NHS CHC Full Day Training Presentation

NHS Continuing Healthcare

Trainer: Steven Pruner

Housekeepi
ng
Introduction

Ground rules – confidentiality

Fire alarms, breaks, mobiles, toilets, evaluation
forms

Objectives & Goal Setting

2 Continuing Healthcare

Agend
a
Health Care versus Social Care

NHS Continuing Healthcare – Framework & Practice

Primary Health Need

NHS Continuing Healthcare Tools


Health vs. Social
Care
NHS Act 1946
National Assistance Act 1948
---------

NHS has a history of providing social care
Large NHS institutions for OP, LD, MH
1980s’ closure programme: people moved into the
community from free NHS care to means-tested social care
Historically, LA care homes were for the frail, vulnerable,
confused – now most care homes are in the independent
sector, mainly for those very unwell (The LA is now looking
after people who in the past would have been in NHS
institutions.)

Health vs. Social
Care
HEALTH: No legal definition of a healthcare need “in general
terms can be said that such a need is one related to treatment,
control or prevention of disease, illness, injury or disability, and
the care or aftercare of a person with these needs (whether or
not the tasks involved have to be carried out by a health
professional)”. (PG4.11)

SOCIAL CARE: In general terms a social care need “is one that is
focused on providing assistance with activities of daily living,
maintaining independence, social interaction, enabling the
individual to play a fuller part in society, protecting them in
vulnerable situations, helping them to manage complex
relationships and (in some cases) accessing a care home or
other supported accommodation”. (PG4.11)


Social Care
Social care needs which are directly related to welfare services
that LAs have a duty or power to provide, including:

Social work services Provision of meals
Advice, support, Facilities for
information occupational, social,
Practical assistance in cultural, recreational
the home activities outside the
Assistance with home
equipment & home Assistance to take
adaptations advantage of educational
Visiting & sitting facilities
services Assistance with finding
accommodation

Health Care
Health care needs are related to:
Diagnosis, treatment, control or prevention of
disease, illness, injury or disability

Who Pays?
Health care is free at point of delivery
Social care is means-tested and subject to FACS criteria

If someone is eligible for NHS CHC, the NHS is
responsible for meeting both health and social care
needs.


Vocabular
y 1
EXERCISE

Continuing Care

Continuing Healthcare (CHC)

NHS-Funded Nursing Care (FNC)


Document
s NHS Continuing Healthcare Fast Track Tool

and NHS-funded Nursing Ordinary Residence
care – Public Information
booklet Who Pays? Responsible
Commissioner
National Framework for NHS
Continuing Healthcare NHS CHC (Responsibilities)
Directions 2009
National Practice Guidance
(CHC) Delayed Discharges
(Continuing Care) Directions
National Practice Guidance 2009
(FNC)
NHS (Nursing Care in
Refunds Guidance Residential Accommodation)
(Amendment) (England)
Checklist Directions 2009

Decision Support Tool NHS CHC Training Materials


What is it?

Package of care arranged and funded solely by the
NHS

Can receive it in any setting

Free

Different from NHS-Funded Nursing Care

Have to meet eligibility criteria: demonstrate “primary
health need”

Eligibility

Have to undergo an assessment for CHC and be found
eligible under the criteria

Not based on particular disease, diagnosis or condition,
or where the care is provided

Based on the level of care needs

the nature, intensity, complexity, or unpredictability of
the care needs determines eligibility

Primarily health need rather than primarily social care
need

Eligibility
OTHER ISSUES

Eligibility is not based on (NF49):
Diagnosis
Setting of care
Provider ability to manage care
Use or not of NHS staff
The need for specialist staff
That a need is well managed
Existence of other NHS-funded care
Any other input-related rationale (opposed to needs-
related)


What is your role?
MULTI-DISCIPLINARY TEAM (MDT)

To participate in the determination process to:

Complete your own professional assessment and
report
Engage with other MDT members to discuss care
needs based on the MDT assessments / reports
Assist to complete the DST, weighing up the level of
care needs on each care domain
Apply the Primary Health Needs test and make a
recommendation on eligibility


Core Values
PRINCIPLES

Person-centred approach (NF 33, PG 2.3)

Consent (NF 36, PG 2.3.4)

Capacity (NF 39, PG 3.2)

Advocacy (NF 43, PG 3.6)


Framework: Process
FLOW CHART from NF page 18


Framework: Process
Steven’s Simplified Version

Fast Track Tool YES Use Fast Track Tool
NOT Required

Checklist NOT Eligible Care Package: LA, PCT, Private or Joint
YES Consideration

MDT Identified: DST Completed
Do Assessments

MDT Recommendation to PCT NOT Eligible Care Package: LA , PCT, Private or Joint
YES Eligible

PCT Validation (Panel) NOT Eligible Care Package: LA, PCT, Private or Joint
YES Eligible


Primary Needs
HEALTH or SOCIAL CARE?


Primary Health Need
LEGAL VIEW

Primary health need arises when nursing or other
health services required by the person are

a) where the person is, or is to be, accommodated in a care home,
more than incidental or ancillary to the provision of
accommodation which a social services authority is, or would be
but for the person’s means, under a duty to provide; or
b) of a nature beyond which a social services authority whose
primary responsibility is to provide social services could be
expected to provide.

(NF22)


Primary Health Need
LEGAL VIEW

The Coughlan Judgment (1999)
R v North and East Devon Health Authority, ex parte Pamela Coughlan

About the respective responsibilities of NHS and social care
regarding nursing care. Court of Appeal said:

NHS is not responsible for all nursing care
No precise legal line between health & social care services
Local authority can provide nursing care that is:
a) merely incidental /ancillary to provision of accommodation or
b) of a nature which it can be expected to provide under NA Act 1948
This is the quantity/quality test.


Primary Health Need
LEGAL VIEW

The Grogan Judgment (2006)
R v Bexley NHS Trust, ex parte Grogan

Eligibility criteria used did not comply with Coughlin judgment and
the level of nursing needs in the Medium and High Band of the
RNCC indicated a primary health need. The judge said:

Can be an overlap, or a gap, between health and social care
depending on test applied
Should be no gap in those “health” services provided by NHS
and social care
PCT did not apply criteria which identified the test used to
determine primary health need


Primary Health Need
THE TEST

Each of these characteristics may, in combination or alone,
demonstrate a primary health need, because of the quality and/or
quantity of care required to meet the individual’s need.
NICU
NATURE
Type of needs, overall effect, type (quality) of interventions

INTENSITY
Extent (quantity) and severity (degree) of needs and need for regular interventions

COMPLEXITY
How different needs arise and interact to increase skill needed to manage / monitor

UNPREDICTABILITY
Unexpected changes in condition which are difficult to manage; degree of risk and
timeliness of intervention


NICU
EXERCISE 2

Go to NF page 10. Read each of the characteristics of PHN.

What kinds of questions would you consider under each
characteristic of PHN to capture what is being assessed?

1) Compare answers to PG page 23


Determining
Eligibility
THE TOOLS

Fast Track Pathway Tool

Checklist

Decision Support Tool


Using the Tools
WHERE and WHEN?

Fast Track Pathway Tool
Usually in hospital (PG 5.12)
Action by PCT within 48 hours (PG 5.11)

Checklist & Decision Support Tool
Preferably not in an acute setting (NF 60, PG 6.4)
After all treatment and rehab completed (PG 6.4)

Section 2 and 5 Notifications
After CHC process has been concluded (PG 7.1)


Fast Track Pathway
Tool DECISION
FAST-TRACK

Elements to consider:
(1) rapidly deteriorating condition that
(2) may be entering a terminal phase
(3) with an increasing level of dependency

Appropriate clinician (consultant, registrar, GP, nurse) with
appropriate level of knowledge or experience

Supported by prognosis, if possible (but length of time left to
live does not determine eligibility)

Recommendation sent to PCT: should be accepted for urgent
package of care


Fast Track Pathway
Tool
FAST TRACK PATHWAY TOOL

Clinician should consider the definition of a Primary Health
Need when outlining why it is considered that the
individual has a rapidly deteriorating condition that may be
entering a terminal phase


Checklist
SCREENING TOOL

Consent should be obtained, explain process, give leaflet

Completed by health or social care professional

Threshold deliberately set low

Used to identify who needs a full assessment of eligibility

Should be offered to be involved and have representative
present

Be informed of the outcome and next steps in WRITING
with a copy of the Checklist (NF 66, PG 6.7)


Checklist
OUTCOME

A full assessment is required if:
2 or more domains in column A (HIGH needs)
5 or more domains in column B, or 1 A and 4 in B
(MODERATE needs)
1 domain in column A which carries a PRIORITY need

PROCESS: Checklist sent to PCT who is responsible for
coordinating the whole process (NF 67, PG 6.8)

NOTE: It does not mean that if someone is referred on to the
full process that they will be eligible. The threshold is low. It is
only to be referred for full consideration.


Checklist
SCREENING TOOL

Based on the 11 specific care domains on the DST
For each domain, descriptions represent “no and low”, “moderate”
and “high” needs
Select description that closely matches current needs
Evidence of needs should be available

C B A

Behaviour *

Cognition

Psychological


Checklist
EXERCISE 3

Behaviour Report (from nursing notes):

Occasional episodes of challenging behaviour when providing
personal care and toileting; usually shouts “leave me alone”; has
only thrown a cup once; never strikes out. Episodes much less
frequent now, e.g. x1 on 24/05/10 and x1 on 5/6/10. This was
contributed to by other issues on ward and time. Mr W. is able to be
diverted and reassured. Also at these times he will accept PRN
meds if necessary.


Decision Support
ToolDECISION MAKING
INFORMED

Coordinator identified; MDT is brought together, made
up of 2 or more health and social care professionals

Involve the individual or their representative

With consent, the assessment process is undertaken
and specialist assessments obtained if necessary
(mental health nursing needs)

MDT, ideally with the individual or their representative,
meet and complete the DST together, domain by
domain


Decision Support
ToolDECISION MAKING
INFORMED

Information collected during the assessments used to
complete the DST

Purpose of DST is help decide:
NATURE INTENSITY
COMPLEXITY UNPREDICTABILITY

DST has 11 specific domains and one “other” = 12 in
total


Decision Support
Tool
12 CARE DOMAINS

1. Behaviour *
2. Cognition
3. Psychological & Emotional
4. Communication
5. Mobility
6. Nutrition
7. Continence
8. Skin
9. Breathing *
10.Drug Therapies *
11.Altered States of Consciousness *
12.Other


Decision Support
Tool
LEVELS OF NEED

Each domain broken down into between 4 and 6 levels of need

no need low moderate high severe priority

See NF page 23, Figure 2 for relationship between level of needs
and PHN (intensity, complexity, unpredictability)


Checklist
EXERCISE 4

Behaviour Report (from nursing notes):

Occasional episodes of challenging behaviour when providing
personal care and toileting; usually shouts “leave me alone”; has
only thrown a cup once; never strikes out. Episodes much less
frequent now, e.g. x1 on 24/05/10 and x1 on 5/6/10. This was
contributed to by other issues on ward and time. Mr W. is able to be
diverted and reassured. Also at these times he will accept PRN
meds if necessary.


MAKING A
DECISION
PRIMARY HEALTH NEED

Role of MDT is to make a decision on eligibility
Inform the PCT of that decision (recommendation)
Recommendation of eligibility would be expected by
the MDT where there is:
one priority level of need
two or more severe levels of need

Recommendation of eligibility may be expected where
there is:
one severe with a number of needs in other domains
a number of domains with high and/or moderate needs

Judgment of PHN is based on evidence
All “no needs”; all “low needs” = unlikely PHN


MAKING A
DECISION
THE RATIONAL

Rational shows the reasoning for the recommendation

Must address: Nature, Intensity, Complexity, Unpredictability

See Practice Guidance 8.10

DST supports decision-making (not an assessment tool)
Evidence / reports must be attached
Everyone in MDT signs and dates

Recommendation sent to PCT

28 days from referral (Checklist) to decision
(acceptance of MDT recommendation by PCT)


PC
CHCT
PANELS

PCTs do not have to use a panel, but where they do, it is to check for
consistency and quality of decision making (NF 80, PG 9.1 to 9.3)

PCT can ask the MDT to carry out further work (NF 81)

PCT should not make a decision without a recommendation from the
MDT (NF 82)

Checklist, DST, Reports, Recommendation to relevant PCT
Mid Essex: June Murphy 0300 123 8095 Fax: 0300 123 8096
NE Essex: Sue Chan 01206 286758 Fax: 01206 286763
SE Essex: Nicky Justice 01702 226550 Fax: 01702 224666
SW Essex: Jan Crozier 01277 695502 Fax: 01277 695221
W Essex: Beau Klusko 01992 566132 Fax: 01992 566133


ELIGIBLE
WHAT HAPPENS?

PCT becomes responsible for care planning, commissioning &
funding

The PCT will decide how best to meet assessed needs

Require a nursing care home? Can express preferences, but do
not have the right to choose location or specific care home

Remain at home? PCT will consider if needs can be met there

It cannot be provided through Direct Payments

If at home, informal carer? Carers’ Assessment


ELIGIBLE
AFFECT ON BENEFITS

If receiving NHS CHC in a care home (self-funder or
not), will lose Attendance Allowance and Disability
Living Allowance

If receiving NHS CHC in your own home, can keep AA
and DLA

State Pension not affected; pension credit may be
affected if you are receiving the severe disability
element of the pension credit


REVIEW
STILL ELIGIBLE?

Review held 3 months after initial eligibility (Fast
Track or DST route)

At 3-month review, could be found not eligible if PHN
not demonstrated

After 3 month review, subject to an annual review
(minimum)


FUNDED NURSING
CARE ELEMENT IN CARE HOME
PAYS FOR NURSING

Not eligible for NHS Continuing Healthcare
Paid directly to nursing home: £108.70 per week
Cover cost of register nurse who may be providing:
Direct nursing care
Supervision / monitoring of care provided by non-
registered nurse
Planning & reviewing care plans
Monitoring & reviewing medication
Identifying & addressing potential health problems


APPEAL
LOCAL and INDEPENDENT REVIEW PANEL

If found not eligible, can appeal:

1. PCT - Attempt local resolution first

2. SHA - Independent Review Panel

3. Health Service Ombudsman


END OF LIFE CARE

Fast Track Pathway Tool to get an immediate decision
on eligibility, if PHN demonstrated

Subject to 3-month review

IMPORTANT: PHN still needs to be demonstrated:
Nature, Intensity, Complexity and Unpredictability

If eligible: should have choice about where the care
will be delivered


ODDS &
SODS
If you go into a nursing home for 6 weeks or less, you
will qualify for NHS funding (nursing respite or
emergency placement because your carer is ill) –
must be agreed with PCT first

If receiving FNC and you go into hospital, FNC stops
during your stay in hospital


QUESTIONS
MORE INFORMATION

Department of Health website
Age UK
Counsel and Care
Citizens Advice Bureau
PCT / NHS services


Twelve Golden Quality Principles
The people of Essex have identified twelve key quality principles they expect ; the aim
for the organisation is to achieve consistently high targets relating to these principles

1. I know where to find the information I need about options for care and support
2. My communication needs are understood and addressed
3. My dignity has been respected at all times
4. I am given enough time and help to express my needs and wishes and to identify desired
outcomes
5. I am supported to make my own decisions about my care
6. My preferences relating to culture, ethnicity, religious beliefs and sexuality are considered
7. I am satisfied with the quality of service I am receiving
8. I feel in control of the services and support I receive
9. I live my life free from abuse and harassment
10. My quality of life has improved since receiving/managing my support
11. I have enough help and support to maintain my independence
12. I am achieving (have achieved) the personal goals set out in my support plan

The Dignity Challenge
High-quality services that respect people’s dignity should:

1. Have a zero tolerance of all forms of abuse
2. Support people with the same respect you would want for yourself or a member of your
family
3. Treat each person as an individual by offering a personalised service
4. Allow people to maintain the maximum possible level of independence, choice and control
5. Listen and support people to express their needs and wants
6. Respect people’s right to privacy
7. Ensure people feel able to complain without fear or retribution
8. Engage with family members and carers as care partners
9. Assist people to maintain confidence and a positive self-esteem
10. Act to alleviate people’s loneliness and isolation

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