Essential CHC Funding – According to the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care, NHS Continuing Healthcare (‘CHC’ for short) is described as “a complete package of ongoing care arranged and funded solely by the NHS, for adults with the highest levels of complex, intense or unpredictable needs, who have been assessed as having a ‘primary health need’. It can be provided in any setting. Where a person lives in their own home, it means that the NHS funds ALL the care and support that is required to meet their assessed health and care needs. Such care may be provided either within or outside the person’s home, as appropriate to their assessment and care plan. In care homes, it means that the NHS also makes a contract with the care home and pays the full fees for the person’s accommodation, board and care.”
So, if you are found eligible for CHC, then ALL your assessed healthcare needs AND cost of care home or nursing home fees, should be paid in full by the NHS. That could represent an estimated average of £50,000 to £100,000 per annum in care fees per patient, depending on the area where the individual lives and, of course, can be even higher, commensurate with the level of care required. We have heard of some individuals paying £15,000+ a week for intense round-the-clock care. A staggering amount, but such eye-watering figures are becoming more common, as the cost of care is increasing nationwide. To fund this level of care for years on end, your savings and financial resources can be emptied frighteningly quickly. That’s why CHC Funding can make such a difference to so many thousands of families across the country – that is, IF you know it exists and understand HOW to get it!
In the majority of cases, the MDT Meeting (Multi-Disciplinary Team) is the first assessment of an individual’s eligibility for CHC Funding. The MDT assessment is carried out by two professionals, preferably one healthcare and one social care professional. The assessors are appointed by the local Integrated Care Board (ICB) and the Local Authority, and are supposed to be familiar with the individual’s care needs, having been involved in their treatment or care. In practice, the latter is not always possible, so you may be faced with assessors who have no prior knowledge of your relative’s medical history or assessed needs.
The MDT process is complex and can be a daunting experience for families – most of whom don’t really understand it until they have been through it. Families often tell us they have felt intimidated by the ICB’s appointed assessors who were bullish, or did not allow sufficient opportunity for them to speak and express their views. Some even say that the ICB’s assessors appeared to come to the MDT with a preconceived outcome in mind i.e., that the individual was not eligible for CHC, whatever the level of needs, and despite the overwhelming evidence to the contrary.
However confident and well-rehearsed you may think you are going into the MDT, nothing can prepare you for the frustration and anguish of trying to fight your corner when faced with assessors who either do not appear to understand the NHS National Framework, or else don’t know how to apply the eligibility criteria correctly, and don’t want to listen to you.
Success at MDT is paramount if you are going to get CHC Funded care and/or stop the flood of funds being drained from your savings.
The MDT uses the DST (Decision Support Tool) – an assessment tool with 12 Care Domains, as follows:
1.Breathing. 2 Nutrition 3. Continence 4. Skin Integrity 5. Mobility 6. Communication 7. Psychological & Emotional needs 8. Cognition 9. Behaviour 10. Drug therapies and medication 11. Altered states of consciousness & 12. Other significant care needs.
Each Care Domain is subdivided into levels of need with a description of needs in each category, ranging from no needs (N), low (L), moderate (M), high (H), severe (S) or priority (P) levels of need, depending on the Care Domain. These increase in intensity, complexity and unpredictability.
Four of the Care Domains, highlighted in bold above (Breathing, Behaviour, Drug Therapies & Medications, and Altered States of Consciousness) carry a weighting of ‘priority’. A priority level of need in any one of these Domains should automatically indicate eligibility for CHC Funding. The care needs described would usually suggest a need for care in a clinical setting, such as a hospital or mental health facility (i.e., NHS-funded bed).
While eligibility for CHC Funding is always dependent on a robust assessment of the nature, intensity, complexity and unpredictability of the individual’s needs, there are some situations where we would expect eligibility to be indicated, apart from the ‘priority’ levels of need described above.
One such example is a need for “one-to-one care”, often referred to simply as “one-to-one” ( or “1:1”) – i.e., a staffing ratio of one person for one patient.
Formal one-to-one care is when a dedicated member of staff is employed to look after one patient exclusively, usually to manage severe challenging behaviours or an intractable risk of falls.
This is not the same as needing intermittent one-to-one care for a time-limited activity – e.g., feeding or taking part in activities. Formal one-to-one care is usually required for a prolonged period of time, e.g., 12 or 24 hours a day, to manage the substantial risks arising from a specific assessed need. These risks may be to the patient (e.g., injury from repeated falls) or those around them (e.g., physical aggression directed towards other residents).
If your relative has one-to-one care in place, that would strongly support the contention that their care needs are intense, per se. Intensity is about the number of staff required to meet the needs, the amount of time required to achieve safe care, and the need for sustained (“continuous”) care.
A requirement for formal one-to-one care to manage an assessed need in any of the 12 Care Domains should be sufficient to demonstrate eligibility for CHC Funding, as it is clearly indicative of an intensity of need that exceeds the lawful remit of the Local Authority. The ICB may argue that the person providing the one-to-one care is not doing anything skilled or difficult, beyond diversion, supervision or distraction. However, this is irrelevant – it is the need for sustained, continuous care from a dedicated staff member that gives rise to intensity, beyond the expectations of social care.
Example: Behaviour Domain
Let’s consider an adult with a diagnosis of pica – an eating disorder causing the person to try to ingest inedible substances with no nutritional value. Some common examples are paper, soap, cloth, string, wool, soil, paint, chalk, talcum powder, paint, metal, pebbles, charcoal, ash, clay, starch, or ice.
Pica can lead to serious health consequences, such as poisoning, infection, gastrointestinal complications, severe damage to the teeth or gums, and death. If the individual is also independently mobile, this disorder can be very difficult to manage in a care home setting, where potential hazards abound, and staff are often busy tending to other residents.
In order to keep the person safe, a dedicated member of staff will be required to provide continuous, one-to-one supervision, to prevent them from ingesting dangerous items.
As another example, consider an individual who absconds from a care facility, waiting by the door for others to leave or perhaps memorising the code for the keypad. They may have absconded several times, despite all attempts to prevent this, requiring the involvement of the police to bring them back. Apart from being a risk to themselves or others, they could be at risk of abuse, road traffic accidents, exploitation, injury and getting lost. The risks in this situation are so severe, the care home must take immediate action to keep the person safe, by implementing one-to-one supervision.
Often, care providers will tell the family that the patient NEEDS one-to-one care, but that this cannot be arranged without a prior agreement from the NHS to fund. This is unacceptable! The care provider has a duty of care to the individual, and those living with them, and must implement the necessary level of care to ensure their safety as soon as the need is identified.
Financial implications should never take precedence over the safety and wellbeing of a vulnerable person.
TIP: Our best tip here is to get one-to-one care in place BEFORE the MDT, in order to demonstrate an intensity of need and eligibility for CHC, rather than applying for CHC first, and asking the NHS to fund one-to-one care. The latter is likely to be a more difficult route and more susceptible to challenge or a reduced package of care, due to the huge costs involved. The onus is on the care provider to demonstrate an intensity of need BEFORE a decision on CHC eligibility is made. The fact that there is already one-to-one in place is indicative of a degree of intensity that exceeds the parameters of social care.
Finally, it is ESSENTIAL that the care provider is able to evidence why this intensive level of care is needed, through detailed care planning and observation records. The staff member providing one-to-one care MUST keep a detailed record of care – usually 15-minute observations – and diligently document all interventions required to meet the person’s needs. If they fail to do so, the NHS will likely argue that one-to-one care is not needed, leading to a finding of ineligibility for CHC Funding and a withdrawal of one-to-one care.
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