The National Framework for NHS continuing healthcare (“CHC”) and NHS funded nursing care has recently been revised, with tools and revisions coming into place in October 2018.
CHC: Framework Revisions
The revised framework aims to provide greater clarity around the provision of continuing healthcare funding. The amendments make no changes to the eligibility criteria:
PATIENTS WILL STILL BE ENTITLED TO CONTINUING HEALTHCARE IF THEY HAVE A PRIMARY HEALTH NEED
However, the revisions provide clarity on the responsibilities of health and social care providers, and highlights the following1:
1. The expectation that CHC assessments will take place outside of an acute setting.
2. Care package reviews are to be assessed for appropriateness on a regular basis (3 and 12 months), not to reassess eligibility (unless care needs have increased or decreased).
3. The eligibility for a CHC package of care is to remain the same, based on a ‘primary health need’.
CHC funding allocation continues to be a multi-disciplinary decision. CHC providers work closely with local authorities to assess patients’ needs, but this arrangement can prove difficult with limited capacity in health and social care providers to find mutually convenient times to determine a multi-disciplinary decision. Collaborative working is required to remove delays within the CHC process. The new guidance gives commissioners the opportunity to review their current service model. GE Healthcare Partners recently worked with a large CHC provider to review their current service arrangements, and to recommend initiatives that would help to increase the productivity and effectiveness of the service, to comply with the National Framework standards.
A Productive Delivery Model
Increasing the productivity of CHC services goes beyond cost-saving initiatives. CHC providers need solutions that improve patient experience, speed up decision-making, and improve placement of patients into the most appropriate care setting. Services need to be agile to respond to fluctuating demand. Outside of framework assessments and reviews, the services need to be able to respond to ad-hoc requests from external partners, such as safeguarding requests and reviews due to increased patient need.
One of the core factors that limit CHC providers meeting framework obligations is a lack of clinical capacity to undertake assessments and reviews. In the provider that we recently worked with, clinical resource was often utilised to complete non-clinical tasks, and this meant that the amount of clinical time available to complete assessments was reduced. Where a health system does not yet have integral ‘discharge-to-assess’ processes, this can result in extended waits in hospital for assessments. Equally, having constrained time to undertake reviews in the community means that patients may be on packages of care not consistent with their health needs.
Simple measures- such as reviewing the end-to-end process and eliminating unnecessary administrative duplication - can significantly increase the ability to complete the assessments and reviews required.
Understanding the current case load- potentially using weighted case load management tools- will help service providers to allocate cases to the correct professional. This improves continuity of care for the patient, whilst also ensuring that teams of nurse assessors have a defined workload that they can hold accountability for managing. Supplementing this with clear expectations for how assessments and reviews should be undertaken (for example, how they should be scheduled, recorded in the database and ratified in a standardised way) will enable service leads to have visibility and provide intervention where the process has gone off track or the demand outweighs the resource available.
For the service that GEHCP recently worked with, we evaluated how the models and volume of work varied across multiple different teams (see below), and what tasks the nursing teams were undertaking that could be impacting on their ability to complete patient assessments. As can be seen, the two teams with the highest volumes of assessments either complete multi-disciplinary Decision Support Tools (DSTs) electronically, or do this partly (some members of Team B choose to complete paperwork electronically). Team A also has administrative support for scheduling and scanning:
Applying a ‘lean’ approach to this evaluation to identify what tasks are less ‘value-adding’ to patients and the service can support vital service improvements. Reducing the administrative burden and utilising technology can free up critical clinical capacity to focus on timely assessments and reviews within framework standards. This has a whole health system benefit: getting patients assessed quickly, and reviewed within standard framework helps support good patient flow through the acute and non-acute setting. It is also cost effective, ensuring that funding is allocated correctly.
The Multi-Disciplinary Team
To continue this joint working, CHC providers could take this opportunity to think about ways in which health and care service representatives can support the redesign and delivery of CHC services. This may include the ‘discharge to assess’ process by which a patient can be discharged from the acute setting prior to full CHC assessment (a standard which supports hospital flow and ensures that patient assessments reflect a more accurate picture of the patient’s ongoing care needs). Considering both the care capacity and staffing needed to successfully implement such a model requires engagement from health and social care partners across broad settings.
Within the CHC assessment itself, social care professionals are integral in the multi-disciplinary team. However, they do not always have the capacity to respond effectively to the demands of CHC. The Framework outlines that the two (minimum) professionals who are part of the MDT must be involved in the patient’s care and be knowledgeable about their health and social care needs. The list of potential professionals within the Framework is much wider than CHC and Social Care professionals: Discharge Nurses, GPs, Occupational Therapists and Dieticians can all form part of the MDT. A multi-disciplinary workforce within CHC providers would undoubtedly enhance service delivery, as well as ensuring a holistic assessment for patients.
Taking stock of the current CHC service model, and the staff required to deliver it, provides an opportunity to work with partner organisations across the health and care landscape to deliver CHC services that are high quality, effective, and timely for patients and for the health service, as well as aligning local services to the National Framework.
Maintaining a CHC service that offers high quality and timely assessments and reviews requires a whole system approach. For CHC providers to work within framework standards, the CHC process must be effective and productive. Working with partners to design an end-to-end process will be of benefit to the whole health system, with benefits including better patient flow and more cost-effective services.
This article was written by Molly Kavanagh, Senior Consultant at GE Healthcare Partners.