REFERRAL PROCESS FOR CONTINUING HEALTH CARE ... · Web viewREFERRAL PROCESS FOR CONTINUING...

Referrals will only be accepted once completed by a health care professional who knows the person well i.e. Consultant, GP, District Nurse, Ward Nurse and or a Registered Therapist i.e. Occupational Therapist/Physiotherapist/Registered Social Worker.

Tick on completion Has the discharge destination been decided?

Can the person consent to sharing information?

If the person is unable to consent, has the decision been made in line with the Mental Capacity Act?

Have you provided your name and contact details?

Have all the care domains been completed? This must include your rationale

** This referral will not be accepted and will be returned to the referrer unless all the above are completed and relevant information accompanies

the completed referral. **

1CHC Referral Checklist Version September 2016

REFERRAL PROCESS FOR

CONTINUING HEALTHCARENEEDS ASSESSMENT

Recent changes to Consent

Recent changes implemented by the NHS South Central Strategic Health Authority requiresthe following information to be completed and returned/included:

A Signed consent formComplete pages 7 & 8 (A&B) If client/patient/resident has capacity.Complete pages 9 – 11 (C,D&E) where the person does not have capacity and the family member has a registered Lasting Power of Attorney (LPA) - for Welfare Complete pages 12 -14 (F,G&H) where the person does not have capacity, and there is no LPA. A full Mental Capacity Assessment should be completed with the Best Interests checklist, by a registered clinician who knows the person.

Please note LPA for financial affairs and property will not be accepted for healthcare.

It is the referrer’s responsibility to ensure all forms are correctly filled in and, if required, a copy of the Lasting Power of Attorney (LPA) for ‘Welfare’, registered with the Court of Protection is included.

CONTINUING CARE FACT SHEET - PROCESS & CONSENT‘Continuing Care’ is care provided over an extended period of time, to an individual aged 18 or over, to meet physical or mental health needs that have arisen as a result of disability, accident or illness. The assessment is based on the needs that the person is currently experiencing demonstrating Intensity, Complexity and Unpredictability. NHS Continuing Healthcare’ is a package of care that is arranged and funded solely by the NHS. The National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care, November 2012 (revised). The Continuing Care process involves two stages:

Stage One

NB: before considering the referral to continuing care and completing the Checklist, please ensure that the client/Next of Kin (NOK) contacts the Department of Works and Pensions (DWP) on 08457 123 456 to clarify what benefits are affected by being awarded Continuing health Care funding.

1. A referral is made by a Healthcare professional i.e. NHS Nursing staff, Social Worker, Community Psychiatric Nurse, GP, Occupational Therapist or Physiotherapist etc (a registered clinician) who is closely involved in your needs.

2. The referrer makes the initial decision of whether a referral to Continuing Care is appropriate and will involve you or the appropriate person in completing the referral which includes the Department of Health Checklist Tool 2012 to identify your eligibility for a full assessment.

Before completing the referral pack, the referrer is responsible for ensuring that consent is obtained from the client. If capacity is established the client/patient/resident must complete forms 1A and 1B.

3. Where the person does not have capacity and the family member has a registered Lasting Power of Attorney (LPA) – for Health and Welfare complete sections C, D & E (please ask the family member to bring the original authorisation documentation and check that the document clearly identifies the authorisation to act in the persons best interest and that this has the official court stamp and it is signed and dated. Please ensure that a copy is retained and submitted with the completed referral pack.

4. Where a client does not have capacity and the family members do not have the LPA Health and Welfare authorisation follow point 5 below.

5. Where the client does not demonstrate mental capacity, the referrer must undertake a full mental capacity assessment and ‘Best Interests’ Consent to Screening and Assessment for NHS Continuing Healthcare/Funded Nursing Care/Fast Track tool.

6. Once the referral is complete and sent to the Continuing Care office, it will go through an initial screening to determine whether you meet the criteria for eligibility for a full Continuing Care assessment. The referrer will be informed of the outcome within 48 hours and the family member or Nursing Home will be notified within 10 working days in writing.

7. If you are found to meet the eligibility for a full assessment, a Healthcare Manager from the Continuing Care department will contact you and/or the appropriate person and referrer, to arrange a suitable date for the assessment to take place.

Stage Two

1. A comprehensive assessment to support completion of the decision support tool (DST), involving two or more disciplines from the Multi Professional Disciplinary Team (MDT) will then take place including a Social Worker where possible. The Healthcare Manager coordinates the assessment process, which can involve requesting additional supporting evidence from other specialists e.g. physiotherapist, speech and language therapists, consultant neurologists, psychiatrists, care providers, if this is felt to contribute towards your assessment. The Healthcare Manager will also keep you and/or the appropriate person informed and involved in the assessment process.


2. The assessment is person centred and your involvement and/or the appropriate person are very important to our processes, and we welcome your comments and views as part of the assessment.

3. Once the multidisciplinary team has reached agreement, it should make a recommendation to the Clinical Commissioning Group on eligibility. A decision is expected to be reached within 28 days. The DST and recommendation will go forward for ratification, this may involve the Oxford Health NHS Foundation Trust Continuing Healthcare panel. The panel members include Healthcare, Social Care and Mental Health representatives. You will be notified of the outcome by letter within 5 working days with the full report in approximately 4 weeks. If funding is awarded a review will be undertaken three months after the initial eligibility decision, in order to reassess care needs and continued eligibility. And that identified healthcare needs are being met. Reviews will then take place annually, as a minimum. The National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care, November 2012 (revised).

4. There is a process to request a review of the outcome should you disagree with the decision. A copy of this process is attached to the outcome letter.

Mental Health (please confirm below if the client you are referring has ever or is still subject to mental health sections two and or three and or after care 117).

Name and date of birth of client:

Section applicable please circle:

TwoThreeAftercare 117

Date: Signature and role of person submitting declaration:

Address:

Date:

Please return the completed referral to:Continuing Care Services, c/o Abingdon Community Hospital, Marcham Road, Abingdon, Oxon OX14 1AG. Telephone: 01865 904519 Fax: 01865 261754 email: [email protected]


mailto:[email protected]

National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care


OXFORDSHIRE SINGLE ASSESSMENT PROCESS

Surname NHS no:Social & Health Care no.N.I. no.

First Names Other Ref. No.Main User Groups

Preferred Name Permanent Home Address:

Date of Birth Title

Gender Male / Female

Marital Status Postcode

Ethnic Origin Phone Number

Preferred first language

Work PhoneNumber

Interpreter Needed YES / NO Mobile PhoneNumber

Advocate Needed YES / NO E-mailAddress

Current or Previous Occupation

How Long at this address

Religion/Special needs/Cultural needs

Accommodation Type/ ownership

Lifeline/Pendant Alarm system

YES / NO Household members - Please state if carers or dependants

Communication Aid Needed

YES / NO

Current or temporary address (if different from above):

Phone Number :

Housing Issues and access arrangements: getting in/out of property e.g. ramps, health, key code, etc.

Agency CollectingInformation

Referred by:

Name

Source type

Address

Tel no

Person Collecting Information/titleService User aware of referral YES / NO

Signature DateTime

Method of ContactName of Service User: Reference Numbers: Date of birth:


OXFORDSHIRE SINGLE ASSESSMENT PROCESS

Emergency Contact DetailsNAME:(Person most close to Service User)

GP NAME:

Relationship:

Is this person NOK: YES / NO

GP Practice Name

Date of Birth GP Practiceaddress

Address:

Postcode

Town

Postcode

Telephone Telephone

E-mail E-mail

NAME:(Main carer if different from above and relationship)

Dentist Name

Date of Birth Dentist PracticeName / Address

Postcode

Address:

PostcodeTelephone Telephone

E-mail E-mail

OTHER SERVICES CURRENTLY (C) OR PREVIOUSLY INVOLVED (P)C / P Contact Name/No C / P Contact

Name/NoSocial and Health Care

OT (Health)

Voluntary Sector Physio

Informal Carer / Family

Hospital

Neighbours/Friends

District Nurse

Domiciliary Care (tick days)

M T W T FS S

Health Visitor

Day Centre (tick days) M T W T FS S

Warden

Day Hospital (tick days)

M T W T FS S

IICS

Community Meals Service (tick days)

M T W T FS S

CPN

Other Services


Other Information

ALL SECTIONS MUST BE COMPLETED

Admitted from: (if applicable)

Date of admission: (if applicable)

Reason for admission:(If applicable)

Funding status: Self / State / FNC or otherMedical history (with dates):

Does section 117, S3, MHA apply?

Chosen placement: ( if applicable)

Date of assessment


CLIENT DETAILS:

Patient’s Name: Date of Birth:

Home Address: GP:

NHS Number: Current Location:

Under the Terms of the 2005 Mental Capacity Act, a person must be assumed to have capacity unless it is established that they lack capacity

A. PERSON HAS CAPACITY (NB – If a person has capacity, only they can consent)Please Tick () as Appropriate

1) I have received information on both the Continuing Healthcare Process and the Appeals Pathway (leaflet and verbal explanation).

2) I am aware that I can withdraw consent an engagement in this process at any time.

3) I agree to an NHS Continuing Healthcare Checklist, Decision Support Tool, Fast Track Pathway and all subsequent reviews being undertaken.

4) I have been made aware that if I become eligible to receive NHS Continuing Healthcare, this may/will affect my eligibility to receive certain benefits paid via the Local Authority. My right to withdraw consent or engagement in this process is not affected.

5) I agree to relevant information being gathered, collated and shared where necessary with relevant professionals, both as part of the PCT NHS Continuing Healthcare process and also, as part of any potential Dispute Resolution or Appeals Process, to include the preparation of the case file for the PCT and for Independent Review Panel at the Strategic Health Authority / Parliamentary and Health Service Ombudsman (PHSO).

I would like the following person / representative involved in the assessment

Name:

Relationship:

Contact Number:

Email:

Signature of Patient: Date:

Print Name:

Signature of Witness (if individual unable to sign) Date:



CONSENT TO SCREENING AND ASSESSMENTFOR NHS CONTINUING HEALTHCARE / NHS-FUNDED NURSING CARE


B. CONSENT TO SHARE AND PROTECT YOUR PERSONAL INFORMATION

Please Tick () as Appropriate

I agree that the information provided in this assessment may be shared with Health and Social Care staff, Service Providers who contribute to my care and any agencies acting on behalf of these organisations for the purpose / process relating to NHS Continuing Healthcare.

I understand that this information will be used in the assessment of my eligibility for NHS Continuing Healthcare funding and may be used for the purpose of providing a service, or care to me.

I understand that I may withdraw my consent to share information at any time.

I understand that I have the right to restrict what information may be shared and with whom but that this may affect the provision of care to me.

I have made the following restrictions (if applicable):

I understand that my information will be held securely on paper and on computer in accordance with the Data Protection Act 1998

Signature of Patient: Date:

Print Name:



IF THE PERSON DOES NOT HAVE THE CAPACITY TO CONSENT, THEN A ‘BEST INTEREST’ DECISION OR CONSENT FROM AN INDIVIDUAL WITH A LASTING POWER OF ATTORNEY WILL

NEED TO BE MADE

PLEASE PROCEED TO COMPLETE THE BEST INTEREST/ LASTING POWER OF ATTORNEY PART OF THE FORM

Always retain a copy of this form in the patient’s notesA copy must be forwarded with the Checklist referral to the Continuing Healthcare Team at:

Continuing Care, Abingdon Community Hospital,Marcham Road, Abingdon, Oxon, OX14 1AG

Tel: 01865 904519 Fax: 01865 261754A copy must be included in the evidence files for an Independent Review Panel (IRP)


CONSENT TO SCREENING AND ASSESSMENTFOR NHS CONTINUING HEALTHCARE / NHS-FUNDED NURSING CARE (Individuals with a Lasting Power of Attorney - Welfare)


Home Address: GP:



C. PATIENT DOES NOT HAVE CAPACITYIn many cases, continuing with the assessment process where a person is deemed to lack capacity to consent will be undertaken in line with one of the key principles of the Mental Capacity Act. This is that any act done for, or any decision made on behalf of a person who lacks capacity must be done, or made in the person’s best interests. The exception to this is circumstances where a person has made an Advance Decision, consideration must be given to its applicability and validity in the circumstances

BEST INTEREST CHECKLIST YES NO HOWI have made every possible attempt to permit and encourage the person to take part in the assessment process

I have tried to identify all the things that the person would take into account if they were making the decision or acting for themselves

I have tried to find out the views of the person who lacks capacity, including part/present wishes and feelings, any beliefs and values and any other factors that the person themselves would be likely to consider if they were making the decision or acting for themselvesI confirm that I have not made assumptions about their best interests on the basis of the person’s age, appearance, condition or behaviour

I have considered whether the person is likely to regain capacityo If Yes, can the decision wait until then?o If No, is the person likely to regain capacity?o If Yes, can the decision wait until then?o If No, continue with the Best Interest AssessmentIf it is practical and appropriate to do so, consult other people for their views about the person’s best interests. This may include:o Any individual appointed under a lasting Power of Attorneyo Any deputy appointed by the Court of Protectiono Anyone previously named by the person as someone to be consulted on either

the decision in question or similar issueso Anyone engaged in caring for the persono Close relatives, friends or others who take an interest in the person’s welfareo An Independent Mental Capacity Advocate (IMCA)Where the patient has nobody to act for them other than paid carers, and a decision concerns serious medical treatment or a change in living arrangements (NHS accommodation for 28 days or more, or Local Authority/Care Home


accommodation for 8 weeks or more), then a referral must be made to an IMCA

Referral Made By: Referral Date:


D. PEOPLE CONSULTED

I confirm that I am the attorney appointed under a Lasting Power of Attorney – Welfare made by the person / deputy appointed by the Court of Protection and agree to give consent on the patient’s behalf.

YES / NO

NB: Lasting Power of Attorney (LPA) must have the power / scope to act in the circumstances and the LPA must be registered with the Office of the Public Guardian.

Copy LPA verified / received by referrer - Yes / No

I have received written / verbal information on both the Continuing Healthcare process and the Appeal Pathway. This has been explained to me and I am aware that should my view change regarding the best interests (of the patient) in connection with this process, I should raise it at any time.

YES / NO

I have been told about the potential consequences of the assessment; that if found eligible to receive NHS Continuing Healthcare, this may/will affect eligibility to receive certain benefits paid via the Local Authority. My right to withdraw consent or engagement in this process is not affected.

YES / NO

I confirm that it is in the best interests of ………………………….. to a NHS Continuing Healthcare Checklist, Decision Support Tool, Fast Track Pathway and all subsequent reviews being undertaken.

I confirm that it is in the best interests of ……………………….. to relevant information being gathered, collated and shared where necessary with relevant professionals, both as part of the PCT NHS Continuing Healthcare process and also, as part of any potential Dispute Resolution or Appeals Process, to include the preparation of the case file for the PCT and for Independent Review Panel at the Strategic Health Authority / Parliamentary and Health Service Ombudsman (PHSO).

Signature: Print Name:

Date: Relationship/ Designation:

Email: Contact Number:






E. CONSENT TO SHARE AND PROTECT PERSONAL INFORMATIONPlease Tick () as

Appropriate

I agree that it is in the individual’s best interests that the information provided in this assessment may be shared with Health and Social Care staff, Service Providers who contribute to their care and any agencies acting on behalf of these organisations.

I understand that this information will be used for the purpose of providing a service, or care to the individual.

I understand that I may withdraw consent to share information at any time.

I have understood that certain restrictions can be made in the sharing of information if it is deemed in the best interest of the individual.

Therefore, the following restrictions should apply:

I understand that this information will be held securely on paper and on computer in accordance with the Data Protection Act 1998








Continuing CareAbingdon Community Hospital

Marcham Road, Abingdon, Oxon, OX14 1AGTel: 01865 904519 Fax: 01865 261754


A copy must be included in the evidence files for an Independent Review Panel (IRP)


BEST INTEREST CONSENT TO SCREENING AND ASSESSMENTFOR NHS CONTINUING HEALTHCARE / NHS-FUNDED NURSING CARE


Home Address: GP:



F. PATIENT DOES NOT HAVE CAPACITYIn many cases, continuing with the assessment process where a person is deemed to lack capacity to consent will be undertaken in line with one of the key principles of the Mental Capacity Act. This is that any act done for, or any decision made on behalf of a person who lacks capacity must be done, or made in the person’s best interests. The exception to this is circumstances where a person has made an Advance Decision, consideration must be given to its applicability and validity in the circumstances

BEST INTEREST CHECKLIST YES NO HOWI have made every possible attempt to permit and encourage the person to take part in the assessment process

I have tried to identify all the things that the person would take into account if they were making the decision or acting for themselves

I have tried to find out the views of the person who lacks capacity, including part/present wishes and feelings, any beliefs and values and any other factors that the person themselves would be likely to consider if they were making the decision or acting for themselvesI confirm that I have not made assumptions about their best interests on the basis of the person’s age, appearance, condition or behaviour

I have considered whether the person is likely to regain capacityo If Yes, can the decision wait until then?o If No, is the person likely to regain capacity?o If Yes, can the decision wait until then?o If No, continue with the Best Interest AssessmentIf it is practical and appropriate to do so, consult other people for their views about the person’s best interests. This may include:o Any individual appointed under a lasting Power of Attorneyo Any deputy appointed by the Court of Protectiono Anyone previously named by the person as someone to be consulted on either

the decision in question or similar issueso Anyone engaged in caring for the persono Close relatives, friends or others who take an interest in the person’s welfareo An Independent Mental Capacity Advocate (IMCA)Where the patient has nobody to act for them other than paid carers, and a decision concerns serious medical treatment or a change in living arrangements (NHS accommodation for 28 days or more, or Local Authority/Care Home accommodation for 8 weeks or more), then a referral must be made to an IMCA

Referral Made By: Referral Date:



G. PEOPLE CONSULTED

Name Designation Name Designation

Taking all of above information into account, I confirm that proceeding with the assessment process is in the best interest of Mr / Mrs………………………………

I have received written / verbal information on both the Continuing Healthcare process and the Appeal Pathway. This has been explained to me and I am aware that should my view change regarding the best interests (of the patient) in connection with this process, I should raise it at any time.

YES / NO

I have been told about the potential consequences of the assessment; that if found eligible to receive NHS Continuing Healthcare, this may/will affect eligibility to receive certain benefits paid via the Local Authority. My right to withdraw consent or engagement in this process is not affected.

YES / NO

I confirm that it is in the best interests of ………………………….. to a NHS Continuing Healthcare Checklist, Decision Support Tool, Fast Track Pathway and all subsequent reviews being undertaken.

I confirm that it is in the best interests of ……………………….. to relevant information being gathered, collated and shared where necessary with relevant professionals, both as part of the PCT NHS Continuing Healthcare process and also, as part of any potential Dispute Resolution or Appeals Process, to include the preparation of the case file for the PCT and for Independent Review Panel at the Strategic Health Authority / Parliamentary and Health Service Ombudsman (PHSO).









H. CONSENT TO SHARE AND PROTECT PERSONAL INFORMATIONPlease Tick () as

Appropriate

I agree that it is in the individual’s best interests that the information provided in this assessment may be shared with Health and Social Care staff, Service Providers who contribute to their care and any agencies acting on behalf of these organisations.

I understand that this information will be used for the purpose of providing a service, or care to the individual.

I understand that I may withdraw consent to share information at any time.

I have understood that certain restrictions can be made in the sharing of information if it is deemed in the best interest of the individual.

Therefore, the following restrictions should apply:

I understand that this information will be held securely on paper and on computer in accordance with the Data Protection Act 1998








Continuing CareAbingdon Community Hospital

Marcham RoadAbingdon

Oxon OX14 1AGTel: 01865 904519Fax: 01865 261754

A copy must be included in the evidence files for an Independent Review Panel (IRP)


NHS Continuing Healthcare ChecklistNovember 2012 (Revised)Notes1. Clinical commissioning groups (CCGs) and the NHS Commissioning Board (the Board) will

assume responsibilities for NHS Continuing Healthcare (NHS CHC) from 1 April 2013.

2. The Board will assume commissioning responsibilities for some specified groups of people (for example, prisoners and military personnel). It therefore follows that the Board will have statutory responsibility for commissioning NHS CHC, where necessary, for those groups for whom it has commissioning responsibility. This will include case co-ordination, arranging completion of the decision support tool, decision-making, arranging appropriate care packages, providing or ensuring the provision of case management support and monitoring and reviewing the needs of individuals. It will also include reviewing decisions with regards to eligibility where an individual wishes to challenge that decision.

3. Where an application is made for a review of a decision made by the Board, it must ensure that in organising a review of that decision, it makes appropriate arrangements to do so, so as to avoid any conflict of interest.

4. Throughout the Checklist where a CCG is referred to, the responsibilities will also apply to the Board (in these limited circumstances).

5. This Checklist is a tool to help practitioners identify people who need a full assessment for NHS continuing healthcare. Please note that referral for assessment for NHS continuing healthcare is not an indication of the outcome of the eligibility decision. This fact should also be communicated to the individual and, where appropriate, their representative.

6. The Checklist is based on the Decision Support Tool for NHS Continuing Healthcare. The notes to the Decision Support Tool and the National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care guidance will aid understanding of this tool. Practitioners who use this tool should have received suitable training.

7. The aim is to allow a variety of people, in a variety of settings, to refer individuals for a full assessment for NHS continuing healthcare. For example, the tool could form part of the discharge pathway from hospital; a GP or nurse could use it in an individual’s home; and social services workers could use it when carrying out a community care assessment. This list is not exhaustive, and in some cases it may be appropriate for more than one person to be involved. It is for each organisation to decide for itself which are the most appropriate staff to participate in the completion of a Checklist. However, it must be borne in mind that the intention is for the Checklist to be completed as part of the wider process of assessing or reviewing an individual’s needs. Therefore, it is expected that all staff in roles where they are likely to be involved in assessing or reviewing needs should have completion of Checklists identified as part of their role and receive appropriate training.

8. Individuals may request an assessment for NHS continuing healthcare. In these circumstances, the organisation receiving the request should make the appropriate arrangements for a Checklist to be completed.

9. All staff who apply the Checklist will need to be familiar with the principles of the National 17

CHC Referral Checklist Version September 2016

Framework for Continuing Healthcare and NHS-funded Nursing Care and with the Decision Support Tool for NHS Continuing Healthcare.

How to use this tool

10. Before applying the Checklist, it is necessary to ensure that the individual and (where appropriate) their representative understand that completing the Checklist is not an indication of the likelihood that the individual will necessarily be determined as being eligible for NHS continuing healthcare.

11. The individual should be informed that the Checklist is to be completed and should have the process for completion explained to them. The individual and (where appropriate) their representative should be supported to play a full role in the process and should be given an opportunity to contribute their views about their needs. Decisions and rationales should be transparent from the outset.

12. As with any examination or treatment, the individual’s informed consent should be obtained before the process of completing the Checklist commences. Further advice on consent issues can be found at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_103643

13. It should be made explicit to the individual whether their consent is being sought for a specific aspect of the eligibility process (e.g. completion of the Checklist) or for the full process. It should also be noted that individuals may withdraw their consent at any time in the process.

14. If there is a concern that the individual may not have capacity to give their consent, this should be determined in accordance with the Mental Capacity Act 2005 and the associated code of practice. Anyone who completes a Checklist should be particularly aware of the five principles of the Act:

A presumption of capacity: A person must be assumed to have capacity unless it is established that they lack capacity.

Individuals being supported to make their own decisions: A person is not to be treated as unable to make a decision unless all practicable steps to help him or her to do so have been taken without success.

Unwise decisions: A person is not to be treated as unable to make a decision merely because he makes an unwise decision.

Best interests: An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his or her best interests.

Least restrictive option: Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action.

15. It must also be borne in mind that consideration of capacity is specific to both the decision to be made and the time when it is made – i.e. the fact that a person may be considered to lack capacity to make a particular decision should not be used as a reason to consider that they cannot make any decisions. Equally, the fact that a person was considered to lack capacity to make a specific decision on a given date should not be a reason for assuming that they lack capacity to make a similar decision on another date.

16. If the person lacks the mental capacity to either give or refuse consent to the use of the Checklist, a ‘best interests’ decision, taking the individual’s previously expressed views into account, should be taken (and recorded) as to whether or not to proceed. Those making the decision should bear in mind the expectation that everyone who might meet the Checklist threshold should have this opportunity. A third party cannot give or refuse consent for an assessment of eligibility for NHS continuing healthcare on behalf of a person who lacks capacity, unless they have a valid and applicable Lasting Power of Attorney (Welfare) or they have been appointed a Welfare Deputy by


the Court of Protection. Before making a best interest decision as to whether or not to proceed with the completion of the Checklist the assessor should be mindful of their duty to consult with appropriate third parties. This is particularly important if the decision is not to complete a Checklist.

17. Further information on consent and mental capacity can be found in paragraphs 48 - 51 of the National Framework for NHS continuing healthcare and NHS-funded Nursing Care.

Completion of the Checklist

18. In an acute hospital setting, the Checklist should not be completed until the individual’s needs on discharge are clear.

19. Please compare the descriptions of need to the needs of the individual and select level A, B or C, as appropriate, for each domain. Consider all the descriptions and select the one that most closely matches the individual. If the needs of the individual are the same or greater than anything in the A column, then ‘A’ should be selected. For each domain, please also give a brief reference, stating where the evidence that supports the decision can be accessed, if necessary.

20. Where it can reasonably be anticipated that the individual’s needs are likely to increase in the next three months (e.g. because of an expected deterioration in their condition), this should be reflected in the columns selected. Where the extent of a need may appear to be less because good care and treatment is reducing the effect of a condition, the need should be recorded in the Checklist as if that care and treatment was not being provided.

21. A full assessment for NHS continuing healthcare is required if there are:

• two or more domains selected in column A;

• five or more domains selected in column B, or one selected in A and four in B; or

• one domain selected in column A in one of the boxes marked with an asterisk (i.e. those domains that carry a priority level in the Decision Support Tool), with any number of selections in the other two columns.

22. There may also be circumstances where a full assessment for NHS continuing healthcare is considered necessary, even though the individual does not apparently meet the indicated threshold.

23. Whatever the outcome, assessors should record written reasons for the decision and should sign and date the Checklist. Assessors should inform the individual and/or their representative of the decision, providing a clear explanation of the basis for the decision. The individual should be given a copy of the completed Checklist. The rationale contained within the completed Checklist should give enough detail for the individual and their representative to be able to understand why the decision was made.

24. Individuals and their representatives should be advised that, if they disagree with the decision not to proceed to a full assessment for NHS continuing healthcare, they may ask the Clinical Commissioning Group (CCG) to reconsider it. This should include a review of the original Checklist and any new information available, and might include the completion of a second Checklist. If they remain dissatisfied they can pursue the matter through the normal complaints process.

25. Each CCG should have clear local processes that identify where a completed Checklist should be sent, in order for the appropriate next steps to be taken. Completed Checklists should be forwarded in accordance with these local processes.

26. The equality monitoring data form should be completed by the patient who is the subject of the 19

CHC Referral Checklist Version September 2016

Checklist. Where the patient needs support to complete the form, this should be offered by the practitioner completing the Checklist. The practitioner should forward the completed data form to the appropriate location, in accordance with the relevant CCG’s processes for processing equality data.


NHS Continuing Healthcare Needs ChecklistDate of completion of Checklist _____________________________

Name D.O.B.

NHS number and GP/Practice:

Permanent address and Current location (e.g. name oftelephone number hospital ward etc)

Gender _____________________________

Please ensure that the equality monitoring form at the end of the Checklist is completed.

Was the individual involved in the completion of the Checklist? Yes/No (please delete as appropriate)

Was the individual offered the opportunity to have a representative such as a family member or other advocate present when the Checklist was completed? Yes/No (please delete as appropriate)

If yes, did the representative attend the completion of the Checklist? Yes/No (please delete as appropriate)

Please give the contact details of the representative (name, address and telephone number).

Did you explain to the individual how their personal information will be shared with the different organisations involved in their care, and did they consent to this information sharing? Yes/No (please delete as appropriate).


* PLEASE ENSURE ALL CARE DOMAINS ARE COMPLETED WITH A WRITTEN SUMMARY STATEMENT *

Name of patient Date of completion

Please circlestatement A, B or C in each domain

C B A Evidence in records to support this level

Behaviour* No evidence of ‘challenging’ behaviour.

OR

Some incidents of ‘challenging’ behaviour. A risk assessment indicates that the behaviour does not pose a risk to self, others or property or a barrier to intervention. The person is compliant with all aspects of their care.

‘Challenging’ behaviour that follows a predictable pattern. The risk assessment indicates a pattern of behaviour that can be managed by skilled carers or care workers who are able to maintain a level of behaviour that does not pose a risk to self, others or property. The person is nearly always compliant with care.

‘Challenging’ behaviour that poses a predictable risk to self, others or property. The risk assessment indicates that planned interventions are effective in minimising but not always eliminating risks. Compliance is variable but usually responsive to planned interventions.

Cognition No evidence of impairment, confusion or disorientation.

Cognitive impairment (which may include some memory issues) that requires

Cognitive impairment that could include frequent short-term





ORCognitive impairment which requires some supervision, prompting or assistance with more complex activities of daily living, such as finance and medication, but awareness of basic risks that affect their safety is evident.

OROccasional difficulty with memory and decisions/choices requiring support, prompting or assistance. However, the individual has insight into their impairment.

some supervision, prompting and/or assistance with basic care needs and daily living activities. Some awareness of needs and basic risks is evident.

The individual is usually able to make choices appropriate to needs with assistance. However, the individual has limited ability even with supervision, prompting or assistance to make decisions about some aspects of their lives, which consequently puts them at some risk of harm, neglect or health deterioration.

memory issues and maybe disorientation to time and place. The individual has awareness of only a limited range of needs and basic risks. Although they may be able to make some choices appropriate to need on a limited range of issues, they are unable to do so on most issues, even with supervision, prompting or assistance.

The individual finds it difficult, even with supervision, prompting or assistance, to make decisions about key aspects of their lives, which consequently puts them at high risk of harm, neglect or





health deterioration.

Psychological/Emotional

Psychological and emotional needs are not having an impact on their health and well-being.

ORMood disturbance or anxiety or periods of distress, which are having an impact on their health and/or well-being but respond to prompts and reassurance.

ORRequires prompts to motivate self towards activity and to engage in care planning, support and/or daily activities.

Mood disturbance or anxiety symptoms or periods of distress which do not readily respond to prompts and reassurance and have an increasing impact on the individual’s health and/or well-being.

ORDue to their psychological or emotional state the individual has withdrawn from most attempts to engage them in support, care planning and/or daily activities.

Mood disturbance or anxiety symptoms or periods of distress that have a severe impact on the individual’s health and/or well-being.

ORDue to their psychological or emotional state the individual has withdrawn from any attempts to engage them in care planning, support and daily activities.





Communication 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.

OR 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.

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.

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 person has to have most of their needs anticipated because of their inability to communicate them.

Mobility Independently mobile.

OR

Not able to consistently weight bear.

Completely unable to weight bear and is unable to assist or cooperate with





Able to weight bear but needs some assistance and/or requires mobility equipment for daily living.

ORCompletely unable to weight bear but is able to assist or cooperate with transfers and/or repositioning.

ORIn one position (bed or chair) for majority of the time but is able to cooperate and assist carers or care workers.

OR

At moderate risk of falls (as evidenced in a falls history or risk assessment)

transfers and/or repositioning.

OR Due to risk of physical harm or loss of muscle tone or pain on movement needs careful positioning and is unable to cooperate.

OR At a high risk of falls (as evidenced in a falls history and risk assessment).

OR Involuntary spasms or contractures placing the individual or others at risk.

Nutrition Able to take adequate food and drink by mouth to meet all nutritional requirements.

OR

Needs feeding to ensure adequate intake of food and takes a long time (half an hour or more), including liquidised feed.

Dysphagia requiring skilled intervention to ensure adequate nutrition/hydration and minimise the risk of choking and aspiration to





Needs supervision, prompting with meals, or may need feeding and/or a special diet.

OR

Able to take food and drink by mouth but requires additional/supplementary feeding.

ORUnable to take any food and drink by mouth, but all nutritional requirements are being adequately maintained by artificial means, for example via a non-problematic PEG.

maintain airway.

OR

Subcutaneous fluids that are managed by the individual or specifically trained carers or care workers.

OR

Nutritional status ‘at risk’ and may be associated with unintended, significant weight loss.

OR

Significant weight loss or gain due to an identified eating disorder.

OR

Problems relating to a feeding device (e.g. PEG) that require skilled assessment and review.





Continence Continent of urine and faeces.

OR

Continence care is routine on a day-to-day basis.

OR

Incontinence of urine managed through, for example, medication, regular toileting, use of penile sheaths, etc.

AND

Is able to maintain full control over bowel movements or has a stable stoma, or may have occasional faecal incontinence/constipation.

Continence care is routine but requires monitoring to minimise risks, for example those associated with urinary catheters, double incontinence, chronic urinary tract infections and/or the management of constipation.

Continence care is problematic and requires timely and skilled intervention, beyond routine care. (for example frequent bladder wash outs, manual evacuations, frequent re-catheterisation).

Skin integrity No risk of pressure damage

Risk of skin breakdown which

Pressure damage or open wound(s),





or skin condition.

OR

Risk of skin breakdown which requires preventative intervention once a day or less than daily, without which skin integrity would break down.

OR

Evidence of pressure damage and/or pressure ulcer(s) either with ‘discolouration of intact skin’ or a minor wound.

OR

A skin condition that requires monitoring or reassessment less than daily and that is responding to

requires preventative intervention several times each day, without which skin integrity would break down.

OR

Pressure damage or open wound(s), pressure ulcer(s) with ‘partial thickness skin loss involving epidermis and/or dermis’, which is responding to treatment.

OR

A skin condition that requires a minimum of daily treatment, or daily monitoring/reassessment to ensure that it is responding to treatment.

pressure ulcer(s) with ‘partial thickness skin loss involving epidermis and/or dermis’, which is not responding to treatment.

OR

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 responding to treatment.

OR

Specialist dressing regime in place which is responding to treatment.





treatment or does not currently require treatment.

Breathing* Normal breathing, no issues with shortness of breath.

ORShortness of breath, which may require the use of inhalers or a nebuliser and has no impact on daily living activities.

OREpisodes of breathlessness that readily respond to management and have no impact on daily living activities.

Shortness of breath, which may require the use of inhalers or a nebuliser and limit some daily living activities.

OREpisodes of breathlessness that do not respond to management and limit some daily activities.

ORRequires any of the following:

low level oxygen

therapy (24%);

room air ventilators via a facial or nasal mask;

other therapeutic

Is able to breathe independently through a tracheotomy that they can manage themselves, or with the support of carers or care workers.

ORBreathlessness due to a condition which is not responding to therapeutic treatment and limits all daily living activities.

OR

A condition that requires management by a non-invasive device to both stimulate and maintain breathing (non-





appliances to maintain airflow where individual can still spontaneously breathe e.g. CPAP (Continuous Positive Airways Pressure) to manage obstructive apnoea during sleep.

invasive positive airway pressure, or non-invasive ventilation)

Drug therapies and medication: symptom control*

Symptoms are managed effectively and without any problems, and medication is not resulting in any unmanageable side-effects.

ORRequires supervision/administration of and/or prompting with medication but shows compliance with medication regime.

Requires the administration of medication (by a registered nurse, carer or care worker) due to:

– non-concordance or non-compliance, or

– type of medication (for example insulin); or

– route of medication (for example PEG).

OR

Moderate pain which follows a predictable pattern; or other symptoms which are

Requires administration and monitoring of medication regime by a registered nurse, carer or care worker specifically trained for this task because there are risks associated with the potential fluctuation of the medical condition or mental state, or risks regarding the effectiveness of the medication or the potential nature or severity of side-effects. However, with such





ORMild pain that is predictable and/or is associated with certain activities of daily living; pain and other symptoms do not have an impact on the provision of care.

having a moderate effect on other domains or on the provision of care.

monitoring the condition is usually non-problematic to manage.

OR

Moderate pain or other symptoms which is/are having a significant effect on other domains or on the provision of care.

Altered states of consciousness*

No evidence of altered states of consciousness (ASC).

ORHistory of ASC but effectively managed and there is a low risk of harm.

Occasional (monthly or less frequently) episodes of ASC that require the supervision of a carer or care worker to minimise the risk of harm.

Frequent episodes of ASC that require the supervision of a carer or care worker to minimise the risk of harm.

OROccasional ASCs that require skilled intervention to reduce the risk of harm.

Total from all pages


Client Name: DOB: Location

Please highlight the outcome indicated by the checklist:

1. Referral for full assessment for NHS continuing healthcare is necessary.

or

2. No referral for full assessment for NHS continuing healthcare is necessary.

(There may be circumstances where you consider that a full assessment for NHS continuing healthcare is necessary, even though the individual does not apparently meet the indicated threshold. If so, a full explanation should be given.)

Rationale for decision

Name(s) and signature(s) of assessor(s) Date

Contact details of assessors (name, role, organisation, telephone number, email address)

About you – equality monitoringPlease provide us with some information about yourself. This will help us to understand whether everyone is receiving fair and equal access to NHS continuing healthcare. All the information you provide will be kept

completely confidential by the Clinical Commissioning Group. No identifiable information about you will be passed on to any other bodies, members of the public or press.

1 What is your sex? Tick one box only.

MaleFemaleTransgender

2 Which age group applies to you? Tick one box only.0-15

16-2425-3435-4445-5455-64

65-7475-8485+

3 Do you have a disability as defined by the Disability Discrimination Act (DDA)? Tick one box only.The Disability Discrimination Act (DDA) defines a person with a disability as someone who has a physical or mental impairment that has a substantial and long-term adverse effect on his or her ability to carry out normal day to day activities.

YesNo

4 What is your ethnic group? Tick one box only.A WhiteBritishIrishAny other White background, write below

B MixedWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed background, write below

C Asian, or Asian BritishIndianPakistaniBangladeshiAny other Asian background, write below

Client Name:DOB:

35

D Black, or Black BritishCaribbeanAfricanAny other Black background, write below

E Chinese, or other ethnic groupChineseAny other, write below

5 What is your religion or belief? Tick one box only.Christian includes Church of Wales, Catholic, Protestant and all other Christian denominations.

NoneChristianBuddhistHinduJewishMuslimSikhOther, write below

6 Which of the following best describes your sexual orientation? Tick one box only.Only answer this question if you are aged 16 years or over.Heterosexual / StraightLesbian / Gay WomanGay ManBisexualPrefer not to answer

Other, write below

Client Name:DOB:

36

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