NHS Continuing Care and NHS-funded Nursing Care

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1 NHS Continuing Care and NHS-funded Nursing Care What do the terms mean? Units 6 & 8, Hill View Business Park Old Ipswich Road, Claydon, Suffolk IP6 0AJ enquiries@suffolkfamilycarers.org Website Reception Information Line NHS-funded Nursing Care The Health and Social Care Act introduced this in It is an amount of money that is provided to Nursing Homes by the NHS to support the provision of nursing care by registered nurses for anyone assessed as eligible. It is per week (until April 2013) and is paid directly to the nursing home as an additional contribution to the normal residential fees. It can only be paid to homes registered as able to provide nursing care. If a person has some health needs requiring the care of a registered nurse or care monitored or supervised by a registered nurse, it is eligible for payment, therefore if you are not eligible for NHS Continuing Care, you may well be eligible for this contribution and your eligibility should be reviewed annually. It does not affect your state benefit or tax entitlement. NHS Continuing Care Is provided to those over 18 who have physical or mental health needs arising as a result of a disability, illness or accident. The assessment is required to consider the nature, complexity, intensity and unpredictability of the person s needs. When assessing a person s needs, the assessor must consider all the needs and not just their health needs. It is a complete package of ongoing care arranged and funded solely by health (each area now has a Clinical Commissioning Group or CCG which is responsible for assessing and providing the funding to those living in their area. It is allocated when the CCG has assessed that the individual s primary need is a health need. See below for more information on what a health need is. You can receive it in any setting, including the person s own home or in a residential care home. Joint packages Joint packages can be offered where social care and health agree to split the cost of the care perhaps because of a high health and social care need, but neither one is more dominant that the other. If so it is not NHS Continuing Care funding but a joint package. S117 funding If you have been detained in hospital under some sections of the Mental Health Act 1983, both adult social care and health have a duty under Section 117 of the Mental Health Act to provide you with aftercare services until such time as they both agree are no longer needed, therefore if you are placed into a care home or provided with care under s.117, the care you receive will be free. There may be cases where aftercare services are no longer needed for your mental health but other services are required. Each case has to be individually assessed, but in cases of dementia, the High Court has ruled that the mental state is very unlikely to improve and so, therefore, it is unlikely that the services are not going to be required. Suffolk Carers Limited Registered Charity No A company limited by guarantee in England No Registered Office: Unit 8, Hill View Business Park, Claydon IP6 0AJ

2 Which needs are which? What is a health need? The definition is: A need relating to the treatment, control or prevention of a disease, illness, injury or disability and the care or aftercare of a person with those needs. What is a social need? The definition is: A need where the focus is on providing assistance with activities of daily living, maintaining independence, social interaction, playing a part in society or protecting their vulnerability. These are generally the responsibility of the Local Authority and include things like practical assistance in the home, with equipment, with meals and accessing the community, work and education etc. It is worth noting that if a person is eligible for NHS Continuing Health Care funding the CCG must pay for the social needs such as personal care. What is the process? Discharge from hospital The Delayed Discharge direction advises that the NHS should (not must) screen (using the checklist or screening tool) or carry out a full assessment of CHC funding before they give a fit for discharge certificate. They must take reasonable steps to ensure an assessment of eligibility is carried out in all cases where it appears that the patient may need health care; they should discuss this with the Local Authority. This consideration can delay the assessment if a period of rehabilitation or therapy may improve the person s condition. Once a clearer picture of the person s future needs is available, the assessment of eligibility should be carried out promptly. If an individual is urgently in need of community care services, the Local Authority should assess them and when doing so, should consider their health needs. If they identify a need for health services as well, the CCG should be invited to carry out a joint assessment. The Checklist or Screening Tool The assessors will use the Checklist to see if a full NHS Continuing Care Assessment is needed. Either health or social care professionals can do this checklist. There should be a joint local process in place to identify who should complete the checklist. Not everyone will need to be assessed, but the CCG can only use this tool to screen eligibility for CHC funding if they are considering a person s eligibility. Assessors must have undertaken training to use the checklist tool. They should involve the person and their representatives in the process. The person should consent to the process. If the person lacks capacity and there is not a welfare attorney or welfare deputy appointed, a best interest s decision can be taken and the person s family and friends should be involved in the decision-making process, (See separate factsheet on Best Interests). The assessors score the person A (high need), B (moderate need) or C (low need) in 12 areas or domains. The 12 areas are the same as those used for the full assessment (set out below). If a person scores two or more A s or 5 or more B s or one A and 4 B s or one A in any of these categories; behavior, breathing, drug therapies or altered states of consciousness as well as needs in any other category, they should be referred for a full Decision Support Tool Assessment. The Checklist does not have to contain evidence but the assessors should record where the evidence is to support their assessment. Whatever the outcome of the Checklist, the reasons should be communicated clearly in writing to the person (or their representative) as soon as possible. If the decision is not to proceed, details of how to ask for a reconsideration of the decision or how to complain should also be provided.

3 If a person has a rapidly deteriorating condition which may be entering the terminal phase, the Fast Track Pathway Tool can be used by an appropriate clinician (usually this will be the person responsible for care and a registered medical practitioner). Additional evidence should not be needed to support this assessment. The CCG must accept this as long as it was completed in line with the Fast Track Guidance. If the person s condition improves, the funding decision cannot be changed until a full Decision Support Tool has been used. If the person does not have a rapidly deteriorating condition and may be entering the terminal phase, and has been positively assessed, a full assessment should be carried out. This is called the Decision Support Tool. The Decision Support Tool or Full Assessment If the person has been positively assessed, a full assessment should be done. The assessor will look at the: Nature - the type of condition or treatment required and its quality and quantity Complexity - how symptoms interact to make care and care management more difficult Intensity - one or more severe needs requiring regular, sustained care Unpredictability of your health - the degree to which unexpected changes in the condition occur which may affect level of risk and care needs. A multi-disciplinary team of two or more health and/ or social care professionals should do the full assessment. This assessment is then used to complete the Decision Support Tool which looks at twelve different types of need and depending on the nature, complexity, intensity and unpredictability of your health; you receive a score for each area. Each area is classed as a care domain (see below) and each area is scored as low, moderate, high, severe or priority. Some areas cannot be scored as priority or severe. Those have boxes in black below. Care Domain Priority Severe High Moderate Low None Behaviour Cognition Psychological Needs Communication Mobility Nutrition Food and Drink Continence Skin (inc. tissue viability) Breathing Drug Therapies & Medication Altered States of Consciousness Other significant care needs TOTALS If a person scores a level of priority or two or more severe scores they are entitled to NHS Continuing Health Care. If a person scores a severe in one area and has needs in a number of other domains, or if they score a number of highs and/or moderate s this can (but it s not automatic) also indicate a primary health need. In these cases, the overall needs, the interactions between needs in different care domains, and the evidence from risk assessments, should be taken into account when deciding whether a recommendation for NHS Continuing Healthcare should be made. It is not possible to equate a number of incidences of one level with a number of incidences of another level, for example two moderates equal one high.

4 If needs in all domains are recorded as low or no need, this would indicate ineligibility, however, because low needs can add to the overall picture, influence the continuity of care necessary and alter the impact that other needs have on the individual, all domains should be completed. If a need is successfully managed it should not be assessed lower unless it has permanently reduced or removed an ongoing need. Consideration should be given to what would happen if the needs were not successfully managed, for example, behaviours that were managed with support might revert back if the support was not maintained. Where health needs are managed successfully by medication, this should be reflected within the drug therapies section with a higher rating in this domain. Assessments should be obtained from those professionals involved in the individuals care. Assessments need to be of good quality to be able to inform the Multi-Disciplinary Team. They should take a holistic approach to the person s needs and be evidence based. Assessments need to be clear about the degree and nature of any risks and focused on improving outcomes for the person. They should also contain the person s views and should be informed by information from those providing the care. The information the MDT considers can include health assessments, Occupational Therapy reports, Physiotherapy reports, Speech and Language Therapy reports, Psychiatric assessments, care plans, 24/48 hour diaries, specialist nurse information, risk assessments and the use of standard tests or measures as well as information from the person and their family. If a person has a deteriorating condition, the assessments should consider this and an earlier review date should be considered. Assessments should not be based on the person s condition, but on how it affects them. Even if a person does not score highly enough, practitioners can still decide that a person has a primary health need overall. The reasoning for this must be clearly set out in the recommendation. The Multi-Disciplinary Team coordinator collates the information collected and explains the process to the person and their family, seeking their views. Those involved in the Multi-Disciplinary Team should meet to discuss the case and then agree on a recommendation. The person and relatives do not have to be involved in this discussion but their views of the assessment should be taken in to account. Once a decision has been made, it should be communicated to the person and their family as soon as possible. The recommendation should include: A summary of the person s needs in light of each of the domain s and any further information required Statements about the nature, complexity, intensity and unpredictability of each of the individuals needs An explanation of how the needs in one category can inter-relate to other categories The recommendation itself A copy of the completed assessments, the Decision Support Tool and other documents should be sent to the Clinical Commissioning Group. To summarise, you must show that your primary need is a health need that you require frequent supervision for by a member of the NHS multi-disciplinary health team. You need to show that you require the routine use of specialist healthcare equipment under the supervision of NHS staff and that you have a rapidly deteriorating or unstable condition due to physical, mental or medical health requiring regular supervision or you are in the final stages of a terminal illness. The Behaviour category A person s behaviour might be deemed as challenging but what does this mean in terms of NHS continuing care funding?

5 To be assessed as priority the behaviour would need to be severe and/or of a frequency that presents an immediate and serious risk to the self and others. The risks would need to require urgent skilled responses at all times to ensure safe care. To be assessed as severe the behaviour would need to be severe and /or pose a significant risk to the self and others. The risks would require a prompt and skilled response. To be assessed as higher level the behaviour is likely to be predicted as posing a risk to the self or others. The risk assessment might indicate that planned interventions are able to manage the risk most of the time and where compliance is variable but usually responsive to a planned intervention. What if they don t agree? If, after considering all the evidence no agreement can be reached on the level of a domain, the higher level should always be used. What happens to the recommendation? The recommendation is put to the Clinical Commissioning Group or to a panel. Panels are often used if there is disagreement between the Local Authority and the Clinical Commissioning Group on who is responsible. Panels are also used when an appeal is made and to audit the case or cases which are not eligible for continuing care funding and cannot be considered for joint funding with health and the Local Authority. If there is not a panel, the Clinical Commissioning Group should still consider how to obtain the Local Authorities views before any decisions are made. The recommendation should be followed unless there are exceptional circumstances clearly articulating the reasons for not doing so. The Clinical Commissioning Group/Panel could pass the recommendation back and ask for more evidence, especially if there was disagreement within the MDT about a person s level of need If there is no recommendation, the Clinical Commissioning Group should not make a decision unless in exceptional circumstances. How long should it all take? It should not take longer than 28 days from when the Clinical Commissioning Group receives the completed Checklist. Reviews A review could be part of a dispute resolution process or appeal procedure or if the Clinical Commissioning Group/Panel felt there was insufficient evidence. A review may also take place if a person s needs have changed. A person who is eligible could be reviewed by a consultant or another health professional who could conclude that they are no longer eligible without involvement from the local authority or the person and their family. The person is given 28 days notice when funding is going to cease and this decision will stand unless it is challenged. Ongoing Case Management Once a person is deemed eligible, the Clinical Commissioning Group is responsible for all aspects of an individual s care package, not just the health aspect. The Clinical Commissioning Group should commission services to maximise individual control and reflect preferences as far as possible. Any cost comparisons should be completed on the basis of how much an alternative would cost. The Clinical Commissioning Group should consider the use of assistive technology in meeting a person s needs and whether a nurse is required or just for specific tasks or required to provide overall supervision. The willingness of Family Carers should be considered but they should not be pressured to provide support. The costs should be balanced against the person s desire to live in their family environment.

6 If the Family Carer is willing and able to provide some support the Clinical Commissioning Group should consider whether they require any training and whether they may need to provide additional support to the person whilst the Family Carer has a break from their caring role. What about welfare benefits? If you receive funding from the NHS Continuing Care fund you are still treated as being in hospital for the purposes of welfare benefits, therefore, the DLA care component and Attendance Allowance is not payable to a person who s care is funded in this way (there are a very few number of exceptions to this). If you are funded under S.117, the DLA care component and Attendance Allowance you receive may be affected. Other benefits, such as Income Support should continue to be paid.