Formal assessment of an individual’s eligibility for NHS Continuing Healthcare Funding (CHC) is conducted by an NHS Multi-Disciplinary Team using the Decision Support Tool (DST).
The DST is a screening tool used by Multi-Disciplinary Team (MDT) assessors to record assessed levels of healthcare needs across all 12 Care Domains in one document – based on the frequency and/or severity of the care requirements in each Care Domain (namely: Breathing, Nutrition, Continence, Skin, Mobility, Communication, Physical/Emotional Needs, Cognition, Behaviour, Drugs/Medication /Symptom Control, Altered State of Consciousness and Other).
Focusing on whether an individual is displaying challenging behaviour can be a pivotal point in determining their eligibility for CHC.
Challenging behaviour can impact upon many Care Domains and this should not be forgotten when completing an assessment for eligibility.
Often the NHS Clinical Commissioning Group’s assessor will compartmentalise the needs in Behaviour and will fail to cross-reference them with the other Care Domains. This can have a prejudicial effect on the whole case. So, make sure that the details of behaviour are well recorded in the Behaviour section on the DST and also in the four Key Characteristics.
In the Behaviour section (section 9) of the DST it states;
‘Behaviour: Human behaviour is complex, hard to categorise, and may be difficult to manage. Challenging behaviour may be caused by a wide range of factors including extreme frustration associated with communication difficulties or fluctuations in mental state.
Challenging behaviour in this domain includes but is not limited to:
- aggression, violence or passive non-aggressive behaviour
- severe disinhibition
- intractable noisiness or restlessness
- resistance to necessary care and treatment (but not including situations where an individual makes a capacitated choice not to accept a particular form of care or treatment offered.)
- severe fluctuations in mental state
- inappropriate interference with others
- identified high risk of suicide’.
The DST also gives the following descriptions against the different levels of need that can be selected:
|Description||Level of need|
|No evidence of ‘challenging’ behaviour.||No needs|
|Some incidents of ‘challenging’ behaviour. A risk assessment indicates that the behaviour does not pose a risk to self, others or property or create a barrier to intervention. The individual is compliant with all aspects of their care.||Low|
|‘Challenging’ behaviour that follows a predictable pattern. The risk assessment indicates a pattern of behaviour that can be managed by skilled carers or care workers who are able to maintain a level of behaviour that does not pose a risk to self, others or property. The individual is nearly always compliant with care.||Moderate|
|’Challenging’ behaviour of type and/or frequency that poses a predictable risk to self, others or property. The risk assessment indicates that planned interventions are effective in minimising but not always eliminating risks. Compliance is variable but usually responsive to planned interventions.||High|
|‘Challenging’ behaviour of severity and/or frequency that poses a significant risk to self, others or property. The risk assessment identifies that the behaviour(s) require(s) a prompt and skilled response that might be outside the range of planned interventions.||Severe|
|‘Challenging’ behaviour of a severity and/or frequency and/or unpredictability that presents an immediate and serious risk to self, others or property. The risks are so serious that they require access to an immediate and skilled response at all times for safe care.||Priority|
To select the correct level of need, there needs to be a close study of all the aspects of the behaviour. There needs to be a degree of clinical judgment to consider the impact of the behaviour on the individual, on the people providing their care, and on the people sharing the care setting.
Firstly, the specific detail of the behaviour needs to be recorded. If there is a list of incidents recorded with the date, duration, what happened and what action was needed, it is imperative that such matters are noted on the DST.
TIP: If your relative is living at home, you could start keeping a record of any incidents on a list, spreadsheet or in a diary. This will be helpful when completing the DST. If your relative is living in a care setting, hospital or rehabilitation type setting, the care provider will likely start recording incidents on purpose printed behaviour recording sheets (sometimes referred to as ABC’s i.e. an Antecedent (what happens before the behaviour i.e. what might have triggered it, a Behaviour and a Consequence). You can ask the manager of the care setting to do this if they are not doing it already.
TIP: It is a good idea to regularly check that the care records are up to date and accurately reflect details of behaviour.
Here are some key details that ought to be noted in the care records and which will be important to record on the DST:
What is actually happening?
- Is the individual just being verbally aggressive or are they being physically aggressive, too, and if so, what are they doing? An individual who is feebly pushing a carer away will not be as difficult to care for as another who is lashing out and directing punches at carers or using a weapon (such as a walking stick or handbag).
- Is the individual doing things that could attract negative behaviour from other users of the care service? For example, an individual that invades the personal space of other residents in a care home or shouts in their faces. These actions could create risks for the person displaying the behaviour, particularly where there are other residents with cognitive problems that do not understand what is happening, as they can retaliate, causing risks to safety.
How often does the behaviour happen?
- Is it daily, weekly or monthly or less frequent? Behaviour can be sporadic, frequent or occasional.
How long does each incident last?
- For example, is it an instant response that ends quickly, like lashing out when care is given? Or is it longer lasting, for example, an individual that is constantly being noisy or constantly being aggressive?
- It is relevant to consider how often carers need to manage the behaviour and how much of their time it takes up.
Is there a trigger to the behaviour?
- If there is, it can make it easier for carers to anticipate or avoid.
- If there are no identifiable triggers, conversely, this can make it harder to give care safely.
- Consider what led to the behaviour happening. Is it likely that it will keep happening?
- What measures have been taken or can be taken to prevent that trigger?
How is the behaviour managed?
- What do carers need to do to calm the situation down? For example, do they have to isolate the person?
- Do they need to restrain the individual? Are there any other special techniques needed?
- Does the individual need to be given medication to manage their behaviour – and does this need to be overseen by a specialist?
- How many carers need to be called to manage the behaviour? For example, does it need just one person to guide the individual away from a situation, or are two or three people needed to resolve it?
- Is there anyone with specialist training involved in managing their behaviour? For example, a psychiatrist or other member of a mental health team.
How much risk is involved in the behaviour?
- Is it likely that the individual might injure themselves or others?
- Have they injured themselves?
- Could they injure someone else?
- How strong are they?
- Are they able to move around or are they confined to a chair or bed (this can limit the risks to others)?
Other considerations could include:
- Is there a past history of very aggressive behaviour, and if so, is the behaviour still happening in a similar form?
- Has the individual caused previous injury to others or themselves due to the behaviour?
- Have there been lots of types of medication tried? Has the medication dose been changed a lot? Does the medication cause any side effects?
- Is the behaviour happening at night when there are few carers around to manage it?
- Are there any reports from specialists about the behaviour?
- Does the behaviour impact on other areas of care, for example does it make it harder to provide continence care?
- How does the behaviour affect the person’s psychological and emotional needs?
- It is important to reflect on the incidents of behaviour also in the Psychological and Emotional Needs section, as often, an individual displaying challenging behaviour will be anxious, distressed or agitated at the same time.
It would be expected that the Multi-Disciplinary Team completing the DST will take into account all the appropriate factors, including the above, in order to arrive at the correct level of assessed need.
It would normally be expected that physical aggression would be given a higher level of need than verbal aggression. Similarly, frequently displayed behaviour would be given a higher level of need than infrequent behaviours.
Essentially, it is important to consider the risk versus the frequency. However, one very aggressive episode with serious consequences could be enough to warrant a ‘Severe’ or ‘Priority’ level of need in the DST.
As can be seen, there are lots of factors to consider and it is important to understand the clinical opinion of the appointed assessors. The DST should record all the considerations of the MDT so that family members and other people reading the DST can understand why one level of need was chosen over another.
The needs reflected in the Behaviour section should be reflected also in the four Key Characteristics and should examine how the behaviour impacts on other areas of care.
It is a tricky subject and can give rise to differences of opinion between one clinician and another, as well as family members, care givers and advocates. Getting the right information and detail is key.
For more reading about MDTs and assessments, here’s a selection of previous blogs to help you…
Plus, don’t forget, there is plenty of free information and resources to help you on our Care To Be Different website.
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