STANDARD OPERATING PROCEDURE: CONTINUING NHS HEALTHCARE Standard Operating... · CHC SOP 10 May...

CHC SOP 10 May 2011 of 31

STANDARD OPERATING PROCEDURE: CONTINUING NHS HEALTHCARE

Version Number 10 Previous Version Date of Issue May 2011 Previous Issue

Date

Review Date

Author (s) CHC Implementation Group Members Responsible Officer(s)

Mrs Elizabeth Powell, Mrs Lowri Welnitschuk Mrs Bethan Nickson, Mrs Denise Griffiths

List Groups and / or Individuals consulted CHC Implementation Group Members CHC Teams in BCUHB ACOSs BCUHB Community Health Council Independent Care Sector Local Authorities

Those listed opposite have been consulted and comments / actions incorporated as required (Author to ensure that relevant individuals / groups have been involved in consultation as required prior to this document being submitted for approval

Voluntary Sector

SOP approved / rejected

Ratification Signature Date

Ratifying Body


Index 1. Introduction and Background 1.1 Procedure - Eligibility Consideration Flowchart 2. Discharge Planning, Review or other trigger 2.1 Could NHS services enable improvements that cou ld alter the

outcome of eligibility? 2.2 Other NHS Funded Services 2.3 Possible eligibility for CHC 2.4 Decision support tool – Full consideration for CHC 2.5 Establishing Primary Health Needs 3. No Eligibility 3.1 Consider need for Joint NHS/LA package includin g need for

registered nurse (FNC) 3.2 Process 3.3 Continuing NHS Healthcare funded Care package

Community, Primary and Specialist Medicine Clinical Programme Group Mental Health and Learning Disabilities Clinical P rogramme Group Children and Young People - Transition to Adult se rvices 3.4 Fast Track 4. Governance 4.1 Scrutiny Panels 4.2 Reviews 4.3 Complaints 4.4 Dispute Resolution 4.5 Communication & Advocacy 4.6 Training


4.7 Process Appendix 1 – CC10 Continuing Health Care Cover Shee t Appendix 2 – Fast Track Process Appendix 3 – Fast Track Tool Appendix 4 – Terms of reference of Scrutiny Panels Appendix 5 – Dispute Panels and Arbitration Appendix 6 – CHC teams Contact Details This is a working document and the following will b e inserted at a later date.

� Mental Health - S117

� Retrospective Reviews

� Equipment requests

� Out of County – In the interim please refer to Who Pays? Establishing the Responsible Commissioner. DOH 2007

� Records Management

� Direct Payments


1. Introduction and Background

Context

• This Standard Operating Procedure (SOP) has been developed to aid the Betsi Cadwalader University Health Board (BCUHB) and its partner Local Authorities to implement the National Framework for Continuing NHS Healthcare (WAG 015/ 2010). It should be read in conjunction with this Framework.

• From the 16th August 2010, people being considered for eligibility for

Continuing NHS Healthcare (CHC) will be assessed using this document and the Decision Support Tool (DST).

• Reviews of patients receiving CHC will also be carried out using this tool

to assess if there are any changes in care needs • The purpose of the Framework is to provide a consistent foundation for

assessing, commissioning and providing CHC for adults across Wales. This is to ensure that there is a consistent, equitable and appropriate application of the process for determining eligibility. The framework is not intended to replace existing joint commissioning strategies

. • The NHS and Local Authority operate under different legislation, deciding

on the balance between local authority and health service responsibilities with respect to long-term care has been the subject of key court judgments. Further details are contained within the National Framework.

• BCUHB and its partner organisations will work to ensure a person and

carer centred approach and any decisions made will be

� person and carer centred � equitable, fair and consistent � anti discriminatory � robust and transparent � informative and clearly explained � adheres to guidance and best practice

• This Standard Operating Procedure applies to all adults over the age of 18yrs in all settings where possible eligibility for CHC will need to be determined


1.1. Procedure The eligibility consideration flowchart which follows is taken from the National Framework (p 26) and illustrates the process of determining eligibility for CHC. The headings of this SOP mirror the flowchart.


2. Discharge Planning, Review or other trigger 2.1 Could NHS services enable improvements that cou ld

alter the outcome of eligibility? 2.1.1 Staff must consider whether there is scope for further re ablement and

rehabilitation before any decision to consider eligibility for CHC. 2.1.2 Staff should screen patients for rehabilitation, intermediate care or

reablement and assess whether core services can meet patient needs. 2.2 Other NHS Funded Services 2.2.1 ‘Assessments in acute settings can sometimes poorly represent an

individual’s capacity to maximise their potential. Similarly, assessments conducted in poor quality care environments may also artificially inflate health care needs. To help avoid this and to ensure that unnecessary stays on acute wards are avoided, it should be considered whether further NHS-funded therapy and/or rehabilitation might make a difference to the potential of the individual in the following few months (section 5.24 National framework).

2.2.2 The range of services that the NHS can be expected to arrange and

fund includes (but is not limited to):

� Primary healthcare � Assessments involving doctors and registered nurses � Rehabilitation and recovery � Community Health Services � Specialist support for Healthcare needs � Additional support for episodic higher needs � Palliative care and end of life care � Specialist transport (i.e. ambulances)

2.3 Possible eligibility for CHC including consent and capacity. 2.3.1 The guidance in the Framework indicates that full consideration for

CHC is determined at contact assessment phase (first assessment) where a decision is made that a comprehensive assessment is required.

2.3.2 A comprehensive assessment should be completed where the amount

of support and treatment likely to be offered is intensive or prolonged, including permanent admission to a care home, intermediate care packages or substantial packages of home care. No decisions on where individuals are best supported should be made before all


information from a comprehensive assessment has been evaluated, including information from medical assessments and a thorough exploration or rehabilitation potential.

2.3.3 The rationale for not undertaking a CHC assessment must be

discussed with the individual / family/ representative and documented. The individual / family / representative must be informed that they may appeal against the decision making process but not the outcome.

2.3.4 An individual’s informed consent should be obtained and documented

before the CHC assessment process begins and decisions made. 2.3.5 If there are concerns regarding the individual’s mental capacity to

consent to the CHC assessment, this should be determined in accordance with the Mental Capacity Act (2005), including a referral to the IMCA service if appropriate. A third party cannot give or refuse consent to an assessment on behalf of an individual lacking capacity. Staff should check whether anybody has been authorised to consent on the individual’s behalf by way of a Lasting Power of Attorney (POA).

2.3.6 In the case of an individual who lacks capacity, a best interest decision

involving those who know the individual well and can help inform consideration should be made.

2.3.7 If an individual with capacity refuses an assessment, this must be

documented in the individual’s records. The individual must then be informed of the potential effect this will have on the ability of both BCUHB and the Local Authorities to provide services and it may mean their needs cannot be met. The MDT would in this instance consider existing assessments and any other relevant information to make a recommendation to both the Local Authority and the BCUHB respective panels.

2.3.8 Consenting to a CHC assessment is not a precondition to accepting

any subsequent offer of CHC funding. 2.4 Decision Support Tool - Full consideration for CHC

The purpose of the tool is to explain the rationale for the decision that is made. This tool should not take the place of professional or clinical judgements. The DST clarifies the decision making process using professional assessments to establish the Primary Health Needs.

2.4.1 A multidisciplinary team meeting must be held to discuss eligibility for

Continuing NHS Healthcare for each individual in all settings.

2.4.2 Ideally, one member of staff should have a co-ordinating role to oversee an individual’s care package. Often the role is best handled by practitioners with a long term role with the individual. Where needs are mainly health related, a nurse or other health worker should act as co-


ordinator. Where social care needs are to the fore, a social worker might be expected to co-ordinate.

2.4.3 The care co-ordinator must take responsibility for the whole process

until a decision about funding has been made and a care plan written. This role is best handled by practitioners who know the individual the best at that time.

2.4.4 Even where the individual is supported by an integrated team, minimum attendees at a multidisciplinary meeting must be a registered nurse employed by the NHS and a registered Social Worker unless otherwise agreed. If a Doctor is unable to attend the Multidisciplinary Team Meeting a medical opinion should be completed beforehand. Any other specialist practitioner currently involved in the care of the individual should also be invited to attend to enable completion of a comprehensive assessment. The individual and/ or their family, carer, advocate should be invited to attend.

2.4.5 The DST is not an assessment in itself but a way of bringing together

and applying the evidence in a single practical format to facilitate consistent evidence based decision making on CHC eligibility.

2.4.6 If a multidisciplinary assessment has recently been completed (within

the last 3 months), this may be used; but care should be taken to ensure that it provides an accurate reflection of current need. If no change this should be documented signed and dated

2.4.7 Every recommendation on whether an individual is eligible for CHC or

not and the basis of the recommendation must be recorded and signed:

� In the person’s clinical records � In the person’s Personal Care Plan � In the formal record of the MDT meeting

The documentation should be organised to ensure the recommendation can be easily identified.

2.4.8 Following completion of the DST the Multidisciplinary Team will make

a recommendation as to whether the individual is eligible for Continuing NHS Healthcare or if not, is eligible for any other services. The recommendation on page 44 of the DST must be completed.

2.5 Establishing Primary Health Needs 2.5.1 The sole criterion for determining eligibility for CHC is whether a

person’s primary need is a health need. (ref Chapter 4 of the National Framework)


2.5.2 Certain characteristics of need and their impact on the care required to manage them will determine whether a person’s primary need is a health need:

2.5.3 Nature : This describes the particular characteristics of an individual’s

needs (which can include physical, mental health or psychological needs) and the type of those needs. This also describes the overall effect of those needs on the individual, including the type (‘quality’) of interventions required to manage them.

2.5.4 Intensity: This relates both to the extent (‘quantity’) and severity

(‘degree’) of the needs and to the support required to meet them, including the need for sustained/ongoing care (‘continuity’).

2.5.5 Complexity: This is concerned with how the needs present and

interact to increase the skill required to monitor the symptoms, treat the condition(s) and/ or manage the care. This may arise with a single condition, or it could include the presence of multiple conditions or the interaction between two or more conditions. It may also include situations where an individual’s response to their own condition has an impact on their overall needs, such as where a physical health need results in the individual developing a mental health need.

2.5.6 Unpredictability : This describes the degree to which needs fluctuate

and thereby create challenges in managing them. It also relates to the level of risk to the person’s health if adequate and timely care is not provided. Someone with an unpredictable healthcare need is likely to have either a fluctuating, unstable or rapidly deteriorating condition.

2.5.7 Each of these characteristics may alone or in combination,

demonstrate a primary health need, because of the quality and/or quantity of care required to meet the individual’s needs. The totality of the overall needs and effects of the interaction of needs should be carefully considered.

2.5.8 The diagnosis of a particular disease or condition does not, of itself,

determine eligibility. Eligibility is not determined or influenced by the setting where the care is provided, or by the characteristics of the person who delivers the care, or any of the following factors:

� Changes in the competence and the ability of the care provider

to manage care � The use (or not) of NHS employed staff to provide the care � The need for/presence of “specialist staff” in care delivery � The existence of other NHS funded care � The number of staff delivering the care � The cost of the care package � Changes made to an existing package of care � Any other input-related (rather than needs related)matters


3. No Eligibility 3.0.1 If, following completion of the DST, the multidisciplinary team does not

recommend eligibility for Continuing NHS Healthcare, the rationale for this decision must be recorded and shared with the individual/family/representative together with information regarding the process for decisions to be reviewed by the care co-ordinator.

3.1 Consider need for joint NHS/LA package, Registered

Nurse in the community and NHS Funded Nursing Care 3.1.1 If the MDT does not recommend eligibility for Continuing NHS

Healthcare but joint funding in one of the following ways:

� NHS Funded Nursing Care – Care Homes Nursing only � Additional Registered Nurse care, over and above contracted

hours in community or care home residential settings. � Jointly funded care packages where the BCUHB and Local

Authorities each contribute towards the whole cost of the care package

The care co-ordinator should collate all documentation and forward to the CHC scrutiny panel and relevant local authority for consideration.

3.1.2 The care co-ordinator or BCUHB lead must complete the CC10 Cover

Sheet (Appendix 1) and submit it along with the specified documentation to the relevant panel.

3.2 Process 3.2.1 If the MDT recommends that the individual is eligible for Continuing

NHS Healthcare the rationale for this decision must be given to the individual or their representative and recorded in the patient notes by the care coordinator. Individuals or their representatives must be informed that this recommendation must be further ratified by a Scrutiny Panel

3.2.2 If the MDT recommends eligibility for Continuing NHS Healthcare, the

care co-ordinator must collate the required documentation as identified on the CC10 cover sheet and forward it to the CHC Scrutiny Panel within agreed timescales for presentation at a scrutiny panel.

3.2.3 Applications for the CHC Scrutiny Panel should be sent to the relevant

CHC Locality Team Office (Addresses and contact numbers available in appendix 6 and they must be received by the CHC team as noted in the CPG sections below.


3.2.4 CHC Managers and the Lead Nurses will be able to make decisions ‘in principle’ where there is a need for a ‘fast track decision’ as described in section 3, or when a decision is required to expedite an immediate discharge from hospital on receipt of the required documentation. These cases will then be presented to the next scrutiny panel.

3.2.5 Decisions following Scrutiny Panel will be communicated in writing to

the individual, the care coordinator and relevant local authority. 3.3 Continuing NHS Healthcare Care Package 3.3.1 In order to ensure that decisions on eligibility are fair, rational, and

consistent and comply with the requirements of this framework, the St Helen’s judgement clarified that the NHS is the primary decision maker on questions of eligibility for CHC (see annex 3 National Framework, page 59-62). Locally the CHC scrutiny panels will confirm or otherwise the MDT recommendations.

Community, Primary and Specialist Medicine Clinical Programme Group 3.3.2 The Community, Primary & Specialist Medicine CPG will hold twice

weekly panels on Tuesday in both the East and West localities and any application over £600 per week will need to be presented at the high cost panel, held on Thursday morning in order to agree the care package proposed by the MDT. The terms of reference and panel process for the CHC team is contained in Appendix 4

3.3.3 The Care Coordinator will need to ensure applications are sent to the

relevant CHC panel by the preceding Friday for the Tuesday panel and Tuesday for the Thursday panel.

3.3.4 Where a decision is required ‘in principle’ to expedite discharge, staff

should contact the relevant CHC locality office and discuss the case with the CHC Manager or Lead Nurse who on consideration of the facts will be able to make a decision in principle, the documentation must be forwarded to the relevant CHC locality office.

Mental Health and Learning Disabilities Clinical Programme Group 3.3.5 The Mental Health and Learning Disabilities CPG hold a weekly panel

on a Tuesday in the Central area of BCUHB. Any application over £600 will need to be presented at the high cost panel which is held fortnightly on Tuesday afternoon in order to agree the care package proposed by the MDT.


3.3.6 All information should be received three working days prior to the Tuesday panel. (i.e. Wednesday previous week). As a minimum, each application must contain the following

• Current nursing assessment including care plan • Care plan from proposed provider demonstrating ability to meet care

needs of patient • Medical report from psychiatrist • Social work report • Risk assessments • Completed DST with a recommendation regarding eligibility, and

copies of MDT minutes 3.3.7 It is not expected that the CPN or CLDN / Reviewer attends panel to

present the case unless there are exceptional circumstances. 3.3.8 Where an assessed need is related to a condition, illness or

circumstance that is other than a mental health or learning disability need, joint working with other CPGs and a potential application to another CPG may be required.

Children and Young People Clinical Programme Group - Transition from children’s to adult services. 3.3.9 The NSF for children, young people and maternity services set

standards for transition. This requires planning to start at 14 for anyone who may require adult services and the identification of a named transition worker. The involvement of the young person in the process and the development of a transition plan that is monitored 6 monthly is required. This process involves all agencies including LHBs and those who understand adult CHC.

3.3.10 Future entitlement to adult CHC should be clarified as early as possible

in the transition process. Eligibility should be assessed at age 17 to ensure that services are available for when the young person reaches their 18th birthday. If needs may change then a provisional decision should be made at this stage. Entitlement should be based on the 2010 eligibility framework and processed including completion of the decision support tool. Multi-agency services should ensure smooth transition from children’s to adult services and no service should be stopped without an assessment taking place.

3.3.11The term continuing care has different meanings in children’s and adult

services and this should be explained to the young person and their family. It is important that adult services are involved in the transition process.

3.4 Fast Track

3.4.1 Occasionally, individuals with a rapidly deteriorating condition who may

be entering a terminal phase or terminal care will require ‘fast tracking’


for immediate provision of CHC so that they can be supported in their preferred place of care as quickly as possible without waiting for the full CHC eligibility process to be completed.

3.4.2 Appropriate clinicians i.e. registered nurse or medical practitioner

should complete the fast track pro forma and ensure that a prognosis is stated, along with a nursing assessment, the details and costs of the required care package. Further guidance contained in Appendix 2 & 3

3.4.3 The BCUHB CHC teams will ensure that staff has access to a member

of staff who is able to make an urgent decision. 3.4.4 Details of the CHC team offices and contact numbers are contained at

the end of this document and on the BCUHB Intranet page. 4. Governance 4.1 Scrutiny Panels 4.1.1 CHC Scrutiny Panels will be held across North Wales to ratify the

recommendations of the MDT and to ensure, at the very least, the consistency and quality of decision-making.

4.1.2 Where CHC applications require the involvement and / or funding from

other Clinical Programme Groups, the relevant CHC team will contact staff from the CPG to request attendance, or provide written evidence to the CHC Scrutiny Panel.

4.1.3 Only in exceptional circumstances and for clearly articulated reasons

should the Scrutiny Panel not accept the multidisciplinary team’s recommendations. A decision not to accept the recommendation should not be made by one person acting unilaterally.

4.1.4 The Scrutiny Panels may request the MDT to carry out further work if

the DST is incomplete or if there is significant inconsistency between the evidence in the assessment, the DST and the recommendation made.

4.1.5 The Scrutiny Panel will not make decisions in the absence of the

recommendations on eligibility from the MDT, except where it is necessary for an urgent decision to be made.

4.1.6 Finance officers will not be part of the decision making panel. 4.1.7 The time taken for assessments and agreeing a care package may

vary but should be completed in six to eight weeks from initial trigger to agreeing a care package.


4.1.8 The care co-ordinator should ensure that time scales, decisions and rationale relating to eligibility are transparent from the outset for individuals, carers, family and staff.

4.2 Reviews and Handover 4.2.1 An individual’s eligibility for CHC is subject to review. Reviews will

follow the format of an assessment, and will consider all the services received by the individual.

4.2.2 As a minimum there will be an initial review of the care plan within 6

weeks and a further review at 3 months of services first being provided. Thereafter reviews will be at least annually. Where an individual’s condition is anticipated to deteriorate, more regular review may be necessary. Frequency of such reviews will be determined by the individual’s assessed needs or if there is a change in circumstances. Where there is an obvious deterioration in circumstances reviews should also be held within 2 weeks, and acted upon appropriately.

4.2.3 Review timescales will be identified and communicated to the individual

and their relatives verbally and in writing by the lead Nurses or Nurse Reviewers.

4.2.4 If the local authority is also responsible for any part of the care, both

the LHB and the local authority will have a requirement to review needs and the service provided. In such circumstances, it would be beneficial to conduct a joint review. Even if all the services are the responsibility of the BCUHB, it would be beneficial for the review to be held jointly by the BCUHB and the local authority especially as any decision affecting CHC will require input from both sectors.

4.2.5 Following review, where the MDT recommends eligibility for CHC, as a

norm the care package should be funded from the date of the MDT meeting.

4.2.6 For patients who may no longer be eligible for CHC funding, 35

working days should be given as a handover period from the date of the letter from the CHC team to SSD requesting an MDT to determine eligibility. This allows time for any financial assessment to be undertaken during this period.

4.3. Complaints 4.3.1 Where a full assessment has been undertaken of potential eligibility

and a decision has been reached, an individual may apply to BCUHB for an independent review of the decision if they are dissatisfied with:

� the procedure followed by BCUHB in reaching its decisions around the individuals eligibility for CHC or


� the application of the primary health need consideration 4.3.2 Individuals may ask BCUHB to reconsider its decision and BCUHB will

give this request due consideration, taking into account all the information available, including any additional information from the individual and/or carer.

4.3.3 Where individuals request a review of the decision via the BCUHB

complaint department, the request will initially be forwarded to the CHC Central team at Matthew House, St Asaph who will determine whether the request should be investigated by BCUHB or passed on to the All Wales Retrospective CHC Team.

4.3.4 Where an individual disagrees with the recommendation made by the

MDT, the following process will apply :

� MDT reconvened with relevant line managers (if required ) to confirm that the assessments accurately reflect the needs of the individual and the recommendation of the MDT � All documentation forwarded to the relevant CHC locality office specifying that this is a request from the individual / family or representative for consideration at CHC Scrutiny Panel. � Request will be heard at the CHC Scrutiny Panel and the outcome communicated to the care coordinator, individual and relevant local authority as per usual process. � Where the individual / family /representative remains dissatisfied they may be offered a meeting with the relevant CHC manager to discuss the panel outcome.

4.3.5 Where local resolution options have been exhausted, the case should

be referred to the Independent Review Panel. 4.3.6 If the original decision is upheld and the individual still wishes to

challenge the decision, the individual has access to the Public Services Ombudsman.

4.3.7 If an individual / family / or their representative is dissatisfied with the

decision making process or any other process under Continuing NHS Healthcare they may access the BCUHB Complaints procedure at http://www.bcu.wales.nhs.uk

4.4. Dispute Resolution 4.4.1 Neither the BCUHB nor any of the 6 local authorities should unilaterally

withdraw from an existing funding arrangement without a joint reassessment of the individual and without first consulting one another and the individual about the proposed change of arrangement. Any proposed change should be put in writing to the individual by the organisation that is proposing to make such a change. If joint


agreement cannot be reached upon the proposed change, the disputes procedures in appendix 5 should be invoked.

4.4.2 BCUHB Board and Local Authorities should in the first instance work

closely with individuals to solve any disputes informally and in the minimum time.

4.4.3 Disputes should not delay the provision of care or established

funding/care scheme provided pending resolution. The aim will be to resolve any disputes in the minimum time. Information regarding disputes panels is contained in appendix 6.

4.5. Communication 4.5.1 A guide to Continuing NHS Healthcare has been designed by WAG as

a communication tool to help health and social care practitioners, the individual undergoing the assessment their families, carers, friends or appointed advocates to better understand the process. A public information leaflet is also available to help operational staff give advice on the process. Electronic copies are available on the BCUHB Intranet page at http://www.bcu.wales.nhs.uk

4.6. Training 4.6.1 The training programme arranged by BCUHB will be multidisciplinary/agency in its approach and health and social care organisations will be expected to release relevant staff to participate. 4.6.2 Copies of the All Wales CHC Training will be made available on the

Health Board’s Intranet site along with all relevant documentation. 4.6.3 BCUHB will review their current assessment, governance, and

discharge processes to ensure they comply with the Framework.

4.7 Governance Process 4.7.1 In order to improve practice and ensure a consistent application of the

Framework in North Wales, BCUHB has instigated the following actions.

� An authorised signatory list detailing all arrangements made

in agreement with Clinical Programme Groups � A programme of audits to check the consistency of the

decision making process, and the quality of the documentation presented to the Scrutiny Panel and the use of the fast track process.

� A summary of reports where “alternative services” could be developed to offset CHC spend.


4.7.2 Database development -BCUHB will develop a database to record the

following:

� total number of individuals in receipt of continuing NHS healthcare, joint funding and the registered nursing care contribution

� total number of assessments undertaken � timing of assessments � outcomes of assessments undertaken � the costs of continuing NHS healthcare packages.


CC10: Continuing NHS Healthcare Cover Sheet

Client Name

Date of Birth

NHS Number/ Agency Number

Current location of the Service user

Local Authority Name

Is the patient self funding? Yes No Summary of Service to be provided

Care home Placement Yes No Care in the Persons own home Yes No

Name of care home / Independent Hospital

Describe in brief

Summary of MDT Recommendation, please tick one box only A The patient has nursing needs and is eligibl e for NHS Funded Nursing Care

B The patient is eligible for joint funding

C The patient has a primary health need and is eligible for Continuing NHS Health Care

Documentation – as a minimum please ensure that each CHC application has Yes No Copy of the DST MDT minutes / case conference Current care plan Risk assessments Specialist reports as required (nursing, medical and social work as a minimum) Copies of all professional assessments in line with UA/ CPA

Please complete the following checklist to ensure a ll the necessary documentation has been completed. Incomplete applications will no t be accepted.

Yes No

Is the MDT satisfied that all available interventions that may impact on health needs have been implemented and all potential for rehabilitation and regaining independence has been explored

Patient / Family/ Representative informed of need and financial implications of the assessment

Patient information booklet – ‘Continuing NHS Healthcare for Adults in Wales’ given Consent Has the consent form within the UA/ CPA documentation been completed You should not proceed with the assessment until you are sure that the patient and / or family/ representative understand the need for the assessment and consent has been given to share information.

Mental Capacity Does the patient have mental capacity, decision specific? What evidence is there to provide support (URUC)

Appendix 1


If no, please consider the MCA Decision Process

Does the patient have any of the following (please tick if applicable)

Family/ Friend/ Advocate

Advanced Decision Lasting Power of Attorney – Financial / Welfare Enduring power of Attorney – financial and business only Court Appointed Deputy Comprehensive Assessment Are there copies of the specialist / non specialist assessments used to complete the DST and support the application in the patient’s notes

Decision Support Tool Have all members of the MDT/ patient / family / carer or advocate signed the DST

Care Homes – Nursing- has the home manager agreed and signed the Care Plan

Domiciliary Setting – Is there a care plan / timetable detailing all care services required Has the care agency provided written costs of the service

Independent Hospitals – Has the hospital manager agreed and signed the Care Plan

Subject to Deprivation of Liberty Safeguards (Autho risation or Application)

Subject to 117 MHA 1993 Aftercare Plan

Equipment - Please detail the specialist equipment required by the patient

In the proposed care plan what placement options have you considered: please give details and reasons: Consider value for money and whether BCUHB currentl y fund the services but services are not available (report instances on AIR)

Funding

Cost per week

Funding Cost per week

Total CHC funding

Total Cost of Care Package

NHS Registered Nursing Care Betsi Cadwaladr University Health Board Contribution

Joint funding requested

Local Authority Contribution

Signature of Care Co-ordinator

Designation Date


FAST TRACK PROCESS – User notes The fast track assessment should be completed by an appropriate clinician who should give the reasons why the individual meets the conditions requiring a fast track decision to be made. The clinician should have an appropriate level of knowledge and experience of the type of health needs to decide on whether the individual has a rapidly deteriorating condition that may be entering a terminal phase. Applications for a fast track decision should contain the fast track tool, nursing assessment, letter from medical practitioner, details and costs of the care package. Referrals will be accepted via telephone, fax, letter or e-mail to the relevant CHC Locality Team Office (contact details at the end of this document). Referrals can be made verbally but the fast track tool, letter from medical practitioner, details and costs of the care package must be received by the relevant CHC Team within 2 working days of the request being made. An NHS professional must co-ordinate the fast track assessment; however others involved in supporting those with end of life needs, including wider voluntary and independent sector organisations and the patient and family may identify the fact that the individual has needs for which the fast track process should be considered. In these cases, they should contact the patient’s care co-ordinator (e.g. District Nurse, Social Worker, and Community Psychiatric Nurse). The completed fast track assessment should be supported by a prognosis. However, strict time limits that base eligibility on some specified expected length of life remaining should not be imposed. It is the responsibility of the assessor to make a decision based on the relevant facts of the case. Where a recommendation is made for an urgent package of care by an appropriate clinician through the fast track process, this should be accepted and actioned immediately by the HB. Disputes about the fast track process should be resolved outside of the care delivery. No individual who has been identified through the fast track process should have their care package removed without their eligibility being reviewed in accordance with the review process detailed in the SOP. However the CHC team will contact the patient’s care coordinator within 2 weeks of the fast track decision being made to determine whether a review is needed. This review should include completion of the DST by the MDT, including a recommendation on future eligibility. This overall process should be carefully and sensitively explained to the individual and, where appropriate, their representatives. Sensitive decision making is essential in order to avoid the undue distress that may result from an individual moving in and out of CHC eligibility within a very short period of time.

Appendix 2


(The guidance on fast track assessments is contained in section 5.49- 56 of the Framework)

Continuing NHS Healthcare Fast Track Tool To enable immediate provision of a package of Continuing NHS Healthcare

Date of completion of Fast Track Tool

Patients Name

Date of Birth

NHS NUMBER

Permanent Address and Telephone Number

Current Residence (if not permanent address)

Tel:

Tel:

Please give the contact details of the representati ve (name, address and telephone number) if known Name & Address Relationship

to client Tel No Email Date

Contact details of referring clinician (name, role, organisation, telephone number, email address, fax number) Name

Role Organisation Tel Number

Email Fax

Appendix 3


Continuing NHS Healthcare Fast Track Tool To enable immediate provision of a package of Continuing NHS Healthcare

Patients Name

NHS Number

The individual fulfils the following criterion: A primary health need arising from a rapidly deteriorating condition, which may be entering a terminal phase, with an increasing level of dependency.

Brief outline of reasons for the fast-tracking reco mmendation: Please set out below the details of how your knowledge and evidence of the patient’s needs mean that you consider that they fulfil the above criterion. This may include evidence from assessments together with triggers such as diagnosis, prognosis where this is available, together with details of both immediate and future needs and any deterioration that is present or expected. When outlining reasons why a clinician considers that a person has a rapidly deteriorating condition that may be entering a terminal phase, the clinician should consider the following definition of a primary health need: Primary health need arises where nursing or other health services required by the person are of a: Nature: This describes the particular characteristics of an individuals needs, (which can include physical, mental health or psychological needs) and the type of those needs. This also describes the overall effect of those needs on the individual, including the type (quality) of interventions required to manage them . Intensity: This relates to the extent (quantity) and severity(degree)of the needs and the support required to meet them Including the need for sustained/on going care (continuity)

Complexity: This is concerned with how the needs present and interact to increase the skill required to monitor the symptoms, and treat the conditions and/or manage the care. This may arise with a single condition or it could include the presence of multiple conditions or the interaction between two or more conditions. It may also include situations where an individual’s response to their own conditions has an impact on there overall needs, such as where a physical health need results in the individual developing a mental health need. Unpredictability: This describes the degree to which needs fluctuate and thereby creates challenges in managing then. It also relates to the level of risk to the person s health if adequate and timely care is not provided. Someone with an unpredictable healthcare need is likely to have a fluctuating, unstable, rapidly deteriorating condition.


Continued

Identified care package Nursing Home �

Home Care Package (the HB will require a copy of the proposed care package to agree before care can commence)

�

Name, designation, signature and contact details of referring clinician: Date: Name, designation and signature confirming approval by BCUHB: Date:


TERMS OF REFERENCE

Continuing NHS Healthcare Scrutiny Panels

Overview Following the introduction of the Welsh Assembly Governments, circular, 015/2010, Continuing NHS Healthcare, “The National Framework for Implementation in Wales” May 2010, Betsi Cadwaladr University Health Board (BCUHB) has a responsibility to ensure that decisions on eligibility are fair, rational, and consistent and comply with the requirements of the framework. In order to carry out this obligation, a CHC scrutiny panel will be set up, whose main function will be to scrutinise the conclusions of the multidisciplinary team’s (MDT) recommendations The role of the CHC Scrutiny Panel:

• To improve practice and ensure a consistent approach to the application of the Framework by scrutinising the recommendations made by the MDT.

• To request the MDT to carry out further work for example, if the

decision making tool (DST) is incomplete or if there is significant inconsistency between the evidence in the assessment, the DST and the recommendation made. However, the CHC scrutiny panel should not refer a case back or decide not to accept a recommendation simply because the MDT has made a recommendation that differs from one that those who are involved in the final decision-making would have made, based on the same evidence.

• To record the decisions made by the Scrutiny Panel and provide

written outcomes of the applications presented to the panel.

• The CHC scrutiny panel should not make decisions in the absence of the recommendations on eligibility from the MDT, except where it is necessary for an urgent decision to be made. Because the final decision on eligibility should be independent of budgetary constraints, finance officers should not be part of the decision making panel.

• Only in exceptional circumstances and for clearly articulate reasons

should the CHC scrutiny panel not accept the multidisciplinary team’s recommendations. A decision not to accept the recommendation will not be made by one person acting unilaterally.

Appendix 4


Membership Scrutiny panels will take place as a minimum on a weekly basis and chaired by:

• CHC Manager: for Primary care, community and specialist medicine, Clinical Programme Group (CPG).

• CHC Manager: for Mental Health and Learning Disabilities, CPG

Panel members will include: • Lead Nurses representing their relevant CPG • Nurse Reviewers: deputising for lead nurses in their absence and

presenting applications • Discharge Coordinator • Local Authority representative. • Administrative Support

A quorum will need to be a minimum of three) panel members, one of which must be the Continuing Health Care Manager or authorised signatory. Observers to the panel will only be permitted to attend at the discretion of the chair. Role of the CHC Team within the scrutiny panel proc ess is to ensure that:

• The designated care co-ordinator is aware of the scrutiny panels

function and processes, including deadlines for submitting applications and has overall responsibility for preparing the documents required for panel

• The Lead Nurse for the CHC review team or their deputy will ensure all applications submitted for presentation at panel are complete and demonstrate consistent, comprehensive decision-making processes, which will enable the panel to confirm the conclusions of the MDT recommendations and prevent unnecessary delays.

• The Lead Nurse for the CHC review team or their deputy will prepare the necessary paperwork for presenting their cases to panel and possibly that of other professionals who may be unable to attend on that date.

• The Lead Nurse for the CHC review team or their deputy will record scrutiny panel’s actions and recommendations.

• Administration staff will prepare correspondence confirming the outcome of panel’s recommendations to the relevant individuals/agencies.


Authorised Signatories:

• A threshold for authorisation of CHC applications by the Continuing Healthcare Manager is restricted to £600.00per week or under.

• Applications over £600 will be presented to a high cost, complex care panels, which will also sit once weekly.

HIGH COST ,COMPLEX CARE Applications (over £600.00) • These panels will require representation from the Chief of Staff, or

his/her designated representative before conclusions on eligibility can be made and recommendations agreed.

• Should the Chief of Staff or his/her deputy be unavailable, it will be the responsibility of the Continuing Healthcare Manager to liaise with the Chief of Staff, or his/her deputy to obtain agreement relating to the MDT’s conclusions and recommendations as soon as possible after the panel has met.

• In cases where the placement cost exceeds over £800 a third signatory will be required from identified senior staff in CPGs and the Central function team, whose names will be held by the Continuing Healthcare Managers.

Communication

• A standard operating procedure has been developed. This is a working document that will be subject to review as developments occur.

Declaration of Interest

• All panel members should declare if they are aware that they have any personal or professional knowledge of the case.

Review of Terms of Reference and Governance Arrange ments

• These arrangements will be reviewed within a 6 months period following implementation of National Framework for Implementation in Wales. (January 2011)

• The panel process will be subject to audit and review Information Resources to Support Scrutiny Panels

• List of care homes residential /nursing • List of Independent Hospitals • List of Agencies/Independent Providers • Equipment and source


Disputes Process Preventing disputes informally There should be recognition that NHS Continuing Healthcare is a high risk, complex area affecting all organisations who are working with differing issues and agendas. Therefore, resources should be aimed at preventing formal disputes before they reach this stage. In order to prevent formal disputes:

• Strategic managers from health and partner agencies should take steps

to strengthen joint working and agreements in order to prevent conflict.

• Strategic managers should send out clear messages to all staff of the importance of accepting joint responsibility for problem solving and settling disagreements before they become disputes.

• The individuals themselves, families and carers should have their opinions taken into account and an explanation given so they have a clear understanding of the dispute resolution process and the part they will play.

• The above should be achieved through purposeful, constructive discussions and negotiations with partner agencies, families and carers.

• Staff should stay focused on the key objective, which is to ensure CHC is correctly determined in a timely manner. The sole criterion for determining eligibility for CHC is now whether a person’s primary need is a health need

• Accurate needs assessments are crucial when determining eligibility for CHC; these should include all relevant specialist and non-specialist assessments carried out by a multidisciplinary team who know the person best.

• Clear reasoned decisions for eligibility must be recorded supported by the Decision Support Tool.

• Determining eligibility for CHC must be undertaken by a MDT(multidisciplinary team) who will make it’s recommendation to a CHC panel

• Members of the MDT panel must have up-to-date knowledge of the individual needs

• Chairs of the MDT panel must have completed the CHC training and have experience in chairing meetings

Appendix 5


Dispute Resolution Inter-Agency Disputes

• Wherever possible, different interpretations between health and social care professionals about the application of the continuing NHS healthcare eligibility criteria will be resolved at the multi disciplinary team (MDT) level. This may include seeking objective clinical and social care advice. The same principles and timescales as outlined below can be applied to disputes regarding joint funding of packages and NHS Funded Nursing Care.

• In no circumstances will a dispute between statutory organisations be

allowed to delay

� an individual’s discharge from hospital or

� the commencement of a package of care.

• If an organisation remains dissatisfied following the outcome of the MDT case conference then the following procedure will apply:

• A nominated officer from the MDT (Chair, care manager, care co-

ordinator) will inform the CHC Team in the relevant locality and LA senior officers in the relevant locality in writing of the outcome of the case conference and initiate the disputes process as described below.

• The nominated officer must ensure that the outcomes of all discussions

are documented and shared with all relevant organisations involved in the dispute.

• The patient and/or family/carer may be informed that a dispute is

proceeding. However, they will not be directly involved in the resolution of the dispute and the dispute will not affect the quality of the care received by the patient.

• The care package will be funded on a 50:50 basis between health and

social services until the dispute is resolved with agreement that either party will retrospectively pay the other depending upon the outcome of the dispute. A Lead Commissioner must be identified. Retrospective payments will apply from the date of discharge or from the date of MDT if the individual concerned is in a community setting.

• It is important that patients/service users should not be involved or

concerned by any part of the dispute process other than to be aware of its purpose and time scales.

• The organisations involved will in the spirit of partnership and

cooperation ensure that the patient /service user is being cared for in


the correct environment and that their assessed and financial needs are being met at all times during the dispute.

• The aim of the resolution process is to resolve disputes in the minimum

time possible. 7.7.1 Level one

• The case will be fully considered by the relevant Lead Nurse from the CHC Locality Team and the appropriate Social Services Service Team Manager ( and lead officers from Education, the Probation service or any other relevant agency if appropriate) together with members of the multi-disciplinary teams. This is likely to take the form of a case conference and every effort should be made to resolve matters at this level. Responsibility for arranging the case conference will lie with the nominated officer from the MDT. The nominated officer will convene a meeting within 10 working days (best practice standard) or no later than 20 working days.

• The case conference will consider the clinical case based on the multi-

agency and multi-disciplinary assessments of the individual concerned. The case conference will be recorded and minutes and will be sent with a cover letter to all relevant persons.

• Officers who attend the case conference should be able to make decisions on behalf of their organisation.

• The officer responsible for convening the case conference will ensure that minutes are kept, decisions recorded on the agreed pro-forma and letters sent out as appropriate.

7.7.2 Level two

If the case cannot be resolved at level one it will be referred to the Continuing Care Manager at BCUHB and Service Manager / equivalent senior manager in the Local Authority (and any other senior officers from Education, the Probation service or any other relevant agency if appropriate).

• The best practice standard is for the meeting to take place within 10 working days. In any event, the meeting will take place within 20 working days.

• Responsibility for arranging this meeting will alternate between BCUHB and SSD managers locally who will ensure that the necessary documents are submitted with any additional relevant information.

• Each partner agency must ensure staff responsible to undertake level

two processes are authorized to resolve issues on the frontline as long as they act within their organisations policies and procedures


• Previous members involved in level one must not take part in level two

to ensure objectivity.

• The outcome of the Level 2 meeting will be recorded and minutes will be sent with a covering letter to all relevant persons by the nominated officer, again using the standard pro-forma.

• It is expected that the Continuing Care Manager and Service Manager / or equivalent senior manager of the Local Authority will resolve the dispute at this level.

7.7.3 Level three

• In exceptional circumstances, if the case is not resolved at level two, the details of the reasons for the failure to agree will be submitted in writing to the Assistant Director of Nursing (Primary care) or equivalent senior manager and nominated senior manager of the Local Authority and a meeting will be convened with those present at the level two meeting to reach a final and binding decision about eligibility and agency responsibility. The organisation with responsibility for convening the level two meeting has responsibility for arranging the level three meeting.

• This will take place within 10 working days, or no later than 20 working days following the level two meeting.

• In level three, it is probable that discussions will take place face to face,

however it may be agreed that they will be through other forms of communication to expedite the process.

• During level three the information presented at level two will be reconsidered but any additional information if available at this stage will also be taken into account which may help discussions and the decision making process.

• The outcome of the Level 3 meeting will be recorded and minutes kept. These minutes will be sent with a covering letter to all relevant persons by the nominated officer, again using the standard pro-forma.

• In cases where BCUHB is required to retrospectively reimburse the local authority, it will also reimburse the individual (through the local authority) for any financial contribution incurred during the disputed period either though

� The application of a means test or � Through self funding arrangements.


Continuing NHS Healthcare Team Offices The CHC teams are based in the following locations Community, Primary and Specialist Medicine Clinical Programme Group Môn and Gwynedd Localities– Eryldon, Campbell Road, Caernarfon, Gwynedd LL55 1HU Tel: 01286 674215 Fax: 01286 674 366 Conwy Locality – Colwyn Bay Hospital, Hesketh Rd, Old Colwyn, Colwyn Bay. LL29 8AY Tel: 01492 515 218 Fax: 01492 807723 Denbigh Locality – Matthew House, Llys Edmund Prys, St Asaph Business Park, St Asaph. LL17 0JA. Tel: 01745 582721. Fax: 01745 584715 Wrexham and Flintshire Locality – Preswylfa, Hendy Road, Mold. CH7 1PZ, Tel: 01352 700227 Fax: 01352 753081 Mental Health and Learning Disabilities Clinical Programme Group Matthew House, Llys Edmund Prys, St Asaph Business Park, St Asaph LL17 0JA. Tel: 01745 582721 Fax: 01745 584715

Appendix 6

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