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The patient, who had been diagnosed with Parkinson’s Disease and Dementia, had a number of severe health issues and required constant supervision during waking hours. She lived at home with full-time care provided by live-in carers and paid for privately by the family.
BaNES (Bath & North East Somerset) Clinical Commissioning Group outsource their services to external company Sirona Care & Health to undertake clinical assessments for continuing healthcare funding.
Compass CHC was brought in by the family to oversee the appeal process after BaNES Clinical Commissioning Group deemed that the patient didn’t have primary health needs and denied the family access to NHS continuing healthcare funding
The family of the patient thought her needs were sufficiently complex, intense and unpredictable in their nature to be considered a ‘primary health need’ which would have entitled her to NHS continuing healthcare funding to pay for the cost of her care in full. This is entirely separate to social care funding and the fact that she had assets over the threshold of £23,250 was irrelevant.
Accordingly, the patient’s family requested that an assessment of their relative's care needs be undertaken. These services are commissioned to an external company, Sirona Care & Health, in Bath.
An assessment took place in the spring of 2015 following an initial checklist assessment 3 months earlier.
The first issue here is that the National Framework for continuing healthcare funding states that the entirety of the process should be completed within 28 days of the date of the initial checklist. In this instance, it was some 3 months before the secondary assessment, the Decision Support Tool (DST) assessment, was undertaken.
Secondly, and separately, there was not a representative from the local authority in the form of a social worker in the DST assessment, it is set out in the National Framework that there must be a multi-disciplinary team panel of individuals involved in the assessment to look at matters from both a clinical and social care perspective. Clearly the absence of the social care representative meant this was not possible in this case.
Despite the recommendations of the nurse assessor present at the Decision Support Tool assessment, Sirona Care & Health - the company acting on the CCGs behalf - down scored and downgraded the levels of need the nurse assessor had awarded at the initial assessment and the patient was deemed ineligible for funding.
It was at this point that the family contacted Compass CHC who instigated an appeal of this assessment.
As part of the appeal process an independent panel must be convened to review the initial recommendation and afford the family an opportunity to explain why they disagree with the outcome and how the evidence contradicts the negative decision. This took place in early 2016 (a year after the initial checklist assessment) and Tim Davies of Compass CHC represented the family’s interests as the advocate.
From the outset, the appeal meeting was farcical in that the ‘independent’ chairperson was a Director of Sirona Care & Health. The attitude of the chairperson was unprofessional and bordering on aggressive and the whole process was entirely unsatisfactory from the perspective of the family. Despite presenting the panel with clear evidence of the incorrect scores in relation to levels of need provided throughout the initial assessment and the clear primary health need that warranted the funding, the outcome of the appeal panel was that the initial decision stood.
Therefore, the family advanced through Compass CHC to an appeal at NHS England level. This took place in late 2016 where Mr Davies again represented the families’ interests and presented matters to the NHS England panel.
Examples were provided of issues which occurred when the CCG scored the patient’s needs as merely moderate in rather than high across a number of domains (or categories).
The evidence and the view of Compass CHC was that as a minimum the level of need for the behaviour domain was in fact high because the restless behaviour and the need for constant supervision presented a predictable risk of harm to the patient. In the domain of nutrition, the level of need was recorded as being ‘moderate’ by the BaNES Clinical Commissioning Group but the evidence, in Compass’ view supported a higher classification. It was highlighted that the patient satisfied the requirement of being nutritionally at risk given that she was on a fortified diet requiring dietary supplements to keep her weight at a stable level. Further, there was a risk of aspiration of food associated with the Parkinson’s Disease and the fact she had swallow function issues. In light of the fact the patient had a BMI of less than 18 and a malnutrition universal screening tool scoring of 2 which indicated she as at high risk of malnutrition, the only conclusion which could be reached was that the patient was at high risk of malnutrition and a high – not moderate – level of need was the appropriate assessment.
In the domain of drug therapies, the Clinical Commissioning Group scored the level of need as being moderate whereas Compass CHC thought the evidence supported a high domain. Indeed, the nurse assessor at the original assessment recorded a high level of need and this was downgraded by Sirona and BaNES CCG to ‘moderate’. Due to the Parkinson’s medicine needing to be administered at very set timeframes and monitored for its effectiveness and symptom control, Compass CHC reviewed that these potential fluctuations of condition meant that the only sensible outcome was a ‘high’ level of need. Further, Compass CHC argued that in light of these increased issues the needs were sufficiently complex, intense and unpredictable in their nature to warrant the consideration that the needs were primarily health needs and there was a funding entitlement.
The NHS England panel agreed and continuing healthcare funding was awarded and backdated to the date of the original Decision Support Tool assessment 21 months previously. In totally Compass CHC managed to secure c£90,000 for the family.
This goes to show that unfortunately when the National Framework is ignored, incorrect decisions can be made at every stage of the continuing healthcare funding process and even when the initial appeal process has been exhausted there is justification to pursue matters further to ensure that an individual receives the funding they should be entitled to.
When Mr CF contacted us to instigate the continuing healthcare funding process, Mrs JF (his mother) was living at home with agency carers attending 4 times a day. In 2016, Mrs JF suffered from ulcers on her leg which did not respond to treatment. Consequently, she required a leg amputation in May 2016 which brought with it many challenging needs. For example, Mrs JF is now unable to weight bear and refuses hoisting due to her level of pain and impaired cognition. Mrs JF suffers with severe pain which is not responding to medication. She is also allergic to antibiotics and some pain relieving medication which further complicates matters. Such a high level of pain and the inability to walk has had a direct impact on Mrs JF’s psychological and emotional status. Mrs JF has also lost a significant amount of weight. In addition, Mrs JF has a cognitive impairment which has an impact on her behaviour (due to lack of understanding) and her ability to reliably communicate her needs.
We gathered and reviewed the records in the case and drafted detailed representations to support our case for continuing healthcare funding. We then submitted representation to the CCG (Clinical Commissioning Group) and requested a date for the CHC Checklist (the first stage of the continuing healthcare process).
Our advocate, Natasha, attended the Checklist in January 2017. It was evident that the recent carer’s notes where not in sufficient detail at the Checklist stage, however we were able to argue the levels of need. We obtained a positive Checklist which triggered for a full assessment. Natasha advised the care agency to re-write their Care Plan to ensure that it accurately reflects Mrs JF’s needs and asked carers to write in the daily notes when Mrs JF was suffering from pain, refusing care and when she was tearful and upset. Additionally, Natasha advised Mr CF (who also cared for his mother) to keep a detailed diary regarding his mother’s pain, behaviour and psychological and emotional state.
Due to our attendance at the Checklist, we were able to ensure that the levels of need were not underscored (which could put a halt on the entire process). Further, we could make sure that the supporting evidence was in place for the DST stage. Supporting evidence is crucial, as the DST is an evidence based exercise. Natasha presented the case for funding at the DST in March 2017and secured continuing healthcare funding for Mrs JF.
The Compass CHC team was approached by a lady whose mother was in hospital following a serious fall. The hospital was seeking to discharge her home with a care package of 4 carers a day however the lady was completely immobile with a number of severe, complex health conditions, including a diagnosis of terminal cancer.
Her daughter felt that the care package offered was completely insufficient and her mother required 24 hour care but the hospital discharge team and social services were adamant that her mother should be discharged home. We intervened and drafted a letter to the discharge team outlining why the patient’s requirement for care was a significant health need and how the individual was entitled to NHS continuing healthcare funding to meet the cost of her care. Further, we explained that a “fast track assessment” was appropriate.
Following receipt of our representations the hospital discharge team reviewed the position and fast track funding was provided. The patient was discharged to a nursing home with the full care cost being met via continuing healthcare funding.
We can assist at every stage of the process. It is not necessary to wait for a negative outcome before contacting us for assistance; we can provide support and assistance from the very outset and help influence assessments in the patient’s favour where they ought to be receiving continuing healthcare funding.
In this case we assisted in successfully influencing the outcome of our client’s assessment for continuing healthcare funding prior to their discharge from hospital. Whilst in hospital, the patient was advised they were not well enough to return to their own home and required nursing care but, due to owning their own home, they would have to meet the cost of care themselves.
The Compass CHC team were instructed to take on the case by the patient’s power of attorney. We secured the hospital records and, having reviewed them and cross referenced the patient’s condition to the National Framework criteria for continuing healthcare, it was clear that the patient satisfied the eligibility for NHS continuing healthcare funding.
We drafted detailed representations explaining the basis for the patient’s entitlement to the funding and highlighting the independent evidence contained in the hospital records that supported this. The assessment team agreed with our representations and the funding was awarded, despite the fact that a matter of weeks earlier they had attempted to discharge the patient on a fully self-funding basis without any NHS funding to meet her care costs.
This is another example of how we were able to assist at a very early stage in the process, while the patient was still in hospital and before discharge.
The Compass continuing healthcare team were contacted by the spouse of a patient who was in hospital and suffering from severe issues with their mental wellbeing and behaviour as a result of dementia.
The hospital had advised the family that the patient would need to be discharged to a nursing home and that they would have to pay these costs in full. The family researched the point and contacted the Compass CHC team for advice.
Having reviewed the position in terms of the patient’s health needs, we were able to advise that they met the NHS criteria for continuing healthcare funding. We intervened on their behalf and took over dealing with the hospital team. The hospital discharge team had incorrectly applied the continuing healthcare funding process, for example the family were not involved or afforded an opportunity to contribute to the assessment process. We requested that a new assessment be carried out where the procedures were correctly adhered to and we drafted representations detailing what the scorings for the assessment should be based upon the needs of the patient.
We worked closely with the family ensuring that they were fully prepared for the assessment and armed with our representations when attending the meetings. NHS continuing healthcare funding was awarded and the patient was discharged to a nursing home with the full cost met by NHS continuing healthcare.
Mr B was admitted to a care home after being discharged from hospital. Despite clear guidance that at such a time it is good practice to assess someone’s eligibility for Continuing Healthcare funding prior to discharge, no assessments were done. The care home was costing Mr B £1000 per week and so his family got in touch with us. We were able to secure both the hospital records and those from the care home, draft detailed representations and instigate the NHS assessment process. We were soon able to organise a Checklist assessment. Although there were some obvious attempts to down score at the Checklist, our advocate was able to ensure that Mr B’s case progressed to the next stage of the assessment process where the Decision Support Tool (DST) is completed. Again, our advocate attended the DST and although there were some attempts to underscore and downplay the health needs of the patient contrary to the independent evidence, we were able to secure full NHS Continuing Healthcare funding.
Mr M was living in a care home for 4 years prior to Compass CHC being instructed. Compass CHC were contacted by his family as his funds were running low and they felt that he shouldn’t be paying for his care as his needs were primarily health needs. On securing the available care records we drafted detailed representations supporting the contention that the needs were primarily health needs. Thereafter we instigated the NHS assessment process.
The Clinical Commissioning Group (CCG) initially, incorrectly, refused to complete a Checklist as they stated it was not their responsibility to do so. On referring them to the National Framework they eventually agreed to complete the assessment. With our advocate in attendance we were able to ensure that Mr M progressed on to the Decision Support Tool (DST) assessment. Even though he more than met the threshold the CCG were reluctant to compete the DST and wanted to put it on hold. They then wanted to complete a further checklist. With our persistence and knowledge of the National Framework we were able to get them to agree that the mistake was theirs. They then completed a DST with our advocate in attendance and we were able to secure full funding. This decision was reviewed after 3 months, again with our advocate in attendance, we were able to ensure the funding would be in place for a further 12 months.
We were contacted by Mrs P’s family after she had moved from home into a nursing home. On securing the available care records, we drafted detailed representations supporting the contention that the needs were primarily health needs. Thereafter, we instigated the NHS assessment process. A few days before the checklist, Mrs P fell and fractured her pubic rami, which meant she went from being able to mobilise independently to being nursed in bed or a chair. She was also in significant pain due to the fracture. With the assistance of our advocate, Mrs P passed the checklist and a full assessment was triggered.
Around three weeks later, a full assessment was completed. A multi-disciplinary team was present, with a nurse assessor and social worker. Mrs P had an over-arching diagnosis of dementia, but she also had significant psychological and emotional needs caused by paranoid hallucinations which meant she would not leave her room and would often not engage with care staff. In addition, she was still immobile and experiencing pain from her fracture pubic rami which meant she could no longer independently mobilise or reposition. Given her cognitive impairment and significant psychological and emotional needs, there was significant complexity in Mrs P’s care. With the assistance of our advocate, the most appropriate levels of need were secured during the assessment and the complexity and intensity of Mrs P’s care was highlighted, which led to funding being secured. Click here to read the client testimonial
Prior to instructing Compass CHC, Mrs IB had been a resident in the care home for over 4 years. During which time, no Continuing Healthcare assessments had been completed, despite it being good practice for an assessment to be completed when somebody enters a care setting.
Compass were contacted by Mrs IB’s son and on receipt of instructions, were able to secure the care homes records in support of an application. Having reviewed the records we were able to draft a detailed letter of representations setting our why we were of the view that Mrs IB should be in receipt of full NHS Continuing Healthcare funding. These were then submitted to the CCG to instigate their assessment process.
On receipt of our letter, the CCG stated that we should contact the community nursing team, who would be able to complete the Checklist assessment, as the initial screening tool. The community nursing team denied responsibility and referred us back to the CCG, who in turn passed the responsibility on to the care home, who they stated needed to ask the District Nurses to complete the assessment. The care home initially refused to make such a request to the District Nurses, as they believed that they could meet IB’s needs and so a Checklist was not necessary. However, CHC funding is not about whether the patients’ needs can be met and so we persevered with our claim. Eventually, the CCG wrote to the District Nursing team requesting that they complete the Checklist. Despite this instruction from the CCG, the District Nurses claimed they could only complete the assessment if they received a referral from the GP. We therefore contacted the GP requesting the referral. The referral was eventually made and the District Nurses arranged the Checklist. However, they failed to inform the relevant parties until 10 days after the proposed date of completion. This clear lack of communication was unsatisfactory and so a request was made for a further date, to allow all those involved to attend. Despite their involvement so far and further correspondence from the District Nurses, they eventually and rather out of the blue, wrote to the CCG informing them that they were refusing to complete the Checklist assessment.
When we challenged the CCG on the above point, we were informed that they would accept a Checklist from either a nurse at the care home or a social worker. The issue was that the care home was residential only and so they had no registered nurses working at the home and the local authority confirmed they would only send a social worker for the final DST assessment and not the Checklist.
The above was clearly not acceptable and so we made a formal complaint to the CCG, setting out that under the National Framework for NHS Continuing Healthcare, they were the body with overall responsibility for ensuring that everybody who should be assessed, is. We also offered an alternative option at this point, which was for Compass to arrange for an independent nurse assessor to complete the Checklist assessment. The CCG eventually agreed to this plan and so the nurse, along with one of our advocates attended the care home.
IB passed the Checklist and this was duly submitted to the CCG, who in turn arranged for the final assessment, the Decision Support Tool (DST), to be completed. With the assistance of one of our expert advocates at the DST, Mrs IB was assessed as being eligible for full NHS continuing Healthcare.
This case illustrates the obvious complexities of the CHC process and the minefield that must be navigated even just to arrange the first assessment. Not one of the professionals involved in her care wanted to step up and take responsibility for completing the assessment. Neither did those professionals deemed responsible for the CHC process by the Department of Health, through the National Framework. This would have left IB in a veritable ‘no-man’s land’, whereby although she was clearly eligible for the funding, it would not have been put in place as the process was simply not completed. However, with our tenacious approach and knowledge of the National Framework, as well as the eligibility criteria, Compass were able to find a workable solution to the problem and secure full funding on an ongoing basis.
We were initially instructed in May 2016, where we looked to pursue a standard case to secure funding in place going forward for Mrs Seddon. Unfortunately, however, Mrs Seddon passed away in February 2017 and so we then proceeded with the case with a view to claim back previously incurred care costs. We gathered and reviewed medical records to cover the period that Mrs Seddon was in Brendoncare care home, which was from April 2014 up until her passing in February 2017. We then drafted comprehensive representations outlining evidence to support the contention that Mrs Seddon was eligible for full CHC funding throughout this period.
On the basis of our letter of representations alone, the CCG agreed that Mrs Seddon was eligible for CHC funding throughout the entire period from 01/04/2014 – 27/02/2017. This will result in an approximate reimbursement of just below £150,000, as the care fees were approximately £4,400 per month.
Do not delay, contact us today. We specialise in securing funding from day 1 and assisting families with the process from the outset. Don’t wait until a negative decision has been made and it is then necessary to have to appeal the outcome. This can take many months and all the while the patient will be having to pay the cost of their care.
Did you know?
If an individual is approaching the end of their life then a “fast track” Continuing healthcare funding assessment may be appropriate. This enables the individual to receive prompt NHS funding to meet the cost of care at the end of life stage.