Agenda Item: 12.2 Subject: Presented by: Continuing Health Care Pathway Proposal Dr Sue Crossman, Chief Officer Submitted to: NHS West Norfolk CCG Governing Body, 24 September 2015 Purpose of Paper: Decision Executive Summary: Continuing Health Care (CHC) is an area of care that causes confusion, delays to transfers of care and tension between families, Social Services and the NHS. The Clinical Commissioning Group (CCG) has seen CHC costs increase year on year by approximately 8% with variations in the consistency in process of assessments and package reviews. There are a number of reasons relating to quality of care and financial affordability that make CHC a high priority for improvement in West Norfolk. This paper sets out a proposal to apply the National Framework more consistently, providing a fair, equitable model across all patients, wherever they may live. Currently, patients in hospital undergo a CHC assessment if it appears that their complex care needs may have a clinical origin as opposed to a social one. This is notoriously difficult to assess during a hospital stay and the national guidance recommends undertaking the assessment in the community once the patient has recovered from the acute episode. Experience shows that the patient s condition often improves very considerably in the first few weeks after discharge but a review of the CHC package is not normally conducted until three months later. Models such as the Sheffield and the Great Yarmouth and Waveney Discharge to Assess schemes have produced positive results and this paper explores the opportunities for the development of a local similar initiative. The paper also explores the opportunity to pool funding with Social Services to simplify the process and greatly reduce bureaucracy, confusion and delays for patients. KEY RISKS Clinical: None - Reduced discharge delays, appropriate packages of care put in place, right first time. Finance and Performance: No risks - Savings will be released to invest in patient care. Impact Assessment (environmental and equalities): Enhanced equality, all patients treated equally. Reputation: Potentially enhanced by addressing a widely acknowledged problematic issue, potentially some damage if not clearly communicated to stakeholders. Legal: Phase 1 - None the proposal simply recommends the consistent application of the national guidance. Phase 2 Requires new legislative framework (currently in discussion with NHS England). Patient focus (if appropriate): Patients rights are unchanged. Information will be clearly produced to reduce concerns about the movement of the assessment to the community. Reference to relevant Governing Body Assurance Framework: RECOMMENDATION: Governing Body members are invited to discuss the proposal and to decide whether to support the plan. 1
Continuing Health Care (CHC) Proposal 1. INTRODUCTION CHC costs are spiralling at a time when health service funding cannot keep pace with demand. In addition, there are anomalies in the CHC assessment process that result in subjective decision-making, which raises expectations for the people receiving care and sometimes has to be reversed following a review, thereby creating high numbers of appeals and complaints. The two-stage CHC assessment process (eligibility checklist followed by a full assessment if positive) takes time to conduct in hospital at a time when patients often have the potential for significant recovery, making it an unreliable measure of on-going support needs. It also puts a delay in the discharge process, for a group of patients that are vulnerable to hospital complications when they should be moved to a more appropriate setting to complete their rehabilitation. These issues in combination have created a risk-averse, illogical set of processes that result in inequalities, delays and open-ended spending. 1.1 The root causes: 1. Case law, Acts of Parliament and the national framework are interpreted variously, often creating confusion about the legalities of assessment; two tests relating to whether or not care could be provided by social care and whether or not the patient has a primary health need and inconsistent messages about health and social assessment sequencing. 2. National Decision Support Tool (DST) is open to interpretation, creating inconsistency. 3. Inequalities in access to CHC in community vs hospital. 4. CHC trigger test checklist is unreliable when conducted in hospital and creates lots of false positives (95% in West Norfolk). 5. On discharge from hospital, people are often placed in care on the assumption that it will continue to be paid for by the NHS, resulting in dispute when this is not the case. 1.2 Current attempts to address the problems include: a) Discharge to assess models designed to expedite discharge from hospital and move the assessment to a more appropriate setting where the patient is continuing to recover. Cohorts of patients who triggered a positive checklist in hospital are discharged to NHS funded community beds until the full assessment has been conducted. b) National Policy Advisory Group reviewing the DST to improve clarity and reliability in determining health needs. 1.3 Likely outcomes: a) Moves the bottle-neck outside hospital but does nothing to address the assessment inequalities, expectations and unreliability of check-listing in hospital setting. Some financial savings but only partial. b) Risk of layering more bureaucracy onto an already complex, confusing and unreliable process without addressing the root cause of the problems. Opportunity for savings unclear. 1.4 Solutions: The obvious panacea is total health and social integration, which would remove the need to make a false distinction between health and social care needs in order to invoice the right government department. Given that this will take some time, we need a pragmatic short term solution to improve the pathway, eradicate inequalities and reduce waste. Three steps proposed: 1. De-couple hospital discharge and CHC assessment completely (except in cases of fast track for End of Life care or other clinical exceptions). 2
2. Only assess people once they have recovered from their acute episode of illness, thereby creating a community-based process that is consistent for all. 3. Means-test for care on discharge, unless their needs indicate they are suitable for funded reablement, intermediate care or rehabilitation, thereby treating people in hospital and in the community equally. 1.5 Likely outcomes Consistent process Appropriate discharge destination, based on current need Managed expectations and Financial savings 1.6 Savings would be generated through: 1. Abolishing hospital checklists. 2. A reduction in the number of full CHC assessments, due to longer recovery period. 3. Reducing Length of Stay in hospital. 2. LEGAL AND POLICY CONSIDERATIONS The Coughlan Case in 1999 established that people should receive NHS funded care providing their needs could not reasonably be expected to be provided in a social care setting and the test for this was proving primary health need. It also tested the right in that case to receive free care for life, which was deemed a legitimate expectation following the promise made to Ms Coughlan. The statutory guidance Delayed Discharge (Continuing Care) Directions 2013 pertaining to the NHS Act 2006, places a duty on Trusts to conduct the CHC assessment. However, it does not stipulate what kind of Trust, nor where the assessment should be carried out and there is a wide body of evidence that hospital is not the appropriate setting for CHC assessments. This is also quite clearly supported by the National CHC Framework. However, the Care Act 2014 has more specific instructions. This is detailed in Schedule 3 of the Act and the associated regulations - The Care and Support (Discharge of Hospital Patients) Regulations 2014. The Regulations state that: Before issuing an assessment notice (to social care) the NHS body must have also completed any assessment of the potential Continuing Health Care needs of the patient and if applicable made a decision on what services the NHS will be providing. A model template for an Assessment Notice within the Regulations includes a box to confirm the following: An assessment of their continuing health care needs has been completed and a decision made. The final reference to CHC within the Regulations is in connection with reasons to withdraw Assessment Notices, one of which is that: The NHS body considers that the patient s on-going need is for NHS Continuing Health Care. The following are extracts from The National Framework for NHS Continuing Healthcare and NHS funded Nursing Care November 2012 (revised) illustrates the recognised process regarding screening. Eligibility Consideration (page 23) Section 64 Assessment of Eligibility for NHS continuing healthcare can take place either in hospital or non-hospital settings. It should always be borne in mind that the assessment of eligibility that takes place in an acute hospital may not reflect the individuals capacity to maximize the potential. This could be because with appropriate support, that individual has the potential to recover in the near future. 3
It could also be because it is difficult to make an accurate assessment of an individual s needs whilst they are in an acute service environment. Anyone who carries out an assessment of eligibility for NHS continuing healthcare should always consider whether there is further potential for rehabilitation or for independence to be regained and how the outcome of any treatment or medication may affect ongoing needs. Section 65 In order to address the issue and ensure that unnecessary stays in acute wards are avoided, there should be consideration of whether the provision of further NHS funded services is appropriate. This may include therapy or rehabilitation, if that could make a difference to the potential of the individual in the following few months. It might also include intermediate care or interim package of support in an individual s own home or in a care home. In such situations, assessment of eligibility for NHS continuing healthcare should usually be deferred until an accurate assessment of future needs can be made. Section 66 Where NHS funded care other than an acute ward is the next appropriate step, this does not trigger the responsibility under Community Care Delayed Discharged Act 2003. 3. WHAT THIS MEANS IN PRACTICE The current application of CHC guidance results in patients and families being told the discharge is delayed until the hospital has confirmation of NHS or Social Services funding for care. This creates expectations and delays to discharge that are avoidable and can result in harm. The requirement to defensively prove at an inappropriate point in time, using an unreliable tool, that a patient does not have continuing healthcare needs before being able to refer to Social Services creates unnecessary delays and costs. It is widely accepted as best practice and supported by the national DST framework that CHC assessment should not be conducted in hospital. Conversely, the regulations can be interpreted as meaning that in circumstances where a patient is to be discharged to an NHS funded placement, there is no need to conduct a CHC assessment as this is better to be done at a later stage. Where the patient is to be discharged to a non-nhs funded placement, the NHS has a duty to issue an assessment notice to the Local Authority, stating that the patient does not meet CHC criteria. It is quite possible to make this assessment without going through the lengthy and unreliable CHC checklist, so long as the Multi-disciplinary Team (MDT) members in charge of their care (including a social worker) agree that the patient s needs can be met by Social Care. The other important consequence of this regulation is that hospital inpatients are currently being treated preferentially in comparison to those being cared for in the community, thereby creating discrimination. Patients in the community who develop care needs are responsible for paying for it themselves until they trigger the criteria for a CHC assessment. It is accepted that means tested self-funding for personal care is a societal norm for those people who are no longer independent. Ethical reasoning follows that people who are ready for discharge from hospital and no longer need hospital care should be treated the same as others in the community with the same level of care needs, ie once they have recovered from their acute illness, if they trigger an assessment, they will be given one. However, at the moment, hospital patients are being assumed eligible until proven otherwise, which is not a consistent or fair application of the CHC framework. Families should therefore be made aware at the point of admission, that when the patient is ready for discharge, if they are suitable for social services care, the family will be means tested for a contribution to the costs. If the patient requires nursing intervention other than care that can be provided by Social Services then they should be treated in an NHS community setting and assessed for CHC there once recovered. 4
The basis for this argument is clear currently, the destiny of patients is being dictated by a policy to determine which government department pays, instead of their health and care needs. This causes avoidable delays in transfers, which are never in the interests of the patient. It also causes a great deal of dispute, complaints and appeals from families 3.1 Current local picture Currently 50 checklists a month, 44 ineligible, 6 have full CHC assessments, 3 are confirmed eligible. The 44 ineligible are currently passed to Social Services for assessment. These are not tracked in any way and are discharged presumably with social care packages. Of the 6 that have full CHC assessment approximately 46% (3 patients) are eligible. The other 3 patients are discharged with a social care package and are not tracked in terms of developing later CHC eligibility. The destination of the 3 eligible patients is usually one of many care homes with a CHC package. All are currently funded by the NHS for 3 months until their review. 4. PHASE 1 CHC PATHWAY NEW PROPOSAL 1. Hospital Discharges a) Patient is identified by MDT as able to go home but having social care needs on discharge hospital raises an assessment notice and discharge notice to social care. Nursing needs can be met by the community nursing service in patient s home. b) Patient has immediate care needs which can be met in a residential care home - hospital raises assessment notice to social care. Nursing needs can be met by care home staff and/or community nursing service in care home. c) Patient has immediate nursing care needs which cannot be met by Social Services Patient discharged (depending on their level of need) either to: i) Virtual Ward home care team; ii) Community NHS hospital; iii) Community rehabilitation unit; iv) Intermediate care bed in a nursing home. A CHC assessment will be conducted within 28 days following discharge, if deemed appropriate when the patient has reached optimal recovery. 2. Community Assessment (unchanged) a) Patients being cared for in a residential or nursing home with no CHC funding, whose needs become more complex care managers or community nursing staff will arrange for a CHC assessment once a patient triggers the criteria for an assessment. This will be conducted by the Commissioning Support Unit CHC team. b) Patients at home being supported by a GP and community nursing service will trigger an assessment in the same way. It is likely that both groups a) and b) will already have had a social services assessment of eligibility for care and this will have determined whether the family had to fund the nursing home costs. Care home staff and community nurses are very experienced at recognising when a patient should be given a CHC assessment. The proposed hospital discharge pathway is illustrated in the flowchart at Figure 1 below. 5
Figure 1: Patient has complex care needs on discharge (Assessed by ward nurses/ discharge team, agreed by MDT and recorded) (44 patients/month) MDT decision (6 patients/month) Can their needs be met by Social care? NO Complex, substantial nursing care needs? YES Refer to Social Services Nursing assessment determines level of on-going care needs Social care package and re-ablement at home with GP and community nurse input Residential care home (means tested) with GP, community nurse/ therapist input NHS funded Virtual Ward home care Rehabilitation unit Community hospital Intermediate care bed CHC assessment if indicated (within max. 28 days to allow optimal recovery) Eligible, care funded In-eligible, package self-funded CHC Funding Awarded 4.1 What this changes in practice Currently, 44 check-listed patients go straight into social care and a proportion of the 6 who have a full CHC assessment but do not qualify, will also end up with a social care package. 6
Of the 3 patients currently eligible on discharge, data show that these do not convert to ineligible at the 3 month review. Of 36 patients between August 2014 and July 2015, 20 have since died, 1 declined the CHC package and 15 remain on CHC funded care (see Table 1). Table 1 QEH CHC eligibility data 2014/15 These data suggest that the full CHC assessment is between 20-60% reliable and is preceded by a 95% unreliable checklist. Hopefully by 28 days post-discharge the full CHC assessments will be closer to 100% reliable, thereby saving two rounds of unnecessary CHC assessments for around 44 people per month as they continue to recover. For people who are discharged to social care support and subsequently trigger a CHC assessment within 28 days and are found to be eligible, the NHS will now agree to back-pay the family or Social Services for the month after discharge. If they become eligible at a later date, they will be treated as any Social Care placement that develops CHC eligibility. 4.2 Consequences for LHE partners and patients Phase 1 Discharge to Assess 1) Hospital Time freed up (175 hours a month) for nurses to plan discharge as no longer required to do checklists or full CHC assessments. 2) Social Care Social workers freed up from lengthy CHC MDT decision meetings (6.5 times a month), allows them to focus on social care assessments in hospital resulting from ward MDT Board Rounds. 3) CHC Team Time freed up from reviewing and signing off hospital assessments (6.5/month), allows them to do more pro-active reviews and reduce backlog. Re-direct resource to doing community CHC assessments at 28 days for those who still present as needing long term complex care (2-3 a month). 7
4) Care Homes Avoid admission delays whilst confirmation sought on who is paying. More coordinated CHC pathway with clearer links between intermediate care/ rehabilitation clarity about access to therapy to support discharge home. 5) Patients and families Clarity about discharge arrangements on admission. Managed expectations about destination and funding responsibilities. Discharge based on care needs, not confused by CHC assessment. Hospital and community treated the same currently patients in the community have to wait far longer for a CHC assessment, whilst hospital patients have immediate assessments, 95% of which prove to be unnecessary. Patients often experience a disruption to their care when they change eligibility status often switching to different providers for CHC or non-chc packages of care although their needs have changed little. This can be distressing for frail elderly people. Patients rights to assessments and care are unaltered. For 95% of the patients currently check-listed the only change will be reduced number of assessments and quicker discharge process. 6) Commissioners Social Care NHS funded intermediate care beds for patients discharged with complex needs at time of discharge. NHS repayment for patients discharged to Social Care who become eligible within 28 days of discharge. NHS Potential savings generated from smaller CHC packages @ 28 days than in hospital and quicker recovery due to earlier discharge. Potential added risk of increased spend on patients needing nursing care on discharge, mitigated by enhanced community intermediate care team promoting optimal recovery. Potential risk that NHS funded placements that do not convert to CHC funding at 28 days will become subject to funding dispute between care home and family. Mitigate by clear information on admission to QEH. 4.3 Evaluation metrics for the pilot Baseline data on destination, numbers of CHC eligible and outcome of 3 month review. Pre and post comparison of CHC spend and Social Services spend post-hospital discharge. Pre and post data on discharge delays for patients waiting for a CHC assessment. Pre and post backlog of CHC reviews. CHC assessment results numbers done and numbers eligible at 28 days. 4.4 Financial consequences for health and social care A conservative estimate of financial savings is illustrated below, currently difficult to quantify due to insufficient data. 1. CHC assessors in QEH no longer required to do CHC checklists or full assessments Saving circa 60,000 per year. 2. Cost pressure for those patients who were previously positively check-listed, now having an NHS funded service until they have a CHC assessment if necessary. 3. Potential risk that some of the 3 patients who are currently eligible for CHC funding will transfer to social care needs instead. Seems unlikely due to the apparent non-conversion rate at 3 month reviews. 4. NHS costs reduced by 1 st 28 days residential care being charged at 670 per week instead of 908, saving circa 37,000 per year. 8
5. The new process will eliminate any spend on excess bed days for CHC Patients. Data on this is variable, depending on the source, so cannot be confirmed yet and will be explored further. However, as an estimate, around 78 patients a year (6.5 a month) currently complete the CHC full assessment process in QEH. Based on an average of 50% patients going over their trim point by one day (50% of 78 = 3.9 patients per year), costing the CCG one extra bed day of 220, the new process would see a saving of 8,580 per year for every day saved. As the removal of assessments from QEH is likely to reduce length of stay by several days per patient, the savings are likely to offset any potential costs in transferring them to a community bed while they recover. 6. The cost of CHC packages will vary from case to case. Some packages will be less expensive as they will be planned 28 days later than currently. Some packages may be of shorter duration due to intensive reablement support. Current reviews of high cost packages are yielding several hundred thousand pounds YTD, so it would seem reasonable to assume there are savings to be made on package costs. 7. A reduction in full CHC assessments is anticipated in Phase 1 due to patients following a more active coordinated reablement pathway in the 28 days before the assessment is undertaken, resulting in an improved recovery rate. This would reduce the number of CHC packages. The goal is to achieve independent living for as many people as possible. There will be a cumulative effect to savings year-on-year as the benefits highlighted relating to number and cost of packages affect an increasing proportion of all CHC cases annually. 5 PHASE 2 DESIGNING A NEW FRAMEWORK 5.1 Pooling budgets and redefining care The second stage of the work aims to create an assessment framework and funding arrangement that abolishes the need for CHC completely as a pooled budget will fund the care. As a means for testing eligibility the current assessment process is clearly flawed; a better process would result in care packages being awarded appropriately and consistently, without confusion about who should pay. Instead, an assessment will build on the nursing care plans already in place, using a new framework to determine whether the on-going needs are nursing or care. The benefit of Phase 2 is that the risks are shared between the Local Authority and the CCG, avoiding any conflict about perceived cost-shunting from one to the other. Increasing demand for social care will be offset by the new framework, which will apply mean-testing to the personal care and hotel costs elements of all care packages. This is consistent with the accepted societal principle that health care is free and social care is means tested. Grounds for appeals would therefore be significantly diminished. In addition, there would be a consistent, common contract with care providers, which would address anomalies in charging and interpretation and application of current Price Bands. This should release further savings and clamp down on any irregularities. The starting point for this extension to the arrangements is a dialogue between health and social care about the definitions of nursing and care. 5.2 Outcomes A new framework will be developed, whereby people s needs are classified as nursing or care. Nursing is free, care is mean-tested. NHS and Social Care budgets are pooled and administered jointly. No CHC assessment is therefore necessary to determine who funds the care. Hotel costs for residential nursing care are not paid unless the nursing is provided in an NHS funded bed. Hotel costs for residential care are paid according to means testing. This will release savings currently paid for by CHC that will no longer be part of funded care. 9
The proposals have been discussed with NHS England Director of New Models of Care Team and national Director of Strategy along with other national authorities on CHC and policy. There is strong support for this work to be progressed and legal advice will be closely adhered to throughout. 6. CONCLUSION AND RECOMMENDATION Taking into account the key points raised in this document, it is apparent that the current system for determining CHC eligibility is not fit for purpose and does not treat patients and families fairly. West Norfolk CCG, a national Integration Pioneer, wishes to pilot the three steps above and is working on the pathway with the Acute Trust and Local Authority. The proposal has the following benefits: 1. Supports prompt discharge from hospital. 2. Simplifies decision-making, improving consistency. 3. Improves equity and fairness. 4. Makes financial savings. 5. Reduces bureaucracy. 6. Reduces complaints, appeals and judicial reviews. There is a risk that the pathway could be perceived (incorrectly) as altering eligibility to funded care. Legal advice has already been sought and the view is that so long as there is a local policy between the Local Authority and CCG and that the application of the policy is in the best interests of patients, then there would be no case to challenge the decisions about care. The benefits analysis from this pilot will be widely disseminated, to inform national policy development to underpin a streamlined, high quality, cost effective pathway. The CCG would also be interested in contributing to the Policy Advisory Group review of the DST. Members are asked to support the adoption of the proposed pathway pilot. 10