This series of blogs will take an in-depth look at the Decision Support Tool (DST) and its function in the assessment process. By breaking the DST down and considering each of the domains and associated descriptors in detail, we will help you to accurately assess your relative’s “level of need” in each domain of care.
You’ve managed to get a Checklist completed, which was difficult enough. The Checklist is “positive”, indicating that a full assessment for CHC funding should be undertaken. You are invited to a Multi-disciplinary Team Meeting ( “MDT”), where, you are informed, representatives from the NHS and Social Services will complete a “Decision Support Tool” before making a recommendation on eligibility for health funding. This can often be a worrisome time for families, most of whom are not trained clinicians and have never taken part in such an assessment.
If you are new to the CHC assessment process, the Decision Support Tool, usually referred to as the “DST”, can be a daunting document. Split into eleven “domains of care” and spanning a hundred pages, the DST is used to provide an holistic picture of the individual’s daily care requirements, and aid consistency in applying the primary health need test.
As we considered in our recent three-part series on the subject, the National Framework and DST were drafted in response to the 1999 Court of Appeal Case, R. v. North and East Devon Health Authority, ex parte Coughlan – often referred to as the Coughlan Judgment – and the Court’s comments about the quality and quantity of care that Social Services could be expected to provide.
For more information, read our in-depth series about the 1999 Coughlan Judgement:
Eligibility for Continuing Healthcare funding is dependent on the individual’s “primary need”. The DST helps commissioners to answer the questions: Are the majority of the services required, or is the overriding need medical or social in nature? Do the quantity and/or quality of services required exceed those that medically unskilled carers could reasonably be expected to provide?
The Decision Support Tool helps CCGs to assess the degree (quantity and quality) of an individual’s needs in eleven key areas, with a twelfth category for additional needs. As the DST is completed, each of the care domains will be weighted with a “level of need”, which helps the MDT identify the extent of the person’s care requirements in that particular area.
Once the assessors have determined the level of need in each domain, they can then apply the primary health need test – also referred to as the four Key Characteristics of nature, intensity, complexity and unpredictability – and make a recommendation as to eligibility for CHC funding. By using the Decision Support Tool to apply the primary health need test, CCGs should be able to ensure compliance with the National Framework and, crucially, the law.
The DST is broken down into twelve categories of care, as follows:
- Skin (including tissue viability)
- Psychological & Emotional Needs
- Drug Therapies & Medications: Symptom Control
- Altered States of Consciousness
- Other Significant Needs
IMPORTANT – In the vast majority of cases, all the individual’s daily needs will be captured in the first eleven categories and there will be no need to complete the twelfth domain. Don’t worry if the MDT finds no additional needs to consider in the twelfth domain and don’t try to “create” additional needs for the sake of it.
In every care domain there are a number of “descriptors”, each of which is assigned a level of need, ranging from “no needs” to “priority”. Just to make things extra complicated, not all of the domains carry the same weightings, as this somewhat baffling table on page 93 of the DST demonstrates:
|Nutrition- Food and Drink|
|Skin (including tissue viability)|
|Psychological and Emotional Needs|
|Drug Therapies and Medication|
|Altered States of Consciousness|
|Other significant care needs|
The columns along the top indicate the level of need – “no needs” (N), “low” (L), “moderate” (M), “high” (H), “severe” (S) and “priority” (P) – in each care domain. Perhaps most confusing at a first glance are the blacked-out cells, which denote that the level of need is not applicable to that particular domain.
So, in the domains of Continence, Psychological & Emotional Needs and Communication, the greatest level applicable is “high”. In the domains of Nutrition, Skin, Mobility and Cognition, the highest applicable level is “severe”. In the domain of ASC, a “priority” level of need may be applicable, but there is no descriptor for a “severe” level of need. While this may appear confusing, understanding why certain levels of need are only applicable to some domains can help us to better understand the eligibility criteria.
Paragraph 31 of the DST User Notes confirms that, “a clear recommendation (and decision) of eligibility for NHS Continuing Healthcare would be expected in each of the following cases:
- A level of priority needs in any one of the four domains that carry this level.
- A total of two or more incidences of identified severe needs across all care domains.”
Only four domains in the DST carry a weighting of “priority”. These are: Breathing, Behaviour, Drug Therapies & Medications, and Altered States of Consciousness.
|Level of Need||PRIORITY
|Breathing||Unable to breathe independently, requires invasive mechanical ventilation.|
|Behaviour||‘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.|
|Drug Therapies & Medication||Has a drug regime that requires daily monitoring by a registered nurse to ensure effective symptom and pain management associated with a rapidly changing and/or deteriorating condition.
Unremitting and overwhelming pain despite all efforts to control pain effectively.
|Altered States of Consciousness||Coma.
ASC that occur on most days, do not respond to preventative treatment, and result in a severe risk of harm.
In each of these domains, the descriptor for the “priority” level of need makes clear that a failure to meet the needs for any reason would result in an immediate risk to life. In the Breathing domain, the person cannot breathe independently and requires invasive mechanical ventilation. In the Behaviour domain, the person’s behaviour presents a risk of life-threatening injury, or even death, either to themselves or those living with or caring for them. In the Drug Therapies & Medications domain, the person is in unremitting or constant pain, and/or has a rapidly changing or deteriorating condition, often associated with the administration of anticipatory (end of life) medications. In the Altered States of Consciousness domain, the patient is in a coma or suffering daily, life threatening seizures which do not respond to treatment. The descriptor for a “priority” level of need in each case makes it easy to understand why such an individual would automatically qualify for 100% health funding due to the nature, intensity, complexity and/or unpredictability of their needs in this one domain of care. Indeed, such a patient would often be treated in a hospital or other NHS setting.
Six care domains carry a weighting of “severe”. These are: Nutrition, Skin, Mobility, Cognition, Behaviour and Drug Therapies & Medications.
|Level of Need||SEVERE
|Nutrition||Unable to take food and drink by mouth. All nutritional requirements taken by artificial means requiring on-going skilled professional intervention or monitoring over a 24 hour period to ensure nutrition/hydration, for example I.V. fluids/total parenteral nutrition (TPN).
Unable to take food and drink by mouth, intervention inappropriate or impossible.
|Skin||Open wound(s), pressure ulcer(s) with ‘full thickness skin loss involving damage
or necrosis to subcutaneous tissue, but not extending to underlying bone, tendon or joint capsule’ which are not responding to treatment and require regular monitoring/reassessment.
Open wound(s), pressure ulcer(s) with ‘full thickness skin loss with extensive
destruction and tissue necrosis extending to underlying bone, tendon or joint capsule’ or above
Multiple wounds which are not responding to treatment.
|Mobility||Completely immobile and/or clinical condition such that, in either case, on movement or transfer there is a high risk of serious physical harm and where the positioning is critical.|
|Cognition||Cognitive impairment that may, for example, include, marked short or long-term memory issues, or severe disorientation to time, place or person.
The individual is unable to assess basic risks even with supervision, prompting or assistance, and is dependent on others to anticipate their basic needs and to protect them from harm, neglect or health deterioration.
|Behaviour||‘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.|
|Drug Therapies & Medication||Requires administration and monitoring of medication regime by a registered nurse, carer or care worker specifically trained for this task because there are risks associated with the potential fluctuation of the medical condition or mental state, or risks regarding the effectiveness of the medication or the potential nature or severity of side-effects. Even with such monitoring the condition is usually problematic to manage.
Severe recurrent or constant pain which is not responding to treatment.
Non-compliance with medication, placing them at severe risk of relapse.
A person with two or more “severe” levels of need in the above domains will meet the complexity characteristic due to the way their needs interact, and/or the intensity characteristic owing to the amount of skill required to meet their daily care requirements, and/or their need for sustained care throughout the 24-hour period.
It is not difficult to grasp why a person presenting with two or more of the needs described above would require 24-hour, skilled care and thus qualify for CHC funding.
When preparing for your MDT, it is crucial to remember that in all other cases, regardless of the assessed levels of need, eligibility cannot be decided without first analysing the four Key Characteristics of nature, intensity, complexity and unpredictability. The presence of one or more of these criteria is what determines eligibility for CHC, nothing else.
REMEMBER – The assessed levels of need quantify the degree of the needs. The primary health need test analyses the quality and quantity of interventions required to meet the assessed needs.
In our experience, families often place far too much emphasis on the levels of need, spending too little time considering the Key Characteristics and mistakenly believing that a certain combination of “moderate” and “high” levels of need will lead to a finding of eligibility. Don’t make this mistake! Keep reading this series to ensure focus on the most important aspects of your relative’s needs.
If you need help analysing the CCG’s DST and how to respond, preparing your own DST, what happens next in the assessment process, or just want to speak to an advisor or need expert advocacy support at your MDT, get in touch.
Visit our Care To Be Different website for lots more free information to help with your MDT.