Support for all people with disability to better navigate mainstream and disability supports

Finding the right supports can be complex, costly and time consuming
There are issues with the implementation of the Partners in the Community program
Support coordination is not available consistently and not proportional to need
The Complex Support Needs Pathway is not meeting the specialised needs of some participants
The Panel’s vision: The Panel’s vision: Proactive navigation support is needed for all people with disability
Recommendation 4: Support all people with disability to navigate mainstream, foundational and NDIS service systems

Finding the right supports can be complex, costly and time consuming

We have heard about the complexity people with disability and their families face navigating poorly integrated service systems every day. This includes services across different levels of government and different departments and programs.

Complexity acts as a barrier to social and economic participation. Despite being highlighted multiple times by previous reviews and inquiries, change has been slow, complexity persists and little help has been provided to help people navigate the system.⁹⁴

Most people with disability have multiple interactions with other government service systems. Participants and providers alike find the interfaces between the NDIS and other systems confusing.

The NDIS currently has multiple functions to help participants navigate in and outside the NDIS. However, these roles are split, and sometimes unintentionally duplicated, across Partners in the Community, Support Coordinators, Specialist Support Coordinators and Community Connectors, as well as Plan Managers. National Disability Insurance Agency (NDIA) Health and Justice Liaison Officers also play a role working with hospital and correctional service systems.

I think what makes that particularly worse for the person with a disability is it's complex and there is no single service or someone that can represent their views other than an advocate to navigate those complexities. So be it, you know, NDIS and SDA, social housing, access to the private rental and those processes, so you are pretty much on your own navigating all of that, unless you get a good advocate.

– Person with disability ⁹⁵

Splitting these roles into so many pieces has added unnecessary complexity and resulted in considerable variation in the type and quality of navigation support. The level of access or availability of these functions is also inconsistent. Some participants are not funded to access Support Coordinators and Partners in the Community are constrained by significant caseloads and aren’t present in all locations. This means there is often no single point of contact to help people access supports.

Not having a consistent contact point means that I feel like I have to repeat my story on multiple occasions, and that I am just a random client, not a family and a human with a story, cause and knowledge that I bring, and a plan.

– Carer ⁹⁶

We have heard from participants and their families that additional external support is required to successfully navigate the NDIS and interfaces with other service systems.

Support Coordination isn't just an option for NDIS participants, it's a must have thing. Participants need an advocate on their side who knows the system, how to interact with providers and to book services. Not having this is wasting the NDIS's money, as participants who don't have these services are left spending their funding without guidance and are open to exploitation.

- Participant ⁹⁷

There are issues with the implementation of the Partners in the Community program

Issues with the implementation of the Partners in Community program have been raised in previous reviews.⁹⁸ We have heard the same issues from participants, families and other technical experts. Partners in the Community are community based organisations that work with the NDIA to deliver the NDIS. They include Local Area Coordinators who assist people 9 years and older and early childhood partners who assist children under the age of 9 and their families.

The Productivity Commission originally envisaged the local area coordination model as having a key role as ‘the scheme’s case managers’. Their purpose was to provide “broad services, including individual or family-focused case management and capacity building within a specified geographical area”.⁹⁹

Funding and staffing constraints in the NDIA have led to Partners in the Community being diverted from their intended role to focus almost entirely on access and planning tasks. This has left people with disability without support to implement their plans and prevented community capacity building. Very high caseloads have meant Partners in the Community spend limited time with each person. As a result, relationships have become transactional rather than relational, and people with disability are not being supported to achieve the outcomes that matter to them.

The large-scale contracting of Partners in the Community means they can often lack the deep local knowledge and disability expertise needed to provide people with support that meets their needs.

Support coordination is not available consistently and not proportional to need

Support coordination is currently funded by the NDIS to assist participants to understand their plan and make the best use of their budget, connect people to supports and build individual capacity. We have heard many participants do not receive enough help to coordinate and implement their plans effectively. Support coordination is only available to some people and there is not a consistent approach to ensure people receive support that is proportional to their needs.

"For many participants there is no, or inadequate, support coordination funding. Families and carers of participants with no, or inadequate Support Coordination funding, face difficulty navigating the complex NDIS service market." – NGO ¹⁰⁰

Decisions about the level of support coordination funding can be influenced by how well participants and their supporters - or Support Coordinators - can advocate for funding. There can also be inconsistent application of the concept of reasonable and necessary supports and unclear guidelines to determine what level of support coordination is needed.

"Many Participants who are in desperate need of support coordination funding, either receive no such funding or inadequate funding. The fact that some Participants are reluctant to use their allocated funding, due to being considered as a “burden to society” means that they might leave things until they escalate into a crisis situation. Thus ultimately needing an increase, not decrease in support coordination funding." – Person with disability ¹⁰¹

There is mixed feedback on the quality of support coordination. We have heard of some providers that are very highly valued by participants and their families, as well as other providers that are not providing support with sufficient care, skill or integrity. There is little consistency in the support coordination market and participants can experience a lottery of whether their provider or specific Support Coordinator is effective or not.

There is also strong concern about conflict of interest and client capture when providers or other NDIS services also provide support coordination to participants. This is of particular concern when participants have limited natural safeguards.

The Complex Support Needs Pathway is not meeting the specialised needs of some participants

There were approximately 10,400 participants in the NDIS on the Complex Support Needs Pathway as at June 2023.¹⁰² This pathway was designed to provide specialised assistance from the NDIA for participants who have many different challenges in their lives. These may include mental health, incarceration, homelessness, or a higher level of specialised supports required to meet their needs.

People with disability and the broader disability community have told us there are many challenges with the Complex Support Needs Pathway, including that the number of participants eligible is surprisingly low. Limitations on NDIA resources have meant that the additional support isn’t available for many participants with higher needs.

There is a support gap to help people with disability with many different challenges meet access requirements. This is because streaming to the Complex Support Needs Pathway happens after access has been granted. Those who are transitioning from hospital or justice are supported by specialist Health and Justice Liaison Officers, but this is not consistently available to support broader access requests.

These challenges are compounded by a lack of coordination between different government service systems to provide a continuum of care outside the NDIS. The people with the most complex needs generally have the most complex support arrangements and require person-centred rather than system-centred support to manage this complexity.

All people with disability should have access to a Navigator, who acts as their agent. This should be complemented by the proposed changes to foundational supports, and mainstream and community services (see Recommendations 1 and 2). This is needed to avoid people navigating to nothing, or feeling they have to keep using services that do not meet their needs.

Navigators should act on behalf of the person with disability, at their direction, and be incentivised to build capability, help the person meet their goals, facilitate choice and enable inclusion. They should not be an agent of the NDIA to ensure a separation between those who set a budget and those who help a participant to use it. They should be funded outside of individual budgets to ensure participants do not need to choose between a Navigator and other supports.

The Navigators must have realistic caseloads and be able to flex up or down as the needs of participants change. This would overcome a major challenge with individualised support coordination budgets today, which are fixed and do not change as circumstances change. Where appropriate, Navigators should operate out of locally based ‘hubs’ with other relevant services and be able to share information on support quality and opportunities for greater community inclusion.

Navigators should help all people with disability find and coordinate the support they need and achieve what is important to them. For people who will not access the NDIS, Navigators should support people to determine their own goals, connect with mainstream services, community supports and foundational supports to participate in their community.

For people who may be eligible for the NDIS, Navigators should help people understand what the NDIS is, who it is for and how to make an access request if required. It also includes amplifying the voice of participants with providers, helping them switch providers where existing arrangements aren’t working or finding better alternatives in the local community. Though it should not be their responsibility, Navigators would help to make NDIS markets work more effectively.

Specialist Navigators should be available for people with more complex support needs, certain population groups and people at key life transitions, such as preparing for education, employment and independent living. These Navigators should have more experience and smaller caseloads.

Navigators should be delivered locally by people who have genuine local connections, knowledge and links to local services. There should be a national framework to ensure consistent delivery, with local design to capture the unique needs of different locations. Navigators and Specialist Navigators must not be involved in information gathering or budget setting functions and should not deliver other NDIS services to avoid potential conflicts of interest.

The role and functions of Navigators should be scoped and designed with people with disability as well as other sector representatives and others with technical expertise. This should keep features of the current Partners in the Community and Support Coordinator functions that are working well, and reimagine those that are not. It should involve a carefully planned approach to testing the new navigation model and staged transition to mitigate disruption to participants and their families.

The staged approach to transitioning to the new approach should also provide the opportunity for existing Support Coordinators to become Navigators and to allow continuity of support. There is significant capability and expertise for many of the required activities in the new approach already in the market and this should be harnessed as part of the new approach to navigation.

Figure 4: Overview of proposed navigation support

Navigation support

Plan of action

Specific roles/ competencies

Data gathering and reporting

General Navigator
Support for all people with disability

Navigation supports (varied caseloads based on need)

Support finding and accessing NDIS and non-NDIS supports

Help understanding what the NDIS is and who it is for

Connect to individualised safeguards, including support for decision making

Supporting participants and nominees to develop a plan of action to implement mainstream, foundational and funded supports

Helping to identify supports and providers

Outreach for people with barriers to access

Critical life transition points (including education, employment and independent living)

Support those who would benefit from early intervention to access and adapt supports that work for them

Collecting data and reporting on demand for services and unmet need for all people with disability

Reporting gaps in local service systems

Information gathering for people with barriers to access

Sharing good practice

Specialist Navigator
Support for participants with complex needs

Same as general, with higher intensity and more time per participant (lower caseloads (max 1:12)) due to complexity of needs, situations and/or interfaces with multiple services systems

Same as general, with a greater need for a coordinated approach to the range of services needed

Work with NDIA Justice and Health Liaison Officers to help with transitions

Higher levels of experience and training

Specialist expertise to navigate transition points in the context of complex situations and interaction of multiple services systems

Same as general, with a focus on data for people with complex needs

Additional service offerings

Navigation support

Plan of action

Specific roles/ competencies

Data gathering and reporting

Psychosocial recovery
Support for participants with psychosocial disabilities

Same as general, with varied caseload, depending on need

Outreach and assist people with psychosocial disability to connect with non-NDIS services and apply to the NDIS

Assist participants with psychosocial disability to set and achieve goals, identify evidence based supports, and connect with mental health, primary care and housing services

Evidence informed and best practice approaches in mental health and supported decision making

Same as general, with a focus on data for people with psychosocial disability

Housing and living
Support for participants with housing and living needs

Advises Navigator when participant is starting to explore housing and living options

Provides time-limited support to participant and their Navigator to identify and negotiate with providers; implement housing and living solutions; trial different housing and living options

Provides advice to either the participant’s general or Specialist Navigator in developing a plan of action

Evidence informed and best practice approaches to housing and living

Knowledge of the wide range of housing and living supports available across service systems, as well as local housing and living options

Same as general, with a focus on participants with a need for housing and living supports

Recommendation 4: Support all people with disability to navigate mainstream, foundational and NDIS service systems

* Legislative change required

Action 4.1: The National Disability Insurance Agency, through the joint commissioning process described in Action 4.3, should be the lead commissioner of a local navigation function to help people with disability find supports in their community and make the best use of their funding. Significantly greater support should be provided by a Navigator with genuine local connections, knowledge and links to local services. Navigator support should be provided to people with disability, regardless of whether they are a participant or not. This should be aligned to the new Foundational Supports Strategy (see Action 1.2).
The Navigator should act on behalf and at the direction of the person with disability when providing information and supporting access to mainstream, foundational and NDIS services. This should include connecting people with disability to individualised safeguards, including support for decision-making. The Navigator should support participants to develop a plan of action, book and coordinate support where needed, undertake progress check-ins, and provide specific advice on key transition points or key issues. There should be additional service offerings for those with psychosocial disability (see Action 7.1) and those with housing and living needs (see Action 8.2) as part of the Navigator function.
A carefully planned and staged transition to implement navigation would be essential to mitigate disruption to participants and their families. The staged approach to transitioning to the new approach should also provide the opportunity for existing Support Coordinators to transition to the provision of Navigator supports and allow continuity of support. Implementation should ensure the features of roles that are working well are retained and those that are not are reimagined (see Action 4.4).
Action 4.2: The National Disability Insurance Agency, through the joint commissioning process described in Action 4.3, should be the lead commissioner of a Specialist Navigation function for participants who have more complex or specific needs that cannot be reasonably met by general navigation support. A Specialist Navigator should be available for participants with more complex support needs. This includes those with interactions with acute service systems and where complex situations or significant risks have been identified as part of the access or needs assessments. Opportunities for the National Disability Insurance Agency (NDIA) to jointly commission these specialist Navigators with other service systems should be explored by the NDIA to improve coordination.
Specialist navigation should be provided locally by staff with lower caseloads than other Navigators and have relevant experience managing complex situations and risks and ideally are qualified in allied health, social work or related fields. They should provide a higher level of support to participants when delivering Navigator functions to help respond to the participant’s complex support needs, environmental complexity, or mitigate risk. Specialist Navigators should work closely with (but not duplicate) the role of NDIA Hospital or Justice Liaison Officers to ensure smooth transitions and coordination of supports for those participants who are exiting other service systems.
Action 4.3: The National Disability Insurance Agency should ideally adopt a joint commissioning approach to deliver local navigation support within a nationally consistent framework developed in partnership with other relevant Australian government and state and territory government agencies. Design of the navigation function should balance the need to design services that would be delivered locally to meet the specific needs of a community, while maintaining national consistency. This ideally should be approached through a process of joint commissioning between all Australian governments to ensure a coordinated approach to local service navigation. Local delivery should be underpinned by a nationally consistent approach to governance, branding, online service options, information management, communities of practice, monitoring and evaluation, and capability and training.
Wherever possible, there should be a local physical space or hub for people to interact with Navigators, co-located with existing community service organisations and foundational supports to increase service integration. The footprint for the navigation function should be significantly more local than the current NDIS service areas, and resourcing should allow for appropriate caseloads. This should ensure Navigators have the necessary local knowledge and connections, and can spend time providing genuine support. An alternative approach to delivering Navigators in remote communities should be considered to align with alternative commissioning of supports (see Action 14.1) and the general approach to outreach in the Navigator model.
Action 4.4: The National Disability Insurance Agency should design, test and implement the navigation function gradually, prioritising continuity of support for participants and their families and a smooth transition for the workforce and market. The navigation function should be designed and tested with people with disability and other relevant experts through agile projects commissioned by the NDIS Experience Design Office (see Action 24.3). The design process should be aligned with the principles and implementation considerations set out in the Co-Group Feedback to the NDIS Review Panel, developed as part of the Review’s participatory engagement process (for further details on the Co-Group’s work see Appendix C). The design should include trial(s) across multiple service areas. Trials should encourage the formation of consortia and allow for multiple organisations (including existing independent support coordination providers) within a local area so that smaller organisations can contribute to genuinely local approaches. Trials should take an iterative and inclusive approach to designing functions with people with disability, as well as sector and technical experts. This should provide an opportunity to test both local approaches and measures to ensure national consistency and quality prior to wider implementation. The function should then be rolled out gradually to ensure continuity of support for existing participants, steward the significant existing capability in the support coordination and Partners in the Community workforce, and minimise impacts on the market.

Support for all people with disability to better navigate mainstream and disability supports

On this page

Finding the right supports can be complex, costly and time consuming

There are issues with the implementation of the Partners in the Community program

Support coordination is not available consistently and not proportional to need

The Complex Support Needs Pathway is not meeting the specialised needs of some participants