Your CHC Appeals support thread

[luggy]

Result - Local Resolution Meeting

I am pleased to report that the ICB have overturned their original decision and have found that mum was eligible to receive CHC for the period considered at the LRM.

Mum was found to have Primary Health Needs in 3 out of the 4 Key Indicators - Nature, Intensity & Complexity. They even upgraded her score in the Drug Therapies domain from 'High' to 'Severe' which was a bit of a shock as we hadn't asked for it.

We're not at the end of the road yet as there is still another period to be investigated retrospectively, but this is a huge step forward. It also gives me more confidence in challenging the current MDT debacle which was abandoned unfinished by the assessor last week - no further movement on that yet.

I had legal representation. I don't think I could have done it without legal help. The Chairperson at the LRM commended my legal representative for her detailed submission of the facts. I couldn't have done that.

Time for a small celebration.

 

[Kevinl]

Round of applause, well done you.

 

[Dave63]

Fantastic news @luggy

A small celebration is definitely called for - just make sure it's in a large glass

 

[sdmhred]

Great news 😊😊👏👏

 

[helpingpeggy]

Hello, please can I ask for advice. My mum’s initial CHC screening assessment was done today. We came to the psychology category and I said that she was highly anxious all the time and this week has been referred to the older persons mental health team. At that, the assessor said she couldn’t continue the screening as mum was not yet “optimised” and we should restart the screening assessment once she’d been seen by the OPMH team and their recommended interventions had been tried. I argued that the screening was an assessment of her needs now, that there may be a long wait for the OPMH team and no certainty that she’d change once they’d seen her. But I couldn’t persuade them. Any advice? Many thanks

 

[Dave63]

Hello, please can I ask for advice. My mum’s initial CHC screening assessment was done today. We came to the psychology category and I said that she was highly anxious all the time and this week has been referred to the older persons mental health team. At that, the assessor said she couldn’t continue the screening as mum was not yet “optimised” and we should restart the screening assessment once she’d been seen by the OPMH team and their recommended interventions had been tried. I argued that the screening was an assessment of her needs now, that there may be a long wait for the OPMH team and no certainty that she’d change once they’d seen her. But I couldn’t persuade them. Any advice? Many thanks

The governments own guidance (grey box bottom of page) has six criteria for when a checklist should not be completed. Optimisation is not one of them. We had this issue and the ICB refused every argument we put to them until we got mums MP involved.

NHS continuing healthcare checklist guidance

www.gov.uk

As advised in the article below ask the ICB to point you to the section of the National Framework which details that not being 'optimised' is a valid reason for denying completion of a checklist assessment.

Has your relative been “optimised?” NHS invent more delays to avoid CHC Funding… - Care to be Different

We have spoken to a number of people over the past month who have been refused assessment for NHS Continuing Healthcare Funding (CHC) because their relative is not “optimised”. This seems to be the latest NHS buzzword, as it is not mentioned anywhere in the National Framework. We told you about...

caretobedifferent.co.uk

As an aside, I noticed during our battles that some portions of the CHC process are sub-contracted out to third party companies. Our 'optimisation' issue was instigated by Virgin Care who were contracted to arrange assessments. After getting CHC funding the 3 month review was carried out by an outside agency. It does make me wonder whether there is a conflict of interest issue with these third parties trying to meet contractural targets instead of ensuring the guidelines are followed to ensure fair and proper assessments?

 

[helpingpeggy]

The governments own guidance (grey box bottom of page) has six criteria for when a checklist should not be completed. Optimisation is not one of them. We had this issue and the ICB refused every argument we put to them until we got mums MP involved.

NHS continuing healthcare checklist guidance

www.gov.uk

As advised in the article below ask the ICB to point you to the section of the National Framework which details that not being 'optimised' is a valid reason for denying completion of a checklist assessment.

Has your relative been “optimised?” NHS invent more delays to avoid CHC Funding… - Care to be Different

We have spoken to a number of people over the past month who have been refused assessment for NHS Continuing Healthcare Funding (CHC) because their relative is not “optimised”. This seems to be the latest NHS buzzword, as it is not mentioned anywhere in the National Framework. We told you about...

caretobedifferent.co.uk

As an aside, I noticed during our battles that some portions of the CHC process are sub-contracted out to third party companies. Our 'optimisation' issue was instigated by Virgin Care who were contracted to arrange assessments. After getting CHC funding the 3 month review was carried out by an outside agency. It does make me wonder whether there is a conflict of interest issue with these third parties trying to meet contractural targets instead of ensuring the guidelines are followed to ensure fair and proper assessments?

Thank you so much for this. All very useful and I will challenge them.

 

[Dave63]

It may also be worth pointing out to them that the checklist stage is purely a screening process with a deliberately low bar to determine if a person may be eligible for funding. It is not, and should not, be used as a mechanism for determining what medical/psychological interventions a person should be receiving - that's what the full MDT assessment is for.

Also, make sure every communication is done via email so you have everything recorded.

 

[sdmhred]

So we have our MDT on tuesday unless it is cancelled again. As I said before I haven’t had the energy to put in what I should so my game plan is to get representation and appeal BUT I do want to give them an appropriate run for their money on Tuesday. A couple of specific queries I have:

1) I have been keeping a diary of the various medical interventions needed for the past month. This provides evidence of how the domains all interact with each other and the complexity of things. Should I send this to them on Monday or keep it up my sleeve so I can suddenly quote dates and interventions on the cuff?

2) Is there anywhere where ‘they’ outline nature, intensity, complexity so I can prepare using their own language. I’ve got Beacons info but if you quote them back their own guidelines that’s better I asusume.

3) I remain utterly unconvinced that no-one apart from me in the MDT will have much understanding and working knowledge of her rare conditions. This massively impacts as a type 7 stool for example which the home would normally just note and keep an eye on, can have her unconscious within a few hours if not assessed and the medication administered immediately. Do I challenge this knowledge at the start of the meeting or do I ride the meeting and pick this up on appeal.

thank you!

 

[Dave63]

1) I have been keeping a diary of the various medical interventions needed for the past month. This provides evidence of how the domains all interact with each other and the complexity of things. Should I send this to them on Monday or keep it up my sleeve so I can suddenly quote dates and interventions on the cuff?

If it were me I'd probably send it to them beforehand so it's included as part of the evidence to be referred to. After each domain is discussed you'll be given the opportunity to add anything relevant effecting that particular domain. After all domains have been discussed and scored you will again be given the opportunity to make any additional comments so you could refer back to your diary to highlight how you believe the issues you've raised effect her needs in totality (not just individual domains) and how this shows a level of complexity, intensity etc.

2) Is there anywhere where ‘they’ outline nature, intensity, complexity so I can prepare using their own language. I’ve got Beacons info but if you quote them back their own guidelines that’s better I asusume.

Page 114 of the National Framework gives guidance on how the key indicators should be considered.

https://assets.publishing.service.gov.uk/media/64b0f7cdc033c100108062f9/National-Framework-for-NHS-Continuing-Healthcare-and-NHS-funded-Nursing-Care_July-2022-revised_corrected-July-2023.pdf

Looking At The 4 Key Indicators

Looking At The 4 Key Indicators - In order to meet the eligibility criteria for NHS Continuing Healthcare Funding (CHC) your relative must have a 'primary health need'...

caretobedifferent.co.uk

3) I remain utterly unconvinced that no-one apart from me in the MDT will have much understanding and working knowledge of her rare conditions. This massively impacts as a type 7 stool for example which the home would normally just note and keep an eye on, can have her unconscious within a few hours if not assessed and the medication administered immediately. Do I challenge this knowledge at the start of the meeting or do I ride the meeting and pick this up on appeal.

Has a diagnosis or medical opinion been given for the condition? If so, has any evidence been sought from the person who gave the diagnosis or medical opinion? Either way, I'd mention it during the MDT and ask for it to be noted in the DST, it can then be shown to have been ignored or considered if you have to go to appeal.

 

[sdmhred]

Thanks Dave.

I found the explanations on the NSF last night - they are not as detailed as I had imagined. I will add a little blurb on each to the bottom of my diary and send that back.

She has diagnoses from both endocrinology and rheumatology but no I don’t think their opinion has been sought. The GP struggles with the complexity - the endo team have told me I have to get him to ask for help as they cannot just offer it 🙈🙈(how am I supposed to do that 😱😱)…..The home were sent a 3 day behaviour chart to fill in which was odd as I am not thinking she is eligible on behaviours and 3 days is not long enough anyway! My impression is that this is being seen as a tickbox exercise for FNC rather than a proper CHC assessment. I think she may be eligible due to the complexity of her physical health issues whereas they see her in a dementia home (needed due to anxiety over personal care) and thus not worth even worth assessing.

My own issue is that due to her complexity I have to keep a real eye on how she is being treated and just don’t have the time or head space for doing this justice. Hence I will employ someone if needed. It made me sad yesterday that I spent my visit time going through each domain and calculating her ‘needs’ rather than reading to her which is one of our usual pleasures 😢

 

[Dave63]

1) I have been keeping a diary of the various medical interventions needed for the past month.

I forgot to mention that if there is evidence of a variety of medical interventions required by the nursing staff then I would argue that that indicates her needs may exceed the social aspect of her care and therefore exceed the legal limits of what a local authority should provide.

NHS Continuing Healthcare assessments | Care To Be Different

NHS Continuing Healthcare assessments – and the legal limit for local authority care. One vital question to ask the social worker in an assessment...

caretobedifferent.co.uk

 

[Dave63]

My impression is that this is being seen as a tickbox exercise for FNC rather than a proper CHC assessment.

Have a look throught the DST form they must use during the MDT. The first part outlines how the MDT should be conducted and starting at page 43 it outlines how the four key indicators should be considered.

https://assets.publishing.service.gov.uk/media/635165f38fa8f554cb9dc2e8/NHS-continuing-healthcare-decision-support-tool-guidance-2022.pdf

 

[Dirge]

The key words for me would be "complexity" and "totality", I would also try and establish how the key indicators interrelate with each other, I'm on an NHS appeal at the moment and the biggest thing seems to be how the ICB how kept everything isolated rather than taking everything into account.

 

[sdmhred]

Thank you all

i have sent my diary off as well as a brief summary of how the domains interact with each other.

I work for SS in a different capacity and there is no doubt she has a primary healthcare need but whether they will accept it is severe and complex enough I don’t know.

The dementia comes into play as she has zero awareness of a condition which is usually self managed….normally a patient would ‘learn their own body’ and daily adjust their medication and behaviour accordingly but mum cannot do that.

I fully expect to come back to you for advice as to how to seek good counsel but I’m worried they will be rude and dismissive of me in the meeting - my brother will attend for moral support but he has no idea of the systems! 🙈🙈

 

[luggy]

Thank you all

i have sent my diary off as well as a brief summary of how the domains interact with each other.

I work for SS in a different capacity and there is no doubt she has a primary healthcare need but whether they will accept it is severe and complex enough I don’t know.

The dementia comes into play as she has zero awareness of a condition which is usually self managed….normally a patient would ‘learn their own body’ and daily adjust their medication and behaviour accordingly but mum cannot do that.

I fully expect to come back to you for advice as to how to seek good counsel but I’m worried they will be rude and dismissive of me in the meeting - my brother will attend for moral support but he has no idea of the systems! 🙈🙈

@sdmhred you have already been given some excellent advice from other contributors, but I will be keeping my fingers crossed that the MDT goes well for you and your mum.

The only thing I would add, is that make sure you have a copy of the DST with you so that when it comes to scoring each domain you are able to read the descriptors for each level - it is sometimes the case that one word or a short sentence can mean the difference between a 'moderate' & a 'severe'. Good Luck.

 

[sdmhred]

A couple of quickies if u don’t mind:

1) psychological domain - mum became too anxious to stand up - didn’t respond to anything - so they have stopped trying and she is now hoisted….I’m assuming that I can’t take that as a high? Ultimately anxiety has had a severe impact as she is no longer offered the chance to walk or get in the car for me taking her out - which she did daily prior to the anxiety

2) cognition domain - does late stage dementia always a severe…..mum has no awareness of her serious conditions so definitely needs others to protect her from health deterioration.

🤷‍♀️🤷‍♀️🤷‍♀️🤷‍♀️

 

[luggy]

A couple of quickies if u don’t mind:

1) psychological domain - mum became too anxious to stand up - didn’t respond to anything - so they have stopped trying and she is now hoisted….I’m assuming that I can’t take that as a high? Ultimately anxiety has had a severe impact as she is no longer offered the chance to walk or get in the car for me taking her out - which she did daily prior to the anxiety

2) cognition domain - does late stage dementia always a severe…..mum has no awareness of her serious conditions so definitely needs others to protect her from health deterioration.

🤷‍♀️🤷‍♀️🤷‍♀️🤷‍♀️

@sdmhred the psychological domain is one of those which is quite often open to interpretation. The assessor will be looking at your mum's symptoms of distress/anxiety and how these might impact on the delivery of her care - e.g. resistance and/or aggression around personal or healthcare, non-compliance with the administration of medication, long and protracted periods of loud vocalisation which might aggravate other residents and, therefore, compromise your mum's safety. An example of having a severe impact on health or well-being might be being combative when a nurse is attempting to tend to a troublesome pressure sore. Consider whether your mum hallucinates - do they distress her? Can your mum be easily reassured, and if so, for how long? Is your mum prescribed sedatives to keep her calm, and if so, are they effective? Can your mum be too distressed to eat her meals, causing her nutritional status to be compromised? How many care staff are required to provide your mum's care - perhaps 2, but is a 3rd needed to distract? This domain is closely linked to the Behaviour domain, as you've probably guessed.

Cognition - to get a Severe in this domain, you need to demonstrate that your mum cannot follow or participate in conversations, that she is not orientated to time, place or person and cannot identify her own needs. In my mum's case, she is wholly reliant on care home staff to recognise, plan, evaluate and deliver her care. A Severe in this domain would usually result in a High in the Communication domain - but nothing is a given. It also impacts on many of the other domains.

I'm not an expert, but I hope that helps a little.

 

[sdmhred]

Thanks @luggy - I think each domain needs a reference book to aid interpretation!

There is no doubt case law on past cases hence using legal advocate / representation.

Im not expecting much in behaviour but I will ask the awkward questions….

Cognitively - it will be interesting to see what they say….

Is coming over asking lots of difficult questions seen as awkward and annoying and likely to want them rid of you asap or more likely to get a thorough assessment?

 

[Dave63]

The only thing I would add regarding the psychological domain is to consider whether it's neccessary for a nurse to make judgement calls regarding when to administer anxiety medication. If they do then that would be a case of a need which can not be managed safely by carers alone and requires the intervention of a qualified nurse. It's also an area which can have a major impact on the behaviour and drug therapies and medication domains. This is the case with my mum and we argued that because of this her needs were often unpredictable, intense and complex.

Cognition also has crossover with other domains and can be difficult to manage. With mum we find she never has a continuous level of cognition, it varies depending on the time of day and also her level of anxiety. The cognition, behaviour and psychological domains are like a stack of cards for mum, any change in one domain has a big impact on the others.

Is coming over asking lots of difficult questions seen as awkward and annoying and likely to want them rid of you asap or more likely to get a thorough assessment?

No, not at all. I'm not a confrontational person by nature but during the whole process I became reasonably good at politely disagreeing and questioning everything. I think they finally agreed to the funding just to get rid of me If there's anything you're not happy with then question it and if you're still not happy then ask for your disagreement to be noted in the DST. If this was an MDT for one of the assessors relatives you can better your house on the fact they wouldn't worry about asking awkward questions.