Preferred Place of Care Policy for NHS Commissioned Healthcare and NHS funded Nursing Care

Preferred Place of Care Policy for NHS Commissioned Healthcare and NHS funded Nursing Care July 2017 Author: Hilary Jones & Jan Wood Owner: David Foord Programme Continuing Healthcare Document Status: Ratified by the Quality Committee 08/08/17 Date: 21 June 2017 Revision & Circulation History Version number Date Reviewer Change Reference & Summary 0.1 20 Jun 2017 Initiation 0.2 03 Jul 2017 0.3 10 Jul 2017 Hilary Jones, D Mordecai, Lynne French David Foord GPH PMG Hilary Jones Sylvia Manson Mary Tagon Lynne French Reference to Quality and Values Framework. Revision of section 6 Comments considered from clinical experts 0.4 24 Jul 2017 HWBB Comments incorporated 27 th July 2017 R Alsop, J Wilkinson, M Wogan, A Morton, M Webb, A Stenning, M Cox, D Holling, W Rowlands, A Joyner, M Hancock, V Collins 1

Table of Contents 1. Introduction... 3 2. Purpose and Scope... 3 3. The Provision of Services for People Who are Eligible for NHS Continuing Healthcare (CHC)... 4 4. Continuing Healthcare Funded Care Home Placements... 5 5 Non acceptance of available placement... 6 6 Self funders who become CHC eligible... 6 7. NHS Continuing Health Care Funded Packages Of Care At Home... 7 8 Appeals Process... 9 Appendix A Draft Brokerage and Care at Home Referral Forms... 9 Appendix B PEOPLE TO BE FUNDED BY CONTINUING HEALTHCARE - PROTOCOL OF CHOICE LETTER... 10 Appendix C Choice Leaflets... 11 Appendix D Non Acceptance of Placement Letter... 12 2

1. Introduction 1.1 In line with the NHS Constitution 2013, NHS Milton Keynes Clinical Commissioning Group (MKCCG) has developed this Preferred Place of Care Policy to balance individual preference alongside safety and value for money. It also provides transparency for those wishing to scrutinise the decision-making processes, including those for Continuing Healthcare. 1.2 The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care November 2012 (Revised), practice guidance 83 documents what limits, if any, can be put on individual choice where, if followed, this would result in the CCG paying for a very expensive care arrangement. The Framework says (Paragraph 167) that the package to be provided is that which the CCG assesses is appropriate for the individual s needs 1.3 The NHS is responsible for identifying, commissioning and contracting appropriate services to meet the needs of individuals who qualify for NHS funded care. This policy describes the ways in which the CCG commissions and provides care taking into consideration the individual s preferences, while balancing the need for the CCG to commission care that is safe, effective and makes best use of available resources. 1.4 It should be used to inform practice and decision making where an individual wishes to exercise choice in relation to where or how their care is arranged and delivered. 1.5 This policy supports the CCG s strategy to move the commissioning of NHS funded care to formal contract arrangements to ensure the quality of care is provided to standards based on the NHS Outcomes Framework and Adult Social Care Outcomes Framework: People with care and support needs have an enhanced quality of life People are helped to recover from episodes of ill health or following injury. People have a positive experience of care People are treated and cared for in a safe environment and protected from avoidable harm. 2. Purpose and Scope 2.1. The policy applies to all adults except in exceptional circumstances, such as care for children. It excludes children and young adults. 2.2. This policy sets out the roles and responsibilities of NHS and Local Authority staff for meeting the health funded care needs of patients by providing them or their representative with a choice of care homes or packages of care. 2.3. The policy also sets out the process to resolve those situations where the offered choices are not accepted. 2.4. This policy describes the way in which the CCG will commission and provide care in a manner that reflects patient choice and preferences of individuals but balances the need for the CCG to commission care that is safe and effective and makes best use of resources. 3

3. The Provision of Services for People who require health funded care 3.1 This policy supports consistent and equitable decisions about the provision of care regardless of the person s age, condition or disability. These decisions need to provide transparency and fairness in the allocation of resources. 3.2 Application of this policy will ensure that decisions about care will: be robust, fair, consistent and transparent be based on the objective assessment of the person s clinical need and safety have regard for the safety and appropriateness of care to the individual, their family/representatives and staff involved in the delivery of care involve the person and their family/representative wherever possible and consider the location of the service for family access offer a choice of Providers that meet the quality requirements expected in the NHS Outcomes Framework and Adult Social Care Outcomes Framework take account of the: o o Human Rights Act; Equality Act 2010 (cultural and spiritual beliefs); o Mental Capacity Act 2005; If a person does not have the mental capacity to make a decision about the location of their commissioned care package and suitable placement, the CHC team will commission the most cost effective, safe care available based on an assessment of the person s best interests. This will be carried out in consultation with any appointed advocate, Attorney under a Lasting Power of Attorney or a Court Appointed Deputy or the Court of Protection directly, family member or other person who should be consulted under the terms of the Mental Capacity Act 2005. Ensure the cost of the care demonstrates good value in meeting the individual's assessed needs while making good use of resources. sustainability of the package of care; in that it is able to be provided in the agreed manner and for the duration that it is required take into account the need for the CCG to allocate its financial resources in the most cost effective way; support choice to the greatest extent possible in view of the above factors. 3.3 The CCG has a duty to provide care to a person with continuing healthcare needs in order to meet those assessed needs. An individual however, has the right to decline NHS services and make their own private arrangements. However, any individual making this decision must have the potential risks assessed and the implications fully explained to them. As long as an individual has mental 4

capacity they are entitled to choose to take risks, even if professionals or other parties consider the decision to be unwise. It is important to work with the individual to explain any risks involved and not to make generalised assumptions about these. This decision and its outcome will be documented in the individual s notes and the CCG will send written confirmation that the offer of CHC has been declined. 3.4 Where an individual is assessed as eligible for CHC in a care home they cannot choose to return to Local Authority funded care in a care home, with or without NHS- funded nursing care as to do so would place the Local Authority beyond its legal powers. As an individual's eligibility for CHC will be kept under review, an individual may be reassessed and if found that they are no longer eligible for heath-funded care, they may at this time return to Local Authority care, provided they meet the criteria. 3.5 Access to NHS services depends upon clinical need, not ability to pay. The CCG will not charge a fee or require a co-payment from any NHS patient in relation to the assessed needs, as NHS services must remain free at the point of delivery. 3.6 The statutory guidance means CCG is not able to allow personal top up payments into the package of healthcare services, where the care is wholly health funded, where the additional payment relates to core services assessed as meeting the needs of the individual and covered by the fee negotiated with the service provider as part of the contract. 3.7 However, where service providers offer additional services which are unrelated to the person s identified health care needs; the person may choose to use personal funds to take advantage of these services. Examples of such services falling outside NHS provision include hairdressing, enhanced TV packages etc. The provider will only be able to invoice the CCG for the care costs and/or reasonable accommodation costs associated with the person s primary healthcare needs and will need to invoice the client separately for any services unrelated to those needs. The invoices will detail what the CCG and client is being charged for. 3.8 In instances where more than one suitable care option is available (i.e. a nursing home placement and a home care package) the total cost of each package will be identified and assessed for the overall cost effectiveness. While there is no set upper limit on the cost of care, the expectation is that the most cost effective option will be commissioned that meets the individual s needs, while taking into account the views of service users and their families. 3.9 Any assessment of a care option will include the psychological and social care needs and the impact on the home and family life as well as the individual s care needs. The outcome of this assessment will be taken into account in arriving at a decision. 3.10 The setting in which care is provided is a decision made by the CCG and not the individual or their family. However the CCG will act on all reasonable requests to the best of its ability. 4. Health Funded Care Home Placements 4.1 The CCG works with its Brokerage Team to identify Providers that meet the individual s needs. Once eligibility for health funded care has been established, the Brokerage function will work with Providers to identify suitable options for care provision. Brokerage will advise the Hospital, Community, Mental Health and/or Social Care Teams working directly with the patient of the choices available to offer the patient. 5

4.2 The individual and their family will be offered the choice of two Providers dependent on availability. One placement may be offered where there is limited availability of Providers to meet the needs. The individual/family will ideally agree which Provider they wish to choose within 48 hours. Longer time frames will be considered in exceptional circumstances. A template letter is included in Appendix A. Example leaflets for the individual/representative are included in Appendix B. 4.3 All options offered will meet the Care Quality Commission standards of registration and the quality requirements expected in the NHS Outcomes Framework and Adult Social Care Outcomes Framework 4.4 For care home placements, only single rooms will be commissioned unless there is an identified health need for a shared room, and is agreed with the CCG. 4.5 Geographical proximity of identified care homes to family and friends will be given full consideration depending on availability. 4.6 Where the placement of preference is not available, a provisional placement may be offered as remaining in an acute setting is undesirable and not in the best interests of the individual as this may expose the individual to the risks of increasing dependency and acquired infections. A provisional placement, in this context, is defined as one that is suitable to meet the individual s assessed needs and can be provided whilst waiting for the individual s preference. The CCG will, in discussion with the individual and their representative, make reasonable effort to take into account the individual s desires and preferences and circumstances when offering a provisional placement. 4.7 If the individual or their representative wishes to select a different Provider to those recommended, the CCG will consider on a case by case basis as long as the home meets the CCG s Quality and Value Framework (para 1.2 and 3.2), can meet the patient s care needs and comply with the usual standards commissioned by the CCG. It is the CCG s responsibility to place individuals locally. 4.8 Out of area placements will be considered and families/representatives will be asked to source potential placements which meet the CCG Quality and Value Framework and link with the brokerage team for relevant checks. If there is a time lapse a temporary local placement will be put in place. 5 Non acceptance of available placement 5.1 If the individual, or their representative, declines to accept a reasonable offer (and potentially an alternative), and is in NHS funded care (e.g. hospital, rehabilitation facility, discharge to assess service) the CCG will consider that it has fulfilled its statutory duty to provide NHS funded care. It will then inform the individual in writing that they will be moved to an interim placement. A letter template is included in Appendix C. 5.2 The CCG will, in discussion with the individual and their representative, make reasonable effort to take into account the individual s desires and preferences and circumstances when offering a provisional placement. 6 Self funders who become eligible for health funded care 6

6.1 Before a continuing healthcare assessment starts for any individual who is already in a home the individual and /or their representative of family or representative will be given a leaflet to explain the process and enable them to make an informed decision about whether to proceed with the assessment. This is usually done when a completed checklist indicates the need for a full Decision Support Tool or before a fast track is completed. 6.2 Once the assessment is completed the CCG will inform the individual and /or representative in writing that they are eligible for continuing healthcare funding. 6.3 For any individual who is already in a care home, the home will be assessed to see if it meets the CCG s Quality and Value Framework. If the current care home is unable to meet the patient s needs following risk assessment or is unable to provide care cost effectively the CCG will inform the individual and/or representative and care provider in writing. 6.4 If the reason for not meeting the Framework is linked to cost, continuing healthcare commissioning will work with the provider to reach an agreement. 6.5 If an agreement cannot be reached then the CCG will discuss with the individual and/or their representative future appropriate care arrangements following the process described in section 4 above. 6.6 If the individual/representative declines alternative placements, then the CCG will consider that they have declined NHS funding and are continuing with a private contract with the home. 6.7 The CCG will inform the individual/representative and care home in writing that the CCG will cease funding 14 days (or the agreed contractual period) after a reasonable alternative placement has been offered and rejected. 7. NHS Continuing Health Care Funded Packages of Care At Home 7.1 The CCG is not obliged to meet the cost of providing accommodation if the individual is living in their own home or wishes to return to it, but will take into account individual preference (see Paragraphs 1.2 and 1.3 above). 7.2 People who are eligible for continuing healthcare tend to have a complexity, intensity, frequency and unpredictability in their health needs, which may means in some cases packages of home based care do not meet the CCG s Quality and Value framework. 7.3 The CCG will take account of the following issues before agreeing to commission a care package at home: That care can be delivered safely and without undue risk to the person, the staff or other members of the household (including children) That quality of care can be provide to the same standards expected in the NHS Outcomes Framework and Adult Social Care Outcomes Framework That safety will be determined by a written assessment of risk undertaken by an appropriately qualified professional in consultation with the person or their family. The risk assessment will include the availability of equipment, the appropriateness of the physical environment and the availability of appropriately trained care staff and/or other staff to 7

deliver the care at the intensity and frequency required. Acceptance by the Provider of the care, and each person involved in the person s care of any identified risks in providing care and the person s acceptance of the risks and potential consequences of receiving care at home. If an identified risk can be reduced to a safe level by an agreed care plan and actions by the individual, family or care (whether a formal or informal carer) then all persons must agree in writing to comply with the care plan and agreed actions. The person s GP agrees to provide primary care medical support or the suitability and availability of alternative GP care options. The cost of providing the care at home in the context of cost effectiveness The relative costs of providing the package of choice considered against the relative benefit to the person The psychological, social and physical impact on the person The willingness and ability of family, friends or informal carers to provide elements of care where this is part of the care plan and the agreement of those persons to the care plan. 7.4 Many persons wish to be cared for in their own homes rather than in residential care, especially people who are in the terminal stages of illness. A person s choice of care setting should be taken into account but there is no automatic right to a package of care at home. The option of a package of care at home should be considered, even if discounted, with documented reasons. 7.5 It may be necessary to pay more to meet an individual s assessed needs in a way that does not discriminate against them, but the NHS does not have to provide a home care package if it is significantly more expensive than caring for the person within a residential setting. 7.6 Home care packages in excess of eight hours per day would indicate a high level of need that could perhaps be more appropriately met within a residential placement. These cases would be carefully considered and a full risk assessment undertaken. 7.7 Persons who need waking night care may generally be more appropriately cared for in a residential placement. The need for waking night care indicates a high level of supervision day and night. 7.8 Residential and nursing home placements are deemed more appropriate for persons who have very complex and high levels of need. Residential and nursing home placements benefit from direct oversight by registered professionals and the 24 hour monitoring of persons. 7.9 If the clinical need is for registered nurse direct supervision or intervention throughout the 24 hours, the care would normally be expected to be provided within a nursing home placement. This would include the requirement for 1-2 hourly intervention/monitoring for turning, continence management, medication, feeding, manual handling or for the management of significant cognitive impairment. 7.10 There are specific conditions or interventions that it would not generally be appropriate to 8

manage in a home setting and these are considered on an individual basis. 7.11 Individuals and their families need to be aware that there may be times where it will no longer be appropriate to provide care at home. For example, deterioration in the person s condition may result in the need for clinical oversight and 24 hour monitoring that can only be provided in a residential setting. 7.12 The care package will be reviewed in at least three monthly intervals, and then annually, as a minimum requirement, alongside any continuing healthcare review to ensure that it is still meeting the person s needs at that time. However, professionals, the individual or their family can request an earlier review if the individual s needs have changed. 7.13 If the weekly cost of the care increases, apart from a single period of up to two weeks to cover either an acute episode or for end of life care to prevent a hospital admission, the care package will be reviewed. It may be that other options (for example a nursing home placement) will be explored following consideration of the issues outlined in paragraph 7.3. 8 Appeals Process 8.1. In the first instance, any concerns should be raised with the member of staff responsible for the case. 8.2. If the issue is not resolved, it should then be raised with the Commissioning Manager Milton Keynes Continuing Healthcare Team 8.2 If, after speaking to Commissioning Manager the concerns have not been satisfactorily resolved, the issues should be formally outlined in a letter to the Commissioning Manager who will then arrange for the appeals process to be followed as outlined in the CCG Local Resolution Dispute Pathway. 9

Appendix A CCG Funded care PPoT Letter This template letter should be personalised to reflect the patient s individual circumstances. For patients who have been assessed under the Mental Capacity Act 2005 as not having capacity to make decisions regarding their discharge, a copy of this letter should be addressed to the patient but given to their representative. Address Date Dear Patients name Re: NHS Continuing Healthcare I am pleased to confirm that you are now ready to [leave hospital/transfer]. The team caring for you have recommended that you should now be transferred [home with a package of care/to a care home/to another hospital] where your needs will be best met. I would like to confirm the process for arranging this. As discussed, you have been assessed as eligible for NHS Continuing Healthcare funding. Milton Keynes Clinical Commissioning Group (the CCG) will aim to offer you a choice of up to two (care homes/packages of care) that have been assessed by the CCG as appropriate to meet you individual assessed needs. Please be aware that there are occasions when it can be difficult to locate (care homes / packages of care) that will meet individual assessed needs or in a specific area; so there are times when only one choice will be offered and when a wider search area may be required. Once you have been offered appropriate options dependent on availability, you will be supported to make arrangements for your transfer, which will be made without undue delay. The reason for this is that staying in hospital for longer than necessary can increase dependence and prolong exposure to unnecessary hospital acquired infections; so it is important that your ongoing care needs are met in a more suitable environment. At the same time hospital beds are in great demand and it is essential that beds are available for patients who require hospital care. When you have been offered a choice of care home/packages of care, please make your choice within 48 hours. If you are unable to make a choice from the choices offered, then [name of hospital] working in partnership with the Milton Keynes CCG will arrange your transfer to one of the care home/packages of care you have been offered. This will be considered as an interim arrangement and will allow you further time to consider the choices you have been given, or for you or representatives to select a different provider which meet the CCG s quality and value requirements. Please contact me if you have any questions about the process, or if I you require additional help concerning your transfer arrangements. Yours sincerely Name of Continuing Health Care Team Representative cc: Head of Nursing, Inpatient notes, Discharge Co-ordinator, CHC Team 10

Appendix B Preferred Place of Care Leaflets 11

Appendix C Non Acceptance of Placement Letter This template letter should be personalised to reflect the patient s individual circumstances. For patients who have been assessed under the Mental Capacity Act 2005 as not having capacity to make decisions regarding their discharge, a copy of this letter should be addressed to the patient but given to their representative. Address Date Dear Patient name Re: Non Acceptance of Offer of NHS Continuing Health Care, hospital number Following our discussion on [date] we are pleased to say that you are ready for discharge from hospital. We do not wish to cause you [or your family] undue anxiety, however as previously explained your continued stay in this hospital is not in your best interest and will delay other people receiving the care they require. We have been able to provide you with details of (packages of care/care homes/another hospital) to consider and to make a choice. The placements offered by Milton Keynes Clinical Commissioning Group (CCG) meet your needs and the CCG consider that it has fulfilled its statutory duty to provide you with NHS continuing healthcare. It is now outside of the agreed timeframe for a decision to be made and as explained at the start of this process, arrangements will now be made to transfer you on [add day and date] [back home with a package of care/to name of care home/to name of hospital] as an interim arrangement, which is one of the options you were offered initially. We appreciate that making arrangements for longer term care and support can be difficult however it is not in your best interest and the interest of others for you to remain in the hospital. This interim arrangement will allow you the time you require to make decisions about your longer term care. You may find that you choose to make the interim arrangement a permanent one and this option is open to you. Please contact me if you have any further questions about the process explained above, or if I can help any further with arrangements for leaving hospital. Yours sincerely Name of Continuing Healthcare Team Representative cc: Head of Nursing, Inpatient notes, Discharge Co-ordinator, CHC Team 12