The value of instructing an Advocate from Compass CHC to attend CHC assessments
Introduction: Compass CHC often receive instructions to act for clients that have experienced significant delays from Health Boards (as is the format in Wales) and CCGs (in England). Delays are often experienced from the point at which the family first initiated a Continuing Healthcare (‘CHC’) assessment, and a full assessment being completed. In cases with an eligible outcome, this inevitably causes a delay in relation to when the individual will be considered to have been entitled to CHC funding.
In a recent case, Compass CHC were instructed due to the family experiencing significant delay in a DST assessment being completed by a Welsh Health Board.
When Compass CHC attended the DST in March 2020, several problems arose…
The unnecessary delay: The family had already experienced a five-month wait, from when they initiated a CHC assessment to the DST scheduled for March 2020. Within that time, a nurse assessor had reviewed the patient (hereinafter ‘Mrs M’) and concluded that it was inappropriate to conduct a DST assessment until Mrs M’s weights were more stable. Mrs M was continuing to lose weight and was considered at risk of malnutrition when the nurse assessor conducted a review. His reasoning for delaying a DST was so that Mrs M’s weight could become stable before an assessment is scheduled.
This same nurse assessor attended the March 2020 meeting where an Advocate from Compass CHC was present. The nurse assessor introduced the meeting as being a further review and stated that he would not be conducting a DST.
The Advocate from Compass CHC explained to the nurse assessor that he had unjustifiably delayed the CHC assessment of Mrs M, had not acted in the best interests of Mrs M and had acted negligently. There is no provision in the framework or other supplementary documentation stating that a patient’s weight must be stable before conducting a DST assessment. Mrs M was at risk of malnutrition and required a dietician referral at his previous review, and this was the same at the meeting in March 2020, where she had lost a further 5kg. Given that there was no justification for delaying a DST assessment, the Advocate submitted that a DST assessment should have taken place during, or immediately following, his review.
The nurse assessor continued to state that he was only instructed to complete a review in the March 2020 meeting and did not have the authority to complete a DST. After much persuasion from the Advocate, and a refusal for the meeting to conclude without a DST being completed given that we had been instructed by the family and costs had been incurred, the nurse assessor eventually agreed to conduct a DST assessment.
The impact on CHC funding: It is normal practice that, where an individual is deemed eligible for CHC, the eligibility period runs from the date of the CHC assessment. As such, it appeared that the Health Board were attempting to delay a CHC assessment by conducting ‘reviews’ of Mrs M and providing the family with unjustified reasons for further delay, i.e., her weights needing to become stable before an assessment.
This means that, if Mrs M was considered eligible at the DST in March 2020, the funding period would commence from the date of the DST meeting. However, had the nurse assessor not caused unnecessary delays leading up to and following his previous review, Mrs M should have been considered eligible from October 2019, given that:
a. The family of Mrs M requested a CHC assessment in October 2019;
b. Mrs M’s care needs in October 2019 were fundamentally the same in March 2020; and
c. There was no reasonable justification for the delay in a DST assessment.
The nurse assessor rejected the Advocate’s submissions in relation to the funding period during the March 2020 meeting, and so the Advocate made a detailed argument to the Health Board on this point within the post DST representations that Compass CHC submit to Health Board’s following a DST assessment.
No multidisciplinary team: Given that the nurse assessor had intended for the March 2020 meeting to simply be a review, and was not expecting to conduct a DST assessment, there was no multidisciplinary team present at the meeting. Specifically, no social worker had been invited to form part of the multidisciplinary team to determine Mrs M’s eligibility for CHC funding. Due to the provision set out in the framework for a multidisciplinary to be present at DST assessments, the Advocate from Compass CHC did not want a procedural issue to arise after the meeting where the decision may be deemed unsound by the Health Board due to the lack of a multidisciplinary team.
As such, the Advocate ensured that:
a. The manager of the care home, who was a registered nurse, was involved in the DST assessment, offered levels of need and made a CHC eligibility decision; and,
b. The nurse assessor submitted the DST documentation to a social worker within 5 days of the March 2020 meeting for a social worker to make an eligibility decision and to sign and date the document.
By doing so, the Advocate was able to ensure, as far as possible, that the DST assessment was procedurally correct. The Advocate followed this up with the nurse assessor the day after the meeting until he confirmed that a social worker had agreed with the eligibility decision and had signed and dated the documentation.
Eligibility criteria – the care domains: At the meeting in March 2020, the Advocate submitted that Mrs M had a Severe level of need in Mobility and a Severe level of need in Cognition, with several High and Moderate needs in other domains. While the nurse assessor had initially suggested that Mrs M had a Moderate level of need in Mobility, after persuasive submissions from the Advocate, the nurse assessor and care home manager agreed with a Severe level of need.
As the multidisciplinary team had agreed that Mrs M had two Severe levels of need, when the Advocate asked them to consider Mrs M’s eligibility for CHC, the Advocate reminded them of the provision in the national framework where it states:
“A clear recommendation of eligibility to NHS continuing healthcare would be expected in each of the following cases:
• A level of priority needs in any one of the four domains that carry this level.
• A total of two or more incidences of severe needs across all care domains.”
Accordingly, the nurse assessor and care home manager recognised they were required to follow this provision and so, concluded that Mrs M was entitled to CHC funding.
Conclusion: This case illustrates the value of instructing an Advocate from Compass CHC. Had Mrs M’s family not had an Advocate attend the meeting in March 2020, no DST would have been completed, the nurse assessor would have conducted a review of a review, likely giving a further unjustified, procedurally unsound reason for delaying a CHC assessment again.
By having an Advocate from Compass CHC, a DST was completed without procedural error and thorough post DST representations were submitted to the Health Board, including all relevant care records and detailed submissions requesting for the CHC eligibility decision to be backdated. Additionally, the Advocate maintained correspondence with the nurse assessor following the meeting to ensure a social worker signed the documentation and to confirm when the documentation was submitted to the Health Board. This meant that the family of Mrs M did not have to attempt to contact the Health Board and, rather, received regular updates from their Advocate.
