Continuing Healthcare (Adults) – Clinical Team Standard Operating Procedure

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SUMMARY

This document sets out the standard operating procedure, roles and responsibilities for staff working within the NHS Haringey CCG continuing healthcare clinical team. It includes expectations for adhering to the National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care (2012). The role of the continuing healthcare team is to provide robust assessment, review and management of patients. This standard operating procedure sets out the respective roles and responsibilities of the team. The procedure ensures that the model and processes for the continuing healthcare is consistent, robust and timely in line with the NHS Haringey CCG Continuing Healthcare Policy. http://www.haringeyccg.nhs.uk/downloads/policies/Haringey%20CCG%20Continuing%20Healthcare%20Policy%20and%20Procedure%20v2.1.pdf

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RESPONSIBLE PERSON:

Hazel Ashworth

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ACCOUNTABLE DIRECTOR(S):

Jennie Williams

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All staff that have a role in continuing healthcare assessment or review.

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GROUPS/ INDIVIDUALS WHO HAVE OVERSEEN THE DEVPT OF THIS POLICY:

Continuing healthcare clinical team Commissioning team

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GROUPS WHICH WERE CONSULTED AND HAVE GIVEN APPROVAL:

Continuing Healthcare team Commissioning team

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EQUALITY IMPACT ANALYSIS COMPLETED:

Policy Screened

Add date

Template completed

Add date

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RATIFYING COMMITTEE(S) & DATE OF FINAL APPROVAL:

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VERSION:

2.1

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AVAILABLE ON:

Intranet

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RELATED DOCUMENTS:

Standard Operating Procedure Individual Packages of Care – all staff in the commissioning team for individual packages of care (Adults)

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DISSEMINATED TO:

ALL NHS HARINGEY CCG STAFF

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DATE OF IMPLEMENTATION:

March 2018

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DATE OF NEXT FORMAL REVIEW:

March 2020

DOCUMENT CONTROL

Date

Version

Action

Amendments

14th November 2017

1.0

SOP completed

24th January 2018

2.0

Document revised Flowchart replaced by process, addition of local timescales for actions, minor text changes

16th February 2018

2.1 Document revised Changes to joint funding section – highlighting clinical involvement in joint funding decisions

1 Introduction

The National Framework for NHS Continuing Healthcare and NHS funded Nursing Care (revised 2016) [hereafter referred to as ‘the National Framework’] is a statutory framework which sets out the process for assessing patients age of 18 or over according to a legally prescribed decision making process, in order to determine whether the individual has a ‘primary health need’. The National Framework is underpinned by the NHS Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012 as amended by The National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) (Amendment) Regulations 2013). Individuals assessed and agreed by the CCG as having a primary health need will be eligible for a package of care arranged and funded solely by the NHS.

This operating procedure sets out the principles for the delivery of NHS Continuing Healthcare (NHS CHC) and NHS Funded Nursing Care (FNC) for all adult patients who are registered with a London Borough of Haringey GP.

2 Scope

The responsibilities set out in this document relate to individuals who are 18 or over (or 17 year olds transitioning to adult care services) and who may require help as a result of long term conditions and complex and inter-connected disabilities, learning disabilities, autism and functional and organic mental illness, frailty, physical disabilities or illness and those requiring palliative care. The clinical team provide assessment and review for over 18s. This Standard Operating Procedure (SOP) sets out the roles, responsibilities and local implementation methodology that Haringey CCG (HCCG) clinical team will work to in order to standardise practices in the effective operation of the National Framework. The primary role of the clinical team is to provide robust assessment and review of patients requiring continuing healthcare assessment. This standard operating procedure sets out the respective roles and responsibilities of the team, the acute hospitals and London Borough of Haringey. The procedure also describes the relationship with the CHC commissioning team.

3 Statutory Responsibilities and Duties

NHS Continuing Healthcare is a package of care for adults aged 18 or over which is arranged and funded solely by the NHS. In order to receive NHS CHC funding individuals have to be assessed by Clinical Commissioning Groups (CCGs) according to a legally prescribed decision making process to determine whether the individual has a ‘primary health need’. This care is provided to meet needs that have arisen as a result of disability, accident, condition or illness. Eligibility for NHS Continuing Healthcare is determined through a legally prescribed decision-making process. The Health and Social Care Act 2012 sets out the powers for this process which is underpinned by The National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012 and by The NHS Continuing Healthcare (Responsibilities of Social Services Authorities) Directions 2013. The process has to be followed by every CCG, meaning that there should be no variation in access, and the assessment process should be consistent across the NHS. The first review is required no later than three months after the initial decision and at least one year subsequently. The reviews provide a determination of whether individuals remain eligible for NHS Continuing Healthcare as well as an assessment of the appropriateness and/or effectiveness of care and support arrangements. To provide a good standard of NHS Continuing Healthcare with no delays in assessment or decision making, which receives positive patient feedback, it is essential that CCG teams are sufficiently resourced, appropriately trained and supported. The CHC Team is required to fulfil the statutory duties outlined above and deliver the following National Key Performance Indicators: Eligibility decisions following a referral (where the CCG does not use a checklist)

or checklist for NHS CHC must be made within 28 days of the date of receipt of the referral or checklist.

No more than 15% of all full NHS CHC eligibility assessments should take place in an acute hospital setting

All fast track applications should be ratified within 48 hours. Reviews following an appeal against a ‘not eligible’ decision must be completed

within 90 days of receipt of the appeal.

In addition, the CCG and CHC team are developing a Discharge to Assess Pathway to support the transfer of patients from acute services and to facilitate their assessment out of an acute hospital setting.

3.1 Local Haringey CCG Performance Indicators

In addition to the National Key Performance Indicators, Haringey CCG sets targets for the delivery of Continuing Healthcare:

100% of checklists (in community or in the acute hospital) completed and agreed within two working days of referral.

90% of eligibility assessments using the Decision Support Tool and multi-disciplinary team process completed within ten working days of receipt of a positive checklist – in the case of hospital inpatients the process to be completed within five working days.

Response to complaints within 28 calendar days. Referral to commissioning team for changed/new packages of care within one

working day. All patients in receipt of CHC support will have a review of their eligibility and

placement at least annually.

4 The CHC Clinical Team

4.1 The Clinical Team Structure

The chart below shows the structure of the clinical team.

4.2 Clinical CHC Team Responsibilities

Carry out responsible commissioner assurance checks to make ensure that all referred for CHC are CCG’s responsibility

Develop or ensure appropriate care/support plan which details the needs of the patient and interventions to meet them as well as risk management plans (as appropriate) are made available to the CHC Commissioning Team to commission services

Ensure compliance with CHC statutory duties and co-ordination and completion of assessments, CHC and FNC reviews within statutory timescales.

Ensure that there is a fair and efficient process and a good quality assessment to reflect individual need

Use the national tools including checklists (where required) and the Decision Support Tool in the determination of the primary healthcare need

Ensure that a multi-disciplinary team assessment is carried out ensuring involvement of the individual and/or their representative in the process

Ensure that the appropriate consent or best interest decision is made to undertake a CHC assessment process and if necessary share data with professional agencies.

Notify the individual/their representative in writing of the eligibility decision and of their right to request a review of this decision.

Accept that an individual has a primary health need where a Fast Track application has been completed by an 'appropriate clinician’ and where there is evidence of a ‘rapidly deteriorating condition that may be entering a terminal phase’.

Ensure availability of information and support to allow take-up of the full range of personal health budget options.

Coordinate an appeal and retrospective process including a requirement from NHS England to provide clinical expertise to Independent Review Panels.

Deliver inter-agency CHC training.

Management accuracy of the Care Track patient database and other data collection systems such as The Performance Workbooks.

Reduce Delayed Transfers of Care through timely assessment and ratification of assessments.

Ensure compliance with the statutory duty for safeguarding including: investigating S42 safeguarding enquiries, chairing safeguarding meetings, implementing safeguarding plans, participating in Safeguarding Adult Reviews, completing Individual Management Reviews.

Ensure that any person registered with a Haringey CCG General Practitioner (GP), referred for NHS Funded Continuing Healthcare or NHS Funded Nursing Care receives an appropriate and robust assessment.

Work in partnership with patients, families, advocates, and other health and social care professionals to deliver an excellent service at the point of contact.

Provide a responsive service to the needs of individuals from all communities.

Work closely with the CHC commissioning team to inform commissioning decisions, at strategic and patient level.

Monitor complaints, appeals and outcomes and act upon any actions accordingly.

Any other duty reasonably assigned by the CHC Clinical Team Manager, the CHC Clinical Team Lead or officer of the CCG.

5 NHS Continuing Healthcare Process

Please refer to the National Framework NHS Continuing Healthcare and NHS Funded Nursing Care (revised 2016) for further guidance:

https://www.gov.uk/government/publications/national-framework-for-nhs-continuing-healthcare-and-nhs-funded-nursing-care

Patients and their relatives should be kept informed from the outset of the process so that they are aware of options, and of next steps, and to reasonably assist to manage

their expectations. The following public information leaflet should be routinely given to patients and their families at the outset of the process:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/193700/NHS_CHC_Public_Information_Leaflet_Final.pdf

5.1 Screening, Assessment & Referral process for NHS Continuing Healthcare

Prior to any application for NHS Continuing Healthcare, the patient must finish any active treatment and have reached their optimum potential for any rehabilitation.

The documents and processes below outline the respective process for individuals who are referred whilst in a hospital and community setting.

In all cases it is essential that appropriate consent is obtained and evidenced prior to assessing an individual for Continuing Healthcare.

5.2 London Health Needs Assessment

In London the health needs assessment (LHNA) is required. This tool supports clinicians in assessing the individual’s level of care needs. As part of the assessment process a LHNA should be completed for all patients undertaking the CHC assessment process.

However, there is a local agreement between Haringey CCG and North Middlesex University Hospital NHS Trust that completion of the London Health Needs Assessment will not be required routinely for assessments completed within the Trust.

5.3 CHC Checklist

When a person is identified as potentially qualifying for NHS CHC, the NHS CHC Checklist is completed. The purpose of the checklist is to ensure that resources are directed toward those who are more likely to be eligible for NHS Continuing Healthcare and that there is a rationale for all decisions regarding eligibility.

The checklist should be completed by an appropriate nurse, doctor, another health professional or social worker who has a professional engagement with the person.

The trigger for a positive checklist – one that indicates that a full assessment should be undertaken – is set deliberately low by the Department for Health, and patients and families should be made aware that a checklist that triggers a full assessment for CHC this does not necessarily indicate eligibility for CHC.

Whatever the outcome of the checklist, the decision is communicated to the individual and/or their representative, providing a clear explanation of the decision and advising them of the next steps, including the option to complain to the CCG if they disagree with the outcome. The CCG is obligated to give consideration to complaints about the outcome of a checklist through their normal complaints procedures.

A template letter for communicating the outcome is available on Care Track.

5.4 Decision Support Tool

Once the need for a full Decision Support Tool (DST) eligibility assessment has been established through the checklist, a DST is completed by a Multidisciplinary Team (MDT) which normally will include a health professional and a representative of the local authority. The DST is a statutory document that helps set out the evidence in a detailed, needs-based format which builds up a picture of the care needs, aiming to establish whether an individual has a primary health need, and that they are therefore eligible for NHS CHC. 5.5 Fast Track Applications Fast Track applications for CHC are defined within the National Framework and the NHS Haringey CCG’s CHC Policy. Fast Track should be considered where care needs are not being met and where an appropriate clinician (as defined in the National Framework) considers and can provide evidence that a person has a rapidly deteriorating condition, which may be entering a terminal phase. It is expected that the CCG will agree eligibility on all fast track applications that have been completed by an appropriate clinician and evidence a rapidly deteriorating condition that may be entering a terminal phase.

5.6 Submission to Haringey CCG

The completed DST, LHNA (where completed), NHS Continuing Healthcare Checklist or Fast Track must be submitted to the Continuing Healthcare Team of HCCG upon completion. This paperwork is received by the duty officer of the CHC clinical team.

5.7 The Duty System

The Clinical Team will operate a Duty system/rota.

The Duty Nurse is responsible for the review and ratification of all completed assessments submitted to the generic mail address HARCCG.continuingcare1@nhs.net. The team administrator will assist by ensuring that the submitted documents are complete. Once agreed the records are uploaded to Care Track, which will be updated as the case moves from Active to Monitor/Passive /Closed.

5.8 Duty Officer’s Role

Ensure that standard documentation is complete, including signatures and dates.

Ensure that Haringey CCG is the responsible commissioner for the referral.

Ensure that appropriate consent has been obtained and is evidenced.

For Fast Track applications: ensure that the application has been completed by an appropriate clinician and that there is evidence of a rapidly deteriorating condition that may be entering a terminal phase.

For DSTs and Checklists: ensure weightings and descriptors are identified and evidenced

For DSTs: ensure the recommendation of the MDT is clear and has given consideration of the four key indicators – nature, complexity, intensity and unpredictability

Inform the referrer where documentation is missing or incomplete

Ensure relevant responsible commissioner checks are undertaken are in

place at the point of accepting a CHC referral

Following the ratification outcome:

Ensure that an appropriate care and support plan is completed and identify 3 nursing home placements if indicated.

Handover to Placement officer (Commissioning CHC Team) for costing and placement.

Ensure that all records are updated on Care Track.

5.9 Timeframes

The time between the checklist being received by HCCG and the eligibility decision being made, should not, in most cases, exceed 28 days. Where an individual is otherwise fit for discharge from acute services this should be expedited. Where there are valid and unavoidable reasons for the process taking longer, timescales should be clearly communicated to the person and other appropriate persons as indicated by the consent form, the National Framework or the Mental Capacity Act 2005. The timeframe for ratification of Fast Track applications should be within 48 hours of receipt of a properly documented and appropriately completed application, and in most cases should be ratified within 24 hours. 5.10 Processes 5.10.1 Fast Track Process

This process applies for both community and acute settings.

5.10.1.1 The patient is identified as having a ‘rapidly deteriorating condition that may be entering a terminal phase’ – this is identified by a clinician involved in and responsible for the patient’s care. If it has not been done so already, the patient should be referred to the palliative care team. 5.10.1.2 The clinician must discuss the referral for fast track with the patient or their legal representative and obtain consent. Consent does not have to be written but the clinician must be able to document that it has been sought. 5.10.1.3 The clinician completes the Fast Track Tool, including the patient and their representative as appropriate. The clinician must document that consent has been obtained or a best interest decision has been made. Completion of the Fast track Tool should not be delayed once the decision to fast track a patient. The clinician should explain the process of fast track to the patient and family members. If the patient lacks capacity and does not have anyone to act on their behalf a referral must be made for an Independent Mental Capacity Advocate (IMCA). Once completed the Fast Track Tool should be submitted without delay to the Duty Nurse for the CHC team at the CCG. It is advised that the clinician calls the Duty Nurse to confirm receipt.

5.10.1.4 The Duty Nurse will assess the application to confirm:

a) Consent or best interest decision, b) Completed documentation, c) Evidence that Haringey CCG is the responsible commissioner, d) An ‘appropriate clinician’ has completed the application, and e) There is evidence of a ‘rapidly deteriorating condition that may be entering a terminal phase’.

If any of the above are not present the Duty Nurse must, without delay, contact the referring clinician and advice that the application is not accepted. The application can only be accepted once all of these are completed. All referrals for fast track must be accepted or rejected within two working days of receipt. Once accepted, Haringey CCG agrees that the patient is eligible for Continuing Healthcare. 5.10.1.5 The Duty Nurse will, with the referring clinician as necessary, agree the appropriate package of care to support the patient. Once agreed the Duty Nurse will inform the Commissioning Team of the fast track and the need for a package of care. The Commissioning Team will begin the brokerage process without delay, and inform the patient and/or their representative in writing that the patient is eligible for Continuing Healthcare following a fast track application within two working days of referral from the clinical team. 5.10.1.6 The Duty Nurse will record all interactions on Care Track and will schedule a review of eligibility for three months’ time.

5.10.2 Community Assessment for Continuing Healthcare Process

5.10.2.1 The patient is identified as having complex health needs that may be eligible for Continuing Healthcare and having no potential for rehabilitation. 5.10.2.2 The patient should have a checklist assessment completed – this can be done by the District Nursing service, the GP or other health or social care professional involved in the care and support of the patient. Appropriate consent or a best interest decision must be obtained and documented. The patient and/or their representative must be included in the process. 5.10.2.3 If the checklist does not trigger for full assessment the patient is not eligible for Continuing Healthcare. The checklist, consent and supporting evidence must be submitted to the CHC Duty Nurse at the CCG to be logged, recorded onto Care Track and for the Duty Nurse to consider Funded Nursing

Care (FNC) – whether to agree FNC is not dependent on where the patient receives their care and the CCG is obligated to make a decision on FNC in all cases. 5.10.2.4 If the checklist triggers for full assessment the patient may be eligible for Continuing Healthcare. The checklist, consent and supporting evidence must be submitted to the CHC Duty Nurse to log and record onto Care Track, and who will make a referral to the District Nursing team to complete a Decision Support Tool (DST). The CHC team will facilitate as able local authority representation and/or other professional support for the subsequent assessment. 5.10.2.5 The community multi-disciplinary team (MDT) complete the DST. All appropriate evidence is gathered and based on the evidence a clear recommendation on eligibility is recorded on the DST, taking into consideration the four key indicators, which is discussed with the patient and/or their representative – it should be made clear to the patient/representative that this is a recommendation only and that the CCG will make the decision on eligibility. Where the MDT make a ‘not eligible’ recommendation consideration must be given for eligibility for FNC. 5.10.2.6 All documentation is submitted to the CHC Duty Nurse to consider the recommendation of the MDT. Where the recommendation of the MDT can be agreed this is considered the out of panel decision of the CCG on eligibility. If the Duty Nurse is unable to agree the recommendation they must seek additional information, evidence or a revised recommendation from the MDT who will have five working days to provide such additional information/revisions. Once this information has been received or the five working days have elapsed the Duty Nurse will reconsider the recommendation – if the recommendation can now be agreed this is considered the out of panel decision of the CCG on eligibility. If the recommendation remains unsupported the case will have to be heard at a Resolution Panel. The Duty Nurse must record actions onto Care Track.

5.10.3 Secondary Care Assessment for Continuing Healthcare Process

5.10.3.1 The patient is identified as having complex health needs that may be eligible for Continuing Healthcare and having no potential for rehabilitation, whilst as an inpatient.

5.10.3.2 A decision must be made, using an appropriate tool where necessary, whether to discharge the patient into a health funded package of care for the assessment process. Whether the assessment is conducted in or out of the acute hospital a CCG CHC assessor will undertake a checklist assessment. Appropriate consent or a best interest decision must be obtained and documented. The patient and/or their representative must be included in the process. 5.10.3.3 If the checklist does not trigger for full assessment the patient is not eligible for Continuing Healthcare. The checklist, consent and supporting evidence must be submitted to the CHC Duty Nurse at the CCG to be logged, recorded onto Care Track and to record the decision for Funded Nursing Care (FNC) – where the checklist is completed by a CCG assessor they can make the decision for FNC on the basis of a negative checklist that they have completed. 5.10.3.4 If the checklist triggers for full assessment the patient may be eligible for Continuing Healthcare. If not already, the patient should be considered for discharge to a health funded package of care (Discharge to Assess pathway). The checklist, consent and supporting evidence must be submitted to the CHC Duty Nurse to record the checklist and to record onto Care Track. The CHC team will arrange a full assessment using the Decision Support Tool, ideally within ten working days of the positive checklist. 5.10.3.5 The multi-disciplinary team (MDT) led by the CCG CHC assessor complete the DST. All appropriate evidence is gathered and based on the evidence a clear recommendation on eligibility is recorded on the DST, taking into consideration the four key indicators, which is discussed with the patient and/or their representative – it should be made clear to the patient/representative that this is a recommendation only and that the CCG will make the decision on eligibility. Where the MDT make a ‘not eligible’ recommendation consideration must be given for eligibility for FNC. 5.10.3.6 All documentation is submitted to the CHC Duty Nurse to consider the recommendation of the MDT. Where the recommendation of the MDT can be agreed this is considered the out of panel decision of the CCG on eligibility. If the Duty Nurse is unable to agree the recommendation they must seek additional information, evidence or a revised recommendation from the MDT who will have five working days to provide such additional information/revisions. Once this information has been received or the five working days have elapsed

the Duty Nurse will reconsider the recommendation – if the recommendation can now be agreed this is considered the out of panel decision of the CCG on eligibility. If the recommendation remains unsupported the case will have to be heard at a Resolution Panel. The Duty Nurse must record actions onto Care Track.

5.11 Eligibility

Whether a decision on eligibility is made outside panel, or in Resolution Panel, the following procedures are followed:

5.11.1 Eligible for continuing healthcare: once the decision on eligibility is made the CHC will establish an appropriate package of care for the patient – which, in the case of a patient already in the community may be a continuation of their current care arrangements. This will be communicated without delay to the commissioning team to negotiate the appropriate contracts. The CHC team will write to the patient and/or their representative and inform them of their eligibility and that this eligibility and care package will be intermittently reviewed. All new cases of eligibility will be scheduled for a review by the clinical team in three months’ time.

5.11.2 Not eligible for continuing healthcare, eligible for funded nursing care: irrespective of the patient’s current package of care a decision must be made on FNC for a not eligible decision on continuing healthcare. The CHC team will write to the patient and/or their representative and inform them of this outcome. This decision must be communicated to the commissioning team without delay. With FNC cases the local authority may be lead commissioner and it is the local authority who will need to inform the commissioning team of commissioned packages of care that are eligible to receive the FNC contribution. In private funding cases the commissioning team must liaise with the patient and/or their representative to arrange meeting the CCG’s obligation in regards of FNC. Where FNC contribution is to be paid the CHC clinical team will arrange a review in twelve months’ time. 5.11.3 Not eligible for continuing healthcare and not eligible for funded nursing care: the clinical team will communicate this to the patient and/or their representative. No review will need to be booked.

6 Decision Making The CCG has a statutory responsibility to make eligibility decisions. The manner in which the CCG makes eligibility decisions on new applications is set out below.

6.1 Fast Track applications

It is expected that all Fast Track applications will be agreed as eligible for Continuing Healthcare provided the following information has been submitted to the CCG CHC team:

A legible NHS London Fast Track Tool for NHS Continuing Care, completed and signed by an appropriate clinician with clinical rationale clearly identifying a “rapidly deteriorating condition that may be entering a terminal phase”, care needs and proposed management.

Appropriate consent.

A completed Care Plan.

Any further relevant information, for example medical reports.

If the outcome of the Fast Track referral is appropriate and agreed by NHS Haringey CCG, the CHC team will inform the referrer and liaise with them to identify the patient needs and required care package. The outcome should be communicated to the individual in writing as soon as possible. Where the CHC team cannot agree an application the duty nurse will return the application to the referrer stating clearly why the application is not accepted and will update Care Track with the appropriate record.

6.2 Checklists

Checklist for Continuing Healthcare will be accepted provided that the following information has been submitted to the CCG CHC team:

A legible NHS Continuing Healthcare Checklist completed and signed by a professional person.

A clear indication whether the checklist is positive (indicates a full assessment is required) or negative (indicates a full assessment is not required and furthermore that the individual is not eligible for continuing healthcare).

Appropriate consent.

Where the CHC team cannot agree the checklist the duty nurse will return the application to the referrer stating clearly why the checklist is not accepted and will update Care Track with the appropriate record.

Where the checklist is negative the duty nurse may determine on the basis of the information and evidence submitted with the checklist that the individual being assessed is eligible for Funded Nursing Care. The duty nurse must liaise with the referrer to confirm the outcome of the checklist and to advise whether the individual will be eligible for Funded Nursing Care.

Where a checklist is positive the duty nurse will inform the referrer and advise the next steps or make arrangements with them for the completion of a full DST assessment.

6.3 Decision Support Tools

It is expected that the recommendation of the MDT will be ratified provided that the following information has been submitted to the CCG CHC team:

An NHS Decision Support Tool (2016 revision) fully completed, legible and signed by an appropriate MDT as defined in the National Framework.

Appropriate consent.

A clearly stated recommendation on eligibility which is agreed by all members of the MDT that gives full and robust consideration to the four key indicators of nature, intensity, complexity and unpredictability, that articulates a clear primary health need.

Evidence in support of: o the levels of need indicated in the domains, o the health and social care needs of the individual being assessed, o involvement of the individual and/or their representatives, o an appropriately formed MDT taking into consideration those

professionals involved in the care of the individual being assessed, and o in the case of a not eligible recommendation, that due consideration has

been given to whether the individual may be eligible for Funded Nursing Care.

Where the duty nurse is unable to accept a DST (for example, where there is missing information, the MDT have not made a recommendation, or the evidence submitted is not supportive of the recommendation made), the duty nurse must return the assessment to the coordinator of the DST assessment making clear why the application is not accepted and make the appropriate record on Care Track. In order to adhere to decision making timescales, the MDT/coordinator are to have seven days to provide further evidence, information or to reconsider the recommendation.

If the recommendation of the MDT is appropriate and agreed by NHS Haringey CCG, the CHC team will inform the referrer, and in the case of eligible applications liaise with them to identify the patient needs and required care package.

6.3.1 Unratified Recommendations

In some cases it may not be possible for the duty nurse to ratify a recommendation made by an MDT. Reasons for this may be that in the duty nurse view the evidence submitted is not supportive of the recommendation, or that the MDT have not been able to agree on a recommendation. Wherever possible the DST should be returned to the MDT to address these issues, and be given five working days to review the assessment or to provide additional evidence. However, in some cases it may be that it is not possible to return the DST to the MDT or that even after the MDT have reconsidered the issues raised by the duty nurse the issue remains unresolved. In such cases the DST and supportive evidence should be discussed with either the CHC Clinical Team Lead or CHC Clinical Team Manager for a decision next steps which may include referral to Resolution Panel.

7 Challenges, Appeals and Disputes Under the terms of the National Framework the CCG is required to develop processes for managing where the decision of the CCG is not agreed by the individual (or their legally appointed representative) or the professional persons involved in the individual’s care. ‘Challenges’ refer to where the outcome of a checklist is challenged. Under the National Framework there is no formal pathway required to manage checklist challenges, and all challenges should be processed through the CCG’s usual complaints process. ‘Appeals’ relate to where the CCG have determined that an individual is not eligible for continuing healthcare following a full MDT DST assessment. An appeal can be raised by the individual assessed for continuing healthcare or by their legally appointed representative within six months of the date of the decision letter being sent. Appeals cannot be raised against checklists or Fast Track applications, and cannot be raised by professionals or organisations on behalf of the individual unless they have been legally appointed to do so. Under the National Framework appeals must be considered within 90 days of receipt.

‘Disputes’ relate to where the CCG have determined that an individual is not eligible for continuing healthcare following a full MDT DST assessment, and are raised by the local authority following a formally agreed dispute process. Disputes can only relate to decisions following a full MDT DST and must be raised within seven days of the CCG’s decision on eligibility. 7.1 Challenges

Challenges to the outcome of a checklist are managed via the CCG’s usual complaints route. All challenges, whether they are from the individual (or their legally appointed representative) or from a professional involved in the individual’s care will be managed in this way. The CCG must make a record of the challenge and give consideration to the rationale given for challenging the outcome, before responding to the complaint. The complaint should be answered within the nationally agreed timescales for the management of complaints. 7.2 Appeals

Appeals must be received within six months of the decision letter informing of the ‘not eligible’ outcome, and must have a clear rationale for appealing the decision. An appeal will not be accepted if no rationale is given for appealing the decision. In such cases the CHC team will write to the appellant requesting a rationale for the appeal. Once the CHC team receive an appeal with a rationale the 90-day deadline for reviewing the appeal begins. Appeal rationale should be based on either the process that was followed, the quality of the decision, or both. Issues over process do not generally impact on the eligibility of an individual – however, issues regarding process should be investigated and resolved to the best ability of the CHC team. In cases where process has been deviated from significantly this may necessitate a new MDT DST or retrospective review of the case. In the unlikely event that failure of process has led to a decision that is unsupportable this should be discussed with the CHC Clinical Team Manager both to determine a plan to resolve the issue and to give feedback, guidance or performance management to the assessors and/or professionals involved in the assessment. Issues over the quality of the decision must be based on evidence. This usually is a disagreement on the interpretation of evidence available at the time of the assessment, but may also include contemporaneous evidence that was overlooked at

the time of the assessment. The reviewer must take into account all relevant evidence that was available at the time of the assessment and evidence submitted as part of the appeal. Evidence for a period after the date of the assessment cannot be used as evidence of eligibility. The reviewer must be able to evidence in their review that they have considered the rationale, comments and evidence supplied by the appellant, and reach their own conclusion whether the decision of the CCG can be upheld. The review must then have a peer-to-peer review within the CHC team. Where the reviewer is of the opinion that the appeal should be upheld in part or in full, this must be discussed with the CHC Clinical Team Lead or CHC Clinical Team Manager for advice and next steps. If the reviewer is supportive of the CCG decision a local review meeting (LRM) must be offered to the appellant to discuss the outcome of the review and how the CCG have reached their decision. The date that is first offered for the LRM, or the date of the letter agreeing eligibility, is considered the date that the appeal is finalised for the purposes of the statutory duty to review all cases within 90 days. A copy of the appeal policy, flowchart for appeals, guidance on the appeals process and guidance for conducting local review meetings are appendices to this standard operating procedure. 7.3 Disputes

Disputes that arise over eligibility decisions or joint funding arrangements made by the CCG are addressed in the Joint Disputes Resolution Policy.

8 Reviews

Under the National Framework the CCG is required to review eligibility decisions periodically, both to ensure that the package of care provided under CHC is continuing to meet the needs of the individual, but also to determine if the individual remains eligible for CHC.

All newly eligible individuals – whether eligible through fast track or full DST assessment – should be reviewed after three months with a full clinical review at the place where the individual’s care is provided. This clinical review must take into account the current health care and social care needs of the individual, and consider whether eligibility for CHC may have changed. It is important for good governance and responsible use of NHS resources that any change in need for care, whether an increase or a decrease, is reported to the CCG CHC commissioning team and recorded on Care Track to ensure that the appropriate care can be commissioned. The CHC clinical team will complete a Package of Care Variation form which will be copied to the shared commissioning folder (link here). A good example is ensuring that where has been provided that there is continued clinical evidence of ongoing 1:1 need and support. All individuals eligible for CHC should be as a minimum reviewed annually. The National Framework does not prescribe how annual reviews should be undertaken. At Haringey CCG all eligible individuals will have a clinical review conducted by a nurse assessor. The manner of the assessment will depend on the case concerned but in most cases should consist of an onsite visit by the nurse assessor to conduct a clinical review. Wherever a clinical review indicates that an individual may no longer be eligible, an MDT DST must be organised. It is important that if care needs have changed that commissioning for an appropriate package of care continues, but an assessment should not be delayed unreasonably. There is no requirement to undertake a new MDT DST unless the clinical review indicates that a person may no longer be eligible. The only way to remove eligibility is to undertake an MDT DST through the CHC processes. 8.1 ‘Not Eligible’ After DST Where a review indicates the individual may no longer be eligible for health funding the nurse assessor will:

• Discuss their findings with the individual and their representatives. (No package will be withdrawn without the individual being fully engaged in the decision making process.)

• Confirm their findings with the CHC Clinical Lead or CHC Clinical Team Manager.

• Make a referral to social services for assessment. • The nurse assessor must ensure that the social worker’s senior manager has

signed off the recommendation which will then be considered by the CCG.

• The nurse assessor will liaise with the CHC commissioning team who will inform the manager of the nursing home/ service provider in writing and give due notice of change of funding authority.

9 Retrospective Reviews

Retrospective reviews are historical reviews for eligibility. Currently, all cases before 30th April 2012 have been closed down by the Department of Health under the Previously Unassessed Periods of Care agenda (PUPOC) and CCGs are not obligated to undertake retrospective assessments prior to that date. However, there may be occasions when the CCG is asked to consider a historical period. This usually occurs when an individual is made newly eligible, or when the individual dies in the process of being assessed. Retrospective reviews can only be conducted on individuals who were not previously assessed during the period being requested. For the purposes of retrospective reviews checklists, DSTs and FNC assessments are considered previous assessments and are considered to apply for one year from the date they are completed. Full guidance on the process for undertaking a retrospective review is included as an appendix to this standard operating procedure. 10 Individuals Cared For Under Section 117

10.1 What is Section 117 Aftercare? Section 117 after care applies when an individual has been in hospital for treatment subject to a section of the Mental Health Act 1983. The relevant sections are sections 3, 37, 45a, 47 or 48. It entitles the individual to free aftercare when they leave hospital and continues for as long as the individual has needs applicable that gave rise to the relevant section being enacted. 10.2 Section 117 and Continuing Healthcare

As Section 117 applies for as long as the individual has mental health needs that require treatment to prevent readmission, and care should be provided under that legislation rather than NHS Continuing Healthcare. However, this is not always the

case as individuals may develop physical health needs in conjunction with mental health needs, and in some cases the physical health need becomes a primary health need. Individuals under Section 117 are entitled to be assessed for Continuing Healthcare, but during the assessment and eligibility process careful consideration must be given to which needs are covered by Section 117 aftercare, which needs are possibly Continuing Healthcare needs. 10.3 Management of Individuals Cared For Under Section 117

When an individual cared for under Section 117 after care it is the care coordinator in Barnet, Enfield and Haringey Mental Health Trust (BEHMHT) or the Haringey Learning Disability Partnership (HLDP) who lead on the review process. They will arrange and invite to the review meetings. It however remains the responsibility for the clinical team to obtain assurance that health needs are fully met which includes engaging in the activities below:

• Review paperwork, considering where there are health needs and have input into the placement of individuals, some of which will be very specialist and outside of Haringey. This will therefore sometimes require visits to new placements to consider suitability. This will occur in collaboration with local authority colleagues. • Conduct regular reviews and to obtain assurance that health needs are being appropriately met. • Liaising with the individual, family and carers. • Attending CPAs.

11 Joint Funding Arrangements

Joint funding arrangements exist between the CCG and local authorities where an individual has been assessed as not eligible for Continuing Healthcare, but where there are some elements of their care needs that remain the responsibility of the CCG to provide. A request for consideration for joint funding may come from the local authority, from the CHC clinical team, the MDT, or following discussion at the resolution panel. In all cases the clinical CHC team are responsible for determining an appropriate level of joint funding, considering only the health needs that are not already commissioned by NHS Haringey CCG or covered by FNC.

In these cases the CCG and the local authority will reach agreement on what aspects of an individual’s care package will be met by each body. Where the CCG are obligated to provide greater than 50% of the care package consideration should be given to whether the individual has a primary health need and should, therefore, be made fully eligible for Continuing Healthcare. In all other cases, as the local authority will be funding the greater part of the package of care, they will be the lead commissioners of that care. Suggested joint funding proposals must be approved by the CHC Clinical Team Manager before being passed to the commissioning team. When an individual cared for under a joint funding arrangement it is the care coordinator in Barnet, Enfield and Haringey Mental Health Trust (BEHMHT), the Haringey Learning Disability Partnership (HLDP) or other local authority representative who lead on the review process. They will arrange and invite to the review meetings. However, it remains the responsibility for the clinical team to ensure that health needs are fully met which includes engaging in the activities below:

• Review initial paperwork, considering where there are health needs and identify appropriate placements some of which will be very specialist and outside of Haringey. This will therefore sometimes require visits to new placements to consider suitability. This will occur in collaboration with local authority colleagues. • Conduct regular reviews and ensure that health needs are being appropriately met. • Liaising with the individual, family and carers. • Attending CPAs.

12 Neurological Rehabilitation

Any person having experienced an Acquired Brain Injury (ABI) whilst no longer requiring an acute hospital bed may have rehabilitation needs. These patients are referred for specialist in-patient rehabilitation. This rehabilitation is funded via a pan London Neuro Consortium. NHSE At the end of their rehabilitation they are screened for NHS Continuing Healthcare in the usual process. 13 Safeguarding, Auditing and Oversight

13.1 Safeguarding and Quality Assurance The team are expected to work closely with Safeguarding and Quality Assurance (Care Homes Team) colleagues as well as the commissioning team. They should be

vigilant towards Safeguarding or Quality Concerns and quickly raise them through the appropriate channels. When unsure they should discuss their concerns with Safeguarding and Quality leads within the CCG. All staff are expected to complete their mandatory training in a timely fashion. They will receive (weekly), monthly supervision and regular (4-6 times a year) clinical supervision. Appraisals will occur on a yearly basis and identify objectives and training needs. 13.2 Auditing

NHS Haringey CCG is responsible for ensuring quality standards are met and sustained. An audit of the activity and funding of the NHS Continuing Healthcare will be completed on an annual basis. This will be led by the Lead Nurse for Continuing Healthcare.

13.2.1 Internal Reporting Dashboard (Care Track)

The Clinical Team leader will provide a quarterly report to the Senior Management Team and Quality Committee which details the performance of the team against national/local KPIs and highlights any areas of concern or challenge.

14 Review

This Standard Operating Procedure will be reviewed and revised as directives regarding Continuing Healthcare are produced by the Department of Health are released, and in any event at periods not greater than every two years.