Friday, 29 April 2011
Australian Government Productivity Commission
disability-support@pc.gov.au

Re: 	Disability Care and Support – 
Productivity Commission Draft Report February 2011
Dear Commissioners
I would like to thank you for producing such an interesting and thought provoking draft Report. I have not been asked for or provided any specific input to this draft Report; however, much of the input I provided, as Director of the Home Modification Information Clearinghouse, to the Caring for Older Australians draft report, and my response to that draft Report, would also apply to this draft Report. I appreciate the opportunity to comment on this draft report and would like to draw to your attention a few issues specific to the area of disability care and support for people with a disability (PWD).
I am aware that you will receive a large number of submissions addressing all aspects of the draft Report, so will confine my comments to those parts that have a direct relevance to housing/accommodation, home modifications, and early interventions related to the potential to reduce ongoing waged care costs and support families/carers through timely and appropriate home modifications. Although there are strong links between accessible/appropriate housing and Assistive Technologies (AT), as a Director of the NSW Independent Living Centre, I am aware that they are forwarding you a submission specifically to address AT issues relevant to this draft Report.
As you noted in your draft Report, additional research is required to identify the effectiveness of home modification services in economic terms. In this respect, I would like to draw to your attention our recently completed research on: “Home modifications and their impact on waged care substitution” . In this research, the major findings are that timely, appropriately prescribed and installed home modifications:
1.	Maintain independence;
2.	Reduce hazards in the home environment; 
3.	Act as a substitution for assisted care services, this reducing the need for ongoing support; and
4.	Facilitate ageing in place.
Therefore, the economic benefits of timely, appropriately prescribed and installed home modifications could include:
1.	Reduced, or even negated, need for ongoing care assistance.
2.	Reduced length of stay in hospital (timely discharge)
3.	Reduced risk of injury to clients, carers and careworkers.
The full report will be available from www.homemods.info. An advance copy is attached for your information.
My comments/suggestions in the table below are matched to relevant parts of the draft Report:
Overview
Place	Issue/Comment	
Table 1
‘Failures to intervene early’	I note that you have correctly identified that people may remain in hospital due to time delays in accessing home modifications. In fact, even when home modifications can be progressed fairly quickly, there may be a lack of certainty about who will fund the home modifications in each instance and what the client will contribute. Clarity around this issue would potentially expedite discharges.	
Table 1
‘Poor evidence base’	Please note that the Home Modification Information Clearinghouse (HMinfo) has been funded by the Home and Community Care Program since 2002, specifically to build the evidence base for effective home modifications and their relationship to effective and efficient care delivery. See www.homemods.info. This means that with respect to home modifications, there is a solid and growing evidence base as HMinfo also sources robust evidence from other researchers.	
Box 2	While it is noted that the NDIS would fund home modifications and therapy services (which are needed to assess home modifications and their interaction with ongoing care and supporting client independence), there is a dearth of qualified and experience occupational Therapists (OTs) who are skilled in assessing and prescribing home modifications and standardised, robust tools to support them. See later comments on workforce.	
P 23	If the NDIS were to support people cashing out the value of their modified public housing and/or specialist accommodation, there needs to be recognition that very few families would have the knowledge and skills to identify and purchase, renovate or build suitable housing without professional support from an OT and an experienced builder. A handbook to assist families could be produced, based on Universal Design Guidelines. A similar handbook, “Guidelines for the Development of Design Standards for Group Homes” was authored by Dr Catherine Bridge and Michelle Donelly for the then NSW Department of Ageing, Disability and Home Care’s Strategic Asset Management & Procurement (SAMP) Division in 2008. However, these Guidelines have not been published. Nevertheless, they could easily be adapted for PWD and their families to use when choosing/buying/modifying housing to meet their needs. 	
P 38 Workforce issues	As noted before, workforce issues are particularly stark with respect to allied health workers, especially OTs experienced in assessing and prescribing home modifications. Similar shortages are experienced with respect to architects and tradesmen who are experienced in accessible housing or home modifications. Incentives for them to acquire the relevant competencies need to be explored. They also need to be included in any diffusion of best practice.
Also, in the paragraph starting ‘Apart from wage increases ...”, I suggest adding a dot point: “using home modifications and AT to reduce the need for care staff and increase independence”	
Draft Recommendations
Place	Issue/Comment	
P 58, draft Recommendation 7.11	With respect to the final dot point, this should also include families who choose to buy or move to housing that is not suitable for their PWD and who then request public funds to carry out extensive modifications. Information on how to choose appropriate housing needs to be available to families before purchasing inappropriate properties.	
P 59, draft Recommendation 8.1	The centralised database should also contain links to information on standard home modifications, such as ramps and grab rails (such as that provided by HMinfo), as well as AT (such as that provided by the Independent Living Centre of NSW).	
P 59, draft Recommendation 8.3	In addition, information to consumers needs to include access to information about home modifications and AT and the trade-offs between them. Enhancement of relevant databases may be needed to make them appropriate for consumer, rather than professional, access.	
P 60, draft Recommendation 10.2 and 10.3	Please note the existing role of the HMinfo in researching, identifying and disseminating evidence-based best practice. This is a very successful, low cost model of applied research. A similar model, based in relevant university faculties, could be applied to other areas, such as personal assistance services, or AT, to enable their evidence bases to be built then disseminated.	
P 61, draft Recommendation 11.1	Home modifications, and their relationship with training and AT, needs to be clearly identified as an early intervention strategy because of their potential to increase independence, reduce ongoing care costs and support families and care workers.	
P 63, draft Recommendation 13.1	Subsidies for training should also be available for allied health and design professionals, such as occupational therapists, architects and industrial designers, to encourage the development and consistent provision of postgraduate training designed to enable them to develop, assess and prescribe effective home modifications and/or AT. Subsidies/tax incentives could also be considered for tradesmen to encourage them to acquire the relevant competencies to undertake prescribed home modifications.	
P 65, draft Recommendation 16.3	Please note that there are currently no robust tools in Australia for assessing home environments and the extent to which they are disabling/enabling for PWD and their families or care workers.	
Information requests
Place	Issue/Comment	
P67 re Chapter 4	HMinfo would support the NDIS providing artificial limbs and similar appliances to ensure timely access and consistency in the provision of both home modifications and AT. This would reduce incentives to choose the most available option, rather than the most enabling option.
HMinfo notes that higher electricity costs can be reduced to a certain extent through judicious choice of housing type/aspect and home modifications. For example, it may be better to shade a western wall, rather than run air conditioning for cooling.	
P68 re Chapter 5	HMinfo considers the assessment process to be critical in effective implementation of the NDIS. However, as previously noted there are no robust, evidence-based tools for assessing the home environment and its enabling/disabling impact on PWD, their families and care workers. 
HMinfo has identified the core elements of such a tool, and would be pleased to progress that work if funding were available. Such as tool would also assist PWD and their families to decide whether to modify or move, and then what their requirements would be.	

Introduction
Place	Issue/Comment	
P1.14 Figure 1.1	In the box labelled ‘What?’, it mentions aids and appliances, but not home modifications.
Also, in ‘Who gets other supports?’, it does not recognise the vital role of carers and providing support to them, including home modifications to support their caring role.
The ‘Social and physical infrastructure’ box needs to recognise that the physical environments (home and community) are also vital factors.	

Why Real Change is Needed
Place	Issue/Comment	
P2.6 Figure 2.4	Given the extreme paucity of suitable housing for PWD, may I suggest a complementary diagram showing the proportion of housing stock that is suitable to the needs of PWD? For example:

From: Carnemolla, P. & Bridge, C. (2011). Home Modifications and their impact on waged care substitution. Home Modification Information Clearinghouse, University of New South Wales. Available from www.homemods.info	
P2.19
Underfunding in one area shifts costs to another	This phenomenon is well known and the evidence-based research being undertaken by HMinfo includes the gathering of anecdotal evidence from home modification services and allied health practitioners.
Further underfunding can also lead to the purchase and use of short-term solutions, such as increased personal care, which can become permanent and lead to loss of self-care skills and reduced independence. 	

Who is the NDIS for?
Place	Issue/Comment	
P3.1 Key Points	Please note that PWD who with home modifications could be completely, or substantially more, independent should be a high priority for the NDIS.	
P3.13 Capturing the gains from early intervention	HMinfo endorses the necessity of taking an early intervention approach and would urge the productivity Commission to recognise the value of one-off early interventions, which are as effective as home modifications in maintaining/enhancing independence and reducing ongoing care costs.	
Supports
Place	Issue/Comment	
P4.3 Box 4.1	HMinfo notes that home modifications are included in supports that could be provided under the NDIS. However, it may also be appropriate to look at supports to assist PWD/families moving to more appropriate housing, as in some cases this may be more cost effective than modifying their present home, which in some cases is not possible.	
P4.5 Specialised Housing	As noted above, there is very little housing available that meets even basic universal design principles, let alone the more specialised needs of people with higher levels of disability. It will be many generations before the bulk of housing stock is updated – and even then most of it is unlikely to be accessible as current planning systems to not consider this a priority for private housing. 
Therefore an education campaign is required to encourage people to look at this issue when buying or renovating, not just relying on social housing to provide accessible/adaptable housing. This would be particularly important where people were cashing out benefits to put towards appropriate housing. In addition, a handbook for PWD and their families, along the lines of the “Guidelines for the Development of Design Standards for Group Homes” already developed, would be most useful in supporting families and PWD in making housing decisions.
Although the draft Report on Caring for Older Australians makes the key point that “Universal design standards are increasingly being applied to new private and social housing”, these changes will have little impact on the capacity of PWD and their families to live more independently without specialised housing or home modifications, as the vast majority of current houses and communities were not designed to support any level of disability. 
In this section it should also be noted that many PWD live in boarding houses, both licensed and unlicensed. This is a viable accommodation option for many PWD, particularly those who cannot sustain a normal tenancy and are therefore at risk of homelessness. This accommodation option needs to be included in the Productivity Commission’s considerations. Boarding houses, as businesses, could provide greater accessibility through minor changes to local government planning codes as they are semi-public buildings.	
P4.10 Additional costs of everyday living	As noted above, judicious modifications to a house can reduce power needs for heating and cooling. This can also be applied to sound proofing and internal fit outs for safety.	
P4.15 Public Housing	HMinfo is well aware of the desperate shortage of public housing, especially for those with special needs. However, if tax incentives for investment in housing were reconsidered so that, for example, negative gearing was only available for housing that was built to universal design standards, then additional investment could be encouraged.	
P4.29 
Box 4.6	HMinfo considers the parameters used by LTCS to identify when a home modification is ‘reasonable and necessary’ to be sound. However, it is suggested that in considering the trade-offs between whether to invest in home modifications or not, additional factors need to be considered, such as:
•	The risk of injury to PWD, carers/care workers if the modifications are not done
•	The alternate/additional costs of care, over the timeframe in which those supports are likely to be required, if the home modifications are not done. 
•	The availability and cost of AT and their associated training, which would have the same effect as the home modifications, but at a lesser cost with no loss of independence or self-care skills
•	The costs of moving to appropriate accommodation, which requires no or substantially less modification, in the same community.	
P4.33 
Co-payments	HMinfo agrees with the productivity Commission’s view that most PWD and their families would not have the means to pay for substantial home modifications. In this context, home modifications, when that is the most enabling option, are best considered as an early intervention strategy to maintain/build maximum independence and reduce ongoing care costs and risks to carers. As such, home modifications would form part of the support package developed for a PWD and their family with appropriate safeguards to protect public investment.	
Assessment
Place	Issue/Comment	
P 5.6 Figure 5.1 and following text	The figure refers to the ICF and the following text to the WHO Disability Assessment Schedule. However, neither of these considers the role that the home and community environment can contribute to creating or maintaining disability. For example, the WHODAS 2.0 36 item, self-administered assessment tool has no questions or response options across any domain about whether the person would be more independent in a more enabling environment. For example:
•	‘Getting Around’ – does not ask if the reason the person cannot move around inside their home is because they cannot manage stairs or because they cannot move; nor does it distinguish between people who cannot get out of the their home because they need a ramp, and those who cannot get out because they cannot move around independently even with assistance.
•	‘Self-care’ does not distinguish between those who could wash themselves in a hobless shower with a shower seat and hand shower and those who always need assistance to wash themselves.
•	‘Life activities’ does not distinguish between those who cannot do their household tasks, such as vacuuming, because they cannot manage a vacuum cleaner, and those with a house with an internal layout which has no stairs and so could use one of the new robot vacuum cleaners to do it for them. 
•	‘Participation in society’ does not distinguish between those who are capable of participating in society but cannot due to environmental constraints such as no footpaths with kerb ramps or no accessible transport, cinemas or shops.
For this reason, HMinfo considers it urgent that an environmental assessment tool is developed to ensure that all PWD who need support are assessed in the context of their home and community environment, so as to identify how to enable them to the maximum before allocating ongoing support services.	
P5.16 Table 5.1	It is surprising that this table does not include the evidence-based and well-accepted functional assessment tools already in use in Australia, such as the ACCNA, ONI and CENA. These tools or near relations of them are used across Australia to assess people with a disability, and their carers (CENA), for HACC services. They do not include an environmental assessment domain or response option, but are robust with respect to identifying care needs and have successfully moved away from diagnostic approaches to classifying disability and identifying need. In addition, some of the ‘assessment’ tools cited are not assessment tools, but costing tools e.g. SNAP. These are not the same thing.
Only one of the assessment tools listed, D-START, covers ‘environmental factors’.  In reviewing D-Start, HMinfo notes that ....
There are very few assessment tools, which include appropriate elements to identify or assess the enabling/disabling effect of the client’s environment.  This means that simple home modifications, such as the installation of grabrails which would enable the client to self-care, may not be considered until after the care plan is developed and the initial home visit is undertaken by the service provider for the OH&S assessment of the workplace for their care workers. 
Research into the use of home modifications to reduce/replace waged care services  has indicated that it is essential that assessment for the potential for enabling home modifications be carried out prior to allocating ongoing care needs as, in some cases, they may replace or defer the need for care services, particularly personal care.
There is also a poor understanding of the interaction of home modifications and assistive technologies (AT). Where either could assist the client, home modifications are preferable for chronic ongoing conditions, but not suitable for short-term, rapidly deteriorating or palliative conditions. However, due to long waiting lists or lack of access to AT or home modifications (including choices being made on the basis of who pays for which), the two are often used as inappropriate substitutions for each other. There is little policy/practice guidance available to practitioners/assessors on what these trade-offs are and which option is preferred in any particular instance.
There are a number of different ways that people access home modification services. In NSW alone these include:
•	Through a hospital or community based occupational therapist (OT)
•	Through referral from another community care service
•	Direct or self referral to a HACC Home Modification service
•	Through the Department of Veterans Affairs HomeFront service
•	Through NSW Lifetime Care and Support Authority
•	Through the Disability Services Program, insurance companies, Workcover etc.
Each pathway may have different guidelines and funding conditions, which may be differently interpreted and applied. This directly affects how large items of technology e.g. lifts, ceiling hoists and major bathroom modifications, are funded and supplied.
In addition, it needs to be acknowledged that inappropriate prescriptions or poorly installed home modifications have the capacity to cause injury. The Australian Standards cannot be relied upon to ensure appropriate prescription/installation. This was exemplified in research conducted into grabrails, which found that, with respect to grabrails, AS 1428.1 is a poor guide to the needs of individuals in a domestic setting as optimal design is needed to accommodate individual difference. They noted that:
“Appropriate prescription and design of a grabrail affects successful outcomes. Successful use of a grabrail is achieved when the individual has completed the given activity in a safe and dignified manner. This includes minimising the risk of secondary disability due to falls or overuse injuries”
Current home modification services are also primarily geared around the trades involved, rather than the balance of home modification and care services for an individual. This means that aesthetics, emotions, capacity for enablement or reablement, and alternative solutions are usually not considered in the assessment/prescription phase e.g. landscape solutions such as earth-berming and bridging rather than installing institutional-looking ramps, which may decrease the value of the client’s home, and may also increase their vulnerability by publicising it. Consequently, clients have been known to reject home modifications which fail to appropriate consider good design and aesthetic. Additional research and evidence and the involvement of committed architects is required to build a portfolio of solutions which meet self-care needs, cost constraints and aesthetics.
Ideally, all PWD who need any level of personal assistance, including children, would receive an in-home environmental assessment at their initial intake to identify opportunities to support self-care or reduce ongoing formal care needs, as well as any needs of the carer, prior to their care plan being finalised. For children with disabilities and people with rapidly deteriorating conditions, there would be a need for regular updates of their environmental assessment as their functional capacities changed.
A hypothetical layering for assessment and advice to replace/reduce ongoing care costs could comprise:
1.	Low level client – has low vision and limited gross motor skills and cannot prepare food:
•	Recommend purchase by client of microwave and press-to-pour boiling water jug so that client can make cups of tea and reheat pre-prepared meals. Supplement with weekly outings to a local club with friends. Result: no need for assistance with food preparation and client remains independent and self-caring.
2.	Medium level client – has mobility impairment and cannot stand in shower or step over bath
•	Recommend removal of shower hob, installation of grab rails around shower and toilet and shower chair. Result: No need for personal care assistance and client remains independent and self-caring with increased privacy.
3.	High level client with cerebral palsy – cannot transfer without assistance, which prevents self care in bathing, toileting etc.
•	Recommend reinforcement of ceilings in bedroom and adjacent bathroom to enable installation of travelling hoist; modify shower/toilet access to enable a single care worker (instead of two) to provide personal care. Result: reduced ongoing cost of care as only one personal care worker is required and carer does not sustain injury trying to lift client.
Please note that an internet search for D-START shows that it is also a “New IDF [International Diabetes Federation] initiative to support the development of projects in low- and middle-income countries (LMCs) which have less exposure to international funding.” It may be worthwhile to clarify in the final Report, which D-Start is being referred to.	
P5.21
When should assessments occur?	It is important that at each assessment and re-assessment, the environmental assessment is updated. This is because:
•	the ‘fit’ of the PWD, particularly a child with a disability, to their home and community will change over time; and 
•	new technologies may come on the market and may have the potential to increase independence and/or reduce ongoing care costs. The home modifications appropriate to a child with a disability are unlikely to remain appropriate as they mature, acquire new skills and seek greater independence.	
P5.21
When should assessments occur?	It is particularly important to note that children with disabilities require a very different approach to assessment than that for adult PWD.
Due to their rapid growth rate, and the now acknowledged phenomenon of brain plasticity, it is very difficult to make accurate functional prognoses of a child’s functional capacities into the near or distant future. There is a body of literature specific to the needs of children with disabilities. Some key references are available from the HMinfo at www.homemods.info and include:
•	an annotated list of resources on home modifications for children with disabilities at http://www.homemods.info/design_for_children
•	a paper on anthropometric measurements for children with disabilities at http://www.homemods.info/resource/occasional/considerations_for_using_anthropometrics_to_determine_modifications_for_children
•	a summary bulletin on assessing and prescribing home modifications within Australian Standards that take into account a child’s growth at http://www.homemods.info/resource/occasional/summary_bulletin_home_modification_and_childrens_growth
There are also issues with the timely and appropriate prescription of AT for children to enable them to interact with their environment as part of their normal development. For example, it has been standard practice that children who need wheelchairs permanently are not provided with electric wheelchairs until they are five years old. Recent research indicates that this is too late to facilitate the appropriate brain development for interacting with their environment. Ideally, children who need wheelchairs would be provided with an electric wheelchair at the age when they would otherwise have been crawling and learning to walk to optimise the normal wiring of their brain. This means they would also need to live in a home suitable for a young wheelchair user.	
P5.22
Shifting the emphasis towards wellness	HMinfo supports the move towards a wellness approach to providing support to PWD. However, because home modifications and AT have the capacity to enhance independence and minimise ongoing care costs, they should always be considered as part of any wellness approach.	
P5.23
Should carers have their own assessment?	HMinfo supports carers having their own assessment – not only for any support needs they may have as carers in terms of counselling and support, but also with respect to identifying home modifications or AT which could assist them in their caring role and minimise the risk of injury to them.	
P5.25
What to expect	The proposed ‘early planning and information package’ needs to include information on how home modifications or AT can assist. This would be an appropriate means of disseminating the suggested handbook to assist PWD and their families to choose/modify or purchase appropriate housing.	
P5.26
Figure 5.2	This diagram does not indicate at which stage environmental assessment of the home or community of the PWD would be undertaken. Although some information about the environment of the PWD could be obtained at “Person (or their carer or family member) fills in a self report questionnaire....”, may I suggest that there are two possible points in the assessment process where the environmental assessment could be carried out: “Case manager visits the person to better understand their circumstances” or “A meeting between the person, their carer and a trained assessor to assess needs”.	
P5.28
The transition to a fully fledged assessment toolbox	As noted previously, HMinfo is of the view that none of the current assessment tools is adequate for assessing home and community environments and their interaction with supporting independence, self-care and community participation.
HMinfo has identified some of the core elements of such an assessment tool as part of its work on waged care substitution and would be able to fully develop such a tool if funds were available.	
P5.29
Recommendation 5.2	May I suggest an additional source be added to the first dot point after “current medical information...”:
-	information about the person’s home and local community environment and the extent to which it is enabling or disabling for them 	
P5.28
Recommendation 5.4	There may be a need to identify and/or train specialist OT assessors for environmental assessments due to the workforce issues as expanded on below in the relevant section.	
Who has the decision-making power?
Place	Issue/Comment	
P6.1 Key points	It would appear that expenditure on home modifications will not be included in self-directed funding, as home modifications are an early intervention strategy, required specialist knowledge and is usually non-recurrent expenditure. This should perhaps be clarified.	
P6.5 
Figure 6.1	This figure does not include home modifications or their service providers.	
P6.15
Table 6.2	This table clearly shows that where PWD and their families use self-directed care, they expend on home modifications and AT with measurable improvements to themselves.	
P6.25
Step 3...	The third dot point notes that home modifications would be one of the items where spending flexibility would be typically constrained. HMinfo supports this as it is essential that home modifications be specific to each PWD, assessed and prescribed by a relevantly qualified practitioner, and implemented by tradesmen with relevant experience and knowledge. 	
P6.49 
Recommendation 6.10 	There is a need to ensure that the issue of home modifications is raised in a taxation context. The costs of prescribed home modifications ought to be either funded as part of a disability support package, or, if funded privately, be tax deductible by the PWD, or their family where the family has paid for them. This is especially important where the PWD or their family have the means to pay for the modifications and thus reduce demand on public monies.
The same issue needs to be raised with respect to early release of superannuation funds.	
Governance and structure
Place	Issue/Comment	
P7.17
Figure 7.2	The list of ‘Functions controlled outside the national Disability Insurance Authority’ needs to include ‘Other non-government providers’ e.g. home modification providers, most of whom are HACC-funded NGOs. This could be added below ‘Disability providers’. In the future, mainstream private providers may include trained tradesmen and builders who are able to offer these services.	
P7.139
Complaints and dispute resolution	The intersection with the Building Codes of Australia and state and local government planning and building regulations with respect to home modifications needs to be acknowledged. Many of the complaints over the years regarding the quality of home modifications have related to breaches of those codes/regulations, rather than non-compliance with the HACC or Disability Standards. Other sources of complaint have included inappropriate prescription by the OT. In those cases, the relevant health complaints body or professional association has handled the complaints. These intersections need to be articulated.	
P7.53
Quality assessment	This is a particularly contentious area for home modifications. The need for a multi-disciplinary team of client, OT, builder and often multiple tradesmen, and sometimes an architect, make for a complicated project. Ensuring that all professional participants are appropriately qualified and experienced with respect to assessing, prescribing, designing and building/installing home modifications is not easy. The qualifications required are very different and none of the relevant undergraduate courses for these professions in Australia currently have appropriate core units on home modifications or inclusive design practices.	
Delivering Disability Services
Place	Issue/Comment	
P8.5
Disability Support Services	The current Disability Services program, at least in NSW, makes no allowance for home modifications per se. Nor are home modifications included in the normal service suite on offer from any individual service provider as those costs are not usually included in block funding to DSOs. The existing DSOs have very limited experience of home modifications since most of them have traditionally provided care in large institutions or specially built group homes.
However, this means that the disability service system, unlike the HACC service system, has not invested in any infrastructure for home modifications and has relied on the HACC program to build and maintain that infrastructure, and, in many cases, to provide the services. The HACC home modification and maintenance services (HMMS) infrastructure is also used by other programs such as DVA’s Veterans Home Care and NSW Lifetime Care and Support to deliver their home modifications and maintenance services.
With the proposed changes to the aged care system, there is uncertainty as to the range and scope of this infrastructure in the future. Therefore, this report needs to consider the intersection of the disability services system with the HMMS part of the HACC system so as to assist the Productivity Commission in deciding whether and to what extent it should be block funded during the transition phases for both the aged care and disability systems, at least in the short term.	
P8.13
Providing information portals to consumers	HMinfo proposes that where information portals are already established, such HMinfo and the ILCNSW AT database, that those portals be enhanced for consumer use and linked into any disability information portal; rather than duplicated. Assessors and consumers both need access to timely, evidence based information on home modification options and AT and these are specialist areas best supported by an applied research function as both are in a period of rapid technological development.	
P8.25
Box 8.7	HMinfo notes that although they have served us well, the Disability Standards are now out-dated. They do not reflect the person-centred, consumer directed and enabling approach that is now part of public policy and consumer expectation.
HMinfo would propose that the Standards be redrafted with a focus on outcomes of independence and self care as a priority, with timely interventions to support these being the basis of service, especially through different life stages.	
P8.29
The role of standards	This section needs to note that many aspects of service will need to comply with other standards e.g. allied health with health/professional standards, builders and tradesmen with building standards, industrial and OH&S standards for staff etc.
Breaches of those other standards should also be considered with respect to remaining on a list of approved providers of NDIS-funded services.	
P8.39
Table 8.1	There are no indicators shown for evaluating one-off services, such as home modifications or AT. These can be evaluated by asking consumers about whether they were used or made a difference – and if not why not. Failures of prescription e.g. toilet not accessible from the side for carer to assist, or implementation e.g. bathroom leaks, need to be followed up separately.	
Indigenous disability
Place	Issue/Comment	
P9.16
Box 9.1	HMinfo is aware of the high rates of disability and illness in indigenous communities. For this reason, HMinfo is of the view that all Aboriginal community housing should be built to the platinum standard outlined in the Livable Housing Design Guidelines.  This would minimise disabling environmental effects on indigenous PWD and, potentially, the costs of home modifications.	
Collecting and using data
Place	Issue/Comment	
P10.21	HMinfo notes the paucity of data on home modifications. HMinfo has provided in the past MDS data analysis services to ADHC for HACC MDS data. HMinfo has the knowledge and skills to develop appropriate data items relating to home modifications and AT for a new Disability MDS. In particular, data is required not just on cost per job, as is collected in the current HACC MDS, but on the nature of the modification and the projected and actual outcome for the client. This could enable estimations of the putative cost savings from reduced formal care services.	
P10.28
‘cost effectiveness analysis’	HMinfo is uniquely positioned to continue to provide a well-researched evidence base for home modifications. The HMinfo website, www.homemods.info, already provides access to evidence around the effectiveness of different interventions. This function should be expanded to focus on areas where there are indications of potential for significant cost savings, as identified in recent HMinfo research.	
Early intervention
Place	Issue/Comment	
P11.1
Key points	It is important to note that early interventions are not just for children but for all people with a newly identified significant disability.
In addition, home modifications, AT and other one-off interventions must be a routine part of early intervention, as they have the capacity to increase/maintain self-care skills and community participation, reduce the need for ongoing care services, facilitate normal development in children and rehabilitation in adults with disabilities, and reduce the risks of carer injury and burden.
The concept of early intervention also needs to recognise that it may occur more than once, as different life stages will require different early interventions. This is particularly so for children with disabilities and adults with rapidly deteriorating conditions.	
P11.12
Box 11.4	It is suggested that an example of how home modifications enable self-care and independence is also included here. Suitable, de-identified, case studies are included in the HMinfo paper on waged care substitution.	
P11.19
Table 11.1	There is a growing body of literature on the economic impacts of timely and effective home and environmental modifications. However, this is an area that requires more strategic research and analysis, which HMinfo could undertake if funded to do so. In addition, separate research needs to be funded on the long term cost benefits, both economic and social, of environmental interventions for children with disabilities.	
P11.24
Interventions outside the NDIS	Disability friendly housing options are one of the core interventions outside the NDIS, which would have a direct and significant impact on providing enabling or disabling environments for PWD.
The current initiative to increase the supply of social housing, which is accessible and based on universal design principles, is laudable. However, it does nothing to address the core issue that almost all private and public housing and communities in Australia have no capacity to support people with any but the mildest level of disability.
Typical Australian houses have at least several front steps, narrow halls and doorways and inaccessible bathrooms. Typical Australian communities have inaccessible shops, buses, trains and, often, poorly designed and maintained, or even no, footpaths. This is well illustrated in communities with a high number of motorised scooter users by those who divert along the roadway until they find a kerb ramp and can get back on the footpath.
New housing construction in Australia has remained relatively stable for many years at only a relatively small percentage change in overall housing stock. Indeed, changes in housing stock occur gradually over time through construction of new dwellings and alterations to existing homes. For instance, in the nine years from 1994–95 to 2003–04 an estimated 1.5 million new dwellings were completed in Australia (an average of 146,000 per year). These additional dwellings represent less than one-fifth (19%) of the 7.7 million households in 2003–04, the same statistics underscore the trend to larger buildings with fewer occupants.  
While PWD who live in public or community housing have access to modified or accessible housing, those who live in private rental or privately owned housing do not. Private owners can modify their homes, but often do not have the funds to do so or leave it too late, e.g. after the carer has injured themselves. Private renters have less choice and, if older, are more likely to be admitted to residential care. Even if a PWD or their family were to sell their home to move to more suitable premises, there is a dearth of accommodation, which is suitable and available in any community. For example, new apartments may have accessible common areas, but the internal layout is not required to be accessible. In addition, the costs and the challenges of dealing with an Owners Corporation and local council to undertake any necessary modifications would be overwhelming for most people. In the absence of mandated requirements for private housing to be accessible to some extent, then home modifications will remain an essential part of supporting PWD to live in their community.	
Financing
Place	Issue/Comment	
P12.15
Box 12.1	These views only relate to ongoing care costs. There are none about how one-off interventions, such as home modifications and AT would be funded. It would be helpful if views relating to one-off costs were also included.	
Workforce issues
Place	Issue/Comment	
P13.11	There are significant issues of workforce with respect to Occupational Therapists (OTs), the main assessors for home modifications. These include universities not having sufficient places to meet demand, and the move from a four-year undergraduate qualification to a two year postgraduate one. Consequently, new practitioners graduating from Allied Heath courses are poorly equipped to understand and complete on behalf of their clients the many systems and forms which are required for effective assessment and prescription of home modifications. This leads to service gaps and inconsistencies. 
Also, with the move to training on home modifications being provided at post-graduate level, rather than undergraduate level, most undergraduates would not have received sufficient training in this area and there is insufficient time now allowed in their courses for it to be acquired. Given the grave shortage of allied health workers generally, and OTs in particular, their motivation to undertake post-graduate courses would be limited. As trained problem solvers, OTs are also in demand as assessors, case managers and managers. This means that there is constant leakage of OT skills out of OT practice.
There is also a shortage of skilled tradesmen and architects who have knowledge and experience of home modifications and accessible housing and of working with the OT and client in partnership.
While some organisations e.g. the Independent living Centre NSW offer competency-based training for tradesmen in this area, the uptake is low as there is no incentive for tradesmen to acquire new skills when there is no shortage of work.
Therefore, HMinfo would recommend that initially there would be a need to work with relevant universities and VETAB to identify the core units for each of the relevant courses. Incentives could then be provided to encourage the professionals to attain the required qualifications or competencies or have their existing experience/skills recognised as equivalent. Incentives could include paying HECS or course fees and/or automatic inclusion on a register of approved providers for those services.	
P13.31
Training for carers	HMinfo endorses the need for carers to receive training. This is especially required for their use of AT as well as optimising the outcomes from any home modifications. This is why an assessment of the carer’s need should be part of each intake and review assessment, including the environmental assessment. The economic costs to the community of not supporting carers have been well documented.	
P13.45
Specialist staff	See comments above on workforce and training issues for OTs, tradesmen and architects.	
Costs of the scheme
Place	Issue/Comment	
P14.17
Box 14.1	Although the costs of home modifications have been annualised in this example from DIG, the savings have not. Is it possible to identify the savings in ongoing care? Or would care at home have not been possible without the modifications? If that were the case, then the alternate residential care costs would form a basis of comparison.	
P14.20
Table 14.13	It is worth noting that the number of people who have their dwelling modified could be expected to rise if environmental assessments were included in all early intervention and initial intake assessments. However, ideally the offsetting savings to ongoing care costs, or the costs of alternate institutional/group home care, could be quantified.
In addition, for children, there would potentially be multiple home modifications as they grow and their needs change and when leaving home as adults. The community investment in home modifications at that transition stage would be substantially reduced if all public and community housing incorporated the platinum standard set out in the Livable Housing Design Guidelines produced by FAHCSIA and ANUHD.	
P14.21
Table 14.14	The amortisation of home modification costs over a period of ten years is realistic. This will assist in clarifying the situation for PWD, especially children, who require more than one home modification as their needs change.	
Implementation
Place	Issue/Comment	
P17.6
‘assessment toolbox’	HMinfo agrees that development of the assessment toolbox is a high priority for implementation. HMinfo would like to propose that HMinfo be commissioned to undertake the development of an Environmental Assessment Tool, based on evidence and designed to work within the Building Code of Australia and the Australian cultural contexts, including for indigenous and remote communities.
HMinfo would also like to contribute to a data dictionary of common terms around environmental assessment and home modification, as well as AT.	
 Conclusion:
The strengths of the draft Report would be enhanced by consideration of the issues raised in this submission. In particular, that:
•	the majority of people with a disability live, and will continue to live, in housing that is not designed to support any but the mildest level of disability;
•	the economic benefits of promoting self care supported by appropriate home modifications or housing choice, and thus minimising ongoing formal (waged) care, is the preferred policy setting for supporting the independence of people with a disability;
•	the potential cost savings of delaying or reducing ongoing care costs through the identification of appropriate home modifications are significant;
•	the recognition that assessment for the potential for home modifications to reduce care costs is an early intervention service and required at the initial assessment and care planning stage for all people with a disability that requires ongoing assistance;
•	in the case of children, recognition that environmental assessments and outcomes need to be reassessed at key stages in order to support their development and interaction with their environment;
•	the recognition that there is a shortage of appropriately qualified allied health professionals to identify and prescribe home modifications; and
•	recognition that the use of home modifications and AT intersect across the health, aged care and disability service systems and that restriction in one area can lead to inappropriate use of the other e.g. delays in discharge, or purchase of assistive technologies to compensate for a disabling home environment.
Please contact me if you have any queries or would like more information about any of the points that I have raised. I would like to thank you for the opportunity to comment on this draft Report and look forward to your final Report and the implementation of the proposed new care models.

Yours sincerely

Dr Catherine Bridge.
Associate Professor Faculty of the Built Environment
CityFutures Research Centre at UNSW