AVON, GLOUCESTERSHIRE AND WILTSHIRE STRATEGIC HEALTH
AUTHORITY
NHS CONTINUING CARE POLICY: GUIDANCE NOTE 1
About this Guidance
1.
This guidance supplements Avon, Gloucestershire and Wiltshire Strategic Health
Authority’s Continuing Care Policy which is set out in a document dated 4 February
2003. It does not replace this document nor does it seek to change any aspects of the
agreed policy.
2.
It should be read alongside the Continuing Care Policy document and is designed to
assist understanding by either giving examples or setting out more clearly what the
policy means in practice.
3.
Any queries about the contents of this guidance should in the first instance be addressed
to the Primary Care Trust. The document owner is Stephen Thorpe, Head of
Partnerships, Avon, Gloucestershire and Wiltshire Strategic Health Authority
(stephen.thorpe@agwsha.nhs.uk)
Definitions
4.
This relates to paragraph 1.8 (page 3) of the Continuing Care Policy.
It describes “continuing health and social care” as a package of care that involves
services funded from both the NHS and Social Care agencies (e.g. Social Service
Departments).
This arises where the individual does not meet the criteria for CHC. It is important to
understand that top up or joint funding of packages is only permissible on the basis of
a joint assessment of the health and social care needs. Once these have been
identified (including the RNCC as part of the Health needs) the contributions should
reflect the cost of the separate parts of the package.
This does not affect the ability of either the PCT or the relevant Council to make
payments under S28a or 28b of the NHS Act 1977 to share the overall cost of the
package or to enter into pooled funds under S31 of the Health Act 1999.
Principles for providing NHS continuing health care
5.
This relates to paragraph xiii (page 6) of the Continuing Care Policy.
Where a decision is made to award NHS Continuing Health Care to a person it must be
made clear that this is subject to review and a date should be specified – normally 3
months (based on clinical assessment) but no longer than 1 year. The person must
also be told in writing that if their health needs reduce they may no longer be entitled
to NHS CHC and under such circumstances they may be asked to make a means tested
contribution towards the cost of their care.
This is a very important point for people who are self funders as the
award of NHS CHC is needs led and may be awarded on an episodic basis rather than
for the remainder of the person’s life.
Final Version – 28 October 2003
Palliative care
6.
This refers to criterion 3 of the eligibility criteria (pages 12 – 14). In order to deal with
concerns over the access to fully funded CHC it should be clearly understood that the
identification of the 3 levels is at paragraphs 6.5 to 6.7 of the Continuing Care Policy.
Access to CHC would arise in the following circumstances for patients at level 3:
a) those who no longer respond to curative treatment and whose condition is
unpredictable, unstable or sufficiently complex that they require professional input
from NHS staff, OR
b) where a patient is diagnosed by a relevant medical practitioner (usually the
clinician in charge of their care) as likely to die within eight weeks. Every effort
should be made to help the patient die where they wish. This should be reviewed
after six weeks. If the patient is then diagnosed as likely to live for longer than the
original prognosis, they may no longer qualify for Continuing NHS Health Care
under this criterion and payment would cease allowing a reasonable time for
changed arrangements to be discussed with the family. The NHS would continue to
provide primary care eg. GP and pay for free nursing care and provide other
specialist services as required. However, if the patient qualifies under paragraph 6a
above Continuing NHS Health Care would continue to be paid.
Paragraph 6.11 should be read according to this guidance.
Specialist health care support to people in care homes or in the
community
7.
This refers to Section 8 (pages 17 & 18) of the Continuing Care Policy.
The RNCC process will assess the need for nursing care by a registered nurse. Where
the amount of registered nursing care is greater than that provided for under the
scheme, then NHS CHC may apply.
Specialist equipment
8.
This relates to Appendix 2 (pages 24 & 25) of the Continuing Care Policy.
Specialist medical, nursing or functional equipment which is over and above that
required to be provided in care homes, and is not available through either the local
NHS trusts or community loan service, can be provided through the NHS continuing
health care budget. This does not entitle the person to NHS CHC.
Where an individual needs specialist equipment that also requires specialist NHS
personnel to operate it that may indicate a qualification for NHS CHC.
Borderline cases
9.
Inevitably there will be a small number of cases which require a greater level of
scrutiny and consideration to determine whether NHS CHC applies. Taking account of
the Coughlan judgment, and guidance from the Department of Health, the following
rules of thumb should be used to assist in applying Avon, Gloucestershire and
Wiltshire’s Continuing Care Policy:
Final Version – 28 October 2003
a)
People in a care home whose nursing needs are being met fully through
the RNCC scheme and whose medical needs are met in primary care, will
not normally qualify for NHS CHC;
b)
A person who requires a higher level of registered nursing support (than
provided for under RNCC) and regular attendance by NHS specialist staff
should be regarded as somebody whose needs are predominantly health
related and NHS CHC would normally apply;
c)
People living at home whose health care needs are being met fully through
the district nursing service, GP and other specialist NHS services, will not
normally qualify for NHS CHC;
d)
A person in the community whose health care needs cannot be met by
community services and requires additional nursing care and specialist
support should be regarded as somebody whose needs are predominantly
health related and would normally qualify for NHS CHC;
e)
An individual whose needs are assessed as moving from being
predominantly personal care (and accommodation) to health care (e.g.
because of a deteriorating condition) and whose health care needs cannot
be provided through the normal arrangements for living either in a care
home or in the community would normally qualify for NHS CHC;
f)
An individual who is currently in receipt of NHS CHC whose condition
improves and is assessed as being able to have their health care needs
met through RNCC or community services would be unlikely to qualify for
NHS CHC and in such circumstances payment would cease.
Further Guidance
10.
Avon Gloucestershire and Wiltshire Strategic Health Authority reserve the right to issue
further guidance notes from time to time in the light of policy changes, developing case
law or operational experience. Any such guidance will be distributed widely.
Stephen Thorpe
Head of Partnerships, AGW
22 October 2003
Guidance Note 1 – Case Studies
Final Version – 28 October 2003
About these case studies
1. The case studies in this document are designed to assist practioners, patients and advisers
to understand better the application of the Continuing Health Care (CHC) eligibility criteria
in Avon Gloucestershire and Wiltshire (AGW) Strategic Health Authority (SHA).
2. The patient’s names are fictitious and any resemblance to anyone living or dead is entirely
coincidental. The cases are drawn from examples provided by the Department of Health
(DoH) for the introduction of the Registered Nurse Care Contribution (RNCC) scheme. AGW
have provided further examples based on the same patients to illustrate circumstances in
which medium and high band RNCC and CHC might apply.
3. The case studies provide more information to help understand the eligibility criteria and the
rationale behind decisions. They do not in any way change, or take precedence over, the
published AGW continuing care policy (4 February 2003). They should be read in
conjunction with the policy and this Guidance Note (No 1 dated October 2003).
4. The case studies are the intellectual property of AGW SHA. Any questions about the case
studies should in the first instance be referred to the local Primary Care Trust. The
document owner is Stephen Thorpe, Head of Partnerships, AGW SHA
(stephen.thorpe@agwsha.nhs.uk).
How to use the case studies
5. There are five case studies in this document. Each one seeks to illustrate the difference in
nursing needs between RNCC and CHC using different client groups and conditions. The
studies illustrate a patient’s initial assessment, determination of nursing need and clinical
rationale for the decision about level of NHS support needed.
6. The first two studies are based on DoH examples of a fictious patient whose medical needs
are assessed at RNCC medium band level. AGW have provided further details at RNCC high
band level and NHS CHC. These further examples show how needs have changed by the
time the first and second reviews are carried out and how they result in new assessments
of the level of NHS support which is required.
7. A further two case studies are based on DoH training material which show examples of
fictious patients whose medical needs are assessed at RNCC high band level. AGW have
provided further details to show how the needs have changed by the time a planned
review is carried out and how they result in an assessment that they would qualify for NHS
CHC.
Points to note
Final Version – 28 October 2003
8. These case studies are highly unlikely to replicate an actual set of patient conditions. Each
case is unique and will be treated as such by PCTs in AGW. All assessments will be made in
open manner (whilst respecting patient confidentiality) using the published eligibility
criteria and any guidance in force at the time.
9. NHS staff will use their professional judgment in the multi disciplinary assessment process
and at all other points in the assessment and review of a patient’s medical needs. There is
always an element of clinical judgment in cases which may result in a slightly different
prognosis possibly leading to a different outcome. The case studies will help all concerned
to understand more fully the level of complexity, stability or predictability that may indicate
that NHS CHC should apply.
10. Selective quoting of individual or groups of symptoms, nursing needs or
clinical assessment from these case studies will NOT affect the final outcome of
consideration about qualification for NHS CHC.
Stephen Thorpe
Head of Partnerships, AGW
22 October 2003
CASE STUDIES
1. Chronic disease increasing needs to palliative care
Final Version – 28 October 2003
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Initial assessment medium band RNCC
1st review high band RNCC
2nd review CHC
a. History summary Mrs X: Initial Assessment (Medium Band RNCC)
An 87-year-old woman who has been admitted to hospital following a fall. Four weeks
previously she had a CVA, which has resulted in a left side weakness. On admission she
was diagnosed with fractured neck of femur, and following surgery she developed a Grade
3 pressure sore. Her nutritional state is poor and she requires dietary supplements.
Transferred to a rehabilitation ward but developed a chest infection in the second week.
Became increasingly reluctant to eat or drink, and her mobility declined. Her sacral
pressure sore deteriorated further. The care plan, based on evaluation of assessment
information, leads to the decision that a care home providing nursing care is needed.
Determination of Nursing Needs
The determination of registered nursing needs identified the following requirements:
1.
2.
3.
4.
5.
6.
Daily wound care of sacral sore
Encouragement and monitoring of fluid and nutritional intake.
Daily review of skin integrity
Working with patient to ensure safe transfer
Weight monitoring
Working with care staff to ensure participitation in washing and dressing and promote
independence
7. Review of withdrawn mental state and encouragement to maintain social interaction
8. Review of mental state GP and assess need for anti-depressants
9. Assistance in managing the transition into a care home.
Clinical Rationale:
This patient requires at least daily intervention by a registered nurse, but her health status
is stable and predictable and is likely to remain so with the care regime outlined.
b. Mrs X: 1st review
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Health needs have become complex and unstable due to coughing and occasionally
choking when eating and drinking. Repeated chest infections
High band RNCC
Clinical rationale following assessment:
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Assessment and monitoring of altered gag/swallow reflex
Protection of airway
Monitoring and assessment of mood and behaviour
Administration of medication and close monitoring of effects on pain
Liase with GP to review pain management
Review of withdrawn mental state and encouragement to maintain social interactions
Monitoring weight
Encouragement and monitoring of fluid and nutritional state
Monitor patients ability to safely swallow
Ongoing assessment and evaluation of effectiveness of treatments
Establish program of pressure area care
Dressing of pressure sore
Promotion of effective communication
Final Version – 28 October 2003
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Working with patient to ensure safe transfer
Regular risk and manual handling assessment
Maintain and promote skin integrity
Assessment and treatment of pressure sore
Monitor and assessment of pain, intervention required and effectiveness.
Registered Nurse intervention required throughout a 24-hour period. Mrs X
physical and mental health is unstable & unpredictable
c. Mrs X: 2nd Review:
Continued Health needs increasing to reach eligibility for Continuing NHS Health
Care funding.
1. Need for ongoing specialist assessment/intervention, treatment of deteriorating
pressure sore by tissue viability nurse and specialist support and intervention on
regular basis for pain control.
2. Assessment and treatment of mental health by psychiatric team on an ongoing basis
3. Excessive saliva production producing risk to airway and need for regular suction.
4. Deteriorating swallow resulting in PEG insertion, high risk of self-removal due to
unpredictable behaviour and poor awareness of situation requiring constant supervision
by RN.
Mrs X requires regular specialist input from NHS staff and a higher level of
Registered Nursing intervention/management to meet needs, which are highly
complex, unpredictable and unstable and requiring ongoing NHS support.
2. Dementia, condition and behaviour deteriorating
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Initial assessment Medium band RNCC
1st review High band RNCC
2nd review Continuing NHS Health Care
a. History Summary
76-year-old man (Mr Y) has been diagnosed with dementia for five years, lives at home
with his wife, but his condition and behaviour have recently deteriorated. He is entering a
nursing home for ongoing care. He has become forgetful and his short-term memory is
poor but he can communicate needs eg. toileting and drinking. He is occasionally tearful
and can become fretful and worried, this can result in him becoming frustrated towards
carers but has not resulted in any physical aggression. Requires prompting to attend to
personal hygiene and dressing. He also requires assistance with feeding, drinking and
walking. Occasional disturbed nights.
Clinical Rationale of Mr Ys Initial Assessment:
This patient is judged to have multiple care needs, which will require the intervention of a
registered nurse on at least a daily basis and may need access to a nurse at any time.
However, the patient's condition is stable and predictable and likely to remain so if
treatment and care regimes continue. Specific registered nursing care needs would include:
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Administration of medication and close monitoring of effects on sleep and mood
Work with care staff to manage periods of agitation
Development of behavioural programme to address challenging behaviour
Assistance in managing the transition to a nursing home
Working with care staff to provide supervision to minimise risk of falls
Regular risk and manual handling assessment
Final Version – 28 October 2003
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Working with care staff to ensure participation in washing and dressing and oral
hygiene and promote independence
Supervise assistance at meal times
Development of continence programme
Establish program of pressure area care
b. Mr Y: 1st review
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Mr Smith Now has multiple care needs which are unstable & unpredictable
Health needs increasing to High Band RNCC due to
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Needs assistance with personal hygiene and dressing
Tendency to wander, needs constant supervision
Poor eye/hand co-ordination and problems in feeding self, sometimes choking
Disorientated in time, place and person
Unable to make self understood
Weepy and frustrated
Restless and hard to distract
Erratic and disturbed sleep
Poor spatial awareness
Doubly incontinent
Physically aggressive towards wife
Clinical rationale
The community Mental Health Team carried out a joint assessment and recommended
placement in a specialist care home. The patient was judged to have multiple and high
level needs, reflecting an unstable/unpredictable condition, and requiring a high level of
registered nursing care, with frequent registered nursing intervention and re-assessment.
Specific registered nursing care needs would include:
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Administration of regular medication and close monitoring of effects on sleep pattern
and behaviour
Assess, monitor and administer prescribed medication when required to address
episodes of challenging behaviour
Development of behavioural programme to address frequent challenging behaviour
Supervising feeding
Monitoring weight
Development of continence and bowel management programme
Assist patient to express feelings and needs through non-verbal communication
Assist in maintaining personal hygiene
Assist team in developing programme for Social stimulation
Assist patient in managing the transition to an EMI nursing home.
c. Mr Y: 2nd Review
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Health needs now complex, unpredictable and unstable
Amount of nursing care and specialist intervention warrant Continuing NHS Health
Care funding
After assessment Mr Y now presents:
1. Resistant to care, unaware of hygiene needs
2. At risk to self and others, tries to escape daily. Wanders and remains disorientated.
3. Cannot co-ordinate feeding self. Can choke on food, careful monitoring of feeding at
every meal
Final Version – 28 October 2003
4.
5.
6.
7.
8.
9.
Not orientated to time and place, becomes agitated and restless
Tearful, frustrated and restless with aggressive outbursts.
Mood swings to being angry without notice.
Is restless during the day appears constantly distracted
Disturbed and wandering at night
No spatial awareness. Can sustain skin injuries from traumatic falls, bumps to walls
and furniture, will attempt to use stairs
10. Incontinence with resistance to toileting
11. Continuous agitation, aggressive to other residents and carers
Clinical Rationale for Mr Y requiring CHC:
The nature and complexity of Mr Y’s health is now requiring routine re-assessment from
NHS specialist psychiatric staff, for medication review, managing and supervising
challenging behaviour, monitoring and evaluating risk management programmes of care. A
high intensity of health care requirements is required daily to maintain safety and ongoing
management of Mr Y’s case.
3. Degenerative Disease
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Initial assessment High band RNCC
1st review CHC
a. Case History
Mr. Z is 35 and was diagnosed with Huntington’s disease five years ago. He has been
living with his wife with support from Social Services Home Care and the District Nursing
Service. His condition has deteriorated both physically and mentally and now has multiple
and complex nursing care needs. Following a multi-disciplinary assessment it has been
decided that he now requires nursing care in a care home.
Current Physical Health
1.
2.
3.
4.
5.
6.
Reluctant to eat or drink can sometimes choke on fluids.
Unstable mobility with occasional falls
Wounds sustained due to falls and involuntary movements of limbs
Poor spatial awareness, cannot judge distances.
Incontinent of urine and faeces, unaware of the need to void bladder and open bowel.
Some resistant behaviour, cognitive ability variable and sometimes cannot
communicate needs.
7. Can become withdrawn.
8. Has insight into condition as his mother suffered with the disease.
RNCC high banding Clinical Rationale:
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Administer medication and observe that it has been swallowed
Monitor effects of medication on symptoms of Huntington’s Disease
Assistance in managing the transition to a nursing home
Development of behavioural programme to address challenging behaviour
Work with care staff to manage patient's unpredictable behavior
Working with care staff to provide supervision to minimise risk of falls
Regular risk and manual handling assessment
Assist in maintaining personal hygiene and oral care
Supervise assistance at meal times
Monitor patients ability to safely swallow
Development of a bowel management programme
Development of continence programme
Final Version – 28 October 2003
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Daily review of skin integrity
Establish program of pressure area care
Dressing to lacerations
Ensure safe environment to reduce the risk of injury
b. Mr Z’s 1st Review
His condition has deteriorated and health needs have increased to reach eligibility for
Continuing NHS Health Care funding.
Physical Health:
1. Swallowing reflex is very unstable, at risk of aspirating fluids. Peg in situ & Bolus feed
required x 6 a day with medication given via peg. Continued weight loss and
exhaustion.
2. Poor balance and unable to support body weight without two carers and mobility aid.
Involuntary movements causing extreme difficulty to mobilise.
3. Monitor and risk assess safety for Mr Z re: surrounding environment, specialist
assessment for chair and wheelchair.
4. Constant support to reassurance Mr Z of his surroundings.
5. Is incontinent of urine and faeces. Requires reassurance.
6. Poor speech, Mr Z can become very frustrated and agitated at lack of comprehension
and ability to communicate.
7. Withdrawn behavior now presenting with hallucinations requiring psychiatric support
and advice, plus a medication review.
8. Mr Zs ability to understand his disease process has remained, creating anxiety and
challenging behaviour.
Mr Z is now presenting with a high level of health needs and regular monitoring
from a dietician and Speech & Language therapy team.
Clinical rationale for CHC.
1. Dietitian to support Registered Nurse with dietary support and advice re. nutritional
intake due to increased weight loss. High calorific intake required.
2. Mobility aids and hoist assessments from physiotherapist & occupational therapist.
Registered Nurse risk assessment over 24 hours for moving and handling.
3. Wound care ongoing due to limb movements and severe involuntary action of arms,
legs and head.
4. Spatial awareness deficit.
5. Double incontinence causing anxiety and depression.
6. Speech and language therapy specialist assessment to assist with communication &
advise staff how to manage Mr Z’s frustration.
7. Withdrawn behaviour and hallucinations require specialist support to assist Mr Z in
calming after the event. Constant monitoring required to assess effectiveness of
medication.
8. Specialist nurse and medical support required to re-assure Mr Z, prevent and manage
irrational behaviour.
4.
Palliative care to Terminal care
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Initial Assessment High Band RNCC
Terminal prognosis leads to award of Continuing Health Care
a. History Summary
Final Version – 28 October 2003
Miss A is 48 year with carcinoma of the rectum with metastases in the liver. Living alone she
was supported by three homecare visits a day and recently the district nurse has been giving
daily support with a Lymphoedema specialist nurse providing advice. Prognosis is poor and
Miss A’s GP and palliative care consultant have given a life expectancy of less than one year.
Miss A’s pain control was poor and so admission to a local hospice to monitor and manage
the pain has taken place. Miss A is now assessed as requiring nursing in a care home.
Current physical health:
1.
2.
3.
4.
5.
6.
7.
8.
Reluctant to eat or drink due to nausea
Weight loss & poor nutritional state
Oedema to both legs restricting mobility
Episodes of diarrhoea
Pressure sore to sacrum
Withdrawn mental state
Low self esteem, no initiative to attend to personal hygiene
Poor pain control
After Assessment Clinical Rationale for RNCC (High Band)
Miss A has complex needs, unstable and unpredictable signs and symptoms that require
Registered Nurse intervention within a 24-hour period.
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Administration of medication and close monitoring of effects on pain and nausea
Venepuncture as requested by GP
Monitor patient for the signs and symptoms of their illness
Allow and facilitate the patient to express feelings
Work with team to encourage patient to mobilise within capabilities
Regular risk and manual handling assessment
Ensure participation in washing, dressing and oral hygiene and promote independence
Monitor nutritional status
Management of lymphodeama
Maintenance of fluid volume chart
Monitor for episodes of diarrhoea
Daily dressing to pressure sore and monitoring for signs of infection.
Monitor and liaise with GP re. low mood and withdrawn mental state. Review mental
health needs
b. Miss A 1st Review
Health needs have increased to reach the Continuing NHS Health Care criteria; her life
expectancy is now assessed by her Doctor at less than 8 weeks.
Physical Health:
1.
2.
3.
4.
5.
6.
7.
Not able to tolerate fluids or a soft diet
Diarrhoea continuous – no formed stool
Incontinent of urine.
Pressure sore deteriorating and not responding to treatment.
Semi conscious state
Pain intractable and uncontrolled requiring regular review and adjustment of medication
Doctor has signed eight week prognosis of probable death
After Assessment Clinical Rationale for CHC decision:
Final Version – 28 October 2003
Miss A has complex needs, unstable and unpredictable signs and symptoms that require
frequent RGN intervention over a 24-hour period. Miss A is in a progressive state of decline
and is thought to have a life expectancy of less that 8 weeks and requires continuing health
care support.
Final Version – 28 October 2003