NHS West Sussex Continuing Healthcare Operational Policy for Adults

Transcription

1 NHS West Sussex Continuing Healthcare Operational Policy for Adults Summary: This policy sets out the operational management of NHS West Sussex Continuing Healthcare department APPROVED BY (Director Contracting and Performance West Sussex Primary Care Trust): 20/01/09 RATIFIED BY ( NHS West Sussex Executive Team): 20/01/09 REVIEWED: 15/02/10 REVIEW DATE: 31/03/11 To be read in conjunction with: National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (2007 revised July 2009) The National Assistance Act 1948 Local Authority Social Services Act 1970 The National Health Service Act 2006 The Delayed Discharges (Continuing Care) Directions 2009 The National Health Service (Nursing Care in Residential Accommodation) (Amendment)(England) Directions 2009 The NHS Continuing Healthcare (Responsibilities) Directions 2009 Coughlan Judgment (1999) The National Service Framework for Older People (2001) The Health & Social Care Act 2001 Section 49 The Community Care Act (delayed discharge) (2003) Grogan Judgement (2006) NHS West Sussex Home Care Policy Sussex Multi-Agency Policy and Procedures for Safeguarding Vulnerable Adults

2 Appendices 1-9 NHS Constitution Who Pays? Establishing The Responsible Commissioner 2007 (and amendments) Other Legislation pertinent to this Operational Policy, also addressed within National Framework for NHS Continuing Healthcare and NHS-funded Nursing: The Mental Health Act & Code of Practice (1983/2007) Mental Capacity Act & Code of Practice (2005) Deprivation of Liberty Safeguards (2009) All reasonable steps have been taken to ensure that this Policy reflects the: Equality and diversity agenda Relevant articles of the Human Rights Act 1998 Philosophy of Clinical Governance, providing evidence for compliance with the requirements of the Standards for Better Health of the Department of Health and the NHS Litigation Authority Risk Management Standard for PCTs Health and Safety at Work Act 1974 and associated legislation Freedom of Information Act 1998 (amended 2000) Disability Discrimination Act 1995 (amended 2005) Sex Discrimination Act 1975 (amended 2003) Race Relation Act 2000 Age Discrimination Act 2006 An Equality Impact Assessment has been carried out to ensure that this policy is antidiscriminatory. Page 2 of 57

3 CONTENTS 1. Introduction and Purpose..Page 4 2. Definitions...Page 5 3. Requirements.....Page 6 4. Roles and Responsibilities..... Page 6 5. Supporting Organisational Structures... Page Training and Education. Page Monitoring, Audit and Review...Page References.... Page Appendices Page 17 APPENDIX 1 = NHS WEST SUSSEX CHC PROCESSES. APPENDIX 2 = NHS WEST SUSSEX CHC CONSENT FORM. APPENDIX 3 =REFFERAL FORM TO ACCOMPANY DECISION SUPPORT TOOL AND CHECKLIST TOOL. APPENDIX 4 =TERMS OF REFERENCE, CHC ELIGIBILITY PANEL. APPENDIX 5= TERMS OF REFERENCE, CHC & WEST SUSSEX LOCAL AUTHORITY (Adults) DISPUTE PROCESS. APPENDIX 6 = TERMS OF REFERENCE, LOCAL REVIEW PANEL. APPENDIX 7= TERMS OF REFERENCE, WEST SUSSEX CHC FUNDING PANEL APPENDIX 8= NHS CONTINUING HEALTHCARE COMMISSIONING REVIEW. APPENDIX 9 = REQUEST FOR FULL NHS CONTINUING HEALTHCARE FAST TRACK TOOL. Page 3 of 57

4 1. Introduction and Purpose NHS West Sussex (NHSWS) has a statutory responsibility to implement the Department of Health s 2009 National Framework for NHS Continuing Healthcare (revised 2009) and for commissioning care for individuals that meet the eligibility criteria. This Operational Policy for NHS West Sussex NHS Continuing Healthcare, details the process within NHS West Sussex for referring, assessing and agreeing eligibility for NHS Continuing Healthcare and for providing/ reviewing that care. This policy ensures that the model and processes are consistent, robust and are timely in their response and are in accordance with the National Framework for NHS Continuing Healthcare revised 2009 and in relation to the commissioning structure of NHS West Sussex. This Policy sets out the operating framework for NHS Continuing Healthcare to ensure that the teams work in accordance with the National Framework for NHS Continuing Healthcare Eligibility and NHS Funded Nursing Care and maintains and develops close working arrangements with colleagues in West Sussex County Council and provider NHS Trusts and all other relevant statutory and non statutory providers. The eligibility for NHS Continuing Healthcare is based on an individual s assessed health needs and is not disease specific, nor is it determined by either the setting where the care is provided, or who delivers that care. Access to consideration and assessment is not based on age, condition or type of health need diagnosed. The aim of the NHS Continuing Healthcare Team is to implement the National Framework for NHS Continuing Healthcare eligibility criteria (revised 2009). In order to achieve this, the implementation of the National Framework for NHS Continuing Healthcare and local application for NHS Continuing Healthcare, in conjunction with other agencies, should meet the following principles: Person and carer centered Equitable, fair and consistent Anti discriminatory Robust and transparent Informative and clearly explained Adheres to guidance and best practice 1.1 Scope This policy applies to all adults over 18 years of age, are registered with a NHS West Sussex GP practice and for whom the Responsible Commissioner Guidance April 2007 ( Who Pays? Establishing the Responsible Commissioner and subsequent amendments to this guidance) and January 2009 supplement, Transfer of patients to other PCT areas under continuing care arrangements, indicates a NHS West Sussex commissioning responsibility to assess for, and consider eligibility for NHS Continuing Healthcare, under the National Framework for NHS Continuing Healthcare and (if appropriate) subsequently provide funding for care. Page 4 of 57

5 2. Definitions What is continuing care? Continuing care means care provided over an extended period to a person aged 18 and over who suffers from physical and/or mental health needs which have arisen as a result of disability, accident or illness. An individual who needs continuing care may require services from NHS bodies and/or local authorities. If a person does not qualify for NHS Continuing Healthcare the NHS may still have responsibility to contribute to meeting that person s health needs. (Department of Health 2009) What NHS Continuing Healthcare means. 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. It can be provided in any setting including in a person s own home. It means that the NHS funds all the care that is required to meet their assessed health needs. In care homes, it means that the NHS also makes a contract with the care home and pays the full fees including for the person s accommodation and all their care. (Department of Health 2009) What is NHS funded Nursing Care? This was introduced in October 2001 under the Health and Social Care Act 2001, and refers to the assessment and funding provided to nursing homes, by the NHS, to support the provision of nursing care by registered nurses for those assessed as eligible. (Department of Health 2009) A Glossary of terminology relating to the above areas is contained within annex A: Glossary of National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care. Policy statement This policy sets out the roles and responsibilities for key health and social care staff and explains the process for determining eligibility and the review process related to NHS Continuing Healthcare in NHS West Sussex. The following organisations endorse the policy: West Sussex County Council Adult Social Services (WSCC) NHS West Sussex Brighton and Sussex University Hospital NHS Trust Western Sussex Hospitals NHS Trust Surrey and Sussex Healthcare NHS Trust Sussex Partnership NHS Foundation Trust Page 5 of 57

6 3. Requirements 3.1 Legislation West Sussex NHS Continuing Healthcare team commission appropriate care for people and are therefore governed and subject to relevant legislation and guidance as required. West Sussex NHS Continuing Healthcare Team, in their decision-making regarding NHS Continuing Healthcare eligibility, are subject to the following legislation documented in: Annex A: Legal Framework. National Framework for NHS Continuing Healthcare (revised 2009) National Framework for NHS Continuing Healthcare and NHS-Funded Nursing Care. Resource Pack 2, Understanding the Tools and Processes. (2007) The National Assistance Act 1948 The National Health Service Act 2006 Coughlan Judgment (1999) The National Service Framework for Older People March 2001 The Health & Social Care Act 2001 In March 2003 the Community Care Act (delayed discharge)(2003) Grogan Judgement (2006) National Health Service and Community Care Act 1990 Chronically Sick and Disabled Persons Act 1970 Other Legislation pertinent to this Operational policy, also addressed within National Framework for NHS Continuing Healthcare and NHS-funded Nursing: The mental Health Act & Code of Practice (1983/2007) Mental Capacity Act & Code of Practice (2005) Deprivation of Liberty Safeguards (2009) Mental Health Act (2007) The National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care was issued as best practice guidance in June The Framework for NHS Continuing Healthcare (2007) was revised in July The revised framework clarifies and supports consistency in the determination of eligibility for NHS Continuing Healthcare and NHS Funded Nursing Care, and was implemented on 1st October These Directions made compliance with that guidance mandatory as of 1 October The Delayed Discharges (Continuing Care) Directions 2009 The National Health Service (Nursing Care in Residential Accommodation) (Amendment)(England) Directions 2009 The NHS Continuing Healthcare (Responsibilities) Directions 2009 Page 6 of 57

7 4.1 Roles and Responsibilities The Continuing Healthcare department is responsible for implementation of the National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care (2009). This sets out a single policy on who should receive NHS funding, be that fully funded NHS Continuing Healthcare (where the NHS funds the whole care package) or NHS-Funded Nursing Care (where the NHS is responsible for the nursing required from a registered nurse in a care home.) For full guidance see The National Framework (2009) proposes a standard process for assessing eligibility for these services, to help support consistent decision-making. 1. Full Multidisciplinary Assessment 2. NHS Continuing Healthcare Checklist, Eligibility Considerations Eligibility, Eligibility Considerations: Care Planning, Care Planning & Provision: Process 3. Funding decisions. 4. Care Packages & Placements 5. Eligibility Review 6. Commissioning Reviews West Sussex Primary Care Trust responsibility to provide or commission care (including NHS Continuing Healthcare) is not indefinite as needs might change. This should be made clear to the individuals and their representatives. West Sussex NHS Continuing Healthcare Processes (Appendix 1) NHS West Sussex has produced four agreed processes regarding NHS Continuing Healthcare: The referral process for NHS Continuing Healthcare for adults (Process One) NHS West Sussex process for the funding of NHS Continuing Healthcare eligible clients (Process Two) NHS West Sussex process for the review of both funding and eligibility. (Process Three) NHS West Sussex End of life FAST TRACK process. (Process 4) Process one NHS Continuing Healthcare (Adults) Assessment, Consent and the Mental Capacity Act 2005 Clients, their representatives and advocates where appropriate should be fully involved in the assessment process. In order that the process for assessment complies with the Mental Capacity Act the multidisciplinary team (MDT) are required to consider an individuals capacity to consent to assessment for NHS Continuing Healthcare and are therefore required to complete the NHS West Sussex Continuing Healthcare Consent form. (See Appendix2) MDT s should refer to the Core Values and Principles, National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care (2009) for further guidance on Consent Capacity and Advocacy consideration. Page 7 of 57

8 NHS Continuing Healthcare Referral Process Refer to National Framework NHS Continuing Healthcare and NHS Funded Nursing Care (2009), for guidance. Completion of the Checklist Refer to Checklist p20, National Framework NHS Continuing Healthcare and NHS Funded Nursing Care (2009), for guidance. The Checklist is a tool to assist practitioners to identify individuals who may need full consideration for a Primary Health Need and who could be eligible for NHS Continuing Healthcare. It is not an indication of the outcome of the eligibility decision and this should be clearly communicated to the individual and their representatives as appropriate. Prior to a Checklist being completed there is a need for a comprehensive assessment of need by a multidisciplinary team to have been completed, updated risk assessments, patient records, specialist assessments, incident forms, and for the team to have addressed capacity issues regarding the clients care home placement or care package and have a clear picture of assessed needs. When the Checklist is completed this should be sent to the NHS Continuing Healthcare team in order to initiate the Decision Support Tool assessment and determination process if appropriate. A number of models of comprehensive assessment are already in place, for example: Single Assessment Process (SAP) & The Care Programme Approach (CPA). Who can complete a Checklist? A nurse, doctor, other qualified health professional or social worker could apply the checklist to refer an individual for full consideration of eligibility or for consideration of the single NHS Funded Nursing Care payment. The single payment for NHS Funded Nursing Care will be agreed if the result of the Checklist is that the individual is not to progress to full consideration and has identified registered nursing needs and is either to be discharged to or is resident in a care home with nursing. Whoever applies the Checklist will need to be familiar with, and have regard to the content, core values and principles of the National Framework for NHS Continuing Health, NHS Funded Nursing Care and the Decision Support Tool. If guidance is required this should be sort from the locality NHS Continuing Healthcare team. The Checklist Process The Checklist process is not a full assessment of need. It is a preliminary indication of potential eligibility for NHS Continuing Healthcare in line with the primary health need approach that triggers the requirement for a full assessment, or identifies those individuals for whom the full assessment is not applicable. For example, an individual who is expected to make a full recovery or whose condition will respond to treatment and does not have long term care needs would not need a full assessment completed. Individuals should have a NHS Continuing Healthcare Checklist applied on discharge from services, at review or other trigger. A comprehensive assessment of an individual s care needs i.e. Single Assessment Process or Care Programme Approach together with any relevant medical, nursing or specialist reports informs the NHS Page 8 of 57

9 Continuing Healthcare Checklist in line with the principles of good record keeping as identified within the National Framework for NHS Continuing Healthcare and NHSfunded Nursing Care (Department of Health 2009) FULL ASSESSMENT FOR NHS CONTINUING HEALTHCARE ELIGIBILITY A comprehensive multidisciplinary assessment is an assessment of an individual s care needs, including all relevant specialist and non-specialist assessments. It should be carried out by a multidisciplinary team in line with the core values and principles outlined in the National Framework (2009) and guidance relating to the Single Assessment process and care programme Approach. A Comprehensive Multidisciplinary assessment needs to occur preceding any NHS Continuing Healthcare consideration, which should be based on, the principles of good assessment as defined in Assessments p16-17, National Framework for NHS Continuing Healthcare and NHSfunded Nursing Care (Department of Health 2009),. Assessments, and the consideration of eligibility for, NHS Continuing Healthcare and NHS-funded Nursing Care should be organised so that the person who is undergoing an assessment and their family or their representative understand the process, and receive advice and information to enable them to participate in informed decisions about their future care. Decisions and rationales relating to eligibility should be transparent from the outset: to individuals, and their representatives, and staff. Individuals should be given the opportunity to read and understand the NHS Continuing Healthcare and NHS funded Nursing care material, which are available from the Continuing Healthcare team or accessed from the Department of Health website. Establishing that an individual s primary need is a health need, and that they are therefore eligible for full NHS funding, requires a clear, reasoned decision based on evidence of needs from a comprehensive assessment and the evidence and decision fully recorded. Once possible eligibility has been established by a Checklist Tool, a Decision Support Tool (DST) needs to be completed by a Multidisciplinary Team (MDT) What is a Decision Support Tool (DST)? Refer to Decision Support Tool p21, National Framework NHS Continuing Healthcare and NHS Funded Nursing Care (2009), for guidance. a) The DST supports the application of the National Framework for NHS Continuing Healthcare and ensures consistency in decision making it in line with the primary health need approach. b) This tool provides practitioners with a needs led approach by describing the different aspects of an individual s care needs in care domains. The descriptors relate to the various levels of needs, low, moderate, high, severe and priority levels of need depending on the domain. The DST helps set out the evidence in a detailed needs based format and in building up a picture of the care needs determines whether the primary need is a health need. (Appendix 3) c) The DST clarifies the evidence used to make professional judgements Page 9 of 57

10 and supports the recommendation It is recommended that standardised assessment tools are used where appropriate to support the DST. Up to date rating scales and objective measurements with a focus on the domains within the DST should be undertaken by the multi-disciplinary team as part of this initial process. Once mental capacity is established and the multidisciplinary team s recommendation regarding eligibility is made, the completed information should be forwarded to the NHS Continuing Healthcare team to validate the decision. What is a Multi-Disciplinary Team (MDT) An MDT can consist of a minimum of two professionals with different roles, in certain settings this may most appropriately be Health and Social Care Professionals. MDT s need to identify and record a rationale for decisions, which demonstrate a comparison of the nature, intensity, complexity or unpredictability (or any combination of these) of the person s care needs to the primary health need approach, so a consistent approach is demonstrated. Multidisciplinary teams working with West Sussex Primary Care Trust will result in the NHS making an informed decision on responsibility for NHS Continuing Healthcare working in close partnership with Adult Services. The process can be initiated wherever the individual is living but they must be registered with a West Sussex General Practitioner. It is important that the process does not delay treatment or appropriate care being put in place. Individual s their family and representative input. The individual, their carer or advocate are able to contribute to the DST and there is a section for their comments or comments regarding their input. Guidance on individual s their carer or advocate s and their input into the process for establishing NHS Continuing Healthcare is explicit within the National Framework and MDT s need to be mindful of their responsibilities regarding individual s, their carer or advocate s involvement with the whole process of establishing an individual s NHS Continuing Healthcare eligibility. OUTCOME OF THE DECISION SUPPORT TOOL Following recommendation by multidisciplinary team to NHS West Sussex the responsible locality Eligibility Panel of NHS West Sussex is required to validate the recommendation. Only in exceptional circumstances, and for clearly articulated reasons, should the multidisciplinary team s recommendation not be followed. It is the responsibility of the Eligibility Panel to inform the individual and/or representatives in writing of the rationale for the decision. Copies will be forwarded to all the relevant contributors of the multidisciplinary team who completed the assessment. The completed Decision Support Tool will result in one of the following outcomes: a) A primary health need is established and the recommendation is for NHS Continuing Healthcare to fund and commission the care. b) A primary health need is not established and the recommendation supports this decision and a referral will be made by NHS West Sussex or NHS Trust to West Sussex County Council, Adult Services using the Single Assessment process. Page 10 of 57

11 c) Where other care needs are identified consideration may be given to joint funding arrangements with Adult Services. This process has yet to be finalised. d) A primary health need is not established in line with the recommendation due to lack of evidence to support the recommendation. In this instance the case will be deferred and the Decision Support Tool will be returned to the multidisciplinary team for them to address. Making Recommendation To NHS West Sussex on an individuals eligibility for NHS Continuing Healthcare. MDT s should familiarise themselves and with the Primary Health Need concept when making a recommendation to NHS West Sussex as to individuals eligibility for NHS Continuing Healthcare. Refer to Primary Health Need p9-11, National Framework NHS Continuing Healthcare and NHS Funded Nursing Care (2009), for guidance. ELIGIBILITY PANELS NHS West Sussex Eligibility Panels are held on a weekly basis in the following areas: South East - Tuesday North East - Wednesday Western - Thursday Each Panel is managed by a Lead Continuing Healthcare Nurse and is attended by a senior Social Worker or team manager Adult Services. All NHS West Sussex panels agree to the eligibility panel s Terms of Reference. (Appendix 4) If an individual requires a rapid decision the case will be heard in a Panel operating in a different locality subject to agreement of Panel members. Following Eligibility Panels Outcome Appeal Processes. There are two distinct appeal processes dependent on who is the appellant. NHS West Sussex operates an arbitration process where West Sussex County Council Adult Services, brings appeals against eligibility. (For Terms of Reference see Appendix 5) NHS West Sussex operates an appeal process where Clients or their representatives bring appeals against eligibility. (For Terms of Reference see Appendix 6) Funding without prejudice In law, the phrase without prejudice means that a claim or proceeding has been brought to a temporary end but that no legal rights or privileges have been determined, waived or lost by the result. The stakeholders involved in this policy subscribe to the principle that there should be no delay in the provision of services due to disagreements on the assessment or outcome of the decision on eligibility. Should a disagreement arise the National Framework (2009) is explicit that any existing funding arrangements cannot be unilaterally withdrawn without agreement from the other party Page 11 of 57

12 Therefore anyone in their own home, or care home funded by the local authority must continue to be financially assisted by the Local Authority until the dispute is resolved. Similarly, anyone assisted by the NHS must remain funded by the NHS until the dispute is resolved. NHS West Sussex and Local Authorities must therefore adopt a without prejudice approach to such situations. This means that if the council has continued to fund an agreement that subsequently is decided to be NHS Continuing Healthcare then NHS West Sussex funding should be backdated to the date that the Local Authority gave notification (date of Decision Support Tool) to NHS West Sussex. Similarly, when NHS West Sussex has continued to fund an agreement that subsequently is decided to have been a local authority responsibility the local authority will reimburse NHS West Sussex to the date of notification (date of Decision Support Tool). During this appeal process a Decision Support Tool must be completed at three month intervals involving representation from both parties. Care planning if a patient is eligible for NHS Continuing Healthcare NHS West Sussex-process for commissioning of NHS Continuing Healthcare eligible clients (See Process Two Appendix 1) NHS West Sussex operates a variety of panels regarding the funding of care. NHS West Sussex, NHS Continuing Healthcare Eligibility, Funding & Appeal / Arbitration Panels are detailed within the appendices. For Terms of Reference for NHS West Sussex funding Panels can be obtained from the appropriate relevant commissioning authority. Care planning if a patient is not eligible for NHS Continuing Healthcare NHS West Sussex- process to support The Single Payment of NHS Funded Nursing Care (See Process Three Appendix 1) Following a decision that a person s primary need is not a health need, they may receive a package of health (single payment) and social care (rather than being fully funded by the NHS). As part of this planning process, the NHS determines its responsibility for the services that are required to be provided by a registered nurse, as the Local Authority, following the 2001 Health and Social Care Act cannot provide this. Arrangement of care and funding process for NHS Continuing Healthcare for eligible patients Once eligibility has been agreed and the client or their representative have been consulted and the clients care plan has been agreed, arrangements to move to a Care Home placement or into the community with a package of care, is organised by the CHC Nurse in partnership with the key worker. For clients on the fast track process this involves the Continuing Healthcare nurse and /or other involved professionals agreeing funding with a lead nurse with immediate effect For clients assessed as requiring NHS Continuing Healthcare home care packages, funding will be considered in relation to Home Care Policy guidance. Page 12 of 57

13 For new clients and those whose funding arrangements have changed due to a Continuing Healthcare review, and remain eligible for NHS Continuing Healthcare, all applications above 750 are presented at the Continuing Healthcare Funding Panel (see Terms of Reference, Appendix 7) For all existing clients who are reviewed and where funding remains unchanged, and for all other funding that is below Lead Nurses agree funding. For all urgent funding agreements sought before the Continuing Healthcare Funding Panel is sitting, a discussion with the Continuing Healthcare manager or deputy takes place before Commissioning Manager agrees funding above 750 Continuing Healthcare clients where funding responsibility is that of West Sussex Mental Health Commissioning Team are agreed by the Continuing Healthcare Mental Health Lead nurse up to West Sussex Mental Health Commissioning Team will review funding requests above 775 at their Continuing Health Care Funding Panel. NHS West Sussex End of life FAST TRACK process. (Process 4, See Appendix 1) Refer to Fast Track Pathway Tool p25, National Framework NHS Continuing Healthcare and NHS Funded Nursing Care (2009), for guidance. Fast track Applications The Fast Track pathway is designed for those individuals who have a rapidly deteriorating condition, which may be in a terminal phase, with an increasing level of dependency. The Fast Track Pathway Tool is for use within the guidance of the National Framework for NHS Continuing Healthcare (See Appendix 9). Who can complete it? The application can be completed by: a General Practitioner, Consultant or Nurse Practitioner Nurse Specialist, Discharge Coordinators, District Nurse or Ward Sister. It can be used in any setting and its purpose is to fast track an individual for NHS Continuing Healthcare provision. What should be the outcome? Correctly identified individuals who meet the Fast Track requirements should receive the care they need without delay. They may need NHS Continuing Healthcare funding to enable their needs to be urgently met (e.g. to allow them to go home to die or to allow appropriate end of life support to be put in place). The Fast Track Tool needs to be accompanied with a minimum data set (see Appendix 3) NHS Continuing Healthcare Reviews NHS Continuing Healthcare Eligibility Review If the NHS is providing any part of the care, the multidisciplinary team caring for the individual assessed as eligible for NHS Continuing Healthcare repeats the eligibility process. Page 13 of 57

14 The eligibility reassessment should be undertaken to reassess the client s needs and eligibility for NHS Continuing Healthcare no later than 3 months following the initial assessment and then as a minimum standard on an annual basis. These clients include those who did not receive a full consideration for NHS Continuing Healthcare eligibility following application of the Checklist. Clients fully funded by NHS West Sussex, Continuing Healthcare Team will be assessed for eligibility using the Decision Support Tool within a multi-disciplinary environment and the assessment will progress to the Eligibility Panel. Those clients who are receiving the single payment will be assessed using the Checklist Tool, which may or may not lead to a Decision Support Tool being undertaken dependent on health need. NHS Continuing Healthcare Commissioning Review Clients, who have been assessed as meeting NHS Continuing Healthcare eligibility and are funded by NHS West Sussex, will also require a Continuing Healthcare Commissioning Review.As the commissioner of funded care, NHS West Sussex is responsible for monitoring the need for ongoing care, treatment or intervention provided by the NHS or independent providers of care. The Continuing Healthcare nurse will review at a minimum annual basis and will complete the NHS Continuing Healthcare Review unless initiated before the annual date (see Appendix 8) Vulnerable Adults The NHS Continuing Healthcare Team will adhere to Sussex Multi-Agency Policy and Procedures for Safeguarding Vulnerable Adults. The NHS Continuing Healthcare Team on receipt of information regarding an Adult Protection Alert that has been raised on an individual who NHS West Sussex is funding under their NHS Continuing Healthcare arrangements will undertake a Commissioning Review as an initial measure. What is the NHS Continuing Healthcare commissioning element? NHS Continuing Healthcare commission s services from the statutory and independent sector to provide care that is agreed through service level agreements once eligibility has been established. The NHS vision is to deliver a health and care system that is fair, personalised, effective and safe as acknowledged in World Class Commissioning, (Department of Health 2007). Accordingly Continuing Healthcare will complete Continuing Healthcare Commissioning Reviews (Appendix 8) and will develop a team approach to building close relationships with clients, the public, local authorities, clinicians and providers. Continuing Healthcare Commissioning Reviews will be undertaken on at least a minimum of an annual basis. The principles around best value commissioning will underpin commissioning by the Continuing Healthcare Team. CHC will continuously seek to improve our efficiency, productivity and performance in order to provide the best value for taxpayers money, recognising that best care and best value go together. CHC are committed to the sustainable use of resources and will aim to reduce our use of energy and other natural resources, minimise production of waste and contribute to the sustainable development of the wider community. Annexe C: The NHS England Operating Framework for 2007/08 (DOH, 2006) Page 14 of 57

15 5. Supporting Organizational Structure in NHS Continuing Healthcare NHS West Sussex Contracting & Procurement Directorate Continuing Care Team Page 15 of 57

16 Director of Contracting and Performance Band 6 Trainer Band 7 Interim Bed Lead 1.0 WTE Band 6 Nurse 0.5 WTE 0.60 WTE Band 7 Specialist Leads Band 7 Lead Nurses Band 3 Admin 1.0 WTE Finance Dept ABI 1.0 WTE MH 1.0 WTE Band 6 Nurse 1.0 WTE Band 3 Admin 1.0 WTE CHILDREN S 1.0 WTE Band Transition Nurse Vacant Jointly Funded LD 1.0 WTE Band 6 Nurses 1.0 WTE 1.0 WTE 1.0 WTE 0.93 WTE 0.5 WTE Band 5 Nurse 0.80 WTE Band 3 Admin 1.0 WTE 0.76 WTE SE 1.0 WTE NE 1.0 WTE Band 6 Nurses 1.0 WTE 1.0 WTE 1.0 WTE 1.0 WTE 1.0 WTE 0.80 WTE Band 4 Admin 0.8 WTE W 1.0 WTE Band 6 Business Manager 1.0 WTE Band 6 Nurses 1.0 WTE 1.0 WTE 0.8 WTE 0.5 WTE 0.5 WTE Band 3 Admin 0.66 WTE 1.0 WTE Business Team Band 5 Data Analyst/ Admin Lead 1.0?????? Band 4 Business Support 1.0 WTE Band 3 WTE 1.0 WTE Band 2 Admin 0.4 WTE (NE) Band 3 Admin 1.0 WTE 1.0 WTE 0.53 WTE Band 2 Admin 0.4 WTE

17 Training and Education NHS West Sussex and West Sussex County Council are committed to provide joint training initiatives to facilitate the National Framework (2009) Initial training in 07/08 will be provided to a minimum of 1000 professionals across the health economy; on completion of this training a rolling programme of training will be maintained. Formal training days will be organized and cascaded by NHS West Sussex and WSCC every 6 months for all professionals to attend. Training will also be provided to the independent sectors free of charge. Additionally quarterly lunch and learn briefings will be provided in the locality offices in North East Western and South East Areas of NHS West Sussex. All training will be evaluated and attendance monitored on an annual basis. A training report will be completed on an annual basis and attendance reminders requested from areas not accessing the training Department managers should be aware of their staffs training requirements and ensure that their staff have access to information regarding training sessions and that they are released to attend at an appropriate agreed time. Line managers should ensure that new staff are included at the earliest opportunity. Maintaining competence is the responsibility of all staff. Monitoring The safe keeping and good order of paper documentation will at times be subject to monitoring by the Risk Manager. Monitoring and review of this Operational Policy will be undertaken by NHS West Sussex NHS Continuing Healthcare Team s Operational Policy Group. Audit A shared audit of the National Framework (2009) implementation will be commenced on an annual basis, the format to be agreed with NHS West Sussex and West Sussex County Council. An annual report of NHS Continuing Healthcare activity and funding will be completed on an annual basis and presented to the NHS West Sussex Director of Commissioning and West County Council Director Chief Executive The Chief Executive has overall accountability for the reduction of risks associated with the development, implementation, embedment, monitoring, audit and review of the guidelines.

18 9. References National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care (DOH, 2009) Annexe C: The NHS England Operating Framework for 2007/08 (DOH, 2006) 10. Appendices APPENDIX 1 = NHS WEST SUSSEX CHC PROCESSES. APPENDIX 2 = NHS WEST SUSSEX CHC CONSENT FORM. APPENDIX 3 =REFFERAL FORM TO ACCOMPANY DECISION SUPPORT TOOL AND CHECKLIST TOOL. APPENDIX 4 =TERMS OF REFERENCE, CHC ELIGIBILITY PANEL. APPENDIX 5= TERMS OF REFERENCE, CHC & WEST SUSSEX LOCAL AUTHORITY (Adults) DISPUTE PROCESS. APPENDIX 6 = TERMS OF REFERENCE, LOCAL REVIEW PANEL. APPENDIX 7= TERMS OF REFERENCE, WEST SUSSEX CHC FUNDING PANEL APPENDIX 8= NHS CONTINUING HEALTHCARE COMMISSIONING REVIEW. APPENDIX 9 = REQUEST FOR FULL NHS CONTINUING HEALTHCARE FAST TRACK TOOL. Page 18 of 57

19 Appendix Page 19 of 57

20 Appendix 1 PROCESS ONE (Eligibility) NHS CONTINUING HEALTHCARE (ADULTS) Consent to Undertake NHS CHC Checklist 14 Days from Checklist Tool to CHC decision Checklist and FACE Rapid assessment/ Care Plan Approach/ or equivalent and consent sent to CHC by Monday to Friday YES Peer review x1 CHC nurse to ensure checklist is completed ELIGIBILTY OUTCOME for full CHC consideration. No Checklist/Criteria approved: DST Required. Organised by MDT DST not required Consent to Undertake NHS CHC DST DST completed and returned with evidence to CHC Peer reviewed by 2 CHC nurses IF NO: Referrer needs to be informed Checklist letter sent to referrer, individuals or their representatives within 3 working days. Single Payment if Appropriate. MDT informs CHC of discharge outcome or continued placement YES EP Yes letter sent to patient cc referrer No letter sent to patient cc referrer Key EP- Eligibility Panel CHC- Continuing Health Care DST- Decision Support Tool MDT- Multi Disciplinary Team FACE- Functional Analysis of Care Environments Process 2 Page 20 of 57

21 PROCESS TWO (Funding) NHS CONTINUING HEALTHCARE (ADULTS) Eligibility panel Mental Health/ Learning Disability funding panels CHC nurse allocated to case by CHC lead nurse. Care plan agreed by CHC & initial costs agreed with Provider Below 650: Reviewed. Approved by CHC Lead Nurse Above 750; CHC nurse prepares for Funding Panel. Decision YES NO Letter confirming package of care to individuals/ or individuals representative CHC Business Team Review Process 3 Key EP- Eligibility Panel CHC- Continuing Health Care DST- Decision Support Tool FP- Funding Panel Page 21 of 57

22 PROCESS THREE (Review) NHS CONTINUING HEALTHCARE (ADULTS) CHC REVIEW Eligibility Commissioning 3 month review: CHECKLIST DST+ evidence + consent. Monitored by allocated CHC nurse Commissioning Review Undertaken by CHC Nurse & referral to other agencies as appropriate Peer reviewed by CHC nurses Outcome of Commissioning review sent to CHC Business Team & Lead Nurse where appropriate. Eligibility panel as per process 2 A minimum of annual review or as required. Key CHC- Continuing Health Care DST- Decision Support Tool Page 22 of 57

23 PROCESS FOUR-(End of Life) NHS CONTINUING HEALTHCARE (ADULTS) Fast track tool/ rapid FACE assessment form (or equivalent), + consent form received by CHC Peer review x 1 CHC nurse to ensure complete and appropriate POC/Placement set up Request further information Reviewed within two weeks. Consent & DST Completed as per Process 1 Referral not supported for Fast Track (Primary health need/ single payment need identified) Process 1 Key CHC- Continuing Health Care POC- Package of Care DST- Decision Support Tool Page 23 of 57

24 Appendix 2 NHS Continuing Healthcare: Consent Form CONSENT TO THE ASSESSMENT PROCESS & INFORMATION SHARING v5 Does the person have the mental capacity to consent to participating in the assessment process? If the person is deemed to have mental capacity, has their consent been obtained for this assessment? Has the person being assessed given consent to have information shared with their representative or advocate? Does the person being assessed have Independent Mental Capacity Advocate (IMCA) service representation? Has the person being assessed made a Lasting Power of Attorney/, Enduring Power of Attorney? If so, please give details and the name, address and telephone number of the persons representative: Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ ] If the person is deemed to not have the mental capacity to consent, how was their mental capacity determined? How and by whom has it been decided that it is in the person s best interests to complete this assessment? Where the person is mentally incapacitated and unable to consent, information should only be disclosed in their best interests and then only as much information as is needed to support their care. For further guidance, see the Mental Capacity Act 2005 Code of Practice on and the guidance booklet Making Decisions: a guide for people who work in health and social care on MDT Staff Member: Designation: Clients Name: Clients Signature: Date Responsible of birth: Director: Contracting and Performance Date: Status: Final Draft Page 24 of 57 MDT Staff Member Signature: Date:

25 Appendix 3 REQUEST FOR FULL NHS CONTINUING HEALTHCARE CONSIDERATION PERSONAL DETAILS Name: Date of Birth: NHS Number: Home Address: Current Address: Ethnic Origin: Telephone Number: Telephone Number: First Language: Address and telephone number of where assessment is needed: Date of referral: Reason: Has the patient given consent for the NHS Continuing Healthcare assessment process to continue? YES / NO Does the patient have a person representing them with regard to their Full NHS Continuing Healthcare consideration? YES / NO Details of representative/next of kin: Name: Address: Telephone Number: Relationship to patient: General Practitioner: Name, address and telephone number: Past History: Diagnosis Summary: Referrer Name and Telephone Number: Checklist result enclosed: YES / NO (Please attach any relevant reports, care package details, discharge plan as appropriate) Is the patient at risk? YES / NO (If YES please state) Is there a lone worker risk? YES? NO (If YES please state) Date of Initial Assessment: Dates of reassessments: Date of Admission to Care Home: Full / Single Rate / Nil Payment: Locality: Source of Funding: Social Services/Self Funding/Continuing Healthcare Page 25 of 57

26 Appendix 4 NHS Continuing Healthcare Eligibility Panel Terms of Reference & Guidance Page 26 of 57

27 October 2007 Terms Of Reference Purpose The Purpose of the Eligibility Panel is to assess an individual s eligibility for NHS Continuing Healthcare following a comprehensive needs assessment and a recommendation by an individual s multidisciplinary team in accordance with the National Framework for NHS Continuing Healthcare (Department of Health 1/10/2009) & The NHS Continuing Healthcare (responsibilities) Directions 2009 (National Heath services Act 2006, Local Authority Social Services Act 1970) Scope/Objectives The Eligibility Panel will: Review multidisciplinary team s recommendations, application of the Decision Support Tool (DST), the rationale for their decision and the accompanying supporting clinical evidence, in respect of those individuals recommended as eligible for NHS Continuing healthcare. Make decisions following the recommendations from multidisciplinary teams regarding an individual s eligibility for NHS Continuing Healthcare and either support or reject the recommendation giving the rational for their decisions and documenting and communicating these decisions to the relevant parties. Frequency of Panel Meetings Panels will be held weekly. There will be three panels across West Sussex that will be coterminous with Adult Services and NHS West Sussex Localities, representing North East, Western and South East. Membership Core membership of the Eligibility Panels will comprise: NHS Continuing Healthcare Lead Nurse or representative (Chair & Signatory) Adult Services Team Manager (Signatory) Administrator/Note Taker Co-opted Eligibility Panels membership NHS Continuing Healthcare Manager Specialist Health or Social Care Practitioner (Advisor) Access to clinical or social care advice may be required in all or some cases. NHS West Sussex should identify nurses and/or consultant physicians/psychiatrist/medical advisers with specialist knowledge in continuing care across a range of care groups, who may be called upon to offer advice. Adult Services should identify relevant Specialist Social Care Practitioner who may advise the panel members. Quorum The Eligibility Panels will be quorate with signatories representing NHS West Sussex and Adult Services. NHS West Sussex signatories must represent the appropriate commissioning funding streams within NHS West Sussex. Where clinical or Social Care advisers attend a panel meeting it should be made clear they are there to offer advice and are not part of the formal decision-making. Page 27 of 57

28 Eligibility Panel Decisions Decisions Whilst the National Framework requires consultation with Local Authorities and also requires that NHS West Sussex should only in exceptional circumstances not support the recommendations of the multidisciplinary team, the final decision regarding an individual s eligibility for NHS Continuing Healthcare remains with the Primary Care Trust and therefore the NHS West Sussex representative at the Eligibility Panel has the ultimate decision. It is not anticipated that there will be conflict between panel members. However should this arise and members are unable to resolve their differences, NHS West Sussex and LA should escalate the disagreement through the established arbitration process until resolution is reached. Communicating the decision Consideration should be given as to the Individuals or their representative being informed of the recommendations made to the Eligibility Panel as they may differ from the Eligibility Panel s final decision and it is important to be mindful of individual s expectations. If the assessment documentation submitted to the Eligibility Panel does not satisfy the requirements as indicated in the Eligibility Panels Principles and Guidance notes as detailed below, the Panel will Defer the recommendation and a clear rationale as to why the recommendation is being deferred will be returned to the multidisciplinary team within two working days. If an individual or their representative ask for a review of the decision made by the panel members not to provide fully funded NHS continuing care then the individual or their representative should follow NHS West Sussex established appeal procedure. If a multidisciplary team asks for a review of the decision made by the panel members not to provide fully funded NHS continuing care then the multidisciplary team will be encouraged to follow NHS West Sussex established Arbitration procedure. Time scale for decisions The Panel will review recommendations ideally within six working days from the completion of a multidisciplinary teams recommendation. Multidisciplinary teams making the recommendation will be notified of the Eligibility Panel s decision within five working days of the Panel s decision. In urgent or palliative cases a decision will be made as soon as practicable. NHS West Sussex will inform the individual or designated contact of the decision by letter within five working days of the Eligibility Panel decision. Documentation The Panel members will be required to complete the Rationale for Decision on Eligibility (Appendix 1) and will require NHS West Sussex & Adult Services signatories at the panel to agree and sign. Confidentiality The individuals involved in making decisions, should only receive information that is relevant and necessary for them to exercise their duties. Panel Outcome Notes Page 28 of 57

29 Panel Outcome Notes will be circulated to Panel members who were in attendance. The Panel Outcome Notes will reflect any differences in opinion, any dissenting views as to the outcome of any case presented. The Rationale for decision on eligibility form and notes will be circulated. Audit In order to ensure consistent decision-making, local Eligibility Panels will need effective audit procedures in place, which are linked to NHS West Sussex clinical governance framework. A formal record of cases and decisions should be kept and reported to appropriate management groups within health and social care. Information on challenges to panel decisions should be monitored and action taken to address performance as necessary The Eligibility Panels should be in a position to undertake an audit of their performance and report to health or social care organisation requests. Eligibility Panels Principles. To ensure good practice and equity across West Sussex general principles need to be adopted by Eligibility Panels. These principles are: All panel members should be conversant with National Framework for NHS Continuing Healthcare (Department of Health 1/10/2009) and in the application of the NHS Continuing Healthcare assessment process. Best Practice would indicate that Panel members had attending training on the National Framework for NHS Continuing Healthcare (Department of Health 1/10/2009) Guidance Notes The principles of the National Framework for NHS Continuing Healthcare (Department of Health 1/10/2009) will guide the Eligibility Panels decision-making. Panel members need to ensure that the eligibility criteria are applied consistently and equitably to all clients who are presented. All options of rehabilitation and recovery should be offered before assessment for continuing care had taken place. A multidisciplinary team has undertaken a comprehensive assessment of a person s needs for whom eligibility is being decided upon. Decision making is supported by proportionate, comprehensive, accurate and timely documentation using locally agreed formats -taking into account all relevant evidence; giving proper consideration to supporting information from The individual, carers or the individuals representatives taking into account only material factors, acting in good faith. In order for effective and equitable decision making the quality of assessments must be of the highest quality. The individual has been informed of the decision to undertake a NHS Continuing Healthcare assessment and that if there is consideration regarding the individual s mental capacity to consent to such an assessment that the multidisciplinary team have clearly provided evidence that they considered and addressed their responsibilities under the Mental Capacity Act The NHS Continuing Healthcare consent form needs to be completed and addressed prior to the NHS Continuing Healthcare assessment process commencing. Page 29 of 57