Continuing Health Care - Preparing to fight PCT's decision

oldtwin

Just heard on the Welsh news that the deadline for appeals for incorrect decisions on continuing healthcare funding is 4 Dec - help! Has anyone had any experience of applying for retrospective funding when the person receiving care has died. Thanks in anticipation.

Les_Booth

I spoke to the manager of the Nursing Home yesterday to ask if I could see a copy of the assessment that was done prior to granting the funded nursing care. He explained that,because they are an "ethical" home, the home automatically deducts this amount from day 1 and awaits the assessment before claiming this back. The assessment was done last week i.e. the one my sister and I attended.

CHCscandal

Les_Booth wrote: »

I spoke to the manager of the Nursing Home yesterday to ask if I could see a copy of the assessment that was done prior to granting the funded nursing care. He explained that,because they are an "ethical" home, the home automatically deducts this amount from day 1 and awaits the assessment before claiming this back. The assessment was done last week i.e. the one my sister and I attended.

Les

Quite simply, the RNCC element is only assessed and subsequently MAY be awarded AFTER a full CHC assessment,

There is simply no other system in place, RNCC cannot be assessed until all of the CHC process is completed included appeal.

Lovely to hear of an 'ethical' home!.

In Nottingham Area, Wren Hall NH is run by Anita Astle, she appeared on Panorama programme in 2006,w hen they investigated CHC, she received it for 6 of her 24 services users at that time, since then she has successfully obtained it for 19 presently m because she insits on the assessors using the correct process and INTERPRETING it correctly.

When it is interpretted correctly, for presenting health needs ONLY, not inputs for caring for someone, not a need for health care, as health needs may not require any nursing care, Pam coughlan, case 1999, had no nursing needs, what so ever, the judge determined she had health needs that were of a nature that the LA could not place, provide and charge for.

Seems as though the mananger of the home is merely waiting for the LA to arrange the payments.

Has your BiL been placed by the LA/SS?, who has a contract with the home, your sister or the LA?

Finally A social Services assessment is not an assessment for fully funded continuing health care and funded nursing care.

Please do not divulge any financial details to the LA/SS until it is absolutely determined that CHc is not applicable and you are totally happy with that decision.

Katykat

I'd like to tell my tale. Mum has vascular dementia after several TIA's.She was first in NHS psychiactric ward before transfer to residential care 2 yrs ago. I am not aware of any CHC assesment being done prior to the move ( it was done whislt I was on holiday, although I had stated a preference for this home because it had both residential & nursing units. She is self funding & I had to sell her home. 8 months ago she was transferred to the nursing unit as she had become too difficult to manage in residential care. She had what I thought was a CHC assesment at that time ( although today I have found out that it was only the basic checklist)She was judged then to need only NHS contribution. I asked for a review which was today. She scored 1 severe, 4 high, 1 moderate, 3 low &2 no needs. The 2 no needs were breathing & altered conciousness. 2 severes would have automatically qualified her for CHC, but - i think!!!- her particular score means that the PCT gets to decide whether they pay or not. I feel it was a fair assesment apart from the behaviour domain which was awarded high & I felt it should be severe, but I was happy at this stage to just register my disagreement. The decision will take 3-4 weeks. Anyone have any clues about what its likely to be? My PCT scores 28 out of 50,000 in the league table for CHC awards.
I feel mum should have had this assesment 2 yrs ago before discharge from hospital. Up to now, its cost £48,000.

Les_Booth

Interesting development on B.I.L. - message left on answerphone today to say the assessor ".....had come up with a positive check list and it would now need to go to a consistency panel for consideration..." their words not mine - is this yet another layer ?

monkeyspanner

Katykat wrote: »

I'd like to tell my tale. Mum has vascular dementia after several TIA's.She was first in NHS psychiactric ward before transfer to residential care 2 yrs ago. I am not aware of any CHC assesment being done prior to the move ( it was done whislt I was on holiday, although I had stated a preference for this home because it had both residential & nursing units. She is self funding & I had to sell her home. 8 months ago she was transferred to the nursing unit as she had become too difficult to manage in residential care. She had what I thought was a CHC assesment at that time ( although today I have found out that it was only the basic checklist)She was judged then to need only NHS contribution. I asked for a review which was today. She scored 1 severe, 4 high, 1 moderate, 3 low &2 no needs. The 2 no needs were breathing & altered conciousness. 2 severes would have automatically qualified her for CHC, but - i think!!!- her particular score means that the PCT gets to decide whether they pay or not. I feel it was a fair assesment apart from the behaviour domain which was awarded high & I felt it should be severe, but I was happy at this stage to just register my disagreement. The decision will take 3-4 weeks. Anyone have any clues about what its likely to be? My PCT scores 28 out of 50,000 in the league table for CHC awards.
I feel mum should have had this assesment 2 yrs ago before discharge from hospital. Up to now, its cost £48,000.

You may be lucky and get a positive decision but on the scores you mention I would think it's at best borderline. Not because I don't think those scores would indicate a primary health need but just from past experience.

You mention your disagreement with the behaviour score and a past need for psychiactric care. Is your Mum on medication to control mood or behaviour and if so did the assessor score as though this medication was not in place. The framework is clear that a well controlled need is still a need. I would put your objection to the score in writting and ask for it to be submitted to the panel for consideration.

As regards history the panel will only consider the current DST assessment. If you want the past expediture looked at you will need to request a retrospective review.

Prior to your Mum being discharged to the care home 2 years ago a checklist should have been carried out and the patient or representative made aware of the result. This would have given you the opportunity to request a full assessment. The discharge is covered by CRAG proceedures.
The new DST assessment system was bought in on 1 October 2007 so it is possible your Mum may have been discharged under old rules.

Errata

I guess the assessor asseses but doesn't have authority to make a funding decision.

monkeyspanner

Les_Booth wrote: »

Interesting development on B.I.L. - message left on answerphone today to say the assessor ".....had come up with a positive check list and it would now need to go to a consistency panel for consideration..." their words not mine - is this yet another layer ?

Sounds like it, but I have never heard that term before. A positive checklist should result in a full DST based CHC assessment. If you don't get it I would press for one.

Les_Booth

Hi Errata
I think you may be right. Had an interesting discussion with a lady in his department today who left me with the distinct impression that what I had attended was the CHC assessment. Certainly he completed the July 2009 DST which is referred to in her subsequent e-mail and which I am am trying to get a copy of............

To confirm the POA documentation has been received. Someone will be in touch when Decision Support tool is available as I understand you wish to collect it by hand from the office due to current postal strike.

She further went on to say that the DST together with evidence supporting his decisions will be forwarded to the consistency panel for them to decide if B.I.L. will be eligible for funding. Presumably we just have to sit back and wait for their decision ?

CHCscandal

Les_Booth wrote: »

I spoke to the manager of the Nursing Home yesterday to ask if I could see a copy of the assessment that was done prior to granting the funded nursing care. He explained that,because they are an "ethical" home, the home automatically deducts this amount from day 1 and awaits the assessment before claiming this back. The assessment was done last week i.e. the one my sister and I attended.

Presumptious!, CHC ruled out as normal practice!!,

The instructions have always clearly stated that CHC assessment is mandatory and must be assessed first on every case and occasion, this process, starting with the checklist in some case, must be conveyed to the person at the centre /carer/family, even if found not eligible, where appeals can be instigated.


Funded nursing contribution is not assessed at this stage, and cannot be assumed at this stage either.


If the family have , unfortunately, involved the social services, they will attempt to use the single assessment process, which is supposed to include the CHC assessment, SW cannot assess for primary health needs by law, (YET) they have to orchestrate/co-ordinate the nurse assessors to carry out this duty.

Errata wrote: »

I guess the assessor asseses but doesn't have authority to make a funding decision.

The dst assessment has to be completed with at least two assessors/professionals, at the end of the DST the decision is made by the assessors after input from all at the MDA/MDT.

The summary and rationale of the assessors will cover the 'totality of the findings from the dst gathering tool, the family input is vital and must be central to the process, also the person at the centre of the assessment/family/carer must sign to agree or not agree the findings.

This is all clearly documented in the framework responsibilities and directions, nobody else makes the decision.

The assessors are the decision makers, the MDA/MDT is the only chance one gets to fully input to the process.

From this, gatekeeping panels exist, the recomendation of the assessors is then sent to the PCT, who should put the package of care outlined into action.

Most PCT's, if not all, have PCT panels as the next stage, used as gatekeeping functions, in Les's case, maybe it is the 'consistency panel'?

They have the power to overturn the decision, they do not make the initial decision, they merely check/scrutinise, the process etc as do any other panels down the line or up the appeal trail from that point onwards.

Link to details on NHS website below, drop down menus have examples of definite fully funded NHS continuing healthcare cases that clearly meet the primary health need criteria.

The process in the link is summarised but quote clear about what should happen, which clearly doesn't in most area's STILL it seems, there are links from this site to the DoH for the framework and DST.

http://www.nhs.uk/CarersDirect/guide/practicalsupport/Pages/NHSContinuingCare.aspx