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What are the 12 Care Domains of Continuing Healthcare?

We have analysed the care domains and how they assessed in more detail here.

There are 12 key care domains that make up the decision support tool stage of the assessment for the entitlement for continuing healthcare funding.  The patient is assessed against each domain and awarded a level of need ranging from no needs, to low needs, moderate needs or high needs depending upon the particular issues they present with.

The domains of cognition, mobility, skin, and nutrition extend further still to include severe needs as an option, while the four domains of behaviour, breathing, altered states of consciousness and drug therapies and medication and the 12th domain of other needs extend further still with options of severe and priority.

The key question that flows from this information, therefore, is how is an individual determined to have ‘primary health needs’ such that would entitle them to NHS continuing healthcare funding to pay for their care costs?

The process is a two-stage assessment, the first being a checklist assessment which is designed as a screening tool to syphon off those cases that do not have the levels of complexity, intensity, unpredictability or nature of need that would warrant consideration via a full decision support tool assessment.

The decision support tool assessment is the second assessment stage, and it is this that determines whether somebody will be entitled to full NHS continuing healthcare funding.

Continuing healthcare funding is provided by the NHS where an individual’s need for care is deemed to be primarily for health reasons. In these circumstances, the NHS is obligated to meet the full cost of an individual’s care, regardless of what assets they have.  It is NOT in any way means tested.

The decision support tool assessment considers 12 care domains and should be undertaken by a multi-disciplinary team of clinicians and social care representatives. We shall look in turn at each of the 12 domains and the points that are considered.

1. Behaviour

Consideration as to whether somebody has ‘challenging behaviour’ is the point for attention in this first care domain.

Examples of what can be considered challenging behaviour are given as including aggression, which can be via violence or passive non-aggressive behaviour, severe disinhibition, intractable noisiness or restlessness, resistance to necessary care and treatment, severe fluctuations in mental state, extreme frustration associated with communication difficulties, inappropriate interference with others and/or identified high risk of suicide.

It should be noted that this is not intended as an exhaustive list but rather examples of what can constitute challenging behaviour.

In the behaviour domain needs are scored in range from no needs through to priority, the stepped range being no needs, low, moderate, high, severe and at the top end of the spectrum, priority.

2. Cognition

This domain considers whether the individual has any cognitive impairment and scores it accordingly on a level of need from no needs, low needs, moderate, high and up to a maximum of severe.  It should be noted that there is no priority need in this domain.

At the top end of the spectrum, a severe level of need indicates that an individual may have marked short-term memory issues or severe disorientation to time, place or person.  They are also noted to be unable to assess even basic risk with supervision and are utterly dependant on others to anticipate their basis needs to protect them from harm.

3. Psychological & emotional

This domain considers what psychological and emotional needs an individual may have and how they contribute to their overall care needs.  In this domain the levels of need range only from no needs through to high and do not extend any further.

In this domain two separate aspects are considered, namely first, whether the individual has mood disturbance, hallucinations, anxiety symptoms or periods of distress and second, whether in fact their issues are related to a psychological or emotional state that has resulted from them withdrawing from attempts to engage in their care planning, support or daily activities.  These considerations are looked at separately and distinctly.

This acknowledges the fact that psychological and emotional needs can take two very different forms and manifest themselves in very different ways.  At one end would be being exceptionally distressed and anxious, the other would be exceptionally withdrawn and unwilling to engage.  Both aspects are considered within the domain.

4. Communication

This domain looks at an individual’s ability to reliably communicate their needs.  The levels of need range from no needs, low needs, moderate needs to a maximum of high needs.

Within the high level of need, an individual is noted to be unable to reliably communicate their needs at any time in any way even when all steps have been taken to assist them. As a result of this inability to communicate reliably, the individual has to have all of their needs anticipated.

An example of where this might occur would be somebody who has severe cognitive impairment as a result of a condition such as dementia or Alzheimer’s disease where they are able to talk but their ability to reliably communicate their needs is severely impaired as a result of their cognitive impairment.

5. Mobility

The mobility domain has a range of levels of need from no needs, low needs, moderate needs, high needs up to severe needs. The mobility domain looks at a number of different factors and considers them all.

Mobility issues can manifest themselves in several different ways ranging from somebody who is at high risk of falls who falls frequently, through to somebody who is completely bedbound and is unable to assist or cooperate with any transfers or repositioning.

Further issues such as needing careful positioning due to the risk of physical harm or loss of muscle tone are considered, as are issues surrounding involuntary spasms or contractions which would place the patient or others at risk. It is a comprehensive assessment that considers all aspects of potential issues surrounding mobility, and it should not be the case that only matters relating to a risk of falls are considered.

6. Nutrition

This domain considers issues as to whether there are risks of malnutrition or dehydration and also separately considers whether there are problems relating to aspiration of food. Such a scenario might be associated with somebody who has a swallow function impairment that can often flow from Parkinson’s disease or clinical instances such as having suffered a stroke.

The domain will also consider whether the individual has suffered from significant weight loss or gain and comment on the same. The levels of need in this domain extend from no needs through to and including severe needs.

7. Continence

This domain considers the continence needs that an individual may have. It looks at levels of need from no needs through to low needs, and moderate to a maximum of high needs. Somebody will only be classed as having high continence needs where their continence care is problematic such that it requires timely and skilled intervention beyond routine care.

An example of such a scenario would be somebody who is having to have frequent bladder wash-outs or frequent re-catheterisation. Simply being doubly incontinent would not constitute a high level of need in the continence domain but rather would fall within the moderate level of need according to the criteria set out in the decision support tool assessment.

8. Skin

This domain considers all aspects of problems surrounding an individual’s skin. The levels of need range from no needs to low needs, moderate, high and severe. Factors for consideration will be whether an individual has open wounds or whether they have pressure sores.

The degree of grading for any pressure sores will reflect on the severity of the level of need awarded in this domain. For example, a grade 4 sore would be considered to be in the severe category where there is ‘full thickness skin loss involving damage or necrosis to subcutaneous tissue”.

9. Breathing

This domain considers whether the individual suffers from any breathing-related issues. Examples would include COPD (chronic obstructive pulmonary disease), emphysema or issues such as recurrent chest infections that give rise to breathing difficulties.

The levels of need in this domain include no needs, low needs, moderate, high, severe and priority. A priority level of need would be applied where somebody is unable to breathe independently and requires invasive mechanical ventilation.

10. Drug therapies & medication: symptom control

This domain considers both the drug regime an individual has and the complexity that is associated with the same as well as separately looking at any pain issues that they may suffer from.

The levels of need range from no needs, low needs, moderate needs, high needs, severe needs and priority needs.

An example of the severe level of need for pain would be somebody who has severe recurrent or constant pain which is not responding to treatment.

11. Altered states of consciousness

Altered states of consciousness are noted to include a range of conditions that can affect consciousness, including transient ischaemic attacks (TIAs), epilepsy and vasovagal syncope.

The levels of need in this domain range from no needs, low needs, moderate, high and priority.  Strangely there is no severe level of need between high and priority as is the case in other domains.

An example of a priority level of need for altered states of consciousness would be someone who is in a coma or somebody who suffers from altered states of consciousness on most days that are not responsive to preventative treatment and can result in severe risk of harm.

12. Other significant care needs to be taken into consideration

There is a twelfth domain that is very broad in its potential scope as there may be circumstances on a case by case basis where an individual has significant particular needs that do not fall within the 11 domains set out within the standard decision support tool assessment.  It is intended that the 12th domain is available to consider such circumstances and to ensure that an individual’s needs are not incorrectly weighted by the absence of such an opportunity to consider their issues.

Should you have any questions regarding continuing healthcare funding or the application of the decision support tool assessment, you should not hesitate to contact a member of the Compass CHC team to discuss matters further on a free, no obligation basis.

Author: Tim Davies LLB

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