The National Framework for the Implementation of Continuing NHS Healthcare in Wales (2014) Priority Training Module June to October 2014

What is CHC? (A reminder….)

“A complete package of ongoing care arranged and funded solely by the NHS, where it has been assessed that the individual’s primary need is a health need. Continuing NHS Healthcare can be provided in any setting.”

Why we need to take a different approach…….the user & carer perspective

‘They just ticked the boxes and didn’t seem to care about my beautiful and amazing mother’ ‘I felt bullied and misled by a sick system within the National Health Service that is being deplorably used in order to save money.’ ‘I barely understood a word, there was so much jargon’ ‘ It was like watching dogs fight over scraps of meat. It was all about the money, not my Dad’ ‘Of course I took my lawyer; it’s a legal process isn’t it??’

Key Message

For those people who are

eligible

to receive it, Continuing NHS Healthcare is an

entitlement

Background

Wales Audit Office Report (June 2013)

http://www.wao.gov.uk/ publication/implement ation-national framework continuing-nhs healthcare

Retrospective Reviews: Lessons Learnt

• Quality costs less! Need to get it right first time • Time taken to communicate is a good investment • We must give a clear and evidenced rationale for eligibility decisions.

2014 Framework

http://wales.gov.uk/topics/health/nhswales/healt hservice/chc-framework/?lang=en http://wales.gov.uk/topics/health/nhswales/healt hservice/chc-framework/?skip=1&lang=cy • Published 30 th June 2014 • To be implemented from 1 st October 2014 So what’s new?

1.Underpinning Principles

• All guidance, however well crafted, is subject to interpretation.

• These underpinning principles are designed to support practitioners and managers to keep to the spirit of the Framework when applying the guidance to practical situations.

Principle 1: People first.

Principle 2: Integrity of decision-making

Principle 3: No decisions about me without me.

Principle 4: No delays in meeting an individual’s needs due to funding discussions

Principle 5:

Understand diagnosis; focus on need.

Principle 6:

Co-ordinated care & continuity.

Principle 7: Communicate.

2. Governance, Accountability & Performance

• Named Executive Director responsible for strategic oversight and performance • Equivalent status link in Local Authority • Active engagement with third & independent sectors • Required to use agreed national performance framework

3. Roles & Responsibilities

The individual who is being assessed: • Give honest information • Express views • Ask if you don’t understand Family/representatives • Provide information • Attend MDT (if individual wishes) in timely manner • Co-ordinate family communication through one person.

Roles & Responsibilities

(continued) • • • • • • • The Care Co-ordinator Co-ordinate assessment & ensure evidence available (when should info be available to members of MDT? Ideally beforehand but with the caveat it should reflect current needs at MDT) ‘Back up’ CC required Person centred not service centred Make sure the individual and/or representative are informed and involved Keep the process moving Principles of managed handover Make sure the decision and rationale is recorded and QA’d

Roles & Responsibilities

(continued) • • • • • • • • The multidisciplinary team Work with individual and/or representative Mature, mutually respectful MDT Honest, thorough, detailed and objective assessment/discussion Provide expert advice on eligibility to LHB- expert in the individual and expert in applying the process Provide clear rationale about decision Clearly articulate how they’ve reached decision Recommend setting & skill set for service delivery Advise if can identify date where Primary Health Need became apparent.

Roles & Responsibilities

(continued) The Commissioning Team • Commission services required to deliver the care plan • Balance individual preferences and sustainability • Must be aligned with wider commissioning agenda • Consider formal partnerships/pooled budgets

4. User and Carer involvement

• Not an optional extra • Onus on professionals to make the process accessible • Use of national public information leaflets

4. Advocacy

• 2014 Framework requires LHBs to routinely offer advocacy to anyone undergoing assessment and determination of CHC eligibility • Needs to be independent of HB’s and LA’s • Supporting/helping individuals/families understand a process which can be overwhelming • Advocates need to have comprehensive knowledge of the process • Training for Advocates

5. The Assessment Process

Right Process: • Robust comprehensive assessment.

• CHC is not a separate assessment process.

• Must provide the evidence to assess against the four key characteristics of a primary health need.

• Meetings add value but shouldn’t add delay – we can work in between!

The Assessment Process

(continued) Right Place:

Transfer/discharge to assess model: ‘adopt or justify ’

• Rehabilitation & reablement • Step up/down • Own home with appropriate support

x

The Assessment Process

(continued) Right People: • Care co-ordinator role pivotal • Everyone who is involved with individual - include specialists - recognise long-term relationships NB progressive disease • The person themselves and/or family • Advocate (if required)

6. New Decision Support Tool

English DST now adopted but no need to duplicate paperwork: •Changes to some of the domains • Audit trail of assessment • DST summary sheet (matrix) • Summary record of recommendation & rationale • Equality Monitoring Form

Using the Decision Support Tool

It’s not: • An assessment or • A substitute for professional judgement or • A requirement for duplication Move away from the tick box and focus rationale on the 4 key characteristics of a primary health need

MDT ‘Expert Advice’ or Recommendation what does this mean?

The MDT: • Are the experts on the individual’s needs • Provide advice based on their professional expertise • Must be competent in determining eligibility The combination of the above means that the LHB receives expert advice on that individual’s eligibility for CHC, and should only reject it in exceptional circumstances.

9.Trigger Tool/Checklist

• Not mandated in Wales as risks premature assumptions re level of need prior to recovery/reablement • May be useful e.g. to trigger earlier review for individual in care home or to illustrate why someone is clearly outside the criteria and requires social care support only • Use DoH tool for consistency: https://www.gov.uk/government/publications/national-framework-for-nhs continuing-healthcare-and-nhs-funded-nursing-care

10. Reimbursement and Good Public Administration

• Legal responsibility commences at the point where MDT recommendation is accepted by LHB • Principles of good public administration mean individual should be reimbursed (if they have paid for care) from date MDT determined eligibility • MDT to advise LHB if they can identify date at which PHN became evident & LHB should reimburse accordingly.

11. Eligibility in progressive disease

• Use professional judgement • Take deterioration and disease progression into account when considering eligibility • Review more frequently if needed • MDT to advise if individual’s disease pattern indicates stabilisation is likely to be short-term.

12. Fast Track process extended to ‘catastrophic events’

• Permission granted to use common sense • If someone has a ‘catastrophic event’, evidently has a primary health need, and is paying for their own care, consider fast track.

• Build in earlier review date if necessary.

13. Quality Assurance

• Can challenge quality of assessment but must not subject MDT to pressure to change views due to financial constraint • Must not delay the provision of the services the individual requires • Must be proportionate; should consider streamlining for non-contentious cases (the Framework does not require a panel process) • Must identify teams or individuals who do not follow the process to expected standards and tackle root cause.

OVERVIEW OF STANDARD ASSESSMENT & CHC ELIGIBILITY DECISION-MAKING PROCESS TIMEFRAME Up to 8 weeks

(can be longer if further rehabilitation is required but not due to eligibility process) Comprehensive assessment for longer-term care needs triggered.

Deliver rehabilitation/reablement programme (unless clinically contra-indicated) Collate co-produced comprehensive assessment.

1 week max.

Complete The quality assurance process Identify the Care Co-ordinator/Lead Professional Obtain valid consent to comprehensive assessment.

Transfer individual (if required) to the most appropriate environment for assessment.

2 weeks

Arrange the MDT meeting at which CHC eligibility will be considered.

Ensure the individual and/or their representatives have the information and support they need to fully participate.

At the meeting, review the comprehensive assessment and determine whether the individual has a primary health need.

Ensure that a clear and agreed rationale is documented and shared with the individual and/or their representatives.

Arrange the care package Contact individual and/or their representatives within 48 hours to answer queries etc.

14. Review timescales

• Aligned to English Framework • Requirement for initial 6 week review removed • As a minimum the first review should be undertaken within 3 months unless triggered earlier by the individual their representative or the service provider.

• Annual as a minimum thereafter but use professional judgement • If earlier review requested due to deterioration, this should be held within 2 weeks

15. Other issues addressed/expanded on in 2014 Framework

• Service provision and joint working • The relationship between Direct Payments and CHC • The use of personal contributions (‘top ups’) in CHC • Guidance on the management of retrospective claims • Application of the Framework to specialist groups

Proposed Training Programme

A modular training programme is under development and will be accessible from Autumn 2014. Will include: • CHC Foundation Course • Chairing an MDT meeting • The Care Co-ordinator Role • Specialist modules for mental health and learning disability practitioners and children’s services (transition)

Complex Care Information & Support Site

An online resource will be available from July. Checkout the Complex Care Information and Support Site (CCISS) at www.cciss.org.uk

To be built on over time with contributions from partner agencies