What is NHS CHC funding?
CHC is a non-means tested package of care funded by the NHS (available to individuals aged 18 or over) .CHC is only granted if it is assessed that you have a “primary health need”, usually the result of a disability, accident or illness. Continuing Healthcare is available in England, Wales and Northern Ireland. How is NHS CHC funding used to pay for care? NHS Continuing Healthcare funding can be used in any setting (apart from acute hospitals) – including in your own home or in a residential or nursing care home.
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If you require care at home- you can choose the option of a personal health budget to choose the health care you receive.
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If you require care in a residential or nursing home
You will not be able to choose the option of a personal budget to pay for care home fees. It is important to note that if you have been assessed as eligible for NHS CHC funding and require care in a residential/nursing care home, it is still important that you have the right to a choice in where you live and this should be discussed with the Clinical commissioning group responsible for your ongoing care and support.
How to apply for NHS CHC funding
This will be dependent on where you are at the time the assessment is required : In hospital- At present, the current process for assessing your ongoing care needs and requirements for CHC following a stay in hospital is known as the ”Discharge to Assess” (D2A) process which was introduced as a response measure during the CIVID19 pandemic.
This means Social care needs assessments and NHS Continuing Healthcare (NHS CHC) assessments of eligibility of finances should be made in a community setting. They should not take place during the acute or community hospital inpatient stay except where there are safeguarding concerns which need to be investigated and assessed prior to discharge. Any care required whilst the assessment process is taking place in the community will be funded by the NHS for a short period of time.
Under normal circumstances, if you are in hospital and it is evident that a CHC assessment is appropriate, it is the hospital’s responsibility to ensure that this is carried out prior to discharge. You should speak to the nursing team in charge of your care to request this. In a nursing home- If you are already in a nursing home, you should firstly request this from the clinical commissioning group (CCG) in charge as they are responsible for coordinating all assessments.
It may be that they instruct the nursing team based at the home to carry out the assessment, therefore you can also speak with them regarding this request. In a residential Home or in your own home- If you are already in a residential home or in your own home, you should again firstly request this from the clinical commissioning
group (CCG) in charge as they are responsible for coordinating all assessments. You can find your local Clinical commissioning group here .
You could also speak with your social worker or allocated district nursing team regarding this request ( if you have one) as they may be instructed to carry out this assessment if they already have involvement in your case. You could also speak with your GP regarding this request if you require further support in accessing an assessment having already followed the above steps.
Preparing for the assessment
There are many things you can do to help prepare for the assessment . The best thing you can do is to familiarise yourself with the documentation that will be used here. You could start by breaking this down by each care domain and thinking about how the individual being assessed is impacted in each section . Preparing some notes for the assessment and jotting them down for each category is good practice. Pay close attention to the scoring criteria listed in each domain and think about how the individual being assessed may have similar care and support needs . Think of specific real life examples you could present as evidence to support this during the assessment. You may also wish to gather the following information which can be considered as supporting evidence from the last 3 months as part of the assessment process:
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Gather any social care records if applicable.
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Gather any previous CCG records from previous assessment(s) if applicable
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Ask for GP summary/records
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Care home/domiciliary care records for the last 3 months.
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Mental health records if applicable (particularly important if a person is living with dementia)
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Speech language/OT/Physio records
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Specialist nurse/Long term condition nurse/coordinator records.
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District nurse records
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Ay specialist consultants records (Parkinson for example)
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Department of Work and Pensions - copies of any applications for benefits that may have been made.
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List of prescribed medication
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Copies of any hospital records
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Family/informal care - keep a diary for 72hrs or week.
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Behaviour Chart (if applicable) to be kept for 24hrs
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Fluid charts if applicable
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Meal charts if applicable
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Falls chart if applicable
Having the right people involved in the assessment process
Anyone being assessed for CHC funding should make sure they have the right people in place to support them. It is vital that anyone involved in decision making ( like an appointed guardian or Power of Attorney) is kept up to date and given the opportunity to be present during the decision support tool process (described below). This will ensure that a true reflection of an individual's day to day care and support needs from a loved one or unpaid carers perspective can be considered as part of the assessment process. An individual may also wish to have an independent person advocate on their behalf as part of the assessment process. This could be either in a volunteer capacity through perhaps a charity support network, or there are organisations out there who can be employed to support you through the whole assessment process and the appeals process if required . This can be very expensive , and it is important to note
that they will not be able to complete the Decision support tool. Only a team of qualified Health / Social care professionals can complete this. Karehero can help you to understand any potential entitlement to CHC funding based on your current care and support needs. We can also talk you through the assessment process and provide you with guidance on how to access an assessment and how to best prepare for this assessment. We can be here to answer any questions that may come up for you throughout the assessment process and clarify things for you . Karehero can also guide you on the appeals process including how to appeal and what to expect. We cannot fill out any forms or liaise directly on your behalf.
What is the assessment process?
This can be broken down into three steps:
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Consent - The first step is to ensure that the appropriate consent is in place for any assessments to take place. The person being assessed or their legal representative needs to give consent to be screened for CHC funding
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National Screening CHC checklist - The checklist aims to help trained health/social care professionals identify people who should have a full assessment to determine their eligibility. It can be completed by a variety of health and social care practitioners who have been trained in its use. This could be registered nurses employed by the NHS, GPs, other clinicians or local authority staff such as social workers, care managers or social care assistants.
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It can be completed in a community or a hospital setting
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The result will either be positive and the person will be referred for a full assessment, or will be negative and it will be recommended that the person does not require a full assessment. They may still be eligible for Funded Nursing Care payments if nursing care is required is a registered nursing home. This will be assessed at this time.
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The checklist covers 11 out of 12 ‘care domains’, and for each domain the individual’s need is marked as either A (High need), B (Moderate need) or C (low/no need).
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Anyone with two or more A scores, or a total of five scores across A and B will receive a positive result.
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Full assessment of eligibility using the decision support tool (DST) - This will only be used when someone gets a positive checklist result. Unlike the checklist process which is usually carried out by an individual, this part of the process is carried out by more than one trained health or social care professional, usually one already involved in an individual's care and support package and is referred to as the “multi disciplinary team” or MDT. The individual and/or their representatives should be invited and welcomed to this meeting and their views considered as part of the assessment. The DST is essentially a framework which considers an individual’s level of ongoing care and support needs focusing on the following categories:
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Breathing
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Nutrition - Food and Drink
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Continence
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Skin (including tissue viability)
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Mobility
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Communication
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Psychological and Emotional Needs
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Cognition
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Behaviour
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Drug Therapies and Medication
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Altered States of Consciousness
The MDT will score the individual being assessed across each category or “care domain”. This will be a score of either Priority (P), Sever (S), High (H), Low (L) or No needs (N). This will assist the MDT in their decision making process. An example of the full DST can be found here to help better understand the severity of each care domain.
How is the final decision made?
When considering whether or not you should be awarded CHC, the multidisciplinary team who carry out the assessment have sole discretion on whether or not you should be awarded funding. There are no strict “point scoring’ criteria, however there are guidelines which they must follow when considering the outcome. The MDT will consider four main things from the information they have gathered during the assessment process :
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The nature of your needs - What aspects of your health and wellbeing you need support with
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How complex your needs are - what impact this has on the complexity of the care you require
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How intense your needs are - any need for sustained or ongoing care
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How unpredictable your needs are - someone with unpredictable need is likely to have a deteriorating or rapidly fluctuating need. This also considers the level of risk an individual faces if their needs cannot be met right away in accordance with the agreed care and support in place.
If the individual being assessed scored “priority” in a y domain, generally CHC funding will be awarded . However, if the individual being assessed has been considered as “severe” in two or more of the care domains, this may also be awarded CHC funding. This does not mean that an individual who scores one priority and several highs will not be awarded CHC funding, it simply means that the MDR team will need to consider all other factors relating to the 4 points detailed about to build a clear picture of their current care and support needs and whether or not this warrants a “primary health need”. Once the MDT has reached a decision, they will send this to the local Clinical Commissioning Group (CCG) relevant to the individual being assessed for approval who has the final say on whether or not CHC funding is awarded for that individual.
How long should I expect to have to wait for an assessment outcome?
Once the completed assessment has been received by the Clinical commissioning group (CCG), a decision on eligibility for CHC funding must be made within 28 days ( unless there is a reason outside the CCG control as to why the time must exceed this).
You are entitled to receive a decision in writing from the Clinical Commissioning Group (CCG), along with a copy of the fully completed Decision Support Tool (DST). Anyone who receives a positive outcome and has been self-funding their care should make sure they don't pay any further care fees from the onset. It is also a good idea to make sure that the Local Authority is informed of the recent award of CHC funding. Fast track assessments.
It is possible to receive a much quicker assessment outcome for CHC funding through a process known as the “fast track pathway tool” allowing an individual to access NHS CHC funding urgently.
This will usually be completed by a GP and is only used in circumstances where an individual is approaching the end stages of life. How to appeal if you are not happy with the decision you have received If an individual receives a negative outcome from the assessment ( this means they have been refused funding for NHS CHC funding) they will receive a letter stating the reasons why this decision has been made and a
copy of the full completed Decision Support Tool (DST).It is important to ensure you receive this information so you can fully understand any decision made, why this was made , and how to appeal this if you don’t agree with the decision. If you have not received this, you can get in touch with any of the local CCG departments who issued the decision to request this.
The letter will detail that they have 28 days to appeal this decision and can do so by writing to the CCG at the address detailed on the letter to state that they do not agree with the decision and wish to appeal against this. It is a good idea to post this recorded delivery to ensure it is received and also email this as a back up.
The next stage will be a review which will be set up by the CCG coordinators to review and explain the reasoning behind the negative decision. Following this will be the actual appeal referred to as a Local Resolution Panel (LRP) meeting. This will be an opportunity for the individual , their representative and even a professional representative if they wish to employ someone of this nature to represent them to plead their case as to why they feel the decision was unfair/ not accurate. It is important to be prepared to present factual inaccuracies from the DST based on evidence from records etc at this meeting . The LRP will make a decision based on the information presented at this meeting.
If following this meeting the decision is rejected, there is a further appeals process where an individual can appeal the LRP decision. This involves making a case to NHS England and presenting this to an Independent Review panel for consideration. If this fails, the case can be taken to Parliamentary and Health Service Ombudsman (PHSO), but only if there is evidence that the process has been abused, not simply because an individual does not agree with the decision that has been made.
What options are available if I don't want to appeal?
Funded Nursing care NHS-funded Nursing Care is a standard rate contribution towards the cost of providing registered nursing care in a nursing home for eligible individuals.
England: £235.88 per week
Scotland: £111.90 per week for nursing care and/or £248.70 for personal care
Northern Ireland: £100 per week
Wales: £201.74 per week
Funded nursing care payment is paid from the NHS directly to the care home.
Eligibility
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The individual does not qualify for NHS Continuing Healthcare but has been assessed as requiring the services of a registered nurse .
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The individual is within a care home that is registered to provide nursing care.
Assessment
There is no need for a separate assessment for NHS-funded Nursing Care if a full multidisciplinary assessment of eligibility for NHS Continuing Healthcare has already taken place. If necessary, the CCG can arrange for a separate nursing needs assessment to determine eligibility for NHS-funded Nursing Care.
Ask for referral to the local authority This will ensure that an individual is assessed to check if they are eligible for any care and support from the Local authority. They will also carry out a means test assessment to check for any eligibility for funding from the Local Authority towards their care and support.
How often will My NHS CHC funding be reviewed?
If you have a positive assessment outcome and NHS CHC is put in place, this will be reviewed within the first 3 months of award, and then at least annually ( or sooner if required).
The initial review is in place to ensure that the appropriate care and support is now in place and is working well to keep you safe and meet your health and support needs. Annual reviews will take place to make sure that continuing care is still meeting your health and support needs.
The review itself is not in place to revisit the eligibility criteria . It should be noted however that if it is felt at the review visit that there has been a significant change in health and support needs, a recommendation may be made for the full assessment process to be carried out again. This could result in NHS CHC funding being lost if this is deemed appropriate after assessment.
How will NHS CHC affect my benefit entitlement
NHS CHC funding nursing home setting:
If an individual has a Nursing Home placement funded by NHS CHC funding, the following benefits are deemed to ‘overlap’ with NHS funding for care, and will they cease to be payable after 28 days:
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Attendance Allowance
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Disability Living Allowance Care Component
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Disability Living Allowance Mobility Component
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PIP Both components
NHS CHC funding Residential home setting:
If an individual has a Residential Home placement funded by NHS CHC funding, the following benefits are deemed to ‘overlap’ with NHS funding for care, and will they cease to be payable after 28 days:
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Attendance Allowance
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Disability Living Allowance Care Component Only
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PIP Care component only
It is important that the awarding body ( in this case DWP) is notified of any new funding entitlements to NHS CHC funding as soon as an individual becomes aware, to avoid any overpayments.
NHS CHC funding in a home care setting:
If an individual has a home care placement funded by NHS CHC funding, this should not affect any social security benefits that they are already in receipt of. In fact it may be the case that they are now entitled to start re claiming benefits such as DLA or Attendance allowance that had once stopped during a stay in hospital that they are now once again entitled to. Carers allowance may also be applicable to anyone who is caring for them and meets the qualifying criteria. They may also be entitled to housing or council tax benefits and it is worth exploring this further with the Local Authority.