Policy for the provision of fully funded NHS Continuing Healthcare (2012) revised 1. Introduction 1.1 This policy describes the way in which Brent, Harrow and Hillingdon Clinical Commissioning Groups will make provision for the care of people who have been assessed as eligible for fully funded NHS Continuing Healthcare. It describes the process of decision making for provision subsequent to an assessment of eligibility under the National Eligibility Criteria. 1.2 It should be read in conjunction with: The National Eligibility Criteria for NHS Continuing Healthcare revised (2012) Brent Harrow and Hillingdon Clinical Commissioning Group s Continuing Healthcare Pathways and Protocols 1.3 This policy has been drawn using current legislation and case law and has recently been reviewed by the Health Service Ombudsman s and found to be sound document. 2. Context 2.1 Continuing Healthcare is a general term defined as: 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 a result of disability, accident or illness. It may require services from the NHS and/or social care and can be provided in a range of settings. Access to these services is based on assessed need. 2.2 Fully funded NHS Continuing Healthcare describes a package of on-going care arranged and funded solely by the NHS. It is provided to individuals where the nature of their condition is predominantly for health care under the monitoring and supervision of a registered health professional. The individual will demonstrate needs that are complex and/or intense and /or unpredictable. In order to meet these needs the individual would require care which promotes well being, avoids deterioration and distress and manages severe challenging behavior. Ref National Eligibility Criteria for NHS Continuing Healthcare 2.3 The term Continuing Healthcare is used in this policy as an abbreviation of fully funded NHS Continuing Healthcare. 1
2.4 Brent Harrow and Hillingdon Clinical Commissioning Groups will provide fully funded NHS Continuing Healthcare to people after a full assessment of their needs that has incorporated the individual s physical, mental, psychological and emotional state. This assessment will be carried out in accordance with national guidance and local arrangements, as set out in Brent Harrow and Hillingdon Clinical Commissioning Group s Protocol s and pathways on Continuing Healthcare, by an appropriate professional working for Brent Harrow and Hillingdon Clinical Commissioning Group s and in conjunction with other health professionals and social workers from Brent, Harrow and Hillingdon Council s..an assessment will take place only after all appropriate options of rehabilitation have been considered and offered. There is an appeal process against a determination of eligibility, set out in the above protocols. 3. The provision of Continuing Healthcare 3.1 Most patients who require Continuing Healthcare will receive it in a specialised environment. The treatments, care and equipment required to meet complex, intense and unpredictable health needs often depend on highly trained professionals for safe delivery, management and clinical supervision. Specialised care, particularly for people with complex disabilities may only be provided in specialist nursing home or hospital settings, which may be distant from the patient s ordinary place of residence. Placements may be very costly. 3.2 These factors mean that there is likely to be limited choice of a safe and affordable package of care. 3.3 The CCG S hold the responsibility to promote a comprehensive health service on behalf of the Secretary of State and to not exceed its financial allocations. It is expected to take account of patient choice, but must do so in the context of those two responsibilities. 3.4 In the light of these constraints, Brent Harrow and Hillingdon Clinical Commissioning Groups have agreed this policy to guide decision making on the provision of Continuing Healthcare. 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 interests, will involve the individual and their family or advocate where possible and appropriate, take into account the need for the CCG S to allocate its financial resources in the most cost effective way, offer choice where available in the light of the above factors. 2
3.5 Continuing Healthcare is generally provided in a range of nursing homes. These are established and managed specifically for the purpose of providing multi-disciplinary interventions in an environment designed to promote safety, dignity and choice within the constraints of the patient s condition. These may include registered nursing homes. These settings have high levels of expertise in the successful management of complex or unusual physical and mental health care, and employ staff trained, managed and supervised in specialist interventions. They provide care significantly beyond the degree of complexity which can generally be managed safely in community settings. 3.6 When the decision on eligibility is agreed, the case manager, in conjunction with the Brent, Harrow and Hillingdon CCG s Brokers, Care Home Selection, will identify establishments which are capable of meeting the assessed needs and which are in a position to provide a place within a reasonable space of time using the following Commissioning Protocol and the Commissioning Resource Allocation Pathway. This process does not apply to the commissioning of care for patient with a Learning Disability/autism or Pediatric placements 3.7 Older People EMI and Palliative care placements 1 A nursing home which accepts the standard or usual costs of a placement for Brent, Harrow and Hillingdon CCG s and is located within the Boroughs of Brent, Harrow and Hillingdon (if a nursing home cannot be located under this criteria) 2 A nursing Home which accepts the standard or usual costs of a placement for Brent, Harrow and Hillingdon CCG s, that is located in a neighbouring CCG s area (e.g. Harrow, Brent, Hillingdon, Ealing, Hounslow etc.) (if a nursing home cannot be located under this criteria) 3 A Nursing Home which accepts the standard or usual costs of a placement for Brent, Harrow and Hillingdon CCG s in a neighbouring County (e.g., Hertfordshire, Bucks or other) 3.8 Physically Disabled / Brain Injury Patients under 65 / Adult Mental Health Patients under 65 The following criteria will apply:- 1 A specialist nursing Home which accepts the standard or usual costs of a placement for Brent, Harrow and Hillingdon CCG s within the Borough of Brent, Harrow, and Hillingdon (if a nursing home can not be located under this criteria) 2 A specialist nursing Home which accepts the standard or usual costs of a placement for Brent, Harrow and Hillingdon CCG s, that is located in a 3
neighbouring CCG s area (e.g. Harrow, Brent, Hillingdon, Ealing, Hounslow etc.) (if a nursing home cannot be located under this criteria 3 A specialist nursing home which accepts the standard or usual costs of a placement for Brent, Harrow and Hillingdon CCG s in a neighbouring CCG County (e.g., Hertfordshire, Bucks or other) 4 Commissioning of Care packages must be in line with paragraph 4 below. 3.9 Learning disability Patients under 65 The arrangements for the commissioning of nursing home care for this client group are different within Brent, Harrow and Hillingdon CCG s. Brent, Harrow and Hillingdon Clinical Commissioning Groups will undertake the Continuing Healthcare Assessment and establish eligibility for full funding. The specialist Learning Disability Nurse Assessors for this group of patients will lead the identification of a suitable care provider and will take into account the following:- Provision of a nursing home placement in Brent and Harrow is as follows:- 1 A Nursing Home which accepts the standard or usual costs of a placement for Brent, and Harrow in the Boroughs of Brent and Harrow (if a nursing home can not be located under these criteria) 2 A Nursing Home which accepts the standard or usual costs of a placement for Brent, Harrow and Hillingdon CCG s, that is located in a neighbouring CCG s area (e.g. Harrow, Brent, Hillingdon, Ealing, Hounslow etc.) (if a nursing home cannot be located under this criteria. 3 A Nursing Home in a neighbouring county (e.g. another London Borough or a county i.e. Hertfordshire, Bucks or other) 4 Commissioning of Care packages must be in line with paragraph 4 below. Wherever possible the Care Funding Calculator must be applied to the nursing home provider and costs and fees negotiated accordingly. 4
Provision of a nursing home placement in Hillingdon Hillingdon Clinical Commissioning Groups has a Section 75 Agreement with Hillingdon Local Authority, Social Care, to case manage and support NHS Continuing Healthcare patients. Wherever possible the Care Funding Calculator must be applied to the nursing home provider and costs and fees negotiated accordingly All Client Groups 3.10 If more than one suitable establishment or care package is available, the total costs of each package will be identified and assessed for overall cost effectiveness by the Continuing Healthcare Team Manager and the Brokerage Manager these discussions will include the use of the above Commissioning Protocol and the Commissioning Resources Allocation Pathway before a placement is offered to the patient and their family. 3.11 Brent Harrow and Hillingdon Clinical Commissioning Groups will make a commissioning decision and following this decision a discussion will take place between the Brokerage Team, the patient and family on the respective merits of the alternatives. Where the patient and family preference is consistent with the most cost effective package, the placement will be negotiated and the arrangements made and reviewed by the case management team. 3.12 Where the establishment preferred by the patient and family is not the most cost effective, the overall circumstances will be considered by the manager and the lead commissioner, and a decision made which takes account of clinical need and risk, patient preference and overall cost to the CCG S. 3.13 There is no provision for patients and their families to Top Up Brent, Harrow and Hillingdon CCG s will locate a suitable placement that can meet the needs of the individual patient within its standard or usual cost structure. 3.14 If placement at home is more cost effective than in an establishment setting, it will only be agreed with the consent of the patient and family or advocate. 3.15 An individual may appeal the commissioning decision in writing within 10 days through Complaints and Governance Team. 5
4. Fully funded NHS Continuing Healthcare at home All Client Groups 4.1 Given the complexity of Continuing Healthcare cases, Brent Harrow and Hillingdon Clinical Commissioning Groups will consider the following conditions:- a) Care can be delivered safely to the individual and without undue risk to the staff. 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; b) The patient s General Practitioner agrees to provide primary medical support; c) It is the individuals informed and preferred choice; where an individual lack the capacity to make such a decision then the registered Deputy with the lasting Power of Attorney for Health and Welfare will make the decision. Where no Deputy has been appointed then this decision can be made in the Best Interest of the patient. d) Where the individual can actively interact with their environment to an appropriate extent given their mental capacity. e) If action by family members or friends is needed to provide elements of care they must also agree to the care plan. f) Where the total cost of providing care is within 10% of the equivalent average cost of a Nursing Home placement. i.e. The average cost of the Nursing Home placement + 10% g) Patient and their families can opt to receive a Personal Health Budget. The indicative budget would be based on the cost of a nursing home placement + 10%. A personal Health Budget will enable more a flexible approach to meeting the individual needs of the patient. 4.2 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) 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. b) The individual agrees to receive care at home with a full understanding of the risks and possible consequences. c) The organization with responsibility for providing the care agrees to accept the risks to their staff of managing the care package. d) The patient s primary care team agrees to provide clinical supervision of the care package, accepting the risks. e) If action by family members or friends is needed to provide elements of care they must also agree to the care plan. f) Actions to be taken to minimize risk will include those that must be taken by the individual or their family. 6
g) Any objections from other members of the household are taken into consideration. h) Costs are expected to fall within 10% of equivalent care in a nursing home, and the assessed needs to be met within the cost are itemized within the care plan i) Care is provided by an organization or individual under a formal agreement and meeting standards acceptable to NHS commissioner; j) Patient and their families can opt to receive a Personal Health Budget. The indicative budget would be based on the cost of a nursing home placement + 10%. A personal Health Budget will enable more a flexible approach to meeting the individual needs of the patient. 4.3 If a service user does not have the mental capacity to make an informed choice and is placing them at risk by indicating choice of a care package at home a mental capacity assessment will be undertaken. If there is no person able to make a best interest decision of behalf of the patient then an Independent Mental Health Advocate (IMCA) will be offered to support the user in this process, under the provisions of the Mental Capacity Act 2005. 4.4 If the service user does not have the capacity to make an informed choice the CCG S will deliver the safest and most cost effective care available based on an assessment of best interests and in conjunction with any advocate, close family member or other person who should be consulted under the terms of the Mental Capacity Act. 4.5 An individual may appeal the decision in writing within 10 days through BHH Complaints and Governance Team.. 5. Review of NHS Continuing Healthcare support 5.1 All service users will have their care reviewed at 3 months and thereafter on an annual basis or sooner if their care needs indicate that this is necessary. Individuals with palliative care needs will have their care reviewed more frequently in response to their medical condition. 5.2 The review may result in either an increase or a decrease in support offered and will be based on the assessed need of the individual at that time. Reviews will involve the individual, their family or advocate as possible and appropriate. 5.3 Where the individual is in receipt of a home support package and the assessment determines the need for a higher level of support the criteria set out in section 4 will be applied. This may result in care being offered from in nursing home, whichever best meets the patients overall needs. 5.4 Changes of placement on financial grounds only would be exceptional circumstances and would need to follow the Resource Allocation Pathway prior to any decision being made about any move 7
5.5 The individual s condition may have improved or stabilized to such an extent that they no longer meet the criteria for NHS fully funded Continuing Healthcare. Consequently, the individual will become either self-funding or the responsibility of the Local Authority who will assess their needs against the Fair Access to Care criteria. This may mean that the individual will be charged for all or part of their ongoing care. 5.6 The appeal process set out in the Continuing Healthcare Policy will be used if the patient wishes to appeal the eligibility outcome of a Continuing Healthcare review. 8
Continuing Healthcare Eligibility Ratification Panel Resource Allocation Pathway Resource Panel With Care Home Selection or Responsible Commissioner Domiciliary Package at Home Nursing Home Placement PLACEMENT HIERARCHY Care Home Selection research suitable provider Care Plan and assessment provided to Agency Patent and Family Contacted Care Package Authorisation form completed by Care Home Selection Care Home Selection research homes at the Standard Cost (LPP rate) Care Plan & Assessment documents sent to suitable nursing homes Patient and Families contacted Short list of suitable Nursing Homes (3 or more) Nursing Home within Brent Harrow or Hillingdon Borough Nursing Home outside of Brent Harrow and Hillingdon Borough e.g other London Borough or County Package up to 1000 per week Authorised by Team Manager Continuing Healthcare Packages over 1000 per week authorised by Head of Continuing Healthcare Placement Authorisation form completed by Care Home Selection or Brokerage Packages over 1500 per week Director of Quality and Patient Safety approval Care Package Agreement sent to Domicilliary Care Agency by Care Home Selection Placements up to 1000 per week authorised by Team Manager Continuing Healthcare Packages over 1500 per week Director of Quality and Patient Safety approval Contract sent out by Care Home Selection Placements over 1000 per week authorised by Head of Continuing Healthcare 9
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