NDIS Review Conversation Series: Paper No. 11

Recalibrating support coordination and plan management to boost participant outcomes

Key points

• Despite becoming a billion-dollar intermediary industry, support coordination and plan management roles remain ill-defined and confusing for many participants
• There is a clear and useful distinction between demand-side intermediary functions that support the participant to make and commission choices and supply-side intermediary functions coordinating formal supports
• This distinction creates clear role boundaries and separation that helps avoid conflicts of interest or time; therefore an intermediary should be either a demand-side or supply-side intermediary, not both

 

During the first 10 years of the National Disability Insurance Scheme (NDIS), the provision of support coordination and plan management services has developed into a combined billion-dollar intermediary industry despite the purposes and functions of these roles remaining ill-defined and unclear. In the 12 months to 31 March 2023, total expenditure on support coordination was $905.6 million and on plan management was $467.5 million.^[i] These roles also sit alongside those provided through the Partners in the Community (PITC) program, including both Local Area Coordinators (LACs) and Early Childhood (EC) partners, which in the 2019-20 financial year, when the number of Scheme participants was still about 480,000, cost an additional $525 million.^[ii] Currently, all participants are assigned a PITC, while 45 per cent of participants have funding in their plan for support coordination and 59 per cent of participants use a plan manager.^[iii] There is no doubt intermediary roles have become central to the operation of the Scheme and represent a significant cost within the NDIS, making it essential there be a clear articulation of what each role is and where the role boundaries lie.

The National Disability Insurance Agency (NDIA) has committed to updating its guidance on plan management during the second half of this year and providing clearer parameters for support coordination by March 2024.^[iv] Meanwhile, the NDIS Review will also consider the future of support coordination, plan management, LACs, EC partners, and remote community connectors this year. Released in June, its interim report ‘What we have heard’ identified that intermediary roles currently ‘overlap, leave gaps, and are confusing’.^[v] It is critically important this work is undertaken holistically with the aim of ensuring participants can access effective support at all stages of the pathway without the confusion that currently exists in understanding who does what.

Intermediary roles are arguably both a product of there being too much complexity in the Scheme and a source of additional complexity within the Scheme. Therefore, there is a risk that this complexity becomes self-perpetuating and feeds on itself. In this eleventh paper in our NDIS Review Conversation Series, we unpack the functions of the current intermediary roles and consider how these can be provided more effectively within a simple participant pathway. We propose a separation between intermediary functions that occur on the demand side of the pathway and those that occur on the supply side of the pathway in order to create clearly defined roles and role boundaries, which will reduce complexity and help negate the current problem of conflicts of interest or time.  

Support coordination and plan management roles in the NDIS

In its 2011 report on disability care and support, the Productivity Commission envisaged a primary role for LACs in supporting people to interact with the NDIS and a secondary role(s) for intermediaries – these being a ‘new form of organisation’ – to undertake brokerage and administrative functions if participants sought these types of support.^[vi] Specific roles were not defined. During the design and early implementation of the Scheme, LAC functions shifted from their traditional articulation of supporting the person, into a largely Agency-orientated role managing Scheme steps, as outlined in the second paper in this Series. Additionally, the intermediary roles of support coordination and plan management emerged without a clear alignment to the participant pathway, distinct boundaries between roles, or coherence with Scheme values. These roles remain ill-defined and many participants are confused about who can assist them with which elements of the Scheme.

Aside from generating a lack of role clarity, the loose scope of intermediary roles and who can undertake them creates fertile ground for conflicts of interest that make the motivations and purposes of those entrusted to perform these roles, including questions of who they serve, murky. The prevalence of referrals to and among intermediaries indicates that participant choice and control may be taking a back seat to these conflicts. For example, it appears quite common that the provision of support coordination is linked to a participant’s accommodation provider, sometimes even when a participant has not identified they need or want a budget for this type of support included in their plan.

Both support coordination and plan management are categorised as ‘capacity building’ supports even though in their current forms these roles have a strong disincentive for providers to build participants’ capacities because, if they do, their own services may no longer be needed. Hence, the roles are skewed toward being transactional in character rather than transformational, as we argued in the third paper in this Series. Indeed, for a few years beginning with the 2019-20 Support Catalogue, there were Support Item numbers for both support coordinators and plan managers to provide ‘Capacity Building and Training in Plan and Financial Management’.^[vii] These lines are no longer available.

Instead, while some plan managers view their role in broader terms, many appear to follow a largely ‘accounts payable’ approach; one where arguably the greatest level of system automation drives the highest profits, rather than profitability being linked to outcomes for participants. When the plan management role is limited to processing invoices and not to managing budgets and expenditure, there is a risk of overspending and a participant draining their budgets before the end of their plan. The consequence of budget overspends is indicated by the intraplan inflation rate – increases occurring within plans, not after reassessments – which was running at an annualised rate of 7.7 per cent during the third quarter of 2022-23.^[viii] If this intraplan inflation is present for participant budgets where there is a plan manager, it raises an important question about whether that role in its current form is effective in supporting participants to manage their plans and budgets.

Alternatives to plan management are also overly complicated for participants to navigate. The portal that enables participants with agency-managed supports to access information and monitor spending is not user friendly, including in basic aspects such as the names of support categories, with many given different names to what appears in a plan.^[ix] Self-management requires a burdensome process before a person is approved to manage their own budgets, and it is complicated to navigate all the rules that apply. While there is significant potential for more participants to self-manage, and it is so valuable the NDIA offers this option, it should be made easier to choose and undertake this option so that participants have real choice of management type. The NDIA is currently undertaking work to improve how payments and claims occur, and we hope the improvements make it easier for participants to consider self-management. After all, any time we bring new or more professionals into people’s lives, we should do so with caution and question what value is added to their life as opposed to creating additional complexity. We believe the NDIS goals can be well-served by more people self-managing their budgets and supports, as the experts in their own lives. Where participants do not wish to self-manage, we hope that the system improvements mean participants with plan managers can expect higher-value support from such intermediaries than a semi-automated payment service.

Recalibrating roles to boost participant outcomes

In the first paper in this Series, we talked about the importance of establishing simplicity as the key anchor point for the NDIS pathway. In applying this principle of simplicity to charting the future roles of intermediaries like support coordinators and plan managers, it helps to examine the NDIS participant pathway and the types of support the participant might need at each stage.

We assert a distinction can be made between the pathway steps that help a person to decide their priorities and translate that into a plan the NDIA can set a budget for, and the pathway steps that then give effect to the participant’s choices. For those readers who like market language, this distinction might be termed as the difference between quantifying demand and coordinating supply. This distinction is important because it can help to chart the extent to which there might be a conflict of interest in any given situation, for example if an intermediary has a vested interest in the supply choices the participant is being supported to make. Therefore, the NDIS can evolve its arrangements by making the clear distinction between the roles an intermediary might undertake on the demand side of the pathway, and the role an intermediary might undertake on the supply side of the pathway.

The demand-side intermediary

We assert the demand side of the NDIS pathway includes the following features for an intermediary:

• Assist the participant to build a vision-based plan
• Assist the participant to connect into community, including freely given supports
• Assist the participant to choose formal supports
• Assist the participant to track their budget for utilisation and impact

Currently, some LACs might assist with some of the above, and some support coordinators might assist with some of the above, and some plan managers might assist with some of the above. Understandably, this can leave participants unclear about who assists them with what.  To resolve the risk of role confusion, and the duplication or gaps the confusion creates, we assert that all of the above can be provided via the basis of the LAC model we set out in the second paper in this Series, where the participant is able to choose their LAC.

This means those support coordinators or plan managers currently assisting participants with one or more of the above functions are operating, at least in part, as demand-side intermediaries. As such, there would be less need to distinguish between role titles – LAC versus Support Coordinator versus Plan Manager – and instead focus on the nature of the service being offered. Therefore, the participant would be able to choose from a range of demand-side intermediaries and services, depending on what they reasonably needed to advance their goals and those of the Scheme.

Building on the previous list, a demand-side intermediary could offer one, some, or all, of the following supports and services:

1. Planning
   where the intermediary assists the participant to build a vision-based plan that includes a mix of elements: freely given supports and community resources and opportunities, and proposed formal supports
2. Community connecting
   where the intermediary assists the participant to make connections to community resources and opportunities, and the informal supports these links can bring
3. Selecting formal supports
   where the intermediary assists the participant to choose formal support providers that look to be a good match with what the participant wants to achieve
4. Tracking budget
   where the intermediary assists the participant to track the use and impact of their budget, including, for example, assisting the participant to respond to unreliable or ineffective providers, or needs to rethink some choices to stay within budget. 

While we assert the intermediary role has a primary responsibility to the participant, each of the above service elements can be expected to be undertaken in a way that also serves the Scheme’s interests, in that:

1. Good planning increases the focus on outcomes most meaningful to the Scheme’s goals in relation to social and economic participation.
2. Good community connecting also delivers on Scheme goals of social and economic participation, and can help reduce the demand for some aspects of formal supports.
3. Good supports-matching increases the chances the budget will be spent on more impactful formal supports that again deliver on Scheme goals of social and economic participation, and on Scheme sustainability if those supports make the best use of, and grow, the participant’s capacity.
4. Good budget tracking can help make sure the participant’s choices are affordable (they reduce the risk of Scheme intraplan inflation), defendable (they are within Scheme parameters), and impactful (they deliver the outcomes the participant and Scheme are interested in).

The supply-side intermediary

It is important to separate out the work of a demand-side intermediary from that of a supply-side intermediary. The first reason for this is the risk of an inherent conflict of interest, created when the intermediary either has a vested interest in one or more of the supply agencies involved, or when the nature of the work means the intermediary has deeper relationship with those providers than they have with the participant whose services they are coordinating.

The second reason is that when an intermediary has both demand-side role elements and supply-side elements, there can be a conflict of time. This happens because whenever there is a significant supply issue, the intermediary in such a role will need to respond to that quickly, and that gets in the way of demand-side work the intermediary may have planned. For example, an intermediary Jane is assisting a participant Tom to connect into community (demand-side intermediary). However, Jane is also coordinating support services (supply-side intermediary) for another participant Iko. On the morning Jane is due to meet with a local surf-lifesaving club about Tom joining, there is a disruption to Iko’s supports that Jane will need to fix. In this situation, the priority is fixing Iko’s supports. As a result, the meeting about Tom’s community membership gets postponed. This is a fictitious example of the time conflicts that can emerge when an intermediary is covering both demand and supply.

In pursuit of clarity, we have identified the following elements that might be associated with the supply-side intermediary role currently:

• ‘Financial intermediary’
  paying the bills, making NDIS budget claims in relation to those bills, and fulfilling reporting requirements (these tasks are typically associated with the plan manager role)
• ‘Service continuity intermediary’
  making sure services show up and deliver the expected service
• ‘Service complexity intermediary’
  a ‘case coordinator’ role for those participants whose circumstances might mean there are several providers involved, plus other agencies outside the NDIS, and where it is critically important that these are coordinated in their efforts

In terms of the ‘financial intermediary’ role, the NDIA continues to invest in ways to make the operations of payments and claims easier for Scheme participants to navigate, including through work on a Claims at the Point of Support (C-POS) project.^[x] Such work should continue to help reduce the risk that current levels of demand for plan management have only been created by unnecessary complexity within the NDIS system. One of the benefits of this is that it can ‘right-size’ the overall demand for plan management and place it back in the demand side where the intermediary assists the person to track budget and impact. A further benefit of a simpler more accessible payments and claims system is that more participants may be inclined to self-manage their supports. This is good from a choice and control standpoint and may also assist the NDIA to manage inflationary pressures, because our experience is there is less inflationary pressure when people self-manage their supports.

Regarding the ‘service continuity intermediary’ role, we assert that service providers have a primary duty of care to assure the participant that services are delivered as agreed. As such, the intermediary role is to take action when a provider is failing in this regard, including assisting the participant to shift to other provision arrangements. Again, this approach would place it back in the demand side as part of the intermediary role assisting the participant to choose formal supports and track budget and impact.

The ‘service complexity intermediary’ is where the intermediary takes a central role in making sure there is cohesion among different service agencies and individuals involved in the support arrangements for a person whose circumstances are complex or who may be experiencing a period of heightened vulnerability. The NDIA currently calls this role 'specialist support coordination’, or, in some human services systems, it may be known as ‘case coordination’. To call on a metaphor, this intermediary is the conductor of the orchestra. As such, the presence of complexity demands the intermediary plays a central role in service orchestration. This should be managed as a supply-side intermediary role. So long as the intermediary has no vested interest in providing any of the supports being coordinated, we do not see a critical issue with conflicts of interest. This intermediary would have ongoing contact and relationships with service providers but would be separate from the demand-side intermediary who would be primarily involved in supporting choice-making. Therefore, the supply-side intermediary could not influence the participant’s choices in a way that could constitute a conflict of interest.

This separateness also resolves the issue of conflict of time. Because this intermediary’s role is focused on orchestration of formal supports, that becomes their specialty and does not impinge on demand-side intermediary work connecting participants into community resources and opportunities. Ultimately, the supply-side intermediary’s role is to ensure the participant’s interests are being best met through careful coordination of formal supports. In doing so, the intermediary is supporting Scheme goals by helping ensure that a complex budget is having the maximum impact through diligent coordination of various supports and the coordinated involvement of non-NDIS mainstream services, such as health or education.

Mapping the required functions

In the previous section, we have mapped demand-side and supply-side intermediary functions in a manner we think can bring additional clarity and value. These are:

Demand-side intermediary role elements

• Planning
• Community connecting
• Selecting formal supports
• Tracking budget for usage and impact

Supply-side intermediary role elements

• Coordinating complex support and service responses 

In earlier papers in this Series, we set out a simple NDIS participant pathway illustration, and we return to that below to illustrate where these elements sit along the pathway.

This illustration shows where the intermediary role appears along a simple NDIS participant pathway, and how the role elements vary accordingly. This is anchored on the relatively simple idea that at each step of the pathway we might ask, ‘What would be helpful to the participant here?’ This can help reduce the risk of role confusion and give greater clarity about the practice elements at each step.

Making changes

In implementing these proposed improvements to the intermediary roles, key areas of attention for the NDIA would likely include:

• Superseding current service descriptions for LACs, support coordinators, and plan managers, and replacing these with detailed components for each of the demand-side and supply-side role elements in the list above
• Resolving with the NDIS Quality and Safeguards Commission how best to credential these roles so participants have assurance of intermediary accreditation and oversight
• Resolving a new approach to commissioning these services (noting participants are currently assigned an LAC or EC partner rather than selecting and purchasing this through an individual plan budget), so that participants have authentic choice and control over who assists them with each intermediary role
• Resolving a separate commissioning approach for intermediary services for people in what the Productivity Commission referred to as ‘Tier 2’ (people living with disability not eligible for an individual NDIS plan), which would likely be a population-based purchase of information and ‘wayfinding’ to community resources and opportunities, anchored on the intermediary’s excellent local knowledge and connections, as we identified in the second paper in this Series  
• Resolving how the NDIA, in its market stewardship role, might look at a particular type of intermediary role to address issues associated with ‘thin markets’, a topic we will consider in a future paper in this Series

Conclusion

In this short paper we have identified the problems of role confusion across the several ‘intermediary’ roles that currently feature in the NDIS pathway, and that these problems are the result of, and contributing to, Scheme complexity. We have asserted the Scheme and its participants will likely benefit by taking a fresh look at the role of all intermediaries, considering the types of assistance a participant might need to identify and advance their choices and priorities (we have termed this ‘demand side’), and the types of assistance a participant might need for ongoing coordination of formal supports (we have termed this ‘supply side’). Instead of drawing on role titles such as LAC, support coordinator and plan manager, we have identified five main areas of intermediary activity, and have asserted these should be commissioned in ways that give participants authentic choice and control. In such commissioning, we have asserted that demand-side and supply-side intermediary activities are mutually exclusive, and that commissioning should reflect this.

In the next Paper in our NDIS Review Conversation Series, we will consider how the NDIS can maximise the beneficial outcomes of Positive Behaviour Support for participants.

► Join the conversation at our To The POint webinar

Tell us what you think about the current approaches to support coordination and plan management, share your ideas for reform, and help raise expectations about what the NDIS Review can deliver at our eleventh To The POint webinar on Monday, 17 July 2023 at 12:30pm ACST (that is, 1pm AEST and 11am in the West). The webinar will run for 45 minutes and feature Robbi Williams, CEO of JFA Purple Orange, discussing this Paper. Attendees will have the opportunity to ask questions and provide their feedback on how these roles can be recalibrated to boost participant outcomes.

Register to join the To The POint webinar here.

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► Our NDIS Review Conversation Series

With the NDIS Review underway, JFA Purple Orange is publishing a series of papers to help stimulate conversations about the future of the Scheme. Each fortnight, we will tackle a different topic of reform that we think is critical to the work of the NDIS Review. We strongly believe that the NDIS is an essential component of ensuring that Australians living with disability get a fair go at what life has to offer, but it must be strengthened and sustained. We are committed to playing a constructive role in developing ideas for reform that ensure the Scheme delivers on its original promise.

Watch out for Paper No.12: Maximising beneficial outcomes from Positive Behaviour Support on Monday, 24 July 2023, or visit our website to find out more about our NDIS Review Conversation Series. 

► About us

JFA Purple Orange is an independent social profit organisation based in South Australia that undertakes systemic policy analysis and advocacy across a range of issues affecting people living with disability and their families. We also host a range of peer networks for people living with disability including people living with intellectual disability, physical and sensory disability, younger people, people from culturally and linguistically diverse backgrounds, and people in regional South Australia. Our work is characterised by co-design and informed by a model called Citizenhood.

► Media enquiries

If you would like to republish this paper or interview Robbi Williams, CEO of JFA Purple Orange, about it, please contact Marissa on (08) 8373 3833 or email marissab@juliafarr.org.au.

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Footnotes

[i] National Disability Insurance Agency, ‘NDIS Quarterly Report to disability ministers: Q3 2022-23’, March 2023, p.190, Table E.53, available at https://www.ndis.gov.au/about-us/publications/quarterly-reports.

[ii] National Disability Insurance Agency, ‘Partners in the Community Program - Market Engagement: Feedback Summary Report’, January 2022, p.5, available at https://www.ndis.gov.au/media/4037/download? attachment.

[iii] National Disability Insurance Agency, ‘NDIS Quarterly Report to disability ministers: Q3 2022-23’, March 2023, p.87 and Appendix E, Table E.117, available at https://www.ndis.gov.au/about-us/publications/quarterly-reports.

[iv] Ibid, pp.55-56.

[v] NDIS Review, ‘What we have heard: Moving from defining problems to designing solutions to build a better NDIS’, June 2023, p.20, available at https://www.ndisreview.gov.au/resources/reports/what-we-have-heard-report.

[vi] Productivity Commission, ‘Disability Care and Support,’ Report no.54, 2011, p.414, available at https://www.pc.gov.au/inquiries/completed/disability-support/report.

[vii] The relevant Support Item numbers were 07_003_0117_8_3 and 14_031_0127_8_3. Archived Support Catalogues are available at https://www.ndis.gov.au/providers/pricing-arrangements/pricing-arrangements-archive. 

[viii] Office of the Scheme Actuary, National Disability Insurance Agency, 'NDIS Quarterly report to disability ministers: Scheme Actuary Presentation Q3, 2022-23', 31 March 2023, p.46, available at https://www.ndis.gov.au/about-us/publications/quarterly-reports.

[ix] See tables at National Disability Insurance Agency, ‘Support budgets in your plan’, 17 May 2022, available at https://www.ndis.gov.au/participants/using-your-plan/managing-your-plan/support-budgets-your-plan.

[x] For more about the Claims at the Point of Support (C-POS) project, see https://www.ndis.gov.au/news/ 9165-claims-point-support-c-pos.