We recently helped a client obtain NHS continuing healthcare funding and receive a £39,200 refund of incorrectly paid care home fees
The process of securing NHS continuing healthcare funding can be a protracted one, so when we complete a case it is always a pleasure to share the successful outcome.
In this case, a Decision Support Tool (DST) was carried out on the patient in January 2017. Compass CHC was not in attendance at this meeting as the client hadn’t instructed us at this stage.
Following a negative funding decision at the DST, the client called us in February to find out if we thought the case was worth investigating. After undertaking our own assessment, we took on the case and instigated an appeal as we felt, after reviewing the evidence, that the Decision Support Tool findings were incorrect.
To recap: The Decision Support Tool identifies twelve areas of need or ‘domains’ – 11 specific domains and an additional domain for recording needs that don’t immediately fit into the other 11. Each domain is divided into levels of need from: ‘no need’, ‘low’, ‘moderate’, ‘high’, ‘severe’ and ‘priority’. The levels reflect the nature, intensity, complexity and unpredictability of a need.
At assessment, the multi-disciplinary team allocate a level of need to each care domain to determine if the individual has a ‘primary health need’ and then make a recommendation to the Clinical Commissioning Group as to whether the individual should be entitled to NHS continuing healthcare.
A clear recommendation of eligibility would be expected if the individual undergoing assessment has:
- priority level of need in any of the four
- two or more instances of severe needs across all domains
If the following apply, this may, depending on the combination of needs, also indicate a primary health need:
- one domain recorded as severe together with needs in a number of other domains, or
- a number of domains with high and/or moderate needs.
Our appeal centred around the fact that we felt the following scores had been incorrectly attributed to our client:
|Domain||DST Scores||Our view|
|Breathing||No needs||No needs|
|Altered States of Consciousness||Low||Low|
Our Advocate Helen Curtis, who specialises in securing continuing healthcare funding, attended a Local Resolution Panel meeting in September, the board agreed with the reason for our appeal and the outcome of the meeting was in favour of our client. The CCG agreed to increase the behaviour domain score from moderate to high, and concluded that funding should have been awarded from the date the client was admitted to the care home in February 2017 through to September 2017.
After this ruling, Fast Track Funding was initiated and is still in place now so we are happy to report that 7 months of fees have been reimbursed to our client.
As a direct result of the interventions made and negotiations conducted by Helen Curtis and the entire team at Compass CHC we secured a £39,200 reimbursement of fees for the patient (7 months of care home fees at £1400 per week)
Should you, or a relative, have any concerns regarding NHS Continuing Healthcare funding, or you are thinking about starting the funding process, our expert advisors can assist by explaining the ins and outs of what can be a perplexing and complicated process. There is no time limit placed on this free, no obligation consultation. Should you wish to discuss matters further, do not hesitate to contact us directly on 0121 227 8940
Once we accept instructions to act on a patient’s behalf, our team of continuing healthcare experts, comprising lawyers (non-practising) and clinicians (including nurses, tissue viability specialists and pharmacists) work tirelessly to review and consider all the medical evidence from a clinical perspective before drafting reasoned arguments to the patient’s Clinical Commissioning Group identifying how the individual is entitled to NHS continuing healthcare funding. They do this by cross-referring the medical evidence to the National Framework for continuing healthcare criteria.