PART 6 – Reasonable and necessary decision making in the LTCS scheme
This part of the Lifetime Care and Support Guidelines is issued under section 93 of the Lifetime Care and Support (Catastrophic Injuries) Act 2014 (LTCS Act).
To avoid requirements that might be unreasonable in the circumstances on any participant, the Lifetime Care and Support Commissioner of the ACT (LTCS Commissioner) may waive observance of any part or parts of these LTCS Guidelines.
- Treatment, rehabilitation and care
The LTCS Commissioner will pay the participant's reasonable and necessary treatment, rehabilitation and care services related to the motor accident injury. Treatment and care needs are defined in Section 9 of the LTCS Act to include:
- medical treatment (including pharmaceutical treatment;
- dental treatment;
- ambulance transportation;
- respite care;
- attendant care services;
- aids and appliances;
- educational and vocational training;
- home and transport modification;
- workplace and educational facility modifications; and
- any other kinds of treatment, care,support or services prescribed by regulation.
Rehabilitation is the process of restoring or attempting to restore the person, through the combined and co-ordinated use of medical, social, educational and vocational measures, to the maximum level of function of which the person is capable or which the person wishes to achieve and includes placement in employment and all forms of social rehabilitation such as family counselling, leisure counselling and training for independent living.
There may be items that are related to the motor accident injury that are reasonable and necessary in the circumstances but are not regarded as treatment, rehabilitation and care services under the scope of the LTCS Act or regulations. In this case, the LTCS Commissioner will not fund any such services or supports but may work with service providers to facilitate access to such services where there may need to be congruence with treatment, rehabilitation and care services funded by the LTCS Commissioner.
The LTCS Commissioner will not fund:
- Treatment,rehabilitation and care services that are not a result of the motor accident injury in respect of which the injured person is a participant in the LTCS Scheme;
- Treatment,rehabilitation and care services that are not reasonable and necessary in the circumstances; and
- Services or expenses that are not treatment, rehabilitation and care under the scope of the LTCS Act or regulations.
Section 30(5) of the LTCS Act requires that the LTCS Commissioner pay the participant's reasonable and necessary treatment, rehabilitation and care expenses related to the motor accident injury. Each request will be dealt with on a case by case basis, and decided taking into account the "reasonable and necessary" criteria below.
That a specific treatment, service or item of equipment is not the subject of a specific policy does not mean that the LTCS Commissioner will not pay the costs of that service or equipment if it is reasonable and necessary in the circumstances and relates to the motor accident injury in respect of which the person is a participant in the LTCS Scheme.
Service providers need to give the LTCS Commissioner adequate documentation, outlining the reasons to support their requests, for treatment, rehabilitation and attendant care services. The LTCS Commissioner will use this information to make decisions on whether requests are reasonable and necessary.
A number of factors are considered, including the following:
- Benefit to the participant;
- Appropriateness of the service or request;
- Appropriateness of the provider;
- Relationship of the service or request to the injury sustained in the accident; and
- Cost effectiveness considerations.
The following factors will help to identify whether a request is reasonable and necessary.
2.1 Benefit to the participant
Information or benefit to the participant will be gained by the proposed service:
- There are goal(s), expected duration, and expected outcome(s) for the requested service. The participant has understood and agreed to these goals and outcomes.
- The proposed service relates to the participant's goals and facilitates participation.
- The outcome of the service will progress or maintain the participant's recovery/management.
- There is sufficient documentation to show the requested service will benefit the participant.
- There is no adverse outcome or risk from providing the service.
- There would be an adverse outcome or risk if the service was not provided.
- The service has been provided in the past with positive results or outcomes.
- Related services have been provided in the past and there were positive results or outcomes from these services.
2.2 Appropriateness of service or request
The proposed service is appropriate for the participant's injury:
- The requested service is consistent with the participant's current medical or rehabilitation management.
- The proposed service relates to the participant's goals in their Community Discharge Plan, Community Living Plan or LTCS Plan.
- The service is in keeping with current clinical practice, evidence based practice and/or clinical guidelines.
- There is good evidence that the requested service is effective.
- A similar service is not currently provided.
- The proposed services are congruent with other services currently being offered or proposed.
- There are no risks and/or contraindications of the proposed service.
- No other services are being provided.
- Other services or provision of equipment will not provide an improved or equal outcome.
- There is no other appropriate service available, with other services considered and discounted.
- The service is new or innovative,however, there is sufficient rationale for offering the proposed service and measures are proposed to quantify its outcomes.
2.3 Appropriateness of provider
The proposed service provider is appropriate:
- The provider is qualified and appropriately experienced to provide the service.
- The provider is registered (if applicable).
- The provider is appropriate considering the participant's age, ethnicity and any cultural and linguistic factors.
- There are no conflict of interest issues with the provider.
- There is no reason to suggest the participant would not find this provider acceptable.
- The participant has chosen an approved service provider or has expressed a preference.
- The participant can readily access the proposed service provider.
2.4 Cost effectiveness considerations
The proposed service is cost effective:
- Consideration has been given to the long term compared to the short term benefits based on evidence based practice, clinical experience or consensus.
- The long term and short term benefits and expected outcomes of the proposed service have been considered and outweigh the costs.
- The cost of the proposed service is comparable to those charged by providers in the same geographical area or clinical area.
- The service is required because other services or equipment are not available or not appropriate, and it is not feasible to provide other services or equipment more promptly.
- Equipment/modifications are required and factors relating to lease or rental have been carefully considered and compared to the cost of purchase.
- There are no other services that will achieve comparable outcomes.
- Alternatives to purchasing equipment/modifications have been considered, particularly the impacts of technology advances and changes to participant needs over time.
2.5 Relationship to motor accident injury
There is sufficient evidence to demonstrate that the service relates to the injury sustained in the motor accident including exacerbation of pre-existing injuries. Time since injury, subsequent injuries and comorbidities should be considered.