PART 2 – Looking At The 4 Key Indicators: Gathering pieces of evidence

In Part 1- Looking At The 4 Key Indicators: Unlocking the basics, we gave an outline introduction to the 4 Key Indicators, what they are, and how they are considered by the Multi-Disciplinary Team’s assessment process when completing their Decision Support Tool (DST).

In this blog, we explore in more detail the evidence you need and how that ties in with the Key Indicators (otherwise known as ‘Characteristics’).

Assessing eligibility for NHS Continuing Healthcare Funding (CHC) is entirely subjective and relies on the competence, skill, training and integrity of the appointed MDT assessors carrying out the assessment. There should be a minimum of 2 assessors (including a healthcare and social care professional) who have been trained in the National Framework and recently involved with the individual’s treatment or care needs.

The DST is a tool used to build up a comprehensive (holistic) picture of the individual’s care needs which is used by the MDT assessors to make a recommendation for or against CHC Funding.

Think of the DST as a jigsaw puzzle. The DST is the process of collating the pieces of evidence together in one place.

What evidence should the MDT assessors look at when completing the DST?

The whole assessment process is intended to be ‘person centric’ ie putting the individual first and foremost, and to ensure that they and their (family) representatives are involved in the journey and have their views taken into consideration. That is the core essence underpinning the National Framework. The assessment should not be carried out without their knowledge or consent, and they and their representative(s) must be given every opportunity to be present and contribute.

Therefore, it is incumbent upon the MDT assessors to meet the individual in person, in order to be able to identify and assess their medical condition and obvious healthcare needs, first-hand.

In carrying out their assessment and reaching their conclusions as to eligibility, the MDT assessors should access all relevant evidence to get a broader perspective of the individual’s daily needs and the level of care and input required to manage them.

This evidence may include things such as the following examples:

• Care/Nursing home notes and records (including all Care Plans, Risk Assessments eg Falls / Behaviour)
• Health need assessments
• Speech and Language Therapy (SALT) assessments
• Waterlow scores
• Carer’s views
• GP records
• Hospital records
• Any treatment and therapy records
• Occupational assessments
• Nursing and Psychiatric assessments
• Specialist Nursing records (eg Tissue Viability / Dementia)

All this evidence is designed to help build a bigger holistic picture of the individual’s overall care needs, so that an accurate recommendation for eligibility for CHC can be made.

It is vital that you try and obtain all relevant records yourself so that you can see if they accurately reflect your relative’s actual day-to-day care needs. Often the care home records will be inadequate, incomplete, misleading, or just plainly wrong!

Therefore, it is essential that you are present at the MDT to ensure that the MDT assessors have all the necessary and relevant information available to make an informed recommendation. You can supplement any gaps and answer any questions they may have about your relative’s needs. It’s a good idea to check with them what evidence they have seen and read and identify anything that you think is missing and ought to be considered. Don’t be shy to contribute! After all, you and your relative are at the heart of this ‘person centred’ approach. But, be careful not to make representations that could undermine your relative’s case.

The MDT assessors will record the information and sources viewed in the DST in relation to each of the 12 Care Domains. For example, take the ‘Mobility’ Domain. This is the sort of evidence and level of detail that needs to be considered in assessing needs in the DST:

Mobility

Upon admission to the care home, Mrs X was independently mobile. She was prone to wandering and was assessed as being at high risk of falls.

Since admission, Mrs X has fallen on several occasions, sustaining fractures to her wrist and femur as well as minor skin injuries.

Since fracturing her femur, Mrs X has been unable to stand or walk unaided, although she remains able to walk short distances with full support. A standing hoist and two members of staff are required for each transfer; a wheelchair is used for longer distances. Mrs X suffers from dementia, confusion and memory loss; she does not remember that she can no longer mobilise or transfer without assistance and will attempt to stand and walk unaided. Consequently, she remains at a high risk of falls, as confirmed by her falls risk assessments.

Mrs X also suffers with osteoarthritis in her knees and hip which causes her pain and discomfort upon mobilising. Since fracturing her femur, Mrs X is very unsteady on her feet and she requires two members of staff to provide full support when mobilising. Mrs X remains at a high risk of falls and staff are required to record and report any accidents she may have.

Due to her cognitive impairment and reduced mobility, Mrs. X is fully dependent on staff to attend to her continence and personal hygiene needs. A bath hoist is used for Mrs X’s safety and comfort. Mrs X is encouraged and assisted to alter her position throughout the day to reduce risks to her skin integrity.

Risk assessments completed by the care home indicate that Mrs X is at a high risk of falling whilst transferring and mobilising; her attempts to stand and walk unaided mean this risk is unpredictable. Despite hourly checks by staff, care records indicate that Mrs X has continued to fall on numerous occasions whilst at the home, suggesting this risk is not effectively managed.

There are several entries noting that Mrs X has bruising to different parts of her body for unexplained injuries. It is possible that some of these injuries were incurred whilst falling. Staff are required to check Mrs X regularly for signs of injury and to act accordingly to protect her skin integrity.

Owing to her cognitive impairment, Mrs X sometimes has difficulty in understanding instructions which can affect her mobility. Staff reassure her if she is anxious or apprehensive about mobilising and ensure her safety and wellbeing are maintained at all times.

We suggest you look through the records for supporting evidence in each Domain, for example:

Source Code: GPR = GP records  /  CHR = Care Home Records

DATE	Source	Recorded Entry Details
Undated	CHR	Mrs X mobilises quite independently most of the time but has a tendency to place herself on the floor.  Please observe when mobilising. Pain relief given as prescribed
09/02/xx	CHR	Mrs X needs the assistance of two carers when mobilising
10/02/xx	CHR	Able to walk to toilet with 2 carers
15/02/xx	CHR	Mrs X was found outside on the floor? cause she was helped into the wheelchair and brought in. The only apparent injury was to her L elbow which was grazed
03/03/xx	CHR	Mrs X appears not to be as mobile as recently and mobilises with assistance
10/03/xx	CHR	Mobilised slowly with carers and stick
30/03/xx	CHR	Went to bathroom and fell over with her trousers round her knees.  Accident form completed, checked over for injury non apparent
02/07/xx	CHR	Mrs X went into the lounge and was hovering over a fellow client who can be aggressive, staff persuaded Mrs X to walk into the corridor away from the client but she became agitated and tripped falling on to the floor on her left side, on examination it was found that Mrs X had a carpet burn to her left knee and a bruised left thumb. Once up in her room a cold compress was applied, Mrs X was complaining of pain to the area. Accident form completed. Bruise on thumb very obvious, will be quite sore today
11/07/xx	CHR	Fallen when stood up to get out of bed. Staff next door heard a bang and went to investigate and found Mrs X laying across the floor face down, accident form S1 completed, Mrs X has a sore knee and R hand also scratch about 4 inches long on the R side of her back. .. Mrs X was admitted to A&E via ambulance for x-rays on her r hand and wrist – returned from PGI no apparent fracture
18/07/xx	CHR	Happily wandered around although she had a fall this morning, quite unhurt accident form completed
04/08/xx	CHR	It was noticed on dressing Mrs X that she has a very large deep blue bruise on her right thigh, has not fallen during the day cause unknown
06/08/xx	CHR	Care staff noticed a bruised area on upper back, no fall observed? cause
07/08/xx	CHR	Mrs X has appeared unsettled she has mobilised for long periods refusing to sit down
07/11/xx	CHR	Mrs X is prone to falls – was found by night staff on her bedroom floor this am. Emergency services contacted and taken to PGH A&E with a ?# NOF.  Returned from PGH after x rays diagnosed no apparent injury
07/11/xx	CHR	Mrs X has bruising on right shoulder and right hip after a fall early on in the morning
17/12/xx	CHR	Mrs X was on the floor at start of the shift refused to get up, refused supper was undressing herself on the floor
25/12/xx	CHR	Is unsteady on her feet at times but no reports of falls lately
10/01/xx	CHR	Mrs X tripped over a Zimmer frame and ? # R neck of femur. Emergency services contacted and taken to General Hospital
18/01/xx	CHR	Mrs X’s mobility is now very poor she said, and she suggested one of us to go over and re-assess Mrs X, because she might need to be changed from residential to nursing
04/02/xx	CHR	Fell on 10/1/xx and has # NOF
04/02/xx	CHR	Mobilised through assistance. Stand aid and wheelchair
06/02/xx	CHR	Mrs X has been trying to stand throughout the day. She has eaten and drank well. Stand aid used on transfers
07/02/xx	CHR	Transferred from bed, chair and wheelchair using stand aid. Mrs X tried to stand a few times during the day. Mrs X is being assessed for pads now that she can no longer mobilise independently
10/02/xx	CHR	She has continued to be transferred with stand aid and x 2 carer staff
14/02/xx	CHR	Continue with plan although Mrs X’s needs have changed
24/02/xx	CHR	Mrs X was found on the floor at 8.30pm no apparent injury, no mattress on floor, no pressure mat it was under bed.  Accident form completed, taken air bed off her bed and Mrs X has settled and slept all night…. Mrs X’s condition is rapidly deteriorating today on call GP came out

So, from this one Domain alone, we can see that there will inevitably be some interaction with multiple other Domains, including ‘Cognition’, ‘Skin Integrity’, ‘Continence’ and ‘Medication’. It is this sort evidence and level of detail that builds the jigsaw and the bigger picture of overall needs.

Mrs X’s poor cognition, lack of understanding and confusion directly impact on her mobility. She is vulnerable, unable to assess risk, dangers and hazards, and at high risk of falling and causing herself harm without trained staff intervention at all times. Injuries sustained and poor mobility will impact on her skin integrity and the need for regular repositioning and pressure relieving care to be monitored, and the need for medication (and pain relief to be administered). Her poor cognitive state and lack of independent mobility will impact on her toileting and continence needs, and in turn, her skin integrity. Staff are required to monitor and observe Mrs X to ensure she is safe in her surroundings and environment and will not come to any harm.

The overall scores entered against each Care Domain will be summarised in a single page at the end of the DST, which you can access by clicking this link.

The assessors will then complete the DST by making their recommendations for CHC Funding in conjunction with their assessment, any input provided by the individual or their (family) representative(s), and in consideration of the 4 Key Indicators – Nature, Intensity, Complexity and Unpredictability of need.

Let’s look at the Key Indicators in more detail. The National Framework provides some useful guidance to help identify the sort of things to ought to be considered when making a decision as to eligibility.

The 4 Key Characteristics/Indicators

The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (2018) states at paragraph 65, that the reasons given for the decision on eligibility should not be based on:-

• the person’s diagnosis;
• the setting of care;
• the ability of the care provider to manage care;
• the use (or not) of NHS-employed staff to provide care; look only at what was being done.
• the need for/presence of ‘specialist staff’ in care delivery;
• the fact that a need is well managed*;
• the existence of other NHS-funded care; or
• any other input-related (rather than needs-related) rationale.

*For more information on well-managed needs, read our blog: Using the ‘Well-Managed Need’ Principle To Your Advantage.

Practice Guidance Note 3 of The National Framework suggest things that might be helpful to consider, ask and record…

Nature

Nature refers to the type of needs, and the overall effect of those needs on the individual, including the type (“quality”) of interventions required to manage them.

• How would you describe the needs (rather than the medical condition leading to them)? What adjectives would you use?
• What is the impact of the need on overall health and well-being?
• What type of interventions are required to meet the need?
• Is there particular knowledge/skill required to anticipate and address the need. Could anyone do it without specific training?
• Is the individual’s condition deteriorating/improving?
• What would happen if these needs were not met in a timely way?

Intensity

Intensity describes both the extent (“quantity”) and severity (degree) of the needs, including the need for sustained care (“continuity”). The MDT Panel also considers how a series of seemingly low-level needs can combine to create intensity.

The National Framework suggests things that might be helpful to consider, ask and record…

• How severe are the needs?
• How problematic is it to alleviate the needs and symptoms?
• How often and how long is each intervention required?
• How much care is being delivered?
• How many carers are required?
• Does the care relate to needs over several domains?

Complexity

Complexity refers to how the needs arise and interact to increase the skill needed to monitor and manage the care.

The National Framework suggests things that might be helpful to consider, ask and record…

• How difficult is it to manage the needs?
• Are the needs interrelated?
• Do the needs impact on each other to make the needs even more difficult to address?
• How much knowledge is required to address the needs?
• How much skill is required to address the needs?
• How does the individual’s response to their condition make it more difficult to provide appropriate support?

Unpredictability

Unpredictability refers to the degree to which needs fluctuate, creating difficulty in managing needs; and the level of risk to the person’s health if adequate and timely care is not provided. A person may be considered eligible for NHS Continuing Healthcare on the grounds of unpredictability if they have need for monitoring, supervision, or investigations that is not of a nature or extent that a local authority can provide. 

• Are you able to anticipate when the need(s) might arise?
• Does the level of need often change?
• Is the condition unstable?
• What happens if you don’t address the need when it arises? How significant are the consequences?
• To what extent is professional knowledge/skill required to respond spontaneously and appropriately?
• What level of monitoring/review is required?

It is the interaction and interrelationship between these 4 Key Indicators and how they impact on each other that is important.

Don’t forget that any one of the Key Indicators alone, or in combination with others, could be sufficient to present a ‘primary health need’ and justify CHC Funding.

Later in the series we’ll be looking in more detail about the interaction of needs across the Domains and some tips for writing the Key Indicators.

Learning valuable lessons prior to your MDT Assessment and how to avoid pitfalls

Preparing for the Multi-Disciplinary Team Assessment

What Happens At The Multi-Disciplinary Team Meeting?

Don’t let the Decision Support Tool become a ‘tick box’ exercise

What Is The Role Of The MDT Coordinator?

Can The MDT Panel Refuse To Proceed If I Have An Advocate?

Who completes the Decision Support Tool in NHS Continuing Healthcare?

What to do if you’ve been excluded from the MDT Assessment?

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