Continuing Healthcare Policy and Operating Procedures February 2015 Author: Responsibility: Christine Hapeshi All Staff should adhere to this policy Effective Date: February 2015 Review Date: February 2017 Reviewing/Endorsing committees Approved by Governance and Risk Sub Group Date Verified by Executive Team CHC task and finish group 9 th February 2015 19 th February 2015 Version Number 1 Related Documents Safeguarding Vulnerable Adults Policy DOH National Framework for Continuing Healthcare and Funded Nursing Care (revised) 2012 BCCG Complaints Policy Additional services policy Continuing Healthcare Page 1
POLICY DEVELOPMENT PROCESS Names of those involved in policy development Name Designation Email Andrew Cooke Head of Andrew.cooke@bedfordshireccg.nhs.uk CHC/Assistant Director Catherine Contracts Manager Catherine.leverington@bedfordshireccg.nhs.uk Leverington Christine Hapeshi CHC Manager Christine.hapeshi@bedfordshireccg.nhs.uk Diana Butterworth CHC Manager Diana.butterworth@bedfordshireccg.nhs.uk Names of those consulted regarding the policy approval Date Name Designation Email 18/12/2014 Andrew Head of CHC/ Andrew.cooke@bedfordshireccg.nhs.uk Cooke Assistant 18/12/2014 Dr Gail Newmarch Director Interim Director of Strategy & redesign 18/12/2014 Malcolm Miller 30/01/15 Anne Murray Director of Nursing & Quality Gail.newmarch@bedfordshireccg.nhs.uk Anne.murray@bedfordshireccg.nhs.uk Equality Impact Assessment prepared and held by Date Name Designation Email 30/01/15 Christine CHC Manager Christine.hapeshi@bedfordshireccg.nhs.uk Hapeshi Committee where policy was discussed/approved/verified Committee/Group Date Status Equality Impact Assessment CHC policy Equality Impact Assessment - Continuing Healthcare Page 2
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1. Introduction 5 2. Policy Statement.. 5 3. Roles & Responsibilities..6 4. Scope.6 5. Eligibility Criteria for NHS Continuing Healthcare Funding and NHS Funded Nursing Care Contributions.....7 Application Process.7 Checklist..7 Decision Support Tool...8 Eligibility Decisions.9 Fast Track 10 6. Timeframes.11 7. Assessment in Hospital Settings.11 8. Discharge Planning 12 9. Section 117 Aftercare 13 10. Transition from Child to Adult Services 14 11. Retrospective Review of care..15 12. Commissioning of Care packages, Case Reviews, Contracting Arrangements of Choice.15 14. Patient Choice 17 15. Reviews..19 16. Funding 20 17. Complex Case Panel 21 18. Responsible Commissioner..22 19. Jointly funded Packages of Care.23 20. Direct payments.23 21. Personal Healthcare Budgets 23 22. Safeguarding Adults.24 Continuing Healthcare Page 4
23.Management of Complaints, Appeals, Disputes 25 24. Local Resolution Panel.25 25.Complaints 26 26. Disputes...26 27. Training 28 28. Audit & Monitoring. 28 References. 29 1 Introduction NHS Continuing Healthcare (NHS CHC) NHS CHC is a package of care that is arranged and funded solely by the NHS where the individual has been found to have a Primary Health Need as set out in the National Framework for NHS Continuing Healthcare and NHS-Funded Nursing 2012 (Revised). Such care is provided to an individual aged 18 or over, to meet needs that have arisen as a result of disability, accident or illness. The services provided as part of the package should be seen in the wider context of best practice and service development for each client group. Eligibility for NHS continuing healthcare places no limits on the settings in which the package of support can be offered or on the type of service delivery. In order to arrive at a decision for NHS CHC eligibility the panel of experts will have either considered the information provided to them by a suitably qualified clinician in the form of the Department of Health Decision Support Tool for NHS Continuing Healthcare. (DOH 2012). 2 Policy Statement This Policy sets out the responsibilities of The Bedfordshire Clinical Commissioning Group (BCCG) for ensuring the correct implementation of the Department of Health (DH) document, National Framework for NHS Funded Continuing Healthcare and NHS-funded Nursing Care, (DOH 2012 (revised)). This policy provides the operational procedure for determining the eligibility of clients for NHS-funded Continuing Healthcare. It outlines the roles and responsibility of BCCG staff for the implementation of the National Framework and specifies the responsibilities of BCCG in those situations where eligibility for NHS-funded Continuing Healthcare (CHC) has not been agreed. It explains the way in which BCCG 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. BCCG will work towards value based commissioning of care to ensure the best possible care at the best possible price. The policy sets out to ensure that decisions will: be robust, fair, consistent and transparent, be based on the objective assessment of the patient s clinical need, safety and best Continuing Healthcare Page 5
interests, will have regard for the safety and appropriateness of care packages to those involved in care delivery will involve the individual and their family or advocate where possible and appropriate, take into account the need for the CCG to allocate its financial resources in the most cost effective way support choice to the extent possible in the light of the above factors be consistent with the principles and values of the NHS Constitution take into account an individual s needs for both their health and their wellbeing 3 Roles and Responsibilities It is the responsibility of all registered professionals involved in undertaking the Continuing Healthcare Checklist/Health Needs Assessments to ensure individuals deemed eligible for consideration for NHS Continuing Healthcare funding, provide robust information in order that individuals are dealt with equitably and that BCCG is compliant with legislation. It is the responsibility of all registered professionals dealing with the eligibility determination and decision making process to make certain that a full and detailed assessment of need is completed with contemporaneous supporting evidence. 4 Scope NHS-funded Continuing Healthcare is provided free of charge, 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. The more recent provision of Personal Health Budgets will allow an individual that is receiving CHC to purchase the care and support they need. This care can be given in a variety of settings, including a residential care home, a nursing home or in a client s 'own home'. In some cases, the choice of living environment may be restricted in order to meet complex or intensive medical health needs For an application of NHS Continuing Healthcare to be agreed the care must be proven to be more than; incidental or ancillary to the provision of the accommodation that a Local Authority (LA) is under a duty to provided, pursuant to section 21 of the National Assistance Act 1948; and of a nature that an authority whose primary responsibility is to provide social services can be expected to provide. Continuing Healthcare Page 6
If the care is deemed to be outside of this guidance then this may signify a primary health need; that the overall needs are such that, the responsibility for those needs cannot be met by the LA and so must be the responsibility of the NHS. This Policy should be read in conjunction with existing National policy and guidance and Local Bedfordshire CCG policies. 5. Eligibility Criteria for NHS Continuing Healthcare Funding and NHS Funded Nursing Care Contributions. Following the Coughlan judgment (1999), and the Grogan judgment (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 is appropriate for the NHS to provide. There are many aspects to be considered when deciding if an individual has a primary health need. 'It is not about the reason why someone requires care or support, nor is it based on their diagnosis; it is about their overall actual day-to-day care needs taken in their totality...it is the level and type of needs themselves that have been considered when determining eligibility for NHS CHC'. The DH states that there are four characteristics to be taken into account when assessing eligibility for CHC; Nature, Unpredictability, Complexity and Intensity. These NHS Continuing Healthcare characteristics may, alone or in combination, demonstrate a Primary Health Need, because of the quality and /or quantity of care that is required to meet the individual's needs. Assessment for eligibility for NHS CHC can take place in any setting, hospital, care home or domestic home. Anyone carrying out an assessment for eligibility should always consider the individual s potential for rehabilitation and for independence to be regained, and how the outcome of any treatment or medication may affect ongoing needs. Not every individual who uses the health services is eligible for NHS CHC funding and where there is uncertainty the NHS CHC Checklist should be initiated as a screening process. 6 Application Process Checklist Eligibility for NHS CHC will be determined by, at first, using the Department of Health (DH) Checklist tool. This tool is designed to help practitioners determine the appropriateness of an individual to go forward for consideration for assessment for NHS CHC. If after using the tool a referral for CHC assessment is made, this in itself is not an indication of the outcome of the eligibility decision. This fact should be communicated to the individual and, where appropriate their representative/advocate. 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. At this stage, the threshold is set deliberately low to ensure that all those who require full consideration of their needs do get this opportunity. Continuing Healthcare Page 7
A Registered Nurse, Doctor, or other qualified healthcare professional, or Social Worker are qualified to apply the Checklist to refer individuals for full consideration of eligibility for NHS CHC. Informed consent from the individual or their representative should be obtained before commencing the Checklist. It should be noted that individuals or their representative may withdraw their consent for the procedure at any time. 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 a valid and applicable Lasting Power of Attorney (LPA), that is a certificate that states it is for Health & Welfare alternatively, they may have been appointed a Welfare Deputy by the Court of Protection. It is the responsibility of the practitioner to ascertain this before divulging confidential information regarding the individual. If the individual has not assigned an LPA and there is concern that the individual may not have capacity to make informed decisions then a Best Interest process should be invoked in accordance with the Mental Capacity Act 2005 and the associated code of practice. The practitioner should be particularly aware of the principles of the Mental Capacity Act 2005 If the individual lacks the mental capacity to consent to the procedure then a Best Interests decision should be taken (and recorded) as to whether to proceed or not. In a hospital setting the Checklist should be applied as the first stage in the discharge process for individuals, in compliance with the Community Care (Delayed Discharges) Act 2003 which focuses on delayed discharge responsibilities. The screening Checklist should be used by all practitioners in this environment as part of the assessment and care planning process. Checklist-November 2012.doc The Decision Support Tool The Decision Support Tool (DST) is designed to ensure the correct implementation of the National Framework and inform consistent decision making. The DST is not an assessment in itself. The DST is specifically designed to collate and present the evidence provided in the assessment in a way that assists consistent decision making for the NHS Continuing Healthcare eligibility. The DST invites practitioners to document deterioration (this could include observed and likely deterioration) in an individual s condition to allow them to take this into account when determining using the tool. The DST is a national tool and the format is not to be altered. It should be used in conjunction with the guidance in the National Framework. Continuing Healthcare Page 8
The consent of an individual who is the subject of the DST must be obtained before the assessment is carried out, as outlined above and, as always, they should be given the full opportunity to participate in the completion of the DST. The individual should be given the opportunity to be supported or represented by a carer or advocate if they so wish. The DST should be completed by an MDT following a comprehensive assessment of an individual s health & social care needs and their desired outcomes. The MDT comprises of senior practitioners, whose own experience and professional judgment will enable the application of the primary health needs test in a way which is consistent with the limits on what can lawfully be provided by the Local Authority. The DST asks the MDT to set out the individual s needs in relation to 12 care domains (see DST). Each domain is broken down into a number of levels, each of which is carefully described. For each domain the MDT is asked to identify which level of description most closely matches the individual s needs. The MDT, on the evidence provided along with their professional judgment, will make a recommendation as to whether the individual meets the eligibility criteria for CHC funding. If an individual, after assessment, is found to be eligible for funding this should commence on day 29 after receipt of a fully completed copy of the Checklist. DST-NHS-CHC-Nove mber 2012 Version.d Eligibility Decisions The National Framework for Continuing Healthcare states that a CCG or panel can only reject an MDT s recommendation in exceptional circumstances. The NHS CHC Practice guidance defines exceptional circumstances as: where the DST is not completed fully (including where there is no recommendation) where there are significant gaps in evidence to support the recommendation where there is an obvious mismatch between evidence provided and the recommendation made where the recommendation would result in either authority acting unlawfully. In such circumstances BCCG or panel will return the assessment to the MDT with a full explanation of the relevant matters to be addressed. The MDT should respond within 5 working days and the case should be re -submitted to the eligibility panel with the actions completed within 10 working days to ensure minimal delays. BCCG will write to patients to inform them where the outcome of an assessment is delayed due to the use of the escalation process. Where possible, BCCG will inform the patient what the timescale for decision-making is likely to be. All DSTs should be submitted by the practitioner coordinating the assessment to BCCG for verification. Continuing Healthcare Page 9
The MDTs must ensure that recommendations are based on the 4 key indicators of need. Each key indicator, alone or in combination, can demonstrate a primary health need. The key indicators should clearly reference how the needs, recorded earlier in the DST, demonstrate a primary health need. All DSTs must be accompanied by the required evidence to support the weightings and Primary health Needs Test, a social work report and GP report. All DST s must be accompanied by a Form of Consent. The assessment and evidence will be considered by a member of the CHC team who has been identified as a Verifier. This will generally be a senior member of the team at Band 7 or above. BCCG will hold a Verification panel at least twice monthly made up of members of the CHC team who are identified Verifiers in order to ensure quality and monitoring of the verification process. All staff involved in the coordinating of assessments will be required to present cases to the panel as requested. BCCG seek to verify recommendations within 7 working days of the DST being submitted. Fast Track Applications The Fast Track Pathway Tool is used to gain immediate access to NHS Continuing Healthcare funding where an individual needs an urgent package of care/support. This tool bypasses the Checklist and DST and should only be used for individuals who have a Primary Health Need through a rapidly deteriorating condition that may be entering a terminal phase, and have an increased level of dependency. The framework makes it clear that the Fast Track pathway Tool can only be completed by an appropriate clinician, and the Responsibilities Directions define an appropriate clinician as a person who is, (i) (ii) responsible for the diagnosis, treatment of care of the person in respect of whom the fast track tool is being completed, (ii) diagnosing, or providing treatment of care to, that person under the 2006 Act, and (iii) a registered nurse or is included in the register maintained under section 2 of the Medical Act 1983. Those completing the Fast Track Pathway Tool could include consultants, registrars, GPs and registered nurses. This includes relevant clinicians working in end of life care services within independent and voluntary sector organizations if their organization is commissioned by the NHS to provide services. Whoever the practitioner is, they should be knowledgeable about the individual s health needs, diagnosis, treatment or care and be able to provide comprehensive reasons as to why the individual meets the conditions required for the fast-tracking decision. Others involved in supporting an individual with end of life needs, including those working within the wider independent or voluntary sector organisations should, with the individual s consent, contact the appropriate clinician responsible for that individual s healthcare to Continuing Healthcare Page 10
request the Fast Track Pathway Tool to be completed. Alternatively, they may approach the BCCG and make the request. BCCG require that these applications are submitted for individuals with a rapidly deteriorating condition requiring an urgent decision to enable care needs to be met in a timely manner. Neither a terminal condition nor palliative care needs alone are indications for Fast track applications. If a person receiving palliative care for a terminal condition does not have a rapidly deteriorating condition, the DST will still be used to consider eligibility. Approval will be provided on receipt of the Fast Track Pathway document by the Clinical Lead/ Lead Nurse or designated clinician within the Continuing Healthcare Department however, it must be supported with comprehensive and relevant information as without this an appropriate decision cannot be made. NHS-CHC-Fast-Trac k-pathway-tool-fina 7 Timeframes BCCG has a responsibility to respond to referrals within the following timeframes Fast-track applications-decisions made within 2 working days Eligibility for CHC against Decision Support Tool (DST) 28 working days from the date of receipt of fully completed Checklist. Length of time from BCCG verification to decision to letter sent to individual advising outcome within 5 working days completion of the review assessment to decision 28 days All eligible patients to be reviewed at 3 months and then annually FNC eligible patients reviewed annually Incomplete referrals will be returned to the originating referrer within 3 days with notification detailing the reasons why the referral has not been accepted. BCCG will not accept referrals that were completed more than 5 days prior to receipt except in exceptional circumstances and after discussion with the referring agency. 8 Assessment in Hospital settings The Framework states that it is preferable for eligibility for NHS CHC to be considered after discharge from hospital when the person s long-term needs are clearer, and for NHSfunded services to be provided in the interim. This might include therapy and/or rehabilitation, if that could make a difference to the potential further recovery of the individual in the following weeks. It might also include intermediate care or an interim package of support in an individual s own home or in a care home. (see p.24 of the Framework) Continuing Healthcare Page 11
Where Discharge to Assess arrangements are in place for BCCG patients it is dependent upon the following criteria. Local Authority in which the patients address is registered The Patient is registered with a Bedfordshire CCG GP service. Hospital Discharge teams are required to liaise with BCCG for authorisation Patient is not subject to 117 arrangements The patient is deemed Medically fit for discharge The patient does not have complex or challenging behaviours The patient not meet the criteria for other relevant pathways identified by the BCCG 9. Discharge Planning Arrangements for applying the Framework should form an integral part of the local hospital discharge policies, and be implemented in such a way that delays are minimised; timely assessments will prevent whole system delays within the acute hospital sector. BCCG and other NHS bodies providing hospital services should ensure that there is clarity in local discharge protocols and pathways about how NHS CHC fits into these processes, and what their respective responsibilities are. The Delayed Discharges (Continuing Care) Directions 2009 place certain responsibilities upon both CCG s and NHS Trusts in hospital discharge situations these should be referred to, to ensure correct discharge in this situation. Safe discharge from hospital remains the responsibility of the discharging hospital, as set out in Schedule 2, part 2 of the Standard NHS Contract for Acute Services Terms and conditions for the provision of Health Services. Hospital staff must be sure that appropriate provision will be available to meet the person s needs after discharge, including Care provision A safe environment Moving and handling equipment Medication Continence supplies Advance notice to the GP and DN (if applicable) Continuing Healthcare Page 12
Once an individual has been found to be eligible for NHS CHC funding hospital staff should liaise with the Hospital Discharge Team regarding appropriate care provision and implementation prior to discharge and agreement from BCCG CHC team. Applicants/family members do not have a free choice of care home but every effort will be made to accommodate choice taking into account any assessed risk around any care package and overall use of resources. The Key Worker/Discharge Liaison Nurse will communicate the decision, once verified by BCCG, to the applicant and or their legal representative in a timely manner (within 48 hours of the decision wherever possible). The reasons for deciding whether or not an individual is eligible and at what point in time will be fully documented and made available to the applicant or their legal representative. The applicant or legal representative can seek advice from BCCG CHC department with regard to clarity about a decision or how to challenge a decision. NHS CHC decision letter will be sent to the appropriate individual(s. It will inform the applicant of the decision made by the MDT. 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. Should the appropriate individual(s) not agree with the MDT decision there is an appeals process as set out within this policy. 10. Section 117 Aftercare A patient liable to detention under Section 3 of the Mental Health Act may be eligible for Section 117 aftercare and these arrangements are separate and different from NHS funded Continuing Healthcare. Only if an individual has additional health needs that are not covered under the Section 117 might it be necessary to carry out consideration for NHS CHC funding. An example of this might be if there is a significant physical problem in addition to their mental health needs which may be the responsibility of health organisations. However their mental health and associated needs come under the Mental Health Act provision. 11 Transition from Child to Adult Services Transition is the process of planning, preparing and moving from children s health care to adult health care. It is a gradual process of change which gives everyone time to ensure that young people and their families are prepared and feel ready to make move to adult health care. BCCG recognises that it is important to remember that the legislation and the respective responsibilities of the NHS, social care and other services are different in child and adult services. The term continuing care also has different meaning in child and adult services. It is important that young people and their families are helped to understand this and its implication from the start of transition planning. BCCG will establish entitlement to adult NHS Continuing Healthcare by using the decision making process set out in the adult Framework. This includes the completion of the Checklist Continuing Healthcare Page 13
and the Decision Support Tool. The case will then be presented to BCCG for verification and their final decision. In order to ensure quality, continuity of care and smooth transition NHS Bedfordshire s Continuing Healthcare Department will begin the transition process from the age of 14 years of age. Children s services should identify those young people for whom it is likely that adult NHS continuing healthcare will be necessary, and should notify BCCG when a young person reaches the age of 14. A formal referral for screening at age 16 to the adult NHS continuing healthcare team at BCCG. At the age of 17, eligibility for adult NHS continuing healthcare should be determined in principle by the relevant CCG, so that, wherever applicable, effective packages of care can be commissioned in time for the individual s 18th birthday (or later, if it is agreed that it is more appropriate for responsibility to be transferred then). In order to do this staff from adult services (who are familiar with the Adult Framework) will need to be involved in both the assessment and care planning to ensure smooth transition to adult services. If needs are likely to change, it may be appropriate to make a provisional decision, and then to recheck it by repeating the process as adulthood approaches. Entitlement to adult NHS continuing healthcare will initially be established using the decisionmaking process set out in this adult Framework, including the Checklist and the Decision Support Tool. The decision on eligibility should be made using the relevant CCG s usual adult NHS continuing healthcare decision-making processes. The health plans and other assessments and plans developed as part of the transition process will provide key evidence to be considered in the decision-making process. Any entitlement that is identified by means of these processes before a young person reaches adulthood will come into effect on their 18th birthday, subject to any change in their needs. If a young person who receives children s continuing care has been determined by BCCG not to be eligible for a package of adult NHS continuing healthcare in respect of when they reach the age of 18, they should be advised of their non-eligibility and of their right to request an independent review, on the same basis as NHS continuing healthcare eligibility decisions regarding adults. BCCG should continue to participate in the transition process, in order to ensure an appropriate transfer of responsibilities, including consideration of whether they should be commissioning, funding or providing services towards a joint package of care. BCCG seeks to commission services for patients within it geographical area in line with the Winterbourne View Concordant. However, it is acknowledged that there may be occasions where a patients needs may not be met locally and therefore commissioning of care may need to be sought out of the area in which the patient ordinarily resides. BCCG will ensure that full discussions are had with the patient or their representative in the commissioning of these out of area placements. Where a young person receives support via a placement outside BCCG s area, it is important that, at an early stage in the transition planning process, there is clear agreement between the CCGs involved as to who the responsible commissioner presently is, and whether this could potentially change. This should be determined by applying the principles set out in responsible commissioner guidance (currently Who Pays? Establishing the Responsible Commissioner23) All parties with current or future responsibilities should be actively represented in the transition planning process. 12 Retrospective Reviews of Care Continuing Healthcare Page 14
There may be circumstances where an individual not previously awarded NHS CHC funding believes that they were wrongly denied the funding. In these circumstances the appropriate individual(s) can request a retrospective review of the individual s care needs and eligibility for NHS CHC funding in writing to the CHC department. The DH has recently advertised the close down period of April 2004-April 2012. Therefore current retrospective claims can only be made after this this date unless there are extenuating circumstances that need to be taken into consideration. Where a retrospective review of eligibility for NHS CHC funding is successful, appropriate arrangements will be made for financial recompense in accordance with the Department of Health Guidance for Continuing Healthcare Redress 2007. Calculation of interest payment will be made using the Retail Price Index for each month of the relevant period, and using the rate applied to County Court judgment debt, taking into account pension and benefit payments. Payment will be made with interest to the individual for whichever is the advantageous amount. 13 Commissioning of Care Packages and contracting arrangements of choice. BCCG is responsible for identifying commissioning and contracting for services to meet the needs of individuals who qualify for NHS CHC funding; this will be for the whole package of care including social care. All Providers must be registered with the Care Quality Commission. Providers will be commissioned to provide care to Patients with a wide range of medical conditions and/or care and support needs that may require specific training to be delivered either by the Provider or through a 3 rd party identified by the Commissioner s representative e.g. where a patient is ventilated the Care Worker may need additional specific training to be delivered by specialist nurses who are qualified in the care of ventilated patients. This is to enable a patient-centred service to be delivered. Care will only be commissioned from those care providers who have been deemed appropriate by BCCG using the information provided by the Care Quality Commission (CQC). Where a provider does not meet the required standards Continuing Healthcare packages of care will not be commissioned until the required standards have been met. BCCG will agree costs of Residential care home packages using a cost calculator that is aligned with the Central Bedfordshire Council and Bedford Borough Council negotiated rates for residential and nursing care. The purpose of the cost Calculator is to assist BCCG CHC team in ensuring that patients receive the most appropriate care in the most appropriate setting by clearly defining the agreed levels of need. BCCG will use a 3 tier banding model based on the level of need for placing and pricing residential nursing home packages of care. All individuals placed in the provision will have an identified Primary Health Need and be agreed by the Continuing Health Care team as eligible for fully funded Continuing Healthcare. The level of care needs will be determined by the multidisciplinary team based upon the weightings and levels of need identified during the completion of the Decision Support tool. Prices for care will be fully inclusive and paid at the rate specified and agreed by commissioners following the completion of the following cost calculator. Residential Nursing and residential care providers will be required to adhere to the service specifications and BCCG standard contract to ensure payment of invoices. Continuing Healthcare Page 15
Providers will be required to ensure that BCCG CHC team is informed of changes in patient need that would require and any increase or decrease in levels of care provided. BCCG will Aim to respond to requests for increases in funding to meet higher level of need within 48 hours of receipt of the request. The BBCG require providers to ensure that Invoices are submitted within the timeframes agreed within BCCG standard contract. Invoices that are submitted late will be rejected. Any over payment will be recharged within 28 days and must be credited to BCCG within 14 days. 14. Patient Choice BCCG will commission the provision of NHS CHC funding in a manner which reflects choice and preferences of individuals but balances the need for BCCG to commission care that is safe and effective and makes the best use of resources. There may be occasions where patients or their representatives make requests for care that do not reflects BCCG s commitment to equality and cost effective care. BCCG will, where possible, consider patient/representative choice. However in situations where BCCG do not feel that the level of expenditure represents equality and cost effectiveness it may offer alternatives. If more than one suitable establishment or care package is available, or where there is a request for a care package which is not usually commissioned by the CCG, the total costs of each package will be identified and assessed for overall cost effectiveness by the care management team and commissioners. While there is no set upper limit on expenditure, the expectation is that placements will not be agreed where costs exceed 10% of the most cost effective package that has been assessed as able to meet an individual s needs. Where possible care will be commissioned from providers who have signed an NHS contract with Bedfordshire CCG. This is the most effective, fair and sustainable use of finite resources, as set out in the principles and values of the NHS Constitution. CCGs hold the responsibility to promote a comprehensive health service on behalf of the Secretary of State and to not exceed its financial allocations. BCCG is expected to take account of patient choice, but must do so in the context of those two responsibilities. If the individual or their family/representative indicates that they are unwilling to accept any of the placements offered by the CCG then the CCG shall issue a final offer letter setting out the options available. If the CCG does not receive confirmation that the individual has accepted one of the placements within 14 days then the CCG will write to the individual confirming that the NHS funding has been turned down and NHS funding will cease from 28 days after the date of this notice. Where the individual or their family/representative choose to turn down Continuing Healthcare funding, they will not be able to access local authority funding for the care and will need to make private arrangements. If after receipt of a letter from the CCG, stating that funding has been turned down, the individual or their representatives want to access NHS services, they remain entitled to do so and can re-enter the Continuing Healthcare process. Continuing Healthcare Page 16
In circumstances where the quality rating of a chosen care home is poor BCCG will not commission care from the home at that time, however, BCCG will work with individuals and their families to find a home that meets BCCG s commissioning criteria. Where an individual is found eligible for Continuing Healthcare, BCCG must provide any services that it is required to provide, free of charge. In the context of care home placements this will be limited to the cost of providing accommodation, care and support necessary to meet the assessed needs of the patient. Care at Home For care at home packages this will be the cost of providing the services to meet the assessed needs of the individual. The package of care which BCCG has assessed as being reasonably required to meet the individual's needs is known as the core package. BCCG will only consider the provision of Continuing Healthcare at home in the following circumstances: Care can be delivered safely to the individual and without undue risk to the individual, the staff or other resident members of the household. The safety will be determined by professional assessment of risk which will include the availability of equipment, the environment and appropriately trained carers to deliver care whenever it is required; The acceptance by the individual, BCCG and each person involved in the individual's care of any risks relating to the care package. The patient s General Practitioner's opinion on the suitability of the package and confirmation that he/she agrees to provide primary medical support The opinion of a secondary care, specialist clinician, will be taken into account It is the individual s informed and preferred choice. The suitability, accessibility and availability of alternative arrangements The extent of a patient's needs Where the total cost of providing care is within 10% of the equivalent cost of a placement in an establishment. The cost of providing the package of choice The cost (or range of costs) of the care package(s) identified by the CCG as suitable to meet the individual's assessed care needs. The psychological, social and physical impact on the individual The individual's human rights and the rights of their family and/or carers including the right of respect for home and family life. The willingness and ability of family members or friends to provide elements of care where this is a necessary / desirable part of the care plan and the agreement of those persons to the care plan. If the service user has capacity to make an informed decision and still wishes to be cared for at home, the following conditions apply: A full risk assessment must be made covering all the assessed needs and reflecting the proposed environment in which the care is to be provided. The individual agrees to receive care at home with a full understanding of the risks and possible consequences. The organisation with responsibility for providing the care agrees to accept the risks to their staff of managing the care package. Continuing Healthcare Page 17
The patient s primary care team agrees to provide clinical supervision of the care package, accepting the risks, which will need to be made explicit on a case by case basis. If action by family members or friends is needed to provide elements of care they must also agree to the care plan. Actions to be taken to minimize risk will include those that must be taken by the individual or their family. Any objections from other members of the household are taken into consideration. costs are expected to fall within 10% of an equivalent care although there is no set tariff placement and the assessed needs to be met within the cost are itemized within the care plan Care is provided by an organisation or individual under a formal agreement and meeting standards acceptable to NHS commissioners; at this time it is not possible to make payments to individual patients or their families to purchase their care directly. Where an individual wishes to augment any NHS funded care package to meet their personal preferences they are at liberty to do so. However, this is provided that it does not constitute a subsidy to the core package of care identified by the CCG. The CCG is responsible for the core package and must not allow the individual to contribute to it. Environmental Risk Assessment BCCG will must consider all risks that could potentially cause harm to the individual, any family and the staff. Where an identified risk to the care providers or the individual can be minimised through actions by the individual or his/her family and/or carers, those individuals must agree to comply with the steps required to minimise such identified risk. Where the individual requires any particular equipment then this must be able to be suitably accommodated within the home. BCCG is not responsible for any alterations required to a property to enable a home care package to be provided. For the avoidance of doubt, where an individual or representative has made alterations to the home but BCCG has declined to fund the package, BCCG will not provide any compensation for those alterations. Included in the risk assessment will be a robust Safeguarding Adult assessment in order to assess whether there are any actual or potential risks to the individual. 15 Reviews If the NHS is providing any part of an individual s care, a review will be undertaken to reassess that their care needs are being met and to the standard expected by BCCG. Care reviews will be undertaken for individuals no later than 15 weeks following the initial assessment and then as a minimum standard on an annual basis. BCCG aim to ensure that 95% of patients are reviewed initially 3 months after eligibility is agreed and then a Continuing Healthcare Page 18
minimum of annually thereafter. Patients who are eligible under the Fast track criteria may be reviewed more frequently The purpose of the review is to ensure the care remains appropriate for the individual and that the individual remains eligible to receive CHC funding. The NHS has responsibility to provide and to commission care based on the needs of the individual being primarily for healthcare and, therefore, this may not be for an indefinite period of time. In some circumstances an individual s needs might change and due to this, so might their eligibility for NHS CHC funding. Following a full MDT meeting the case will be verified and a decision made regarding ongoing eligibility. If following a MDT review BCCG reaches a decision that a patient no longer meets NHS CHC eligibility. The patient or their representative and appropriate Local Authority members will be informed in writing of the outcome of that decision. BCCG will cease funding the existing care package after giving 28 days notice to allow alternative funding arrangements to be put in place. Neither BCCG nor Local Authority should unilaterally withdraw from an existing funding arrangements without a joint re assessment of the individuals needs or without first consulting one another and the individual about the proposed change of arrangement. 16 Funding In exceptional circumstances where an assessment for NHS CHC is undertaken as part of the hospital assessment and care planning process for an effective discharge if, for any reason this has not been possible and the patient is ready for discharge from hospital and BCCG has not yet reviewed the application for the patient, the patient discharge cannot be delayed. In order to progress discharge arrangements for individuals in these circumstances, where a decision has not yet been made on eligibility for CHC funding, agreement for BCCG to fund the care arrangements in the interim must be officially agreed before progressing discharge; BCCG CHC department is responsible for agreeing the funding arrangements for the care package in these circumstances. Topping up payments, is legally permissible under legislation governing social services but it is not permissible under NHS legislation with regards to provision of care services. Care providers may make private arrangements with clients and their representatives to provide privately paid for services that are not considered to be part of the planned Health care needs of an individual receiving Continuing health care. This may include ensuite, facilities, internet access, hairdressing, chiropody, larger rooms etc. This additional costs will not be the responsibility of BCCG. Where Individuals become eligible for NHS CHC when they are already resident in care home accommodation for which the fees are higher than BCCG would usually pay for someone with their needs. This may be where the individual was previously funding their own care or where they were previously funded by social services or a third party had topped up the fees. In such situations, BCCG, may consider whether there are reasons why they should meet the full cost of the care package, notwithstanding that it is at a higher rate, such as, that the frailty, mental health needs or other relevant needs of the individual Continuing Healthcare Page 19
mean that a move to other accommodation could involve significant risk to their health and wellbeing. Where an individual is in an existing out of area placement funded by either the Local Authority or a third party and becomes eligible for NHS CHC if the fee is of a higher cost than BCCG would usually meet, it is important before refusing, to take into account the market rates in the locality of the placement. NHS Continuing Healthcare BCCG will ensure that when the above situations ensue they are dealt with sensitively and in close liaison with the individuals affected and, where appropriate, their families, the existing service provider and social services if they have up to this point, been funding the care package. Where separation of NHS and privately funded care arrangements is possible, the financial arrangement for the privately funded care is entirely a matter between the individual and the relevant provider and it should not form part of any service agreement between BCCG and the provider. Where an individual wishes to dispute BCCG decision not to pay for higher-cost accommodation, they should do this via the NHS complaints process. 17 Complex Case Panel Following the decision that an individual meets the criteria for Continuing Healthcare or shared funding arrangements, and the cost of the proposed care package exceeds 100,000 per annum, or there is individual complexity which would benefit from panel oversight, the individual recommendation will be referred to the CCG High Risk & Complex Case Panel to consider the request for a specific package of care, or to consider the shared care arrangement where there has been difficulty agreeing that arrangement. The panel will give assurance to both CCG Directors and Council Directors in ensuring packages of care for people with complex needs are appropriate, equitable, outcome focused and provide value for money. The panel will also discuss transition arrangements where there has been a change of eligibility which has triggered a transfer to a different funding arrangement (e.g. CHC to NCC, or NCC to CHC) Packages agreed at the panel are agreed as recommendations for sign off according to BCCG s Standing Financial Instructions. Panel Membership CHC Locality lead nurses (2) CBC Adult/LD/MH Social Services lead BBC Adult/LD/MH Social Services lead BCCG Contracts manager BCCG Head of Patient Safety / Head of Patient Experience and Safeguarding (1) BCCG Head of Continuing Healthcare Continuing Healthcare Page 20
BCCG Deputy Director of Finance Specialist advisor where required (non-voting) Members who cannot attend should send a named representative who has the authority to act on their behalf. Quorum 5 members (or representatives) 18 Responsible Commissioner Who Pays? Determining responsibility for payments to providers (DOH 2014) sets out a framework for establishing responsibility for commissioning an individual s care within the NHS, helping to determine who should pay for the individual s care General principles: - Where the patient is registered on a General Practitioners (GP) practice list of NHS patients when they become eligible for NHS CHC funding, the responsible commissioner will be the CCG that holds the contract with the GP practice. If a patient is not registered with a GP practice, the responsible commissioner will be the CCG in whose geographical area the patient is usually resident. If a patient is unable to give an address, in accordance with Responsible Commissioner directions the responsible commissioner will be determined as the CCG in which the individual is usually resident, There are a number of exceptions to this guidance and BCCG s required to refer to the criteria appropriate to the period being considered, that is the Responsible Commissioner Guidance in place for any particular period (DOH 2003 & 2006a). The guidance indicates If the Trust has identified a person as eligible and the patient or their family exercise their right to request patient choice to move care home in another area, the originating CCG remain responsible to fund the placement. (Obviously if the placement chosen is not suitable, the Trust should liaise with the new host CCG re the placement.) The new host CCG will only pick up funding if the patient has moved (or relative has moved them) without any involvement or knowledge of the originating CCG. This is what the responsible commissioner guidance refers to as independently chosen. This only applies to care home placements. It is different if a person is deemed eligible and the choice is to move to a family home in another area. In this situation the CCG responsible is the receiving CCG (GP registration applies) but the two CCG s need to positively discuss the transfer to allow the receiving CCG to assess the care package. Continuing Healthcare Page 21