Continuing Healthcare Policy

Transcription

1 Continuing Healthcare Policy NHS Swindon Clinical Commissioning Group November 2016 Modified By: Jacqui Date: 02/08/2018 Document Control: Connelly/Amanda du Cros Document ID: Page 1 of 30 Continuing Healthcare OFFICAL PERSONAL SECURE

2 Policy Policy Reference Policy Statement NHS Swindon Clinical Commissioning Group Continuing Healthcare Policy This policy sets out the responsibility of Swindon Clinical Commissioning Group for describing compliance with the National Framework for NHS Continuing Healthcare (2012 revised). Version Number The Policy provides the process guidance for determining the eligibility of patients for NHS-funded Continuing Healthcare 0.6 Version Date Review Date Author Responsible Owner Approving Body To be determined Jacqui Connelly/Amanda du Cros Gill May, Executive Nurse EMT Integrated Governance Committee Governing Body Document Control Reviewers & Approvals This document requires the following reviews and approvals Name Position Version Approved Date Approved Revision History Version Revision Details of Changes Author Date Changes identified by Jacqui Connelly on Amanda du Cros version previously developed in October Comments received from Art Calder Amanda du Cros Comments and updates from Jacqui Connelly Amanda du and Amanda du Cros Cros/Sharon Woolford Comments sought from membership of CHC Amanda du Cros Programme Board Amendments received from EMT held on detailing changes to the PUPOC section. Amanda du Cros Page 2 of 30

3 Comments received from John Martin and comments received from Legal Team at SBC Amanda du Cros Acknowledgement of External Sources List any policies or procedures from external institutions that have been used to inform the writing of this policy. Title/Author Institution Comment / Link The National Framework for NHS Continuing Healthcare and NHSfunded Nursing Care (NHS England, 2012 (revised) NHS England Appendix A Links or overlaps with other key documents & policies Document Title The National Framework for NHS Continuing Healthcare and NHS- funded Nursing Care (NHS England, 2012 (revised) Version and Issue Date Link/Document 28 Nov 2012 See Appendix A NHS Continuing Healthcare Checklist (NHS England, 2012) Decision Support Tool for NHS Continuing Healthcare (NHS England, 2012) Fast Track Pathway Tool for NHS Continuing Healthcare (NHS England, 2012) NHS England Operating Model for NHS Continuing Healthcare 2015 Continuing Healthcare Commissioning Policy (Choice and Equity) The Delayed Discharges (Continuing Care) Directions Nov 2012 See Appendix A 28 Nov 2012 See Appendix A 28 Nov 2012 See Appendix A 31 Mar 2015 See Appendix A TBC 23 Oct 2013 See Appendix A The Mental Capacity Act See Appendix A Guide for Health and Social Care See Appendix A practitioners Personal Health Budget Policyv3 June 2016 Appendix B (to be attached) Terms of Reference for Continuing Health Care Panel May 2016 Appendix C ( to be attached) Page 3 of 30

4 Local Disputes and Resolution Policy ( in draft, to be considered at same time as CHC Policy) September 2016 Appendix D ( to be attached). Distribution & Consultation This document has been distributed to the following people: Name Date of Issue Version Art Calder, Lead Manager, CHS V1 Graeme O Malley, Project Manager, NHS Swindon CCG Sharren Pells, Associate Director for Quality, NHS Swindon CCG Yvonne Knight, Corporate and Information Governance/Risk Manager, NHS Swindon CCG V V V1 Gill May, Executive Nurse, NHS Swindon CCG V1 Caroline Gregory, Director of Finance, NHS Swindon CCG Matthew Hawkins, Deputy Director of Finance, NHS Swindon CCG V V1 Barbara Perchard, Complaints Manager ( PACT) V1 Angela Plummer, Head of Adult Services, Swindon Borough Council Jackie Walker, Head of Finance and Change, Swindon Borough Council Joy Kennard, Head of Commissioning, Swindon Borough Council Alison Forster, Service Operational Manager, Swindon Borough Council and LA representative on CHC Panel Brian O Shea, Service Operational Manager, Swindon Borough Council and LA representative on CHC Panel Kay Reeve, Head of Learning Disability Social Care and Adult Commissioning V V V V V V3 DESIGNATED NURSE ADULT SAFEGUARDING to be in post from November Executive Management Team V4 John Martin, Interim Manager, Swindon Borough Council Document Version Numbering V6 Document versions numbered 0.1, 0.2, and 2.4, are draft status and therefore can be changed without formal change control. Once a document has been formally approved and issued it is version numbered Issue 1.0 and subsequent releases will be consecutively numbered 2.0, 3.0, etc., following formal change control. Page 4 of 30

5 Freedom of Information If requested, this Document may be made available to the public and persons outside the healthcare community as part of NHS Swindon Clinical Commissioning Group s commitment to transparency and compliance with the Freedom of Information Act. Accessibility This document is available in other styles, formats, sizes, languages and media in order to enable anyone who is interested in its content to have the opportunity to read and understand it. These alternatives include but are not limited to: Alternative languages and dialects Larger and smaller print options (font 8 to 18) Simplified versions including summaries and translation into symbols Audio or read versions Web based versions that can be zoomed into or shrunk on screen Braille Page 5 of 30

6 Table of Contents Contents 1 Introduction Purpose & Scope Definitions Responsibilities Principles The CHC Process Flow Chart Procedures Eligibility for NHS Continuing Healthcare (CHC) Application for eligibility process Fast Track Applications Management of Appeals Complaints Discharge Planning Previously unassessed periods of care PUPoC Commissioning of Care Packages De-commissioning of care packages Choice Case Reviews Jointly Funded Packages of Care Transition from Child to Adult Services Handover Process Handover from Social Care (Local Authority) to Health (NHS) Handover from Health (NHS) to Social Care (Local Authority) Retrospective Reviews of Care Commissioning of Care Packages and contracting arrangements of choice Non-acceptance of available placement choices by competent persons Personal Health Budgets Funding Training Audit and Monitoring Page 6 of 30

7 1. Introduction This Policy is for the delivery of a NHS Continuing Healthcare (NHS CHC) service across Swindon. The service will be delivered by NHS Swindon CCG in line with the National Framework for NHS Continuing Healthcare (2012). The National Framework for NHS Continuing Healthcare and Funded Nursing Care (revised 2012) sets out the principles and processes for the implementation of NHS CHC & NHS Funded Nursing Care (FNC) and it provides national tools to be used in assessment applications and for Fast Track cases. It does not change the basis of eligibility decisions for NHS CHC and NHS FNC, or the overall principles, but seeks to provide greater clarity about the levels and types of need to be considered, as well as changes to the wider information that needs to be recorded and the Fast Track Pathway Tool. This policy describes the processes that will be followed by NHS Swindon CCG. Individuals receiving NHS CHC have some of the most clinically complex and severe needs within the local population. The majority of cases have little or no potential for rehabilitation and many are receiving end of life care. In some cases changes to an individual s condition can result in their needs being no longer eligible for NHS CHC funding. This policy should be read in conjunction with the Operating Model for NHS Continuing Healthcare 2015 and is implemented as a complement to the National Framework for NHS Continuing Healthcare and aligned Policy and Legislation (see Appendix A). NHS Continuing Healthcare (NHS CHC) CCG s have a delegated target duty to promote a comprehensive health service; they also have a statutory duty to ensure that each year their expenditure does not exceed the financial allocations and other sums they receive. Although CCGs are expected to take account of patient choice for individuals found eligible for NHS Continuing Healthcare funding, they must do so in the context of those two responsibilities. Although they have a duty to meet a person s reasonable healthcare needs, they do not have a duty to meet their every healthcare need and CCGs must exercise their judgment to provide the appropriate care within the resources available to them and taking into account their priorities for overall expenditure. There is no duty on NHS Swindon CCG to provide a specific package of care although NHS Swindon CCG will take individual choice into account when arranging a suitable package. In the delivery of CHC, NHS Swindon CCG has to ensure consistency in the application of the national framework whilst implementing and maintaining good practice and ensuring quality standards are met and sustained in line with available resources and value for money in the use of public funds. Fully funded CHC is provided following the appropriate assessment, for people aged 18 or over that require assistance as a result of frailty, illness, accident or disability. It is a package of care and support that is provided to meet all assessed needs, including physical, mental health and personal care needs. The care is arranged and funded solely by the National Health Service (NHS), but can be provided by other agencies. Page 7 of 30

8 This care can be delivered in a variety of settings, including a care home, or in a patient s own home. In some cases, the choice of living environment may be restricted in order to meet complex or intensive health needs. The more recent provision of Personal Health Budgets will allow an individual that is receiving CHC to purchase the care and support they need under a locally agreed protocol (Please Refer to NHS Swindon CCG Personal Health Budgets Policy 2015). For an application of CHC to be agreed the care needs must be proven to be more than; o incidental or ancillary to the provision of the accommodation that a Local Authority (LA) is under a duty to provide, pursuant to section 21 of the National Assistance Act 1948; and o of a nature that an authority whose primary responsibility is to provide social services can be expected to provide o the quality and/or quality of health needs would indicate that a person s Primary Need is a health need that requires the responsibility of the NHS the Primary Health Need (PHN). Essentially, all the care must be paid for by the NHS whereby reason of the quantity of care or the quality of that care, the care as a whole is beyond what a social services authority could be reasonably expected to provide. The NHS refers to this as the PHN test, and a set of national tools has been developed to assist practitioners in coming to a reasoned conclusion which is transparent and consistently applied. For more information see 2. Purpose & Scope This policy sets out the roles, eligibility and responsibilities for health and social care staff for the delivery of the National Framework for NHS Continuing Healthcare & NHS funded-nursing care. It provides the process for determining eligibility for continuing healthcare funding and the procedures to be followed. The policy also sets out the responsibilities of NHS Swindon CCG in those situations where eligibility for NHS CHC has not been agreed, and for the management of situations that may arise as a result of NHS CHC eligibility decisions. NHS Swindon CCG will commission and provide care in a manner that reflects the preferences of individuals whilst balancing the need to commission safe and effective care that makes the best use of available resources. NHS Swindon CCG will work towards value based commissioning of care to ensure the best possible care at the best possible price. Page 8 of 30

9 In order to achieve this, the implementation of the criteria and local application for NHS CHC, in conjunction with the local authority, provider trusts and other agencies, should meet the following principles: Needs led Equitable Culturally sensitive Person centred Robust and transparent Easily understood Adheres to guidance and best practice Exceptions a) Persons detained under the Mental Health Act after care orders such as Sections 117. b) Children and young people under 18. The National Framework for NHS Continuing Healthcare applies only to adults aged 18 or over. There is a separate National Framework for Children and Young People s Continuing Care. c) Active Treatment Individuals will be expected to have completed any active treatment and/or reached their optimum potential for any rehabilitation. 3. Definitions Funded Nursing Care Social Care Needs Healthcare Needs Fast Track Tool Care Packages Care Plan Funding Nursing Care (FNC) is a fixed payment paid by the CCG to a care home with nursing which contributes to the registered nursing care element for the residents. are directly related to the type of welfare services that LA s have a duty to provide. These include but are not limited to: assessments of need, advice, information, personal care assistance with daily living tasks. Assessment/assistance with equipment and home adaptations, support to locate a care home, carer support. are related to the treatment, control, or prevention of a disease, illness, injury or disability and the care or aftercare of a person with these needs. should be used for individuals who need an urgent package of care, due to a rapidly deteriorating condition that may be entering the terminal phase. suite of services (nursing, therapies, home care etc.) that are designed to match the assessed needs of a client/patient. Plan drawn up by a clinician to meet the needs of a patient/client, centred on the Decision Support Tool (DST) which establishes the health needs. CHC department to monitor quality of care provider documentation at review. Page 9 of 30

10 Screening Checklist Tool Retrospective review - PUPoC Decision Support Tool Clinical Eligibility Panel Case Manager is designed to help practitioners determine the appropriateness of an individual to go forward for consideration for a full assessment for NHS CHC funding. a retrospective review can be requested by individuals to look back at eligibility for NHS funded Continuing healthcare prior to the current eligibility decision or current referral. An individual can also request a retrospective review if they feel they have never been considered for NHS CHC or feel they have been wrongly denied NHS funding Previously Unassessed Periods of Care a tool providing a framework used by clinicians to collate the multidisciplinary assessment of needs of a client/patient and apply the evidence in a single practical format in order to facilitate consistent, evidence-based decision-making regarding NHS continuing healthcare eligibility. The DST is not an assessment in itself. A Continuing Care Panel to include senior NHS representative and Local Authority representative that ratifies MDT recommendations or in some cases makes a decision for eligibility for NHS continuing healthcare funding. The completed DST is presented to Panel members. Professional responsible for; drawing up a care plan; monitoring the needs of the client/patients receiving a care package and assessing the suitability of the package. 4. Responsibilities Health & Social Care staff referring clients for consideration of eligibility Complete the required NHS documentation, Assessment in Care Planning, Review of patients, Decision making process, Checklist, Fast Track and Decision Support Tool (DST) on time and in line with national timelines, including the provision of supporting evidence As detailed within the CHC Operating Model( ) NHS Trusts Complete the required documentation to include, Assessment, Checklist, Fast Track (if appropriate) and Decision Support Tool (DST) on time and in line with national timelines, including the provision of supporting evidence in line with NATIONAL HEALTH SERVICE ACT 2006 THE DELAYED DISCHARGES (CONTINUING CARE) DIRECTIONS November 2013 Continuing Healthcare Team Receive and review all completed applications to ensure the standards required are met and that they indicate eligibility for receipt of service or further assessment for eligibility. All submitted documents Page 10 of 30

11 must be accompanied by completed consent form (with accompanying Mental Capacity Assessment if applicable) Maintain and control the continuing healthcare patient flow allocation lists, patient files and data base ensuring all referrals are recorded and that all correspondence is kept for each individual patient CHC assessor allocated the case and liaise with a Multi-disciplinary Team (MDT) involved with the individual s care. Receive completed DST s with MDT recommendation for clinical ratification in accordance with local policy. Ratification of Checklists completed within 2 working days Fast Track will be completed within 1 working day Arrange for the DST to be presented to the Clinical Eligibility Panel. The outcome decision to be sent to the referrer and individual or their representative and how to appeal if the outcome is not eligible. If eligibility is ratified by the panel for 100% NHS continuing healthcare, arrange the package of care based on the needs of the individual and provide costing s of the package of care to the Panel for approval. If the individual is not eligible for NHS funding but is entitled to NHS Funded Nursing Care (FNC) arrange for the payments to be made to the care home in a timely manner. Record all eligibility/panel decisions in individual s case records (including on Care Track) and ensure all communication of eligibility/panel decisions is undertaken in a timely and professional manner. Ensure patient case management for the care provision arrangements are in place. Ensure reviews are undertaken in line with national policy and at other times as required. Undertake regular audit to ensure service is meeting agreed Key Performance Indicators (KPIs) including patient, staff and customer feedback. Ensure Swindon CCGs quality and safeguarding professionals are alerted to issues with Care providers which may compromise quality of care. Clinical Eligibility Panel Panel to work to Continuing Care Panel Terms of Reference. Consider all applications for continuing healthcare eligibility in a timely and robust manner where required (Complex cases) focusing on the clinical evidence supporting the MDT recommendation. Clinical evidence not supporting it will be returned for further review. Page 11 of 30

12 Consider all patients who no longer meet the eligibility for 100% care packages. Approve the MDT recommendation on eligibility/non eligibility of a client/patient for a NHS continuing healthcare package of care on behalf of the CCG. NHS Continuing Healthcare funding, care package procurement. To ensure that principles of Personal Health Budgets are implemented in developing an individual s care provision. Ensure that an appropriate selection of packages are offered to each client/patient based on their individual care plan. Review all complex packages of care ensuring value for money has been considered. Approve the placing of contracts for packages up to the manager s delegated limit. Seek assurances that providers are fit and proper organisations to provide care. Seek waivers to Standing Financial Instructions where this is necessary. Ensure that a database of clients and packages is maintained including updating Care Track. Authorise invoices up to the manager s delegated limit. Agree the cost of the NHS share of joint funded packages. Approve one-off payments up to the manager s delegated limit. 5. Principles An individual who needs NHS CHC may require services from NHS bodies and/or from Local Authorities. Clinical Commissioning Groups have responsibility to ensure that the assessment of eligibility for NHS CHC takes place within 28 days from receipt of the Continuing Healthcare Checklist and in a timely and consistent manner. NHS Swindon CCG and Swindon Borough Council are committed to working in partnership to achieve these timeframes, together with local provider services. The principles underlying this policy are that the residents of Swindon have fair and equitable access to NHS CHC. These principles are:- The individual s informed consent will be obtained before starting the process to determine eligibility for NHS CHC and engagement in the Continuing Healthcare / Funded Nursing Care Review Process. If the individual lacks the mental capacity either to refuse or consent, a best interests decision should be taken and recorded in line with the Mental Capacity Act 2005 as to whether to proceed with assessment for eligibility for NHS CHC. A third party cannot give or refuse consent for an assessment of eligibility for NHS CHC on behalf of a person who lacks capacity, unless they have valid and applicable Lasting Power of Attorney for Health and Welfare or have been appointed as a Deputy by the Court of Protection for Welfare only. NHS Swindon Page 12 of 30

13 CCG will act in the best interest of the individual and convene best interest meeting if there is a dispute and no one has power of attorney. Health and social care professionals will work in partnership with individual patients/clients and their families throughout the process All individual patients and their families representatives will be provided with information to allow them to participate in the process NHS Swindon CCG will support the use of advocacy for individuals through the process of application for NHS CHC, as in other services where advocacy is required The process for decisions about eligibility for NHS CHC will be transparent for individual patients and their families and for partner agencies Once an individual has been referred for a full assessment for NHS CHC, following the completion of a Checklist, all assessments will be undertaken by the multi-disciplinary team (MDT) involved in that individual s care ensuring a comprehensive multi-disciplinary assessment of an individual s health and social care needs, following the procedure for completion of the Decision Support Tool (DST). Assessments and decision making about eligibility for NHS CHC will be undertaken within 28 days of the completion of the continuing healthcare Checklist to ensure that individuals receive the care they require in the appropriate environment and without unreasonable delays. Page 13 of 30

14 The CHC Process Flow Chart Page 14 of 30

15 6. Procedures 6.1 Eligibility for NHS Continuing Healthcare (CHC) The National Framework for NHS Continuing Healthcare & NHS funded-nursing care (revised, 2012) provides a consistent approach to establishing eligibility for NHS CHC. This is achieved through the use of the revised National Tools and Guidance developed to assist in making decisions about eligibility for continuing healthcare. As a result of the Coughlan Judgement (1999) and the Grogan Judgement (2006), under the National Health Service Act 2006, the Secretary of State has developed the concept of a primary health need to assist in deciding which treatment and other health services it is appropriate for the NHS to provide under NHS CHC. Eligibility to NHS Continuing Healthcare is based upon a persons assessed levels of need. Where a person s primary need is a health need, they are eligible for NHS CHC. Deciding whether this is the case involves looking at the totality of the relevant needs from the assessment process. Where an individual has a primary health need, the NHS is responsible for providing all of the care to meet that need, including accommodation if that is part of that need. Consideration of primary health need includes consideration of the characteristics of need and their impact on the care required to manage the needs. In particular to determine whether the quantity or quality of care is more than the limits of responsibility of Local Authorities (as in the Coughlan Judgement). Consideration is given to the following areas:- Nature: the particular characteristics of an individual s needs and the overall effect of those needs on the individual, including the type of interventions required to manage them Intensity: both extent (quantity) and severity (degree) of the needs, including the need for sustained care (continuity) Complexity: how the needs present and interact to increase the skill required to monitor and manage the care. This may arise with a single condition or the interaction between a number of conditions. It may also include situations where an individual s response to their own condition has an impact on their overall needs Unpredictability: the degree to which needs fluctuate, creating difficulty/challenges in managing the need. It also relates to the level of risk to the person s health if adequate and timely interventions/care are not provided To minimise variation in interpretation of the principles and to inform consistent decision making, the NHS CHC Decision Support Tool (DST) has been developed for use by practitioners to obtain a full picture of needs and to indicate the level of need that could constitute a primary health need. The DST combined with the practitioners own experiences and professional judgement should enable them to apply the primary health needs test in practice in a way which is consistent with the limits on what can be legally provided by a Local Authority. Eligibility for NHS CHC is based on an individual s assessed health and social care needs. The DST provides the basis for decisions on eligibility for NHS funded continuing healthcare. The DST must be completed by the MDT, which as a minimum should include a health professional and a social care practitioner where possible. The Local Authority should co-operate in arranging for social care practitioners to participate in the multidisciplinary team process where appropriate. Specialist staff and mental health staff should be involved dependent on the individual s needs. Page 15 of 30

16 The MDT will make recommendations on eligibility of the individual patients/clients for NHS CHC to NHS Swindon CCG. The CCG will then consider the MDT recommendation and can make the following decisions with regard to recommendations about eligibility:- Verify the recommendations of the multi-disciplinary team For complex cases pass recommendation to Clinical Eligibility Panel for consideration In exceptional circumstances the Panel on behalf of the CCG will not verify the recommendations of the multi-disciplinary team where the evidence provided does not support the level of need indicated in the DST. In such instances the panel will return the case to the co-ordinator for further evidence, defer the decision and request further evidence to support recommendation and consequently decision on eligibility To remove continuing healthcare funding from an individual who is currently in receipt of it, if the multi-disciplinary team recommendation is no longer eligible for NHS CHC 6.2 Application for eligibility process The first step in the process for the majority of people will be the screening process using the NHS CHC Checklist (Checklist). The purpose of the Checklist is to encourage proportionate assessments so that resources are directed towards those people who are most likely to be eligible for NHS CHC. Before applying the Checklist, it is necessary to ensure that the individual and their representative, where appropriate, understand the Checklist does not indicate the likelihood that the individual will be found eligible for NHS CHC, only that they are entitled to consideration for eligibility. At this stage, the threshold is set deliberately low to ensure that all those who require a full consideration of their needs get the opportunity. A nurse, doctor or other qualified healthcare professional or social care practitioner who has received training in completing Checklists, can apply the Checklist to refer individuals for a full consideration of eligibility from within the community or hospital setting. Whoever applies the Checklist will have to be familiar with, and have regard to, the National Framework for NHS CHC & NHS funded-care (Department of Health 2012) and the DST. All appropriately completed NHS CHC Checklists with a consent or mental capacity assessment and best interest assessment, should be sent to the Continuing Healthcare Team at: NHS Continuing Healthcare Team Fax: Secure SWICCG.Swindonchc@nhs.net Receipt of the completed Checklist and consent is the start of the 28 day target for eligibility decisions and will ensure that monitoring of timelines and activity takes place. In a hospital setting, before an NHS body gives notice of an individual s case to a Local Authority in compliance with the Care Act (2014), it must take all reasonable steps to ensure that an assessment for NHS CHC is carried out in all cases where it appears to the body that the patient may have need for such care. The Checklist should therefore be applied, where relevant, as part of the discharge process. Page 16 of 30

17 Where the Checklist has been used as part of the process of discharge from an acute hospital, and has indicated a need for full assessment of consideration of eligibility, consideration must be given to the person s further potential for rehabilitation and for independence to be regained, and how the outcome of any treatment or medication may affect on-going needs. If completion of the screening Checklist indicates that the individual patient is entitled to a full assessment to determine their eligibility for NHS CHC, the DST must be completed. The DST cannot directly determine eligibility, but it provides the basis from which decisions are made exercising professional judgement and in consideration of the primary health need issue. Once the MDT has reached agreement they make their recommendation on eligibility, recorded on the DST, to NHS Swindon CCG. NHS Swindon CCG review the applications they receive to ensure consistency and quality of decision making processes and to ensure governance of the decision making on eligibility. This process ensures equity of access to NHS CHC and consistent decision making for all applications. A person only becomes eligible for NHS CHC once ratification of the recommendation has been completed by NHS Swindon CCG, informed by the completed DST or Fast Track Tool. Prior to that decision being made, any existing arrangements for the provision and funding of care should continue, unless there is an urgent need for adjustment. Where individuals are found to be eligible for NHS CHC, funding will be agreed from the date of the decision of ratification on eligibility. Fast Track applications will be funded from the introduction of the agreed package of care. Negative Screening Outcome process If the Checklist indicates that the individual does not reach the threshold for full consideration, this must be recorded in the individual s hospital notes, or primary/social care records, together with the reasons. This decision should be communicated clearly and in writing by the Lead Coordinator to the individual and their carers or representatives where appropriate. The letter will also explain how an individual can make a complaint about the process. The Screening Checklist threshold is set deliberately low. As such, it is reasonable for NHS Swindon CCG to assume that any person for whom a checklist determines that a full consideration is not required, then NHS Swindon CCG will not accept any appeals on the basis of outcome. Via the NHS complaints process, NHS Swindon CCG will re-consider any cases where the complainant is able to demonstrate that either extenuating circumstances apply NHS Swindon CCG has not followed due process. If the patient is to be admitted to a Care Home with Nursing, a determination for Funded Nursing Care must be completed by a registered nurse employed within the NHS, as detailed under sections 18 and 36 of the National Framework and the NHS Funded Nursing Care Practice Guide (July 2013 revised). Such eligibility will be set out in writing to the patient (or their representative) alongside the outcome of CHC screening as detailed above. The applicant or their representative can seek Page 17 of 30

18 advice from NHS Swindon CCG CHC department with regard to clarity about a decision or how to challenge a decision. Should the appropriate individual(s) not agree with the MDT decision there is an appeals process as set out within this policy. A decision letter will be sent to the appropriate individual(s) confirming the outcome for eligibility for NHS Continuing Healthcare funding. A copy of the DST will be made available, if requested, enabling the appropriate individual to understand the evidence on which the decision was based. 6.3 Fast Track Applications The Fast Track application is there to ensure that individuals who have a rapidly deteriorating condition, which may be entering a terminal phase get the care they require as quickly as possible. No other test is required. Where a recommendation is made for an urgent package of care via the fast-track process, this should be accepted and actioned immediately by the CCG. It is not appropriate for individuals to experience delay in the delivery of their care package while concerns over the use of the Fast Track Tool are resolved. CCGs should carefully monitor use of the tool and raise any specific concerns with clinicians, teams and organisations. Such concerns should be treated as a separate matter from the task of arranging for service provision in the individual case. The National Framework for NHS CHC & NHS funded-nursing care (2012. Department of Health) provides the Fast Track Tool for use in these circumstances. The Fast Track Tool needs to be completed by an appropriate clinician described in the National Framework as: Someone responsible for an individual s diagnosis, treatment or case as a registered medical practitioner or registered nurse. These can include senior clinicians employed in the voluntary and independent sectors that have a specialist role in end of life needs and the organisations services are commissioned by the NHS. The completed Fast Track Tool should clearly state the patient s diagnosis, prognosis and current condition, as this will enable approval to take place immediately upon receipt of the document. Others involved in supporting those with end of life needs, including those in the voluntary and independent sector organisations, may identify that the individual has needs for which use of the Fast Track Tool would be appropriate. NHS Swindon CCG supports the direct involvement of hospital staff in this process to ensure the timely discharge for these patients, supporting end of life care decisions and providing clear accountability for decision making. The NHS CHC Service currently operates Monday to Friday 9-5pm only. The Fast Track application process ensures that same day decisions about eligibility for NHS CHC can be made to support the preferred priorities of the individual for their end of life care. For patients discharged from hospital over the weekend under the Fast Track guidance NHS Swindon CCG will require the fully completed Fast Track Tool on the following Monday. Use of Fast Track applications will be closely monitored by NHS Swindon CCG and action taken where improper use of the process is evidenced to have occurred. Page 18 of 30

19 7. Management of Appeals The decisions of NHS Swindon CCG are communicated to the individual patients, or their representative, and to lead health and social care professionals making the application. The decision is communicated in writing within 10 working days of the decision. The patient, or their representative, and the lead health and social care professionals making the application can be informed verbally of the decision, if they have not been present, and pending receipt of the formal correspondence. The CCG acknowledged that there may be times when an individual or representative may disagree with the outcome decision following the assessment and application of the eligibility criteria and within the National Framework for NHS Continuing Health and NHS funded Nursing Care. There is a formal process to request a review and the first step of this process is set out below: Step 1 The individual or their representative will request in writing to a senior manager in the Continuing Healthcare department for a review of the decision on eligibility. This should be sent within six months of the date of the letter informing them of the eligibility decision. The letter must include either or both: Additional information on assessed care needs which has not been included in the Decision Support Tool (DST); Information why the individual or their representative is dissatisfied with the procedure followed in reaching decision for eligibility. When an appeal is received, this is acknowledged and the evidence is reviewed by a senior Lead Nurse. If the appeal is not resolved at this stage, an offer of an informal resolution meeting with the individual patient or their representative is made to go through the process and rationale for the decision. Appeals in the first instance should be dealt with the CHC Team and only after all attempts at local resolution have been exhausted, should the applicant be directed to the Patient Advice and Complaints team to make a formal complaint. In such situations, the applicant should be directed to: Patient Advice and Complaints Team South, Central & West Commissioning Support Unit Priory Road Medical Centre Priory Road Park South Swindon SN3 2EZ Tel no: CSCSU.palscomplaints@nhs.net Details of how the complaint/appeal will be handled are included in the pathway at appendix D. If following the informal resolution meeting the patient or their representative remains unhappy with the decision a hearing will be arranged with the NHS Swindon CCG s Continuing Healthcare Page 19 of 30

20 Local Review Panel (LRP). The members of the LRP will be independent of the initial decision makers that reviewed the eligibility application. The patient, or their representative, will be asked to submit evidence on why they disagree with the CCG s decision and to specify those areas of disagreement. Families and individuals are encouraged to attend Local Review Panel meetings to participate in the discussions. Where an individual remains dissatisfied with the LRP outcome, they can request an Independent Review by writing to CCG and arrangements can then be made through the NHS Commissioning Board. Our Regional Office contact is: Continuing Healthcare Business Support Assistant NHS England South West House Blackbrook Park Avenue TAUNTON TA1 2PX An Independent Review Panel s (IRP) key tasks are, at the request of the Board, to conduct a review of the following: a) the procedure followed by a CCG in reaching a decision as to that person s eligibility for NHS Continuing Healthcare; or b) the primary health need decision by a CCG; and c) to make a recommendation to the Board in the light of its findings on the above matters. It is particularly important that, before an IRP is convened, all appropriate steps have been taken by the relevant CCG to resolve the case informally, in discussion with the NHS Commissioning Board where necessary. The Board should have a named contact, who is the first point of contact for queries from partner organisations. Where an individual is found to be no longer eligible for NHS CHC funding the cessation of NHS CHC funding will occur 28 days after the outcome decision is sent to the individual applicant /family representative. A Handover process is in place. The Local Authorities and their employees are not able to appeal against a decision made by NHS Swindon CCG on behalf of a client. Appeals may only be made by individual applicants themselves or their representative. 8. Complaints If an individual patient or their representative is dissatisfied with the manner in which any aspect of the overall process has been conducted rather than specifically the outcome regarding eligibility for NHS CHC, they may make a complaint to NHS Swindon CCG through the NHS Complaints Procedure. Complaints should be sent to:- Patient Advice and Complaints Team South, Central & West Commissioning Support Unit Priory Road Medical Centre Page 20 of 30

21 Priory Road Park South Swindon SN3 2EZ Tel no: Discharge Planning In a hospital setting, before an NHS Trust, NHS Foundation Trust or other provider organisation gives notice of an individual s case to a Local Authority, it must take reasonable steps to ensure that an assessment for NHS CHC is carried out in all cases where it appears to the body that the patient may have a need for such care. Health and Social Care Practitioners who carry out checklist assessment must have undergone appropriate training. Completion of the screening Checklist, and the DST where relevant, should be undertaken as part of the assessment and care planning process for discharge arrangements for individual patients who have completed their treatment and rehabilitation. This should be commenced as early as possible once the patient is being considered for discharge to reduce inappropriate placements, multiple patient moves and minimal need for interim funding and associated administration costs. Where eligibility for NHS CHC should be considered but for whatever reason this has not been possible, or the patient is ready for discharge from hospital, the discharge of the patient from hospital should not be delayed. Where the individual following financial assessment, would be responsible for funding their own package of care, NHS Swindon CCG will fund the care package for the individual on discharge, pending the decision on eligibility for NHS CHC. In order to progress discharge arrangements for individuals in the circumstances, where a decision has not yet been made on eligibility for NHS funded continuing healthcare, agreement for NHS Swindon CCG to fund the care arrangements must be agreed with the NHS Swindon Continuing healthcare lead as soon as possible. Social Care Led Hospital Discharge Where a patient has been admitted to hospital from a care home and was funded by adult social care and a positive checklist has been completed awaiting DST completion, Adult Social care will lead the discharge planning and continue to fund the placement. Our expectation is that the DST will be completed within 28 days and be presented to panel. If there is a significant delay, we will need to review whether we can continue to fund the placement. If the patient is found eligible then the reimbursement to social care would be from the date of application. Where a patient has been admitted to hospital from home, had a care package, checked positively for CHC and is planned to be discharged home with a package, social care will lead the discharge and continue to fund until DST has been completed and presented to panel. We would expect DST to be completed within 28 days as per guidance. And reimbursement to social care if found eligible from date of application. Health led discharges Page 21 of 30

22 Where a patient is admitted to hospital from home, there is a positive checklist completed and the plan is for nursing care, the discharge would be health led and paid for until completion of DST and presentation to panel. Records of Care and GP Summary should be requested at the time of the Checklist Referral. The CHC Assessment Meeting should take place two weeks after admission to the Nursing Home Placement. If the patient is not found to be eligible, the case transfers to social care giving 28 days notice, so social care can complete eligibility assessment and assess the financial contribution. We would expect the process detailed above to also apply to patients who had a small package of care but have very significant deterioration so that nursing care is required. In cases where the checklist is incomplete or further clarification is required from ward staff, the discharge remains health led until a decision is made whether or not to proceed to DST. In the event of the death of a patient CHC funded within a Nursing Home Placement, a period of between hours post the date of death will be given to allow the relatives the opportunity to remove their loved one s possessions from the Nursing Home. *Issue still remains about reimbursement of health if patient is found to be not eligible * Need wording for this element. 10. Previously unassessed periods of care PUPoC This element of the service was set up in response to the introduction of deadlines for patients, their families or representatives to request an assessment of eligibility for NHS CHC for previously un-assessed periods of care. NHS Swindon CCG can only consider requests for retrospective reviews where it is satisfied that one or more of the following grounds for the review exist: NHS Swindon CCG failed to carry out an assessment of the claimant s eligibility for NHS CHC funding when requested to do so Family request for a retrospective review for periods of unassessed care Requests for the period 1/04/ /03/12 no longer accessible If alive the patient can make a request via a questionnaire or their representative who holds LPA (reg Court of Protection). If the patient is deceased the CCG will need evidence they are executor or named within the deceased person s will. In the absence of evidence of any of the above, NHS Swindon CCG is not obliged to undertake a retrospective review of claimant s eligibility for such funding. Where a retrospective review of eligibility for NHS CHC is approved, appropriate arrangements will be made for financial recompense in accordance with the NHS Continuing Healthcare: Refreshed Redress Guidance (NHSE 2015). Pension and benefits payments will also be taken into account in any calculation of sums reimbursed. The process of Continuing Health Care reimbursement involves the redress of the financial position of an individual had Continuing Healthcare been awarded at the appropriate time. Redress is about placing individuals in the position they would have been in had NHS Continuing Healthcare been awarded at the appropriate time and not about the NHS or the public profiting from public funds. Page 22 of 30

23 NHS Swindon CCG applies the Retail Price Index for calculation of compound interest when considering redress cases. This index is calculated monthly by the Office for National Statistics ( Interest is applied at the average rate for the year in which care costs are reimbursed. 11. Commissioning of Care Packages It is the responsibility of NHS Swindon CCG to: Plan strategically Specify outcomes Procure services Manage demand Manage provider performance for all services that are required to meet the needs of all individuals who qualify for NHS CHC Manage provider performance for the healthcare component of joint packages of care. The services commissioned will include on-going case management for all those entitled to NHS CHC, including the assessment and review of individual patient needs. As well as service contracts, NHS CCG as commissioners are responsible for monitoring quality, access and patient experience within the context of provider performance. NHS Swindon CCG takes a strategic as well as an individual approach to fulfilling their NHS CHC commissioning responsibilities within the context of quality, innovation, prevention and productivity agenda. Care packages will be commissioned from care homes, domiciliary care providers and from nursing agencies, where a NHS contract is in place for continuing healthcare provision. When a care package is commissioned by NHS Swindon CCG, where there is no agreement in place, a spot contract purchasing arrangement will be agreed in order to ensure that there are quality standards in place to meet the requirements of the provision of NHS services. Care will not be commissioned from those care providers where there are concerns raised about the quality of the care provided or where they are known not to meet the Care Quality Commission minimum standards for care homes. NHS Swindon CCG will work in partnership with Swindon Borough Council and other Local Authorities as required, to ensure the quality of care in care homes meets the required standards. Where concerns about standards are raised, the owners of the care home provision will be informed that commissioning arrangements for NHS CHC will be suspended until improvements have been made to achieve the Care Quality Commission minimum standards of care and the quality standards within the continuing healthcare spot purchasing contract. Where care is already commissioned for patients in a care setting, a risk assessment currently called care review will be undertaken in partnership with the individual patient and their family to ensure appropriate controls are in place to assure the individual s safety and the quality of care provided. 12. De-commissioning of care packages Neither the NHS nor the Local Authority should unilaterally withdraw from an existing funding arrangement without a joint reassessment of the individual, and without first consulting one Page 23 of 30