There is a difference around the country as to the amount of clinical evidence CCGs will consider when assessing for CHC Funding.
When an assessment is undertaken for NHS Continuing Healthcare Funding (CHC), the CCG will look at clinical records from the care home. Different CCGs have differing approaches to the time period they will review. There is no guidance in the National Framework to govern this. So, each CCG can make its own policy here.
The generally accepted rule of best practice is that reviewing three months’ clinical records is sufficient to give a good picture of an individual’s needs.
However, due to Covid restrictions and the pressure on the NHS to clear backlogs, some CCGs were only considering one month’s clinical records in an effort to get assessments processed much quicker. However, our concern is that when assessing eligibility for CHC Funding, some CCGs may not yet have reverted back to the customary three month period and we worry how that might impact outcomes.
In our view, one month is just not enough to reliably capture an individual’s care needs.
Care home records are often poorly written and lacking in detail. So, looking at a longer period can often really help to get a more accurate picture of the current care needs. But only looking at only one month’s information is not helpful in identifying quality and quantity of the needs; for example, the frequency of challenging behaviours.
Read our blogs on the importance of good record keeping:
The Decision Support Tool (DST) is screening tool used by MDT assessors to record assessed levels of healthcare needs across all 12 Care Domains in one document (namely: Breathing, Nutrition, Continence, Skin, Mobility, Communication, Physical/Emotional Needs, Cognition, Behaviour, Drugs/Medication /Symptom Control, Altered State of Consciousness and Other).
The DST ascribes different levels of need based on the frequency and/or severity of the care requirements in each Care Domain. Therefore, having such a short enquiry period of only one month can skew the level of need – usually in favour of the CCG – resulting in a negative outcome and a finding of ineligibility for CHC Funding.
These skewed results can often be seen in Altered States of Consciousness and Skin. For example, if a pressure sore is not responding to treatment, this can rarely be properly measured in just one month, as more serious sores can take several weeks/months to heal; and then they can partially heal but break down again. Additionally, if a wound is long-standing, this would not necessarily be apparent from reviewing one month’s records. Similarly, a person suffering from unpredictable seizures may experience periods of relative inactivity, only for seizures to reoccur again in future. Looking at only one month’s records would not demonstrate this pattern and would distort the MDT’s impression of the needs.
In addition, the assessment for CHC funding is measured against four Key Characteristics: Nature, Intensity, Complexity and Unpredictability. An individual can qualify for CHC Funding under any one of the four Key Characteristics. To measure Unpredictability, we would normally expect the CCG to consider more than one month’s clinical records in order to build a picture of the ongoing care needs and assess how they are fluctuating.
We contend that DSTs completed using only one month’s clinical records could have great potential to disadvantage families and their relative’s application for CHC Funding. Sadly, the likely outcome is that many people who are entitled to CHC Funding could be turned down incorrectly and end up paying for their own care; perhaps by depleting their savings or even selling their home, quite unnecessarily.
What to do if you have had a DST completed using a one-month period of clinical information?
Firstly, consider whether you think increasing the time-period beyond one month might give you a better outcome.
If so, write to the CCG immediately and complain about the short period and ask them to reassess your relative’s healthcare needs using the usual three months’ evidence.
If the CCG refuses, then request an appeal of that decision (you must do this within 6 months of the decision being communicated to you).
As part of your appeal submission, you may want to consider obtaining the additional two months’ evidence yourself and submitting it to the CCG’s appeal team, highlighting important information you believe has been overlooked.
The CCG will then conduct a Local Review, taking into consideration your concerns. However, it may be that the CCG reaffirms that one month is its policy, and that is as far back as it is prepared to go.
If the matter is not rectified at Local Review, you can always appeal to NHS England and where the matter will be referred to an Independent Review Panel (IRP). Whether the IRP accepts the CCG’s decision to consider only one month’s evidence will depend on the region and the Panel Chair. In our experience, IRPs will increasingly refuse to consider any evidence not already reviewed by the CCG, even if this is patently insufficient to inform a robust decision.
We are extremely concerned by these developments and recommend you challenge an inadequate review period on every occasion it arises. However, without clear guidance from NHS England, CCGs will continue to reduce the enquiry period for current assessments, to their own advantage and the patient’s detriment.
If the IRP refuses to consider a longer enquiry period, and you feel this is consequential to a finding of ineligibility, you will need to complain to the Health Service Ombudsman about the IRP’s process and refusal to review sufficient clinical evidence to inform its decision, despite this having been highlighted as part of the CCG’s Local Resolution process.
It can be a long way round to achieve the result you desire, but at least it will mean that you are likely to get the additional two months’ clinical records looked at – and that could make the difference between being awarded CHC funding or not. In financial terms, it could mean the difference between having all your relative’s care fees and their accommodation being paid in full by the CCG, or possibly having to self-fund – e.g. selling their home to pay for their own care.
IMPORTANT – If you do not submit the additional evidence you wish to be considered to the CCG at Local Resolution stage, it is highly unlikely it will later be accepted by the IRP. This is because the IRP can only consider the information available to the CCG when making its decision. You cannot submit “new” evidence to the IRP, which is not already contained within the CCG’s casefile.
If you do not supply the CCG with the evidence you wish to be considered before requesting an Independent Review then, unfortunately, it may be too late.
Good luck! And don’t forget, if you need help with an MDT assessment, appeal or advocacy support don’t hesitate to contact us or get help from one of our specialist Advice Lines to discuss your case today. Plus, there is plenty of free information and resources to help you on our Care To Be Different website.
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