Continuing Healthcare (CHC) funding in the UK is designed to cover the full cost of care for individuals with primary health needs. Determining eligibility for NHS Continuing Healthcare funding involves a comprehensive assessment process, and a crucial element of this is the Decision Support Tool (DST). This tool evaluates an individual’s needs across 12 care domains, providing a structured framework to assess the complexity, intensity, unpredictability, and nature of their care requirements. Understanding these 12 care domains within the decision support tool is essential for anyone navigating the CHC assessment process.
The assessment for NHS Continuing Healthcare funding is a two-stage process. Initially, a checklist assessment acts as a screening tool to identify individuals who may require a full DST assessment. Those who pass the checklist then proceed to the second stage: the decision support tool assessment. This in-depth evaluation across 12 care domains is the key determinant of whether an individual will be granted full NHS Continuing Healthcare funding. This funding is not means-tested and is provided when an individual’s care needs are primarily health-related.
The decision support tool assessment is conducted by a multi-disciplinary team of health and social care professionals. This team carefully considers the individual’s needs in each of the 12 care domains. For each domain, a level of need is assigned, ranging from no needs to priority needs, depending on the severity and complexity of the issues presented. Let’s delve into each of these 12 care domains to understand what they encompass.
1. Behaviour
The behaviour domain focuses on ‘challenging behaviour’. This isn’t just about being difficult; it encompasses actions that significantly impact care and well-being. Examples of challenging behaviour include aggression (physical or passive), severe disinhibition, persistent noisiness or restlessness, resistance to essential care, rapid changes in mental state, extreme frustration due to communication difficulties, and actions that put themselves or others at risk, including a high risk of suicide. This list isn’t exhaustive, but illustrative of the types of behaviours considered.
Needs in the behaviour domain are graded on a scale from no needs to priority, progressing through low, moderate, high, and severe levels before reaching priority.
2. Cognition
This domain assesses an individual’s cognitive function and any impairments they may have. The level of need is scored from no needs to severe, with levels including low, moderate, and high in between. Notably, there is no ‘priority’ level in the cognition domain.
A severe level of need in cognition indicates significant cognitive impairment. This could manifest as severe short-term memory problems, profound disorientation regarding time, place, or person, an inability to assess basic risks even with supervision, and complete dependence on others for anticipating basic needs to ensure safety.
3. Psychological and Emotional Needs
The psychological and emotional domain considers the impact of an individual’s mental and emotional state on their overall care needs. The levels of need in this domain range from no needs to high, without severe or priority categories.
This domain evaluates two distinct aspects: first, the presence of mood disturbances, hallucinations, anxiety, or periods of distress; and second, whether the individual has withdrawn from care planning, support, or daily activities due to their psychological or emotional state. These are assessed separately to acknowledge the diverse ways psychological and emotional needs can manifest, from severe distress and anxiety to withdrawal and disengagement.
4. Communication
This domain assesses an individual’s ability to reliably communicate their needs. The levels of need range from no needs, low needs, and moderate needs up to a maximum of high needs.
A high level of need in communication signifies an inability to reliably communicate needs at any time, in any way, even with assistance. This complete communication barrier necessitates that all of the individual’s needs must be anticipated by caregivers. This situation might arise in cases of severe cognitive impairment, such as advanced dementia or Alzheimer’s disease, where speech may be present but the ability to reliably convey needs is severely compromised.
5. Mobility
The mobility domain evaluates various factors related to an individual’s physical movement and stability. The levels of need range from no needs, low needs, moderate needs, and high needs up to severe needs.
Mobility issues can present in many forms, from a high risk of frequent falls to being completely bedbound and unable to assist with transfers or repositioning. Other considerations include the need for careful positioning to prevent physical harm or muscle tone loss, and issues related to involuntary spasms or contractions that could endanger the patient or others. This domain offers a comprehensive assessment of mobility challenges, going beyond just fall risk.
6. Nutrition
The nutrition domain focuses on risks related to malnutrition, dehydration, and aspiration of food and fluids. It also considers significant weight loss or gain. The levels of need in this domain extend from no needs up to and including severe needs.
Aspiration risk, often linked to swallowing difficulties arising from conditions like Parkinson’s disease or stroke, is a key consideration. Significant weight changes, whether loss or gain, are also evaluated within this domain.
7. Continence
This domain assesses an individual’s continence needs. The levels of need range from no needs and low needs, through moderate, to a maximum of high needs.
A high level of need in continence is assigned when continence care is complex and requires timely, skilled intervention beyond routine care. Examples include frequent bladder wash-outs or re-catheterization. Double incontinence alone typically falls under the moderate level of need, according to DST criteria, unless it involves these complex care requirements.
8. Skin
The skin domain encompasses all aspects of skin-related problems. The levels of need range from no needs to low, moderate, high, and severe.
Key factors include open wounds and pressure sores. The grading of pressure sores directly influences the level of need assigned. For instance, a grade 4 pressure sore, characterized by ‘full thickness skin loss involving damage or necrosis to subcutaneous tissue,” is categorized as a severe need.
9. Breathing
This domain assesses any breathing-related issues. Examples include Chronic Obstructive Pulmonary Disease (COPD), emphysema, or recurrent chest infections leading to breathing difficulties.
The levels of need in the breathing domain include no needs, low, moderate, high, severe, and priority. A priority level of need is assigned when an individual cannot breathe independently and requires invasive mechanical ventilation.
10. Drug Therapies and Medication: Symptom Control
This domain evaluates both the complexity of an individual’s medication regimen and any pain management needs.
The levels of need range from no needs, low, moderate, high, and severe up to priority needs.
Severe pain, in this context, is defined as severe, recurrent or constant pain that does not respond to treatment, representing a severe level of need in this domain.
11. Altered States of Consciousness
Altered states of consciousness include conditions that affect awareness, such as Transient Ischaemic Attacks (TIAs), epilepsy, and vasovagal syncope.
The levels of need in this domain range from no needs, low, moderate, high, and priority. Interestingly, there is no ‘severe’ level between high and priority in this domain, unlike some others.
A priority level of need for altered states of consciousness applies to individuals in a coma or those experiencing altered states of consciousness most days, which are unresponsive to preventative treatment and pose a severe risk of harm.
12. Other Significant Care Needs
The twelfth domain is intentionally broad. It acknowledges that individuals may have significant care needs that don’t neatly fit into the preceding 11 domains. This domain ensures that unique and substantial needs are considered, preventing an underestimation of an individual’s overall care requirements due to the limitations of a standardized assessment tool. It’s a crucial safety net to capture individual complexities.
Conclusion
Understanding these 12 care domains of the decision support tool is fundamental to grasping how eligibility for NHS Continuing Healthcare funding is determined. Each domain provides a specific lens through which an individual’s needs are assessed, ensuring a holistic evaluation of their health and care requirements. If you have questions about Continuing Healthcare funding or the decision support tool assessment, seeking expert advice is recommended to navigate this complex process effectively.
