When your relative is being assessed for NHS Continuing Healthcare Funding (CHC), the Clinical Commissioning Group will carry out a full assessment at a Multi-Disciplinary Meeting (MDT). Their Panel of assessors must complete a Decision Support Tool (DST) to assist them in making a recommendation as to your relative’s eligibility for CHC.
To find out what to expect at the MDT read our recent blog, “What Happens at the Multi-Disciplinary Team Meeting?”
The NHS Continuing Healthcare Decision Support Tool (October 2018) has 12 headings known as ‘Care Domains’. Each Care Domain is assessed in turn.
The Care Domains include: Breathing, Nutrition – food and drink, Continence, Skin integrity (including tissue viability), Mobility, Communication, Psychological/emotional needs, Cognition, Behaviour, Drugs/medication/symptom control, Altered states of consciousness & Other significant care needs).
How to improve your scoring…
To improve your relative’s overall scoring at the MDT assessment and their chances of getting CHC Funding, you need to adopt a holistic approach and consider the interrelation between the various Care Domains and how they impact on each other.
As an example, look at the “Skin” Domain – which deals with skin integrity and tissue viability eg skin damage and pressure sores.
The ‘Skin’ Domain sets out each level of need, with a description of what type of skin breakdown, wound or pressure ulcer would justify an appropriate level of need. Scoring within this Domain can be from ‘No needs’ to ‘Severe needs’ – see the DST table below:
Decision Support Tool for NHS Continuing Healthcare
Section 2 – Care Domains
- Skin (including tissue viability)
|Description||Level of need|
|No risk of pressure damage or skin condition.||No needs|
|Risk of skin breakdown which requires preventative intervention once a day or less than daily without which skin integrity would break down.
Evidence of pressure damage and/or pressure ulcer(s) either with ‘discolouration of intact skin’ or a minor wound(s).
A skin condition that requires monitoring or reassessment less than daily and that is responding to treatment or does not currently require treatment.
|Risk of skin breakdown which requires preventative intervention several times each day without which skin integrity would break down.
Pressure damage or open wound(s), pressure ulcer(s) with ‘partial thickness skin loss involving epidermis and/or dermis’, which is responding to treatment.
An identified skin condition that requires a minimum of daily treatment, or daily monitoring/reassessment to ensure that it is responding to treatment.
|Pressure damage or open wound(s), pressure ulcer(s) with ‘partial thickness skin loss involving epidermis and/or dermis’, which is not responding to treatment
Pressure damage or 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 is/are responding to treatment.
Specialist dressing regime in place; responding to treatment.
|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.
Pressure sores are primarily caused by a significant lack of mobility, perhaps due to being bed/wheelchair-bound, or generally lying or sitting for too long in one position. Certain medical conditions such as Parkinson’s, heart disease, diabetes, MS and deteriorating mental health are known to make individuals less mobile, and therefore at greater risk of developing pressure sores. Read our helpful blog on Pressure sores for more information.…
Here are some steps you can take to improve your relative’s prospects of getting CHC.
Step 1: Get hold of the care home records prior to attending the Multi-Disciplinary Team assessment, and look for relevant entries, care plans, risk assessments and Waterlow scores to assist your case.
Step 2: Try to match your relative’s skin condition to the relevant description of those needs in the DST.
Step 3: Take a holistic approach and look at the bigger picture. Health needs, such as pressure sores, should be looked at in the wider context and their interaction with other Domains, and not just in isolation under the Skin Domain.
Practice Guidance Note 21.2 of The National Framework for NHS Continuing Healthcare provides that “a good quality multidisciplinary assessment of an individual’s health needs… will be holistic, looking at the range of their needs from different professional and personal viewpoints, and considering how different needs interact”.
Suffering with pressure sores, as described within the Skin integrity Domain, is likely impact upon and interact with other Care Domains. For example, look how pressure sores are influenced by and interact with other Care Domains below:
- ‘Mobility’ Domain. We know that significantly limited mobility however caused, is considered one of the main driving factors causing pressure sores in the first place, and if prolonged, can cause them to deteriorate.
- ‘Continence’ Domain. Incontinence can cause pressure sores to develop, especially if sitting for extended periods in wet patches without regular toileting, good hygiene, changes of clothing or incontinence pads.
- ‘Nutrition’ (Food and drink) Domain should also be considered. Malnutrition, dehydration or poor diet and fluid intake may cause weakness, loss of weight, make the individual more vulnerable to skin tears, hinder or prolong healing and recovery – which may in turn affect skin thickness and integrity.
- ‘Cognition’ and ‘Altered State of Consciousness’. Onset of serious infection or severe pain from pressure sores can cause delirium and hallucinations, which in turn can impact on mobility and the medication administered. If the individual does not have the presence of mind to know that they are immobile, that they need to move or reposition themselves, are incontinent, have mental health issues, suffer with Alzheimer’s, Parkinson’s, or have other serious medical conditions, then they are at risk of developing pressure sores.
- ‘Communication’. The individual may not be able to communicate their need to move, or voice that they are in pain from a pressure sore. Staff need to be alert to observe and regularly monitor skin integrity and interpret needs. Implementing the care plan and regular repositioning can avoid pressure sores.
- ‘Drug Therapies/Medication/Symptom control’. Pain from pressure sores can be so intense it requires skilled intervention to administer pain relief. Pain relief may be required before turning or repositioning.
Note: Although the NHS National Framework states that the DST should be used as an aid to decision-making, you still have to consider the interaction between all the various Care Domains and the impact of the 4 key characteristics – ie nature, intensity, complexity and unpredictability of your relative’s needs, in determining whether they have an overall primary health need.
In summary, you have to look at the totality of the relevant needs when seeking NHS Continuing Healthcare Funding. Be alert to the likelihood that your relative’s health needs described within each of the Care Domains in the DST could have a direct connection to, and impact upon, at least one or more of the other Domains. Think about the implication of any one health need and its wider effects to improve your chances of success. If your relative needs trained staff to manage those healthcare needs by skilled intervention over a sustained 24 hour period to prevent deterioration, then arguably they may meet the eligibility criteria to get CHC.