We have received numerous enquiries from families regarding a CHC assessment and the behaviour domain. They have wanted to understand how their relative’s challenging behaviour can impact upon their chances of being awarded the NHS Continuing Healthcare (CHC) – 100% free-funded care provided by the NHS!
When carrying out an assessment to see whether your relative may be eligible for CHC, there are 12 areas of care needs (‘care domains’) that need to be considered. These 12 care domains are set out in the Decision Support Tool (DST) which is completed by the NHS’s assessors. The DST is then sent to the Integrated Care Board (formerly Clinical Commissioning Group) with the assessors’ recommendations as to eligibility for CHC Funding. These care domains are listed below:
4. Skin (including tissue viability)
7. Psychological and Emotional Needs
10. Drug Therapies and Medication
11. Altered States of Consciousness
12. Other significant care needs
The ninth care domain is ‘Behaviour’. The DST notes that ‘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
When considering eligibility in the ‘Behaviour’ domain, there are six possible levels of need which could be selected – ranging from ‘No Needs’, ‘Low’, ‘Moderate’, ‘High’, ‘Severe’ and ‘Priority’.
They are defined in the DST as follows:
|No evidence of ‘challenging’ behaviour.
|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.
|‘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.
|’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.
|‘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.
|‘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.
‘Behaviour’ is one of the care domains that has a ‘Priority’ level of need assigned. If a ‘Priority’ level of need is awarded, this should automatically ordinarily trigger eligibility for NHS Continuing Health Care Funding (CHC), as the NHS National Framework provides that: ‘A clear recommendation of eligibility to NHS continuing healthcare would be expected where there is a level of priority needs in any one of the four domains that carry this level’.
Why does the ‘Behaviour’ domain present such a challenge?
However, deciding which level of need to select is often particularly difficult with Behaviour. There are three key areas that you need to consider:
Firstly, as indicated by the range of behaviour types listed in the DST (see above bullet points), behaviour can take on different forms, which need to be considered in terms of their impact on care delivery.
Secondly, the frequency of the behaviour needs to be considered; it could be occurring all day every day, or just once or twice a month. Frequency will impact on the level chosen but needs to be also considered against the severity of the behaviour. For example, one or two severe challenging behaviours could be graded as high as multiple lower less severe behaviours.
Thirdly, the severity of the behaviour is relevant. Taka as an example, two people who are both being physically aggressive – one could be very aggressive kicking, biting and punching; whereas the other might be less aggressive, pushing carers away, but with little force.
However, to correctly categorise ‘Behaviour’ you need to consider all the circumstances in more detail. For example:
- Is medication used to reduce challenging behaviours and, if so, is it effective or does it have any side effects?
- Are there any specialists involved to help manage the behaviour? Is the person is accommodated in a EMI unit with staff trained to deal with challenging behaviour?
- Are the behaviours directed at care staff or other care home residents? If targeted at other vulnerable care home residents, there can be a greater risk;
- Is the individual using items as a weapon? For example, hitting other residents with a walking stick?
- How does the individual respond to interventions to try and calm them? For example, do they calm down or does intervention actually cause their behaviour to escalate?
- Is the behaviour triggered by personal care interventions? If so, the number of interventions and how care is being affected should be analysed. It could be that care cannot be delivered, or carers need to retreat and return later. This can impact on the time taken to deliver care and the skill needed to ensure care is given;
- Non-physical aggressive behaviour, such as repetitive movements or words, can put the individual in a vulnerable position – especially if there are other residents who are unable to understand – perhaps due to cognitive impairment e.g dementia;
- Is the person mobile or strong? If so, this can increase the risk to others if they are being physically aggressive;
- What are the risk factors? These should be considered based on the risk not only to the individual exhibiting the challenging behaviour, but also to those on the receiving end.
Often, when a DST is completed, the assessor may ask for a diary of behaviours to be kept. These are often referred to as ABC’s (i.e. Antecedent-Behaviour-Consequence) and involves recording on a chart what triggered the behaviour:
- What happened just before the behaviour occurred – the Antecedent
- The actual Behaviour; and
- What happened afterward as a result – the Consequence
The assessment for CHC funding must consider how ‘Behaviour’ impacts and interacts with other care domains. For example, does it affect continence care (‘Continence’)? Does it cause difficulties feeding the individual (‘Nutrition’)? Does it affect moving and handling a person that is not able to mobilise independently (‘Mobility’)? It should also consider how poor cognition (‘Cognition’) or poor communication (‘Communication’) impacts on calming the person down.
George is severely cognitively impaired, he has no understanding of the world around him and does not understand when carers try to reassure him. He can be physically aggressive towards anyone that comes near him.
Scenario 1: George is not mobile and is normally sat in a chair. The trigger to his aggression is people entering his personal space, when he will hit out. Knowing this makes it easier for carers to know when he is going to need support. They can manage his behaviour by seating him in a quiet place where he is less likely to be disturbed by others. Carers can keep an eye on him and guide other people out of his personal space. He can be aggressive towards carers when they give personal care and some additional time is needed to for his continence care and to move and transfer him safely. Carers need to adopt some techniques when he is aggressive, such as distracting him or leaving him to calm. Carers know that he may be aggressive and can step away to avoid injury. George is aggressive 2-3 times a week, and is not strong enough to cause significant injury to his carers.
This scenario would likely be met with a ‘Moderate’ level of need. The additional time and training needed for carers to meet George’s needs should also be reflected in the 4 Key characteristics under Nature, Intensity and Complexity.
Scenario 2: George is independently mobile and wanders around a lot. Carers cannot sit him in a quiet place for long, as he will get up and move around, bringing him into contact with others. He often punches and kicks other residents if they go near him. He wanders into the rooms of other residents and becomes aggressive. Carers need to be with him to minimise risks to himself and others. He needs 1:1 care. George is also aggressive during personal care every time that care is given. Because he is active and strong, carers need to be very careful as he can kick and punch them and they are unable to get away. There needs to be 2 carers at each personal care intervention, sometimes 3, in order to keep him and his carers safe.
This scenario would likely be met with a ‘High’ to ‘Severe’ level of need. The additional time and training needed for carers to meet his needs should also be reflected in the 4 Key Characteristics under Nature, Intensity and Complexity. Note 1:1 care is generally considered to outside of the remit of the Local Authority to provide.
The decision to choose one level of need over another is a clinical decision made by the Multi-Disciplinary Team (MDT). However, if the MDT members cannot agree, then the highest level of need should be chosen.
Here are some helpful blogs for more reading around the subject:
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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