There are 12 areas of care need that are considered by an NHS Clinical Commissioning Group when assessing eligibility for NHS Continuing Healthcare Funding. These 12 areas of need are set out in the Decision Support Tool (DST) and referred to as ‘care domains’:
- Skin (including tissue viability)
- Psychological and Emotional Needs
- Drug Therapies and Medication
- Altered States of Consciousness
- Other significant care needs
This article focuses on the sixth care domain – Communication. The DST notes that this domain relates to “difficulties with expression and understanding, in particular with regard to communicating needs. An individual’s ability, or otherwise, to communicate their needs may well have an impact both on the overall assessment and on the provision of care. Consideration should always be given to whether the individual requires assistance with communication, for example through an interpreter, use of pictures, sign language, use of Braille, hearing aids, or other communication technology.”
When considering Communication, there are 4 possible levels of need which could be selected – ‘No Needs’, ‘Low’, ‘Moderate’ and ‘High’.
They are defined in the DST as follows:
|Able to communicate clearly, verbally or non-verbally. Has a good understanding of their primary language. May require translation if English is not their first language.||No needs|
|Needs assistance to communicate their needs. Special effort may be needed to ensure accurate interpretation of needs or additional support may be needed either visually, through touch or with hearing.||Low|
|Communication about needs is difficult to understand or interpret or the individual is sometimes unable to reliably communicate, even when assisted. Carers or care workers may be able to anticipate needs through non-verbal signs due to familiarity with the individual.||Moderate|
|Unable to reliably communicate their needs at any time and in any way, even when all practicable steps to assist them have been taken. The individual has to have most of their needs anticipated because of their inability to communicate them.||High|
Some of the care domains on the DST have a ‘Severe’ or ‘Priority’ level of need attached to them. This is not the case in Communication. The highest level in communication is ‘High’.
As would be expected, if a person can communicate without any difficulty, this will be determined as having ‘No Needs’.
A level of ‘Low’ needs will arise if, for example, there is a sight or hearing impairment that is not possible to remedy with glasses or hearing aids. A low level could also be given at the start of dementia, where communication with the person might need to be repeated or explained, but they can still grasp what is being said and understand most aspects of their care. A low level may also be appropriate after stroke, where communication has been mildly affected, such as having slurred speech or word-finding difficulties. It could also cover other conditions where speech is slow, slurred or more difficult to interpret. Essentially, you can communicate with the person, but there is an additional amount of time needed to convey their needs.
A level of ‘Moderate’ needs will arise where the communication difficulties are more substantial than ‘Low’. It could be that, through familiarity with the person, their communication can be better understood, but communication takes longer and is more difficult. They might have nuances or patterns to their speech, which with some practice, carers can understand with close listening. The person might need extra time to make themselves understood. They might need picture cards or other communication aids to assist, such as assistive technology. But in general, they will be able to make themselves understood with the support of a familiar carer. They may need to rely upon gestures and expressions and the use of closed questions, (questions that require a ‘yes’ or ‘no’ answer) which could be conveyed using head movements if the person cannot communicate verbally.
A level of ‘High’ will arise once the need goes beyond ‘Moderate’. This will include someone that has no verbal or non-verbal ability to communicate their needs at all. If a person can indicate pain by grimacing or wincing, it is sometimes noted by assessors that this is ‘non-verbal communication’. If this is the person’s only method of being able to communicate, the level of need should generally be recorded as ‘High’.
The difference between the levels of need is generally based on clinical opinion and recorded evidence. That is why good record keeping is essential.
Read our blogs on the importance of good record keeping:
Reliability of Communication
A key word used in the descriptions for ‘Moderate’ and ‘High’ is ‘reliability’. In ‘Moderate’, reliability is described as having communication that is ‘sometimes’ unreliable, whereas ‘High’ describes a person who is ‘unable to reliably communicate at any time in any way’. There is a large gap between ‘sometimes’ and ‘at any time’. A person may occasionally be unreliable, or always be unreliable, but they might fluctuate frequently so as to be unreliable more often than not, but not necessarily, always. If so, should they be categorised as ‘High’ or ‘Moderate’? Again, this is a question of fact and degree for clinicians, assessors and advocates to establish. The argument may be more productively considered in the four Key Characteristics (see below).
The question of reliability mainly arises with cognitive problems, for instance, a person living with dementia, brain injury, learning disability or after a stroke. These individuals may perhaps say ‘yes’ when they mean ‘no’. When given choices, they may select the last given option rather than making a reasoned choice. They might not understand communication at all. Here it will be a question of fact and degree, as well as considering the written evidence and verbal evidence of carers and family.
The DST assessor, advocate or other clinical staff determining the correct level of need, will need to look at any written evidence indicating the person’s ability to communicate. For example, care home records or GP records that indicate that the person can converse, read or write, answer questions or can indicate some or most of their care needs. Comments written in the care records such as ‘Mr X asked for a drink’, ‘Mrs Y asked to be taken to the toilet’, or ‘Ms Z said she had a headache’ can all be used in evidence to support the appropriate level of need. That is why the written records can be so important to supporting the level of need.
TIPS: Here are some examples of questions which might assist to determine reliability:
- Can the person correctly indicate pain, the level of pain and the site of the pain?
- Can the person correctly indicate whether they need assistance with a particular care need?
- Does the person have cognitive impairment, and if so, to what extent?
In some cases, if the person has been seen by a Speech and Language Therapist (SALT) or Occupational Therapist, it would be helpful to include any letters or reports from these specialists to evidence the needs.
TIPS: Here are some questions to note when thinking about the level of Communication on the DST;
- Can the person communicate their needs easily? What is the quality of their communication? Do people find them difficult to understand? Do carers need to anticipate some, or all of their needs, due to communication difficulties?
- Can they communicate verbally? Can they communicate non-verbally, for example using written word, picture cards, hand gestures, assisted technology etc?
- Is there a hearing or sight impairment? Is this resolved by glasses or hearing aids? Is there any difficulty getting the person to use their glasses or hearing aids? To what extent is their hearing or sight impaired? For example, are they profoundly deaf? Are they registered blind or partially sighted? Are one or both eyes/ears affected? What adjustments can be made/are being made to assist the person to communicate better?
- Does their ability to communicate fluctuate? It might be worse at certain times, for example when tired, when their cognition fluctuates (this is common in people with vascular dementia), during infections. If a person has a lot of time where their communication fluctuates, this should be recorded on the DST and the level of need selected should reflect the needs when they are at their greatest.
- Do they have a cognitive impairment? If so, how great is the cognitive impairment and how does it impact on communication?
- If the person has been assessed by Speech and Language Therapists, what was their view and advice? It is helpful to take a copy of the assessment along with you for reference in assessments and appeals.
Disagreements about the level of need
It can sometimes be tricky to select a level of need that appropriately reflects the person’s ability in Communication. This can lead to differences of opinion in assessors, clinicians, advocates and the family. Where a level of need is proving difficult to agree, it can be helpful to complete the rest of the DST and then return to Communication afterwards as discussions around the other areas of need can often resolve the issue.
Considering the needs in Cognition can often be helpful to decide whether the communication is reliable or not. Generally, if the need in Cognition is ‘Severe’, the need in Communication will be ‘High’, as communication is unlikely to be reliable with this level of cognitive impairment.
If the members of the Multi-Disciplinary Team (MDT) cannot agree the correct level of need and one member thinks, for example, it should be ‘High’ and the other thinks it should be ‘Moderate,’ the highest level should be selected. The reason for the disagreement should be recorded on the DST. If family or carers disagree with the level chosen, this too, should be recorded on the DST.
Considering Communication within the Four Key Characteristics
A good CHC assessment will consider the impact of each of the care domains on each other and how this relates to the four Key characteristics; Nature, Intensity, Complexity and Unpredictability.
Communication affects most of the other care domains and should be mentioned in those domains and/or reflected in the Four Key Characteristics. For example, being unable to communicate or having to rely on communication aids (such as a communication board) can be exhausting and frustrating for the patient and can result in distress. This should be reflected in the Psychological and Emotional Needs domain, and also in the Intensity and Complexity Key Characteristics.
It can also lead to challenging behaviour, for example physical aggression or resistance to care, if the person does not understand why care is being done and if they are unable to communicate this effectively. This should be considered in the Behaviour domain and also in Intensity and Complexity.
Similarly, if a person is known to experience pain but is no longer able to say they are in pain, this will impact on the Medication domain. Carers will need to be vigilant during care provision to watch out for clues such as facial expressions or listen out for sounds of pain. This can add on time to care and can also make it more difficult to assess whether a person needs more pain relief and whether the pain relief given has had good effect. This might add to the complexity of their care.
Other aspects of care that might be affected by communication difficulties are likely to include the other domains of Skin, Continence or Nutrition, where needs in these care domains should also be considered – particularly if the needs in these areas of care are selected as ‘High’.
For further reading around the subject look at these blogs and many more on our Care To Be Different website:
Other blogs in our TIPs on DST series include:
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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