Referral Process for Continuing Health Care Needs Assessment

Referral Process for Continuing Health Care Needs Assessment

Referrals will only be accepted once completed by a health care professional who knows the person well i.e. Consultant, GP, District Nurse, Ward Nurse and or a Registered Therapist i.e. Occupational Therapist/Physiotherapist/Registered Social Worker.

Tick on completion

Has the discharge destination been decided? 

Can the person consent to sharing information? 

If the person is unable to consent, has the decision

been made in line with the Mental Capacity Act? 

Have you provided your name and contact details? 

Have all the care domainsbeen completed?

This must include your rationale 

** This referral will not be accepted and will be returned to the referrer unless all the above are completed and relevant information accompanies the completed referral. **

CONTINUING CARE FACT SHEET - PROCESS & CONSENT

‘Continuing Care’ is care provided over an extended period of time, to an individual aged 18 or over, to meet physical or mental health needs that have arisen as a result of disability, accident or illness. The assessment is based on the needs that the person is currently experiencing demonstrating Intensity, Complexity and Unpredictability. NHS Continuing Healthcare’ is a package of care that is arranged and funded solely by the NHS. The National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care, November 2012 (revised). The Continuing Care process involves two stages:

Stage One

NB: before considering the referral to continuing care and completing the Checklist, please ensure that the client/Next of Kin (NOK) contacts the Department of Works and Pensions (DWP) on 08457 123 456 to clarify what benefits are affected by being awarded Continuing health Care funding.

  1. A referral is made by a Healthcare professional i.e.NHS Nursing staff, Social Worker, Community Psychiatric Nurse, GP, Occupational Therapist or Physiotherapist etc (a registered clinician) who is closely involved in your needs.
  1. The referrer makes the initial decision of whether a referral to Continuing Care is appropriate and will involve you or the appropriate person in completing the referral which includes the Department of Health Checklist Tool 2012 to identify your eligibility for a full assessment.

Before completing the referral pack, the referrer is responsible for ensuring that consent is obtained from the client. If capacity is established the client/patient/resident must complete forms 1A and 1B.

  1. Where the person does not have capacity and the family member has a registered Lasting Power of Attorney (LPA) – for Health and Welfare complete sections C, D &E (please ask the family member to bring the original authorisation documentation and check that the document clearly identifies the authorisation to act in the persons best interest and that this has the official court stamp and it is signed and dated.Please ensure that a copy is retained and submitted with the completed referral pack.
  1. Where a client does not have capacity and the family members do not have the LPA Health and Welfare authorisation follow point 5 below.
  2. Where the client does not demonstrate mental capacity, the referrer must undertake a full mental capacity assessment and ‘Best Interests’ Consent to Screening and Assessment for NHS Continuing Healthcare/Funded Nursing Care/Fast Track tool.
  1. Once the referral is complete and sent to the Continuing Care office, it will go through an initial screening to determine whether you meet the criteria for eligibility for a full Continuing Care assessment. The referrer will be informed of the outcome within 48 hours and the family member or Nursing Home will be notified within 10 working days in writing.
  1. If you are found to meet the eligibility for a full assessment, a Healthcare Manager from the Continuing Care department will contact you and/or the appropriate person and referrer, to arrange a suitable date for the assessment to take place.

Stage Two

  1. A comprehensive assessment to support completion of the decision support tool (DST), involving two or more disciplines from the Multi Professional Disciplinary Team (MDT) will then take place including a Social Worker where possible. The Healthcare Manager coordinates the assessment process, which can involve requesting additional supporting evidence from other specialists e.g. physiotherapist, speech and language therapists, consultant neurologists, psychiatrists, care providers, if this is felt to contribute towards your assessment. The Healthcare Manager will also keep you and/or the appropriate person informed and involved in the assessment process.
  1. The assessment is person centred and your involvement and/or the appropriate person are very important to our processes, and we welcome your comments and views as part of the assessment.
  1. Once the multidisciplinary team has reached agreement, it should make a recommendation to the Clinical Commissioning Groupon eligibility. A decision is expected to be reached within 28 days. The DST and recommendation will go forward for ratification, this may involve theOxford Health NHS Foundation Trust Continuing Healthcare panel.The panel members include Healthcare, Social Care and Mental Health representatives. You will be notified of the outcome by letter within 5 working dayswith the full report in approximately 4 weeks. If funding is awarded a review will be undertakenthree months after the initial eligibility decision, in order to reassess care needs and continued eligibility. And that identified healthcare needs are being met. Reviews will then take place annually, as a minimum. The National Framework for NHS Continuing Healthcare and NHS Funded Nursing Care, November 2012 (revised).
  1. There is a process to request a review of the outcome should you disagree with the decision. A copy of this process is attached to the outcome letter.

Mental Health (please confirm below if the client you are referring has ever or is still subject to mental health sections two and or three and or after care 117).

Name and date of birth of client: / Section applicable please circle:
Two
Three
Aftercare 117 / Date: / Signature and role of person submitting declaration:
Address:
Date:

Please return the completed referral to:

Continuing Care Services, c/o Abingdon Community Hospital, Marcham Road, Abingdon, Oxon OX14 1AG. Telephone: 01865 904519 Fax: 01865261754 email:

National Framework for NHS Continuing Healthcare and NHS-funded Nursing Care
OXFORDSHIRE SINGLE ASSESSMENT PROCESS

Surname / NHS no:
Social & Health Care no.
N.I. no.
First Names / Other Ref. No.
Main User Groups
Preferred Name / Permanent Home Address:
Date of Birth / Title
Gender / Male / Female
Marital Status / Postcode
Ethnic Origin / Phone Number
Preferred first language / Work Phone
Number
Interpreter Needed / YES / NO / Mobile Phone
Number
Advocate Needed / YES / NO / E-mail
Address
Current or Previous Occupation / How Long at this address
Religion/
Special needs/
Cultural needs / Accommodation Type/ ownership
Lifeline/
Pendant Alarm system / YES / NO / Household members - Please state if carers or dependants
Communication Aid Needed / YES / NO
Current or temporary address (if different from above):
Phone Number : / Housing Issues and access arrangements: getting in/out of property e.g. ramps, health, key code, etc.
Agency Collecting
Information / Referred by:
Name
Source type / Address
Tel no
Person Collecting Information/title
Service User aware of referral YES / NO
Signature / Date
Time
Method of Contact
Name of Service User: / Reference Numbers: / Date of birth:

OXFORDSHIRE SINGLE ASSESSMENT PROCESS

Emergency Contact Details
NAME:
(Person most close to Service User) / GP NAME:
Relationship:
Is this person NOK: / YES / NO / GP PracticeName
Date of Birth / GP Practice
address
Address:
Postcode / Town
Postcode
Telephone / Telephone
E-mail / E-mail
NAME:
(Main carer if different from above and relationship) / Dentist Name
Date of Birth / Dentist Practice
Name / Address
Postcode
Address:
Postcode
Telephone / Telephone
E-mail / E-mail
OTHER SERVICES CURRENTLY (C) OR PREVIOUSLY INVOLVED (P)
C / P / Contact Name/No / C / P / Contact
Name/No
Social and Health Care / OT (Health)
Voluntary Sector / Physio
Informal Carer / Family / Hospital
Neighbours/
Friends / District Nurse
Domiciliary Care (tick days) / MTWTFSS / Health Visitor
Day Centre (tick days) / MTWTFSS / Warden
Day Hospital (tick days) / MTWTFSS / IICS
Community Meals Service (tick days) / MTWTFSS / CPN
Other Services

Other Information

ALL SECTIONS MUST BE COMPLETED

Admitted from: (if applicable)
Date of admission: (if applicable)
Reason for admission:
(If applicable)
Funding status: Self / State / FNC or other
Medical history (with dates):
Does section 117, S3, MHA apply?
Chosen placement: ( if applicable)
Date of assessment
CONSENT TO SCREENING AND ASSESSMENT
FORNHS CONTINUING HEALTHCARE / NHS-FUNDED NURSING CARE
CLIENT DETAILS:
Patient’s Name: / Date of Birth:
Home Address: / GP:
NHS Number: / Current Location:
Under the Terms of the 2005 Mental Capacity Act, a person must be assumed to have capacity unless it is established that they lack capacity
A.PERSON HAS CAPACITY (NB – If a person has capacity, only they can consent) / Please Tick () as Appropriate
1) I have received information on both the Continuing Healthcare Process and the Appeals Pathway (leaflet and verbal explanation).
2) I am aware that I can withdraw consent an engagement in this process at any time.
3) I agree to an NHS Continuing Healthcare Checklist, Decision Support Tool, Fast Track Pathway and all subsequent reviews being undertaken.
4) I have been made aware that if I become eligible to receive NHS Continuing Healthcare, this may/will affect my eligibility to receive certain benefits paid via the Local Authority. My right to withdraw consent or engagement in this process is not affected.
5) I agree to relevant information being gathered, collated and shared where necessary with relevant professionals, both as part of the PCT NHS Continuing Healthcare process and also, as part of any potential Dispute Resolution or Appeals Process, to include the preparation of the case file for the PCT and for Independent Review Panel at the Strategic Health Authority / Parliamentary and Health Service Ombudsman (PHSO).
I would like the following person / representative involved in the assessment
Name:
Relationship:
Contact Number:
Email:
Signature of Patient: / Date:
Print Name:
Signature of Witness (if individual unable to sign) / Date:
Signature of Witness (if individual unable to sign) / Date:
Patient’s Name: / Date of Birth:
B.CONSENT TO SHARE AND PROTECT YOUR PERSONAL INFORMATION / Please Tick () as Appropriate
I agree that the information provided in this assessment may be shared with Health and Social Care staff, Service Providers who contribute to my care and any agencies acting on behalf of these organisations for the purpose / process relating to NHS Continuing Healthcare.
I understand that this information will be used in the assessment of my eligibility for NHS Continuing Healthcare funding and may be used for the purpose of providing a service, or care to me.
I understand that I may withdraw my consent to share information at any time.
I understand that I have the right to restrict what information may be shared and with whom but that this may affect the provision of care to me.
I have made the following restrictions (if applicable):
I understand that my information will be held securely on paper and on computer in accordance with the Data Protection Act 1998
Signature of Patient: / Date:
Print Name:
Signature of Witness (if individual unable to sign) / Date:
Signature of Witness (if individual unable to sign) / Date:
IF THE PERSON DOES NOT HAVE THE CAPACITY TO CONSENT, THEN A ‘BEST INTEREST’ DECISION OR CONSENT FROM AN INDIVIDUAL WITH A LASTING POWER OF ATTORNEY WILL NEED TO BE MADE
PLEASE PROCEED TO COMPLETE THE BEST INTEREST/ LASTING POWER OF ATTORNEY PART OF THE FORM
Always retain a copy of this form in the patient’s notes
A copy must be forwarded with the Checklist referral to the Continuing Healthcare Team at:
Continuing Care, Abingdon Community Hospital,
Marcham Road, Abingdon, Oxon, OX14 1AG
Tel: 01865 904519 Fax: 01865 261754
A copy must be included in the evidence files for an Independent Review Panel (IRP)
CONSENT TO SCREENING AND ASSESSMENT
FORNHS CONTINUING HEALTHCARE / NHS-FUNDED NURSING CARE
(Individuals with a Lasting Power of Attorney - Welfare)
Patient’s Name: / Date of Birth:
Home Address: / GP:
NHS Number: / Current Location:
Under the Terms of the 2005 Mental Capacity Act, a person must be assumed to have capacity unless it is established that they lack capacity
C.PATIENT DOES NOT HAVE CAPACITY
In many cases, continuing with the assessment process where a person is deemed to lack capacity to consent will be undertaken in line with one of the key principles of the Mental Capacity Act. This is that any act done for, or any decision made on behalf of a person who lacks capacity must be done, or made in the person’s best interests. The exception to this is circumstances where a person has made an Advance Decision, consideration must be given to its applicability and validity in the circumstances
BEST INTEREST CHECKLIST / YES / NO / HOW
I have made every possible attempt to permit and encourage the person to take part in the assessment process
I have tried to identify all the things that the person would take into account if they were making the decision or acting for themselves
I have tried to find out the views of the person who lacks capacity, including part/present wishes and feelings, any beliefs and values and any other factors that the person themselves would be likely to consider if they were making the decision or acting for themselves
I confirm that I have not made assumptions about their best interests on the basis of the person’s age, appearance, condition or behaviour
I have considered whether the person is likely to regain capacity
  • If Yes, can the decision wait until then?
  • If No, is the person likely to regain capacity?
  • If Yes, can the decision wait until then?
  • If No, continue with the Best Interest Assessment

If it is practical and appropriate to do so, consult other people for their views about the person’s best interests. This may include:
  • Any individual appointed under a lasting Power of Attorney
  • Any deputy appointed by the Court of Protection
  • Anyone previously named by the person as someone to be consulted on either the decision in question or similar issues
  • Anyone engaged in caring for the person
  • Close relatives, friends or others who take an interest in the person’s welfare
  • An Independent Mental Capacity Advocate (IMCA)

Where the patient has nobody to act for them other than paid carers, and a decision concerns serious medical treatment or a change in living arrangements (NHS accommodation for 28 days or more, or Local Authority/Care Home accommodation for 8 weeks or more), then a referral must be made to an IMCA
Referral Made By: / Referral Date:
Patient’s Name: / Date of Birth: /
D. PEOPLE CONSULTED
I confirm that I am the attorney appointed under a Lasting Power of Attorney – Welfare made by the person / deputy appointed by the Court of Protection and agree to give consent on the patient’s behalf.
YES / NO
NB: Lasting Power of Attorney (LPA) must have the power / scope to act in the circumstances and the LPA must be registered with the Office of the Public Guardian.
Copy LPA verified / received by referrer - Yes/ No
I have received written / verbal information on both the Continuing Healthcare process and the Appeal Pathway. This has been explained to me and I am aware that should my view change regarding the best interests (of the patient) in connection with this process, I should raise it at any time.
YES / NO
I have been told about the potential consequences of the assessment;that if found eligible to receive NHS Continuing Healthcare, this may/will affect eligibility to receive certain benefits paid via the Local Authority. My right to withdraw consent or engagement in this process is not affected.
YES / NO
I confirm that it is in the best interests of ………………………….. to a NHS Continuing Healthcare Checklist, Decision Support Tool, Fast Track Pathway and all subsequent reviews being undertaken.
I confirm that it is in the best interests of ……………………….. to relevant information being gathered, collated and shared where necessary with relevant professionals, both as part of the PCT NHS Continuing Healthcare process and also, as part of any potential Dispute Resolution or Appeals Process, to include the preparation of the case file for the PCT and for Independent Review Panel at the Strategic Health Authority / Parliamentary and Health Service Ombudsman (PHSO).
Signature: / Print Name:
Date: / Relationship/ Designation:
Email: / Contact Number:
Signature: / Print Name:
Date: / Relationship/ Designation:
Email: / Contact Number:
Patient’s Name: / Date of Birth:
E. CONSENT TO SHARE AND PROTECT PERSONAL INFORMATION / Please Tick () as Appropriate
I agree that it is in the individual’s best interests that the information provided in this assessment may be shared with Health and Social Care staff, Service Providers who contribute to their care and any agencies acting on behalf of these organisations.
I understand that this information will be used for the purpose of providing a service, or care to the individual.
I understand that I may withdraw consent to share information at any time.
I have understood that certain restrictions can be made in the sharing of information if it is deemed in the best interest of the individual.
Therefore, the following restrictions should apply:
I understand that this information will be held securely on paper and on computer in accordance with the Data Protection Act 1998
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