The ATHM Scheme Evidence Loop
What happens when you need funding to obtain the evidence required for more funding?
A scenario that many older adults are currently facing.
A participant’s AT-HM funding is insufficient.
The Occupational Therapist has identified that a more complex or costly intervention is likely to be required. However, trials, supplier consultation, measurements, drawings or further technical work must occur before the OT can safely complete the prescription.
The provider needs evidence to request a higher funding tier.
But the existing allocation may not cover the work required to produce that evidence.
This is one of the most significant practical implementation problems emerging under the Support at Home Assistive Technology and Home Modifications Scheme.
What does the current guidance say?
The Australian Government’s AT-HM Scheme Guidelines state that, when requesting a Support Plan Review, providers must attach supporting documentation or other evidence to demonstrate the need for additional funding where appropriate.
The guidelines then say:
Evidence may include prescriptions, quotes and/or medical/allied health reports.
However, the table immediately following this statement is titled “Evidence required to support a Support Plan Review.”
For a change in an AT or HM funding tier, it lists:
item prescription
quote/s
This creates an important question: are both a completed prescription and quote mandatory, or can preliminary allied health evidence support the review where those documents cannot yet be safely or reliably produced?
The wording is not clear enough for consistent implementation.
The circular problem
In straightforward cases, producing a prescription and quote may be relatively simple.
In more complex cases, a final prescription may require:
further functional or environmental assessment
equipment trials
supplier consultation
measurements or technical specifications
builder or trades consultation
drawings or a scope of works
risk assessment
consultation with the participant, family and support team
comparison of alternative interventions
confirmation of implementation, training and review requirements.
These activities take clinical time and may incur supplier, builder or technical costs.
The implementation loop is therefore:
Additional funding is needed to complete the work required for a prescription and reliable quote, but the prescription and quote appear to be required before the additional funding can be requested.
The government’s current AT-HM information notes that prescriptions used as evidence may be funded through the AT-HM Scheme, the participant’s ongoing Support at Home budget or private funding. However, this does not fully resolve what happens when no practical funding source is available or the existing allocation is already insufficient.
Why premature prescription is not the answer
The pressure to obtain a higher tier must not lead to an OT naming a product or finalising a modification before the necessary clinical work has been completed.
A prescription communicates that the health professional is prepared to recommend a particular intervention based on sufficient assessment and clinical reasoning.
For complex AT or home modifications, that may not be defensible before:
relevant products have been trialled
essential features have been confirmed
the environment has been assessed
technical feasibility has been explored
risks and alternatives have been considered
the expected costs are sufficiently reliable.
A funding process should not create an incentive for false precision.
Writing a product name and attaching an indicative supplier price may produce the appearance of a complete evidence package, but it does not necessarily constitute safe or appropriate prescription.
Identified need, funding evidence and prescription are not interchangeable
Three different stages are often being collapsed into one.
1. An AT-HM need has been identified
The OT has evidence of a functional problem, environmental barrier or risk that may require AT or home modification intervention.
2. Further funding appears necessary
The available evidence indicates that the existing tier is unlikely to cover the appropriate intervention and the services required to assess, prescribe and implement it.
3. The final intervention is ready to be prescribed
The necessary assessment, trials, measurements and consultation have occurred. The OT can identify the intervention, required features, implementation requirements and associated clinical services.
An OT may have enough evidence to support the first two conclusions without yet being able to complete the third.
That distinction should be visible in the documentation.
What can OTs do while clarification is sought?
Until clearer operational guidance is available, OTs should avoid presenting preliminary evidence as a final prescription.
Where the intervention cannot yet be prescribed, documentation can clearly identify:
the participant’s assessed needs and goals
the functional consequences and relevant risks
the likely category of intervention
why the current funding tier appears insufficient
the assessment, trials or technical work still required
whether any cost information is indicative rather than final
interim strategies or risk-management measures
the specific action required from the provider
the limits of the current recommendation.
The provider can then determine how this preliminary evidence should be used within its processes and whether further clarification is needed before lodging a Support Plan Review.
Importantly, this type of needs-and-evidence summary should not automatically be described as a substitute for the prescription and quote listed in the current guidelines.
Questions that require answers.
Are both a final prescription and quote mandatory for every tier-change Support Plan Review?
Can an allied health report outlining needs and evidence summary be accepted when the intervention cannot yet be prescribed?
Can an indicative quote be used to determine the appropriate tier?
How should providers proceed when the current allocation cannot fund the work needed to develop the required evidence?
Can preliminary evidence support the initial review, followed by final prescription before purchase or implementation?
These are not minor administrative details. They affect access, clinical safety, provider consistency and whether participants can progress when their current tier is inadequate.
The practical challenge for OTs
The OT’s role is not to guarantee funding or reverse-engineer documentation to satisfy an unclear process.
Our role is to:
assess the person’s needs, goals, function and environment
make the level and consequences of need visible
distinguish what is known from what still requires investigation
avoid prescribing beyond the available evidence
communicate the likely funding gap
identify the next clinical and operational steps
work with the provider on proportionate interim options.
The gap between an identified need and a final prescription is where much of the current difficulty sits.
It is also where our skills as Occupational Therapists and clinical reasoning matters most.
Explore this in AT-HM in Practice
In the upcoming AT-HM in Practice workshop, we will work through the real practical challenges that OTs are facing.
In this workshop, we will come together as a profession and navigating these situations in practice.
Register below to secure your place.
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