialist Support Plan
The SSC will work with the participant and their support network to complete all necessary assessments and develop a tailored Specialist Support Plan which will:
- be based on information sourced from a range of resources and multiple stakeholders
- be developed collaboratively with the participant, and/or their carer or nominee
- include completion of a participant review to obtain an overview of the participant’s current supports and identify any complexities relating to the administration of supports to develop an action plan that effectively manages available NDIS funding.
- include the participant’s needs, support requirements, preferences, strengths and goals
- include any relevant information derived from risk assessments
- identify potential triggers to crises and appropriate strategies to treat these
- identify potential appropriate support solutions, including NDIS providers and community support networks who have appropriate skills and experience, to deliver desired supports
- seek to resolve points of crisis
- assist the participant in connecting with supports and build capacity and resilience to decrease the continued need for high-intensity support.
- work with the participant to build their capacity so that they can coordinate, self-direct and manage their supports
- help the participant better manage their budget funding to be more flexible in meeting their own needs and support requirements.
Where appropriate, and with the participant's consent, information on the Specialist Support Plan is communicated to family members, carers, advocates, other providers and relevant government agencies.
The SSC will implement strategies to provide participants and their support networks information using their preferred communication methods, including using plain language, translators, repeated information or Easy Read documents.
7.3 Plan Implementation
Proactive Support will arrange for supports and services to be utilised as per the participant’s NDIS amounts directed and for the purposes intended by the participant. In achieving this, Proactive Support will continue to provide information to the participant, carer and/or nominee in an accessible format, using suitable language and communication mode to ensure the participant fully understands their support options to make an informed decision.
The SSC will consult and negotiate proactively with multiple stakeholders to implement a well-coordinated Specialist Support Plan.
The SSC will help stakeholders resolve crisis points for participants to provide consistent service delivery and provision of relevant supports during crises.
As appropriate, participants will be supported to build their capacity to coordinate, self-direct and manage their supports and understand how to participate in their planning processes (e.g., establishing agreements with service providers and managing budget flexibility).
Referrals to and from other providers will be documented for each participant following our normal referral procedures and outcomes and interactions documented in the participant’s Support Coordination Case Notes
Specialist support coordination services and assistance may include:
- linking the participant with the right mainstream support and ensuring the provider meets their obligations
- engagement and networking with the participant’s preferred communities
- coordination of various supports, both funded and mainstream
- resolving points of crisis with the participant
- training of support workers
- promoting safety for the participant
- building the participant's capacity and ability (and their informal supports) to understand and implement their own NDIS plan
7.4 Monitoring and Review
The Director ensures the plan is implemented, effectively managed, monitored and reviewed to address all reporting obligations associated with the participant are met.
The Director will regularly review specialist support plans to ensure that:
- risks are being adequately addressed
- changes are made in response to a participant’s changed circumstances
- the participant is receiving value for money
- the participant’s funds are used effectively and efficiently
- any supports funded under a participant’s plan are complemented by the community and mainstream services.
When working with the participant, the Director will review the requirements and provisions the participant requires.
7.5 Conflict of Interest
A conflict of interest exists when an organisation may benefit from managing a participant’s plan and providing support coordination or other support types to a participant.
In this event, Proactive Support will ensure that each participant is supported (using the language, mode of communication and terms that the participant is most likely to comprehend) to understand:
- the distinction between the provision of specialised support coordination and other reasonable and necessary funded supports
- the full range of options available to them
- any choice they make about providers of other supports will not impact Proactive Support’s provision of specialised support coordination
7.6 Collaborative Approach
Proactive Support will:
- use a collaborative approach when undertaking all decision-making processes regarding support for a participant, to allow for an informed approach and can include collaboration with mainstream service providers with appropriate skills/ experience in delivering the required supports, involve allied health or medical practitioners and the participant and their support networks
- ensure the process is explained to the participant, or their carer or nominee, at the time of development, including how and when support will occur
- work with suitable NDIS providers (who have experience and appropriate skills required to deliver supports) that have been identified and are in-line with available funding
- work across service boundaries to provide participants with complex care needs access to a full range of services, including allied health, health and social support services
- employ team members and providers that have all the necessary skills and knowledge to make informed decisions in the development of a participant's plan
- ensure all team members continue to undertake professional development to maintain an understanding of practices that are required for their specific role
- ensure the participant, carer and/or nominee is involved in the evaluation of their situation and the identification of the supports required to prevent or respond to a crisis, incident or breakdown of support arrangements, and the promotion of safety for the participant and others
- gain consent from the participant or their advocate, carer or nominee and the participant’s support network and mainstream services (as appropriate) before support coordination being implemented.
7.7 Documentation
All documentation is kept confidential and secure as per Participant’s Information policies.
Case notes
The SSC will write their case notes in the SC Case Notes for the participant.
The information included in the notes may include but is not limited to:
- outcomes of all ongoing assessments and reassessment
- changes or redevelopment of supports including revised goals or preferences
- critical incidents or major changes in the participant's health or wellbeing
- conversations held with the participant, family members, their representative, carer, nominee or advocate
- conversations (regarding the participant) with any other providers, agencies, health or medical professionals, family members or other individuals who have an interest in the participant
- referrals
- activities associated with participant's admission and exit
Reports
The SSC will complete NDIS Reporting requirements as per the agreed schedule using the appropriate NDIS forms.
8. Participant Check-in
The frequency of a SSC’s check-in with a participant is based on a participant’s situation, circumstances and funding. It is Proactive Support’s intention that an SSC will check-in with a participant, either face to face or by video conferencing, every six months as per the 037 Support Co-ordination Six-Monthly Check-in Procedure. It is usual that, during the course of their support coordination work, an SSC will connect with a participant via phone, email or text message at least once a month.
9. Related Documentation
Proactive Support
Participant Charter of Rights
001 Participant’s Rights Policy
003 Participant’s Privacy, Dignity and Confidentiality Policy
006 Work Health and Safety Policy
007 Feedback and Complaints Management
009 Information Management Policy
010 Quality Management Framework
011 Human Resource Management Policy
012 Participant’s Supports Management Policy
014 Complaints Procedures
017 Participant’s Information, Money and Property Procedures
023 Maintaining Connection with Participants
024 SC PRC Supervision Policy
025 Conflict of Interest Policy
037 Support Co-ordination Six-Monthly Check-in Procedure
External
National Disability Insurance Scheme (Quality Indicators) Guidelines 2020
Human Rights Act 2019
Disability Services Act 2006
Disability Services Regulation 2017
National Disability Insurance Scheme (Provider Registration and Practice Standards) Rules 2018
NDIS Practice Standards and Quality Indicators 2021
Work Health and Safety Act, 2011
Work Health and Safety Regulation, 2011
NDIS Code of Conduct 2019
Commonwealth Privacy Act 1988
