Title: Developed by: Document type: Policy library: Sub Section: Document status: Date of ratification: CHC Operational Guidelines CHC Senior Operational Managers Guidelines Ratified 31 January 2017 Performance and Quality Committee Date to be reviewed: January 2020 Version 3.0 (Final) HISTORY Revisions: (Enter details of revisions below) Date: Author: Description: 12/07/2016 31/08/2016 CHC Leads General Manager Review of document Review of document 06/01/2017 Tracey Coles Embedding CHC Charter
1 Purpose These guidelines set out the roles and responsibilities for health and social care staff for the implementation of the National Framework for NHS Continuing Healthcare and NHS-funded nursing care in Cornwall and the Isles of Scilly. It describes the process for determining eligibility for NHS Continuing Healthcare within NHS Kernow and includes the procedures for this in the relevant appendices. 2 Responsibility All NHS Kernow Clinical Commissioning Group (NHS Kernow) staff 3 Definitions Guidelines 4 Training Implications None identified 5 This Policy/Guidance/Strategy/Protocol is cross referenced to: NHS Kernow Personal Health Budgets Mental Capacity Act NHS Kernow Dispute Resolution Policy CFT Records Management Policy NHS Kernow Section 117 Policy NHS Kernow CHC Choice Policy 6 Equality and Diversity Impact Assessment taken place: Yes (See attached JCIA) This document: Can X Cannot Be released under the Freedom of Information Act 2000 (For more information - Please contact the FOI Officer on 01726 627800).
Contents 1. What is Continuing Healthcare?... 4 2. Introduction... 5 3. Purpose and scope... 5 4. Screening checklist application and referral... 6 5. Assessment and use of the decision support tool... 6 6. Fast track and end of life support... 8 7. Decision making process... 9 7a. New appeals... 9 8. Care planning and choice... 10 9. Personal Health Budgets... 11 10. Prime financial policies... 11 11. Roles and responsibilities... 11 12. Reviews... 12 13. Out of area placements... 12 14. No longer eligible... 12 15. Disputes and disputes management... 12 16. Retrospective review requests... 13 17. Funded Nursing Care... 14 18. Joint funded packages of care... 14 19. Education and training... 14 20. Audit and monitoring... 14 21. Records Management... 14 22. Complaints... 15 23. Consent and capacity... 15 24. Advocacy... 15 25. Legal advice... 16 Appendix 1... 17 Appendix 2... 21 Appendix 3... 23 Appendix 3a... 29 Appendix 4... 30 Appendix 5... 31 Appendix 6... 31 Page 3 of 31
1. What is Continuing Healthcare? 1.1 Continuing care means care provided over an extended period of time to a person aged 18 or over to meet physical or mental health needs which have arisen as the result of disability, accident or illness. NHS Continuing Healthcare means a package of continuing care arranged and funded solely by the NHS (DH 2007 revised November 2012) 1.2 An individual who needs continuing care may require services from NHS bodies and/or from local authorities. Both NHS bodies and local authorities therefore have responsibilities to ensure that the assessment of eligibility for and provision of continuing care takes place in a timely and consistent way (DH 2007 revised November 2012). NHS Kernow and Cornwall Council are committed to working in partnership to achieve this, together with local NHS Trusts and Cornwall Partnership Foundation Trust. The overriding intention of all agencies is to ensure that care and support is personalised, the least restrictive option and provided in the home or as close to home as is possible. 1.3 The intention of the Department of Health in developing The National Framework was to improve consistency of approach across England, and ease of understanding of, NHS Continuing Healthcare, and to simplify the interaction between NHS Continuing Healthcare and NHS-funded nursing care. 1.4 The principles underlying this Guidelines support the provision of a consistent approach, and fair and equitable access to NHS Continuing Healthcare. These principles are as follows: 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 will be provided with information to enable them to participate in the process; NHS Kernow will inform an individual who requires an advocate to assist him/her through the process of application for NHS Continuing Healthcare; the process for decisions about eligibility for NHS Continuing Healthcare will be transparent for individual patients/clients, their families/carers and for partner agencies; all assessments for Continuing Healthcare will be undertaken by the relevant agencies involved using the checklist and DST or fast track tool; assessments and decision making about eligibility for NHS Continuing Healthcare will be undertaken in a timely manner to ensure that individuals receive the care they require in the appropriate environment, without unreasonable delays. Page 4 of 31
2. Introduction 2.1 This document has been reviewed in line with the agreed cycle following its ratification in 2009 by the Integrated Governance Committee. NHS Kernow implemented the National Framework for NHS Continuing Healthcare and NHSfunded Nursing Care on 1 October 2007, in accordance with the directions from the Department of Health. The National Framework was subsequently revised in July 2009 and November 2012. It sets out the principles and processes for the implementation of NHS Continuing Healthcare and NHS-funded nursing care and provides national tools to be used for assessment, applications and for fast track cases. 2.2 The determination of eligibility for NHS-funded nursing care was integrated into the National Framework so that the same framework for eligibility determination and care planning for NHS Continuing Healthcare also applies for NHS-funded nursing care. It uses the same assessment process to reach the determination for both funding streams. 2.3 These guidelines should be read in conjunction with the National Framework for NHS Continuing Healthcare And NHS-Funded Nursing Care (July 2012) hereafter, The National Framework. 3. Purpose and scope 3.1 These guidelines set out the roles and responsibilities for health and social care staff for the implementation of the National Framework for NHS Continuing Healthcare and NHS-funded nursing care in Cornwall and the Isles of Scilly. It describes the process for determining eligibility for NHS Continuing Healthcare within NHS Kernow and includes the procedures for this in the relevant appendices. 3.2 These guidelines also set out the responsibilities of the CCG in those situations where eligibility for NHS Continuing Healthcare has not been agreed, and for the management of situations that may arise as a result of NHS Continuing Healthcare decisions. 3.3 These guidelines describe the way in which NHS Kernow will commission and provide care in a manner that reflects patient choice and the preferences of individuals; and balances with them the need for NHS Kernow to commission care that is safe and effective and makes best use of resources. 3.4 These guidelines include the following sections: eligibility for NHS Continuing Healthcare applications; fast track applications; management of appeals, complaints and disputes; being revised discharge planning; Mental Health Act Section 117 Aftercare retrospective reviews of previously un-assessed periods of care Page 5 of 31
commissioning of care packages, case reviews, contracting arrangements and choice; jointly funded packages of care; Personal Health Budgets 4. Screening checklist application and referral 4.1 Any person over the age of 18 whom a clinician or social worker has reason to believe may have continuing care needs should be assessed for NHS Continuing Healthcare. People have the right to decline to be assessed for NHS Continuing Healthcare; therefore, the process should only start at this point if the consent form has been completed. 4.2 The first step in the CHC process is completion of a checklist. Before applying the checklist it will be made clear to the individual and his/her representative, where appropriate, that the checklist does not indicate the likelihood that the individual will be found to be eligible for NHS Continuing Healthcare. At this stage, the threshold is set deliberately low to ensure that all those who require a full consideration of their needs get an opportunity to be fully assessed. 4.3 A nurse, doctor, or other qualified healthcare professional or social worker may complete the checklist when they have undertaken the appropriate training. 4.4 If a completed checklist indicates it, a DST should be completed. If not, the CHC team should inform the individual that a referral for further assessment using a DST is not required and give him/her a copy of the completed checklist and the public information leaflet. 4.5 It is NHS Kernow s aspiration that all DST applications will be completed within 28 days from receipt of a positive checklist or sooner if in referral received from a hospital in order to assist with patient flow. 5. Assessment and use of the decision support tool 5.1 Determining eligibility for NHS Continuing Healthcare is an NHS-led process that is based on an individual s assessed health needs made by a registered health professional, usually a nurse. A decision support tool (DST) is completed following the assessment and the recommendation is agreed by a multidisciplinary team (MDT). A decision regarding eligibility is then made by the NHS Kernow eligibility decision making group. 5.2 The National Framework provides a consistent approach for establishing eligibility for NHS Continuing Healthcare. This is achieved through the use of national assessment tools that have been developed to assist in making decisions about eligibility for NHS Continuing Healthcare. 5.3 As a result of the Coughlan judgment (1999), and the Grogan judgement (2006), under the National Health Service Act 2006, the Secretary of State has developed Page 6 of 31
the concept of a primary health need to assist determining eligibility for NHS Continuing Healthcare. 5.4 Where a person has a primary health need, the NHS will be responsible for meeting all of that person s Healthcare needs, including accommodation if they are resident in a care home. 5.5 Consideration of primary health need includes consideration of the characteristics of need and their impact on the care required to manage them. In particular, consideration is given to the following: nature and type of need - the overall effect of those needs on the individual, including the type ("quality") 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 arise and interact to increase the skill needed to monitor and manage the care unpredictability - the degree to which needs fluctuate, creating difficulty in managing needs, and the level of risk to the person's health if adequate and timely care is not provided. 5.6 For clarity, NHS Kernow s decision on eligibility will not be based on: the person s diagnosis the setting of care the ability of the provider to manage care the use (or not) of NHS employed staff to provide care the need for/presence of specialist staff in care delivery the fact that a need is well-managed. 5.7 To minimise variation in interpretation of the principles and to inform consistent decision making, the national DST has been developed for use by practitioners to obtain a full picture of the needs of individuals and to indicate the level of need that could constitute a primary health need. The DST, combined with the practitioners own experience and professional judgement, should enable them to apply the primary health needs test. 5.8 The DST enables determination of eligibility by NHS Kernow and is completed by the CHC Assessor supported by a multi- disciplinary team (MDT). The MDT should include one or more Healthcare professionals from different disciplines who have an up-to-date knowledge of the individual s needs, potential and aspirations. It is best practice, but not essential, for local authority staff to participate directly in an MDT when they know the individual. As a minimum, social care involvement should always include submission of community care assessment documentation to the MDT co-ordinator. NHS Kernow will involve other specialist health staff when Page 7 of 31
indicated, and will always endeavour to involve the individual and/or his carers/advocate. It is necessary that a comprehensive MDT assessment of health and social needs take place as this MDT approach helps to inform the completion of the DST by the CHC Nurse Assessor. The MDT and the local authority must agree the recommendations made before they are presented to the NHS Kernow eligibility decision making group. 5.9 The CHC Nurse Assessor will complete the DST, including a recommendation on the individual s eligibility for NHS Continuing Healthcare, using the information provided by the MDT and other sources. The DST is not an assessment in itself, but allows information about the individual to be collated within a standardised format. The practitioners use the DST to apply the primary health need tests, ensuring that the full range of factors that have a bearing on the individual s eligibility are taken into account in making this decision. The process for application of NHS Continuing Healthcare is set out in Appendix 1and the CHC Pathway Appendix 1a. 5.10 The DST cannot directly determine eligibility. However, it provides the basis from which a recommendation can be made by the MDT in exercising its professional judgment and in consideration of the primary health need. If the MDT cannot reach agreement on the levels of needs and the recommendation regarding eligibility, the CHC Nurse Assessor will note the disagreements on the DST and make a recommendation regarding eligibility. 5.11 Any new completed DSTs for individuals with a recommendation that they do not meet CHC eligibility, will be sent to the assessed individual, their carer or representative, prior to presentation at the decision making group. 5.12 In all cases, consent must be given by the individual or advocates with the appropriate authority. If the individual lacks the mental capacity to make decisions in relation to their health needs, then any action must be taken following Best Interest Decision making. The individual must be given the opportunity to participate fully in the assessment and to be supported by their relatives and carers if necessary. 6. Fast track and end of life support 6.1 There may be circumstances where an individual not previously awarded NHS Continuing Healthcare on the basis of need has a rapidly deteriorating condition. This may indicate they are entering a terminal phase of their life. They may need NHS Continuing Healthcare funding to enable their needs to be urgently met. In these circumstances, the application for NHS Continuing Healthcare will require fast tracking for immediate provision of NHS Continuing Healthcare. 6.2 The National Framework provides a fast track tool for use in these circumstances. The fast track tool may be used by a senior clinician such as a ward sister, consultant, GP or district nurse to outline the reasons for the fast-track recommendation. NHS Kernow 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. Ideally anyone Page 8 of 31
who has had a Fast Track completed and is an inpatient at Royal Cornwall Hospital Trust, should be referred to the Palliative Care Team. This will provide equity for End of Life care. 6.3 The process for fast track applications is set out in Appendix 2 Determining eligibility for NHS Continuing Healthcare is an NHS-led process that is based on an individual s assessed health needs and ensures that, where appropriate, same day decisions about eligibility for NHS Continuing Healthcare can be made to support the preferred priorities of the individual for their end of life care. 7. Decision making process 7.1 Once a DST has been completed where the evidence supports the recommendation, it will be presented to the local NHS Kernow decision making group. 7.2 The decision making group can make one of the following decisions with regard to a recommendation about eligibility for NHS Continuing Healthcare: accept the recommendation of the multidisciplinary team; reject the recommendation of the multidisciplinary team where the evidence provided does not support the level of need indicated in the DST; or defer the decision and request further evidence to support decision making 7.3 NHS Kernow Continuing Healthcare decision making group aims to ensure consistency and quality of decision making and provides governance to the decisionmaking for eligibility for NHS Continuing Healthcare. This ensures equity of access to NHS Continuing Healthcare and consistent decision-making for all applications. 7.4 Where individuals are found to be eligible for NHS Continuing Healthcare, funding will be made 28 days from receipt of the checklist. 7.5 The Terms of Reference for NHS Kernow Continuing Healthcare decision-making group may be found in Appendix 3. 7.6 The CHC team will make every reasonable effort to have a decision on eligibility for CHC within 28 days of the receipt of a positive checklist. However due to the impact on patient flow some client groups may be given priority. All clients in a community & Acute hospital who have had a positive checklist accepted by the CHC team will be assessed and have a decision within five to seven working days. Any exception to this will be agreed with the hospital staff and noted in the Delay Transfer of Care (DTOC) report. All delays to this process must be reported to CHC team administrator on a daily basis. 7a. New appeals 7a.1 Decisions of NHS Kernow Continuing Healthcare decision making group are communicated to individual patients/clients, or their representatives, on whose behalf the application has been made, and to the lead health and social professionals Page 9 of 31
making the application. Whenever possible, a formal letter is sent within 14 working days of the decision making group meeting. 7a.2 When an individual has been found not eligible for Continuing Healthcare funding, they or, where appropriate, their representative may appeal against the decision and have six months from the date of the decision letter to do so. During the appeal period, the individual will be required to pay for their care; but will be reimbursed for any costs they have met if eligibility for some or all of the period is subsequently found. The first stage of such an appeal would be a conversation between the applicant and the CHC Team Manager. This stage is known as local resolution and may result in another DST being arranged by NHS Kernow if the applicant is able to show that due process was not followed or the MDT did not consider all of the relevant, available information. 7a.3 If the local resolution process is exhausted and the individual remains dissatisfied, they may formally appeal against NHS Kernow decision making group decision using the appeals process, which is set out in the flowchart in Appendix 4. NHS Kernow requires applicants to complete a Review Request and Consent Form before commencing to investigate the appeal. If the form is not satisfactorily completed attempts will be made to chase the applicant for completion but if this is not forthcoming, NHS Kernow will be unable to demonstrate a rationale for carrying out an appeal and the applicant will be notified that the appeal has not been upheld. 7a.4 Appeals that pass the above test will be investigated by NHS Kernow s Appeal Clinician. The appeals process will be explained and every effort will be made to ensure that the individual/representative has a clear understanding of NHS Continuing Healthcare eligibility criteria and how it relates to their own situation. If an investigation identifies that a primary health need was evidenced for all or some of the period, the case will be taken to the CHC decision-making group, which, if it agrees, will inform the applicant, and funding may be agreed. 7a.5 If the applicant remains dissatisfied with the decision of the review panel, they may make an application to NHS England for an independent review. 7a.6 If the applicant remains dissatisfied with the Independent review panel decision they may approach the Parliamentary Health Service Ombudsman. 8. Care planning and choice 8.1 NHS Kernow will commission NHS Continuing Healthcare in a manner that, as far as is reasonable, reflects the choice and preferences of individuals, and balances the need for NHS Kernow to commission care that is safe and effective and makes best use of public funding. Where NHS Kernow considers that there are issues with the quality of care being provided, NHS Kernow will work with individuals and their families to commission a more suitable package of care with another provider. Page 10 of 31
8.2 In the light of the need to balance patient preference alongside safety and value for money, NHS Kernow is developing guidelines on equity & choice and cost effective commissioning of NHS Continuing Healthcare. These Guidelines will set out arrangements for cost-effective commissioning of care packages, quality, choice and patient safety. 8.3 The NHS Continuing Healthcare Choice policy describes the way in which NHS Kernow will make provision for the care of people who have been assessed as eligible for fully funded NHS Continuing Healthcare. 8.4 CHC care packages can be commissioned through a Personal Health Budget (See NHS Kernow Personal Health Budget Policy for further details). 9. Personal Health Budgets 9.1 With effect from 1 April 2014, CCGs are required to be able to offer personal health budgets to people in receipt of Continuing Healthcare funding, in order to give patients better flexibility, choice and control over their care. A personal health budget helps people to get the services they need to achieve their agreed health and wellbeing outcomes (agreed between the patient and clinician). Financially, personal health budgets can be managed in a number of ways, including: A notional budget held by the CCG commissioner A budget managed on the individual s behalf by a third party, and A cash payment directly to the individual (a Healthcare direct payment ). Care plans will be reviewed as per the National Framework guidance at three months after the care package has been put in place and a minimum of every 12 months thereafter. For further information please see: NHS Kernow Personal Health Budgets policy. 10. Prime financial policies 10.1 The policies and procedures contained within this document must be operated in accordance with NHS Kernow s Prime Financial Responsibilities which are contained with the Constitution document (page 108 onwards). 11. Roles and responsibilities 11.1 The NHS is responsible for identifying, commissioning and contracting for services to meet the needs of individuals who qualify for NHS Continuing Healthcare, and for the Healthcare part of joint packages. NHS Kernow commissions Cornwall Foundation Trust to fulfil this service. NHS Kernow remains responsible to ensure that on-going case management is maintained by CFT and that the appropriate clinician regularly reviews the care needs of individuals. Page 11 of 31
12. Reviews 12.1 If the NHS is commissioning any part of an individual s care, a case review will be undertaken to reassess that their care needs are being met and that the care is of the standard expected by NHS Kernow, which has a process in place for case reviews in partnership with Adult Care and Support and Cornwall Foundation Partnership Trust for both NHS Continuing Healthcare and NHS-funded nursing care reviews. 12.2 Care reviews will be undertaken for individuals within three months of the assessment that found them eligible and at least annually thereafter. (Some cases will require more frequent review in line with clinical judgement and changing needs). This will ensure that individuals are receiving the care they need and that the individual remains eligible for NHS-funded care. In some cases when there has been a change in health needs identified a review of eligibility for CHC should be considered. This may need completion of a checklist and or DST. 13. Out of area placements 13.1 When the CCG placed an individual who is CHC funded in a residential establishment in the area of another CCG, the placing CCG is required to inform the receiving CCG about this placement. 13.2 A template letter is used to inform the receiving CCG which outlines details of NHS Kernow funding. (Currently NHS Kernow Terms and Conditions are not supplied). 13.3. Robust arrangements need to be agreed and in place to ensure monitoring of the provider and information regarding safeguarding alerts are communicated to the placing CCG. 14. No longer eligible 14.1 The National Framework for Continuing Health Care and NHS funded Nursing Care states that neither the NHS nor Local Authorities should unilaterally withdraw from an existing funding arrangement without a joint reassessment of the individual and without first consulting one another and the individual about the proposed change of arrangement. 14.2 For patients who are found no longer eligible for NHS Continuing Healthcare, Clinical Commissioning Group responsibility for funding will cease. Patients and the provider are advised that funding for their care will cease 28 days following the date of the decision letter. 15. Disputes and disputes management 15.1 NHS Kernow meets with Cornwall Council representatives to advise them of NHS Kernow Continuing Healthcare decision making group decision. Cornwall Council may not appeal against a decision made by NHS Kernow Continuing Healthcare Page 12 of 31
decision making group. Appeals may only be made by individuals who have been assessed or their duly authorised representatives. 15.2 However, Cornwall Council may dispute a decision that is made by NHS Kernow Continuing Healthcare decision making group. This also applies to any other local authority that is affected by a decision made by the NHS Kernow Continuing Healthcare decision making group. In these circumstances, NHS Kernow Dispute Resolution policy should be implemented. 15.3 NHS Kernow and Cornwall Council agree that there should be no delay in the provision of services due to disagreements or disputes on the assessment recommendation or outcome of the decision on eligibility. In such situations, The National Framework explicitly states that any existing funding arrangements cannot be unilaterally withdrawn. In all cases, the present funding arrangements will remain in place pending the outcome of the dispute. NHS Kernow and Cornwall Council or other local authority will adopt a Without Prejudice approach to such situations whereby the final outcome of the dispute will be backdated to the time of the original funding request. 15.4 NHS Kernow and Cornwall Council agree to manage any recharge of funding arrangements in line with the NHS Kernow Dispute Resolution Policy. Recharges will be made direct to either the local authority or NHS Kernow (as appropriate) and will not involve reclaiming costs from the care provider. 16. Retrospective review requests 16.1 There may be circumstances where an individual should have been assessed for funding and therefore may have been found eligible for CHC funding. The DOH has given such requests the title of Previously Un-assessed Periods of Care (PUPoc) and agreed timeframes for individuals to appeal for these previously un-assessed periods of care. The closing date for these applications closed on the 31 st March 2013. 16.2 In these circumstances, the individual can request a retrospective review of their care needs and eligibility for NHS Continuing Healthcare. 16.3 Where an appeal against a decision for NHS Continuing Healthcare is made and upheld, appropriate arrangements will be made for financial recompense in accordance with NHS Continuing Healthcare: Continuing Care Redress (Department of Health 2007). However the Parliamentary Health Service Ombudsman s (PHSO s) latest guidance is that if the CCG is awarding redress, and there has been no fault and the payment is being paid promptly, then it is within the current Redress guidance to make a 'reasonable' offer of interest, and the PHSO is happy with the Retail Price Index (RPI). 16.4 Calculation of interest payment will be made using the retail price index for the relevant period. Payment will then be made to the individual. Page 13 of 31
17. Funded Nursing Care 17.1 Where the NHS is responsible for arranging care by a registered nurse for people in care homes, the Continuing Health Care Team is responsible for undertaking a Funded Nursing Care determination within 28 days of the referral. Every time a FNC review is undertaken a CHC checklist should be undertaken by the CHC team prior to the FNC review decision being made. The FNC Practice Guide and National Framework are available from the Department of Health s website. 18. Joint funded packages of care 18.1 The National Framework states that, if a person does not qualify for NHS Continuing Healthcare, the NHS may still have a responsibility to contribute to a package that meets that person s health needs. A common example of how this is provided is by means of the funded nursing care contribution in a care home setting. 18.2 Joint packages of care may also be provided through the provision of NHS services such as district nursing and physiotherapy. A joint package of care with the local authority will only involve NHS-funding where there are specifically identified health needs that cannot be provided by commissioned health services and that are evidenced as consistently more that incidental or ancillary to their routine support needs. 19. Education and training 19.1 NHS Kernow will ensure that training is provided to all relevant health and adult social care staff to enable them to carry out their duties in relation to assessing people for NHS Continuing Healthcare. Training will include the use of the national tools, the definition of a primary health need and the application process for NHS Continuing Healthcare. 20. Audit and monitoring 20.1 The National Framework will be monitored through reports to NHS Kernow Continuing Healthcare executive leads meetings and through performance reports to the NHS Kernow Board, NHS England and Integrated Governance Committee, as required. 20.2 When appropriate, audits will be undertaken of all decision-making against the criteria and of decisions made for NHS Continuing Healthcare for cases where the domains of care and the level of need in the DST indicate that the eligibility criteria are met. 21. Records Management 21.1 Healthcare organisations have a systematic and planned approach to the management of records to ensure that from the moment a record is created until its ultimate disposal, Page 14 of 31
information serves the purpose for which it was collected and information is appropriately disposed of when no longer required. NHS Kernow procedures are in line with CFT Records Management Policy. 22. Complaints 22.1 An individual or their representative may be dissatisfied with the manner in which the assessment process has been undertaken, their involvement in the process or the manner in which decisions have been made. If so, they may make a complaint to NHS Kernow through the Trust s Complaints process. 21.2 Complaints will be managed through the Clinical Commissioning Group s Complaints Procedures with local resolution where appropriate. 23. Consent and capacity 23.1 NHS Kernow operates within national and professional body guidelines. Before any assessment for eligibility is carried out for NHS continuing healthcare, Funded Nursing Care or Fast Track, including reviewing personal information from files and records, we will seek the consent of the client or patient involved. 23.2 If neither of these is possible, the consent of the next of kin or representative will be sought, although consent obtained via this route may not allow for sharing third party information or records to be accessed if they do not have the appropriate legal authority. If obtaining consent from the next of kin is not possible then a best interest decision will be required. 23.3 This policy links to the Mental Capacity Act and where a patient lacks capacity to make decisions surrounding the Continuing Healthcare process, decisions will be made as part of the best interest decision making process (even if Power of Attorney is present). 24. Advocacy 24.1 Any person may choose to have a family member or other person (who should operate independently of Local Authorities and NHS bodies) to advocate on their behalf. 24.2 Clinical Commissioning Group staff should ensure individuals are made aware of local advocacy and other services that may be able to offer advice and support. It is the responsibility of the individual signing the consent for assessment to ensure that all information discussed during the assessment complies with The Data Protection Act. 24.3 Even where an individual has not elected for a family member to advocate for them, the views and knowledge of family members may be taken into account, where consent has been given to seek these views or where the patient lacks the mental capacity to give their consent and a best interests decision needs to be made. Page 15 of 31
25. Legal advice 25.1 The threshold for referring cases for legal advice from the organisation s solicitors will vary on a case by case basis depending on the circumstances of each case. Escalation for legal advice will therefore be considered on an individual basis and further advice and support should be sought from the in the first instance. Page 16 of 31
Appendix 1 Application process for NHS Funded Continuing Health Care Identifying people who may be eligible for Continuing Healthcare 1. Checklist 1.1 The checklist should be completed by a competent (completed NHSE Checklist online training) health or social care professional who has the most knowledge of the individual. DSTs will only be completed when indicated by a comprehensive positive checklist. 2. Decision Support Tool 2.1 Completion of the DST will be led by a CHC Nurse assessor who will act as the CHC Coordinator and assist the MDT when and making a recommendation on eligibility. In doing so, the nurse assessor and MDT including local authority representatives will ensure that sufficient evidence of the Healthcare needs of the individual is considered to provide a clear rationale for the levels of the domains of care that are completed in the DST. This is essential to identify whether the individual has a primary health need and to enable the Continuing Healthcare decision-making group to reach a decision on eligibility. Such information may include but is not limited to: GP notes hospital notes specialist reports including risk assessments speech and language therapy community psychiatric nurse occupational therapy physiotherapy nursing home records social care records 2.2 The CHC team is responsible for the completion of all DST s in community hospitals, Care Homes and at home. 3. Referral 3.1 Referral is made by submitting a completed checklist to either of the two CHC teams (preferably electronically via email). The teams can be contacted from Monday to Friday 9am to 5pm. Each has an answer phone on which messages can be left. Team Location Tel. Number West Praze 01209 832400 Email Address kccg.westchcteam@nhs.net Page 17 of 31
North and East Liskeard 01579 373837 kccg.chcnorth@nhs.net 3.4 DSTs will be considered by NHS Kernow s Continuing Healthcare decisionmaking group. 4. Decision-Making Process 4.1 Completed DSTs are considered at the next CHC decision-making group. The groups s decision will be based on the completed DST and the assessed levels of need in each of the 12 care domains, and will include consideration of any supporting evidence such as that provided by the individual or his/her family or representative. 4.2 Where the health needs of an individual have been assessed as being at a Priority level in one or more care domains, and the evidence presented supports eligibility by way of a primary health need test (4 key indicators), the decision-making group will find the individual eligible for Continuing Healthcare funding unless there are exceptional reasons not to do so. 4.3 People who have been assessed will be formally advised of the decision by the Locality Team Manager in writing within 4 working days of the decision being made. The letter will include the following information: the decision on eligibility for NHS Continuing Healthcare; the rationale for the decision based on the evidence presented, and comment on the primary health needs of the claimant; Advice on how to appeal against the decision. 5. Commissioning Care Packages 5.1 NHS Kernow is responsible for ensuring appropriate commissioning of care package for NHS Continuing Healthcare. It is the responsibility of Cornwall Foundation Trust to provide a Joint Assessment for Care (JACS) form in order to identify appropriate care plans. This can be done via the health buyer team for domiciliary care or direct via CFT for Care Home Placements. Without this form, NHS Kernow will not agree any packages of care. 5.2 All care packages in nursing and residential care will be commissioned using the Continuing Healthcare contract arrangements and standard nursing home tariff that has been agreed. Where the individual has health needs that are of a degree of complexity and intensity that is more than can be provided through the standard tariff and on receipt of an individualised care plan, the Continuing Healthcare team will negotiate the individual s case using the NHS Kernow Tier pricing structure. Page 18 of 31
5.3 It is the intention that domiciliary care packages will be provided through the standard contract arrangements, with individual care packages negotiated in the same way as for residential care packages. 6. Records Management All records pertaining to a request made on behalf of an adult (of 18 or more years of age) for Continuing Healthcare funding will be retained in line with the NHS Cornwall and Isles of Scilly records management policy. Records will be stored in accordance with the NHS Kernow records management. Page 19 of 31
Appendix 1a Individual identified as possibly eligible for CHC via completed checklist Does individual have a rapidly deteriorating condition? Yes Is checklist complete with supporting rationale/reasoning? No Letter to referrer to revise, redo, provide rationale within 5 working days Yes No No Is checklist positive or Neg negative? Fast Track Review after 3 months Could NHS Services help? Provide rehab/ reablemen t or other services Positive Allocate to a CHC Assessor Provide leaflet, explain process, obtain consent & offer advice on advocacy. Ensure individual and or advocate involved Advise applicant and referrer that DST will not be completed at this stage but if changes then re-apply. Caveat for people with a palliative diagnosis who may have short life expectancy Hospital seeks decision within a maximum of 7 working days Assessor finds out who else is involved and checks if known to local authority Notify local authority (Access and Assessment Service) so they can allocate on a case by case basis Assessor organises and facilitates MDT meeting and recommendations made Decision communicated to family and local authority Eligible CCG Decision made at decision making group Not eligible Consideration of joint funding Joint funding panel Page 20 of 31 Family advised of right to appeal
Appendix 2 Fast Track Application Process Identifying People Who May Be Eligible For Fast Track Application 1. Eligibility for Fast Track Application 1.1 The eligibility criteria for a fast track application for NHS Continuing Healthcare is defined within the National Framework for NHS Continuing Healthcare (DH 2007 revised Nov 2012). The framework states that a fast track application should be made when an individual has a rapidlydeteriorating condition and when s/he may be in a final phase of a terminal illness. 2. Referral 2.1 All referrals should be made to the local CHC team. The teams may be contacted from Monday to Friday 9am to 5pm. Each has an answer phone on which messages can be left. Team Location Tel. Number West Praze 01209 832400 North and East Liskeard 01579 373837 2.2 Referrals should in the first instance be made by telephone / electronically to the local team, which will discuss the case with the referrer and agree whether or not the fast track approach is appropriate. Those made by telephone must be followed up with a written referral to the Continuing Healthcare team within two working days. 2.3 Urgent care packages required out-of-hours, including at weekends and on bank holiday, will be arranged by the referrer. A fast track referral must be made for NHS Continuing Healthcare retrospectively on the next working day in order to be agreed. 2.4 Referrals can be made by the following: Health keyworker (district nurse, ward nurse, CPN, hospital discharge team, palliative care specialist nurse, GP etc.) hospice staff EIS 2.5 If the individual is an inpatient in a hospital, the hospital team must follow the referral process and also identify a community health keyworker if the person involved is returning home. Page 21 of 31
3. Fast track applications for NHS funded Continuing Healthcare 3.1 For fast track applications, the Continuing Healthcare coordinator can make decisions for eligibility for NHS Continuing Healthcare on the same day as the referral is received if the following information is submitted. This information can be given verbally, with the documentation following by the next working day. completed NHS Fast track tool containing details of the health care needs of the individual. Evidence from the medical practitioner or responsible for care (GP, Consultant) on prognosis, or the hospital specialist palliative care nurse in hospital settings. a completed JAC form, including costs. 3.2 If the patient meets the fast track criteria and all information is available to the Continuing Healthcare coordinator, s/he can make a decision about eligibility for NHS Continuing Healthcare. The referrer will be informed verbally of the decision to prevent a delay in arranging care. When appropriate, the family will also be sent a letter that informs them of the decision. Care should be taken with regard to the sensitive nature of this information. 3.3 If the patient meets the above criteria and all information is available to Continuing Healthcare coordinator, s/he can agree a care package in a care home or in the individual s own home. 3.4 All individuals who are approved for fast track application should be reviewed within three months of the Fast Track application. There are only three outcomes of a fast track review CHC eligible Not eligible for CHC Fast track remains appropriate as patient end of life Page 22 of 31
Appendix 3 NHS Continuing Healthcare and NHS-funded Nursing Care Decision Making Group Terms of reference 1. Purpose 1.1 The purpose of the NHS Continuing Healthcare and NHS-funded Nursing Care decision making group is to make a decision on whether a person has a primary health need. If so, NHS Kernow will determine that that person is eligible for NHS Continuing Healthcare (CHC). 1.2 The groups will reach their decisions by examining evidence contained in the Decision Support Tool (DST), considering recommendations made by the Multi-Disciplinary Team (MDT) and taking account of views expressed by the patient, family and other professionals in accordance with the National Framework for Continuing Healthcare and NHS-Funded Nursing Care (Revised 2012) and associated Practice Guidance. 1.3 The groups will consider cases across all client groups and will sign off all applications for CHC and NHS-funded Nursing Care. 1.4 NHS Kernow may choose to use a decision making group to ensure consistency and quality of decision making. However, a decision making group should not fulfil a gate-keeping function, and nor should it be used as a financial monitor. Only in exceptional circumstances, and for clearly articulated reasons, should the multidisciplinary team s recommendation not be followed. A decision not to accept the recommendation should never be made by one person acting unilaterally. 2. Duties and Responsibilities 2.1 The principal duty is to agree whether a person has a primary health need, based on information contained with the DST, and recommendations of the MDT using National Framework for NHS Continuing Healthcare and local operational guidance. 2.2 Each decision making group will keep accurate records of decisions and ensure the communication of outcomes within 4 working days to relevant parties. 2.3 As part of the decision making groups responsibility to ensure consistent application of the National Framework, they may review the quality of DSTs and the pattern of recommendations made by practitioners in order to improve practice. However, this will be carried out separately from the approval of recommendations in individual cases. Page 23 of 31
3. Accountability, Authority and Span 3.1 The decision making groups are accountable to NHS Kernow Senior Management Team and focus on the following areas: Review the MDT assessment presented by the CHC assessor for CHC determination Consider whether sufficient information is presented to support the recommendation of the MDT regarding whether the person has a primary need for Healthcare Refer the CHC assessor to acquire additional information to support the eligibility recommendation if required Ratify the CHC recommendation of the MDT 3.2 The decision making group can make two decisions: Uphold the recommendation of the MDT Defer the case for further information 3.3 The decision making group will not: Consider people requiring funding under MHA Section 117 or rehabilitation. Make decisions regarding the details of joint packages of care funding. However it may be appropriate for the decision making group to recommend for joint package of care funding to be considered. 4. Composition, membership and roles of decision making group members 4.1 In line with the National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012 NHS Kernow cannot delegate the decision whether someone is entitled to CHC funding. For this reason, a NHS Kernow commissioner must be in attendance to Chair each group to confirm entitlement this can be any member of the CHC service at Band 7 or above. 4.2 The decision making groups will consist of the following members: 4.2.1 Chairmanship: Decision making groups will be chaired by an accredited person nominated by the CCG who can act in an authoritative capacity. The chair does not have the voting rights of a decision making group member and therefore does not have the ability to make decision in relation to eligibility but is there to facilitate an equitable decision making process. 4.2.2 Core membership will include: Page 24 of 31
A commissioner from NHS Kernow, generally a Band 7/6 CHC locality team member or more senior member of staff. And at least one of the following: 4.2.3 Additional representation For all decision making groups, representation will be sought from some or all following partner agencies: Department of Education, Health and Social Care at Team Manager or equivalent level Cornwall Foundation Trust - Band 6/7 Team leader or Deputy For complex cases, representation will be sought (on a case by case bases) from the following partner agencies: Mental Health Cases Cornwall Foundation Trust Team Manager or Deputy Learning Disability Cases Department of Education, Health and Social Care Team Leader for LD Services and NHS Kernow Coordinator We note that representation from partner agencies ensures a multidisciplinary approach to decision making. However, whilst every opportunity will be taken to engage partner agencies in the decision making process, decision making cannot be halted by non-attendance from our partner agencies. 5. Quorum and Frequency of Meetings 5.1 A minimum of three people (including the Chair) must be present in order to ratify whether someone has a primary health need. Quorum must include all of the core membership, the chairperson and at least one person from the additional representative list. In addition a member of the CHC administration staff must always be present at the meetings to take notes. 5.2 Decision making groups will be held weekly in both locality CHC teams. Complex cases needing more specialist attendance will be held at the closest locality decision making groups, as soon as this can possibly be arranged. 6. In attendance: A member of the CHC administration staff Page 25 of 31
6.1 Observers from the MDT may be welcomed to attend the decision making group at any time to ensure their professional development. 6.2 Nurse assessors will be in attendance to present their cases where applicable 7. Information provided to the decision making group 7.1 Each case will be presented by the CHC assessor and supported with a completed DST. The patient file will be available to enable reference to other supporting information and evidence. 8. Responsibility, Scope and Conduct of the decision making group 8.1 Preparation for decision making groups 8.1.1 Decision making groups will take place on a different day in each area and should normally last no more than half a day. 8.1.2 A meeting room in each area will be booked in advance which can comfortably hold the numbers of attendees. 8.1.3 Decision making groups representatives are to be agreed in advance with partner organisations and a rota produced to ensure that people are aware of when they are needed to attend. 8.1.4 Administrative staff are to be present at all decision making group meetings with access to a laptop. 8.2 The day of decision making group 8.2.1 All fast track cases reviewed since the previous decision making group will be agreed on the day of meeting. This is due to fast tracks having to be agreed with immediate effect 8.3 Process for decision making group 8.3.1 The chair will introduce the group members and state the process for decision making. 8.3.2 The Continuing Healthcare CHC assessor will present a summary of the identified health and social care needs of the applicant to the group members. 8.3.3 Group members will seek further information from the Continuing Healthcare Care assessor as needed. The case file should be available to reference any notes that may be needed to assist in the decision making or access to the Panel Folder on the CCG shared drive. Page 26 of 31