Domestic Assistance Guidelines Order 2004

WORKPLACE INJURY MANAGEMENT AND WORKERS COMPENSATION ACT 1998

WorkCover Guidelines for the Provision of Domestic Assistance

Explanatory note

These Guidelines are made under sections 376 (1) (c) of the Workplace Injury Management and Workers Compensation Act 1998 and section 60AA of the Workers Compensation Act 1987. They explain the operation of the workers compensation legislation relating to the provision of domestic assistance services to injured workers.

These Guidelines set out procedures to be followed relating to the provision of domestic assistance services and the verification of the provision of those services.

These Guidelines are primarily intended to assist insurers, medical practitioners, rehabilitation providers, injured workers and their carers. Questions about the provision of domestic assistance and these Guidelines should be directed to the Workplace Injury Management Branch of WorkCover NSW on 13 10 50.

JON BLACKWELL, Chief Executive Officer, WorkCover NSW

Signed this15th day of October 2004

WORKCOVER GUIDELINES FOR THE PROVISION OF DOMESTIC ASSISTANCE

1. AIM OF THESE GUIDELINES

These guidelines are designed for use by insurers, medical practitioners, rehabilitation providers, injured workers and their carers. They aim to direct the practical application of those parts of the workers compensation legislation dealing with provision of domestic assistance to injured workers.

1.1 Relevant legislation

These Guidelines are made under section 376 (1) (c) of the Workplace Injury Management and Workers Compensation Act 1998 (‘the 1998 Act’) and section 60AA of the Workers Compensation Act 1987 (‘the 1987 Act’).

1.2 Guidelines for domestic assistance services

Section 376 (1) (c) of the 1998 Act empowers the Authority to issue guidelines as to a matter that a provision of either the 1987 or the 1998 Act provides may be the subject of guidelines.

Under section 60AA (1) (d) of the 1987 Act, compensation is payable for domestic assistance that is reasonably necessary for an injured worker, where the assistance is provided in accordance with a care plan established in accordance with the WorkCover Guidelines. Section 60AA (5) (b) further provides that Guidelines may be made for how the provision of those services is to be verified.

Accordingly, these Guidelines apply in relation to:

  • the provision of domestic assistance, and
  • how the provision of domestic assistance services is to be verified.
1.3 Definitions

In this Guideline, the following definitions apply:

Nursing includes, but is not limited to, regulation/ management of, and/or advice to carers regarding bowel/ bladder care, chest care, skin care, medication, wound care, temperature, nutrition, and blood pressure.

Care of the Worker (also known as “personal care”) applies to care that includes, but is not limited to:

  • Assistance with/supervision of transfers and mobility,
  • Assistance with/supervision of showering, bathing, dressing, grooming, eating, drinking,
  • Planning of daily activity – planning/arranging outings, use of diary/calendar, assisting with respondence, assisting with telephone calls, and
  • Preparing for and attending medical/therapy ppointments.

Domestic Assistance may include, but is not limited to:

  • Household Cleaning – internal and external,
  • Laundry,
  • Meal Preparation,
  • Shopping,
  • Lawn/Garden care,
  • Simple essential home maintenance such as changing light bulbs or tap washers, and
  • Child Care.

Care Plan for the Worker is that part of the Injury Management or Case Management Plan that addresses Domestic Assistance.

2. APPLICATION OF GUIDELINES

These Guidelines apply to the provision of domestic assistance.

These Guidelines replace any previous Guidelines issued by WorkCover NSW in respect of the provision of domestic assistance.

3. ELIGIBILITY FOR DOMESTIC ASSISTANCE

An injured worker is eligible to receive domestic assistance where a medical practitioner has certified that it is reasonably necessary for the worker to receive the assistance and that the necessity arises as a direct result of the worker’s injury.

The type and amount of assistance is to be determined by a functional assessment, and the worker must have undertaken the domestic tasks with which assistance is to be provided prior to the injury.

Assistance can be provided, as part of an injury management plan, on a temporary basis for a period of up to 6 hours per week for a cumulative period of not more than 3 months.

Insurers can provide assistance on a “without prejudice” basis if the person requires assistance beyond 3 months and is likely to be assessed as having 15% Whole Person Impairment (WPI).

Ongoing assistance (subject to medical review) can be provided if the person is certified as 15% WPI.

Eligibility will be assessed when the worker, or a provider on their behalf, requests domestic assistance. For temporary assistance this will be when the worker is recovering from the work related injury or from curative intervention such as surgery.

For longer term assistance, the assessment will be when the worker is able to be assessed for WPI or, in cases of “without prejudice” decisions, when the worker is likely to exceed 3 months’ cumulative assistance. In the latter case, the insurer is to consider the probability of an assessment of 15% WPI in the future and will be guided in this decision by advice of a medical specialist experienced in the management of the particular medical condition who is trained in the application of the WorkCover Guides for the Evaluation of Permanent Impairment.

4. PURPOSE OF PROVISION OF DOMESTIC ASSISTANCE

The provision of domestic assistance services to injured workers is driven by WorkCover NSW’s focus on returning injured workers to work as soon as possible, and mitigating the effects of their injury on their health, wellbeing and ability to achieve, as near as possible, their pre-injury functional status.

The intent is to provide domestic assistance to injured workers in the short term if they are medically and functionally unable to manage their domestic responsibilities, while they concentrate on recovery and rehabilitation.

For workers with permanent, severe disabilities, the assistance is provided to compensate for the worker’s inability to complete their domestic responsibilities.

5. APPROVAL REQUIREMENTS FOR DOMESTIC ASSISTANCE

5.1 Certification by Medical Practitioners

A medical practitioner must certify the requirement for domestic assistance.

Information required in this certification includes:

  1. Details of the functional restrictions limiting the worker’s capacity for performing domestic tasks;
  2. That the need for the domestic assistance is a direct result of the work injury;
  3. That the domestic assistance recommended is reasonably necessary.

In making this functional determination, the certifying doctor may refer to reports from other professionals such as medical specialists, occupational therapists or physiotherapists. If a specific assessment is required, this will be paid as a claim cost.

In cases where the injured worker has been certified with at least 15% whole person impairment (WPI), it is expected that a thorough on-site Functional Assessment (or Functional Capacity Evaluation) be completed by a relevant professional (eg occupational therapist).

In making a decision about the provision of domestic assistance, the following must be considered:

  • whether the injured worker usually undertook the domestic tasks being claimed for prior to their injury; or
  • if the worker did not usually undertake the domestic tasks prior to their injury, but their social circumstances have changed as a result of the injury so they are now required to, assistance for these additional tasks may be considered.
5.2 Reasonable necessity for domestic assistance

In determining the reasonableness and the necessity of domestic assistance, the following principles are also to be applied:

  • The doctors and health professionals involved have considered and provided other alternatives such as adaptive equipment to enable independence, training in work simplification or joint protection principles and working towards independence in domestic tasks as a part of the rehabilitation program, and consider that domestic assistance is required in addition to these.
  • In assessing the eligibility for domestic assistance, Claims Managers should be sensitive to individual needs, cultural and familial issues and personal standards of hygiene and cleanliness and to circumstances where the domestic care cannot be provided by other members of the injured worker’s household because of the extreme burden this would place on those household members.
  • The doctor/health professional has provided a timeframe for the period that the recommended level of domestic assistance will be required and a functional re-evaluation is scheduled.
  • The fact that someone residing with the worker gains a subsidiary indirect benefit from the service does not, of itself, prevent the service from being approved as “domestic assistance”.
  • The injured worker must be residing in the home where domestic assistance is to be provided. Domestic assistance cannot be provided to other members of the household in the absence of the injured worker.

To determine whether or not domestic assistance is reasonably necessary, there must be evidence that the assistance required:

  1. Arises from the worker’s injury/illness, incapacity and those related factors that are hindering the worker’s recovery and RTW,
  2. Is appropriate, ie there is a clear link between the worker’s needs, the purpose of the assistance and its likely benefit(s),
  3. Is likely to be more effective than alternative interventions,
  4. Is cost effective, ie the service is likely to contribute to substantially reducing the worker’s dependence on further treatment, rehabilitation and workers compensation benefits, and
  5. Represents an accepted intervention for those needs arising from the worker’s injury and incapacity, ie it is consistent with current best practice and there is evidence to support its efficacy.

6. LEVEL OF DOMESTIC ASSISTANCE THAT CAN BE APPROVED BY THE INSURER

6.1 Hours per week

In the event the worker has been certified with at least 15% Whole Person Impairment (WPI), the worker is entitled to all reasonably necessary domestic assistance.

In these cases, the hours provided would be determined based on medical/health professional recommendation and application of the principles listed above. A thorough functional assessment by an occupational therapist is required as well as medical certification. Periodic review of the hours required is essential and should be conducted according to medical advice.

If the WPI is less than 15%, or has not yet been determined, then a maximum of 6 hours per week domestic assistance can be provided. The approved amount will always be in accordance with the functional requirements of the injured worker.

6.2 Period of time

In the event the worker has been certified with at least 15% WPI there is no limit on the length of time that domestic assistance can be provided. Where domestic assistance is required in the long term, periodic review of the injured workers circumstances is to be conducted.

If the 15% WPI has not yet been determined, then domestic assistance can be provided for up to 6 hours per week for a maximum period of 3 months. This can be a single block of three months, or can be accumulated by several shorter periods of assistance adding up to three months.

6.3 Periodic Review

The provision of domestic assistance must be re-evaluated at regular intervals. The frequency of these re-evaluations will depend on the prognosis for the injured worker, including speed of recovery and degree of anticipated recovery. Review timeframes must be noted on the Injury Management Plan or Case Management Plan for long term care.

6.4 Where a WPI has not yet been determined

In the circumstance where a WPI has not yet been determined and the injured worker requires domestic assistance beyond 3 months and/or for more than 6 hours per week there is little flexibility available. Under current legislation, injured workers are not entitled to domestic assistance beyond three months or for more than 6 hours per week unless they have a WPI of at least 15%.

It is important to note that this does not prevent nursing or personal care being provided to the worker.

Where a medical specialist experienced in the management of the worker’s medical condition, who is trained in the application of the WorkCover Guides for the Evaluation of Permanent Impairment, determines that a worker’s injury will result in at least 15% WPI, payments can be made on a “without prejudice” basis. The requirements for appropriate assessment also apply in these cases.

In cases where this cannot be manifestly determined, the worker can pay for the service and apply for recovery of the moneys when WPI is able to be determined.

7. SPECIAL REQUIREMENTS – COMPENSATION FOR GRATUITOUS DOMESTIC ASSISTANCE SERVICES

Gratuitous domestic assistance is domestic assistance provided to an injured worker for which the injured worker has not paid and is not liable to pay.

7.1 Lost income or forgone employment

A person claiming compensation for providing gratuitous domestic assistance must provide evidence to the Claims Manager that they have lost income or forgone employment as a result of providing this assistance.

Examples of evidence may include:

  • pay slips demonstrating less overtime worked for that period, with a supporting letter from the employer,
  • pay slips demonstrating fewer hours of work (if casually employed), with a supporting letter from the employer,
  • evidence of reduced hours of work – eg from full-time to part-time,
  • letter of resignation, giving reasons, and
  • letter of termination by an employer – outlining reasons for loss of job.
7.2 Verification of provision of services – Domestic Assistance Diary

Along with this evidence, providers of gratuitous domestic assistance must also submit a diary of the assistance provided. This includes date, hours worked and the activities performed. Both the domestic assistance provider and the injured worker must sign the diary entries. An example of a Domestic Assistance Diary is found in Attachment A.

Payment will only be made for services agreed to and described in the Injury Management Plan or Case Management Plan (the “Care Plan” for the worker).

7.3 Payment to service provider

The Claims Manager then reimburses the service provider directly. Payment is not made to the injured worker under any circumstances

7.4 Maximum amount payable

The maximum hourly fee amount for which an employer is liable under the Act for gratuitous domestic assistance services is the hourly rate calculated by dividing by 35 the amount estimated by the Australian Bureau of Statistics as the average weekly total earnings (full time adult ordinary time) of all employees in New South Wales from time to time. Compensation is not payable for more than 35 hours per week.

8. CHOOSING A DOMESTIC ASSISTANCE SERVICE PROVIDER

In determining the most efficient and cost-effective way to provide the domestic assistance, consideration should be given to:

  • Hourly rates of local service providers,
  • Travel required by the nearest commercially available
  • service provider (most applicable in remote areas),
  • Efficiency of using family or friends – can they complete the domestic assistance as quickly as a commercial service?
  • The preference that family and friends do not lose income as a result of providing domestic assistance, and
  • Cultural, family or individual circumstances or preferences.

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