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7.4 Approving and Reviewing Household Services decisions
Determinations for household services
For MRCA clients, a determination to pay compensation for household services is made under section 214 of MRCA using the criteria specified in section 215. Consistent with the consideration and determination process specified under section 333 of MRCA, the determination must be made in writing, after all matters relevant to the claim have been considered.
For SRCA clients, a determination to pay compensation for household services is made under subsection 29(2) of SRCA and must be made in writing. SRCA clients with eligibility under the 1930 Act or 1971 Act may be assessed for household services through section 124(5) of the SRCA. Their eligibility applies from 1 December 1988 (through the transitional provisions), which is the date of the commencement of the SRCA.
A determination to approve or deny compensation for household services may be made by a delegate of the MRCC at the APS 5 level or above.
In all cases, a formal determination must be sent to the client whenever a decision is made to approve or extend a household services approval for a short time, or reject the claim. The determination letter must address all matters relevant to the claim and clearly explain the reasons for the determination and the issues that have been considered. Issues that must be considered are outlined in section 7.2 of this Guide.
The determination provides the legislative authority for services to be paid. Without a current determination in place, invoices for services cannot be legally paid.
A determination to approve or deny compensation for household services is a reviewable decision and clients must be provided with their appeal rights in the determination letter.
It is mandatory that R&C ISH standard letters are used when communicating with clients about their household services. Letters generated from R&C ISH will automatically attach to the client’s UIN folder in TRIM.
Approved period for household services
Delegates should not make open-ended determinations for the provision of household services and all determinations must have a start date and an end date. This also applies if the determination is approving the continuation of services for a short period of time while, for example, an assessment is conducted by an Occupational Therapist (OT) as part of the review process. The Rehabilitation Coordinator must provide a rationale for the length of the approval by creating a case note in the client’s R&C ISH services claim.
Generally, household services are approved for a maximum of one year. However, Rehabilitation Coordinators are expected to take a client-centric, whole-of-person approach and ensure that the approval period is appropriate to the client’s individual circumstances. Issues that should be taken into consideration include the nature and complexity of the service injury(ies) or disease, whether the client’s needs are ongoing or likely to change, the client’s home and family circumstances and whether there are additional stressors in the household due to the nature of the client’s accepted conditions.
Where a Rehabilitation Coordinator is satisfied that a person has an ongoing incapacitating condition/s that significantly impairs their ability to manage household tasks that are required for the proper running and maintenance of their household, then the household services approval period may be granted for a longer period of time, not exceeding five years. For example, if a client has accepted conditions that are severe, such as paraplegia, traumatic brain injury, or other similar conditions, a longer approval period is considered acceptable given it is not likely that the client’s conditions will improve over time. If there is evidence that the client’s circumstances have not changed in any way, there is no need for an ADL assessment to be conducted each year, however an ADL assessment must be conducted by an OT at least every five years, to ensure that the Rehabilitation Coordinator has an understanding of the client’s current needs and circumstances.
Periodic, but irregular services, such as pool cleaning, must also be included in the approval determination. For example, a client may be able to manage pool cleaning themselves using a creepy crawly however, at times the chemicals in the pool may become unbalanced and the pool becomes unsafe to swim in. In such a case, the pool cleaning approval must document the frequency of the service and the cost of each service. For example, “pool cleaning is approved up to 3 times per year, at a cost of $ per service”. This prevents the client from having to submit quotes each time the pool cleaning is required.
Approved hours and amounts for household services
It is mandatory that R&C ISH standard letters are used when communicating with clients about their household services. Using these letters will also ensure the hours and amounts for household services are appropriately communicated to clients.
Approved hours and amounts for household services must be based on evidence from the household services assessment, and/or information from the client’s treating health professional and/or the client’s rehabilitation provider. Reviewing evidence from all sources will ensure that a whole-of-person approach is utilised.
Where a client is residing in a rural or remote location, and there are a limited number of providers in their location, it is likely that a service provider may need to travel some distance in order to deliver household services to the client. In these cases, it is entirely reasonable for providers to include travel costs in their quotes and clients should not be disadvantaged because of their location. It is the role of the Rehabilitation Coordinator to determine whether these quotes are reasonable and to ensure that any approval of services are within the statutory limit. The Claiming Travel Expenses Under the MRCA and SRCA factsheet provides information on the travel for treatment rates.
Rehabilitation Coordinators must not approve household services in excess of the legislated statutory limits. Details of the maximum limits are available in the current payment rates chart in the CLIK Compensation and Support reference library. The MRCA limit is listed on the MRCA Rates and Allowances page. The SRCA limit is listed on the SRCA and Defence Act payments page.
Where there are difficulties in meeting a client's household service needs within the statutory limits, and the client's conditions are such that they are likely to also require nursing care and attendant care services, Rehabilitation Coordinators must contact the Community Nursing Program with a ‘cc’ to the Rehabilitation Policy Team to discuss the need for an assessment. A Clinical Nurse Consultant recommended by DVA's Community Nursing Program will be utilised to conduct a detailed assessment of the person's needs and make recommendations about the type and level of services that they require. This will ensure that an appropriate level of services can be provided to meet the client's assessed needs, in line with the legislation and the Department's usual contractual arrangements.
Renewing household services
Rehabilitation Coordinators are expected to ensure that the determination letter approving household services clearly communicates:
- the date when the determination expires;
- the client’s responsibility to contact the Department in plenty of time if they require household services after the expiry date; and
- that any invoices received after the expiry date cannot be paid by the Department, and will be the financial responsibility of the client.
Clients have the responsibility for managing their household services including renewing services before the approval period expires, returning claim forms on time and liaising with providers. This approach is to encourage self-management as much as possible. However, clients must be provided with every opportunity to renew their services prior to the end of the approval period. Rehabilitation Coordinators will be prompted by R&C ISH to provide clients with renewal forms, at least one month prior to expiration of the current determination.
Further information about managing the renewal of household services can be found in chapter 7 of the Rehabilitation Procedures Guide.
If a client is not provided with information about renewing their services prior to the end of the approval period and the Rehabilitation Coordinator is aware that they are likely to continue to require household services, an interim determination will need to be drafted. The determination provides the legislative authority for services to be paid and without a current determination in place, invoices for services cannot be legally paid. An interim determination will enable services to be provided for a specified period, until the client is able to return the renewal forms.
Proactive case management is required to ensure that a client is not sent information about renewing services unnecessarily, if they have already contacted the Department themselves to activate the approval process. R&C ISH processing is expected to assist with managing household services cases.
A delegate has the discretion to request another OT assessment as part of the renewal process. However, another OT assessment is not always required and Rehabilitation Coordinators are expected to use a sensible risk management approach to determining whether the client’s needs or living situation are likely to have changed since the last approval period. Delegates may wish to seek the advice of one of the Department’s OT Advisors, when considering whether an OT assessment is required. However, an assessment by an OT must be conducted at least every five years, to ensure that the Rehabilitation Coordinator has an understanding of the client’s current needs and circumstances
Please refer to section 7.3 of the Rehabilitation Policy Library for further information about valude for money with household services.
Reviewing household services
The ongoing requirement for provision of household services should be monitored and regularly reviewed according to the circumstances of each case, to ensure the Rehabilitation Coordinator has a good understanding of the client’s needs.
In some circumstances, it may be necessary to review a person's need for household services during the approval period (e.g. 6 months into a 12 month approved period). This may occur, for example, where a client requests an increase in services due to the worsening of their accepted condition. In these situations, it will be necessary for the delegate to contact the client to ensure that the review is conducted and to request an OT assessment where necessary.
For those circumstances where a longer approval period has been granted because the person is seriously incapacitated, issues may still arise that make it necessary to review the person’s circumstances during the approval period. For example, if the person’s children, who were undertaking certain household tasks move out of home, the person may require an increase in services and a review including requesting an OT assessment where necessary, will need to be conducted.
Where the person is also in receipt of compensation for incapacity or attendant care services delegates should, wherever possible, align these reviews so they can all be undertaken at the same time. As part of the incapacity review process, medical reports or certificates are required from the client’s treating specialist. For the purpose of reviewing household services, if a medical report has been obtained by the incapacity delegate, this can be used by the rehabilitation delegate as part of the household services review. If there is sufficient information in the medical report to satisfy the delegate that the client has an ongoing need for household services, a further assessment by an OT may not be required.
Where clients have high care needs, Rehabilitation Coordinators may need to liaise with the rehabilitation policy section, to consider whether this review may be able to be done as a file review without the need to contact the person, or if the assessment should be done in conjunction with another area within DVA such as Community Nursing or VHC. This decision to undertake a joint assessment will be based on the individual circumstances of the client, and the range of services they are receiving through DVA.
Decision to cease or reduce household services
A person should be given at least 28 days' notice of any intention to reduce or cease the level of household services approved so that they have a fair opportunity to provide further evidence in support of their claim or discuss the change in circumstances.
Where the delegate intends to cease services on notification of a person's death or if the person no longer requires the services (e.g. the person may have been relocated to a full-time care situation because of a change in health circumstances), it is considered reasonable to continue to provide the services approved for 12 weeks to assist the spouse or family of the eligible person. This extended approval is critical for the spouse or family of the person to consider and organise cancellation of services or make alternative arrangements.
Decisions to pay compensation for household services must be based on the merits of each individual case and must be based on clear evidence of the person's need as a result of their accepted service related injuries. It is expected that delegates will always take a whole-of-person, client-centric approach when considering whether it is reasonable to reduce or cease services.
Rehabilitation and the National Disability Insurance Scheme (NDIS)
Household services can be provided by both DVA, through the rehabilitation plan, or by the NDIS, through an individual care plan, as long as the same household service is not provided by both NDIS and DVA. Therefore, it is important to advise Occupational Therapists undertaking assessments for household services that they should discuss with the client whether they are receiving anything from the NDIS. These providers should also be asked to notate in their report that the client has been made aware that they cannot ‘double dip’ for these services.