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Continuing NHS Health Care

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Title: Continuing NHS Health Care


1
Continuing NHS Health Care
  • 2007 Training Programme.

2
Aims of the day
  • Housekeeping arrangements
  • Clear understanding of the continuing healthcare
    policy and legislative background.
  • Understanding of the importance of the
    comprehensive assessment process within the whole
    assessment.
  • Detailed understanding of how eligibility for
    Continuing NHS Health Care is determined.
  • Practical knowledge of the application of the
    criteria.
  • Understand the right to appeal via Independent
    Review.

3
Outline of the Day.
  • Legal Context and Policy Background
  • Triggers for CHC assessment and the 3 levels of
    care
  • Glossary of terms
  • The criteria for Continuing NHS Health Care
  • The Assessment and Decision Making Process
  • Independent Reviews
  • Dispute Procedure
  • Case studies

4
Session 1 - Background
  • 1990 NHS and Community Care Act
  • 1995 WHC(95) 7 CHC (5 policies/criteria in Wales)
    as a result of the Leeds Case (1994)
  • 1998 Royal Commission on Long Term Care
  • 1999 Coughlan Judgement
  • 1999 NWHA Criteria for CHC

5
Session 1 - Background
  • 2001 NHS Funded Care
  • 2003 Ombudsman Inquiry into Long Term Care
  • 2004 WHC (2004) 54 guidance and framework
  • 2005 New CHC criteria introduced
  • 2006 Grogan Judgement
  • 2006 Revision of existing CHC criteria

6
Session 1 - The Coughlan and Grogan Judgments.
  • Coughlan
  • Ancillary or incidental
  • Home for life, closure of NHS facility
  • Primary Health Need
  • Grogan
  • Primary Health Need
  • Services lawfully provided by the LA
  • Assessment process

7
Session 1 The Ombudsman Report
  • Primarily derived from complaints relating to
    local criteria used by Health Authorities to
    decide whether people were eligible for
    Continuing NHS Health Care
  • A special report of the Health Service Ombudsman
    (2003) concluded that some cases were
    inappropriately refused funding for Continuing
    NHS Health Care
  • LHBs tasked with proactively seeking out cases of
    injustice.

8
Session 1 - The Ombudsman Report.
  • Special Review Panels managed by Powys LHB
  • Pre 2003 WAG fund the claims, post 2003 the
    relevant LHB funds the claims.
  • 8.8 million up to July 2006 in Wales
  • The majority of claims pre 2003 were approved as
    there was no evidence of MDT assessment in the
    notes
  • Currently solicitors cite failure to assess,
    negligence - failure to exercise due care and
    attention.

9
Session 2 - Triggers
  • All individuals have a right to an assessment and
    should be informed of this.
  • CHC should always be considered and excluded
    first before considering NHS Funded Nursing Care
    or Joint Funding.


  • Ref Section 5.1

10
Session 2 - Triggers - Process
  • During overview or specialist assessment
  • When planning discharge from hospital
  • When a person is assessed for a care home or
    before transfer between homes
  • During or following a major health episode.
  • During placement panels

  • Ref Section 5.1

11
Session 2 -Triggers Care needs
  • Does the individual have a Primary Health Need
    e.g.
  • Complex, intensive, unstable, unpredictable or
    considerable health care needs or health needs
    more than incidental or ancillary to
    accommodation?
  • Are they deteriorating rapidly?
  • Does the individual require significant
    healthcare input, regular NHS supervision,
    routine use of specialist equipment
  • Is the individual near to death?

  • Ref
    Section 5.1

12
Session 2 Care Options
  • What are the care options on discharge?

13
Patient Admission Need for comprehensive /
specialist assessment identified
MDT Members Patient/Family/Carer/Advocate
MDT Assessment
Other Hospital
Care Home
Home
Nursing
Residential
No identified needs
Independent Hospitals May be LHB or HCW funded
  • NHS
  • can be
  • within
  • contract
  • or
  • OATs

Home Care
CHC funded by LHB
Funded by SSD and / or Patient
D/N
D/N and Home Care
  • If not CHC NHS Funded Nursing Care funded by
  • LHB, SSD and / or Patient

Intermediate Care
CHC
14
Session 2 - Care Options the 3 levels of care.
  • Social Care
  • Continuing NHS Health Care
  • Joint Social Care and NHS Care
  • Private

  • Ref Section 3

15
Session 3 Care Options
  • How do you make the decision regarding any of the
    identified care options?
  • Who makes the decisions?
  • PATIENTS AND FAMILY MEMBERS MUST BE INVOLVED
    IN THE PROCESS

16
Session 3 Glossary of Terms
  • Match the definition to the word.

17
Session 3 Glossary of Terms
  • Amount Total of combined health and social care
    needs
  • Ancillary Subordinate, subservient or auxiliary
  • Ancillary Need Is one that is subordinate to a
    primary need, but can arise from it.
  • Assessment The process whereby the needs of an
    individual are identified and their impact on
    independence, daily functioning and quality of
    life is evaluated, so that appropriate action can
    be planned.
  • Assessment involves both professionals and
    those with the needs thinking through different
    explanations of how needs have arisen and how
    different needs interact with each other.
    Further information is contained in the guidance
    Creating a Unified and Fair System for Assessing
    and Managing Care (NAFW 2002)

18
Session 3 Glossary of Terms
  • Care Co-ordinator An identified NHS clinical
    professional or social care professional who
    takes the lead in ensuring that an individuals
    package of care is properly managed and
    monitored. In addition the care co-ordinator
    ensures that the individual is kept informed of
    the process and involved in discussions about
    their care.
  • Carer Someone over the age of 16 who may or may
    not be a relative and who may or may not be
    living with the person they are looking after,
    this excludes paid care workers and volunteers.
  • Complex When an individuals needs are
    complicated due to the interaction of multiple
    factors that require frequent reassessment.

19
Session 3 Glossary of Terms
  • Comprehensive Assessment This refers to
    assessments in which most or all of the domains
    of the UA process have been triggered and
    explored trough the use of specialist/in-depth
    assessments (see Creating a Unified and Fair
    Assessment NAW 2002). All people entering care
    homes or likely to be eligible for continuing
    healthcare services should have received a
    comprehensive assessment. This will include
    medical assessment.
  • Continuing NHS Healthcare This describes a
    package of healthcare arranged and funded solely
    NHS.
  • Frequent Means occurring or happening often.
    Frequent or frequency cannot be rigidly defined.

20
Session 3 Glossary of Terms
  • Health Commission Wales (HCW) An executive agency
    of The National Assembly for Wales, which became
    operational in April 2003. HCW commissions
    tertiary and other highly specialised services
    for the residents of Wales.
  • Incidental Occurring as a minor part or an
    inevitable accompaniment or by chance.
  • Incidental Need Is a separate need or level of
    support that arises as a direct result of the
    primary need already being catered for.
  • Intensity Intensity relates to the quality and
    quantity of care required to manage or maintain
    health-related needs, with the implication that
    without this care a persons health needs would
    increase. For example, a chronic health
    condition may require a high degree of
    intervention to minimise health risks.

21
Session 3 Glossary of Terms
  •  Intensity contd
  • There may be one or more symptoms that are so
    severe, persistent or intractable that they
    require a timely response to minimise health
    risks.
  • In relation to some conditions, intensity will
    present a significant risk of aggressive,
    resistive or disinhibited behaviour which is
    likely to cause physical injury or significant
    risk to self, others or the wider community and
    requires regular risk assessment, possibly by a
    NHS multi-disciplinary team.
  • A number of apparently low-level needs can result
    in the combination of those needs bringing the
    overall intensity to the level of a primary
    health need.

22
Session 3 Glossary of Terms
  • Multi-disciplinary team Involving more than one
    discipline. MDTs are likely to include medical,
    nursing, occupational therapy, physiotherapy,
    speech and language therapists, social workers,
    psychology or a combination of the above.
  • Nature Nature can describe either the character
    of a particular condition (e.g. symptoms which
    are unstable, episodic, intractable, chronic,
    persistent, involuntary etc) or the type of
    interventions required to manage that condition
    (e.g. invasive treatment, palliative care,
    responsive medication etc). In both cases the
    nature of condition or intervention can be
    described in terms of both the quality of care
    provided i.e. the type or quantity of care
    provided i.e. the level.

23
Session 3 Glossary of Terms
  • NHS Funded Nursing Care This refers to the
    funding by the NHS of the care by a registered
    nurse in a care home providing nursing.
  • Nursing Care The Health and Social Care Act 2001
    defines nursing care by a registered nurse as
    meaning any service provided by a registered
    nurse involving
  •    The provision of care or
  •    The planning, supervision or delegation of
    the provision of care other than any services
    which, having regard to their nature and
    circumstances in which they are provided, do not
    need to be provided by a registered nurse. It
    does not include any time spent by any other
    personnel such as care assistants, who may be
    involved in providing care although it would
    include any nurse time spent in monitoring or
    supervising the care, the provision of which has
    been delegated to others.

24
Session 3 Glossary of Terms
  • Palliative Care The active holistic care of
    patients with advanced progressive illness,
    including the management of pain and other
    symptoms and the provision of psychological,
    social and spiritual support.
  •  
  • Personal Care Care to help meet personal needs
    such as bathing, dressing or eating.
  •  
  • Primary Health Need Assessment of whether an
    individual meets the qualitative and quantitative
    requirements of a primary health need is to be
    made by reference to four key indicators, namely
    nature, complexity, intensity and
    unpredictability (alone or in any combination) of
    an individuals physical, mental, psychological
    or end-of-life care.

25
Session 3 Glossary of Terms
  • Quality The sort, kind or type of care, often a
    nationally or professionally recognised standard.
  •  
  • Quantity Large or considerable amount, being more
    than ancillary or incidental.
  •  
  • Regular In this context, this normally means
    weekly or more frequently, by an NHS MDT Manager.
  •  
  • Respite Care The provision of care (in a care
    home, the persons own home or elsewhere) to
    enable the carer to have a break form their
    normal responsibilities.

26
Session 3 Glossary of Terms
  • Review Re-assessment of an individuals needs and
    consideration of the extent to which services are
    meeting the needs and helping to achieve the
    desired outcomes.
  •  
  • Risk The evidence based chance or likelihood of
    an occurrence which will result in harm to the
    individual or others.
  •  
  • Specialist Undertaken by an NHS clinical
    professional who has undertaken post-basic
    education and training and/or specific expertise
    and experience in the relevant area of
    healthcare.
  • Specialist Healthcare Equipment Equipment not
    normally provided in care homes with nursing or
    on prescription.

27
Session 3 Glossary of Terms
  • Specialist/In-depth Assessment Where the
    information that is required to be gathered
    within the assessment process needs to be
    gathered by a professionally qualified person to
    give a more in-depth look at any domain or
    sub-domain this is called either a specialist or
    in-depth assessment. Examples of specialist or
    in-depth assessments might be a social
    circumstances report for discharge from section
    3 MHA 1983 the measuring of a persons blood
    pressure welfare benefits check of an assessment
    of mobility where the person has complex needs.
  • Terminal Care The care an individual receives at
    the end of their life, usually the last 6-8
    weeks, that is related to a diagnosed life
    limiting illness.

28
Session 3 Glossary of Terms
  • Unified Assessment Person-centred approach to
    assessment, which emphasises the need for
    agencies to collaborate and respond to
    individuals in a joined up manner. Assessments
    are proportionate to an individuals needs and
    will not be repeated because information is
    shared across agencies.
  •  
  • Unpredictable When changes to the individuals
    condition cannot be anticipated with certainty
    and requires ongoing assessment/monitoring.
  • Unpredictability An individual with unpredictable
    needs will have a fluctuating, unstable or
    rapidly deteriorating condition which cannot be
    reliably anticipated. Unexpected or irregular
    fluctuations in physical or mental or
    psychological health of the individual and/or
    their behaviour will require prompt intervention
    by a health professional or an appropriately
    informed carer to manage risk to themselves or
    others.

29
Session 3 Glossary of Terms
  • Unpredictability contd
  • Severe and continuously deteriorating physical
    condition resulting in rapidly increasing
    dependency or a short-term life expectancy.
  •  
  • The individual has a rapidly deteriorating or
    unstable physical or mental condition that
    requires timely intervention to manage symptoms,
    avoid deterioration or distress and minimise
    risk.
  •  
  • Unstable When the individuals condition results
    in alternating or irregular variations in health
    states requiring frequent intervention or
    treatment.
  •  
  •  
  •  

30
Session 4 the CHC Criteria
  • The fundamental basis for decision making is the
    Primary Health Need Approach AND
  • The ancillary or incidental question the
    services a local authority could lawfully provide
    in connection with the provision of
    accommodation.

  • Ref Section 3.1.1

31
Session 4 the Primary Health Need Approach
  • There are 4 key indicators which must be
    considered
  • Nature
  • Complexity
  • Intensity
  • Unpredictability

  • Ref Glossary of terms

32
Session 4 the Primary Health Need Approach
  • In addition consideration must be given whether
    the nursing or other health services required by
    the individual is
  • more than incidental or ancillary to the
    provision of accommodation which Local Authority
    Social Services are under a duty to provide
  • AND
  • are they of a nature beyond which a Local
    Authority whose primary responsibility is to
    provide Social Services could be expected to
    provide?

33
Session 4 the Primary Health Need Approach
  • If the patient has a Primary Health Need then
    they should qualify for Continuing NHS Health
    Care.
  •  If the patient does not have a Primary Health
    Care Need but has needs which are more than
    incidental or ancillary to the provision of
    accommodation which Local Authority Social
    Services are under a duty to provide and the
    needs are of a nature beyond which a Local
    Authority whose primary responsibility is to
    provide Social Services could be expected to
    provide, then they should qualify for Continuing
    NHS Health Care. (Interim Guidance)

34
Session 4 the CHC Criteria
  • If the patient has a primary health need, refer
    to which criteria is met e.g.
  • Criteria 1 - complexity, unpredictability, etc
  • Criteria 2 - specialist equipment
  • Criteria 3 - rapidly deteriorating, unstable
  • Criteria 4 - end stage, terminal

  • Ref Section 4

35
Session 4 the CHC Criteria
  • Criteria 1
  • The nature, or, complexity or intensity or
    unpredictability of the individuals health care
    needs, (or any combination of these needs), or
    the risk to themselves or others means that
    regular input (such as assessment, intervention
    or monitoring) is required by one or more members
    of the NHS multidisciplinary team, such as a
    doctor, nurse, therapist or other NHS member of
    the team.

  • Ref Section 4.4.0

36
Session 4 the CHC Criteria
  • Criteria 2
  • The needs of the individual require the routine
    use of specialist health care equipment involving
    supervision of NHS staff

  • Ref Section 4.4.1

37
Session 4 the CHC Criteria
  • Criteria 3
  • The individual has a rapidly deteriorating or
    unstable medical, physical or mental health
    condition (or is detained in accordance with
    Section 17 of the Mental Health Act) and requires
    regular input (such as assessment, intervention
    or monitoring) by a member of the NHS
    multidisciplinary team

  • Ref Section 4.4.2

38
Session 4 the CHC Criteria
  • Criteria 4
  • The individual is in the final stages of a
    terminal illness and is likely to die in the near
    future

  • Ref Section 4.4.3

39
Session 4 the CHC Criteria
  • Section 3.2
  • The patient needs a joint package of services
    from both the NHS and Social Services.
  • It applies where the patient DOES NOT meet the
    criteria for CHC.
  • Health and Social care needs are often difficult
    to separately identify.

40
Session 5 - Assessment
  • The assessment process is the most important
    element in making decisions about an individuals
    eligibility for CHC
  • The MDT must assess and recommend a package of
    care
  • This must involve the patient and family in the
    decision making process
  • This must be fully documented
  • CHC assessments form part of the UAP and are not
    separate to UA.

  • Ref Section 5

41
Session 5 - Assessment process.
  • Contact assessment indicates high level of needs
    and possible triggers for CHC.
  • Referral to other agencies and professionals as
    appropriate and Care Coordinator identified.
  • MDT assessments undertaken minimum nursing,
    medical and social work.
  • MDT meeting or case conference to discuss care
    needs and CHC eligibility.
  • Patient and family involved.
  • Eligibility for CHC considered and care plan
    proposed
  • Decision documented

42
Session 5 - Documentation Standards
  • All assessments must be
  • Current
  • Consistent
  • In accordance with professional guidance for
    documentation
  • Provide details and costs of the proposed care
    package
  • Care Manager identified (for reviews)
  • Provide evidence of clinical effectiveness (for
    specialist treatment)
  • Provide evidence that alternatives have been
    explored.

43
Session 5 -Decision Making Process
  • The MDT
  • Determine eligibility for CHC and provide
    rationale if not eligible for CHC.
  • Recommend a suitable care package
  • Determine whether these needs be met from within
    existing contracts or is additional funding
    required?

44
Session 5 - Decision Making
  • The MDT will determine eligibility for Continuing
    NHS Healthcare and recommend a package of care.
  • The designated LHB CHC panel will review the
    decision and
  • The panel will decide on the appropriateness of
    the care package and consider value for money and
    choice issues.

45
Session 5 - LHB CHC panel meetings customise
for each area
  • Every Tuesday/please specify
  • Application to be received by previous
    Thursday/please specify
  • Panel members please specify
  • Role of the panel - Evidence of eligibility,
    best value, consider the appropriateness of
    the care package, choice of placement, preferred
    providers
  • NHS professionals can attend these panels by
    prior arrangement.

46
Session 6 -Independent Review
  • A patient and/or their representative, has a
    right to appeal against the decision making
    process.
  • If there is a disagreement all avenues of local
    resolution should be exhausted before progressing
    to an Independent Review.
  • If this is not possible or following discussions
    at local level not being resolved then the
    complainant has a right to request an Independent
    Review.
  • Consider the role of Advocates and the new
    Independent Mental Capacity Advocates (IMCAs)

47
Session 6 -Independent Review
  • Requests for reviews will be allowed where the
    complainant is dissatisfied about either the
    procedure followed or the application of the
    criteria by the LHB
  • Patients are entitled to have someone act on
    their behalf during the Review Process including
    direct representation at the panel meeting
  • This does not extend to the use of a lawyer
    acting in a professional capacity.

  • Ref Section 6

48
Session 6 -Independent Review
  • The panel must uphold the patients
    confidentiality.
  • The panel acts in an advisory capacity, however
    there is an expectation that the panels
    recommendations will be accepted by the relevant
    LHB.
  • Requests for a review must be made within 28 days
    from notification of the outcome of the decision
    being made.

49
Session 6 -Independent Review
  • The purpose of the review is to check that the
    proper procedure has been followed in reaching
    decisions
  • Eligibility has been fairly and consistently
    applied
  • No new information can be introduced by any party
    at Independent Review.

50
Session 6 -Independent Review
  • The review procedure does not apply when patients
    or their families wish to challenge
  • The content rather than the application of the
    criteria
  • The type and location of any offer of Continuing
    NHS Health Care
  • The content of any alternative care package which
    they have been offered
  • Their treatment or any other aspect of the
    services they are receiving or have received

51
Session 7-Dispute process - MDT
  • Disagreements between MDT members occasionally
    occur regarding the patients eligibility for
    Continuing NHS Healthcare
  • If there is a disagreement every effort should be
    made to resolve the differences at local level.
  • The MDT should be reconvened a chairperson
    identified, minutes taken, line managers may be
    invited to this meeting.
  • Consider the use of an advocate to assist with
    the dispute resolution

52
Session 7 - Dispute process
  • Disputes between care providers / funding
    agencies occasionally occur regarding the panels
    decision.
  • Disputes should be resolved between appropriate
    officers of relevant organisations
  • If not resolved arrangements should be made for
    senior managers in each organisation to jointly
    address the problem as per dispute process
    (section 10).
  • Disputes must not delay discharge from hospital
    or commencement of a care package.

  • Ref Section 7

53
Session 8 Case Studies
  • In small groups, discuss the case study and
    decide whether the patient is / is not eligible
    for Continuing NHS Care.
  • Document the reason for your recommendation. You
    must consider the primary health need and relate
    to the 4 criteria
  • Present your answers to the other groups.

54
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